[Federal Register Volume 67, Number 90 (Thursday, May 9, 2002)]
[Proposed Rules]
[Pages 31404-31689]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 02-11290]



[[Page 31403]]

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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, 412 et al.



Medicare Program; Changes to the Hospital Inpatient Prospective Payment 
Systems and Fiscal Year 2003 Rates; Proposed Rule

  Federal Register / Vol. 67, No. 90 / Thursday, May 9, 2002 / Proposed 
Rules  

[[Page 31404]]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 405, 412, 413, 482, 485, and 489

[CMS-1203-P]
RIN 0938-AL23


Medicare Program; Changes to the Hospital Inpatient Prospective 
Payment Systems and Fiscal Year 2003 Rates

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

ACTION: Proposed rule.

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SUMMARY: We are proposing to revise the Medicare acute care hospital 
inpatient prospective payment systems for operating and capital costs 
to implement changes arising from our continuing experience with these 
systems. In addition, in the Addendum to this proposed rule, we 
describe the proposed 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 would be 
applicable to discharges occurring on or after October 1, 2002. We also 
are setting forth proposed rate-of-increase limits as well as proposed 
policy changes for hospitals and hospital units excluded from the acute 
care hospital inpatient prospective payment systems.
    In addition, we are proposing changes to other hospital payment 
policies, which include policies governing: payments to hospitals for 
the direct and indirect costs of graduate medical education; pass-
through payments for the services of nonphysician anesthetists in some 
rural hospitals; clinical requirements for swing-bed services in 
critical access hospitals (CAHs); payments to provider-based entities; 
and implementation of the Emergency Medical Treatment and Active Labor 
Act (EMTALA).

DATES: Comments will be considered if received at the appropriate 
address, as provided below, no later than 5 p.m. on July 8, 2002.

ADDRESSES: Mail written comments (an original and three copies) to the 
following address ONLY:
    Centers for Medicare & Medicaid Services, Department of Health and 
Human Services, Attention: CMS-1203-P, P.O. Box 8010, Baltimore, MD 
21244-1850.
    If you prefer, you may deliver, by hand or courier, your written 
comments (an original and three copies) to one of the following 
addresses:

Room 443-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW, 
Washington, DC 20201, or
Room C5-14-03, Central Building, 7500 Security Boulevard, Baltimore, MD 
21244-1850.

    (Because access to the interior of the Humphrey Building is not 
readily available to persons without Federal Government identification, 
commenters are encouraged to leave their comments in the CMS drop slots 
located in the main lobby of the building. A stamp-in clock is 
available for commenters who wish to retain proof of filing by stamping 
in and keeping an extra copy of the comments being filed.)
    Comments mailed to those addresses specified as appropriate for 
courier delivery may be delayed and could be considered late.
    Because of staffing and resource limitations, we cannot accept 
comments by facsimile (FAX) transmission. In commenting, please refer 
to file code CMS-1203-P.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.
    For comments that relate to information collection requirements, 
mail a copy of comments to the following addresses:

Centers for Medicare & Medicaid Services, Office of Information 
Services, Security and Standards Group, Division of CMS Enterprise 
Standards, Room N2-14-26, 7500 Security Boulevard, Baltimore, Maryland 
21244-1850. Attn: John Burke, CMS-1203-P; and
Office of Information and Regulatory Affairs, Office of Management and 
Budget, Room 3001, New Executive Office Building, Washington, DC 20503, 
Attn: Allison Herron Eydt, CMS Desk Officer.

FOR FURTHER INFORMATION CONTACT: Stephen Phillips, (410) 786-4548, 
Operating Prospective Payments, Diagnosis-Related Groups (DRGs), Wage 
Index, New Medical Services and Technology, Hospital Geographic 
Reclassifications, and Postacute Transfer Issues. Tzvi Hefter, (410) 
786-4487, Capital Prospective Payment, Excluded Hospitals, Graduate 
Medical Education, Provider-Based Entities, Critical Access Hospital 
(CAH), EMTALA Issues. Stephen Heffler, (410) 786-1211, Hospital Market 
Basket Rebasing. Jeannie Miller, (410) 786-3164, Clinical Standards for 
CAHs. Tom Hutchinson, (410) 786-8953, Hospital Communication with 
Medicare+Choice Organizations.

SUPPLEMENTARY INFORMATION:

Inspection of Public Comments

    Comments received timely will be available for public inspection as 
they are received, generally beginning approximately 3 weeks after 
publication of a document, in Room C5-12-08 of the Centers for Medicare 
& Medicaid Services, 7500 Security Blvd., Baltimore, MD, on Monday 
through Friday of each week from 8:30 a.m. to 5 p.m. Please call (410) 
786-7197 to schedule an appointment to view public comments.

Availability of Copies and Electronic Access

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password required). Dial-in users should use communications software 
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password required).

I. Background

A. Summary

1. Acute Care Hospital Inpatient Prospective Payment System
    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)

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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).
    The base payment rate is comprised of a standardized amount that is 
divided into a labor-related share and a nonlabor-related share. The 
labor-related share is adjusted by the wage index applicable to the 
area where the hospital is located; and if the hospital is located in 
Alaska or Hawaii, the nonlabor share is adjusted by a cost-of-living 
adjustment factor. This base payment rate is multiplied by the DRG 
relative weight.
    If the hospital is recognized as serving a disproportionate share 
of low-income patients, it receives a percentage add-on payment for 
each case paid through the acute care hospital inpatient prospective 
payment system. This percentage varies, depending on several factors 
which include the percentage of low-income patients served. It is 
applied to the DRG-adjusted base payment rate, plus any outlier 
payments received.
    If the hospital is an approved teaching hospital, it receives a 
percentage add-on payment for each case paid through the acute care 
hospital inpatient prospective payment system. This percentage varies, 
depending on the ratio of residents to beds.
    The costs incurred by the hospital for a case are evaluated to 
determine whether the hospital is eligible for an additional payment as 
an outlier case. This additional payment is designed to protect the 
hospital from large financial losses due to unusually expensive cases. 
Any outlier payment due is added to the DRG-adjusted base payment rate.
    Although payments to most hospitals under the acute care hospital 
inpatient prospective payment system are made on the basis of the 
standardized amounts, some categories of hospitals are paid the higher 
of a hospital-specific rate based on their costs in a base year (the 
higher of Federal fiscal year (FY) 1982, FY 1987, or FY 1996) or the 
prospective payment system rate based on the standardized amount. For 
example, sole community hospitals (SCHs) are the sole source of care in 
their areas, and Medicare-dependent, small rural hospitals (MDHs) are a 
major source of care for Medicare beneficiaries in their areas. Both of 
these categories of hospitals are afforded this special payment 
protection in order to maintain access to services for beneficiaries 
(although MDHs receive only 50 percent of the difference between the 
prospective payment system rate and their hospital-specific rates, if 
the hospital-specific rate is higher than the prospective payment 
system rate).
    The existing regulations governing payments to hospitals under the 
acute care hospital inpatient prospective payment system are located in 
42 CFR part 412, Subparts A through M.

2. Hospitals and Hospital Units Excluded From the Acute Care Hospital 
Inpatient Prospective Payment System

    Under section 1886(d)(1)(B) of the Act, as amended, certain 
specialty hospitals and hospital units are excluded from the acute care 
hospital inpatient prospective payment system. These hospitals and 
units are: psychiatric hospitals and units; rehabilitation hospitals 
and units; long-term care hospitals; children's hospitals; and cancer 
hospitals. Various sections of the Balanced Budget Act of 1997 (Public 
Law 105-33), the Medicare, Medicaid, and SCHIP [State Children's Health 
Insurance Program] Balanced Budget Refinement Act of 1999 (Public Law 
106-113), and the Medicare, Medicaid, and SCHIP Benefits Improvement 
and Protection Act of 2000 (Public Law 106-554) provide for the 
implementation of prospective payment systems for rehabilitation 
hospitals and units, psychiatric hospitals and units, and long-term 
care hospitals, as discussed below. Children's hospitals and cancer 
hospitals will continue to be paid on a cost-based reimbursement basis.
    The existing regulations governing payments to excluded hospitals 
and hospital units are located in 42 CFR parts 412 and 413.
    Under section 1886(j) of the Act, as amended, rehabilitation 
hospitals and units are being transitioned from a blend of reasonable 
cost-based reimbursement subject to a hospital-specific annual limit 
under section 1886(b) of the Act and Federal prospective payments for 
cost reporting periods beginning January 1, 2002 through September 30, 
2002, to payment on a fully Federal prospective rate effective for cost 
reporting periods beginning on or after October 1, 2002 (66 FR 41316, 
August 7, 2001). The statute also provides that IRFs may elect to 
receive the full prospective payment instead of a blended payment. The 
existing regulations governing payment under the inpatient 
rehabilitation facility prospective payment system (for rehabilitation 
hospitals and units) are located in 42 CFR part 412, subpart P.
    Under the broad authority conferred to the Secretary by section 123 
of Public Law 106-113 and section 307(b) of Public Law 106-554, we are 
proposing to transition long-term care hospitals from payments based on 
reasonable cost-based reimbursement under section 1886(b) of the Act to 
fully Federal prospective rates during a 5-year period. For cost 
reporting periods beginning on or after October 1, 2006, we are 
proposing to pay long-term care hospitals under the fully Federal 
prospective payment rate. (See the proposed rule issued in the Federal 
Register on March 22, 2002 (67 FR 13416).) Under the proposed rule, 
long-term care hospitals would also be permitted to elect to be paid 
based on full Federal prospective rates. The proposed regulations 
governing payments under the long-term care hospital prospective 
payment system would be located in 42 CFR part 412, subpart O.
    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 furnished by 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.
3. Critical Access Hospitals
    Under sections 1814, 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 42 CFR parts 413 and 415.
4. Payments for Graduate Medical Education
    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

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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 existing regulations governing GME payments are located in 42 
CFR part 413.

B. Major Contents of This Proposed Rule

    In this proposed rule, we are setting forth proposed changes to the 
Medicare hospital inpatient prospective payment systems for operating 
costs and for capital-related costs in FY 2003. We also are proposing 
changes relating to payments for GME costs; payments to excluded 
hospitals and units; policies implementing EMTALA; clinical 
requirements for swing beds in CAHs; and other hospital payment policy 
changes. The proposed changes would be effective for discharges 
occurring on or after October 1, 2002.
    The following is a summary of the major changes that we are 
proposing to make:
1. Proposed Changes to the DRG Reclassifications and Recalibrations of 
Relative Weights
    As required by section 1886(d)(4)(C) of the Act, we adjust the DRG 
classifications and relative weights annually. Based on analyses of 
Medicare claims data, we are proposing to establish a number of new 
DRGs and to make changes to the designation of diagnosis and procedure 
codes under other existing DRGs. Our proposed changes for FY 2003 are 
set forth in section II. of this preamble.
    Among the proposed changes discussed are:
     Revisions of DRG 1 (Craniotomy Age >17 Except for Trauma) 
and DRG 2 (Craniotomy for Trauma Age >17) to reflect the current 
assignment of cases involving head trauma patients with other 
significant injuries to MDC 24;
     Reconfiguration of DRG 14 (Specific Cerebrovascular 
Disorders Except Transient Ischemic Attack) and DRG 15 (Transient 
Ischemic Attack and Precerebral Occlusions) and creation of a new DRG 
524 (Transient Ischemia);
     Creation of a new DRG for heart assist devices;
     Reassignment of the diagnosis code for rheumatic heart 
failure with cardiac catheterization;
     Assignment of new, and reassignment of existing, cystic 
fibrosis principal diagnosis codes;
     Designation of a code for insertion of totally implantable 
vascular access device (VAD);
     Changes in the DRG assignment for the bladder 
reconstruction procedure code.
     Changes in DRG and MDC assignments for numerous newborn 
and neonate diagnosis codes; and
     Changes in DRG assignment for cases of tracheostomy and 
continuous mechanical ventilation greater than 96 hours.
    We also are presenting our analysis of applicants for add-on 
payments for high-cost new medical technologies.
2. Proposed Changes to the Hospital Wage Index
    In section III. of this preamble, we discuss proposed revisions to 
the wage index and the annual update of the wage data. Specific issues 
addressed in this section include the following:
     The FY 2003 wage index update, using FY 1999 wage data.
     Exclusion from the wage index of Part A physician wage 
costs that are teaching-related, as well as resident and Part A 
certified registered nurse anesthetist (CRNA) costs.
     Collection of data for contracted administrative and 
general, housekeeping, and dietary services.
     Revisions to the wage index based on hospital 
redesignations and reclassifications by the Medicare Geographic 
Classification Review Board (MGCRB).
     Requests for wage data corrections, including 
clarification of our policies on mid-year corrections.
3. Revision and Rebasing of the Hospital Market Basket
    In section IV. of this preamble, we discuss issues relating to our 
proposed rebasing and revision of the hospital market basket in 
developing the recommended FY 2003 update factor for the operating 
prospective payment rates and the excluded hospital rate-of-increase 
limits. We also set forth the data sources used to determine the 
proposed revised market basket relative weights and choice of price 
proxies.
4. Other Decisions and Proposed Changes to the Prospective Payment 
System for Inpatient Operating and Graduate Medical Education Costs
    In section V. of this preamble, we discuss several provisions of 
the regulations in 42 CFR Parts 412 and 413 and set forth certain 
proposed changes concerning the following:
     Options for expanding the postacute care transfer policy.
     Refinement of the application of a hospital bed-count 
policy that would more accurately reflect the size of a hospital's 
operations.
     Clarification of the application of the statutory 
provisions on the calculation of hospital-specific rates for SCHs.
     Technical change regarding additional payments for outlier 
cases.
     Rural referral centers proposed case-mix index values for 
FY 2003.
     Changes relating to the IME adjustment, including 
resident-to-bed ratio caps and counting beds for IME and DSH 
adjustments.
     Clarification and codification of classification 
requirements for MDHs and intermediary evaluations of cost reports for 
these hospitals.
     Changes to policies on pass-through payments for the costs 
of nonphysician anesthetists in some rural hospitals.
     Clarification of policies relating to implementing 3-year 
reclassifications of hospitals and other policies related to hospital 
reclassifications decisions made by the MGCRB.
     Changes relating to payment for the direct costs of GME.
     Changes related to emergency medical conditions in 
hospital emergency department under the EMTALA provisions.
     Criteria for and payments to provider-based entities.
     CMS-directed reopening of intermediary determinations and 
hearing decisions on provider reimbursements.
5. Prospective Payment System for Capital-Related Costs
    In section VI. of this preamble, we specify the proposed payment 
requirements for capital-related costs which include:
     Capital-related costs for new hospitals.
     Additional payments for extraordinary circumstances.
     Restoration of the 2.1 percent reduction to the standard 
Federal capital prospective payment system rate.
     Clarification of the special exceptions payment policy.
6. Proposed Changes for Hospitals and Hospital Units Excluded From the 
Prospective Payment Systems
    In section VII. of this preamble, we discuss the following 
proposals concerning excluded hospitals and hospital units and CAHs:
     Payments for existing excluded hospitals and hospital 
units for FY 2003.
      Updated caps for new excluded hospitals and hospital 
units.
     Revision of criteria for exclusion of satellite facilities 
from the acute care hospital inpatient prospective payment system.

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     The prospective payment systems for inpatient 
rehabilitation hospitals and units and long-term care hospitals.
     Changes in the advance notification period for CAHs 
electing the optional payment methodology.
     Removal of the requirement on CAHs to use a State resident 
assessment instrument (RAI) for patient assessments for swing-bed 
patients.
7. Determining Prospective Payment Operating and Capital Rates and 
Rate-of-Increase Limits
    In the Addendum to this proposed rule, we set forth proposed 
changes to the amounts and factors for determining the FY 2003 
prospective payment rates for operating costs and capital-related 
costs. We also establish the proposed threshold amounts for outlier 
cases. In addition, we address update factors for determining the rate-
of-increase limits for cost reporting periods beginning in FY 2003 for 
hospitals and hospital units excluded from the acute care hospital 
inpatient prospective payment system.
8. Impact Analysis
    In Appendix A, we set forth an analysis of the impact that the 
proposed changes described in this proposed rule would have on affected 
entities.
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
    Section 1886(e)(3) of the Act requires the Secretary to report to 
Congress on our initial estimate of a recommended update factor for FY 
2003 for payments to hospitals included in the acute care hospital 
inpatient prospective payment system, and hospitals excluded from this 
prospective payment system. This report is included as Appendix B to 
this proposed rule.
10. Proposed Recommendation of Update Factor for Hospital Inpatient 
Operating Costs
    As required by sections 1886(e)(4) and (e)(5) of the Act, appendix 
C provides our recommendation of the appropriate percentage change for 
FY 2003 for the following:
     Large urban area and other area average standardized 
amounts (and hospital-specific rates applicable to SCHs and MDHs) for 
hospital inpatient services paid 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 acute care hospital inpatient 
prospective payment system.
11. Discussion of Medicare Payment Advisory Commission Recommendations
    Under section 1805(b) of the Act, the Medicare Payment Advisory 
Commission (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. This annual report makes recommendations 
concerning hospital inpatient payment policies. In section VIII. of 
this preamble, we discuss the MedPAC recommendations and any actions we 
are proposing to take with regard to them (when an action is 
recommended). 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.

II. Proposed Changes to DRG Classifications and Relative Weights

A. Background

    Under the acute care hospital inpatient 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 in 
treatment patterns, technology, and any other factors that may change 
the relative use of hospital resources. The proposed changes to the DRG 
classification system and the proposed recalibration of the DRG weights 
for discharges occurring on or after October 1, 2002 are discussed 
below.

B. DRG Reclassification

1. General
    Cases are classified into DRGs for payment under the acute care 
hospital inpatient 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).
    For FY 2002, cases are assigned to one of 506 DRGs 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 patients' 
principal diagnosis before assignment to a DRG. However, for FY 2002, 
there are eight DRGs to which cases are directly assigned on the basis 
of ICD-9-CM procedure codes. These are the DRGs for heart, liver, bone 
marrow, lung transplants, simultaneous pancreas/kidney, and pancreas 
transplants (DRGs 103, 480, 481, 495, 512, and 513, 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 
operating room (O.R.) procedures or groups of O.R. 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, nonsurgical procedures and minor surgical procedures not 
usually performed in an operating room are not treated as O.R. 
procedures. However, there are a few non-O.R. 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.
    Patients' diagnosis, procedure, discharge status, and demographic 
information is fed into the Medicare claims processing systems and 
subjected 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

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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, for a limited number of DRGs, 
demographic information (that is, sex, age, and discharge status). The 
GROUPER is used both to classify current cases for purposes of 
determining payment and to classify past cases in order to measure 
relative hospital resource consumption to establish the DRG weights.
    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. However, in the July 30, 
1999 final rule (64 FR 41500), we discussed a process for considering 
non-MedPAR data in the recalibration process. In order for the use of 
particular data to be feasible, we must have sufficient time to 
evaluate and test the data. The time necessary to do so depends upon 
the nature and quality of the data submitted. Generally, however, a 
significant sample of the data should be submitted by mid-October, so 
that we can test the data and make a preliminary assessment as to the 
feasibility of using the data. Subsequently, a complete database should 
be submitted no later than December 1 for consideration in conjunction 
with next year's proposed rule.
    The major changes we are proposing to the DRG classification system 
for FY 2003 GROUPER version 20.0 and to the methodology to recalibrate 
the DRG weights are set forth below. Unless otherwise noted, our DRG 
analysis is based on data from 100 percent of the FY 2001 MedPAR file, 
which contains hospital bills received through May 31, 2001, for 
discharges in FY 2001.
2. MDC 1 (Diseases and Disorders of the Nervous System)
a. Proposed Revisions of DRGs 1 and 2
    Currently, adult craniotomy patients are assigned to either DRG 1 
(Craniotomy Age >17 Except for Trauma) or DRG 2 (Craniotomy for Trauma 
Age >17). The trauma distinction recognizes that head trauma patients 
requiring a craniotomy often have multiple injuries affecting other 
body parts. However, we note that the structure of these DRGs predates 
the creation in FY 1991 of MDC 24 (Multiple Significant Trauma). The 
creation of MDC 24 resulted in head trauma patients with other 
significant injuries being assigned to MDC 24 and removed from DRG 2. 
In FY 1990, there was a 16-percent difference in the DRG weights for 
DRG l and DRG 2. In FY 1992, after the creation of MDC 24, the 
percentage difference in the DRG weights for DRG 1 and DRG 2 had 
declined to 1.2 percent. The FY 2002 payment weight for DRG 1 is 3.2713 
and for DRG 2 is 3.3874, a 3.5 percent difference.
    For FY 2003, we reevaluated the GROUPER logic for DRGs 1 and 2 by 
combining the patients assigned to these DRGs and examining the impact 
of other patient attributes on patient charges. The presence or absence 
of a CC was found to have a substantial impact on patient charges.

------------------------------------------------------------------------
                                                       Number
                Cases in DRGs 1 and 2                    of      Average
                                                      patients   charges
------------------------------------------------------------------------
With CC.............................................    19,012   $49,659
Without CC..........................................     9,618    26,824
------------------------------------------------------------------------

    Thus, there is an 85.1 percent difference in average charges for 
the groups with and without CC for the combined DRGs 1 and 2. On this 
basis, we are proposing to redefine and retitle DRGs 1 and 2 as 
follows: DRG 1 (Craniotomy Age >17 with CC); and DRG 2 (Craniotomy Age 
>17 without CC).
b. Proposed Revisions of DRGs 14 and 15
    To assess the appropriate classification of patients with stroke 
symptoms, we evaluated the assignment of cases to DRGs 14 (Specific 
Cerebrovascular Disorders Except Transient Ischemic Attack (TIA) and 
DRG 15 (Transient Ischemic Attack and Precerebral Occlusions). Our data 
review indicated that the cases in DRGs 14 and 15 fell into three 
discrete groups. The first group included cases in which the patients 
were very sick, with severe intracranial lesions or subarachnoid 
hemorrhage and severe consequences. The second group included cases in 
which patients had not suffered a debilitating stroke but instead may 
have experienced a transient ischemic attack. The patients in the 
second group had one half of the average length of stay in the hospital 
as the first group. The third group of cases included patients who 
appeared to suffer strokes with minor consequences, as well as those 
having occluded vessels without having a full-blown stroke.
    We found that patients who have intracranial hemorrhage and 
patients who have infarction are similar in severity. These cases are 
more frequent in occurrence than cases with patients who have 
subarachnoid hemorrhage. Therefore, we are proposing to continue to 
group patients with intracranial hemorrhage and infarction together. 
These types of cases are different from patients with, for example, an 
occlusive carotid artery without infarction. In this common group of 
cases, patients are not as severely ill because they typically have 
lesser degrees of functional status deficits.
    Our analysis indicates that we can improve the clinical and 
resource cohesiveness of DRGs 14 and 15 by reassigning several specific 
ICD-9-CM codes. For example, code 436 (Acute, but ill-defined, 
cerebrovascular disease) is not a specific code and contains patients 
with a wide range of deficits and anatomic problems. Our data show that 
these cases consume fewer resources and have shorter lengths of stay 
than other cases in DRG 14. Therefore, we are proposing to remove code 
436 from DRG 14 and reassign it to DRG 15. We also are proposing to 
create a third new DRG to further identify these cases. The proposed 
revised or new DRG titles are as follows: DRG 14 (Intracranial 
Hemorrhage and Stroke with Infarction); DRG 15 (Nonspecific 
Cerebrovascular and Precerebral Occlusion without Infarction); and DRG 
524 (Transient Ischemia).
    The following table represents a proposed reconfiguration of DRGs 
14 and 15 and the creation of a new DRG 524 reflecting these three 
categorizations:

----------------------------------------------------------------------------------------------------------------
                                                                     Number of    Average length
                     Proposed DRG and title                            cases      of stay (days)  Average charge
----------------------------------------------------------------------------------------------------------------
Revised DRG 14 (Intracranial Hemorrhage and Stroke with                  164,786             6.1         $15,643
 Infarction)....................................................
Revised DRG 15 (Nonspecific Cerebrovascular and Precerebral               70,866             4.9          11,595
 Occlusion without Infarction)..................................
New DRG 524 (Transient Ischemia)................................          92,835             3.3           8,633
----------------------------------------------------------------------------------------------------------------


[[Page 31409]]

    The proposed reconfiguration of DRGs 14 and 15 would result in the 
following codes being designated as principal diagnosis codes in 
proposed revised DRG 14:

 430, Subarachnoid hemorrhage
 431, Intracerebral hemorrhage
 432.0, Nontraumatic extradural hemorrhage
 432.1, Subdural hemorrhage
 432.9, Unspecified intracranial hemorrhage
 433.01, Occlusion and stenosis of basilar artery, with 
cerebral infarction
 433.11, Occlusion and stenosis of carotid artery, with 
cerebral infarction
 433.21, Occlusion and stenosis of vertebral artery, with 
cerebral infarction
 433.31, Occlusion and stenosis of multiple and bilateral 
arteries, with cerebral infarction
 433.81, Occlusion and stenosis of other specified precerebral 
artery, with cerebral infarction
 433.91, Occlusion and stenosis of unspecified precerebral 
artery, with cerebral infarction
 434.01, Cerebral thrombosis with cerebral infarction
 434.11, Cerebral embolism with cerebral infarction
 434.91, Cerebral artery occlusion, unspecified, with cerebral 
infarction

    In addition, we are proposing that the following two codes be moved 
from DRG 14 to DRG 34 (Other Disorders of Nervous System with CC) and 
DRG 35 (Other Disorders of Nervous System without CC): Code 437.3 
(Cerebral aneurysm, nonruptured) and Code 784.3 (Aphasia). These codes 
do not represent acute conditions. Aphasia, for example, could result 
from a cerebral infarction, but if it does, the infarction should be 
correctly coded as the principal diagnosis.
    The proposed redefined DRG 15 would contain the following principal 
diagnosis codes:

 433.00, Occlusion and stenosis of basilar artery, without 
mention of cerebral infarction
 433.10, Occlusion and stenosis of carotid artery, without 
mention of cerebral infarction
 433.20, Occlusion and stenosis of vertebral artery, without 
mention of cerebral infarction
 433.30, Occlusion and stenosis of multiple and bilateral 
arteries, without mention of cerebral infarction
 433.80, Occlusion and stenosis of other specified precerebral 
artery, without mention of cerebral infarction
 433.90, Occlusion and stenosis of unspecified precerebral 
artery, without mention of cerebral infarction
 434.00, Cerebral thrombosis without mention of cerebral 
infarction
 434.10, Cerebral embolism without mention of cerebral 
infarction
 434.90, Cerebral artery occlusion, unspecified, without 
mention of cerebral infarction
 436, Acute, but ill-defined, cerebrovascular disease

    In addition, we are proposing to remove the following codes from 
the existing DRG 15 and place them in the proposed newly created DRG 
524:

 435.0, Basilar artery syndrome
 435.1, Vertebral artery syndrome
 435.2, Subclavian steal syndrome
 435.3, Vertebrobasilar artery syndrome
 435.8, Other specified transient cerebral ischemias
 435.9, Unspecified transient cerebral ischemia

    We are proposing to move code 437.1 (Other generalized ischemic 
cerebrovascular disease) from DRG 16 (Nonspecific Cerebrovascular 
Disorders with CC) and DRG 17 (Nonspecific Cerebrovascular Disorders 
without CC) and add it to the proposed new DRG 524. This proposed 
change represents a modification to improve clinical coherence and 
seems to be a logical change for the construction of the proposed new 
DRG 524.
3. MDC 5 (Diseases and Disorders of the Circulatory System)
a. Heart Assist Systems
    Heart failure is typically caused by persistent high blood pressure 
(hypertension), heart attack, valve disease, other forms of heart 
disease, or birth defects. It is a chronic condition in which the lower 
chambers of the heart (ventricles) cannot pump sufficient amounts of 
blood to the body. This causes the organs of the body to progressively 
fail, resulting in numerous medical complications and frequently death. 
DRG 127 (Heart Failure and Shock), to which heart failure cases are 
assigned, is the single most common DRG in the Medicare population, and 
represents the medical, not surgical, treatment options for this group 
of patients.
    In many cases, heart transplantation would be the treatment of 
choice. However, the low number of donor hearts limits this treatment 
option. Circulatory support devices, also known as heart assist systems 
or left ventricular assist devices (LVADs), offer a surgical 
alternative for end-stage heart failure patients. This type of device 
is often implanted near a patient's native heart and assumes the 
pumping function of the weakened heart's left ventricle. Studies are 
currently underway to evaluate LVADs as permanent support for end-stage 
heart failure patients.
    We have reviewed the payment and DRG assignment of this type of 
device in the past. Originally, these cases were assigned to DRG 110 
(Major Cardiovascular Procedures with CC) and DRG 111 (Major 
Cardiovascular Procedures without CC) in the September 1, 1994 final 
rule (59 FR 45345). A more specific procedure code, 37.66 (Implant of 
an implantable, pulsatile heart assist system) was made effective for 
use with hospital discharges occurring on or after October 1, 1995. In 
the August 29, 1997 final rule (62 FR 45973), we reassigned these cases 
to DRG 108 (Other Cardiothoracic Procedures), because it was the most 
clinically similar DRG with the best match in resource consumption 
according to our data. In the July 31, 1998 final rule (63 FR 40956), 
we again reviewed our data and discovered that the charges for 
implantation of an LVAD were increasing at a greater rate than the 
average charges for DRG 108. The length of stay for cases with code 
37.66 was approximately 32 days, or three times as long as all other 
DRG 108 cases. Therefore, we decided to move LVAD cases from DRG 108 to 
DRG 104 (Cardiac Valve and Other Major Cardiothoracic Procedures with 
Cardiac Catheterization) and DRG 105 (Cardiac Valve and Other Major 
Cardiothoracic Procedures without Cardiac Catheterization). We 
continued to review our data and discuss this topic in the FY 1999 and 
FY 2000 annual final rules: July 30, 1999 (64 FR 41498) and August 1, 
2000 (65 FR 47058).
    In the August 1, 2001 final rule (66 FR 39838), we remodeled MDC 5 
to add five new DRGs. We also added procedure codes 37.62 (Implant of 
other heart assist system), 37.63 (Replacement and repair of heart 
assist system), and 37.65 (Implant of an external, pulsatile heart 
assist system) to DRGs 104 and 105. We removed defibrillator cases from 
DRGs 104 and 105 and assigned them to DRG 514 (Cardiac Defibrillator 
Implant with Cardiac Catheterization) and DRG 515 (Cardiac 
Defibrillator Implant without Cardiac Catheterization) to make these 
DRGs more clinically coherent. This also increased the relative weights 
for DRGs 104 and 105, as the defibrillator cases had lower average 
charges than other cases in those two DRGs.
    In the FY 2001 MedPAR data file, we found 185 LVAD cases in DRG 104 
and 90 cases in DRG 105, for a total of 275 cases. These cases 
represent 1.3 percent of the total cases in DRG 104, and approximately 
0.5 percent of the total

[[Page 31410]]

cases in DRG 105. However, the average charges for these cases are 
approximately $36,000 and $85,000 higher than the average charges for 
cases in DRGs 104 and 105, respectively.
    This situation presents a dilemma, in that the technology has been 
available since 1995 and is gradually increasing in utilization, while 
LVAD cases involving the technology remain a small part of the total 
cases in these two DRGs. In fact, removing LVAD cases from the 
calculation of the average charge changes the average by only -0.4 
percent and -0.5 percent for DRGs 104 and 105, respectively. Therefore, 
despite the dramatically higher average charges for LVADs compared to 
the DRG averages, the relative volume is insufficient to affect the 
average to any great degree.
    Therefore, we are proposing to create a new DRG 525 (Heart Assist 
System Implant), which would contain these cases. The proposed FY 2003 
relative weight for proposed new DRG 525 is 11.3787.
    The new DRG would consist of any principal diagnosis in MDC 5, plus 
one of the following surgical procedures:

 37.62, Implant of other heart assist system
 37.63, Replacement and repair of heart assist system
 37.65, Implant of an external, pulsatile heart assist system
 37.66, Implant of an implantable, pulsatile heart assist 
system

    Cases in which a subsequent heart transplant occurs during the 
hospitalization episode would continue to be assigned to DRG 103 (Heart 
Transplant) because cases involving procedure codes 336 (Combined 
heart/lung transplant) and 375 (Heart transplant) are assigned to DRG 
103, regardless of other codes included on the bill.
    We reiterate a discussion we included in the August 1, 2000 final 
rule (65 FR 47058) regarding placement of code 37.66 in the MCE 
screening software as a noncovered procedure. The default designation 
for that code will continue to be ``noncovered'' because of the 
stringent conditions that must be met by hospitals in order to receive 
payment for implantation of the device.
    Section 65-15 of the Medicare Coverage Issues Manual (Artificial 
Hearts and Relative Devices) provides the national coverage 
determination regarding Medicare coverage of these devices. This 
section may be accessed online at www.hcfa.gov/pubforms/06_cim/ci00.htm.
b. Moving Diagnosis Code 398.91 (Rheumatic Heart Failure) From DRG 125 
to DRG 124
    DRG 124 (Circulatory Disorders Except Acute Myocardial Infarction 
(AMI), with Cardiac Catheterization and Complex Diagnosis) and DRG 125 
(Circulatory Disorders Except Acute Myocardial Infarction (AMI) with 
Cardiac Catheterization without Complex Diagnosis) have a somewhat 
complex DRG logic. In order to be assigned to DRG 124 or 125, the 
patient must first have a circulatory disorder, which would be one of 
the diagnoses included in MDC 5. However, these DRGs exclude acute 
myocardial infarctions. Therefore, these DRGs are comprised of cases 
with a diagnosis from MDC 5, excluding acute myocardial infarction, but 
also with a cardiac catheterization during the stay.
    DRGs 124 and 125 are then further defined by whether or not the 
patient had a complex diagnosis. If the patient had a complex 
diagnosis, the case is assigned to DRG 124. If the patient does not 
have a complex diagnosis, the case is assigned to DRG 125. A list of 
diagnoses that comprise complex diagnoses is identified within DRG 124. 
These diagnoses can be listed as either a principal or secondary 
diagnosis.
    We have received correspondence regarding the current assignment of 
diagnosis code 398.91 (Rheumatic heart failure). The correspondent 
pointed out that, while other forms of heart failure are listed as 
complex diagnoses under DRG 124, rheumatic heart failure is not 
included as a complex diagnosis within that DRG. Currently, if a 
patient with rheumatic heart failure receives a cardiac 
catheterization, the case is assigned to DRG 125.
    The correspondent had conducted a study and found that patients 
with rheumatic heart failure who receive a cardiac catheterization have 
lengths of stay that are significantly longer than patients with other 
forms of heart failure who receive a cardiac catheterization and who 
are assigned to DRG 125. The correspondent found that these patients 
have lengths of stay more similar to those cases assigned to DRG 124 
(which have other forms of heart failure), and recommended that 
diagnosis code 398.91 be added to the list of complex diagnoses within 
DRG 124.
    Within our claims data, we found 439 cases of patients in DRG 125 
with rheumatic heart failure who received a cardiac catheterization. 
The average charges for these rheumatic heart failure cases were almost 
twice as much as for other cardiac patients in DRG 125 who received a 
cardiac catheterization and who did not have a diagnosis of rheumatic 
heart failure. We also conferred with our medical consultants and they 
agree that rheumatic heart failure with cardiac catheterization is a 
complex diagnosis and should be assigned to DRG 124 along with the 
other complex forms of heart failure cases involving cardiac 
catheterization.
    We are proposing to add code 398.91 to DRG 124 as a complex 
diagnosis. As a result, catheterization cases with rheumatic heart 
disease would no longer be assigned to DRG 125.
c. Radioactive Element Implant
    In the August 1, 2001 final rule, we created DRG 517 (Percutaneous 
Cardiovascular Procedure without Acute Myocardial Infarction (AMI) with 
Coronary Artery Stent Implant) as a result of the overall DRG splits 
based on the presence of AMI (66 FR 39839). We assigned code 92.27 
(Implantation or insertion of radioactive elements) to DRG 517 because 
we believed that code 92.27 would always accompany cases involving a 
percutaneous cardiovascular procedure and intravascular radiation 
treatment. We have since determined that code 92.27 can also be present 
as a stand-alone code in other types of cases. When cases with code 
92.27 do not meet the criteria for DRG 517, they are currently directed 
into DRG 468 (Extensive O.R. Procedure Unrelated to Principal 
Diagnosis). Because DRG 468 is for cases in which the O.R. procedure is 
unrelated to the principal diagnosis, rather than assign cases with 
code 92.27 that would otherwise be assigned to MDC 5 to DRG 468 because 
they do not meet the criteria for assignment to DRG 517, we are 
proposing to assign these cases to DRG 120 (Other Circulatory System 
O.R. Procedures).
4. MDC 10 (Endocrine, Nutritional, and Metabolic Diseases and 
Disorders)
    Currently, when ICD-9-CM code 277.00 (Cystic Fibrosis without 
mention of meconium ileus) is reported as the principal diagnosis, it 
is assigned to the following DRG series in MDC 10: DRG 296 (Nutritional 
and Metabolic Disease, Age >17 with CC); DRG 297 (Nutritional and 
Metabolic Disease, Age >17 without CC); and DRG 298 (Nutritional and 
Metabolic Disease, Age 0-17).
    As part of our annual review of DRG assignments and based on 
correspondence that we have received, we examined claims relating to 
cases involving code 277.00 as a principal diagnosis in DRGs 296, 297, 
and 298. Our analysis of the average charges for cases in which code 
277.00 was the principal diagnosis in DRGs 296, 297, and 298 indicates 
that resource

[[Page 31411]]

utilization for these cases is quite different from resource 
utilization for other cases in the three DRGs. We believe that this 
difference in resource utilization is due to the fact it is not 
uncommon for cystic fibrosis patients to be admitted with pulmonary 
complications. Our findings on the number of cases and the average 
charges in the three DRGs when code 277.00 is assigned as the principal 
diagnosis, and our findings for all cases in the three DRGs, are 
indicated in the charts below.

    Cases in DRG 296, 297, and 298 With Code 277.00 as the Principal
                                Diagnosis
------------------------------------------------------------------------
                                             Number of        Average
           DRG and description                 cases          charges
------------------------------------------------------------------------
DRG 296 (Nutritional & Metabolic Disease             271         $34,111
 Age >17 with CC).......................
DRG 297 (Nutritional & Metabolic Disease             133          21,998
 Age >17 with CC).......................
DRG 298 (Nutritional & Metabolic Disease               0  ..............
 Age 0-17)..............................
------------------------------------------------------------------------


                     All Cases in DRG 296, 297, 298
------------------------------------------------------------------------
                                             Number of        Average
           DRG and description                 cases          charges
------------------------------------------------------------------------
DRG 296 (Nutritional & Metabolic Disease         169,768         $10,480
 Age >17 with CC).......................
DRG 297 (Nutritional & Metabolic Disease          31,560           6,190
 Age >17 without CC)....................
DRG 298 (Nutritional & Metabolic Disease              17           8,603
 Age 0-17)..............................
------------------------------------------------------------------------

    Based on the results of our analysis, we are proposing that three 
new cystic fibrosis principal diagnosis codes be assigned to specific 
DRGs and MDCs, and that other changes be made to DRG and MDC 
assignments of existing cystic fibrosis codes, as discussed below.
    We are proposing to create the following three new principal 
diagnosis codes:
 277.02 (Cystic fibrosis with pulmonary manifestations)
 277.03 (Cystic fibrosis with gastrointestinal manifestations)
 277.09 (Cystic fibrosis with other manifestations)

    We are proposing that existing code 277.01 (Cystic fibrosis with 
mention of meconium ileus) would continue to be assigned to DRG 387 
(Prematurity with Major Problems) and DRG 389 (Full Term Neonate with 
Major Problems) in MDC 15 (Newborns and Other Neonates with Conditions 
Originating in the Perinatal Period), since it is a newborn diagnosis 
code.
    Because proposed new code 277.02 would identify those patients with 
cystic fibrosis who have pulmonary manifestations, we are proposing to 
assign cases in which the principal diagnosis is the proposed new code 
277.02 to DRG 79 (Respiratory Infection and Inflammations Age >17 with 
CC), DRG 80 (Respiratory Infections and Inflammations Age >17 without 
CC), or DRG 81 (Respiratory Infections and Inflammations Age 0-17) in 
MDC 4 (Diseases and Disorders of the Respiratory System).
    We are proposing that proposed new code 277.03 would be assigned to 
DRG 188 (Other Digestive System Diagnoses Age >17 with CC), DRG 189 
(Other Digestive System Diagnoses Age >17 without CC), and DRG 190 
(Other Digestive System Diagnoses Age 0-17) in MDC 6 (Diseases and 
Disorders of the Digestive System), because of its specific 
relationship to the digestive system.
    Since proposed new code 277.09 could involve a number of 
manifestations (excluding pulmonary and gastrointestinal), we are 
proposing to assign this proposed new code to DRGs 296, 297, and 298 in 
MDC 10, where we are retaining the current assignment of existing code 
277.00.
    The following chart summarizes our proposed DRG and MDC assignments 
for new and existing cystic fibrosis principal diagnosis codes:

------------------------------------------------------------------------
                                           Proposed MDC    Proposed DRG
Principal diagnosis code and description    assignment      assignments
------------------------------------------------------------------------
Existing 277.00 (Cystic fibrosis without              10   296, 297, 298
 mention of meconium ileus).............
Existing 277.01 (Cystic fibrosis with                 15        387, 389
 mention of meconium ileus).............
Proposed new 277.02 (Cystic fibrosis                   4      79, 80, 81
 with pulmonary manifestations).........
Proposed new 277.03 (Cystic fibrosis                   6   188, 189, 190
 with gastrointestinal manifestations)..
Proposed new 277.09 (Cystic fibrosis                  10   296, 297, 298
 with other manifestations).............
------------------------------------------------------------------------

5. MDC 11 (Diseases and Disorders of the Kidney and Urinary Tract)
a. Insertion of Totally Implantable Vascular Access Device (VAD)
    In the August 1, 2001 final rule (66 FR 39844), we discussed our 
review of the DRG assignment of code 86.07 (Insertion of totally 
implantable vascular access device (VAD)). Code 86.07 is considered a 
nonoperative procedure when it occurs in MDC 11. Therefore, patients in 
renal (kidney) failure requiring implantation of this device for 
dialysis are grouped to medical DRG 316 (Renal Failure). We examined 
whether implantation of this device should be removed from DRG 316 and 
placed into surgical DRG 315 (Other Kidney and Urinary Tract O.R. 
Procedures).
    Implantation of a VAD into the chest wall and blood vessels of a 
patient's upper body allows access to a patient's vessels via an 
implanted valve and cannula. Two devices are implanted during one 
operative session. One system is implanted arterially (the ``draw''), 
while the other is implanted venously (the ``return''). Typically, the 
VAD allows access to the patient's blood for hemodialysis purposes when 
other sites in the body have been exhausted. The device is usually 
inserted in the outpatient setting. Operative time is approximately 1 
to 1.5 hours.

[[Page 31412]]

    In the FY 2002 final rule (66 FR 39844-39845), we pointed out that 
cases where the VAD was inserted as an inpatient procedure also 
involved other complications, leading to higher average charges. 
Therefore, we indicated that we were not assigning code 86.07 to DRG 
315 at that time, but we would consider other alternative adjustments 
to DRGs 315 and 316.
    For FY 2003, we explored whether DRG 315 should be split based on 
existence or nonexistence of CCs. However, during our consideration of 
this alternative, we discovered that DRG 315 does not lend itself to a 
CC split due to the high occurrence of cases in this DRG that already 
have complications identified on the CC list. Therefore, we reexamined 
cases in DRGs 315 and 316 in the FY 2001 MedPAR file. The results are 
reflected in the chart below:

------------------------------------------------------------------------
                                                           Without Code
                                      With Code 86.07         86.07
------------------------------------------------------------------------
DRG 315 (surgical):
  Number of Cases.................  354................  21,089.
  Average Length of Stay..........  12.6 days..........  6.7 days.
  Average Charges.................  $47,251............  $25,622.
DRG 316 (Medical):
  Number of Cases.................  887................  76,676.
  Average Length of Stay..........  10.3...............  6.6 days.
  Average Charges.................  $31,904............  $16,934.
------------------------------------------------------------------------

    These results are similar to the findings included in the FY 2002 
final rule that were based on data from the FY 2000 MedPAR file (66 FR 
39845).
    We found that the average length of stay in DRG 315 for patients 
not receiving the VAD is 6.7 days, while those patients who received 
the VAD had an average length of stay of 12.6 days. We found the 
average charges in DRG 315 for patients not receiving the VAD were 
approximately $25,622, while the average charges for those patients who 
received the VAD were $47,251.
    We found that the cases receiving the VAD as an inpatient procedure 
are significantly more costly than other cases in DRG 316. Therefore, 
we are proposing to designate code 86.07 as an O.R. procedure under MDC 
11. Specifically, code 86.07 would be recognized as an O.R. procedure 
code in MDC 11 and assigned to DRG 315 when combined with the following 
principal diagnosis codes from DRG 316:

 403.01, Malignant hypertensive renal disease with renal 
failure
 403.11, Benign hypertensive renal disease with renal failure
 403.91, Unspecified hypertensive renal disease with renal 
failure
 404.02, Malignant hypertensive heart and renal disease with 
renal failure
 404.12, Malignant hypertensive heart and renal disease with 
renal failure
 404.92, Unspecified hypertensive heart and renal disease with 
renal failure
 584.5, Acute renal failure with lesion of tubular necrosis
 584.6, Acute renal failure with lesion of renal cortical 
necrosis
 584.7, Acute renal failure with lesion of renal medullary 
(papillary) necrosis
 584.8, Acute renal failure with other specified pathological 
lesion in kidney
 584.9, Acute renal failure, unspecified
 585, Chronic renal failure
 586, Renal failure, unspecified
 788.5, Oliguria and anuria
 958.5, Traumatic anuria
b. Bladder Reconstruction
    We received correspondence regarding the current classification of 
procedure code 57.87 (Reconstruction of urinary bladder) as a minor 
bladder procedure and the assignment of the code under DRG 308 (Minor 
Bladder Procedures with CC) and DRG 309 (Minor Bladder Procedures 
without CC). The correspondent believed that bladder reconstruction is 
not a minor procedure, submitted individual hospital charges to support 
this contention, and recommended that the code be classified as a major 
procedure and assigned to a higher weighted DRG.
    Our clinical advisors indicated that reconstruction of the bladder 
is a more extensive procedure than the other minor bladder procedures 
in DRGs 308 and 309. They agree that the bladder reconstruction 
procedure is as complex as the procedures under code 57.79 (Total 
cystectomy) and the other major bladder procedures in DRGs 303 through 
305.
    As indicated in the chart below, we found that the average charges 
for bladder reconstruction are significantly higher than the average 
charges for other minor procedures within DRGs 308 and 309:

------------------------------------------------------------------------
                                                        With     Without
                                                        Code      Code
                                                        57.87     57.87
------------------------------------------------------------------------
DRG 308 (minor bladder procedure with CC):
  Number of Cases...................................        64     5,066
  Average Charges...................................   $36,560   $19,923
DRG 309 (minor bladder procedures without CC):
  Number of Cases...................................        25     3,021
  Average Charges...................................   $23,390   $11,200
------------------------------------------------------------------------

    We found that procedure code 57.87 may be more appropriately placed 
in DRG 303 (Kidney, Ureter and Major Bladder Procedures for Neoplasm), 
304 (Kidney, Ureter and Major Bladder Procedures for Nonneoplasm with 
CC), and DRG 305 (Kidney, Ureter and Major Bladder Procedures for 
Nonneoplasm without CC), based on average charges for procedures in 
these three DRGS as indicated in the following chart:

------------------------------------------------------------------------
                                             Number of        Average
                   DRG                         cases          charges
------------------------------------------------------------------------
303 (Kidney, Ureter and Major Bladder             14,116         $30,691
 Procedures for Neoplasm)...............
304 (Kidney, Ureter and Major Bladder              8,060          30,577
 Procedures for Nonneoplasm with CC)....
305 (Kidney, Ureter and Major Bladder              2,029          15,492
 Procedures for Nonneoplasm without CC).
------------------------------------------------------------------------

    Based on the results of our analysis and the advice of our medical 
consultants discussed above, we are proposing to classify code 57.87 as 
a major bladder procedure and to assign it to DRGs 303, 304, and 305.
6. MDC 15 (Newborns and Other Neonates with Conditions Originating in 
the Perinatal Period)
    The primary focus of updates to the Medicare DRG classification 
system is for changes relating to the Medicare patient population, not 
the pediatric or neonatal patient populations. However, the Medicare 
DRGs are sometimes used to classify other patient populations. Over the 
years, we have received comments about aspects of the Medicare newborn 
DRGs that appear problematic, and we have responded to these on an 
individual basis. Some correspondents have requested that we take a 
closer

[[Page 31413]]

overall look at the DRGs within MDC 15.
    To respond to this request relating to review of MDC 15, we 
contacted the National Association of Children's Hospitals and Related 
Institutions (NACHRI), along with our own medical advisors, to obtain 
proposals for possible revisions of the existing DRG categories in MDC 
15. The focus of the requested proposals was to refine category 
definitions within the framework of the existing seven broadly defined 
neonatal DRGs. The proposals also were to take advantage of the new, 
more specific neonatal diagnosis codes to be adopted, effective October 
1, 2002, to assist with refinements to the existing DRG category 
definitions.
    In preparing these proposed changes to MDC 15, we have considered 
comments and suggestions previously received, including suggestions 
from NACHRI on how to make improvements within the existing framework 
of seven very broadly defined neonatal DRGs. In the future, we may 
consider broader changes to MDC 15.
a. Definition of MDC 15
    The existing diagnosis definitions for MDC 15 include certain 
diagnoses that may be present at the time of birth but may also 
continue beyond the perinatal period.
    These diagnoses are basically congenital anomalies, and even though 
they may continue beyond the perinatal period, they are assigned to MDC 
15 which is specific to newborns and neonates.
    The diagnosis codes assigned to the DRGs under MDC 15 have been a 
source of confusion because older children and adults can be admitted 
with these principal diagnoses and assigned to newborn or neonate DRGs 
in MDC 15 as if they were newborns.
    Our medical consultants and NACHRI have reviewed the listing of 
diagnosis codes and identified those that should not be routinely 
classified under MDC 15. As a result of this review, we are proposing 
that the following list of diagnosis codes be removed from MDC 15:
 758.9, Conditions due to anomaly of unspecified chromosome
 759.4, Conjoined twins
 759.7, Multiple congenital anomalies, so described
 759.81, Prader-Willi Syndrome
 759.83, Fragile X Syndrome
 759.89, Other specified anomalies
 759.9, Congenital anomaly, unspecified
 779.7, Periventricular leukomalacia
 795.2, Nonspecific abnormal findings on chromosomal analysis

    We are proposing to assign the nine diagnosis codes listed above to 
the following MDCs and DRGs (if medical):

----------------------------------------------------------------------------------------------------------------
                                                                   Proposed MDC
         Diagnosis code                        Title                assignment        Proposed DRG assignment
----------------------------------------------------------------------------------------------------------------
758.9...........................  Conditions due to anomaly of                23  467 (Other Factors Influencing
                                   unspecified chromosome.                         Health Status).
759.4...........................  Conjoined twins...............               6  188, 189, 190 (Other Digestive
                                                                                   System Diagnoses, age >17
                                                                                   with CC, Age >17 without CC,
                                                                                   and Age 0-17, respectively).
759.7...........................  Multiple congenital anomalies,               8  256 (Other Musculoskeletal
                                   so described.                                   System and Connective Tissue
                                                                                   Diagnoses).
759.81..........................  Prader-Willi Syndrome.........               8  256 (Other Musculoskeletal
                                                                                   System and Connective Tissue
                                                                                   Diagnoses).
759.83..........................  Fragile x Syndrome............              19  429 (Organic Disturbances and
                                                                                   Mental Retardation)
759.89..........................  Other specified anomalies.....               8  256 (Other Musculoskeletal
                                                                                   System and Connective Tissue
                                                                                   Diagnoses).
759.9...........................  Congenital anomaly,                         23  467 (Other Factors Influencing
                                   unspecified.                                    Health Status).
779.7...........................  Periventricular leukomalacia..               1  34, 35 (Other Disorders of the
                                                                                   Nervous System with CC and
                                                                                   without CC, respectively).
795.2...........................  Nonspecific abnormal findings               23  467 (Other Factors Influencing
                                   on chromosomal analysis.                        Health Status).
----------------------------------------------------------------------------------------------------------------

    The following three specific 4-digit diagnosis codes have been 
determined invalid by the ICD-9-CM Coordination and Maintenance 
Committee, effective October 1, 2002, and we are proposing to remove 
---------------------------------------------------------------------------
them from MDC 15.

 770.8, Other newborn respiratory problems
 771.8, Other infection specific to the perinatal period
 779.8, Other specified conditions originating in the perinatal 
period

    The above three codes are being replaced by 5-digit codes to 
capture more detail. These new 5-digit codes are assigned to DRGs 
within MDC 15 and are listed among the codes in Table 6A--New Diagnosis 
Codes in the Addendum of this proposed rule.
    In addition, the ICD-9-CM Coordination and Maintenance Committee 
created a number of new codes, effective October 1, 2002, to capture 
newborn and neonatal conditions. Therefore, we are proposing to add the 
following new 23 diagnosis codes to MDC 15:

 747.83, Persistent fetal circulation
 765.20, Unspecified weeks of gestation
 765.21, Less than 24 completed weeks of gestation
 765.22, 24 completed weeks of gestation
 765.23, 25-26 completed weeks of gestation
 765.24, 27-28 completed weeks of gestation
 765.25, 29-30 completed weeks of gestation
 765.26, 31-32 completed weeks of gestation
 765.27, 33-34 completed weeks of gestation
 765.28, 35-36 completed weeks of gestation
 765.29, 37 or more completed weeks of gestation
 770.81, Primary apnea of newborn
 770.82, Other apnea of newborn
 770.83, Cyanotic attacks of newborn
 770.84, Respiratory failure of newborn
 770.89, Other respiratory problems after birth
 771.81, Septicemia [sepsis] of newborn
 771.82, Urinary tract infection of newborn
 771.83, Bacteremia of newborn
 771.89, Other infections specific to the perinatal period
 779.81, Neonatal bradycardia
 779.82, Neonatal tachycardia
 779.89, Other specified conditions originating in perinatal 
period


[[Page 31414]]


b. DRG 386 (Extreme Immaturity or Respiratory Distress Syndrome, 
Neonate)
    The existing DRG 386 is defined by the presence of one of the ICD-
9-CM extreme prematurity codes (765.01 through 765.05) with the fifth 
digit indicating birthweight less than 1,500 grams (3.3 pounds). NACHRI 
has identified two weaknesses in the use of the fifth digit to define 
prematurity.
    One weakness relates to determining extreme immaturity, which, in 
part, is limited by the existing ICD-9-CM diagnosis codes. The existing 
ICD-9-CM definition for the extreme immaturity codes ``usually implies 
birthweight less than 1,000 grams (2.2 pounds) or gestational age less 
than 28 completed weeks,'' or both. The fifth digit provides range 
values for birthweight but gives no information on gestational age. A 
specific and distinct set of ICD-9-CM diagnosis codes for gestational 
age is to be introduced effective October 1, 2002. These new codes will 
provide a clearer basis for differentiating extreme immaturity or 
gestational age, or both.
    The second weakness is that diagnosis code 769 (Respiratory 
distress syndrome in newborn) is currently only associated with DRG 
386, which requires extreme prematurity, but respiratory distress 
syndrome in newborns can occur with all levels of prematurity. 
Therefore, we believe that code 769 should not be used to classify a 
diagnosis under DRG 386.
    The proposed revision to DRG 386 would reflect the upcoming new 
ICD-9-CM diagnosis codes. We are proposing to redefine DRG 386 to 
include those newborns whose preterm birthweight is less than 1,000 
grams or gestational age is less than 27-28 completed weeks, or both. 
Therefore, we would remove diagnosis code 769 from DRG 386, as this 
code is associated with all levels of prematurity, not just extreme 
immaturity. In addition, we are proposing to revise the title of DRG 
386 to read ``Extreme Immaturity''.
    Because birthweight for neonates varies at all gestational ages, 
some neonates will meet the DRG 386 criteria for preterm extremely low 
birthweight (less than 1,000 grams) but not the DRG 386 criteria for 
extremely short gestation age (less than 27-28 completed weeks). The 
reverse may also occur, where a neonate meets the DRG 386 criteria for 
extremely short gestational age (less than 27-28 completed weeks) but 
not for preterm extremely low birthweight (less than 1,000 grams). In 
either situation, the neonate would be assigned to the proposed 
retitled DRG 386 (Extreme Immaturity).
    NACHRI provided the following information on the measurement of 
gestational age and its use in the definition of Medicare neonatal 
DRGs. First, they noted that gestational age can be as powerful a 
predictor of a newborn's hospitalization course as birthweight and 
corresponds more directly to organ system immaturity. Second, while 
gestational age can be identified with a reasonable level of accuracy, 
it cannot be measured as precisely as birthweight. These two 
considerations led NACHRI to recommend the inclusion of gestational age 
in the definition of the Medicare neonatal DRGs, but in a conservative 
manner. Specifically, extremely short gestational age, as identified 
earlier, usually implies gestational age less than 28 weeks. The 
proposed new definition of DRG 386 includes only the gestational age 
codes for less than 27 to 28 completed weeks. Thus, there is a 1-week 
conservative bias in the use of the new gestational age codes for DRG 
386. It is also important to note that the existing DRG 386 definition 
includes existing codes 765.01 through 765.05, which include extreme 
immaturity without a specific identification of gestational age and 
birthweight up to 1,499 grams (3.3 pounds). Thus, the proposed revised 
definition of DRG 386 is actually somewhat more stringent as well as 
more specific.
    To implement these changes, we are proposing to remove the 
following diagnosis codes from the list of ``principal or secondary 
diagnosis'' under DRG 386:

 765.04, Extreme immaturity, 1,000-1,249 grams
 765.05, Extreme immaturity, 1,250-1,499 grams
 769, Respiratory distress syndrome in newborn

    Note, as explained above, while we are proposing to remove 
diagnosis codes 765.04, 765.05, and 769 from the list of principal or 
secondary diagnosis under DRG 386, a neonate would still be assigned to 
DRG 386 if there is a diagnosis of gestational age less than 27 to 28 
completed weeks reported (765.21 through 765.23).
    We are proposing to add the following diagnosis codes to the list 
of ``principal or secondary diagnosis'' under DRG 386:

 765.11, Other preterm infants, less than 500 grams
 765.12, Other preterm infants, 500-749 grams
 765.13, Other preterm infants, 750-999 grams
 765.21, Less than 24 completed weeks of gestation
 765.22, 24 completed weeks of gestation
 765.23, 25-26 completed weeks of gestation

c. DRG 387 (Prematurity With Major Problems)
    The existing definition of DRG 387 has the following three 
components: (1) Principal or secondary diagnosis of prematurity; (2) 
Principal or secondary diagnosis of major problem (these are diagnoses 
that define MDC 15); or (3) secondary diagnosis of major problem (these 
are diagnoses that do not define MDC 15 so they can only be secondary 
diagnosis codes for patients assigned to MDC 15). We are proposing 
changes for each component of the definition for DRG 387.
    We are proposing to revise the definition for the first component 
of DRG 387, ``principal or secondary diagnosis of prematurity'', to 
include all preterm low birthweight codes with fifth digit range code 
values indicating birthweight between 1,000 grams (2.2 pounds) and 
2,499 grams (5.5 pounds), or gestational age between 27 to 28 and 35 to 
36 completed weeks, or both. This would include all of the preterm low 
birthweight and gestational age codes except those assigned to the 
proposed revised DRG 386 and except for the following four preterm and 
gestational age codes: 765.10, 765.19, 765.20, and 765.29.
    It is possible for a neonate to be premature and greater than 2,500 
grams (5.5 pounds). In this instance, one of the new gestational age 
codes that specifically identifies the newborn to be less than 37 
completed weeks of gestation would need to be present to meet the 
criteria for inclusion in DRG 387. This is not a conceptual change for 
DRG 387, in that diagnosis codes 765.10 and 765.19 should both refer to 
newborns less than 37 completed weeks of gestation. Therefore, we are 
proposing to take into consideration the new ICD-9-CM codes that 
require a more specific affirmation that the newborn is less than 37 
completed weeks of gestation. Because DRG 387 is a broadly defined 
category (1,000-2,499 grams or 27-36 completed weeks of gestation), 
NACHRI recommends that it is important to require specific information 
for inclusion of patients at the high end of the birthweight/
gestational age range.
    We are proposing to remove the following diagnosis codes from the 
list of diagnoses defined as ``principal or secondary diagnosis of 
prematurity'' for DRG 387:

 765.10, Other preterm infants, unspecified (weight)

[[Page 31415]]

 765.11, Other preterm infants, less than 500 grams
 765.12, Other preterm infants, 500-749 grams
 765.13, Other preterm infants, 750-999 grams
 765.19, Other preterm infants, 2,500+ grams

    We are proposing to add the following diagnosis codes to the list 
of diagnoses defined as ``principal or secondary diagnosis of 
prematurity'' for DRG 387:

 765.04, Extreme immaturity, 1000-1249 grams
 765.05, Extreme immaturity, 1250-1499 grams
 765.24, 27-28 completed weeks of gestation
 765.25, 29-30 completed weeks of gestation
 765.26, 31-32 completed weeks of gestation
 765.27, 33-34 completed weeks of gestation
 765.28, 35-36 completed weeks of gestation

    We are proposing to revise the definition for the second component 
of DRG 387, ``principal or secondary diagnosis of major problem'', to 
remove certain diagnosis codes and to add other diagnosis codes. We are 
proposing to remove three groups of diagnosis codes. The first group of 
diagnosis codes that we are proposing to remove includes the fetal 
malnutrition codes for the birthweight ranges less than 2500 grams. 
NACHRI indicates that these newborns are not necessarily more 
complicated than preterm infants of the same birthweight range. These 
newborns have fewer problems related to organ system immaturity and 
often demonstrate excellent catch-up growth after delivery. Some of the 
fetal malnutrition diagnosis neonates may have serious problems. 
Therefore, it is best for the classification system to look for other 
more specific, major problem diagnoses than to include all of these 
newborns in DRG 387. We are proposing to remove the following diagnosis 
codes from DRG 387.

 764.11, ``Light-for-dates'' with signs of fetal malnutrition, 
less than 500 grams
 764.12, ``Light-for-dates'' with signs of fetal malnutrition, 
500-749 grams
 764.13, ``Light-for-dates'' with signs of fetal malnutrition, 
750-999 grams
 764.14, ``Light-for-dates'' with signs of fetal malnutrition, 
1,000-1,249 grams
 764.15, ``Light-for-dates'' with signs of fetal malnutrition, 
1,250-1,499 grams
 764.16, ``Light-for-dates'' with signs of fetal malnutrition, 
1,500-1,749 grams
 764.17, ``Light-for-dates'' with signs of fetal malnutrition, 
1,750-1,999 grams
 764.18, ``Light-for-dates'' with signs of fetal malnutrition, 
2,000-2,499 grams
 764.21, Fetal malnutrition without mention of ``light-for-
dates'', less than 500 grams
 764.22, Fetal malnutrition without mention of ``light-for-
dates'', 500-749 grams
 764.23, Fetal malnutrition without mention of ``light-for-
dates'', 750-999 grams
 764.24, Fetal malnutrition without mention of ``light-for-
dates'', 1,000-1,249 grams
 764.25, Fetal malnutrition without mention of ``light-for-
dates'', 1,250-1,499 grams
 764.26, Fetal malnutrition without mention of ``light-for-
dates'', 1,500-1,749 grams
 764.27, Fetal malnutrition without mention of ``light-for-
dates'', 1,750-1,999 grams
 764.28, Fetal malnutrition without mention of ``light-for-
dates'', 2,000-2,499 grams

    The second group of codes we are proposing to remove from the list 
of ``principal or secondary diagnosis of major problems'' under DRG 387 
consists of the following 13 diagnosis codes. The majority of these 
diagnosis codes do not represent a major problem for a newborn at or 
shortly after birth. NACHRI believes that costs associated with 
newborns with these conditions are similar to costs associated with 
neonates without a major problem.

 763.4, Cesarean delivery affecting fetus or newborn
 770.1, Meconium aspiration syndrome
 770.8, Other newborn respiratory problems
 771.8, Other infection specific to the perinatal period
 772.0, Fetal blood loss
 773.2, Hemolytic disease due to other and unspecified 
isoimmunization of fetus or newborn
 773.5, Late anemia due to isoimmunization of fetus or newborn
 775.5, Other transitory neonatal electrolyte disturbances
 775.6, Neonatal hypoglycemia
 776.0, Hemorrhagic disease of newborn
 776.6, Anemia of prematurity
 777.1, Meconium obstruction in fetus or newborn
 777.2, Intestinal obstruction due to inspissated milk in 
newborn

    We note that diagnosis code 770.8 (Other newborn respiratory 
problems) and diagnosis code 771.8 (Other infection specific to the 
perinatal period) are 4-digit codes that are being replaced by a series 
of more specific 5-digit codes, effective October 1, 2002. (See Table 
6C in the Addendum of this proposed rule.) The listing of the codes on 
the second group above includes some of these new 5-digit codes.
    The third group of diagnosis codes that we are proposing to remove 
from the list of diagnosis defined as ``principal or secondary 
diagnosis of major problem'' under DRG 387 includes the following two 
diagnosis codes. These codes are no longer assigned to MDC 15 when they 
are the principal diagnosis.

 759.4, Conjoined twins
 779.7, Periventricular leukomalacia

    We are proposing to add the following nine new and existing 
diagnosis codes to the list of ``principal or secondary diagnosis of 
major problem'' that defines DRG 387. These nine diagnosis codes 
generally represent major problems at the time of birth and have costs 
more similar to those of neonates with major problems than neonates 
without major problems. Many of these diagnosis codes are related to 
congenital anomaly conditions.

 747.83, Persistent fetal circulation (new code)
 769, Respiratory distress syndrome in newborn
 770.84, Respiratory failure of newborn (new code)
 771.3, Tetanus neonatorum
 771.81, Septicemia of newborn (new code)
 771.82, Neonatal urinary tract infection (new code)
 771.83, Bacteremia of newborn (new code)
 771.89, Other infections specific to perinatal period (new 
code)
 776.7, Transient neonatal neutropenia

    Of special note is the handling of diagnosis code 769 (Respiratory 
distress syndrome in newborn). Earlier in this preamble, we discussed 
the proposed removal of this diagnosis code from the definition of 
proposed retitled DRG 386 (Extreme Immaturity) because, even though it 
is usually associated with prematurity, it may occur with all levels of 
prematurity. We are proposing to add respiratory distress syndrome 
(which was previously assigned to existing DRG 386) to the list of 
diagnoses that define ``principal or secondary diagnosis of major 
problem'' for DRG 387. We are not proposing to add it to the list of 
diagnoses that define ``principal or secondary diagnosis of 
prematurity'' for DRG 387. The rationale for not adding code 769 as a 
prematurity diagnosis is that it occurs in only a small subset of 
neonates in the birthweight range of 1,000 to 2,499 grams (2.2 to 5.5 
pounds), and the vast majority of occurrences is in the upper end of 
this birthweight range. Respiratory distress syndrome

[[Page 31416]]

might not be indicative of a major problem for neonates at the low end 
of this range (for example, those closer to 1,000 to 1,249 grams), 
because these neonates will most likely have multiple significant 
problems. Therefore, we are proposing that respiratory distress 
syndrome be classified as a major problem and included among the list 
of ``principal or secondary diagnosis of major problem'' for DRG 387.
    In addition, we are proposing to revise the definition for the 
third defining component of DRG 387, ``secondary diagnosis of major 
problem''. This list of major problem diagnoses can only be secondary 
diagnoses because they are not among the list of principal diagnoses 
that defines MDC 15 for the Medicare DRG classification system. Based 
on NACHRI's recommendations, we are proposing to add and remove 
diagnoses from this list on the same basis as previously described for 
the list of ``principal or secondary diagnosis of major problems'' for 
DRG 387. That is, diagnoses are removed if, in the majority of 
instances, the condition does not represent a major problem for a 
newborn at or shortly after birth, and on average exhibits costs 
similar to the costs associated with neonates without a major problem. 
In addition, we are proposing to remove the asthma with status 
asthmaticus diagnosis codes, as these diagnosis codes pertain to 
newborns or other conditions arising in the perinatal period.
    We are proposing to remove the following diagnosis codes from the 
list of ``secondary diagnosis of major problem'' for DRG 387:

 276.5, Volume depletion
 349.0, Reaction to spinal or lumbar puncture
 457.2, Lymphangitis
 493.01, Extrinsic asthma with status asthmaticus
 493.11, Intrinsic asthma with status asthmaticus
 493.91, Asthma, unspecified type, with status asthmaticus
 578.1, Blood in stool
 683, Acute lymphadenitis
 693.0, Dermatitis due to drugs and medicines taken internally
 695.0, Toxic erythema
 708.0, Allergic urticaria
 745.4, Ventricular septal defect
 785.0, Tachycardia, unspecified
 995.2, Unspecified adverse effect of drug, medicinal and 
biological substance, not elsewhere classified
 999.5, Other serum reaction, not elsewhere classified
 999.6, ABO incompatibility reaction, not elsewhere classified
 999.7, Rh incompatibility reaction, not elsewhere classified
 999.8, Other transfusion reaction, not elsewhere classified

    We are proposing to add the following 65 diagnosis codes to the 
list of ``secondary diagnosis of major problem'' for DRG 387:

 416.0, Primary pulmonary hypertension
 416.8, Other chronic pulmonary heart diseases
 425.3, Endocardial fibroelastosis
 425.4, Other primary cardiomyopathies
 427.0, Paroxysmal supraventricular tachycardia
 427.1, Paroxysmal ventricular tachycardia
 466.11, Acute bronchiolitis due to respiratory syncytial virus 
(RSV)
 466.19, Acute bronchiolitis due to other infectious organisms
 478.74, Stenosis of larynx
 480.0, Pneumonia due to adenovirus
 480.1, Pneumonia due to respiratory syncytial virus
 480.2, Pneumonia due to parainfluenza virus
 480.8, Pneumonia due to other virus not elsewhere classified
 480.9, Viral pneumonia, unspecified
 745.0, Common truncus
 745.10, Complete transposition of great vessels
 745.11, Double outlet right ventricle
 745.12, Corrected transposition of great vessels
 745.19, Other transposition of great vessels
 745.2, Tetralogy of Fallot
 745.3, Common ventricle
 745.60, Endocardial cushion defect, unspecified type
 745.61, Ostium primum defect
 745.69, Other endocardial cushion defects
 746.01, Atresia of pulmonary valve, congenital
 746.1, Tricuspid atresia and stenosis, congenital
 746.2, Ebstein's anomaly
 746.7, Hypoplastic left heart syndrome
 746.81, Subaortic stenosis, congenital
 746.82, Cor triatriatum
 746.84, Obstructive anomalies of heart, congenital, not 
elsewhere classified
 746.86, Congenital heart block
 747.10, Coarctation of aorta (preductal) (postductal)
 747.11, Interruption of aortic arch
 747.41, Total anomalous pulmonary venous connection
 747.81, Anomalies of cerebrovascular system, congenital
 748.3, Other congenital anomalies of larynx, trachea, and 
bronchus
 748.4, Cystic lung, congenital
 748.5, Agenesis, hypoplasia, and dysplasia of lung, congenital
 750.3, Tracheoesophageal fistula, esophageal atresia and 
stenosis, congenital
 751.1, Atresia and stenosis of small intestine, congenital
 751.2, Atresia and stenosis of large intestine, rectum, and 
anal canal, congenital
 751.3, Hirschsprung's disease and other congenital functional 
disorders of colon
 751.4, Anomalies of intestinal fixation, congenital
 751.62, Congenital cystic disease of liver
 751.69, Other congenital anomalies of gall bladder, bile 
ducts, and liver
 751.7, Anomalies of pancreas, congenital
 753.0, Renal agenesis and dysgenesis
 753.5, Exstrophy of urinary bladder
 756.51, Osteogenesis imperfecta
 756.6, Anomalies of diaphragm, congenital
 756.70, Congenital anomaly of abdominal wall, unspecified
 756.71, Prune belly syndrome
 756.79, Other congenital anomalies of abdominal wall
 758.1, Patau's Syndrome
 758.2, Edwards' Syndrome
 758.3, Autosomal deletion syndromes
 759.4, Conjoined twins
 759.7, Multiple congenital anomalies, so described
 759.81, Prader-Willi Syndrome
 759.89, Other specified anomalies
 7797, Periventricular leukomalacia
 785.51, Cardiogenic shock
 785.59, Other shock without mention of trauma
 789.5, Ascites

d. DRG 388 (Prematurity Without Major Problems)
    We are proposing to revise the definition for prematurity for DRG 
388 ((Prematurity without Major Problems) in the same manner that we 
proposed to revise the definition of prematurity for DRG 387 
(Prematurity with Major Problems).
    We are proposing to remove the following five diagnosis codes from 
the list of codes pertaining to the ``principal or secondary diagnosis 
of prematurity'' for DRG 388:

 765.10, Other preterm infants unspecified (weight)
 765.11, Other preterm infants, less than 500 grams
 765.12, Other preterm infants, 500-749 grams
 765.13, Other preterm infants, 750-999 grams

[[Page 31417]]

 765.19, Other preterm infants, 2,500+ grams

    We are proposing to add the following seven diagnosis codes to the 
definition of principal or secondary diagnosis of prematurity for DRG 
388:

 765.04, Extreme immaturity, 1000-1249 grams
 765.05, Extreme immaturity, 1250-1499 grams
 765.24, 27-28 completed weeks of gestation
 765.25, 29-30 completed weeks of gestation
 765.26, 31-32 completed weeks of gestation
 765.27, 33-34 completed weeks of gestation
 765.28, 35-36 completed weeks of gestation
e. DRG 389 (Full Term Neonate With Major Problem)
    We are proposing to revise the definition of ``principal or 
secondary diagnosis of major problem'' for DRG 389 (Full Term Neonate 
with Major Problem) in the same manner that we proposed to revise the 
definition for DRG 387 (Prematurity with Major Problem).
f. DRG 390 (Neonate With Other Significant Problems)
    DRG 390 is defined as patients with ``principal or secondary 
diagnosis of newborn or neonate, with other significant problems, not 
assigned to DRG 385 through 389, 391, or 469 (principal diagnosis 
invalid as discharge diagnosis). As a result of our proposed changes to 
other neonatal DRGs, we are proposing to make conforming changes 
related to diagnosis codes assigned to DRG 390.
g. DRG 391 (Normal Newborn)
    DRG 391 (Normal Newborn) is defined by a list of principal 
diagnoses (for example, V30, Newborn codes plus certain minor newborn 
problems) and no secondary diagnoses or only certain secondary 
diagnoses (that is, minor problem diagnoses). NACHRI recommended that 
the definition of DRG 391 be modified to expand the number of minor 
problem newborn diagnoses included in both the list of principal 
diagnoses and the list of only certain secondary diagnoses that define 
DRG 391. The diagnoses that we are proposing to add to DRG 391 are 
conditions that NACHRI has identified as occurring with some frequency 
in the newborn population and having costs more similar to that of DRG 
391 than DRG 390 (Neonates with Other Significant Problems).
    We are proposing to add the following diagnosis codes to the list 
of ``principal diagnosis'' that defines DRG 391:

 764.00, ``Light-for-dates'' without mention of fetal 
malnutrition, unspecified (weight)
 764.90, Fetal growth retardation unspecified (weight)
 765.10, Other preterm infants unspecified (weight)
 765.19, Other preterm infants, 2,500+ grams
 765.20, Unspecified weeks of gestation
 765.29, 37 or more completed weeks of gestation

    We also are proposing to add the above six diagnosis codes to the 
list of ``only certain secondary diagnosis'' that defines DRG 391, as 
indicated below. Of these diagnosis codes, NACHRI indicates that the 
highest volume diagnosis code is 765.19 (Other preterm infants, 2,500+ 
grams). NACHRI notes that when this diagnosis code is recorded and no 
major problem or significant problem diagnosis is recorded, these 
patients have costs that are not much different than those for other 
normal newborns.
    We are proposing to add the following codes to the list of ``only 
certain secondary diagnosis'' that defines DRG 391:

 216.0, Benign neoplasm of skin of lip
 216.1, Benign neoplasm of eyelid, including canthus
 216.2, Benign neoplasm of ear and external auditory canal
 216.3, Benign neoplasm of skin of other and unspecified parts 
of face
 216.4, Benign neoplasm of scalp and skin of neck
 216.5, Benign neoplasm of skin of trunk, except scrotum
 216.6, Benign neoplasm of skin of upper limb, including 
shoulder
 216.7, Benign neoplasm of skin of lower limb, including hip
 216.8, Benign neoplasm of other specified sites of skin
 216.9, Benign neoplasm of skin, site unspecified
 228.00, Hemangioma of unspecified site
 228.01, Hemangioma of skin and subcutaneous tissue
 228.1, Lymphangioma, any site
 379.8, Other specified disorders of eye and adnexa
 379.90, Disorder of eye, unspecified
 379.92, Swelling or mass of eye
 379.93, Redness or discharge of eye
 379.99, Other ill-defined disorders of eye
 427.60, Premature beats, unspecified
 427.61, Supraventricular premature beats
 427.9, Cardiac dysrhythmia, unspecified
 528.4, Cysts of oral soft tissues
 553.1, Umbilical hernia without mention of obstruction or 
gangrene
 603.8, Other specified types of hydrocele
 603.9, Hydrocele, unspecified
 607.89, Other specified disorders of penis
 607.9, Unspecified disorder of penis and perineum
 624.9, Unspecified noninflammatory disorder of vulva and 
perineum
 692.9, Contact dermatitis and other eczema unspecified cause
 701.1, Keratoderma, acquired
 701.3, Striae atrophicae
 701.8, Other specified hypertrophic and atrophic conditions of 
skin
 701.9, Unspecified hypertrophic and atrophic conditions of 
skin
 702.8, Other specified dermatoses
 705.1, Prickly heat
 706.1, Other acne
 706.2, Sebaceous cyst
 709.8, Other specified disorders of skin
 709.9, Unspecified disorder of skin and subcutaneous tissue
 719.61, Other symptoms referable to joint of shoulder region
 719.65, Other symptoms referable to joint of pelvic region and 
thigh
 755.00, Polydactyly, unspecified digits
 755.01, Polydactyly of fingers
 755.02, Polydactyly of toes
 755.10, Syndactyly of multiple and unspecified sites
 755.11, Syndactyly of fingers without fusion of bone
 755.12, Syndactyly of fingers with fusion of bone
 755.13, Syndactyly of toes without fusion of bone
 755.14, Syndactyly of toes with fusion of bone
 755.66, Other congenital anomalies of toes
 755.67, Anomalies of foot, congenital, not elsewhere 
classified
 755.9, Unspecified congenital anomaly of unspecified limb
 757.2, Dermatoglyphic anomalies
 757.32, Vascular hamartomas
 757.39, Other specified congenital anomalies of skin
 757.4, Specified congenital anomalies of hair
 757.5, Specified congenital anomalies of nails
 757.6, Specified congenital anomalies of breast
 757.8, Other specified congenital anomalies of the integument
 757.9, Unspecified congenital anomaly of the integument
 760.0, Maternal hypertensive disorders affecting fetus or 
newborn

[[Page 31418]]

 760.1, Maternal renal and urinary tract diseases affecting 
fetus or newborn
 760.2, Maternal infections affecting fetus or newborn
 760.3, Other chronic maternal circulatory and respiratory 
diseases affecting fetus or newborn
 760.4, Maternal nutritional disorders affecting fetus or 
newborn
 760.5, Maternal injury affecting fetus or newborn
 760.6, Surgical operation on mother affecting fetus or newborn
 760.70, Unspecified noxious substance affecting fetus or 
newborn via placenta or breast milk
 760.74, Anti-infectives affecting fetus or newborn via 
placenta or breast milk
 760.76, Diethylstilbestrol (DES) exposure affecting fetus or 
newborn via placenta or breast milk
 760.79, Other noxious influences affecting fetus or newborn 
via placenta or breast milk
 760.8, Other specified maternal conditions affecting fetus or 
newborn
 760.9, Unspecified maternal condition affecting fetus or 
newborn
 761.0, Incompetent cervix affecting fetus or newborn
 761.1, Premature rupture of membranes affecting fetus or 
newborn
 761.5, Multiple pregnancy affecting fetus or newborn
 761.7, Malpresentation before labor affecting fetus or newborn
 761.8, Other specified maternal complications of pregnancy 
affecting fetus or newborn
 761.9, Unspecified maternal complication of pregnancy 
affecting fetus or newborn
 762.8, Other specified abnormalities of chorion and amnion 
affecting fetus or newborn
 762.9, Unspecified abnormality of chorion and amnion affecting 
fetus or newborn
 763.4, Cesarean delivery affecting fetus or newborn
 763.5, Maternal anesthesia and analgesia affecting fetus or 
newborn
 763.7, Abnormal uterine contractions affecting fetus or 
newborn
 763.89, Other specified complications of labor and delivery 
affecting fetus or newborn
 764.00, ``Light-for-dates'' without mention of fetal 
malnutrition, unspecified (weight)
 764.90, Fetal growth retardation unspecified (weight)
 765.10, Other preterm infants unspecified (weight)
 765.19, Other preterm infants, 2,500+ grams
 765.20, Unspecified weeks of gestation
 765.29, 37 or more completed weeks of gestation
 767.2, Fracture of clavicle due to birth trauma
 767.3, Other injuries to skeleton due to birth trauma
 767.8, Other specified birth trauma
 767.9, Unspecified birth trauma
 768.2, Fetal distress before onset of labor, in liveborn 
infant
 768.3, Fetal distress first noted during labor, in liveborn 
infant
 768.4, Fetal distress, unspecified as to time of onset, in 
liveborn infant
 768.9, Unspecified severity of birth asphyxia in liveborn 
infant
 70.9, Unspecified respiratory condition of fetus and newborn
 772.8, Other specified hemorrhage of fetus or newborn
 772.9, Unspecified hemorrhage of newborn
 773.1, Hemolytic disease due to ABO isoimmunization of fetus 
or newborn
 773.2, Hemolytic disease due to other and unspecified 
isoimmunization of fetus or newborn
 773.5, Late anemia due to isoimmunization of fetus or newborn
 775.6, Neonatal hypoglycemia
 775.9, Unspecified endocrine and metabolic disturbances 
specific to the fetus and newborn
 776.4, Polycythemia neonatorum
 776.8, Other specified transient hematological disorders of 
fetus or newborn
 776.9, Unspecified hematological disorder specific to fetus or 
newborn
 777.1, Meconium obstruction in fetus or newborn
 777.3, Hematemesis and melena due to swallowed maternal blood 
of newborn
 777.8, Other specified perinatal disorders of digestive system
 777.9, Unspecified perinatal disorder of digestive system
 778.3, Other hypothermia of newborn
 778.4, Other disturbances of temperature regulation of newborn
 778.6, Congenital hydrocele
 778.7, Breast engorgement in newborn
 778.9, Unspecified condition involving the integument and 
temperature regulation of fetus and newborn
 779.9, Unspecified condition originating in the perinatal 
period
 780.6, Fever
 781.0, Abnormal involuntary movements
 781.3, Lack of coordination
 782.1, Rash and other nonspecific skin eruption
 782.2, Localized superficial swelling, mass, or lump
 782.4, Jaundice, unspecified, not of newborn
 782.61, Pallo
 782.62, Flushin
 782.7, Spontaneous ecchymose
 782.8, Changes in skin texture
 782.9, Other symptoms involving skin and integumentary tissues
 783.3, Feeding difficulties and mismanagement
 784.2, Swelling, mass, or lump in head and neck
 784.9, Other symptoms involving head and neck
 785.2, Undiagnosed cardiac murmurs
 785.3, Other abnormal heart sounds
 785.9, Other symptoms involving cardiovascular system
 786.00, Respiratory abnormality, unspecified
 786.7, Abnormal chest sounds
 786.9, Other symptoms involving respiratory system and chest
 787.3, Flatulence, eructation, and gas pain
 790.6, Other abnormal blood chemistry
 790.7, Bacteremia
 790.99, Other nonspecific findings on examination of blood
 795.6, False positive serological test for syphilis
 795.79, Other and unspecified nonspecific immunological 
findings
 796.1, Abnormal reflex
 910.0, Abrasion or frictions burn of face, neck, and scalp 
except eye, without mention of infection
 910.2, Blister of face, neck, and scalp except eye, without 
mention of infection
 910.8, Other and unspecified superficial injury of face, neck, 
and scalp, without mention of infection
 920, Contusion of face, scalp, and neck except eye(s)
 999.5, Other serum reaction, not elsewhere classified
 999.6, ABO incompatibility reaction, not elsewhere classified
 V01.1, Contact with or exposure to tuberculosis
 V01.6, Contact with or exposure to venereal diseases
 V01.7, Contact with or exposure to other viral diseases
 V01.81, Contact with or exposure to communicable diseases, 
anthrax
 V01.89, Contact with or exposure to communicable diseases, 
other communicable diseases
 V01.9, Contact with or exposure to unspecified communicable 
disease
 V02.3, Carrier or suspected carrier of other gastrointestinal 
pathogens
 V05.3, Need for prophylactic vaccination and inoculation 
against viral hepatitis
 V05.4, Need for prophylactic vaccination and inoculation 
against varicella

[[Page 31419]]

 V05.8, Need for prophylactic vaccination and inoculation 
against other specified disease
 V05.9, Need for prophylactic vaccination and inoculation 
against unspecified single disease
 V07.8, Need for other specified prophylactic measure
 V07.9, Need for unspecified prophylactic measure
 V18.0, Family history of diabetes mellitus
 V18.1, Family history of other endocrine and metabolic 
diseases
 V18.2, Family history of anemia
 V18.3, Family history of other blood disorders
 V18.8, Family history of infectious and parasitic diseases
 V19.2, Family history of deafness or hearing loss
 V19.8, Family history of other condition
 V71.9, Observation for unspecified suspected condition
 V72.0, Examination of eyes and vision
 V72.6, Laboratory examination
 V73.89, Special screening examination for other specified 
viral diseases
 V73.99, Special screening examination for unspecified viral 
disease
7. MDC 23 (Factors Influencing Health Status and Other Contacts With 
Health Services)
    In the August 1, 2001 final rule, we included in Table 6A--New 
Diagnosis Codes (66 FR 40064) code V10.53 (History of malignancy, renal 
pelvis), which was approved by the ICD-9-CM Coordination and 
Maintenance Committee as a new code effective October 1, 2001. We 
assigned the code to DRG 411 (History of Malignancy without Endoscopy) 
and DRG 412 (History of Malignancy with Endoscopy).
    We received correspondence which suggested that we should have also 
assigned code V10.53 to DRG 465 (Aftercare with History of Malignancy 
as Secondary Diagnosis). The correspondent pointed out that all other 
codes for a history of malignancy are included in DRG 465.
    We agree that code V10.53 should be included in the list of the 
history of malignancy codes within DRG 465. Therefore, we are proposing 
to add V10.53 to the list of secondary diagnosis in DRG 465.
8. Pre-MDC: Tracheostomy
    DRG 483 (Tracheostomy Except for Face, Mouth and Neck Diagnoses) is 
used to classify patients who require long-term mechanical ventilation. 
Mechanical ventilation can be administered through an endotracheal tube 
for a limited period of time. When an endotracheal tube is used for an 
extended period of time (beyond 7 to 10 days), the patient runs a high 
risk of permanent damage to the trachea. In order to maintain a patient 
on mechanical ventilation for a longer period of time, the endotracheal 
tube is removed and a tracheostomy is performed. The mechanical 
ventilation is then administered through the tracheostomy.
    A tracheostomy also may be performed on patients for therapeutic 
purposes unrelated to the administration of mechanical ventilation. 
Patients with certain face, mouth, and neck disease may have a 
tracheostomy performed as part of the treatment for the face, mouth, or 
neck disease. These patients are assigned to DRG 482 (Tracheostomy for 
Face, Mouth and Neck Diagnoses).
    Therefore, patients assigned to DRGs 482 and 483 are differentiated 
based on the principal diagnosis of the patient. At certain times, 
selecting the appropriate principal diagnosis for the patients 
receiving tracheostomies for assignment to a DRG can be difficult. The 
overall number of tracheostomy patients increased by 13 percent between 
1994 and 1999. During the same period, the percent of tracheostomy 
patients in DRG 483 (patients without certain face, mouth, or neck 
diseases) versus DRG 482 increased from 83.6 percent to 87.6 percent.
    The payment weight for DRG 483 is more than four times greater than 
the DRG 482 payment weight, and this has led to concerns about coding 
compliance. Specifically, the fact that cases are assigned to DRG 483 
based on the absence of a code indicating face, mouth, or neck 
diagnosis creates an incentive to omit codes indicating these 
diagnoses.
    To address issues of possible coding noncompliance, we are 
proposing to modify DRGs 482 and 483 to differentiate the assignment to 
either DRG based on the presence or absence of continuous mechanical 
ventilation that lasts more than 96 hours (code 96.72). This 
modification would ensure that the patients assigned to DRG 483 are 
patients who had the tracheostomy for long-term mechanical ventilation. 
Based on an examination of claims data from the FY 2001 MedPAR file, we 
found that many patients assigned to DRG 483 do not have the code 96.72 
for mechanical ventilation greater than 96 hours recorded. In part, 
this is the result of the limited number of procedure codes (six) that 
can be submitted on the current uniform hospital claim form, and the 
fact that code 96.72 does not currently affect the DRG assignment.
    We found that many of the patients who are assigned to DRG 483 have 
multiple procedures, making it impossible for all procedures performed 
to be submitted on the hospital claim form. Because of the current 
underreporting of code 96.72 for continuous mechanical ventilation 
greater than 96 hours, we do not believe we can accurately determine 
the payment weights for modified DRGs 482 and 483 as described above.
    In order to encourage the reporting of the code 96.72 for 
continuous mechanical ventilation for greater than 96 hours, we are 
proposing to change the definition of DRG 483 so that patients who have 
a tracheostomy and continuous mechanical ventilation greater than 96 
hours (code 96.72) with a principal diagnosis unrelated to disease of 
the face, mouth, or neck would be assigned to DRG 483. DRG 483 would be 
retitled ``Tracheostomy/Mechanical Ventilation 96+ Hours Except Face, 
Mouth, and Neck Diagnosis.''
    We will give future consideration to modifying DRGs 482 and DRG 483 
based on the presence of code 96.72, and invite comments on this area.
9. Medicare Code Editor (MCE) Change
    As explained under section II.B.1. of this preamble, the MCE is a 
software program that detects and reports errors in the coding of 
Medicare claims data.
    The MCE includes an edit for ``nonspecific principal diagnosis'' 
that identifies a group of codes that are valid according to the ICD-9-
CM coding scheme, but are not as specific as the coding scheme permits. 
The fiscal intermediaries use cases identified in this edit for 
educational purposes for hospitals only. That is, when a hospital 
reaches a specific threshold of cases (usually 25) in this edit, the 
fiscal intermediary will contact the hospital and educate it on how to 
code diagnoses using more specific codes in the ICD-9-CM coding scheme. 
The claims identified in this nonspecific principal diagnosis edit are 
neither denied nor returned to the hospital.
    Code 436 (Acute, but ill-defined, cerebrovascular disease) is one 
of the codes included in the groups of codes identified in the 
nonspecific principal diagnosis edit, and is widely used in smaller 
hospitals where testing mechanisms are not available to more 
specifically identify the location and condition of cerebral and 
precerebral vessels. Because of the frequent use of code 436 among 
smaller hospitals, we

[[Page 31420]]

are proposing to remove the code from the nonspecific principal 
diagnosis edit in the MCE. We address the use of code 436 in section 
II.B.3. of this proposed rule under the discussion of MDC 5 changes 
with regard to the remodeling of DRGs 14 and 15.
10. 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 within the 
GROUPER by which these cases are assigned to a single DRG. The surgical 
hierarchy, an ordering of surgical classes from most resource-intensive 
to least resource-intensive, 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 recalibrations, we 
reviewed the surgical hierarchy of each MDC, as we have for previous 
reclassifications and recalibrations, to determine if the ordering of 
classes coincides with the intensity of resource utilization.
    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 the average resources for 
each DRG by frequency to determine the weighted 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 in the class 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 O.R. procedures'' as 
discussed below.
    This methodology may occasionally result in assignment of a case 
involving multiple procedures 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 charge is 
ordered above a surgical class with a higher average charge. For 
example, the ``other O.R. procedures'' surgical class is uniformly 
ordered last in the surgical hierarchy of each MDC in which it occurs, 
regardless of the fact that the average charge for the DRG or DRGs in 
that surgical class may be higher than that for other surgical classes 
in the MDC. The ``other O.R. procedures'' class is a group of 
procedures that are only infrequently related to the diagnoses in the 
MDC but are still occasionally performed on patients in the MDC 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 
charges for two surgical classes is very small. We have found that 
small differences generally do not warrant reordering of the hierarchy 
since, as a result of the hierarchy change, the average charges are 
likely to shift such that the higher-ordered surgical class has a lower 
average charge than the class ordered below it.
    Based on the preliminary recalibration of the DRGs, we are 
proposing modifications of the surgical hierarchy as set forth below.
    At this time, we are proposing to revise the surgical hierarchy for 
the pre-MDC DRGs and for MDC 5 (Diseases and Disorders of the 
Circulatory System) as follows:
     In the pre-MDC DRGs, we are proposing to reorder DRG 495 
(Lung Transplant) above DRG 512 (Simultaneous Pancreas/Kidney 
Transplant).
     In MDC 5, we are proposing to reorder DRG 525 (Heart 
Assist System Implant) above DRGs 104 and 105 (Cardiac Valve and Other 
Major Cardiothoracic Procedures with and without Cardiac 
Catheterization, respectively).
11. 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 valid CCs 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. At this time, we are not proposing to delete any 
of the diagnosis codes on the CC list.
    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 the same condition should not be considered 
CCs for one another.
      Codes for the same condition that cannot coexist, such as 
partial/total, unilateral/bilateral, obstructed/ unobstructed, and 
benign/malignant, should not be considered CCs for one another.
     Codes for 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

[[Page 31421]]

considered CCs 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, the August 1, 2000 final rule (65 FR 47064) for the 
FY 2001 revisions; and the August 1, 2001 final rule (66 FR 39851) for 
the FY 2002 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.
    We are proposing a limited revision of the CC Exclusions List to 
take into account the proposed changes that will be made in the ICD-9-
CM diagnosis coding system effective October 1, 2002. (See section 
II.B.13. of this preamble for a discussion of ICD-9-CM changes.) These 
proposed changes are being made in accordance with the principles 
established when we created the CC Exclusions List in 1987.
    Tables 6G and 6H in the Addendum to this proposed rule contain the 
revisions to the CC Exclusions List that would be effective for 
discharges occurring on or after October 1, 2002. 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, 2002, 
the indented diagnoses would 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, 2002, the indented diagnoses would 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 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 2216l; 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, 1999, 2000, and 2002) and those in Tables 6F and 6G of the 
final rule for FY 2003 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, 2002. (Note: There was no 
CC Exclusions List in FY 2001 because we did not make changes to the 
ICD-9-CM codes for FY 2001.)
    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 19.0, is available for $225.00, 
which includes $15.00 for shipping and handling. Version 20.0 of this 
manual, which includes the final FY 2002 DRG changes, is available 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.
12. Review of Procedure Codes in DRGs 468, 476, and 477
    Each year, we review cases assigned to DRG 468 (Extensive O.R. 
Procedure Unrelated to Principal Diagnosis), DRG 476 (Prostatic O.R. 
Procedure Unrelated to Principal Diagnosis), and DRG 477 (Nonextensive 
O.R. 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 O.R. 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 O.R. 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); in FY 2001, as noted in the August 1, 2000 final 
rule (65 FR 47064); or in FY 2002, as noted in the August 1, 2001 final 
rule (66 FR 39852).
a. Moving Procedure Codes From DRGs 468 or 477 to MDCs
    We annually conduct a review of procedures producing assignment to

[[Page 31422]]

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.
    We 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. Therefore, we are not proposing to 
move any procedures from DRG 477 to one of the surgical DRGs. However, 
we have identified a number of procedure codes that should be removed 
from DRG 468 and put into more clinically coherent DRGs. The proposed 
assignments of these codes are specified in the charts below.

                                    Movement of Procedure Codes From DRG 468
----------------------------------------------------------------------------------------------------------------
                                                                    Included in
         Procedure Code                     Description                 DRG                 Description
----------------------------------------------------------------------------------------------------------------
                              MDC 6--Diseases and Disorders of the Digestive System
----------------------------------------------------------------------------------------------------------------
387.............................  Interruption vena cava........             170  Other Digestive System O.R.
                                                                                   Procedures with CC.
387.............................  Interruption vena cava........             171  Other Digestive System O.R.
                                                                                   Procedures without CC.
3950............................  Angioplasty or atherectomy of              170  Other Digestive System O.R.
                                   noncoronary vessel.                             Procedures with CC.
3950............................  Angioplasty or atherectomy of              171  Other Digestive System O.R.
                                   noncoronary vessel.                             Procedures without CC.
----------------------------------------------------------------------------------------------------------------
                     MDC 7--Diseases and Disorders of the Hepatobiliary System and Pancreas
----------------------------------------------------------------------------------------------------------------
387.............................  Interruption vena cava........             201  Other Hepatobiliary & Pancreas
                                                                                   Procedures.
3949............................  Other revision of vascular                 201  Other Hepatobiliary & Pancreas
                                   procedure.                                      Procedures.
3950............................  Angioplasty or atherectomy of              201  Other Hepatobiliary & Pancreas
                                   noncoronary vessel.                             Procedures.
----------------------------------------------------------------------------------------------------------------
                MDC 8--Diseases and Disorders of the Musculoskeletal System and Connective Tissue
----------------------------------------------------------------------------------------------------------------
387.............................  Interruption vena cava........             233  Other Musculoskeletal System &
                                                                                   Connective Tissue O.R.
                                                                                   Procedures with CC.
387.............................  Interruption vena cava........             234  Other Musculoskeletal System &
                                                                                   Connective Tissue O.R.
                                                                                   Procedures without CC.
3950............................  Angioplasty or atherectomy of              233  Other Musculoskeletal System &
                                   noncoronary vessel.                             Connective Tissue O.R.
                                                                                   Procedures with CC.
3950............................  Angioplasty or atherectomy of              234  Other Musculoskeletal System &
                                   noncoronary vessel.                             Connective Tissue O.R.
                                                                                   Procedures without CC.
----------------------------------------------------------------------------------------------------------------
                    MDC 9--Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast
----------------------------------------------------------------------------------------------------------------
8344............................  Other fasciectomy.............             269  Other Skin, Subcutaneous
                                                                                   Tissue & Breast Procedures
                                                                                   with CC.
8344............................  Other fasciectomy.............             270  Other Skin, Subcutaneous
                                                                                   Tissue & Breast Procedures
                                                                                   without CC.
8345............................  Other myectomy................             269  Other Skin, Subcutaneous
                                                                                   Tissue & Breast Procedures
                                                                                   with CC.
8345............................  Other myectomy................             270  Other Skin, Subcutaneous
                                                                                   Tissue & Breast Procedures
                                                                                   without CC.
8382............................  Muscle or fascia graft........             269  Other Skin, Subcutaneous
                                                                                   Tissue & Breast Procedures
                                                                                   with CC.
8382............................  Muscle or fascia graft........             270  Other Skin, Subcutaneous
                                                                                   Tissue & Breast Procedures
                                                                                   without CC.
----------------------------------------------------------------------------------------------------------------
                       MDC 10--Endocrine, Nutritional and Metabolic Diseases and Disorders
----------------------------------------------------------------------------------------------------------------
387.............................  Interruption vena cava........             292  Other Endocrine, Nutritional,
                                                                                   & Metabolic O.R. Procedures
                                                                                   with CC.
387.............................  Interruption vena cava........             293  Other Endocrine, Nutritional,
                                                                                   & Metabolic O.R. Procedures
                                                                                   without CC.
5459............................  Other Lysis of Peritoneal                  292  Other Endocrine, Nutritional,
                                   adhesions.                                      & Metabolic O.R. Procedures
                                                                                   with CC.
5459............................  Other Lysis of Peritoneal                  293  Other Endocrine, Nutritional,
                                   adhesions.                                      & Metabolic O.R. Procedures
                                                                                   without CC.
----------------------------------------------------------------------------------------------------------------
                          MC 11--Diseases and Disorders of the Kidney and Urinary Tract
----------------------------------------------------------------------------------------------------------------
0492............................  Implantation or replacement of             315  Other Kidney & Urinary Tract
                                   peripheral neurostimulator.                     O.R. Procedures.
3821............................  Blood vessel biopsy...........             315  Other Kidney & Urinary Tract
                                                                                   O.R. Procedures.
387.............................  Interruption vena cava........             315  Other Kidney & Urinary Tract
                                                                                   O.R. Procedures.
3949............................  Other revision of vascular                 315  Other Kidney & Urinary Tract
                                   procedure.                                      O.R. Procedures.
----------------------------------------------------------------------------------------------------------------

[[Page 31423]]

 
                             MDC 12--Diseases and Disorders Male Reproductive System
----------------------------------------------------------------------------------------------------------------
387.............................  Interruption vena cava........             344  Other Male Reproductive System
                                                                                   O.R. Procedures for
                                                                                   Malignancy.
387.............................  Interruption vena cava........             345  Other Male Reproductive System
                                                                                   O.R. Procedures Except for
                                                                                   Malignancy.
8622............................  Excisional debridement of                  344  Other Male Reproductive System
                                   wound, infection, or burn.                      O.R. Procedures for
                                                                                   Malignancy.
8622............................  Excisional debridement of                  345  Other Male Reproductive System
                                   wound, infection, or burn.                      O.R. Procedures Except for
                                                                                   Malignancy.
----------------------------------------------------------------------------------------------------------------
                        MDC 13--Diseases and Disorders of the Female Reproductive System
----------------------------------------------------------------------------------------------------------------
387.............................  Interruption vena cava........             365  Other Female Reproductive
                                                                                   System O.R. Procedures.
----------------------------------------------------------------------------------------------------------------
           MDC 16--Diseases and Disorders of the Blood, Blood Forming Organs, Immunological Disorders
----------------------------------------------------------------------------------------------------------------
387.............................  Interruption vena cava........             394  Other O.R. Procedures of the
                                                                                   Blood & Blood Forming Organs.
----------------------------------------------------------------------------------------------------------------

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 reassigned 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 we 
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 are not proposing 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 are not proposing to add any 
diagnosis codes to MDCs.
13. 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 2003 at public meetings held on May 17 and 18, 
2001, and November 1 and 2, 2001, and finalized the coding changes 
after consideration of comments received at the meetings and in writing 
by January 8, 2002.
    Copies of the Coordination and Maintenance Committee minutes of the 
2001 meetings can be obtained from the CMS home page at: http://www.cms.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; C4-08-06; 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, 2002. The new ICD-

[[Page 31424]]

9-CM codes are listed, along with their DRG classifications, in Tables 
6A and 6B (New Diagnosis Codes and New Procedure Codes, respectively) 
in the Addendum to this proposed 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 
this proposed rule, we are only soliciting comments 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, 2002. 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. There are no invalid procedure 
codes for FY 2002 (Table 6D). Revisions to diagnosis code titles are in 
Table 6E (Revised Diagnosis Code Titles), which also includes the DRG 
assignments for these revised codes. Revisions to procedure code titles 
are in Table 6F (Revised Procedure Codes Titles).
14. Other Issues
    In addition to the specific topics discussed in section II.B.1. 
through 13. of this proposed rule, we examined a number of other DRG-
related issues. Below is a summary of the issues that were addressed. 
However, we are not proposing any changes at this time.
a. Intestinal Transplantation
    We examined our data to determine whether it is appropriate to 
propose a new intestinal transplant DRG. There were nine intestinal 
transplantation cases reported by two facilities. Two of the cases 
involved a liver transplant during the same admission and, therefore, 
would be assigned to DRG 480 (Liver Transplant). We do not believe that 
this is a sufficient sample size to warrant the creation of a new DRG.
b. Myasthenia Gravis
    Myasthenia Gravis is an autoimmune disease manifested by a syndrome 
of fatigue and exhaustion of the muscles that is aggravated by activity 
and relieved by rest. The weakness of the muscles can range from very 
mild to life-threatening.
    This disease is classified to ICD-9-CM diagnosis code 358.0 and is 
assigned to DRG 12 (Degenerative Nervous System Disorders). Myasthenia 
Gravis in crisis patients is being treated with extensive 
plasmapheresis. We received a request to analyze the charges associated 
with Myasthenia Gravis in crisis patients receiving plasmapheresis to 
determine whether DRG 12 is an equitable DRG assignment for these 
cases. We are currently unable to differentiate between the mild and 
severe forms of this disease because all types are classified to code 
358.0. Therefore, we have requested the NCHS to create a new diagnosis 
code for Myasthenia Gravis in crisis so that we can uniquely identify 
these cases to ensure the DRG assignment is appropriate.
c. Cardiac Mapping and Ablation
    In the August 1, 2001 final rule (66 FR 39840), in response to a 
comment received, we agreed to continue to evaluate DRGs 516 
(Percutaneous Cardiovascular Procedure with Acute Myocardial Infarction 
(AMI)), 517 (Percutaneous Cardiovascular Procedure with Coronary Artery 
Stent without AMI), and 518 (Percutaneous Cardiovascular Procedure 
without Coronary Artery Stent or AMI) in MDC 5. We reviewed code 37.26 
(Cardiac electrophysiologic stimulation and recording studies), code 
37.27 (Cardiac mapping), and code 37.34 (Catheter ablation of lesion or 
tissues of heart). The commenter had recommended that CMS either create 
a separate DRG for cardiac mapping and ablation procedures, or assign 
codes 37.27 and 37.34 to DRG 516 after retitling the DRG. We have 
reviewed FY 2001 MedPAR data on these specific codes. Over 97 percent 
of cases with these codes were assigned to DRG 518 and had average 
charges of $1,741 below the average for all cases in the DRG. 
Therefore, the data do not support making any DRG changes for these 
procedure codes.
d. Aortic Endograft
    In the August 1, 2001 final rule (66 FR 39841), we responded to a 
comment concerning the placement of aortic endografts in DRG 110 (Major 
Cardiovascular Procedures with CC) and DRG 111 (Major Cardiovascular 
Procedures without CC). The commenter noted that the cost of the device 
alone is greater than the entire payment for DRG 111 and recommended 
that these cases be assigned specifically to DRG 110. Our response at 
that time was that DRGs 110 and 111 are paired DRGs, differing only in 
the presence or absence of a CC.
    We reviewed the MedPAR data again for FY 2001 using the following 
criteria: all cases were either in DRG 110 or 111, had a principal 
diagnosis of 441.4 (Abdominal aneurysm without mention of rupture), and 
included procedure code 39.71 (Endovascular implantation of graft in 
abdominal aorta). Our conclusion is that the majority of aneurysm cases 
are already grouped to DRG 110, where they are appropriately 
compensated. Therefore, we are not proposing to assign cases without 
CCs from DRG 111 to DRG 110. We reiterate that hospitals should code 
their records completely and record and submit all relevant diagnosis 
and procedure codes that have a bearing on the current admission (in 
particular, any complications or comorbidities associated with a case).
e. Platelet Inhibitors
    In the August 1, 2002 final rule (66 FR 39840), we addressed a 
commenter's concern that modifications to MDC 5 involving percutaneous 
cardiovascular procedures would fail to account for the use of GP IIB-
IIIA platelet inhibiting drugs for cases with acute coronary syndromes. 
GROUPER does not recognize procedure code 99.20 (Injection or infusion 
of platelet inhibitor) as a procedure. Therefore, its presence on a 
claim does not affect DRG assignment. We agreed to continue to evaluate 
this issue.
    We reviewed cases in the FY 2001 MedPAR file for DRG 121 
(Circulatory Disorders with AMI and Major Complication, Discharged 
Alive), DRG 122 (Circulatory Disorders with AMI without Major 
Complication, Discharged Alive) and DRGs 516, 517, and 518. We looked 
at all cases in these DRGs containing procedure code 99.20 by total 
number of procedures and by average charges. There were a total of 
73,480 cases where platelet inhibitors were administered, with 70,216 
of these cases in DRGs 516, 517, and 518. The average charges for 
platelet inhibitor cases in these three DRGs are actually slightly 
below the average for all cases in the respective DRGs. Therefore, we 
believe these cases are appropriately placed in the current DRGs, and 
are not proposing any changes to the assignment of these procedure 
codes.
f. Drug-Eluting Stents
    The drug-eluting stents technology has been developed to combat the 
problem of restenosis of previously treated blood vessels. The drug is 
placed onto the stent with a special polymer

[[Page 31425]]

and slowly released into the vessel wall tissue over a period of 30 to 
45 days, and is intended to prevent the build-up of scar tissue that 
can narrow the reopened artery.
    In Table 6B of the Addendum to this proposed rule, we list a new 
procedure code 36.07 (Insertion of drug-eluting coronary artery 
stents(s)) that will be effective for use October 1, 2002. We also are 
proposing to add code 00.55 (Insertion of drug-eluting noncoronary 
artery stent).
    A manufacturer of this technology requested that code 36.07 be 
assigned to DRG 516 (Percutaneous Cardiovascular Procedure with Acute 
Myocardial Infarction (AMI)) even without the presence of AMI. The 
manufacturer asserted that this technology is significantly more costly 
than other technologies currently assigned to DRG 517 (Percutaneous 
Cardiovascular Procedure with Coronary Artery Stent without AMI) 
(average charges of $29,189 compared to average charges of $22,998), 
and warrants this DRG assignment.
    In addition, the manufacturer argued that this technology should be 
given preferential treatment because it will fundamentally change the 
treatment of multivessel disease. Specifically, the manufacturer stated 
that due to the absence of restenosis in patients treated with the 
drug-eluting stents based on the preliminary trial results, bypass 
surgery may no longer be the preferred treatment for many patients.\1\ 
The manufacturer believes lower payments due to the decline in Medicare 
bypass surgeries will offset the higher payments associated with 
assigning all cases receiving the drug-eluting stent to DRG 516.
---------------------------------------------------------------------------

    \1\ ``Comparison of Coronary-Artery Bypass Surgery and Stenting 
for the Treatment of Multiveasel Disease,'' Serruys, P. W., Unger, 
F., et. al., The New England Journal of Medicine, April 12, 2001, 
Vol. 344, No. 15, p. 1117.
---------------------------------------------------------------------------

    Currently, this technology has not been approved for use by the 
FDA. If the technology is approved by the FDA and further evidence is 
presented to us regarding the clinical efficacy and the impact that 
this technology has on the treatment of multivessel disease, we may 
reassign this code to another DRG or reassess the construct of all 
affected DRGs. We also are specifically soliciting comments on our 
proposal to treat the new codes cited above consistent with the current 
DRG assignment for stents.
g. Cardiac Resynchronization Therapy
    Cardiac resynchronization therapy for heart failure provides 
strategic electrical stimulation to the right atrium, right ventricle, 
and left ventricle, in order to coordinate ventricular contractions and 
improve cardiac output. This therapy includes cardiac resynchronization 
therapy pacemakers (CRT-P) and cardiac resynchronization therapy 
defibrillators (CRT-D). While similar to conventional pacemakers and 
internal cardioverter-defibrillators, cardiac resynchronization therapy 
is different because it requires the implantation of a special 
electrode within the coronary vein, so that it can be attached to the 
exterior wall of the left ventricle.
    Currently, defibrillator cases are assigned to either DRG 514 
(Cardiac Defibrillator Implant with Cardiac Catheterization) or DRG 515 
(Cardiac Defibrillator Implant without Cardiac Catheterization). DRG 
514 has a higher relative weight than DRG 515. We received a 
recommendation that we assign implantation of CRT-D (code 00.51, 
effective October 1, 2002) to either DRG 104 (Cardiac Valve and Other 
Major Cardiothoracic Procedure with Cardiac Catheterization) or DRG 514 
(Cardiac Defibrillator Implant With Cardiac Catheterization). It is 
argued that the change should be made because the current DRG structure 
for cardioverter-defibrillator implants does not recognize the 
significant amount of additional surgical resources required for cases 
involving patients with heart failure.
    The recommendation supported assigning new code 00.50 (Implantation 
of cardiac resynchronization pacemaker without mention of 
defibrillation, total system [CRT-P]) to DRG 115 (Permanent Cardiac 
Pacemaker Implantation With AMI, Heart Failure, or Shock, or AICD Lead 
or Generator Procedure). Currently, pacemaker implantation procedures 
are assigned to either DRG 115 (Permanent Cardiac Pacemaker Implant 
with AMI, Heart Failure, or Stroke, or AICD Lead or Generator 
Procedure) or DRG 116 (Other Permanent Cardiac Pacemaker Implant). DRG 
115 has the higher relative weight. Because DRG 115 recognizes patients 
with heart failure, the manufacturer believed CRT-P cases would be 
appropriately classified to DRG 115.
    Our proposed DRG assignment for code 00.51 would be to DRG 514 or 
515. Our proposed DRG assignment for code 00.50 would be to DRG 115 and 
116. However, we are soliciting comments on these proposed DRG 
assignments and will carefully consider any relevant evidence about the 
clinical efficacy and costs of this technology.
h. Hip and Knee Revisions
    We received a request to consider assigning hip and knee revisions 
(codes 81.53 and 81.55) out of DRG 209 (Major Joint and Limb 
Reattachment Procedures of Lower Extremity) because these revisions are 
significantly more resource intensive and costly than initial 
insertions of these joints.
    We examined claims data and concluded that, while the charges for 
the hip and knee revision cases were somewhat higher than other cases 
within DRG 209, they do not support the establishment of a separate 
DRG.
i. Multiple Level Spinal Fusions
    We received a comment suggesting that we create new spinal fusion 
DRGs that differentiate by the number of discs that are fused in a 
spinal fusion. The commenter indicated that the existing ICD-9-CM codes 
do not identify the number of discs that are fused. Codes were modified 
for FY 2002 to clearly differentiate between fusions and refusions, and 
new codes were created for the insertion of interbody spinal fusion 
device (84.51), 360 degree spinal fusion, single incision approach 
(81.61), and the insertion of recombinant bone morphogenetic protein 
(84.52) (66 FR 39841 through 39844).
    ICD-9-CM codes have not historically been used to differentiate 
among cases by the number of repairs or manipulations performed in the 
course of a single procedure. However, we will explore the possibility 
of creating codes to differentiate cases by the number of discs fused 
during a spinal fusion procedure at the scheduled April 18 and 19, 2002 
meeting of the ICD-9-CM Coordination and Maintenance Committee.
    We also note that DRGs generally do not segregate cases based on 
the number of repairs or devices that occur in the course of a single 
procedure. For instance, DRGs are not split based on the number of 
vessels bypassed in cardiac surgery, nor are they split based on the 
number of cardiac valves repaired. Therefore, we are not proposing DRG 
changes for multiple level spinal fusions in this proposed rule.
j. Open Wound of the Hand
    We received a recommendation that we move code 882.0 (Open Wound of 
Hand Except Finger(s) Alone Without Mention of Complication) from its 
current location in MDC 9 (Diseases and Disorders of the Skin, 
Subcutaneous Tissue and Breast) under DRGs 280 through 282 (Trauma to 
the Skin, Subcutaneous Tissue and Breast Age >17 with CC, Age >17 
without CC, and Age 0-17, respectively) into MDC 21 (Injuries, 
Poisonings and Toxic Effects of Drugs) under DRGs 444 through 446 
(Traumatic Injury Age >17 with CC, Age

[[Page 31426]]

>17 without CC, and Age 0-17, respectively).
    In examining our data, we found relatively few cases with code 
882.0. These cases had charges that were less than the average charges 
for DRGs to which they are currently assigned. The data do not support 
a DRG change. Our medical consultants also believe that the cases are 
appropriately assigned to DRGs 280 through 282.
k. Cavernous Nerve Stimulation
    As discussed in August 1, 2001 final rule (66 FR 39845), we 
reviewed data in MDC 12 (Diseases and Disorders of the Male 
Reproductive System). We looked specifically for code 89.58 
(Plethysmogram) in DRG 334 (Major Male Pelvic Procedures with CC), and 
DRG 335 (Major Male Pelvic Procedures without CC).
    Our data show that very few (six) of these procedures were reported 
on FY 2001 claims. It is not clear whether the small number reflects 
the fact that the procedure is not being performed, the ICD-9-CM code 
is not recorded, or the code is recorded but it is not in the top six 
procedures being performed. However, in all six cases where this 
procedure was performed, it occurred in conjunction with radical 
prostatectomy, so we are confident that these cases are consistent with 
the DRGs to which they have been grouped. Therefore, we are not 
proposing any DRG assignment changes to code 89.58 or DRGs 334 and 335.

C. Recalibration of DRG Weights

    We are proposing to use the same basic methodology for the FY 2003 
recalibration as we did for FY 2002 (August 1, 2001 final rule (66 FR 
39828)). That is, we would recalibrate the weights based on charge data 
for Medicare discharges. However, we are proposing to use the most 
current charge information available, the FY 2001 MedPAR file. (For the 
FY 2002 recalibration, we used the FY 2000 MedPAR file.) The MedPAR 
file is based on fully coded diagnostic and procedure data for all 
Medicare inpatient hospital bills.
    FY 2001 MedPAR data include discharges occurring between October 1, 
2000 and September 30, 2001, based on bills received by CMS through 
December 31, 2001, from all hospitals subject to the acute care 
hospital inpatient prospective payment system and short-term acute care 
hospitals in waiver States. The FY 2001 MedPAR file includes data for 
approximately 11,420,001 Medicare discharges. The data include 
hospitals that subsequently became CAHs, although no data are included 
for hospitals after the point they are certified as CAHs. Section IX. 
of this preamble contains information about how to obtain the MedPAR 
data.
    The proposed methodology used to calculate the DRG relative weights 
from the FY 2001 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. (See section IX.A.15. 
of this proposed rule for information on the availability of the 
prospective payment system standardizing file.)
     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. 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 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.
     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 DRGs 512 (Simultaneous Pancreas/Kidney Transplant) and 
513 (Pancreas Transplant). Because these acquisition costs are paid 
separately from the prospective payment rate, it is necessary to make 
an adjustment to exclude them from the relative weights for these DRGs. 
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 used that same case threshold in 
recalibrating the proposed DRG weights for FY 2003. Using the FY 2001 
MedPAR data set, there are 41 DRGs that contain fewer than 10 cases. We 
computed the weights for these 41 low-volume DRGs by adjusting the FY 
2002 weights of these DRGs by the percentage change in the average 
weight of the cases in the other DRGs.
    The proposed new weights are normalized by an adjustment factor 
(1.43430) 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.
    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 
payments to hospitals are 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 this proposed rule, we are 
proposing to make a budget neutrality adjustment to ensure that the 
requirement of section 1886(d)(4)(C)(iii) of the Act is met.

[[Page 31427]]

D. Proposed Add-On Payments for New Services and Technologies

1. Background
    Section 533(b) of Public Law 106-554 amended section 1886(d)(5) of 
the Act to add subparagraphs (K) and (L) to establish a process of 
identifying and ensuring adequate payment for new medical services and 
technologies under Medicare. Section 1886(d)(5)(K)(ii)(I) of the Act 
specifies that the process must apply to a new medical service or 
technology if, ``based on the estimated costs incurred with respect to 
discharges involving such service or technology, the DRG prospective 
payment rate otherwise applicable to such discharges . . . is 
inadequate.'' Section 1886(d)(5)(K)(vi) of the Act specifies that a 
medical service or technology will be considered ``new'' if it meets 
criteria established by the Secretary (after notice and opportunity for 
public comment).
    In the September 7, 200l final rule (66 FR 46902), we established 
that a new technology would be an appropriate candidate for an 
additional payment when it represents an advance in medical technology 
that substantially improves, relative to technologies previously 
available, the diagnosis or treatment of Medicare beneficiaries 
(Sec. 412.87(b)(1)).
    We also established that new technologies meeting this clinical 
definition must be demonstrated to be inadequately paid otherwise under 
the DRG system to receive special payment treatment 
(Sec. 412.87(b)(3)). To assess whether technologies would be 
inadequately paid under the DRGs, we established this threshold at one 
standard deviation beyond the geometric mean standardized charge for 
all cases in the DRGs to which the new technology is assigned (or the 
case-weighted average of all relevant DRGs, if the new technology 
occurs in many different DRGs) (Sec. 412.87(b)(3)).
    Table 10 in the Addendum to this proposed rule lists the proposed 
qualifying criteria by DRG based on the discharge data used to 
calculate the proposed FY 2003 DRG weights. The thresholds published in 
the final rule will be used to evaluate applicants for new technology 
add-on payments during FY 2004 (beginning October 1, 2003). Similar to 
the timetable for applying for new technology add-on payments during FY 
2003, we are proposing that applicants for FY 2004 must submit a 
significant sample of the data no later than early October 2002. 
Subsequently, we are proposing that a complete database must be 
submitted no later than mid-December 2002.
    In addition to the clinical and cost criteria, we established that, 
in order to qualify for the special payment treatment, a specific 
technology must be ``new'' under the requirements of Sec. 412.87(b)(2) 
of our regulations. The statutory provision contemplated the special 
payment treatment for new technologies until such time as data are 
available to reflect the cost of the technology in the DRG weights 
through recalibration (no less than 2 years and no more than 3 years). 
There is a lag of 2 to 3 years from the point a new technology is first 
introduced on the market and when data reflecting the use of the 
technology are used to calculate the DRG weights. For example, data 
from discharges occurring during FY 2001 are used to calculate the 
proposed FY 2003 DRG weights in this proposed rule.
    Technology may be considered ``new'' for purposes of this provision 
within 2 or 3 years after the point at which data begin to become 
available reflecting the ICD-9-CM code assigned to the technology. 
After CMS has recalibrated the DRGs to reflect the costs of an 
otherwise new technology, the special add-on payment for new technology 
will cease (Sec. 412.87(b)(2)). For example, an approved new technology 
that received FDA approval in October 2001 would be eligible to receive 
add-on payments as a new technology until FY 2004 (discharges occurring 
before October 1, 2003), when data reflecting the costs of the 
technology would be used to recalibrate the DRG weights. Because the FY 
2004 DRG weights will be calculated using FY 2002 MedPAR data, the 
costs of such a new technology would be reflected in the FY 2004 DRG 
weights.
    For technologies that do not qualify for special payments under 
Sec. 412.87, we will continue our past practice of evaluating whether 
existing procedures are appropriately classified to a DRG. To the 
extent the introduction of a new code for existing technology helps to 
better identify higher costs associated with a procedure, we would work 
to expedite the appropriate assignment of that code (for example, using 
more recent MedPAR data).
    In the September 7, 2001 final rule, we established that Medicare 
would provide higher payments for cases with higher costs involving 
identified new technologies, while preserving some of the incentives 
under the average-based payment system. The payment mechanism is based 
on the cost to hospitals for the new technology. Under Sec. 412.88, 
Medicare would pay a marginal cost factor of 50 percent for the costs 
of the new technology in excess of the full DRG payment. If the costs 
of a new technology case exceed the DRG payment by more than the 
estimated costs of the new technology, Medicare payment would be 
limited to the DRG payment plus 50 percent of the estimated costs of 
the new technology.
    The report language accompanying section 533 of Public Law 106-554 
indicated Congressional intent that the Secretary implement the new 
mechanism on a budget neutral basis (H.R. Conf. Rep. No. 106-1033, 
106th Cong., 2d Sess. at 897 (2000)). Section 1886(d)(4)(C)(iii) of the 
Act requires that the adjustments to annual DRG classifications and 
relative weights must be made in a manner that ensures that aggregate 
payments to hospitals are not affected. Therefore, we account for 
projected payments under this provision for new technology during the 
upcoming fiscal year at the same time we estimate the payment effect of 
changes to the DRG classifications and recalibration. The impact of 
additional payments under this provision would then be included in the 
budget neutrality factor, which is applied to the standardized amounts.
    Because any additional payments directed toward new technology 
under this provision would be offset to ensure budget neutrality, it is 
important to carefully consider the extent of this provision and ensure 
that only technologies representing substantial advances are recognized 
for additional payments. In that regard, we indicated that we will 
discuss in the annual proposed and final rules those technologies that 
were considered under this provision; our determination as to whether a 
particular new technology meets our criteria for a new technology; 
whether it is determined further that cases involving the new 
technology would be inadequately paid under the existing DRG payment; 
and any assumptions that went into the budget neutrality calculations 
related to additional payments for that new technology, including the 
expected number, distribution, and costs of these cases.
    To appropriately balance Congress' intent to increase Medicare's 
payments for eligible new technologies with concern that the total size 
of those payments not result in significantly reduced payments for 
other cases, we set a target limit for estimated special payments for 
new technology under the provisions of section 533(b) of Public Law 
106-554 at 1.0 percent of estimated total operating prospective 
payments.
    If invoked, the target limit would reduce the level of payments for 
approved technologies across the board,

[[Page 31428]]

to ensure estimated payments do not exceed the limit. Using this 
approach, all cases involving approved new technologies that would 
otherwise receive additional payments would still receive special 
payments, albeit at a reduced amount. Although the marginal payment 
rate for individual technologies will be reduced, this would be offset 
by large overall payments to hospitals for new technologies under this 
provision.
2. Applicants for FY 2003
    We received five applications for new technologies to be designated 
eligible for inpatient add-on payments under the policy we implemented 
in the September 7, 2001 final rule. One of these applications was 
subsequently withdrawn. The remaining four applicants are discussed 
below.
a. Drotrecogin Alfa (Activated)--XigrisTM
    Eli Lilly and Company (Lilly) developed drotrecogin alfa 
(activated), trade name XigrisTM, as a new technology and 
submitted an application to us for consideration under the new 
technology add-on provision. XigrisTM is used to treat 
patients with severe sepsis.
    According to the application--
    ``Approximately 750,000 cases of sepsis associated with acute organ 
dysfunction (severe sepsis) occur annually in the United States. The 
mortality rates associated with severe sepsis in the United States 
range from 28 percent to 50 percent and have remained essentially 
unchanged for several decades. Each year, 215,000 deaths are associated 
with severe sepsis; deaths after acute myocardial infarction occur at 
approximately an equal rate.''
    XigrisTM is a biotechnology product that is a 
recombinant version of naturally occurring Activated Protein C (APC). 
APC is needed to ensure the control of inflammation and clotting in the 
blood vessels. In patients with severe sepsis, Protein C cannot be 
converted in sufficient quantities to the activated form. It appears 
that XigrisTM has the ability to bring blood clotting and 
inflammation back into balance and restore blood flow to the organs.
    In support of its application, Lilly submitted data from the Phase 
III Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) trial. 
According to Lilly, this was ``an international, multicenter, 
randomized, double-blind, placebo-controlled trial in which 1,690 
patients with severe sepsis received either placebo (n = 840) or 
drotrecogin alfa (activated) (n = 850).'' The results of the trial were 
published in an article in the March 8, 2001 edition of The New England 
Journal of Medicine (Bernard, G. R., Vincent, J. L., et. al., 
``Efficacy and Safety of Recombinant Human Activated Protein C for 
Severe Sepsis,'' Vol. 344, No, 10, p. 699).
    A 6.1 percent reduction in mortality was reported. This conclusion 
was based on a measure of 28-day all-cause mortality. However, at 28 
days, over 10 percent of the study participants were still 
hospitalized. Whether these patients subsequently went on to recover or 
died was not reported.
    Because the reduction in mortality was the result of a treatment 
effect in a relatively small number of patients and mortality was 
looked at only 28 days after treatment, we plan to review unpublished 
data on all-cause mortality at the time of hospital discharge for all 
patients enrolled in the study using an intent-to-treat analysis. We 
have asked the trial sponsor to provide CMS with these unpublished data 
and the analyses performed in the original report, including confidence 
intervals and Kaplan-Meier curve with log-rank statistics, for death 
from any cause assessed at the time of hospital discharge. A small 
increase in the number of deaths among treated patients still 
hospitalized at 28 days could nullify the survival advantage attributed 
to the use of XigrisTM.
    The study had a number of other important methodological 
limitations that also merit further consideration. Therefore, we are 
unable to conclude, based on the published data, that 
XigrisTM represents an advance that substantially improves, 
relative to technology previously available, treatment for Medicare 
beneficiaries. However, we are continuing our assessment and will 
announce our final determination in the final rule. If we subsequently 
determine that XigrisTM represents a substantial 
improvement, payment would likely be limited to a subpopulation of 
patients with severe sepsis, consistent with the FDA labeling and 
possible other restrictions.
    Detailed bills were available for 604 of 705 patients in the United 
States in the PROWESS clinical trial (303 placebo patients and 301 
treatment patients). In all, 83 hospitals submitted detailed bills. 
These data included an indicator whether the patient received the 
treatment or a placebo, total charges and standardized charges for the 
stay as well as for the biological, and the patients' APACHE II scores 
(an assessment of the risk of mortality based on acute physiology and 
chronic health evaluation). The FDA's approval letter (issued November 
21, 2001) stated ``drotrecogin alfa (activated) is indicated for the 
reduction of mortality in adult patients with severe sepsis (sepsis 
associated with acute organ dysfunction) who have a high risk of death 
(e.g., as determined by APACHE II).''
    Of the 604 cases with detailed billing data, 274 were patients age 
65 or older. The average total charge for these 274 cases, including 
the average standardized charge for the biological, was $86,184 
(adjusted for inflation using the applicable hospital market baskets, 
as patients were enrolled in the trial from July 1998 through June 
2000). The inflated average standardized charge of the biological only 
for these cases was $15,562.
    Lilly also submitted detailed ICD-9-CM diagnosis and procedure 
codes for a subset of 157 of the 604 U.S. patients with billing data 
from the PROWESS trial. These data were not requested as part of the 
trial, but were sent in separately. Of these 157 patients, 82 were over 
65 years of age. These 82 patients grouped into 23 DRGs. Approximately 
75 percent of these 82 cases were in 5 DRGs: 29 percent were in DRG 475 
(Respiratory System Diagnosis with Ventilator Support); 17 percent were 
in DRG 483 (Tracheostomy Except for Face, Mouth, and Neck Diagnoses); 
15 percent were in DRG 416 (Septicemia Age >17); 7 percent were in DRG 
415 (OR Procedure for Infectious and Parasitic Diseases); and 5 percent 
were in DRG 148 (Major Small and Large Bowel Procedures With CC).
    Using the methodology described in the September 7, 2001 final rule 
(66 FR 46918), we calculated a case-weighted threshold based on the 
distribution of these 82 cases across 23 DRGs. In order to qualify for 
new technology payments based on these DRGs, the threshold would be 
$82,882 (compared to the average standardized charge of $86,184 noted 
above).
    In the September 7, 2001 final rule, we stated that the data 
submitted must be of a sufficient sample size to demonstrate a 
significant likelihood that the sample mean approximates the true mean 
across all cases likely to receive the new technology. Using a standard 
statistical methodology for determining the needed (random) sample size 
based on the standard deviations of the DRGs identified in the trial as 
likely to include cases receiving XigrisTM, we have 
determined that a random sample of 274 cases can be reasonably expected 
to produce an estimate within $3,500 of the true mean.\1\ Of course, 
the data

[[Page 31429]]

submitted do not represent a random sample.
---------------------------------------------------------------------------

    \1\ The formula is n = 4\2\/\2\, where 
 is the standard deviation of the population, and  
is the bound on the error of the estimate (the range within which 
the sample means can reliably predict the population mean). See 
Statistics for Management and Economics, Fifth Edition, by 
Mendenhall, W., Reinmuth, J., Beaver, R., and Duhan, D.
---------------------------------------------------------------------------

    The 274 case sample was for all U.S. patients over age 65 included 
in the PROWESS trial. In the September 7, 2001 final rule, we indicated 
our preference for using Medicare cases identifiable in our MedPAR 
database, although data from a trial without matching MedPAR data could 
be considered. We also indicated our intention to independently verify 
the data submitted.
    According to Lilly, the patient consent agreements for the PROWESS 
trial did not provide for the collection and submission of data to CMS. 
Therefore, we have been unable to identify matching cases in our MedPAR 
database, or independently verify the data. Due to the passage of 
Public Law 106-554 in December 2000 and the publication of the final 
rule in September 2001, it is understandable that our data requirements 
in order to analyze applicants for new technology add-on payments were 
not accommodated in the design of the PROWESS trial. We will continue 
to work with Lilly to independently verify the data in the event it is 
determined that XigrisTM does represent a substantial 
clinical improvement.
    In particular, we note that, even without the biological charges, 
the standardized mean charge for the cases submitted for analysis is 
well above the standardized case-weighted DRG mean ($70,623 for the 
PROWESS trial cases compared to $54,058 for all cases in the relevant 
DRGs). We are analyzing our MedPAR data to develop a cohort group of 
patients to assess the validity of the charges reported for the 
patients in the PROWESS trial and will report the result of our 
analysis in the final rule. We solicit comments on this and other 
approaches to verifying these data.
    Cases where XigrisTM is administered will be identified 
by use of the new ICD-9-CM procedure code 00.11 (Infusion of 
drotrecogin alfa (activated)). According to Lilly, ``(t)he net 
wholesale price for drotrecogin alfa (activated) is $210 for a 5-
milligram vial and $840 for a 20-milligram vial. The average cost for a 
one-time 96-hour course of therapy for an average adult patient is 
$6,800 (24 ug/kg/hr for 96 hours for a 70 kg person).'' Because code 
00.11 does not identify the actual amount of the drug administered per 
patient, any additional payment would be based on the average cost per 
patient of $6,800. If this technology were to be approved for add-on 
payment under Sec. 412.88, cases involving the administration of 
XigrisTM would be eligible for additional payments of up to 
$3,400 (50 percent of the average cost of the drug).
    For purposes of budget neutrality, we need to estimate the 
additional payments that would be made under this provision during FY 
2003. Lilly has estimated that, initially, 25,000 Medicare patients 
would receive drotrecogin alfa (activated). If the maximum $3,400 add-
on payment is made for all 25,000 of these patients, the total amount 
that would be paid for these cases would be an additional $85 million. 
However, comparing the total standardized charges for the 274 patients 
age 65 or older, 56 percent had average standardized charges below the 
weighted average standardized charges for the 23 DRGs into which these 
cases were categorized. Therefore, assuming the costs for these cases 
would be below the payment received, these 56 percent of cases would 
not receive any additional payment. Therefore, for purposes of budget 
neutrality, we estimate the total payments likely to be made under this 
provision during FY 2003 for cases involving the administration of 
drotrecogin alfa (activated) would be $37.4 million (44 percent of $85 
million).
b. Bone Morphogenetic Proteins (BMPs) for Spinal Fusions
    BMPs have been isolated and shown to have the capacity to induce 
new bone formation. Using recombinant techniques, some BMPs (referred 
to as rhBMPs) can be produced in large quantities. This has cleared the 
way for their potential use in a variety of clinical applications such 
as in delayed unions and nonunions of fractured bones and spinal 
fusions. One such product, rhBMP-2, is developed for use instead of a 
bone graft with spinal fusions.
    An application was submitted by Medtronic Sofamor Danek for the 
InFUSETM Bone Graft/LT-CAGETM Lumbar Tapered 
Fusion Device for approval as a new technology eligible for add-on 
payments. The product is applied through use of an absorbable collagen 
sponge and an interbody fusion device, which is then implanted at the 
fusion site. The patient undergoes a spinal fusion, and the product is 
placed at the fusion site to promote bone growth. This is done in place 
of the more traditional use of autogenous iliac crest bone graft.
    In 1997, in a pilot study conducted under a FDA approved device 
exemption, 14 patients were enrolled at 4 investigational sites. Eleven 
patients received rhBMP-2, with 3 control patients. Radiographs and 
computed tomography scans at 6, 12, and 24 months after surgery showed 
that all 11 patients who received rhBMP-2 had solid fusions, whereas 
only 2 of the 3 patients who received autogeneous bone graft had solid 
fusions. Scores from the Oswestry Low Back Pain Disability 
Questionnaire showed that 6 of 11 patients treated with rhBMP-2 had a 
successful outcome at 3 months after surgery, compared with 0 of 3 
control patients. After 6 months, the results had changed to 7 of 11 
rhBMP-2 patients and 2 control patients with successful treatments; and 
at 12 months, 10 rhBMP-2 patients and 2 control patients were judged 
successful. The results were unchanged at 24 months. The trial results 
were presented in an article in the February 1, 2000 edition of SPINE 
(Bone, S., Zdeblick, T., et. al., ``The Use of rhBMP-2 in Interbody 
Fusion Cages-Definitive Evidence of Osteoinduction in Humans: A 
Preliminary Report''), Vol. 25, No. 3, p. 376.
    The above study was then expanded to involve 281 patients at 16 
sites, with 143 patients in the rhBMP-2 group and 138 patients in the 
autogenous iliac crest bone graft group. In the rhBMP-2 group, 76.9 
percent of the patients showed an improvement of at least 15 points in 
their disability scores at 12 months postoperatively. This compared 
favorably to 75 percent of patients in the control group. At 6 months 
following surgery, 97 percent of patients in the rhBMP-2 group showed 
evidence of interbody fusion, as compared to 95.8 percent in the 
control group. At 12 months, 96.9 percent of patients in the rhBMP-2 
group were fused as compared to 92.5 percent in the control group. At 
this time, the results of this study are unpublished.
    On January 10, 2002, the FDA issued an approvable letter for this 
technology. At this point, however, the technology has not been 
approved by the FDA for general use. Therefore, we are not proposing to 
approve this technology for add-on payments in this proposed rule. We 
discuss thoroughly the data submitted with the application below. 
However, if the FDA approves the product for general use prior to our 
issuance of the final rule by August 1, 2002, we will issue a 
determination whether this technology represents a substantial clinical 
improvement under the criteria outlined in the September 7, 2001 final 
rule.
    Cost data were submitted for 88 patients participating in the 
followup study described above. This trial was a single-level, anterior 
lumbar interbody

[[Page 31430]]

fusion clinical study. Of these 88 bills with cost data, the applicant 
calculated an average standardized charge for these single-level fusion 
cases of $33,757. According to the applicant, ``it is anticipated that 
a large number, if not the majority, of cases using BMP technology 
will, in practice, be multi-level fusions''. The applicant reported the 
estimated hospital charges (based on general charging practices) to be 
$17,780 for each level. In order to account for the use of this 
technology in multilevel spinal fusions, the applicant assumed 47 
percent of spinal fusions were multilevel (based on analysis of 
Medicare spinal fusion cases). Increasing the average standardized 
charge for the cases in the trial by $17,780, the applicant calculated 
a weighted average standardized charge (53 percent single-level and 47 
percent multilevel) of $45,556.
    Of these 88 cases, 11 were assigned to DRG 497 (Spinal Fusion 
Except Cervical With CC) and 77 were assigned to DRG 498 (Spinal Fusion 
Except Cervical Without CC). In order to qualify for new technology 
payments based on these DRGs, the threshold would be $37,815.
    The applicant has submitted data that estimate between 2,300 and 
4,600 Medicare spinal fusion procedures involving this technology in FY 
2003. The cost of the technology is $3,900 per level. For approximately 
45 percent of spinal fusion involving multilevel fusions, the weighted 
cost of the technology is $5,686, resulting in a maximum add-on payment 
amount of $2,843. In reference to the utilization estimates above, the 
total amount for these cases if each case qualified for a new 
technology payment would be between $6.5 million and $13.0 million.
c. ZyvoxTM
    ZyvoxTM is the first antibiotic in the oxazolidinone 
class and is widely used by hospitals in the United States and other 
countries against the medically significant gram-positive bacteria, 
including those that are resistant to other therapies. Gram-positive 
bacterial infections have become increasingly prevalent in recent 
years, most commonly implicated in infections in the lower respiratory 
tract, skin and soft tissue, bone and bloodstream, and in meningitis. 
Significant morbidity and mortality trends are associated with such 
pathogens. Epinomics Research, Inc., submitted the application on 
behalf of Pharmacia Corporation (Pharmacia), which markets the drug.
    The FDA approved ZyvoxTM on April 18, 2000, for the 
treatment of serious infections caused by antibiotic-resistant 
bacteria. The applicant contends that this qualifies ZyvoxTM 
for approval within the 2-year to 3-year period referenced at 
Sec. 412.87(b)(2). Furthermore, the applicant notes that the approval 
of the new ICD-9-CM code 00.14 (Injection or infusion of oxazolidinone 
class of antibiotics) effective October 1, 2002, will permit a more 
precise identification of these cases. However, as noted previously, 
technology will no longer be considered new after the costs of the 
technology are reflected in the DRG weights. Because the costs of 
ZyvoxTM are currently reflected in the DRG weights, 
ZyvoxTM does not meet our criterion that a medical service 
or technology be ``new''. The FY 2001 MedPAR data used to calculate the 
proposed DRG weights for FY 2003 include cases where ZyvoxTM 
was administered. The application itself noted that the use of 
ZyvoxTM is widespread. Therefore, even though the existing 
code, 99.21 (Injection of antibiotic) is a general code used for the 
administration of various antibiotics including ZyvoxTM, and 
does not separately identify the administration of ZyvoxTM 
as will be possible with the new code 00.14, the charges associated 
with these cases are reflected in the proposed FY 2003 DRG weights.
    As stated above, we note that the applicant itself points out that 
ZyvoxTM is widely used currently by hospitals. In its 4th 
quarter 2001 earnings report, Pharmacia reports total sales in the 
United States of $97 million, which is an increase of 105 percent over 
the previous year. This would indicate expanding access to the drug.
    We would point out that, in response to a comment that technologies 
should qualify as ``new'' beginning with the assignment of an 
appropriate tracking code, we clarified in the September 7, 2001 final 
rule that we would not consider technologies that have been on the 
market for more than 2 or 3 years to be ``new'' on the basis that a 
more precise ICD-9-CM procedure code has been created (66 FR 46914). 
However, although such technologies would not qualify for add-on 
payments under this provision, we did indicate that we would evaluate 
whether the existing DRG assignments of the technology are appropriate.
    For example, currently the administration of ZyvoxTM 
does not affect the DRG to which a case is assigned. In its application 
for add-on payments, Epinomics provided CMS data that included clinical 
trials as well as data from a sample that spanned MedPAR files from FY 
2000 through FY 2002. For its sample study, Epinomics obtained patient 
records from 70 hospitals that used ZyvoxTM treatment on 832 
Medicare patients. The cases were distributed across 151 DRGs. 
Epinomics calculated that the mean standardized charge for these 485 
cases was $74,174. The case-weighted mean standardized charge for all 
cases in these DRGs would be $33,740 (based on the distribution of 
ZyvoxTM cases across the 151 DRGs).
    The unit price for the drug varies from approximately $30 for a 100 
milliliter bag (200 milligram linezolid) to approximately $1,350 for 
600 milligram tablets (unit doses of 30 tablets). Nevertheless, it 
appears the high average charges associated with patients receiving the 
drug are not directly attributable to the administration of 
ZyvoxTM. Therefore, we are not proposing any changes to the 
DRG assignment of these cases at this time. To the extent these cases 
are more expensive due to the severity of illness of the patients being 
treated, the current outlier policy will offset any extraordinarily 
high costs incurred.
d. RenewTM Radio Frequency Spinal Cord Stimulation Therapy
    An application was submitted by Advanced Neuromodulation Systems 
(ANS) for the RenewTM Spinal Cord Stimulation Therapy for 
approval as a new technology eligible for add-on payments. ANS is a 
medical device company that deals with management of chronic pain that 
is severe, persistent, and unresponsive to drugs or surgery. Spinal 
cord stimulation (SCS) offers a treatment alternative to expensive 
ongoing comprehensive care. RenewTM SCS was introduced in 
July 1999 as a device for the treatment of chronic intractable pain of 
the trunk and limbs.
    According to the applicant:
    ``SCS is a reversible method of pain control that works well for 
certain types of chronic intractable pain. SCS requires a surgical 
procedure to implant a receiver and leads. These implanted devices 
generate electrical stimulation that interrupts pain signals to the 
brain. SCS is considered to be a treatment of last resort, and is 
usually undertaken only when first and second-line therapies for 
chronic pain fail to provide adequate relief. SCS uses low-intensity 
electrical impulses to trigger nerve fibers selectively along the 
spinal cord. The stimulation of these nerve fibers diminishes or blocks 
the intensity of the pain message being transmitted to the brain. SCS 
replaces areas of intense pain with a more pleasant sensation * * *,'' 
masking the pain that is normally present.
    Prior to RenewTM, SCS systems offered few technical 
capabilities for treating complex chronic pain patients who suffered 
with pain that spanned

[[Page 31431]]

noncontiguous areas (multi-focal) or that varied in intensity over the 
painful area. The RenewTM system features a multiplex output 
mode that controls separate stimulation programs to allow outputs of 
varying frequencies to be used at the same time. According to ANS, 
``The significance of this technology is that it is now possible to 
multiplex (link and cycle) up to 8 programs to provide pain relieving 
paresthesia overlap of anatomical regions that are not contiguous or 
that cannot be captured by a single program.''
    The RenewTM technology also allows the concomitant use 
of separate programs for patients who require different power settings 
for different areas that have pain. With this technology, separate 
programs can be programmed from the same unit, with electrical output 
parameters customized for each painful region. ANS contends that the 
clinical significance of this technology is that patients who find 
satisfactory pain relief will require fewer alternative treatments to 
treat unrelieved pain.
    The ANS application specifically requests add-on payments for the 
costs of the Radio Frequency System (RF System). This system only 
requires one surgical placement and does not require additional 
surgeries to replace batteries as do other internal SCS systems. ANS 
estimates that there are 2,900 RF Systems implanted annually; only 10 
percent are in the inpatient setting. ANS is the only company that 
offers a 16-channel/electrode system.
    ANS provided the 2001 hospital acquisition cost for ANS 
RenewTM 8 and 16 Channel/Electrode RF SCS Systems as 
follows:

------------------------------------------------------------------------
                                                         ANS 2001 List
                                                             Price
------------------------------------------------------------------------
8 Channel/Electrode System:
  One Lead (8 Electrode).............................             $2,750
  One Extension (8 Electrode)........................                695
  Receiver (8 Channel)...............................              4,995
  Transmitter (8 Channel)............................              4,995
                                                      ------------------
      Total System...................................             13,435
                                                      ==================
16 Channel/Electrode System:
  Two Leads (16 Electrodes)..........................              5,500
  Two Extensions (16 Electrodes).....................              1,390
  Receiver (16 Channel)..............................              7,295
  Transmitter (16 Channel)...........................              7,295
                                                      ------------------
      Total System...................................             21,480
------------------------------------------------------------------------

    Currently, implanting the ANS 8 or 16 Channel/Electrode SCS System 
falls into DRG 4 (Spinal Procedures) under ICD-9-CM procedure code, 
03.93 (Insertion or replacement, spinal neurostimulation). According to 
the September 7, 2001 Federal Register, the threshold to qualify for 
additional new technology payments for services classified to DRG 4 
would be $38,242 (based on adding the geometric mean and the standard 
deviation of standardized charges) (66 FR 46922).
    Relative to hospital invoice information, ANS provided the 
following estimates:
    ``* * * 90% of the U.S. hospital cost-to-charge ratios fall between 
.24 and .69, and 75% fall between .29 and .58. The median is .41. This 
median costs-to-charge ratio equates to an average hospital markup of 
144%. If you apply the average hospital markup of 144% to the device 
acquisition cost plus the estimated facility cost, the result is an 
estimated hospital invoice for the SCS implant procedure of $40,101.00, 
for the 8 Channel/Electrode System and $59,731.00 for the 16 Channel/
Electrode System.''
    In support of its application, ANS provided detailed bills for 12 
patients. Of the 12 cases with detailed billing data, 3 patients were 
age 65 or older. The average total charge for these 3 cases, including 
the average standardized charge for operating room costs, was $42,820.
    As noted previously, technology will no longer be considered new 
after the costs of the technology are reflected in the DRG weights. 
Because the RenewTM RF System was introduced in July 1999, 
the FY 2001 MedPAR data used to calculate the proposed DRG weights for 
FY 2003 includes any Medicare cases that involved the implantation of 
the RenewTM RF System. The charges associated with these 
cases are reflected in the proposed FY 2003 DRG weights. Therefore, the 
RenewTM RF System is not considered ``new'' under our 
criteria. However, we will continue to monitor these cases in DRG 4 to 
determine whether this is the most appropriate DRG assignment.

III. Proposed 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). 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 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.
    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 from a rural area to a MSA, one rural area to another 
rural area, or from one MSA to another MSA, for purposes of payment 
under the acute care hospital inpatient prospective payment system.
    In a December 27, 2000 notice published in the Federal Register (65 
FR 82228), OMB issued its revised standards for defining MSAs. In that 
notice, OMB indicated that it plans to announce in calendar year 2003 
definitions of MSAs based on the new standards and the Census 2000 
data. We will evaluate the new area designations and their possible 
effects on the

[[Page 31432]]

Medicare wage index, as well as other provider payment implications. 
Although the final construct of the redefined MSAs will not be known 
until 2003, we intend to work closely with OMB to begin to assess the 
potential ramifications of these changes.
    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.
    Section 304(c) of Public Law 106-554 amended section 1886(d)(3)(E) 
of the Act to 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 (the FY 2005 wage index).
    In the May 4, 2001 proposed rule (66 FR 22674), we suggested 
possible occupational categories from the Occupational Employment 
Statistics (OES) survey conducted by the Bureau of Labor Statistics. In 
response to comments on the proposed rule, we agreed to work with the 
health care industry to develop a workable data collection tool. After 
we develop a method that appropriately balances the need to collect 
accurate and reliable data with the need to collect data that 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.

B. Proposed FY 2003 Wage Index Update

    The proposed FY 2003 wage index values in section V. of the 
Addendum to this proposed rule (effective for hospital discharges 
occurring on or after October 1, 2002 and before October 1, 2003) are 
based on the data collected from the Medicare cost reports submitted by 
hospitals for cost reporting periods beginning in FY 1999 (the FY 2002 
wage index was based on FY 1998 wage data).
    The proposed FY 2003 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 2002 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 2002, the 
proposed wage index for FY 2003 also continues to exclude the direct 
and overhead salaries and hours for services such as skilled nursing 
facility (SNF) services, home health services, and other subprovider 
components that are not paid under the hospital inpatient 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 2003 Wage Index Proposal

1. Removal of Wage Costs and Hours Related to Graduate Medical 
Education (GME) and Certified Registered Nurse Anesthetists (CRNAs)
    Because the hospital wage index is used to adjust payments to 
hospitals under the acute care hospital inpatient prospective payment 
system, the wage index should, to the extent possible, reflect the wage 
costs associated with those cost centers and units paid under the 
hospital inpatient prospective payment system. Costs related to 
graduate medical education (GME) (teaching physicians and residents) 
and certified registered nurse anesthetists (CRNAs) are paid by 
Medicare separately from the hospital inpatient prospective payment 
system. In 1998, the AHA convened a workgroup to develop a consensus 
recommendation on this issue. The workgroup, which consisted of 
representatives from national and State hospital associations, 
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.
    FY 2003 would be the fourth year of the phaseout. Therefore, the 
wage index calculation for FY 2003 would blend 20 percent of a wage 
index with GME and CRNA costs included and 80 percent of a wage index 
with GME and CRNA costs removed. FY 2004 would begin the calculation 
with 100 percent of the GME and CRNA costs removed. However, we are 
proposing to remove 100 percent of GME and CRNA costs from the FY 2003 
wage index, as discussed below.
    We have analyzed the FY 2003 wage index both with 100 percent of 
GME and CRNA costs removed and with 80 percent of these costs removed. 
We found that the majority of labor market areas, both rural and urban, 
would benefit by the removal of all of these costs (298 out of 373). 
Only two rural labor market areas would be negatively impacted by this 
change (Pennsylvania by -0.01 percent, and New Hampshire by -0.12 
percent). We note that, as part of its Report to the Congress on 
Medicare in Rural America (June 2001), the MedPAC recommended fully 
implementing this phaseout during FY 2002. Similar to our findings, 
MedPAC found the effect of completely eliminating GME and CRNA costs 
``might not be negligible for some areas, but it would not be large in 
any case'' (page 76). Of the urban labor market areas that would be 
negatively affected, the impacts on all but two areas are less than 
0.50 percent, and the largest negative impact is 1.12 percent.
    Because we believe removing GME and CRNA costs from the wage index 
calculation is appropriate, and the impact is generally positive and 
relatively small, we are proposing to remove 100 percent of GME and 
CRNA costs beginning with FY 2003 wage index.

2. Contract Labor for Indirect Patient Care Services

    Our policy concerning the inclusion of contract labor costs for 
purposes of calculating the wage index has evolved with the increasing 
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 
for direct patient care contract services in the

[[Page 31433]]

wage index calculation, and with the FY 1999 wage index, we included 
the costs for certain management contract services. (The August 30, 
1996 final rule (61 FR 46181) provided an in-depth discussion of the 
issues related to the inclusion of contract labor costs in the wage 
index calculation.) Further, the FY 1999 wage index included the costs 
for contract physician Part A services, and the FY 2002 wage index 
included the costs for contract pharmacy and laboratory services.
    We continue to consider whether to expand our contract labor 
definition to include more types of contract services in the wage 
index. In particular, we have examined whether to include the costs for 
acquired dietary and housekeeping services, as many hospitals now 
provide these services through contracts. Costs for these services tend 
to be below the average wages for all hospital employees. Therefore, 
excluding the costs and hours for these services if they are provided 
under contract, while including them if the services are provided 
directly by the hospital, creates an incentive for hospitals to 
contract for these services in order to increase their average hourly 
wage for wage index purposes.
    It has also been suggested that we expand our definition to include 
all contract services, including both direct and indirect patient care 
services, in order to more appropriately calculate relative hospital 
wage costs. Our goal is to ensure that our wage index policy continues 
to be responsive to the changing need for contract labor and allow 
those hospitals that must depend on contract labor to supply needed 
services to reflect those costs in their wage data. At the same time, 
we are concerned about hospitals' ability to provide documentation that 
sufficiently details contract costs and hours. The added overhead, 
supplies, and miscellaneous costs typically associated with contract 
labor may result in higher costs for contract labor compared to 
salaried labor. If these costs are not separately identifiable and 
removed, they may cause distortions in the wage index.
    We agree that it may be appropriate to include indirect patient 
care contract labor costs in the wage index. However, in light of 
concerns about hospitals' ability to accurately document and report 
these costs, we believe the best approach is to assess and include 
these costs incrementally. Through incremental changes, we can better 
determine the impact that specific costs have on area wage index 
values. Also, by including these costs incrementally, hospitals and 
fiscal intermediaries are able to adjust to the additional 
documentation and review requirements associated with reporting the 
additional contract costs and hours.
    In this proposed rule, we are proposing to begin collecting 
contract labor costs and hours for management services and the 
following overhead services: administrative and general, housekeeping, 
and dietary. We selected these three overhead services because they are 
provided at all hospitals, either directly or through contracts, and 
together they comprise about 60 percent of a hospital's overhead hours. 
In addition, consistent with our consideration of administrative and 
general services, we propose to collect costs and hours associated with 
contract management services that are not currently included on 
Worksheet S-3, Part II, Line 9 (that is, management services other than 
those of the chief executive officer, chief financial officer, chief 
operating officer, and nurse administrator).
    We propose to revise the FY 2002 Medicare cost report (or the next 
available cost report) to provide for the separate reporting of 
contract management, administrative and general, housekeeping, and 
dietary costs and hours. After evaluating these data, we will determine 
the feasibility of adding these categories of contract labor to the 
wage index calculation.

D. Verification of Wage Data From the Medicare Cost Report

    The data for the proposed FY 2003 wage index were obtained from 
Worksheet S-3, Parts II and III of the FY 1999 Medicare cost reports. 
The data file used to construct the wage index includes FY 1999 data 
submitted to us as of February 15, 2002. 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. Some unresolved data 
elements are included in the calculation of the proposed FY 2003 wage 
index, pending their resolution before calculation of the final FY 2003 
wage index. We have instructed the intermediaries to complete their 
verification of questionable data elements and to transmit any changes 
to the wage data no later than April 5, 2002. We expect that all 
unresolved data elements will be resolved by that date. The revised 
data will be reflected in the final rule.
    Also, as part of our editing process, we removed data for 96 
hospitals that failed edits. For 6 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, are 
under new ownership and the data cannot be verified, or are in 
bankruptcy status. We identified 90 hospitals with incomplete or 
inaccurate data resulting in zero or negative average hourly wages. 
Therefore, they were removed from the calculation. The data for these 
hospitals will be included in the final wage index if we receive 
corrected data that pass our edits. As a result, the proposed FY 2003 
wage index is calculated based on FY 1999 wage data for 4,718 
hospitals.

E. Computation of the Proposed FY 2003 Wage Index

    The method used to compute the proposed FY 2003 wage index follows.
    Step 1--As noted above, we based the proposed FY 2003 wage index on 
wage data reported on the FY 1999 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, 1998 and before October 1, 1999. In addition, we 
included data from some hospitals that had cost reporting periods 
beginning before October 1998 and reported a cost reporting period 
covering all of FY 1999. 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 1999 data. We note that, if a hospital 
had more than one cost reporting period beginning during FY 1999 (for 
example, a hospital had two short cost reporting periods beginning on 
or after October 1, 1998 and before October 1, 1999), 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--Beginning with the FY 2003 wage index, the method 
used to compute a hospital's average hourly wage excludes all GME and 
CRNA costs.
    In calculating a hospital's average salaries plus wage-related 
costs, we subtracted from Line 1 (total salaries) the GME and CRNA 
costs reported on lines 2, 4.01, and 6, the Part B salaries

[[Page 31434]]

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 SNF services, home health services, and other 
subprovider components not subject to the acute care hospital inpatient 
prospective payment system). We also subtracted from Line 1 the 
salaries for which no hours were reported on Line 4. 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 nonteaching physician Part A 
services (Lines 9, 9.01, 9.02, and 10), home office salaries and wage-
related costs reported by the hospital on Lines 11 and 12, and 
nonexcluded area wage-related costs (Lines 13, 14, and 18).
    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 nonteaching physician Part A employees (Line 18) are 
excluded if no corresponding salaries are reported for those employees 
on Line 4.
    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 2, 3, 4.01, 5, 6, 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 2, 
3, 4.01, 5, 6, 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, and 18; 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.
    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, 1998 through 
April 15, 2000 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
------------------------------------------------------------------------
                                                              Adjustment
              After                         Before              factor
------------------------------------------------------------------------
10/14/98.........................  11/15/98................      1.04550
11/14/98.........................  12/15/98................      1.04325
12/14/98.........................  01/15/99................      1.04111
01/14/99.........................  02/15/99................      1.03880
02/14/99.........................  03/15/99................      1.03632
03/14/99.........................  04/15/99................      1.03369
04/14/99.........................  05/15/99................      1.03092
05/14/99.........................  06/15/99................      1.02801
06/14/99.........................  07/15/99................      1.02509
07/14/99.........................  08/15/99................      1.02230
08/14/99.........................  09/15/99................      1.01962
09/14/99.........................  10/15/99................      1.01687
10/14/99.........................  11/15/99................      1.01385
11/14/99.........................  12/15/99................      1.01056
12/14/99.........................  01/15/2000..............      1.00710
01/14/2000.......................  02/15/2000..............      1.00358
02/14/2000.......................  03/15/2000..............      1.00000
03/14/2000.......................  04/15/2000..............      0.99638
------------------------------------------------------------------------

    For example, the midpoint of a cost reporting period beginning 
January 1, 1999 and ending December 31, 1999 is June 30, 1999. An 
adjustment factor of 1.02509 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 1999 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 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.

[[Page 31435]]

    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 data as described 
above, the national average hourly wage is $22.9949.
    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 
$10.8935 for Puerto Rico. For each labor market area in Puerto Rico, we 
calculated the 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 of a State 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 2003, 
this change affects 163 hospitals in 40 MSAs. The MSAs affected by this 
provision are identified by a footnote in Table 4A in the Addendum of 
this proposed rule.

F. Revisions to the Wage Index Based on Hospital Redesignation

1. General
    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. Hospitals can elect to reclassify for the 
wage index or the standardized amount, or both, and as individual 
hospitals or as rural groups. Generally, hospitals must be proximate to 
the labor market area to which they are seeking reclassification and 
must demonstrate characteristics similar to hospitals located in that 
area. Hospitals must apply for reclassification to the MGCRB, which 
issues its decisions by the end of February for reclassification to 
become effective for the following fiscal year (beginning October 1). 
The regulations applicable to reclassifications by the MGCRB are in 
Secs. 412.230 through 412.280.
    Section 1886(d)(10)(D)(v) of the Act provides that, beginning with 
FY 2001, a MGCRB decision on a hospital reclassification for purposes 
of the wage index is effective for 3 fiscal years, unless the hospital 
elects to terminate the reclassification. Section 1886(d)(10)(D)(vi) of 
the Act 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 304(b) of Public Law 106-554 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.
    Beginning October 1, 1988, section 1886(d)(8)(B) of the Act permits 
a hospital located in a rural county adjacent to one or more urban 
areas to be designated 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 area) 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.
    Section 402 of Public Law 106-113 provided that, for FYs 2001 and 
2002, hospitals could elect whether to apply standards developed by OMB 
in 1980 or 1990 in order to qualify for redesignation under section 
1886(d)(8)(B) of the Act. However, we are proposing that, beginning 
with FY 2003, redesignation under section 1886(d)(8)(B) of the Act will 
be based on the standards published in the Federal Register by the 
Director of OMB based on the most recent decennial census.
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

[[Page 31436]]

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.
     The wage data for a reclassified urban hospital is 
included in both the wage index calculation of the area to which the 
hospital is reclassified (subject to the rules described above) and the 
wage index calculation of the urban area where the hospital is 
physically located.
    The proposed wage index values for FY 2003 are shown in Tables 4A, 
4B, 4C, and 4F in the Addendum to this proposed 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.
    Tables 3A and 3B in the Addendum of this proposed rule list the 3-
year average hourly wage for each labor market area before the 
redesignation of hospitals, based on FY 1997, 1998, and 1999 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 proposed 
rule includes the adjusted average hourly wage for each hospital from 
the FY 1997 and FY 1998 cost reporting periods, as well as the FY 1999 
period used to calculate the FY 2003 wage index. The 3-year averages 
are calculated by dividing the sum of the dollars (adjusted to a common 
reporting period using the method described previously under 
computation of the proposed FY 2003 wage index) 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.
    At the time this proposed wage index was constructed, the MGCRB had 
completed its review of FY 2003 reclassification requests. We have 
included in this proposed rule a new Table 9, which shows hospitals 
that have been reclassified under either section 1886(d)(8)(B) or 
section 1886(d)(10)(D) of the Act. This table includes hospitals 
reclassified for FY 2003 by the MGCRB, as well as hospitals that were 
reclassified for the wage index in either FY 2001 or FY 2002 and are, 
therefore, in either the third or second year of their 3-year 
reclassification. There are 60 hospitals reclassified for the wage 
index beginning during FY 2003. In addition, 369 hospitals are 
reclassified for FY 2003 based on their 3-year reclassification that 
became effective during FY 2001, and 170 hospitals are reclassified for 
FY 2003 based on their 3-year reclassification that became effective 
during FY 2002. There are 124 hospitals included in the 3-year 
reclassification from FY 2001 that were reclassified in accordance with 
section 152(b) of Public Law 106-113. In addition, there are 38 rural 
hospitals redesignated to an urban area under section 1886(d)(8)(B) of 
the Act, and 14 urban hospitals that have been designated rural in 
accordance with section 1886(d)(8)(E) of the Act. Finally, there are 61 
hospitals reclassified by the MGCRB for the standardized amount for FY 
2003 (including one hospital that is also redesignated under section 
1886(d)(8)(B) of the Act to a different MSA). The final number of 
reclassifications may vary because some MGCRB decisions are still under 
review by the Administrator and because some hospitals may withdraw 
their requests for reclassification.
    Table 9 shows the various reclassifications and redesignations 
discussed above by individual hospital. The table does not reflect any 
hospital withdrawals from reclassifications approved by the MGCRB or 
decisions of the CMS Administrator. In the final rule to be published 
by August 1, 2002, we will include a similar table that will include 
all final reclassifications for FY 2003.
    Under Sec. 412.273, hospitals that have been reclassified by the 
MGCRB are permitted to withdraw their applications within 45 days of 
the publication of this proposed rule in the Federal Register. In 
addition, hospitals may terminate an existing 3-year reclassification 
within 45 days of the publication of this proposed rule. The request 
for withdrawal of an application for reclassification or termination of 
an existing 3-year reclassification that would be effective in FY 2003 
must be received by the MGCRB by June 24, 2002. A hospital that 
withdraws its application or terminates an existing 3-year 
reclassification may not later request reinstatement of the MGCRB 
decision, except by canceling such a withdrawal or termination in a 
subsequent year (see Sec. 412.273(b)(2)(i), and the proposed changes 
and clarifications to the cancellation procedures in section V. of this 
preamble).
    Any changes to the wage index that result from withdrawals of 
requests for reclassification, wage index corrections, appeals, and the 
Administrator's review process will be incorporated into the wage index 
values published in the final rule following this proposed 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.
    We are proposing limited changes and clarifications to the policies 
related to withdrawals, terminations, and cancellations of the 3-year 
wage index reclassifications. These are discussed in section V. of this 
preamble.
3. OMB Standards for Hospitals To Qualify for Redesignation
    In the August 1, 2001 final rule, we implemented section 402 of 
Public Law 106-113. Section 402 provided that hospitals could elect 
whether to apply standards developed by OMB in 1980 or 1990 in order to 
qualify for redesignation under section 1886(d)(8)(B) of the Act. 
However, section 402 also states 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.
    At this time, the 1990 standards are the most recent available. 
Although OMB is working to develop updated standards based on the 2000 
census, that work is not yet completed. If the 2000 census population 
data become available prior to the preparation and publication of the 
final rule by August 1, 2002, CMS will work with the Population 
Distribution Branch within the Population Division of the U.S. Census 
Bureau to compile a list of hospitals that meet the established 
standards using the 2000 census population data. Otherwise, for 
purposes of redesignation for FY 2003 under section 1886(d)(8)(B) of 
the Act, qualifying hospitals must be located in counties meeting the 
1990 standards.
    In the August 1, 2001 final rule, we determined that three counties 
that qualified for redesignation under the 1980 standards qualified for 
redesignation to a different MSA using the 1990 standards (66 FR 
39869). These counties, which will be redesignated to the MSA to which 
they qualify based on the 1990 standards, are as follows:

[[Page 31437]]



------------------------------------------------------------------------
        Rural county          1980 MSA designation  1990 MSA designation
------------------------------------------------------------------------
Ionia, MI...................  Lansing-East          Grand Rapids-
                               Lansing, MI.          Muskegon-Hollan,
                                                     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 allowed hospitals to elect to use 
either the January 3, 1980 standards or March 30, 1990 standards for 
payments during FY 2001 and FY 2002. Several hospitals in counties that 
did not qualify under the January 3, 1980 standards elected to use 
those older standards so they would not receive the urban designation 
accorded them under section 402 because they would lose their special 
rural designation (that is, a sole community hospital (SCH) or 
Medicare-dependent hospital (MDH)). Under section 402, the option to 
make such an election was available only for FY 2001 and FY 2002. 
Effective for FY 2003, we are proposing that hospitals located in 
counties qualifying for redesignation under section 1886(d)(8)(B) of 
the Act based on the 1990 standards would be redesignated under this 
provision.
    We also noted in the August 1, 2001 final rule that five rural 
counties no longer meet the qualifying criteria when we apply the 1990 
OMB standards (66 FR 39870). These rural counties are as follows: 
Indian River, FL; Mason, IL; Owen, IN; Morrow, OH; and Lincoln, WV. 
Therefore, beginning FY 2003, hospitals in these counties will not be 
eligible for redesignation unless the counties again qualify when the 
standards based on the 2000 census data are available.

G. Requests for Wage Data Corrections

    As stated in section II.D. of this preamble, the data used to 
construct the proposed wage index includes FY 1999 data submitted to 
CMS as of February 15, 2002. In a memorandum dated December 19, 2001, 
we instructed all Medicare intermediaries to inform the prospective 
payment hospitals they service of the availability of the wage data 
file and the process and timeframe for requesting revisions. The wage 
data file was made available on January 12, 2002, through the Internet 
at CMS's home page (http://www.hcfa.gov). We also instructed the 
intermediaries to advise hospitals of the availability of these data 
either through their representative hospital organizations or directly 
from CMS. Additional details on ordering this data file are discussed 
in section IX.A. of this preamble, ``Requests for Data from the 
Public.''
    In addition, Table 2 in the Addendum to this proposed rule contains 
each hospital's adjusted average hourly wage used to construct the 
proposed wage index values for the past 3 years, including the FY 1999 
data used to construct the proposed FY 2003 wage index. It should be 
noted that the hospital average hourly wages shown in Table 2 only 
reflect changes made to a hospital's data and transmitted to CMS prior 
to February 15, 2002. Changes approved by a hospital's fiscal 
intermediary and forwarded to CMS by April 5, 2002, will be reflected 
in the final public use wage data file scheduled to be made available 
on or about May 10, 2002.
    We believe hospitals have sufficient time to ensure the accuracy of 
their FY 1999 wage data. Moreover, the ultimate responsibility for 
accurately completing the cost report rests with the hospital, which 
must attest to the accuracy of the data at the time the cost report is 
filed. Hospitals should know what wage data were submitted on their 
cost reports. In addition, they are notified of any changes to their 
data as a result of their fiscal intermediary's review. However, if a 
hospital believed that its FY 1999 wage data were incorrectly reported, 
the hospital was to submit corrections along with complete, detailed 
supporting documentation to its intermediary by February 8, 2002. 
Hospitals were notified of this deadline, and of all other possible 
deadlines and requirements, through the December 19, 2001 memorandum 
referenced above.
    After reviewing requested changes submitted by hospitals, fiscal 
intermediaries transmitted any revised cost reports to CMS and 
forwarded a copy of the revised Worksheet S-3, Parts II and III to the 
hospitals. In addition, fiscal intermediaries were to notify hospitals 
of the changes or the reasons that changes were not accepted. This 
procedure ensures that hospitals have every opportunity to verify the 
data that will be used to construct their wage index values. We believe 
that fiscal intermediaries are generally in the best position to make 
evaluations regarding the appropriateness of a particular cost and 
whether it should be included in the wage index data. However, if a 
hospital disagrees with the fiscal intermediary's resolution of a 
policy issue (whether a general category of cost is allowable in the 
wage data), the hospital may contact CMS in an effort to resolve policy 
disputes. We note that the April 5, 2002 deadline also applies to these 
requested changes. During this review, we will not consider issues such 
as the adequacy of a hospital's supporting documentation, as these 
types of issues should have been resolved earlier in the process.
    These deadlines are necessary to allow sufficient time to review 
and process the data so that the final wage index calculation can be 
completed for development of the final FY 2003 prospective payment 
rates to be published by August 1, 2002.
    We have created the process described above to resolve all 
substantive wage data correction disputes before we finalize the wage 
data for the FY 2003 payment rates. Accordingly, hospitals that do not 
meet the procedural deadlines set forth above will not be 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, CMS'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)).
    The final wage data public use file will be released on 
approximately May 10, 2002. Hospitals should examine both Table 2 of 
this proposed rule and the May 2002 final public use wage data file 
(which reflects revisions to the data used to calculate the values in 
Table 2) to verify the data CMS is using to calculate the wage index.
    As with the file made available in January 2002, CMS will make the 
final wage data file released in May 2002 available to hospital 
associations and the public on the Internet. However, the May 2002 
public use file will be made available solely for the limited purpose 
of identifying any potential errors made by CMS or the fiscal 
intermediary in the entry of the final wage data that result from the 
correction process described above (with the February 8 deadline). 
Hospitals are encouraged to review their hospital wage data promptly 
after the release of the May 2002 file. Data presented at this time 
cannot be used by hospitals to initiate new wage data correction 
requests.

[[Page 31438]]

    If, after reviewing the final file, a hospital believes that its 
wage data are incorrect due to a fiscal intermediary or CMS error in 
the entry or tabulation of the final wage data, it should send a letter 
to both its fiscal intermediary and CMS. The letters should outline why 
the hospital believes an error exists and provide all supporting 
information, including dates. These requests must be received by CMS 
and the fiscal intermediaries no later than June 7, 2002. Requests 
mailed to CMS should be sent to: Center for Medicare & Medicaid 
Services, Center for Health Plans and Providers, Attention: Wage Index 
Team, Division of Acute Care, C4-07-05, 7500 Security Boulevard, 
Baltimore, MD 21244-1850. Each request must also be sent to the 
hospital's fiscal intermediary. The intermediary will review requests 
upon receipt and contact CMS immediately to discuss its findings.
    At this point in the process, that is, between release of the May 
2002 wage index file and June 7, 2002, changes to the hospital wage 
data will only be made in those very limited situations involving an 
error by the intermediary or CMS that the hospital could not have known 
about before its review of the final wage data file. Specifically, 
neither the intermediary nor CMS will accept the following types of 
requests at this stage of the process:
     Requests for wage data corrections that were submitted too 
late to be included in the data transmitted to CMS by fiscal 
intermediaries on or before April 5, 2002.
     Requests for correction of errors that were not, but could 
have been, identified during the hospital's review of the January 2002 
wage data file.
     Requests to revisit factual determinations or policy 
interpretations made by the intermediary or CMS during the wage data 
correction process.
    Verified corrections to the wage index received timely (that is, by 
June 7, 2002) will be incorporated into the final wage index to be 
published by August 1, 2002 and effective October 1, 2002.
    Again, we believe the wage data correction process described above 
provides hospitals with sufficient opportunity to bring errors in their 
wage data to the fiscal intermediaries' attention. Moreover, because 
hospitals will have access to the final wage data by May 2002, they 
will have the opportunity to detect any data entry or tabulation errors 
made by the fiscal intermediary or CMS before the development and 
publication of the FY 2003 wage index by August 1, 2002, and the 
implementation of the FY 2003 wage index on October 1, 2002. If 
hospitals avail 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(x)(2) of our existing 
regulations, we make midyear corrections to the wage index only in 
those limited circumstances in which a hospital can show (1) that the 
intermediary or CMS 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 2003 (that 
is, by the June 7, 2002 deadline). As indicated earlier, since a 
hospital will have the opportunity to verify its data, and the fiscal 
intermediary will notify the hospital of any changes, we do not expect 
that midyear corrections would be necessary. However, if the correction 
of a data error changes the wage index value for an area, the revised 
wage index value is effective prospectively from the date the 
correction is approved.
    This policy for applying prospective corrections to the wage index 
was originally set forth in the preamble to the January 3, 1984 final 
rule (49 FR 258) implementing the hospital inpatient prospective 
payment system. It has been our longstanding policy to make midyear 
corrections to the hospital wage data and adjust the wage index for the 
affected areas on a prospective basis.
    Section 412.63(x)(3) states that revisions to the wage index 
resulting from midyear corrections to the wage index values are 
incorporated in the wage index values for other areas at the beginning 
of the next Federal fiscal year. Prior to October 1, 1993, the wage 
index was based on a wage data survey submitted by all hospitals (prior 
to that, the data came from the Bureau of Labor Statistics' hospital 
wage and employment data file). Beginning October 1, 1993, as required 
by section 1886(d)(3)(E) of the Act, we began updating the wage index 
data on an annual basis. Because the wage index has been updated 
annually since FY 1994, Sec. 412.63(x)(3) is no longer necessary, and 
we are proposing to delete it. Similarly, Sec. 412.63(x)(4) provides 
that the effect on program payments of midyear corrections to the wage 
index values is taken into account in establishing the standardized 
amounts for the following year. Again, the wage data are now updated 
annually. Therefore, Sec. 412.63(x)(4) is no longer necessary, and we 
are proposing to delete it as well.
    Finally, we are proposing to revise Sec. 412.63(x)(2) to clarify 
that CMS will make a midyear correction to the wage index for an area 
only if a hospital can show that the intermediary or CMS made an error 
in tabulating the hospital's own data. That is, this provision is not 
available to a hospital seeking to revise another hospital's data that 
may be affecting the requesting hospital's wage index. As described 
above, the requesting hospital must show that it could not have known 
about the error, or that it did not have the opportunity to correct the 
error, before the beginning of the Federal fiscal year.

IV. Proposed Rebasing and Revision of the Hospital Market Baskets

A. Operating Costs

1. Background
    Effective for cost reporting periods beginning on or after July 1, 
1979, we developed and adopted a hospital input price index (that is, 
the hospital ``market basket'') for operating costs. Although ``market 
basket'' technically describes the mix of goods and services used to 
produce hospital care, this term is also commonly used to denote the 
input price index (that is, cost category weights and price proxies 
combined) derived from that market basket. Accordingly, the term 
``market basket'' as used in this document refers to the hospital input 
price index.
    The percentage change in the market basket reflects the average 
change in the price of goods and services hospitals purchased in order 
to furnish inpatient care. We first used the market basket to adjust 
hospital cost limits by an amount that reflected the average increase 
in the prices of the goods and services used to furnish hospital 
inpatient care. This approach linked the increase in the cost limits to 
the efficient utilization of resources.
    With the inception of the acute care hospital inpatient prospective 
payment system, the projected change in the hospital market basket has 
been the integral component of the update factor by which the 
prospective payment rates are updated every year. For FY 2003, payment 
rates will be updated by the projected increase in the hospital market 
basket minus 0.55 percentage points. A detailed explanation of the 
hospital market basket used to develop the prospective payment rates 
was published in the Federal Register on September 3, 1986 (51 FR 
31461). We also refer the reader to the August 29, 1997 Federal 
Register (62 FR 45966) in

[[Page 31439]]

which we discussed the previous rebasing of the hospital input price 
index.
    The hospital market basket is a fixed-weight, Laspeyres-type price 
index that is constructed in three steps. First, a base period is 
selected and total base period expenditures are estimated for a set of 
mutually exclusive and exhaustive spending categories based upon type 
of expenditure. Then, the proportion of total operating costs that each 
category represents is determined. These proportions are called cost or 
expenditure weights. Second, each expenditure category is matched to an 
appropriate price or wage variable, referred to as a price proxy. These 
price proxies are price levels derived from publicly available 
statistical series and are published on a consistent schedule, 
preferably at least on a quarterly basis.
    Finally, the expenditure weight for each category is multiplied by 
the level of the respective price proxy. The sum of these products 
(that is, the expenditure weights multiplied by the price levels) for 
all cost categories yields the composite index level of the market 
basket in a given year. Repeating this step for other years produces a 
series of market basket index levels over time. Dividing one index 
level by an earlier index level produces rates of growth in the input 
price index over that time.
    The market basket is described as a fixed-weight index because it 
answers the question of how much it would cost, at another time, to 
purchase the same mix of goods and services that was purchased in the 
base period. The effects on total expenditures resulting from changes 
in the quantity or mix of goods and services (intensity) purchased 
subsequent to the base period are not measured. For example, shifting a 
traditionally inpatient type of care to an outpatient setting might 
affect the volume of inpatient goods and services purchased by the 
hospital, but would not be factored into the price change measured by a 
fixed weight hospital market basket. In this manner, the index measures 
only the pure price change. Only rebasing (changing the base year) the 
index would capture these quantity and intensity effects. Therefore, we 
rebase the market basket periodically so the cost weights reflect 
changes in the mix of goods and services that hospitals purchase 
(hospital inputs) in furnishing inpatient care. We last rebased the 
hospital market basket cost weights in 1997, effective for FY 1998 (62 
FR 45993). This market basket, still used through FY 2002, reflects 
base year data from FY 1992 in the construction of the cost weights.
    We note that there are separate market baskets for acute care 
hospital inpatient prospective payment system hospitals and excluded 
hospitals and hospital units. In addition, we are in the process of 
conducting the necessary research to determine if separate market 
baskets for the inpatient rehabilitation, long-term care, and 
psychiatric hospital prospective payment systems can be developed. 
However, for the purpose of this preamble, we are only discussing the 
market basket based on all excluded hospitals together.
2. Rebasing and Revising the Hospital Market Basket
    The terms rebasing and revising, while often used interchangeably, 
actually denote different activities. Rebasing means moving the base 
year for the structure of costs of an input price index (for example, 
we are proposing to shift the base year cost structure from FY 1992 to 
FY 1997). Revising means changing data sources, cost categories, or 
price proxies used in the input price index.
    We are proposing to use a rebased and revised hospital market 
basket in developing the FY 2003 update factor for the prospective 
payment rates. The new market basket would be rebased to reflect FY 
1997, rather than FY 1992, cost data. The 1992-based market baskets 
contained expenditure data for hospitals from Medicare cost reports for 
cost reporting periods beginning on or after October 1, 1991, and 
before October 1, 1992. The 1997-based market baskets use data for 
hospitals from Medicare cost reports for cost reporting periods 
beginning on or after October 1, 1996, and before October 1, 1997. 
Fiscal year 1997 was selected as the new base year because 1997 is the 
most recent year for which relatively complete data are available. 
These include data from FY 1997 Medicare cost reports as well as 1997 
data from two U.S. Department of Commerce publications: the Bureau of 
the Census' Business Expenditure Survey (BES) and the Bureau of 
Economic Analysis' Annual Input-Output Tables. In addition, preliminary 
analysis of FYs 1998 and 1999 Medicare cost report data showed little 
difference in cost shares from FY 1997 data.
    In developing the proposed rebased and revised market baskets, we 
reviewed hospital operating expenditure data for the market basket cost 
categories in determining the cost weights. We relied primarily on 
Medicare hospital cost report data for the proposed rebasing. We prefer 
to use cost report data wherever possible because these are the cost 
data supplied directly from hospitals. Other data sources such as the 
BES and the input-output tables serve as secondary sources used to fill 
in where cost report data are not available or appear to be incomplete. 
Below we are providing a detailed discussion of the process for 
calculating cost share weights.
    Cost category weights for the proposed FY 1997-based market baskets 
were developed in several stages. First, base weights for several of 
the categories (Wages and Salaries, Employee Benefits, Contract Labor, 
Pharmaceuticals and Blood and Blood Products) were derived from the FY 
1997 Medicare cost reports for operating costs. The expenditures for 
these categories were calculated as a percentage of total operating 
costs from those hospitals covered under the inpatient hospital 
prospective payment system. These data were then edited to remove 
outliers and ensure that the hospital participated in the Medicare 
program and had Medicare costs. However, we were unable to measure only 
those operating costs attributable to the inpatient portion of the 
hospital, because many cost centers are utilized by both inpatients and 
outpatients in the hospital. Health Economics Research (HER), under 
contract with CMS, is currently in the process of researching the 
possibility of constructing a separate outpatient market basket for 
CMS' outpatient hospital prospective payment system. This research may 
provide some insight and guidance for separating inpatient and 
outpatient costs. We excluded hospital-based subprovider cost centers 
(for example, skilled nursing, nursing, hospice, psychiatric, 
rehabilitation, intermediate care/mental retardation, and other long-
term care) as well as the portion of overhead and ancillary costs 
incurred by these subproviders.
    Second, the weight for professional liability insurance was 
calculated using data from a survey conducted by ANASYS under contract 
to CMS. This survey, called the National Hospital Malpractice Insurance 
Survey (NHMIS), was conducted to estimate hospital malpractice 
insurance costs over time at the national level. A more detailed 
description of this survey is found later in this preamble.
    Third, data from the 1997 Business Expenditure Survey (BES) was 
used to develop a weight for the utilities and telephone services 
categories. Like most other data sources, the BES includes data for all 
hospitals and does not break out data by payer. However, we believe the 
overall data from the BES does not produce results that are 
inconsistent with the prospective payment system hospitals, 
particularly at the detailed

[[Page 31440]]

cost category level with which we are working.
    Fourth, the sum of the weights for wages and salaries, employee 
benefits, contract labor, professional liability insurance, utilities, 
pharmaceuticals, blood and blood products, and telephone services was 
subtracted from other operating expenses to obtain a portion for all 
other expenses.
    Finally, the remainder of the weight for all other expenses was 
divided into subcategories using relative cost shares from the 1997 
Annual Input-Output Table for the hospital industry, produced by the 
Bureau of Economic Analysis, U.S. Department of Commerce. The 1997 
Benchmark Input-Output data will be available, at the earliest, in late 
2002, so we will be unable to incorporate these data in the final rule.
    Below, we further describe the sources of the six main category 
weights and their subcategories in the proposed FY 1997-based market 
basket. We note the differences between the methodologies used to 
develop the FY 1992-based and the FY 1997-based market baskets.
     Wages and Salaries: The cost weight for the wages and 
salaries category was derived using Worksheet S-3 from the FY 1997 
Medicare cost reports. Contract labor, which is also derived from the 
FY 1997 Medicare cost reports, is split between the wages and salaries 
and employee benefits cost categories, using the relationship for 
employed workers. An example of contract labor is registered nurses who 
are employed and paid by firms that contract for their work with the 
hospital. The wages and salaries category in the FY 1992-based market 
basket was developed from the FY 1992 Medicare cost reports. In 
addition, we used the 1992 Current Population Survey to break out more 
detailed occupational subcategories. These subcategories were not 
broken out for the proposed FY 1997-based market basket.
     Employee Benefits: The cost weight for the employee 
benefits category was derived from Worksheet S-3 of the FY 1997 
Medicare cost reports. The employee benefits category in the FY 1992-
based market basket was developed from FY 1992 Medicare cost reports 
and used the 1992 Current Population Survey to break out various 
occupational subcategories. These subcategories were not broken out for 
the proposed FY 1997-based market basket.
     Nonmedical Professional Fees: This category refers to 
various types of nonmedical professional fees such as legal, 
accounting, engineering and management and consulting fees. Management 
and consulting and legal fees make up the majority of professional fees 
in the hospital sector. The cost weight for the nonmedical professional 
fees category was derived from the Bureau of Economic Analysis Input-
Output data for 1997. The FY 1992-based index used a combination of 
data from the American Hospital Association (AHA) and the Medicare cost 
reports to arrive at a weight. However, because the AHA survey data for 
professional fees are no longer published, we were unable to duplicate 
this method. Had we used the proposed methodology to calculate the FY 
1992 nonmedical professional fees component, the proportion would have 
been similar to the FY 1997 share.
     Professional Liability Insurance: The proposed FY 1997-
based market basket uses a weight for professional liability insurance 
derived from a survey conducted by ANASYS under contract to CMS 
(Contract Number 500-98-005). This survey attempted to estimate 
hospital malpractice insurance costs over time at the national level 
for years 1996 and 1997. The population universe of the survey was 
defined as all non-Federal short-term, acute care prospective payment 
system hospitals. A statistical sample of hospitals was drawn from this 
universe and data collected from those hospitals. This sample of 
hospitals was then matched to the appropriate cost report data so that 
a malpractice cost weight could be calculated. The questions used in 
the survey were based on a 1986 General Accounting Office (GAO) 
malpractice survey questionnaire that was modified so data could be 
collected to calculate a malpractice cost weight and the rate of change 
for a constant level of malpractice coverage at a national level. The 
1997 proportion as calculated by ANASYS was compared to limited data 
for FYs 1998 and 1999 contained in the Medicare Health Care System Cost 
Report Information System (HCRIS). The percentages are relatively 
comparable. However, since this field was virtually incomplete in the 
FY 1997 cost report file, we were unable to use this cost report data.
    In contrast, the FY 1992-based market basket professional liability 
insurance weight was determined using the cost report data for PPS-6 
(cost reporting periods beginning in FY 1989), the last year these 
costs had to be treated separately from all other administrative and 
general costs, trended forward to FY 1992 based on the relative 
importance of malpractice costs found in the previous market basket.
     Utilities: For the proposed FY 1997-based market baskets, 
the cost weight for utilities was derived from the Bureau of the 
Census' Business Expenditures Survey. For the FY 1992-based market 
baskets, the cost weight for utilities was derived from the Bureau of 
the Census' Asset and Expenditures Survey. The Business Expenditure 
Survey replaced the Asset and Expenditure Survey and the categories and 
results are similar.
     All Other Products and Services: The all other products 
and services category includes the remainder of products and services 
that hospitals purchase in providing care. Products found in this 
category include: direct service food, contract service food, 
pharmaceuticals, blood and blood products, chemicals, medical 
instruments, photo supplies, rubber and plastics, paper products, 
apparel, machinery and equipment, and miscellaneous products. Services 
found in this category include: telephone, postage, other labor-
intensive services, and other nonlabor-intensive services. Labor-
intensive services include those services for which local labor markets 
would likely influence prices. A complete discussion of the labor-
related share is presented later in this preamble. The shares for 
pharmaceuticals and blood and blood products were derived from the FY 
1997 Medicare cost reports, while the share for telephone services was 
derived from the BES. Relative shares for the other subcategories were 
derived from the 1997 Bureau of Economic Analysis Annual Input-Output 
Table for the hospital industry.
    The calculation of these subcategories involved calculating a 
residual from the Input/Output Table using categories similar to those 
not yet accounted for in the market basket. Subcategory weights were 
then calculated as a proportion of this residual and applied to the 
similar residual in the market basket.
     Blood and blood products: When the market basket was last 
revised and rebased to FY 1992, the component for blood services was 
discontinued because of the lack of appropriate data to determine a 
weight. The Medicare, Medicaid, and SCHIP Benefits Improvement and 
Protection Act of 2000 (BIPA) required that CMS consider the prices of 
blood and blood products purchased by hospitals and determine whether 
those prices are adequately reflected in the market basket. In 
accordance with this requirement, CMS has done considerable research to 
determine if a component for blood and blood products should be added 
to the market basket and, if so, how the weight should be determined. 
CMS has studied four alternative data sources to possibly

[[Page 31441]]

determine a weight for blood in the market basket. If none of these 
data sources was deemed acceptable, we could conclude that a component 
for blood should not be reintroduced in the hospital market basket. In 
a December 2001 report by the MedPAC entitled ``Blood Safety in 
Hospitals and Medicare Inpatient Payment,'' MedPAC recommended that the 
market basket should explicitly account for the cost of blood and blood 
products by reintroducing a separate component for their prices.
    The first alternative data source studied was using data from the 
Medicare cost reports. The cost reports have two cost centers where the 
costs of blood can be recorded: (1) whole blood and packed red blood 
cells (nonsalary); and (2) blood storing, processing, and transfusion 
(nonsalary). Although all prospective payment system hospitals submit a 
cost report, less than half of these hospitals reported data in either 
of the two blood cost centers. However, if we can determine that the 
hospitals reporting blood are representative of all prospective payment 
system hospitals, then a cost share can be computed using the cost 
reports.
    The second alternative involves constructing weights from the 
Input-Output Table from the BEA, Department of Commerce. These data 
were used to construct the weight when the market basket was revised 
before FY 1992. Unfortunately, BEA stopped reporting blood separately 
in their Input-Output Table in 1987. One possible use of these data 
would be to calculate a weight by updating the prior weight by the 
relative price change for blood between the last data point available 
and 1997. However, by using this method, only the escalation in prices, 
not the changes in quantity or intensity of use of blood products, 
would be captured.
    The third alternative was using data from the MedPAR files. This 
option was discussed in MedPAC's December 2001 report, and involves 
using claims data or data on hospital charges. In order to construct a 
weight for the market basket, the underlying costs of blood must be 
calculated from the claims data. An analysis of cost-to-charge ratios 
of hospitals can determine if this is feasible.
    The final alternative data source is the Bureau of the Census' 
quinquennial Business Expenditure Survey and the Economic Census. A 
weight can be obtained indirectly by taking the ratio of receipts of 
nonprofit blood collectors to total operating expenses of hospitals. 
Some adjustments would be needed in order for the weight calculated in 
this way to be completely valid. In addition, this method assumes that 
all blood used by hospitals comes from nonprofit sources. However, in 
1999, hospitals collected 7 percent of the donated units.
    After a thorough analysis, CMS has determined that the Medicare 
cost reports, after minor adjustments, are the best option. The data 
from the Input-Output Table are not optimal because they are not 
current and would have to be aged using only price data, which do not 
reflect quantity and intensity changes over this period. Although the 
MedPAR data could be adjusted to compute a cost share, using claims 
data is not the preferred alternative. Census data would be an 
attractive option if the cost reports were not available.
    The main weakness of the Medicare cost reports is the inconsistent 
reporting of hospitals in the two blood cost centers. In 1997, only 
48.0 percent of all hospitals reported blood in one or both cost 
centers. However, these hospitals accounted for 62.2 percent of the 
operating costs of all hospitals. In order for the calculation of the 
blood cost share weight to be acceptable, the hospitals that reported 
blood would need to be adjusted to be representative of all hospitals, 
including those that did not report blood on the cost reports.
    Because of the similarity of data in the two blood cost centers, 
the assumption was made that if a hospital reported blood in only one 
of the two cost centers, all of its blood costs were reported in that 
cost center. In the FY 1997 cost reports, of the hospitals that 
reported blood, 41.3 percent reported only in the blood cells cost 
center, 58.2 percent reported only in the blood storing cost center, 
and only 0.5 percent reported in both blood cost centers. To calculate 
a weight, the numerator was the summation of the data in both blood 
cost centers. The denominator was the summation of the operating costs 
of each hospital that reported blood in each cost center minus the 
operating costs of the few hospitals that reported blood in both cost 
centers to avoid double counting.
    The blood cost share calculated from these data was then adjusted 
so that the hospitals reporting blood had the same characteristics of 
all other hospitals. Adjustments were necessary because the hospitals 
that reported blood were more likely to be urban and teaching hospitals 
than those hospitals that did not report blood. The adjustments made 
less than a 0.1 percent difference in the cost share.
    The weight produced using the cost report for FY 1997 was 0.875 
percent. We also looked at cost report data from FYs 1996 and 1998. The 
weights calculated in these years were similar to the FY 1997 weight. 
The calculation of the blood cost share using the alternative data 
sources cited above was similar to the results using the cost reports. 
Given the consistency with these other sources, the representativeness 
of our estimate, and the stability of the cost share, we are proposing 
to use the Medicare cost reports to determine a weight for blood and 
blood products in the proposed hospital market basket.
    Overall, our work resulted in the identification of 23 separate 
cost categories that represent the rebased weights in the proposed 
rebased and revised hospital market basket. There is one more category 
than was included in the FY 1992-based market basket (FY 1992-based had 
22). The differences between the weights of the major categories 
determined from the Medicare cost reports for the proposed FY 1997-
based index and the previous FY 1992-based index are summarized in 
Table 1.

 Table 1.--FY 1992-Based and Proposed FY 1997-Based Prospective Payment
 Hospital Operating Major Cost Categories and Weights as Determined From
                        the Medicare Cost Reports
------------------------------------------------------------------------
                                                  Proposed
                                                 rebased FY    FY 1992-
                                                    1997        based
              Expense categories                  hospital     hospital
                                                   market       market
                                                   basket       basket
------------------------------------------------------------------------
Wages and Salaries............................       50.686       50.244
Employee Benefits.............................       10.970       11.146
Pharmaceuticals...............................        5.416        4.162
Blood and Blood Products......................        0.875  ...........

[[Page 31442]]

 
All Other.....................................       32.053       34.448
                                               -------------------------
    Total.....................................      100.000      100.000
------------------------------------------------------------------------

    Table 2 sets forth all of the proposed market basket cost 
categories and weights. For comparison purposes, the 1992-based cost 
categories and weights are included in the table.

 Table 2.--FY 1992-Based and Proposed FY 1997-Based Prospective Payment
             Hospital Operating Cost Categories and Weights
------------------------------------------------------------------------
                                                  Proposed
                                                 rebased FY    FY 1992-
                                                    1997        based
              Expense categories                  hospital     hospital
                                                   market       market
                                                   basket       basket
                                                  weights      weights
------------------------------------------------------------------------
1. Compensation...............................       61.656       61.390
    A. Wages and Salaries*....................       50.686       50.244
    B. Employee Benefits*.....................       10.970       11.146
2. Professional Fees*.........................        5.401        2.127
3. Utilities..................................        1.353        1.542
    A. Fuel, Oil, and Gasoline................        0.284        0.369
    B. Electricity............................        0.833        0.927
    C. Water and Sewerage.....................        0.236        0.246
4. Professional Liability Insurance...........        0.840        1.189
5. All Other..................................       30.749       33.752
    A. All Other Products.....................       19.537       24.825
        (1.) Pharmaceuticals..................        5.416        4.162
        (2.) Direct Purchase Food.............        1.370        2.314
        (3.) Contract Service Food............        1.274        1.072
        (4.) Chemicals........................        2.604        3.666
        (5.) Blood and Blood Products.........        0.875  ...........
        (6.) Medical Instruments..............        2.192        3.080
        (7.) Photographic Supplies............        0.204        0.391
        (8.) Rubber and Plastics..............        1.668        4.750
        (9.) Paper Products...................        1.355        2.078
        (10.) Apparel.........................        0.583        0.869
        (11.) Machinery and Equipment.........        1.040        0.207
        (12.) Miscellaneous Products..........        0.956        2.236
    B. All Other Services.....................       11.212        8.927
        (1.) Telephone Services...............        0.398        0.581
        (2.) Postage..........................        0.857        0.272
        (3.) All Other: Labor Intensive*......        5.438        7.277
        (4.) All Other: Non-Labor Intensive...        4.519        0.796
                                               -------------------------
            Total.............................      100.000     100.000
------------------------------------------------------------------------
* Labor-related.
Note: Due to rounding, weights may not sum to total.

3. Selection of Price Proxies
    After computing the FY 1997 cost weights for the proposed rebased 
hospital market basket, it is necessary to select appropriate wage and 
price proxies to monitor the rate of change for each expenditure 
category. Most of the indicators are based on Bureau of Labor 
Statistics (BLS) data and are grouped into one of the following BLS 
categories:
     Producer Price Indexes--Producer Price Indexes (PPIs) 
measure price changes for goods sold in other than retail markets. PPIs 
are preferable price proxies for goods that hospitals purchase as 
inputs in producing their outputs because a PPI would better reflect 
the prices faced by hospitals. For example, we used the PPI for ethical 
(prescription) drugs, rather than the Consumer Price Index (CPI) for 
prescription drugs, because hospitals generally purchase drugs directly 
from the wholesaler. The PPIs that we use measure price change at the 
final stage of production.
     Consumer Price Indexes--Consumer Price Indexes (CPIs) 
measure change in the prices of final goods and services bought by the 
typical consumer. Because they may not represent the price faced by a 
producer, the consumer price indexes were used only if an appropriate 
PPI was not available, or if the expenditure was more similar to that 
of retail consumers in general rather than a purchase at the wholesale 
level. For example, the CPI for food purchased away from home was

[[Page 31443]]

used as a proxy for contracted food services.
     Employment Cost Indexes--Employment Cost Indexes (ECIs) 
measure the rate of change in employee wage rates and employer costs 
for employee benefits per hour worked. These indexes are fixed-weight 
indexes and strictly measure the change in wage rates and employee 
benefits per hour. They are appropriately not affected by shifts in 
employment mix.
    Table 3 sets forth the complete proposed hospital market basket 
including cost categories, weights, and price proxies. For comparison 
purposes, the respective FY 1992-based market basket price proxies are 
listed as well. A summary outlining the choice of the various proxies 
follows the table.

  Table 3.--Proposed FY 1997-Based Prospective Payment Hospital Operating Cost Categories, and Weights, and FY
                               1992-Based and Proposed FY 1997-Based Price Proxies
----------------------------------------------------------------------------------------------------------------
                                         Proposed
                                        rebased FY
                                           1997        Proposed rebased FY 1997
          Expense categories             hospital    hospital market basket price     FY 1992 hospital market
                                          market                proxy                    basket price proxy
                                          basket
                                         weights
----------------------------------------------------------------------------------------------------------------
1. Compensation......................       61.656
  A. Wages and salaries \*\..........       50.686  ECI-wages and salaries,        CMS occupational wage proxy.
                                                     civilian hospital workers.
  B. Employee benefits \*\...........       10.970  ECI--benefits, civilian        CMS occupational benefit
                                                     hospital workers.              proxy.
2. Professional fees \*\.............        5.401  ECI--compensation for          ECI--compensation for
                                                     professional specialty &       professional, specialty &
                                                     technical.                     technical.
3. Utilities.........................        1.353
  A. Fuel, oil, and gasoline.........        0.284  PPI refined petroleum          PPI refined petroleum
                                                     products.                      products.
  B. Electricity.....................        0.833  PPI commercial electric power  PPI commercial electric
                                                                                    power.
  C. Water and sewerage..............        0.236  CPI-U water & sewerage         CPI-U water & sewerage
                                                     maintenance.                   maintenance.
4. Professional liability insurance..        0.840  CMS professional liability     CMS professional liability
                                                     insurance premium index.       insurance premium index.
5. All other products................       30.749
  A. All other products..............       19.537
    (1.) Pharmaceuticals.............        5.416  PPI ethical (prescription)     PPI ethical (prescription)
                                                     drugs.                         drugs.
    (2.) Direct purchase food........        1.370  PPI processed foods and feeds  PPI processed foods and
                                                                                    feeds.
    (3.) Contract service food.......        1.274  CPI-U food away from home....  CPI-U food away from home.
    (4.) Chemicals...................        2.604  PPI industrial chemicals.....  PPI industrial chemicals.
    (5.) Blood and blood products....        0.875  PPI blood and blood            N/A.
                                                     derivatives, human use.
    (6.) Medical instruments.........        2.192  PPI medical instruments &      PPI medical instruments and
                                                     equipment.                     equipment.
    (7.) Photographic supplies.......        0.204  PPI photographic supplies....  PPI photographic supplies.
    (8.) Rubber and plastics.........        1.668  PPI rubber & plastic products  PPI rubber and plastic
                                                                                    products.
    (9.) Paper products..............        1.355  PPI converted paper and        PPI converted paper and
                                                     paperboard products.           paperboard products.
    (10.) Apparel....................        0.583  PPI apparel..................  PPI apparel.
    (11.) Machinery and equipment....        1.040  PPI machinery and equipment..  PPI machinery and equipment.
    (12.) Miscellaneous products.....        0.956  PPI finished goods less food   PPI finished goods.
                                                     and energy.
  B. All other services..............       11.212
    (1.) Telephone services..........        0.398  CPI-U telephone services.....  CPI-U telephone services.
    (2.) Postage.....................        0.857  CPI-U postage................  CPI-U postage.
    (3.) All other: labor intensive          5.438  ECI--Compensation for private  ECI--compensation for private
     \*\.                                            service occupations.           service occupations.
    (4.) All other: non-labor                4.519  CPI-U all items..............  CPI-U all items.
     intensive.
                                      -------------
        Total........................      100.000
----------------------------------------------------------------------------------------------------------------
 \*\ Labor related.

a. Wages and Salaries
    For measuring the price growth of wages in the FY 1997-based market 
basket, we are proposing to use the ECI for civilian hospitals. This 
differs from the proxy used in the FY 1992-based index in which a 
blended occupational wage index was used. The blended occupational wage 
proxy used in the FY 1992-based index and the ECI for wages and 
salaries for hospitals both reflect a fixed distribution of occupations 
within the hospital. The major difference between the two proxies is in 
the treatment of professional and technical wages. In the blended 
occupational wage proxy, the professional and technical category is 
blended evenly between the ECI for wages and salaries for hospitals and 
the ECI for wages and salaries for professional and technical 
occupations in the overall economy, instead of hospital-specific 
occupations as reflected in the ECI for hospitals. This blend was done 
to create a normative price index that did not reflect the market 
imperfections in the hospital labor markets that existed for much of 
the 1980s and early 1990s.
    Between 1987 (the first year the ECI for hospitals was available, 
although the pattern existed before then using other measures of 
hospital wages) and 1994, the ECI for wages and salaries for hospital 
workers grew faster than the blended occupational wage proxy. This 
trend then reversed for the 1995 through 2000 period when the ECI grew 
slower than the blended occupational wage proxy each year. This is the 
apparent result of the shift of private insurance enrollees from fee-
for-service plans to managed care plans and the tighter controls these 
plans exhibited over hospital utilization and incentives to shift care 
out of the inpatient hospital setting. More recently, the ECI for wages

[[Page 31444]]

and salaries for hospital workers is again growing faster than the 
blended occupational wage proxy, raising the question of whether the 
relationship between hospital wages and the occupational wage blend 
from 1994 through 2000 was the signaling of a new era in the 
competitiveness of the hospital labor market, or simply the temporary 
reversal of the long-term pattern of labor market imperfections in 
hospitals.
    In order to answer this question, we researched the historical 
determinants of this relationship and estimated what the future market 
conditions are likely to be. Our analysis indicated that the driving 
force behind the long-term differential between hospital wages and the 
blended occupational wage proxy was the increased demand for hospital 
services and the subsequent increase in hospital utilization, 
particularly in outpatient settings. However, during the 1994-2000 
period, the major force behind the reversal of the differential was the 
shift of enrollees to managed care plans that had tighter restrictions 
on hospital utilization and encouraged the shift of care out of the 
hospital setting. To a lesser extent, the robust economic growth and 
tight economy-wide labor markets that accompanied this period helped to 
reverse the differential as well. Over the last year or two, there has 
been a move back towards less restrictive plans, and a subsequent 
increase in the utilization of medical services. This recent surge 
appears to reflect the true underlying fundamentals of health care 
demand. This concept is reinforced by the similar patterns being 
observed for nursing homes and other health sectors as well. This is an 
important development, specifically when compared to the ECI for wages 
and salaries for nursing homes, which reflect less skilled occupations, 
yet still experienced a similar acceleration in wage growth. Thus, we 
would expect that this recent surge in hospital wages is reflective of 
competitive labor market conditions, and would likely persist only as 
long as the underlying demand for health care was accelerating.
    While the shift to managed care plans had a noticeable one-time 
effect, we do feel that the hospital labor market is more competitive 
than prior to this period and that the expected shift towards more 
restrictive insurance plans over the coming decade will act to create a 
wage differential that reflects the underlying increases in demand for 
hospital services. As shown in Table 5, using the ECI has only a minor 
overall impact (0.1 percentage point per year) from FY 1995 through FY 
2001 on the hospital market basket. For FY 2003, the proposed hospital 
market basket is forecast to increase 0.2 percentage points faster (3.3 
vs. 3.1) than it would have if the occupational blend had been used. 
Based on this, we are proposing to use the ECI for wages and salaries 
for hospitals and the ECI for benefits for hospitals as the proxies in 
the hospital market basket for wages and benefits, respectively. The 
ECI met our criteria of relevance, reliability, availability, and 
timeliness. Relevance means that the proxy is applicable and 
representative of the cost category that it proxies. Reliability 
indicates that the index is based on valid statistical methods and has 
low sampling variability. Availability means that the proxy is publicly 
available. Timeliness implies that the proxy is published regularly, at 
least once a quarter.
b. Employee Benefits
    The proposed FY 1997-based hospital market basket uses the ECI for 
employee benefits for civilian hospitals. This differs from the FY 
1992-based index in which a blended occupational index was used. Our 
conclusions were based on a similar analysis that was done for the 
wages and salaries proxy described above.
c. Nonmedical Professional Fees
    The ECI for compensation for professional and technical workers in 
private industry is applied to this category since it includes 
occupations such as management and consulting, legal, accounting and 
engineering services. The same price measure was used in the FY 1992-
based market basket.
d. Fuel, Oil, and Gasoline
    The percentage change in the price of gas fuels as measured by the 
PPI (Commodity Code #0552) was applied to this component. The same 
price measure was used in the FY 1992-based market basket.
e. Electricity
    The percentage change in the price of commercial electric power as 
measured by the PPI (Commodity Code #0542) was applied to this 
component. The same price measure was used in the FY 1992-based market 
basket.
f. Water and Sewerage
    The percentage change in the price of water and sewerage 
maintenance as measured by the Consumer Price Index (CPI) for all urban 
consumers (CPI Code # CUUR0000SEHG01) was applied to this component. 
The same price measure was used in the FY 1992-based market basket.
g. Professional Liability Insurance
    The percentage change in the hospital professional liability 
insurance price as estimated by the CMS Hospital Malpractice Index was 
applied. In the FY 1992-based market basket, the same proxy was used.
    We are currently conducting research into improving our proxy for 
professional liability insurance. This research includes subcontracting 
with ANASYS through a contract with DRI-WEFA to extend the results of 
its NHMIS survey to set up a sample of hospitals from which malpractice 
insurance premium data will be directly collected. This new 
information, which would include liability estimates for hospitals that 
self-insure, would be combined with our current proxy data to obtain a 
more accurate price measure. Depending on the timing of this new 
information, the proxy for professional liability insurance in the 
market basket may be modified for the final rule. In addition, we are 
researching a BLS PPI for malpractice premiums that may be a more 
appropriate proxy for this cost category.
h. Pharmaceuticals
    The percentage change in the price of prescription drugs as 
measured by the PPI (Commodity Code # PPI283D#RX) was applied to this 
variable. This is a special index produced by BLS. The previous price 
proxy used in the FY 1992-based index (Commodity Code #0635) was 
discontinued after BLS revised its indexes.
i. Food, Direct Purchases
    The percentage change in the price of processed foods and foods as 
measured by the PPI (Commodity Code #02) was applied to this component. 
The same price measure was used in the FY 1992-based market basket.
j. Food, Contract Services
    The percentage change in the price of food purchased away from home 
as measured by the CPI for all urban consumers (CPI Code # 
CUUR0000SEFV) was applied to this component. The same price measure was 
used in the FY 1992-based market basket.
k. Chemicals
    The percentage change in the price of industrial chemical products 
as measured by the PPI (Commodity Code #061) was applied to this 
component. While the chemicals in this category include industrial as 
well as other types

[[Page 31445]]

of chemicals, the industrial chemicals component constitutes the 
largest proportion by far. Thus, Commodity Code #061 is the appropriate 
proxy. The same price measure was used in the FY 1992-based market 
basket.
l. Blood and Blood Products
    The percentage change in the price of blood and derivatives for 
human use as measured by the PPI (Commodity Code #063711) was applied 
to this component. As discussed earlier in this preamble, a comparable 
cost category was not available in the FY 1992-based market basket.
    We are proposing that the blood and blood products cost category 
use the PPI for blood and blood derivatives as its price proxy. This 
proxy is relevant, reliable, available, and timely. We considered 
placing the blood weight in the Chemicals or Pharmaceuticals cost 
category, but found this made only minor changes to the total index. We 
also considered constructing an index based on blood cost data received 
from the American Red Cross, America's Blood Centers, and Zeman and 
Company. However, these data are collected annually and not widely 
available. The PPI for blood and blood derivatives was the only index 
we found that met all of our criteria.
m. Surgical and Medical Equipment
    The percentage change in the price of medical and surgical 
instruments as measured by the PPI (Commodity Code #1562) was applied 
to this component. The same price measure was used in the FY 1992-based 
market basket.
n. Photographic Supplies
    The percentage change in the price of photographic supplies as 
measured by the PPI (Commodity Code #1542) was applied to this 
component. The same price measure was used in the FY 1992-based market 
basket.
o. Rubber and Plastics
    The percentage change in the price of rubber and plastic products 
as measured by the PPI (Commodity Code #07) was applied to this 
component. The same price measure was used in the FY 1992-based market 
basket.
p. Paper Products
    The percentage change in the price of converted paper and 
paperboard products as measured by the PPI (Commodity Code #0915) was 
used. The same price measure was used in the FY 1992-based market 
basket.
q. Apparel
    The percentage change in the price of apparel as measured by the 
PPI (Commodity Code #381) was applied to this component. The same price 
measure was used in the FY 1992-based market basket.
r. Machinery and Equipment
    The percentage change in the price of machinery and equipment as 
measured by the PPI (Commodity Code #11) was applied to this component. 
The same price measure was used in the FY 1992-based market basket.
s. Miscellaneous Products
    The percentage change in the price of all finished goods less food 
and energy as measured by the PPI (Commodity Code #SOP3500) was applied 
to this component. The percentage change in the price of all finished 
goods was used in the FY 1992-based market basket. This change was made 
to remove the effect of food and energy prices, which are already 
captured elsewhere in the market basket.
t. Telephone
    The percentage change in the price of telephone services as 
measured by the CPI for all urban consumers (CPI Code # CUUR0000SEED) 
was applied to this component. The same price measure was used in the 
FY 1992-based market basket.
u. Postage
    The percentage change in the price of postage as measured by the 
CPI for all urban consumers (CPI Code # CUUR0000SEEC01) was applied to 
this component. The same price measure was used in the FY 1992-based 
market basket.
v. All Other Services, Labor Intensive
    The percentage change in the ECI for compensation paid to service 
workers employed in private industry was applied to this component. The 
same price measure was used in the FY 1992-based market basket.
w. All Other Services, Nonlabor Intensive
    The percentage change in the all-items component of the CPI for all 
urban consumers (CPI Code # CUUR0000SA0) was applied to this component. 
The same price measure was used in the FY 1992-based market basket.
    For further discussion of the rationale for choosing many of the 
specific price proxies, we reference the August 30, 1996 final rule (61 
FR 46326). Table 4 shows the historical and forecasted updates under 
both the proposed FY 1997-based and the FY 1992-based market baskets. 
For comparison purposes, the FY 1997-based index incorporating 
different wage and benefit proxies is included in Table 5.

 Table 4.--FY 1992-Based and Proposed FY 1997-Based Prospective Payment
           Hospital Operating Index Percent Change, 1995-2004
------------------------------------------------------------------------
                                                Prospective
                                                  rebased      FY 1992-
                                                    1997        based
               Fiscal year (FY)                   hospital      market
                                                   market       basket
                                                   basket
------------------------------------------------------------------------
Historical data:
    FY 1995...................................          2.8          3.1
    FY 1996...................................          2.3          2.4
    FY 1997...................................          1.6          2.1
    FY 1998...................................          2.7          2.9
    FY 1999...................................          2.7          2.5
    FY 2000...................................          3.3          3.6
    FY 2001...................................          4.2          4.1
    Average FYs 1995-2001.....................          2.8          3.0
Forecast:
    FY 2002...................................          3.7          2.8
    FY 2003...................................          3.3          3.0
    FY 2004...................................          2.9          3.2

[[Page 31446]]

 
    Average FYs 2002-2004.....................          3.3         3.0
------------------------------------------------------------------------
Source: Global Insights, Inc, DRI-WEFA, 1st Qtr. 2002; @USMACRO/MODTREND
  @CISSIM/TRENDLONG0202.

    Table 5 indicates that switching the proxy for wages and benefits 
to the ECI for Civilian Hospitals has a minimal effect on the FY 2003 
update and a minimal effect over time. However, we believe that it is a 
more appropriate measure of price change in hospital wages and benefit 
prices given the current labor market conditions facing hospitals.

  Table 5.--Proposed 1997-Based Prospective Payment Hospital Operating
  Index Percent Change, Using Different Wage and Benefit Proxies, 1995-
                                  2004
------------------------------------------------------------------------
                                                 Proposed
                                                 rebased      Proposed
                                                   1997     rebased 1997
                                                 hospital      market
                                                  market    basket using
               Fiscal year (FY)                   basket    occupational
                                                using ECIs    wage and
                                                for wages      benefit
                                                   and         proxies
                                                 benefits
------------------------------------------------------------------------
Historical data:
    FY 1995..................................          2.8           2.9
    FY 1996..................................          2.3           2.5
    FY 1997..................................          1.6           2.3
    FY 1998..................................          2.7           3.2
    FY 1999..................................          2.7           2.9
    FY 2000..................................          3.3           3.5
    FY 2001..................................          4.2           4.0
    Average FYs 1995-2001....................          2.8           3.0
Forecast:
    FY 2002..................................          3.7           3.0
    FY 2003..................................          3.3           3.1
    FY 2004..................................          2.9           3.1
    Average FYs 2002-2004....................          3.3           3.
------------------------------------------------------------------------
Source: Global Insights, Inc, DRI-WEFA, 1st Qtr. 2002; @USMACRO/MODTREND
  @CISSIM/TRENDLONG0202.

    The reintroduction of a cost component for blood and blood products 
in the market basket also does not make a noticeable impact on the 
market basket. Table 6 shows the proposed FY 1997-based market basket 
percentage change with blood broken out separately compared to market 
baskets with blood included in either chemicals or drugs.

  Table 6.--Proposed 1997-Based Prospective Payment Hospital Operating
     Index Percent Change, Using Cost Categories for Blood and Blood
                           Products, 1995-2004
------------------------------------------------------------------------
                                    Proposed FY 1997-based market basket
                                  --------------------------------------
                                    With blood
         Fiscal year (FY)              as a      With blood   With blood
                                     separate   included in  included in
                                     category    chemicals      drugs
------------------------------------------------------------------------
Historical data:
    FY 1995......................          2.8          2.9          2.8
    FY 1996......................          2.3          2.3          2.4
    FY 1997......................          1.6          1.6          1.6
    FY 1998......................          2.7          2.7          2.8
    FY 1999......................          2.7          2.5          2.7
    FY 2000......................          3.3          3.4          3.3
    FY 2001......................          4.2          4.2          4.2
    Average FYs 1995-2001........          2.8          2.8          2.8
Forecast:
    FY 2002......................          3.7          3.6          3.7
    FY 2003......................          3.3          3.3          3.3
    FY 2004......................          2.9          3.0          3.0
    Average FYs 2002-2004........          3.3          3.3         3.3
------------------------------------------------------------------------
Source: Global Insights, Inc, DRI-WEFA, 1st Qtr. 2002; @USMACRO/MODTREND
  @CISSIM/TRENDLONG0202.


[[Page 31447]]

4. Labor-Related Share
    Sections 1886(d)(2)(H) and (d)(3)(E) of the Act direct the 
Secretary to estimate from time to time the proportion of payments that 
are labor-related: ``The Secretary shall adjust the proportion (as 
estimated by the Secretary from time to time) of hospitals' costs which 
are attributable to wages and wage-related costs of the DRG prospective 
payment rates * * *''.
    In its June 2001 Report to Congress, MedPAC recommended that ``To 
ensure accurate input-price adjustments in Medicare's prospective 
payment systems, the Secretary should reevaluate current assumptions 
about the proportions of providers' costs that reflect resources 
purchased in local and national markets.'' (Report to the Congress: 
Medicare in Rural America, p. 80, Recommendation 4D.) MedPAC believes 
that the labor-related share is an estimate of the national average 
proportion of providers' costs associated with inputs that are only 
affected by local market wage levels. MedPAC recommended the labor-
related share include the weights for wages and salaries, fringe 
benefits, contract labor, and other labor-related costs for locally 
purchased inputs only. By changing the definition, and thereby lowering 
the labor-related share, funds would be transferred from urban to rural 
hospitals, which generally have wage index values less than 1.0.
    Given the recommendation by MedPAC and our proposal to rebase and 
revise the hospital market basket, we have reviewed the definition and 
methodology of the labor-related share. In addition, we reviewed the 
differences between urban and rural hospitals, updated regression 
results, and began reviewing possible alternative methodologies for 
calculating the labor-related share.
    The labor-related share is used to determine the proportion of the 
national prospective payment system base payment rate to which the area 
wage index is applied. In the past we have defined the labor-related 
share for prospective payment system acute care hospitals as the 
national average proportion of operating costs that are related to, 
influenced by, or vary with the local labor market. The labor-related 
share for the acute care hospital inpatient prospective payment system 
market basket has been the sum of the weights for wages and salaries, 
fringe benefits, professional fees, contract labor, postage, business 
services, and labor-intensive services.
    The difference between the CMS definition of the labor-related 
share and MedPAC's recommendation is that MedPAC includes inputs that 
can only be purchased in the local labor market, while CMS' includes 
inputs that are related to, influenced by, or vary with the local labor 
market, even if those services may be purchased at the national level. 
We believe our measure of the labor-related share reflects the cost of 
those inputs that are likely purchased in the local market, and is 
consistent with the requirements under sections 1886(d)(2)(H) and 
(d)(3)(E) of the Act described at the beginning of section IV.A.4. of 
this proposed rule.
    In connection with the rebasing and revising of the prospective 
payment system hospital market basket to 1997 data, we are proposing to 
recalculate the labor-related share of the standardized amounts. Our 
methodology is consistent with that used in the past to determine the 
labor-related share, which is the summation of the cost categories from 
the market basket deemed to vary with the local labor market. Based on 
the relative weights listed in Table 7, the proposed labor-related 
portion (wages and salaries, employee benefits, professional fees, and 
all other labor-intensive services) of the prospective payment system 
hospital market basket is 72.5 percent, and the nonlabor-related 
portion is 27.5 percent. By capturing more than just the direct labor 
costs that are available from the Medicare cost reports, our definition 
captures the ``buy-versus-hire'' decisions hospitals make in the 
purchase of their inputs. Accordingly, effective with discharges 
occurring on or after October 1, 2002, we are proposing to use these 
revised labor-related and nonlabor-related shares of the large urban 
and other areas' standardized amounts used to establish the prospective 
payment rates. Table 7 compares the FY 1992-based labor-related share 
with the proposed FY 1997-based labor-related share. As shown in Table 
7, we have removed postage costs from the proposed FY 1997-based labor-
related share because we do not believe these costs are likely to vary 
with the local labor market. Also, by changing the data source used to 
determine professional fees, the weight for that category has increased 
significantly.

                      Table 7.--Labor-Related Share
------------------------------------------------------------------------
                                     FY 1992-     Proposed
          Cost category               based      1997-based   Difference
                                      weight       weight
------------------------------------------------------------------------
Wages and salaries...............       50.244       50.686        0.442
Fringe benefits..................       11.146       10.970       -0.176
Nonmedical professional fees.....        2.127        5.401        3.274
Postal services*.................        0.272  ...........       -0.272
Other labor-intensive services**.        7.277        5.438       -1.839
                                  --------------------------------------
    Total labor-related..........       71.066       72.495        1.429
                                  --------------------------------------
    Total nonlabor-related.......       28.934       27.505      -1.429
------------------------------------------------------------------------
* No longer considered to be labor-related.
** Other labor-intensive services includes landscaping services,
  services to buildings, detective and protective services, repair
  services, insurance services, laundry services, auto parking and
  repairs, physical fitness facilities, other medical services, colleges
  and professional schools, and other government enterprises.

    We are concerned that the result of this methodology could have 
negative impacts that would fall predominantly on rural hospitals and 
are interested in public comments on alternative methodologies. While 
we are not proposing to change the methodology for calculating the 
labor-related share in this proposed rule, we have begun the research 
necessary to reevaluate the current assumptions used in determining 
this share. This reevaluation is consistent with the MedPAC 
recommendation in MedPAC's June 2001 report. Our research involves 
analyzing the compensation share separately for urban and rural 
hospitals, using regression analysis to determine

[[Page 31448]]

the proportion of costs influenced by the area wage index, and 
exploring alternative methodologies to determine whether all or just a 
portion of professional fees and nonlabor intensive services should be 
considered labor-related. Although we have not completed our research 
into this issue, we are summarizing some of our preliminary findings 
below. We encourage comments on this research and any information that 
is available to help determine the most appropriate measure.
    The compensation share of costs for hospitals in rural areas was 
higher on average than the compensation share for hospitals in urban 
areas. Using FY 1997 Medicare cost report data, rural areas had an 
average compensation share of 62.7 percent, while urban areas had a 
share of 61.5 percent. This compares to a share of 61.7 percent for all 
hospitals. These findings were validated consistently through our 
regression analysis, described in more detail below, as the coefficient 
on the wage index was higher when the regressions were run only for 
rural hospitals compared to when the regressions were run only for 
urban hospitals. Based on these findings, it does not appear that using 
a national average labor share for all hospitals to adjust the national 
payment rate by the area wage index disadvantages rural hospitals that 
tend to have a wage index value below 1.0.
    Our research attempted to validate our national average labor share 
by conducting regression analysis to determine the proportion of 
hospital's costs that varied with the area wage index. We have 
conducted this type of regression analysis before in helping to 
determine the labor-related share, most recently for the SNF 
prospective payment system (66 FR 39585). Our first step was to edit 
the data, which had significant outliers in some of the variables we 
used in the regressions. We originally began with an edit that excluded 
the top and bottom 5 percent of reports based on average Medicare cost 
per discharge and number of discharges. We also used edits to exclude 
reports that did not meet basic criteria for use, such as having costs 
greater than 0 for total, operating, and capital for the overall 
facility and for only the Medicare proportion. We also required that 
the hospital occupancy rate, length of stay, number of beds, full-time 
equivalents (FTEs), and overall and Medicare discharges be greater than 
0. Finally, we excluded reports with occupancy rates greater than 1.
    Our initial regression specification (in log form) was the Medicare 
operating cost per Medicare discharge as the dependent variable and the 
independent variables being the area wage index, the case mix index, 
the ratio of interns and residents per bed (as proxy for IME status), 
and a dummy for large urban hospitals. This regression produced a 
coefficient for all hospitals for the area wage index of 0.638 (which 
is equivalent to the labor share and can be interpreted as an 
elasticity because of the log specification) with an adjusted R-squared 
of 64.3. While on the surface this would appear to be a reasonable 
result, this same specification for urban hospitals had a coefficient 
of 0.532 (adjusted R-squared = 53.2) and a coefficient of 0.709 
(adjusted R-squared = 36.4) for rural hospitals. This highlighted some 
apparent problems with the specification because the overall regression 
results appear to be masking underlying problems. It would not seem 
reasonable that urban hospitals would have a labor share below their 
actual compensation share or that the discrepancy between urban and 
rural hospitals would be this large. The other major problem with the 
regression was that the coefficient on the case-mix index was 
significantly below 1.0 for each specification. When we standardized 
the Medicare operating cost per Medicare discharge for case mix, the 
fit fell dramatically and the urban/rural discrepancy became even 
larger.
    Based on this initial result, we tried two modifications to the 
regressions to correct for the underlying problems. First, we edited 
the data differently to determine if a few reports were causing the 
inconsistent results. We found that when we tightened the edits, the 
wage index coefficient was lower and the fit was worse. When we 
loosened the edits, we found higher wage index coefficients and still a 
worse fit. Second, we added variables to the regression equation to 
attempt to explain some of the variation that was not being captured. 
We found the best fit occurred when the following variables were added: 
the occupancy rate, the number of hospital beds, a dummy for control 
status, the Medicare length of stay, the number of FTEs per bed, and 
the age of fixed assets. The result of this specification was a wage 
index coefficient of 0.620 (adjusted R-squared = 68.7), with the 
regression on rural hospitals having a coefficient of 0.772 (adjusted 
R-squared = 45.0) and the regression on urban hospitals having a 
coefficient of 0.474 (adjusted R-squared = 60.9). Neither of these 
alternatives seemed to help the underlying difficulties with the 
regression analysis.
    Because the market basket method determines the proportion of 
labor-related costs for the entire hospital, not just Medicare costs 
(due to the unavailability of Medicare specific data for such detailed 
cost categories) we also ran the regressions on overall hospital 
operating cost per discharge. The initial specification (only 4 
independent variables) produced similar results to those discussed 
above, that is, what appeared to be a reasonable overall share but with 
major problems underlying the data. The more detailed specification 
also did not improve the results over the previous runs.
    Because of these problems, we did not believe the regression 
analysis was producing enough sound evidence at this point for us to 
make the decision to change from the current method for calculating the 
labor-related share using market basket categories. We plan to continue 
to analyze these data and work on alternative specifications, including 
working with MedPAC, which has done a similar analysis in its studies 
of payment adequacy in the past. We welcome comments on this approach, 
given the difficulties we have encountered.
    We also have been examining ways to refine our market basket 
approach to more accurately account for the proportion of costs 
influenced by the local labor market. Specifically, we have been 
looking at the professional fees and labor intensive cost categories to 
determine if only a proportion of the costs in these categories should 
be considered labor-related, not the entire cost category. Professional 
fees include management and consulting fees, legal services, accounting 
services, and engineering services. Labor-intensive services are mostly 
building services, but also include other maintenance and repair and 
insurance services. While we have identified some possible approaches 
for accomplishing this, we do not believe at this point that we have 
completely validated them and thus are not proposing to change from our 
current method. Below we briefly describe the possible approaches and 
some of the issues surrounding these approaches.
    One possible option would be to only include in the labor-related 
share the compensation portion of the cost category for each industry 
included in professional fees and labor-intensive services. This could 
be done using data from the 1997 BES, which reports detailed cost 
categories by industry (SIC) code. For example, management and 
consulting fees (SIC 874) is one of the major pieces of professional 
fees. The BES indicates that compensation accounts for 59.2 percent of 
operating costs in management and consulting

[[Page 31449]]

fees. If we only considered for inclusion in the labor-related share 
the portion that is compensation, this would result in a lower labor 
share. However, at this point, there does not appear to be enough 
information available from the BES to do this for every industry code. 
It is also not clear that at least some proportion of noncompensation 
costs of these inputs for hospitals would not vary with the local labor 
market. We are still researching the appropriateness of this option and 
whether it could be used to assist in determining the labor-related 
share.
    Another possible option would be to use data from the Bureau of the 
Census' 1992 Enterprise Statistics to attempt to determine the 
proportion of costs for professional fees and labor-intensive services 
associated with centrally located overhead. That is, could we identify 
the proportion of costs that are borne in a central location such that 
they would not be related to the local labor market? The Enterprise 
Statistics include payroll data for both auxiliary establishments of a 
multiestablishment company and the entire company. Since auxiliary 
establishments primarily manage, administer, service, and support the 
activities of other establishments of the company, we were considering 
using this information to estimate the proportion of professional fees 
and labor-intensive services associated with central locations instead 
of with the location of the hospital. The Enterprise Statistics data 
are available for specific enterprise industry codes (EIC) that could 
seemingly be matched to the industry codes from the I-O used to 
determine professional fees and labor-intensive services. The 
methodology would consist of determining the auxiliary establishments 
payroll share of the total establishment, and subtracting that portion 
from the compensation portion of expenses for each I-O industry code. 
The initial research into this method is pointing out some difficulties 
in matching industry and EIC codes since the Enterprise Statistics do 
not contain as much detail as the I-O. In addition, it is not clear yet 
that this method would remove the appropriate amount of central office 
labor costs. We will continue to research this option, but at this time 
we are not proposing to use it in the calculation of the labor-related 
share.
    We plan to continue researching whether an alternative methodology 
for determining the labor-related share would be more appropriate than 
our current methodology, including working with MedPAC. We plan to 
complete this research prior to August 1 and would make the appropriate 
changes in the final rule if we found another methodology to be 
superior to our current methodology. At this time, we are proposing to 
continue to use our existing methodology in determining the labor-
related share.
5. Separate Market Basket for Hospitals and Hospital Units Excluded 
From the Acute Care Hospital Inpatient Prospective Payment System
    In its March 1, 1990 report, ProPAC recommended that we establish a 
separate market basket for hospitals and hospital units excluded from 
the acute care hospital inpatient prospective payment system. Effective 
with FY 1991, we adopted ProPAC's recommendation to implement separate 
market baskets. (See the September 4, 1990 final rule (55 FR 36049).) 
Prospective payment system hospitals and excluded hospitals and units 
tend to have different case mixes, practice patterns, and composition 
of inputs. The fact that excluded hospitals are not included under the 
acute care hospital inpatient prospective payment system in part 
reflects these differences. Studies completed by CMS, ProPAC, and the 
hospital industry have documented different weights for excluded 
hospitals and units and prospective payment system hospitals.
    The excluded hospital market basket is a composite set of weights 
for Medicare-participating psychiatric hospitals and units, 
rehabilitation hospitals and units, long-term care hospitals, 
children's hospitals, and cancer hospitals. We are proposing to use 
cost report data for excluded freestanding hospitals whose Medicare 
average length of stay is within 15 percent (that is, 15 percent higher 
or lower) of the total facility average length of stay for excluded 
hospitals, except psychiatric hospitals. A tighter measure of Medicare 
length of stay within 8 percent (that is, 8 percent higher or lower) of 
the total facility average length of stay is proposed for freestanding 
psychiatric hospitals. This was done because psychiatric hospitals have 
a relatively small proportion of costs from Medicare and a relatively 
small share of Medicare psychiatric cases. While the 15 percent length 
of stay edit was used for the FY 1992-based index, the tighter, 8 
percent edit for psychiatric hospitals was not. We believe that 
limiting our sample to hospitals with a Medicare average length of stay 
within a comparable range to the total facility average length of stay 
provides a more accurate reflection of the structure of costs for 
treating Medicare patients.
    Table 8 compares major weights in the proposed rebased FY 1997 
market basket for excluded hospitals with weights in the proposed 
rebased FY 1997 market basket for acute care prospective payment system 
hospitals. Wages and salaries are 51.998 percent of total operating 
costs for excluded hospitals compared to 50.686 percent for acute care 
prospective payment hospitals. Employee benefits are 11.253 percent for 
excluded hospitals compared to 10.970 percent for acute care 
prospective payment hospitals. As a result, compensation costs (wages 
and salaries plus employee benefits) for excluded hospitals are 63.251 
percent of costs compared to 61.656 percent for acute care prospective 
payment hospitals, reflecting the more labor-intensive services 
conducted in excluded hospitals.
    A significant difference in the category weights also occurs in 
pharmaceuticals. Pharmaceuticals represent 5.416 percent of costs for 
acute care prospective payment hospitals and 6.940 percent for excluded 
hospitals. The weights for the excluded hospital market basket were 
derived using the same data sources and methods as for the acute care 
prospective payment market basket as outlined previously. Differences 
in weights between the proposed excluded hospital and acute care 
prospective payment hospital market baskets do not necessarily lead to 
significant differences in the rate of price growth for the two market 
baskets. If individual wages and prices move at approximately the same 
annual rate, both market baskets may have about the same overall price 
growth, even though the weights may differ substantially, because both 
market baskets use the same wage and price proxies. Also, offsetting 
price increases for various cost components can result in similar 
composite price growth in both market baskets.

[[Page 31450]]



   Table 8.--Proposed FY 1997-Based Excluded Hospital and Prospective
   Payment Hospital Market Baskets, Comparison of Significant Weights
------------------------------------------------------------------------
                                                               Proposed
                                                  Proposed     rebased
                                                  rebased        1997
                                                    1997     Prospective
                   Category                       excluded     Payment
                                                  hospital      System
                                                   market      hospital
                                                   basket       market
                                                                basket
------------------------------------------------------------------------
Wages and salaries............................       51.998       50.686
Employee benefits.............................       11.253       10.970
Professional fees.............................        4.859        5.401
Pharmaceuticals...............................        6.940        5.416
All other.....................................       24.950       25.527
                                               -------------------------
    Total.....................................      100.000      100.000
------------------------------------------------------------------------

    Table 9 lists the cost categories, weights, and proxies for the 
proposed FY 1997-based excluded hospital market basket. For comparison, 
the FY 1992-based cost category weights are included. The proxies are 
the same used in the proposed FY 1997-based acute care hospital 
inpatient prospective payment system market basket discussed above.

  Table 9.--FY 1992-Based and Proposed FY 1997-Based Excluded Hospital Operating Cost Categories, Weights, and
                                                  Price Proxies
----------------------------------------------------------------------------------------------------------------
                                                  Proposed
                                                  rebased      FY 1992-
                                                    1997        based
                                                  excluded     excluded
              Expense categories                  hospital     hospital          FY 1997-based price proxy
                                                   market       market
                                                   basket       basket
                                                  weights      weights
----------------------------------------------------------------------------------------------------------------
1. Compensation...............................       63.251       63.721  ......................................
  A. Wages and salaries*......................       51.998       52.152  ECI-wages and salaries, civilian
                                                                           hospitals.
  B. Employee benefits*.......................       11.253       11.569  ECI-benefits, civilian hospitals.
2. Professional fees*.........................        4.859        2.098  ECI-compensation for professional,
                                                                           specialty & technical.
3. Utilities..................................        1.296        1.675  --
  A. Fuel, oil, and gasoline..................        0.272        0.401  PPI commercial natural gas.
  B. Electricity..............................        0.798        1.007  PPI commercial electric power.
  C. Water and sewerage.......................        0.226        0.267  CPI-U water and sewerage maintenance.
4. Professional liability insurance...........        0.805        1.081  CMS professional liability insurance
                                                                           premiums index.
5. All other..................................       29.790       31.425  --
  A. All other products.......................       19.680       24.227  --
    (1) Pharmaceuticals.......................        6.940        3.070  PPI ethical (prescription) drugs.
    (2) Direct purchase food..................        1.233        2.370  PPI processed foods & feeds.
    (3) Contract service food.................        1.146        1.098  CPI-U food away from home.
    (4) Chemicals.............................        2.343        3.754  PPI industrial chemicals.
    (5) Blood and blood products..............        0.821          N/A  PPI blood and blood derivatives, human
                                                                           use.
    (6) Medical instruments...................        1.972        3.154  PPI medical instruments & equipment.
    (7) Photographic supplies.................        0.184        0.400  PPI photographic supplies.
    (8) Rubber and plastics...................        1.501        4.865  PPI rubber & plastic products.
    (9) Paper products........................        1.219        2.182  PPI converted paper & paperboard
                                                                           products.
    (10) Apparel..............................        0.525        0.890  PPI apparel.
    (11) Machinery and equipment..............        0.936        0.212  PPI machinery & equipment.
    (12) Miscellaneous products...............        0.860        2.232  PPI finished goods less food and
                                                                           energy.
  B. All other services.......................       10.110        7.198  --
    (1) Telephone services....................        0.382        0.631  CPI-U telephone services.
    (2) Postage...............................        0.771        0.295  CPI-U postage.
    (3) All other: labor intensive*...........        4.892        5.439  ECI-compensation for private service
                                                                           occupations.
    (4) All other: Non-labor intensive........        4.065        0.833  CPI-U all items.
        Total.................................      100.000      100.000  --
----------------------------------------------------------------------------------------------------------------
*Labor-related.
Note: Due to rounding, weights may not sum to total.

    Table 10 shows the historical and forecasted updates under both the 
proposed FY 1997-based and the FY 1992-based excluded hospital market 
baskets.

[[Page 31451]]



  Table 10.--FY 1992-Based and Proposed FY 1997-Based Excluded Hospital
                Operating Index Percent Change, 1995-2004
------------------------------------------------------------------------
                                                  Proposed
                                                  rebased      FY 1992-
                                                    1997        based
               Fiscal year (FY)                   excluded     excluded
                                                  hospital     hospital
                                                   market       market
                                                   basket       basket
------------------------------------------------------------------------
Historical data:
    FY 1995...................................          2.7          3.2
    FY 1996...................................          2.4          2.5
    FY 1997...................................          1.7          2.0
    FY 1998...................................          3.0          2.7
    FY 1999...................................          2.9          2.4
    FY 2000...................................          3.3          3.6
    FY 2001...................................          4.3          4.1
    Average FYs 1995-2001.....................          2.9          2.9
Forecast:
    FY 2002...................................          3.7          2.8
    FY 2003...................................          3.4          3.0
    FY 2004...................................          3.0          3.1
    Average FYs 2002-2004.....................          3.4         3.0
------------------------------------------------------------------------
Source: Global Insights, Inc, DRI-WEFA, 1st Qtr. 2002; @USMACRO/MODTREND
  @CISSIM/TRENDLONG0202.

    A comparison of the proposed FY 1997-based index incorporating the 
new wage and benefits proxies (ECIs) and updated occupational wage 
proxies is included in Table 11.

   Table 11.--Proposed FY 1997-Based Excluded Hospital Operating Index
   Percent Change, Using Different Wage and Benefit Proxies, 1995-2004
------------------------------------------------------------------------
                                                 Proposed rebased 1997
                                                excluded hospital market
                                                         basket
                                              --------------------------
               Fiscal year (FY)                 Using ECIs      Using
                                                   for      occupational
                                                 hospital     wage and
                                                wages and      benefit
                                                 nenefits      proxies
------------------------------------------------------------------------
Historical data:
    FY 1995..................................          2.7           2.9
    FY 1996..................................          2.4           2.5
    FY 1997..................................          1.7           2.3
    FY 1998..................................          3.0           3.4
    FY 1999..................................          2.9           3.1
    FY 2000..................................          3.3           3.5
    FY 2001..................................          4.3           4.0
    Average FYs 1995-2001....................          2.9           3.1
Forecast:
    FY 2002..................................          3.7           3.1
    FY 2003..................................          3.4           3.2
    FY 2004..................................          3.0           3.2
    Average FYs 2002-2004....................          3.4          3.2
------------------------------------------------------------------------
Source: Global Insights, Inc, DRI-WEFA, 1st Qtr. 2002; @USMACRO/MODTREND
  @CISSIM/TRENDLONG0202.

    Like the proposed FY 1997-based prospective payment hospital index 
showed, there is little difference in the index over time when 
different compensation proxies are used. Table 12 shows the labor-
related share for excluded hospitals.

           Table 12.--Labor-Related Share, Excluded Hospitals
------------------------------------------------------------------------
                                     FY 1992-   Proposed FY
          Cost category               based      1997-based   Difference
                                      weight       weight
------------------------------------------------------------------------
Wages and salaries...............       52.152       51.998       -0.154
Fringe benefits..................       11.569       11.253       -0.316
Nonmedical professional fees.....        2.098        4.859        2.761
Postal services*.................        0.295  ...........       -0.295
    Other labor intensive                5.439        4.892       -0.547
     services**..................
                                  --------------------------------------
    Total labor-related..........       71.553       73.002        1.449

[[Page 31452]]

 
    Total nonlabor-related.......       28.447       26.998      -1.449
------------------------------------------------------------------------
* No longer considered to be labor-related.
** Other labor-intensive services includes landscaping services,
  services to buildings, detective and protective services, repair
  services, insurance services, laundry services, auto parking and
  repairs, physical fitness facilities, other medical services, colleges
  and professional schools, and other government enterprises.

B. Capital Input Price Index

    The Capital Input Price Index (CIPI) was originally detailed in the 
September 1, 1992 Federal Register (57 FR 40016). There have been 
subsequent discussions of the CIPI presented in the May 26, 1993 (58 FR 
30448), September 1, 1993 (58 FR 46490), May 27, 1994 (59 FR 27876), 
September 1, 1994 (59 FR 45517), June 2, 1995 (60 FR 29229), September 
1, 1995 (60 FR 45815), May 31, 1996 (61 FR 27466), and August 30, 1996 
(61 FR 46196) rules in the Federal Register. The August 30, 1996 rule 
discussed the most recent revision and rebasing of the CIPI to a FY 
1992 base year, which reflects the capital cost structure facing 
hospitals in that year.
    We are proposing to revise and rebase the CIPI to a FY 1997 base 
year to reflect the more recent structure of capital costs. To do this, 
we reviewed hospital expenditure data for the capital cost categories 
of depreciation, interest, and other capital expenses. As with the FY 
1992-based index, we have developed two sets of proposed weights in 
order to calculate the proposed FY 1997-based CIPI. The first set of 
proposed weights identifies the proportion of hospital capital 
expenditures attributable to each capital expenditure category, while 
the second set of proposed weights is a set of relative vintage weights 
for depreciation and interest. The set of vintage weights is used to 
identify the proportion of capital expenditures within a cost category 
that is attributable to each year over the useful life of capital 
assets in that category. A more thorough discussion of vintage weights 
is provided later in this section.
    Both sets of weights are developed using the best data sources 
available. In reviewing source data, we determined that the Medicare 
cost reports provided accurate data for all capital expenditure cost 
categories. We are proposing to use the FY 1997 Medicare cost reports 
for acute care prospective payment system hospitals, excluding expenses 
from hospital-based subproviders, to determine weights for all three 
cost categories: Depreciation, interest, and other capital expenses. We 
compared the weights determined from the Medicare cost reports to other 
data sources for 1997, specifically the Bureau of the Census' BES and 
the AHA Annual Survey, and found the weights to be consistent with 
those data sources.
    Lease expenses are not a separate cost category in the CIPI, but 
are distributed among the cost categories of depreciation, interest, 
and other, reflecting the assumption that the underlying cost structure 
of leases is similar to capital costs in general. We assumed 10 percent 
of lease expenses are overhead and assigned them to the other capital 
expenses cost category as overhead, as was done in previous capital 
market baskets. The remaining lease expenses were distributed to the 
three cost categories based on the weights of depreciation, interest, 
and other capital expenses not including lease expenses.
    Depreciation contains two subcategories: Building and fixed 
equipment and movable equipment. The split between building and fixed 
equipment and movable equipment was determined using the Medicare cost 
reports. This methodology was also used to compute the FY 1992-based 
index.
    Table 13 presents a comparison of the proposed rebased FY 1997 
capital cost weights and the FY 1992 capital cost weights.

               Table 13.--Comparison of FY 1992 and Proposed Rebased FY 1997 Cost Category Weights
----------------------------------------------------------------------------------------------------------------
                                                               Proposed
                                                  FY 1992     rebased FY
              Expense categories                  weights        1997                   Price proxy
                                                               weights
----------------------------------------------------------------------------------------------------------------
Total.........................................       1.0000       1.0000  ......................................
    Total depreciation........................       0.6484       0.7135  ......................................
    Building and fixed equipment depreciation.       0.3009       0.3422  Boeckh Institutional Construction
                                                                           Index--vintage weighted (23 years).
    Movable equipment depreciation............       0.3475       0.3713  PPI for machinery and equipment--
                                                                           vintage weighted (11 years).
Total interest................................       0.3184       0.2346
    Government/nonprofit interest.............       0.2706       0.1994  Average yield on domestic municipal
                                                                           bonds (Bond Buyer 20 bonds)--vintage
                                                                           weighted (23 years).
    For-profit interest.......................       0.0478       0.0352  Average yield on Moody's Aaa bonds--
                                                                           vintage weighted (23 years).
Other.........................................       0.0332       0.0519  CPI--Residential Rent.
----------------------------------------------------------------------------------------------------------------

    Because capital is acquired and paid for over time, capital 
expenses in any given year are determined by past and present purchases 
of physical and financial capital. The vintage-weighted CIPI is 
intended to capture the long-term consumption of capital, using vintage 
weights for depreciation (physical capital) and interest (financial 
capital). These vintage weights reflect the purchase patterns of 
building and fixed equipment and movable

[[Page 31453]]

equipment over time. Because depreciation and interest expenses are 
determined by the amount of past and current capital purchases, we used 
the vintage weights to compute vintage-weighted price changes 
associated with depreciation and interest expense.
    Vintage weights are an integral part of the CIPI. Capital costs are 
inherently complicated and are determined by complex capital purchasing 
decisions over time, based on such factors as interest rates and debt 
financing. Capital is depreciated over time instead of being consumed 
in the same period it is purchased. The CIPI accurately reflects the 
annual price changes associated with capital costs, and is a useful 
simplification of the actual capital accumulation process. By 
accounting for the vintage nature of capital, we are able to provide an 
accurate, stable annual measure of price changes. Annual nonvintage 
price changes for capital are unstable due to the volatility of 
interest rate changes. These unstable annual price changes do not 
reflect the actual annual price changes for Medicare capital-related 
costs. CMS's CIPI reflects the underlying stability of the capital 
acquisition process and provides hospitals with the ability to plan for 
changes in capital payments.
    To calculate the vintage weights for depreciation and interest 
expenses, we used a time series of capital purchases for building and 
fixed equipment and movable equipment. We found no single source that 
provides the best time series of capital purchases by hospitals for all 
of the above components of capital purchases. The early Medicare cost 
reports did not have sufficient capital data to meet this need. While 
the AHA Panel Survey provided a consistent database back to 1963, it 
did not provide annual capital purchases. The AHA Panel Survey did 
provide time series of depreciation and interest expenses that could be 
used to infer capital purchases over time. Although the AHA Panel 
Survey was discontinued after September 1997, we were able to use all 
of the available historical data from this survey since our proposed 
base year is FY 1997.
    In order to estimate capital purchases from AHA data on 
depreciation and interest expenses, the expected life for each cost 
category (building and fixed equipment, movable equipment, debt 
instruments) is needed. The expected life is used in the calculation of 
vintage weights. We used FY 1997 Medicare cost reports to determine the 
expected life of building and fixed equipment and movable equipment. 
The expected life of any piece of equipment can be determined by 
dividing the value of the fixed asset (excluding fully depreciated 
assets) by its current year depreciation amount. This calculation 
yields the estimated useful life of an asset if depreciation were to 
continue at current year levels, assuming straight-line depreciation. 
From the FY 1997 cost reports, we determined the expected life of 
building and fixed equipment to be 23 years, and the expected life of 
movable equipment to be 11 years. By comparison, the FY 1992-based 
index showed that the expected life for building and fixed equipment 
was 22 years, while that for movable equipment was 10 years. Our 
analysis of data for FYs 1996, 1998, and 1999 indicates very little 
change in these measures over time.
    We used the fixed and movable weights derived from the FY 1997 
Medicare cost reports to separate the AHA Panel Survey depreciation 
expenses into annual amounts of building and fixed equipment 
depreciation and movable equipment depreciation. By multiplying the 
annual depreciation amounts by the expected life calculations from the 
FY 1997 Medicare cost reports, we determined year-end asset costs for 
building and fixed equipment and movable equipment. We subtracted the 
previous year asset costs from the current year asset costs and 
estimated annual purchases of building and fixed equipment and movable 
equipment back to 1963. From this capital purchase time series, we were 
able to calculate the vintage weights for building and fixed equipment, 
movable equipment, and debt instruments. Each of these sets of vintage 
weights is explained in detail below.
    For building and fixed equipment vintage weights, we used the real 
annual capital purchase amounts for building and fixed equipment 
derived from the AHA Panel Survey. The real annual purchase amount was 
used to capture the actual amount of the physical acquisition, net of 
the effect of price inflation. This real annual purchase amount for 
building and fixed equipment was produced by deflating the nominal 
annual purchase amount by the building and fixed equipment price proxy, 
the Boeckh institutional construction index. Because building and fixed 
equipment has an expected life of 23 years, the vintage weights for 
building and fixed equipment are deemed to represent the average 
purchase pattern of building and fixed equipment over 23-year periods.
    Vintage weights for each 23-year period are calculated by dividing 
the real building and fixed capital purchase amount in any given year 
by the total amount of purchases in the 23-year period. This 
calculation is done for each year in the 23-year period, and for each 
of the twelve 23-year periods from 1963 to 1997. The average of the 
twelve 23-year periods is used to determine the 1997 average building 
and fixed equipment vintage weights.
    For movable equipment vintage weights, we used the real annual 
capital purchase amounts for movable equipment derived from the AHA 
Panel Survey. The real annual purchase amount was used to capture the 
actual amount of the physical acquisition, net of price inflation. This 
real annual purchase amount for movable equipment was calculated by 
deflating the nominal annual purchase amount by the movable equipment 
price proxy, the PPI for machinery and equipment. Because movable 
equipment has an expected life of 11 years, the vintage weights for 
movable equipment are deemed to represent the average purchase pattern 
of movable equipment over 11-year periods.
    Vintage weights for each 11-year period are calculated by dividing 
the real movable capital purchase amount for any given year by the 
total amount of purchases in the 11-year period. This calculation is 
done for each year in the 11-year period, and for each of the twenty-
four 11-year periods from 1963 to 1997. The average of the twenty-four 
11-year periods is used to determine the FY 1997 average movable 
equipment vintage weights.
    For interest vintage weights, we used the nominal annual capital 
purchase amounts for total equipment (building and fixed, and movable) 
derived from the AHA Panel Survey. Nominal annual purchase amounts were 
used to capture the value of the debt instrument. Because debt 
instruments have an expected life of 23 years, the vintage weights for 
interest are deemed to represent the average purchase pattern of total 
equipment over 23-year periods.
    Vintage weights for each 23-year period are calculated by dividing 
the nominal total capital purchase amount for any given year by the 
total amount of purchases in the 23-year period. This calculation is 
done for each year in the 23-year period and for each of the twelve 23-
year periods from 1963 to 1997. The average of the twelve 23-year 
periods is used to determine the FY 1997 average interest vintage 
weights. The vintage weights for the FY 1992 CIPI and the proposed FY 
1997 CIPI are presented in Table 14.

[[Page 31454]]



                Table 14.--Current and Proposed Vintage Weights for Capital-Related Price Proxies
----------------------------------------------------------------------------------------------------------------
                                       Building and fixed         Movable equipment             Interest
                                            equipment        ---------------------------------------------------
    Year (from farthest to most    --------------------------
              recent)                            Proposed FY   FY 1992 10  Proposed FY   FY 1992 22  Proposed FY
                                     FY 1992 22    1997 23       years       1997 11       years       1992 23
                                       years        years                     years                     years
----------------------------------------------------------------------------------------------------------------
1.................................        0.019        0.018        0.069        0.063        0.007        0.007
2.................................        0.020        0.021        0.075        0.068        0.008        0.009
3.................................        0.023        0.023        0.083        0.074        0.010        0.011
4.................................        0.026        0.025        0.091        0.080        0.012        0.012
5.................................        0.028        0.026        0.097        0.085        0.014        0.014
6.................................        0.030        0.028        0.103        0.091        0.016        0.016
7.................................        0.031        0.030        0.109        0.096        0.018        0.019
8.................................        0.032        0.032        0.115        0.101        0.021        0.022
9.................................        0.036        0.035        0.124        0.108        0.024        0.026
10................................        0.039        0.039        0.133        0.114        0.029        0.030
11................................        0.043        0.042  ...........        0.119        0.035        0.035
12................................        0.047        0.044  ...........  ...........        0.041        0.039
13................................        0.050        0.047  ...........  ...........        0.047        0.045
14................................        0.052        0.049  ...........  ...........        0.052        0.049
15................................        0.055        0.051  ...........  ...........        0.059        0.053
16................................        0.059        0.053  ...........  ...........        0.067        0.059
17................................        0.062        0.057  ...........  ...........        0.074        0.065
18................................        0.065        0.060  ...........  ...........        0.081        0.072
19................................        0.067        0.062  ...........  ...........        0.088        0.077
20................................        0.069        0.063  ...........  ...........        0.093        0.081
21................................        0.072        0.065  ...........  ...........        0.099        0.085
22................................        0.073        0.064  ...........  ...........        0.103        0.087
23................................  ...........        0.065  ...........  ...........  ...........        0.090
                                   -----------------------------------------------------------------------------
    Total.........................        1.000        1.000        1.000        1.000        1.000        1.000
----------------------------------------------------------------------------------------------------------------

    After the capital cost category weights were computed, it was 
necessary to select appropriate price proxies to reflect the rate of 
increase for each expenditure category. Our proposed price proxies for 
the FY 1997-based CIPI are the same as those for the FY 1992-based 
CIPI. We still believe these are the most appropriate proxies for 
hospital capital costs that meet our selection criteria of relevance, 
timeliness, availability, and reliability. We ran the proposed FY 1997-
based index using the Moody's Aaa bonds average yield and using the 
Moody's Baa bonds average yield as proxy for the for-profit interest 
cost category. There was no difference in the two sets of index percent 
changes either historically or forecasted. The rationale for selecting 
the price proxies is explained more fully in the August 30, 1996 final 
rule (61 FR 46196). The proposed proxies are presented in Table 13.
    Global Insights, Inc., DRI-WEFA forecasts a 0.7 percent increase in 
the proposed rebased FY 1997 CIPI for FY 2003, as shown in Table 15.

Table 15.--FY 1992 and Proposed FY 1997-Based Capital Input Price Index,
                        Percent Change, 1995-2004
------------------------------------------------------------------------
                                                               Proposed
              Federal fiscal year                 CIPI, FY     CIPI, FY
                                                 1992-based   1997-based
------------------------------------------------------------------------
1995..........................................          1.2          1.5
1996..........................................          1.0          1.3
1997..........................................          0.9          1.2
1998..........................................          0.7          0.9
1999..........................................          0.7          0.9
2000..........................................          0.9          1.1
2001..........................................          0.7          0.9
Average: FYs 1995-2001........................          0.9          1.1
Forecast:
2002..........................................          0.6          0.8
2003..........................................          0.5          0.7
2004..........................................          0.6          0.7
Average: FYs 2002-2004........................          0.6         0.7
------------------------------------------------------------------------
Source: Global Insights, Inc, DRI-WEFA, 1st Qtr. 2002; @USMACRO/MODTREND
  @CISSIM/TRENDLONG0202.

    This 0.7 percent increase is the result of a 1.3 percent increase 
in projected vintage-weighted depreciation prices (building and fixed 
equipment, and movable equipment) and a 2.7 percent increase in other 
capital expense prices, partially offset by a 2.2 percent decrease in 
vintage-weighted interest rates in FY 2003, as indicated in Table 16.

[[Page 31455]]



 Table 16.--CMS Proposed Capital Input Price Index Percent Changes, Total and Components, Fiscal Years 1985-2005
----------------------------------------------------------------------------------------------------------------
                                                          Depreciation,
                                                Total      building and  Depreciation,
         Fiscal year              Total     depreciation      fixed         movable       Interest      Other
                                                            equipment      equipment
----------------------------------------------------------------------------------------------------------------
Wgts FY 1997.................        1.000        0.7135        0.3422         0.3713        0.2346       0.0519
----------------------------------------------------------------------------------------------------------------
                                         Vintage-Weighted Price Changes
----------------------------------------------------------------------------------------------------------------
1995.........................          1.5           2.7           4.0            1.6          -1.8          2.5
1996.........................          1.3           2.5           3.8            1.4          -2.3          2.6
1997.........................          1.2           2.3           3.6            1.2          -2.4          2.8
1998.........................          0.9           2.1           3.3            0.9          -3.0          3.2
1999.........................          0.9           1.9           3.2            0.7          -2.8          3.2
2000.........................          1.1           1.7           3.1            0.4          -1.6          3.4
2001.........................          0.9           1.5           2.9            0.1          -2.2          4.3
Forecast:
2002.........................          0.8           1.4           2.8            0.0          -2.2          4.0
2003.........................          0.7           1.3           2.7           -0.1          -2.2          2.7
2004.........................          0.7           1.3           2.5           -0.1          -2.1          2.8
2005.........................          0.7           1.3           2.5           -0.1          -2.0          2.8
----------------------------------------------------------------------------------------------------------------

    Rebasing the CIPI from FY 1992 to FY 1997 increased the percent 
change in the FY 2003 forecast by 0.2 percentage points, from 0.5 to 
0.7 as shown in Table 15. The difference is caused mostly by changes in 
cost category weights, particularly the smaller weight for interest and 
larger weight for depreciation. Because the interest component has a 
negative price change associated with it for FY 2003, the smaller share 
it accounts for in the FY 1997-based index means it has less of an 
impact than in the FY 1992-based index. The changes in the expected 
life and vintage weights have only a minor impact on the overall 
percent change in the index.

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

A. Transfer Payment Policy

1. Expanding the Postacute Care Transfer Policy to Additional DRGs 
(Sec. 412.4)
    Existing regulations at Sec. 412.4(a) define discharges under the 
acute care hospital inpatient prospective payment system as situations 
in which a patient is formally released from an acute care hospital or 
dies in the hospital. Section 412.4(b) defines transfers from one acute 
care hospital to another, and Sec. 412.4(c) defines transfers to 
certain postacute care providers. Our policy provides that, in transfer 
situations, full payment is made to the final discharging hospital and 
each transferring hospital is paid a per diem rate for each day of the 
stay, not to exceed the full DRG payment that would have been made if 
the patient had been discharged without being transferred.
    Under section 1886(d)(5)(J) of the Act, which was added by section 
4407 of Public Law 105-33, a ``qualified discharge'' from one of 10 
DRGs selected by the Secretary to a postacute care provider is treated 
as a transfer case beginning with discharges on or after October 1, 
1998. This section requires the Secretary to define and pay as 
transfers all cases assigned to one of 10 DRGs selected by the 
Secretary if the individuals are discharged to one of the following 
postacute care settings:
     A hospital or hospital unit that is not a subsection 
1886(d) hospital. (Section 1886(d)(1)(B) of the Act identifies the 
hospitals and hospital units that are excluded from the term 
``subsection (d) hospital'' as psychiatric hospitals and units, 
rehabilitation hospitals and units, children's hospitals, long-term 
care hospitals, and cancer hospitals.)
     A skilled nursing facility (as defined at section 1819(a) 
of the Act).
     Home health services provided by a home health agency, if 
the services relate to the condition or diagnosis for which the 
individual received inpatient hospital services, and if the home health 
services are provided within an appropriate period (as determined by 
the Secretary).
    In the July 31, 1998 final rule (63 FR 40975 through 40976), we 
specified the appropriate time period during which we would consider 
postacute home health services to constitute a transfer situation as 
within 3 days after the date of discharge. Also, in the July 31, 1998 
final rule, we did not include in the definition of postacute transfer 
cases patients transferred to a swing-bed for skilled nursing care (63 
FR 40977).
    The Conference Agreement that accompanied Public Law 105-33 noted 
that ``(t)he Conferees are concerned that Medicare may in some cases be 
overpaying hospitals for patients who are transferred to a postacute 
care setting after a very short acute care hospital stay. The conferees 
believe that Medicare's payment system should continue to provide 
hospitals with strong incentives to treat patients in the most 
effective and efficient manner, while at the same time, adjust PPS 
[prospective payment system] payments in a manner that accounts for 
reduced hospital lengths of stay because of a discharge to another 
setting.'' (H.R. Report No. 105-217, 105th Cong., 1st Sess., 740 
(1997).)
    In the July 31, 1998 final rule (63 FR 40975), we implemented 
section 1886(d)(5)(J) of the Act, which directed the Secretary to 
select 10 DRGs based upon a high volume of discharges to postacute care 
and a disproportionate use of postacute care services. As discussed in 
the July 31, 1998 final rule, these 10 DRGs were selected in 1998 based 
on the MedPAR data from FY 1996. Using that information, we identified 
and selected the first 20 DRGs that had the largest proportion of 
discharges to postacute care (and at least 14,000 such transfer cases). 
In order to select 10 DRGs from the 20 DRGs on our list, we considered 
the volume and percentage of discharges to postacute care that occurred 
before the mean length of stay and whether the discharges occurring 
early in the stay were more likely to receive postacute care. We 
identified the following DRGs

[[Page 31456]]

to be subject to the special 10 DRG transfer rule:
     DRG 14  (Specific Cerebrovascular Disorders Except 
Transient Ischemic Attack);
     DRG 113  (Amputation for Circulatory System Disorders 
Except Upper Limb and Toe);
     DRG 209  (Major Joint Limb Reattachment Procedures of 
Lower Extremity);
     DRG 210  (Hip and Femur Procedures Except Major Joint 
Procedures Age >17 with CC);
     DRG 211  (Hip and Femur Procedures Except Major Joint 
Procedures Age >17 without CC);
     DRG 236  (Fractures of Hip and Pelvis);
     DRG 263  (Skin Graft and/or Debridement for Skin Ulcer or 
Cellulitis with CC);
     DRG 264  (Skin Graft and/or Debridement for Skin Ulcer or 
Cellulitis without CC);
     DRG 429  (Organic Disturbances and Mental Retardation); 
and
     DRG 483  (Tracheostomy Except for Face, Mouth and Neck 
Diagnoses).
    Similar to our existing policy for transfers between two acute care 
hospitals, the transferring hospital in a postacute transfer for 7 of 
the 10 DRGs receives twice the per diem rate the first day and the per 
diem rate for each following day of the stay prior to the transfer, up 
to the full DRG payment. However, 3 of the 10 DRGs exhibit a 
disproportionate share of costs very early in the hospital stay in 
postacute transfer situations. For these 3 DRGs, hospitals receive 50 
percent of the full DRG payment for the first day of the stay and 50 
percent of the per diem for the remaining days of the stay, up to the 
full DRG payment. This is consistent with section 1886(d)(5)(J)(i) of 
the Act, which recognizes that in some cases ``a substantial portion of 
the costs of care are incurred in the early days of the inpatient 
stay.''
    The statute provides that, after FY 2000, the Secretary is 
authorized to expand this policy to additional DRGs. In July 1999, the 
previous Administration committed to not expanding the number of DRGs 
included in the policy until FY 2003. Therefore, CMS did not propose 
any change to the postacute care settings or the 10 DRGs in FY 2001 or 
FY 2002.
    Under contract with CMS (Contract No. 500-95-0006), Health 
Economics Research, Inc. (HER) conducted an analysis of the impact on 
hospitals and hospital payments of the postacute care transfer 
provision. We included in the August 1, 2000 final rule (65 FR 47079) a 
summary of that analysis. Among other issues, the analysis sought to 
evaluate the reasonableness of expanding the transfer payment policy 
beyond the current 10 selected DRGs.
    The analysis supported the initial 10 DRGs selected as being 
consistent with the nature of the Congressional mandate. According to 
HER, ``[t]he top 10 DRGs chosen initially by HCFA exhibit very large 
PAC [postacute care] levels and PAC discharge rates (except for DRG 
264, Skin Graft and/or Debridement for Skin Ulcer or Cellulitis without 
CC, which was paired with DRG 263). All 10 appear to be excellent 
choices based on the other criteria as well. Most have fairly high 
short-stay PAC rates (except possibly for Strokes, DRG 14, and Mental 
Retardation, DRG 429).''
    The HER report discussed the issues related to potentially 
expanding the postacute care transfer policy to all DRGs. In favor of 
this expansion, HER pointed to the following benefits:
     A simple, uniform, formula-driven policy;
     The same policy rationale exists for all DRGs;
     DRGs with little utilization of short-stay postacute care 
would not be harmed by the policy;
     Less confusion in discharge destination coding; and
     Hospitals that happen to be disproportionately treating 
the current 10 DRGs may be harmed more than hospitals with an 
aggressive, short-stay, postacute care transfer policy for other DRGs.
    The complete HER report may be obtained at: http://www.cms.gov/medicare/ippsmain.htm.
    Consistent with HER's findings, we believe expanding the postacute 
care transfer policy to all DRGs may be the most equitable approach at 
this time, since a policy that is limited to certain DRGs may result in 
disparate payment treatment across hospitals, depending on the types of 
cases treated. We are considering implementing this expansion of the 
postacute transfer policy in the final rule. For example, a hospital 
specializing in some of the types of cases included in the current 10 
DRG transfer policy would receive reduced payments for those cases 
transferred for postacute care after a brief acute inpatient stay, 
while a hospital specializing in cases not included in the current 10 
DRGs may be just as aggressive in transferring its patients for 
postacute care, but it would receive full payment for those cases.
    Another aspect of the issue is that some hospitals have fewer 
postacute care options available for their patients. In its June 2001 
Report to Congress: Medicare in Rural America, MedPAC wrote: ``[a] 
shortage of ambulatory and post-acute care resources may prevent rural 
hospitals from discharging patients as early in the episode of care as 
urban hospitals would'' (page 68). MedPAC went on to note that the 
decline in length of stay for urban hospitals since 1989 was greater 
for urban hospitals than for rural hospitals (34 percent compared with 
25 percent through 1999), presumably due to earlier discharges to 
postacute care settings. Although MedPAC contemplated returning money 
saved by expanding the policy to the base payment rate, thereby 
increasing payments for nontransfer cases, currently section 
1886(d)(5)(I)(ii) of the Act provides that any expansion to the 
postacute transfer policy would not be budget neutral. (Budget 
neutrality refers to adjusting the base payment rates to ensure total 
aggregate payments are the same after implementing a policy change as 
they were prior to the change.) Nevertheless, over the long run, 
reducing the Medicare Trust Fund expenditures for patients who are 
transferred to a postacute care setting after a very short acute care 
hospital stay will improve the program's overall financial stability. 
Our analysis indicates that expanding the postacute care transfer 
policy to all DRGs would reduce program payments for these cases by 
approximately $1.9 billion for FY 2002.
    If we were to expand the transfer policy to all DRGs, we would 
expand the list of those DRGs where a disproportionate share of the 
costs of the entire stay occurs early in the stay. We conducted 
analysis to identify those DRGs that would be eligible for the special 
transfer payment methodology specified in Sec. 412.4(f)(2). As stated 
above, currently, three DRGs (DRGs 209, 210, and 211) are paid under a 
special transfer payment calculation whereby they receive 50 percent of 
the full DRG payment amount on the first day of the stay for cases 
transferred to a postacute care provider.
    We identified cases that were transferred to home health care, 
SNFs, or long-term care, matching records by beneficiary identification 
numbers and discharge and admission dates. We standardized charges to 
account for differences in area wage levels, indirect medical education 
costs, and disproportionate share payments, and we reduced charges to 
costs using the available cost-to-charge ratios.
    We then grouped the costs by DRG and length of stay. The average 
costs for transfer cases with a length of stay of 1 day were compared 
to the costs of transfer cases whose length of stay

[[Page 31457]]

approximated the geometric mean length of stay for that particular DRG. 
The average costs for the transfer cases with a length of stay of 1 day 
were also compared to costs for all cases with a length of stay 
approximating the geometric mean length of stay across the DRG. Based 
on this analysis, we identified the following DRGs that, if the 
postacute care transfer policy were to be expanded, would qualify for 
the special postacute care transfer payment policy of 50 percent of the 
full DRG payment for the first day of the stay:
     DRG 7  (Peripheral and Cranial Nerve and Other Nervous 
System Procedures with CC);
     DRG 159  (Hernia Procedures Except Inguinal and Femoral 
Age >17 with CC);
     DRG 218  (Lower Extremity and Humerus Procedure Except 
Hip, Foot, Femur Age >17 with CC);
     DRG 226  (Soft Tissue Procedures with CC);
     DRG 263  (Skin Graft and/or Debridement for Skin Ulcer or 
Cellulitis with CC);
     DRG 264  (Skin Graft and/or Debridement for Skin Ulcer or 
Cellulitis without CC);
     DRG 306  (Prostatectomy with CC);
     DRG 308  (Minor Bladder Procedures with CC);
     DRG 315  (Other Kidney and Urinary Tract O.R. Procedures);
     DRG 493  (Laparoscopic Cholecystectomy without C.D.E. with 
CC); and
     DRG 497  (Spinal Fusion Except Cervical with CC).
    This list contains DRGs not currently paid under the special 
formula (DRGs 209, 210, and 211 will continue to receive the special 
payment). All of the DRGs in the list meet the following criteria: The 
average costs of transfer cases on the first day equals the average 
costs of cases staying the geometric mean length of stay; the geometric 
mean length of stay is 4 days or greater; and there were at least 50 
transfer cases occurring on the first day of the stay.
    We also note that DRGs 263 and 264 (which are included in the 
current list of 10 DRGs subject to the postacute care transfer policy) 
would qualify for special payment, even though both DRGs have not 
previously received payment under the special payment provision. 
However, DRG 264 does qualify under the criteria described above for 
identifying cases for the potential expanded postacute care transfer 
policy. Because DRGs 263 and 264 are paired DRGs (that is, the only 
difference in the cases assigned to DRG 263 as opposed to DRG 264 is 
that the patient has a complicating or comorbid condition), we would 
include both DRGs under this expanded policy. If we were to include 
only DRG 264, there would be an incentive not to include a code 
identifying a complicating or comorbid condition, so that a transfer 
case would be assigned to DRG 264 instead of DRG 263 due to the higher 
per diem payment for DRG 264.
    Rather than expand the postacute care transfer policy to all DRGs, 
another option that we are considering for the final rule is expanding 
the postacute care transfer policy only to additional DRGs that have 
high rates of transfers, similar to the initial implementation of only 
10 DRGs. For example, an incremental expansion would be to add another 
10 DRGs to the policy. Using the same criteria to identify DRGs with 
high postacute care transfer rates, we identified additional DRGs to 
include in the postacute care transfer policy. We note that three of 
the DRGs we identified are paired DRGs (that is, they contain a CC/no-
CC split). For the same reason given above for treating paired DRGS 
consistently, we would include the pairs for the 10 DRGs identified. We 
estimate the impact of this approach would be to reduce payments to 
hospitals by approximately $916 million for FY 2002. Under this 
approach, discharges from the following 13 DRGs (in addition to the 10 
DRGs already subject to the postacute care transfer policy) could be 
considered to be subject to an alternative postacute care transfer 
policy:
     DRG 12  (Degenerative Nervous System Disorders);
     DRG 79  (Respiratory Infections and Inflammations Age >17 
with CC);
     DRG 80  (Respiratory Infections and Inflammations Age >17 
without CC);
     DRG 107  (Coronary Bypass with Cardiac Catheterization);
     DRG 109  (Coronary Bypass with PTCA or Cardiac 
Catheterization);
     DRG 148  (Major Small and Large Bowel Procedures with CC);
     DRG 149  (Major Small and Large Bowel Procedures without 
CC);
     DRG 239  (Pathological Fractures and Musculoskeletal 
System and Connective Tissue Malignancy);
     DRG 243  (Medical Back Problems);
     DRG 320  (Kidney and Urinary Tract Diagnoses Age >17 with 
CC);
     DRG 321  (Kidney and Urinary Tract Diagnoses Age >17 
without CC);
     DRG 415  (O.R. Procedure for Infections and Parasitic 
Diseases); and
     DRG 468  (Extensive O.R. Procedure Unrelated to Principal 
Diagnosis).
    Expanding the postacute care transfer policy in this limited 
manner, however, would retain many of the potential inequities of the 
current system. Although we are concerned about the potential for a 
large impact of implementing any expansion of the postacute care 
transfer payment policy, we believe that the current policy may create 
payment inequities across patients and across hospitals. By expanding 
the postacute transfer policy, we would expect to reduce or eliminate 
these possible inequities. Therefore, we are soliciting comments on the 
two options we have identified and discussed in this proposed rule. In 
the final rule, we could adopt one of the approaches discussed above, 
or some other approach based on comments received on this proposal for 
addressing this issue. If commenters submit comments on alternate 
approaches, we are asking them to also provide useful data relating to 
alternative DRGs to which the expansion should or should not apply and 
detailed supporting explanations.
    If we adopt either of the proposals discussed above or a variation 
based on comments submitted, we would follow procedures similar to 
those that are currently followed for treating cases identified as 
transfers in the DRG recalibration process. That is, as described in 
the discussion of DRG recalibration in section II.C. of this proposed 
rule, additional transfer cases would be counted as a fraction of a 
case based on the ratio of a hospital's transfer payment under the per 
diem payment methodology to the full DRG payment for nontransfer cases.
2. Technical Correction
    When we revised our regulations on payments for discharges and 
transfers under Sec. 412.4 in the July 31, 1998 final rule (63 FR 
41003), we inadvertently did not exclude discharges from one hospital 
area or unit to another inpatient area or unit of the hospital that is 
paid under the acute care hospital inpatient prospective payment system 
(Sec. 412.4(b)(2)) from the types of cases paid under the general rule 
for transfer cases. We are proposing to correct the regulation text to 
reflect our policy (as reflected in prior preamble language) that 
transfers from one area or unit within a hospital to another are not 
paid as transfers (except as described under the special 10 DRG rule at 
Sec. 412.4(c)). We are proposing to correct this error by revising 
Sec. 412.4(f)(1) to provide that only the circumstances described in 
paragraph (b)(1) and (c) of Sec. 412.4 are paid as transfers under the 
general transfer rule. This proposed correction

[[Page 31458]]

would reflect the fact that transfers under Sec. 412.4(b)(2) are to be 
paid as discharges and not transfers.

B. Sole Community Hospitals (SCHs) (Secs. 412.77 and 412.92)

1. Phase-In of FY 1996 Hospital-Specific Rates
    Under the acute care hospital inpatient prospective payment system, 
special payment protections are provided to a sole community hospital 
(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, 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 located in 
Sec. 412.92.
    To be classified as an SCH, a hospital either must have been 
designated as an SCH prior to the beginning of the hospital inpatient 
prospective payment system on October 1, 1983, or must be located more 
than 35 miles from other like hospitals, or the hospital must be 
located in a rural area and meet one of the following requirements:
     It is located between 25 and 35 miles from other like 
hospitals, and it--
--Serves at least 75 percent of all inpatients, or at least 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 at 
least 75 percent of its area's inpatients except that some patients 
seek specialized care unavailable at the hospital.

     It is located between 15 and 35 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 to the hospital for the cost reporting period:
     The Federal rate applicable to the hospital;
     The updated hospital-specific rate based on FY 1982 costs 
per discharge; or
     The updated hospital-specific rate based on FY 1987 costs 
per discharge.
    Section 405 of Public Law 106-113 added section 1886(b)(3)(I) to 
the Act, and section 213 of Public Law 106-554 made further amendments 
to that section of the Act extending to all SCHs the ability to rebase 
their hospital-specific rates using their FY 1996 operating costs, 
effective for cost reporting periods beginning on or after October 1, 
2000. The provisions of section 1886(b)(3)(I) of the Act were addressed 
in the June 13, 2001 interim final rule with comment period (66 FR 
32177) and were finalized in the August 1, 2001 final rule (66 FR 
39872).
    In the June 13, 2001 interim final rule, we correctly described the 
provisions of section 1886(b)(3)(I) of the Act, as amended, and their 
implementation. However, in the August 1, 2001 final rule, in 
summarizing the numerous legislative provisions that had affected 
payments to SCHs, we incorrectly described the application of the 
statutory provisions in the background section of the preamble on SCHs 
(66 FR 39872). (We wish to point out that the Addendum to the August 1, 
2001 final rule accurately describes the calculation of the hospital-
specific rate (66 FR 39944).) Specifically, the payment options that we 
described in the August 1, 2001 preamble language on SCHs were 
incorrect in that we did not include the Federal rate in the blends. 
Therefore, we are providing below a correct description of the 
provisions of section 1886(b)(3)(I) of the Act and clarifying their 
application in determining which of the payment options will yield the 
highest rate of payment for SCHs.
    For purposes of payment to SCHs for which the FY 1996 hospital-
specific rate yields the greatest aggregate payment, the Federal rate 
is included in the blend, as set forth below:
     For discharges during FY 2001, 75 percent of the greater 
of the Federal amount or the updated FY 1982 or FY 1987 hospital-
specific rates (identified in the statute as the subsection 
(d)(5)(D)(i) amount), plus 25 percent of the updated FY 1996 hospital-
specific rate (identified in the statute as the ``rebased target 
amount'').
     For discharges during FY 2002, 50 percent of the greater 
of the Federal amount or the updated FY 1982 or FY 1987 hospital-
specific rates, plus 50 percent of the updated FY 1996 hospital-
specific rate.
     For discharges during FY 2003, 25 percent of the greater 
of the Federal amount or the updated FY 1982 or FY 1987 hospital-
specific rates, plus 75 percent of the updated FY 1996 hospital-
specific rate.
     For discharges during FY 2004 and subsequent fiscal years, 
the hospital-specific rate would be determined based on 100 percent of 
the updated 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 disproportionate share 
hospital (DSH) adjustment, or the indirect medical education (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.
    The regulation text of Sec. 412.77 and Sec. 412.92(d) that was 
revised to incorporate the provisions of section 1886(b)(3)(I) of the 
Act, as amended, and published in the June 13, 2001 interim final rule 
with comment period (66 FR 32192 through 32193) and finalized in the 
August 1, 2001 final rule (66 FR 39932), is accurate.
2. SCH Like Hospitals
    Section 1886(d)(5)(D)(iii) of the Act provides that, to qualify as 
a SCH, a hospital must be not more than 35 road miles from another 
hospital. There are several other conditions under which a hospital may 
qualify as a SCH, including if it is the ``* * * sole source of 
inpatient hospital services reasonably available to individuals in a 
geographic area * * *'' because of factors such as the ``* * * absence 
of other like hospitals * * *'' We have defined a ``like hospital'' in 
regulations as a hospital furnishing short-term, acute

[[Page 31459]]

care (Sec. 412.92(c)(2)). Like hospitals refers to hospitals paid under 
the acute care hospital inpatient prospective payment system.
    We have become aware that, in some cases, new specialty hospitals 
that offer a very limited range of services have opened within the 
service area of a SCH and may be threatening the special status of the 
SCH. For example, a hospital that offers only a select type of surgery 
on an inpatient basis would qualify under our existing rules as an SCH 
``like hospital'' if it met the hospital conditions of participation 
and was otherwise eligible for payment under the acute care hospital 
inpatient prospective payment system. Under our existing regulations, a 
SCH could lose its special status due to the opening of such a 
specialty hospital, even though there is little, if any, overlap in the 
types of services offered by the SCH and the specialty hospital.
    We believe that limiting eligibility for SCH status to hospitals 
without SCH like hospitals in their service area is a way to identify 
those hospitals that truly are the sole source of short-term acute-care 
inpatient services in the community. A limited-service, specialty 
hospital, by definition, would not offer an alternate source of care in 
the community for most inpatient services and therefore, we believe, 
should not be considered a ``like'' hospital with the effect of 
negating SCH status of a hospital that is the sole source of short-term 
acute care inpatient services in the community. Therefore, we are 
proposing to amend the definition of SCH like hospitals under 
Sec. 412.92(c)(2), effective with cost reporting periods beginning on 
or after October 1, 2002, to exclude any hospital that provides no more 
than a very small percent of the services furnished by the limited-
service facility that overlap with the services provided by the SCH. We 
believe the percentage of overlapping services should be sufficiently 
small so that we can ensure that only hospitals that truly are the sole 
source of short-term acute-care in their community qualify for SCH 
status. Therefore, we are proposing that this percentage be set at 3 
percent. However, we are soliciting public comments on alternate 
appropriate levels of service overlap, as well as on the overall 
proposed change to the definition of like hospitals.

C. Outlier Payments: Technical Change (Sec. 412.80)

    Sections 1886(d)(5)(A) and (d)(5)(K) of the Act provide for 
payments, in addition to the basic prospective payments, for 
``outlier'' cases; that is, cases involving extraordinarily high costs. 
Cases qualify for outlier payments by demonstrating costs that exceed a 
fixed loss cost outlier threshold equal to the prospective payment rate 
for the DRG plus any IME (Sec. 412.105) and DSH (Sec. 412.106) payments 
for the case and, for discharges on or after October 1, 2001, 
additional payments for new technologies or services.
    Implementing regulations for outlier payments are located in 
subpart F of part 412. Paragraph (a) of Sec. 412.80 specifies the basic 
rules for making the additional outlier payments, broken down into 
three applicable effective periods. We have become aware that in 
paragraph (a)(2), which relates to outlier payments for discharges 
occurring on or after October 1, 1997, and before October 1, 2001, we 
did not include language to specify that the additional costs of 
outlier cases must exceed the standard DRG payment and any additional 
payment the hospital would receive for IME and for DSH, plus a fixed 
loss dollar threshold. Therefore, we are proposing to make a technical 
change by revising Sec. 412.80(a)(2), applicable for discharges 
occurring during the period between October 1, 1997 and October 1, 
2001, to include the appropriate language regarding additional payments 
for IME and payments for DSH. (We note that when we amended Sec. 412.80 
to incorporate the provisions on the additional payments for new 
technology under paragraph (a)(3) (66 FR 46924, September 7, 2001), 
effective October 1, 2001, we did include this language.)

D. 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 that a hospital must 
meet in order to qualify 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 continue to 
receive special treatment under both the DSH payment adjustment and the 
criteria for geographic reclassification.
    Section 1886(d)(8)(E) of the Act, as amended, 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. 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, a primary 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).
    Although hospitals that are reclassified as rural under section 
1886(d)(8)(E) of the Act are not permitted to reclassify through the 
MGCRB, effective 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. These hospitals may then take 
advantage of the waiver from the proximity requirements for 
reclassification.
    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--
     The hospital's 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
     The hospital's 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

[[Page 31460]]

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 
proposed national and regional case-mix index values is set forth in 
regulations at Sec. 412.96(c)(1)(ii). The proposed national mean case-
mix index value includes all urban hospitals nationwide, and the 
proposed regional values are 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). These values are based on 
discharges occurring during FY 2001 (October 1, 2000 through September 
30, 2001) and include bills posted to CMS's records through December 
2001.
    We are proposing 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, 2002, must have a case-mix index value for FY 2001 
that is at least--
     1.3229; 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 median case-mix index values by region are set forth in the 
following table:

------------------------------------------------------------------------
                                                          Case-Mix index
                         Region                                value
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT).................          1.2089
2. Middle Atlantic (PA, NJ, NY).........................          1.2235
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)..          1.2985
4. East North Central (IL, IN, MI, OH, WI)..............          1.2377
5. East South Central (AL, KY, MS, TN)..................          1.2459
6. West North Central (IA, KS, MN, MO, NE, ND, SD)......          1.1616
7. West South Central (AR, LA, OK, TX)..................          1.2641
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)............          1.3255
9. Pacific (AK, CA, HI, OR, WA).........................          1.2779
------------------------------------------------------------------------

    The preceding numbers will be revised in the final rule to the 
extent required to reflect the updated FY 2001 MedPAR file, which will 
contain data from additional bills received through March 31, 2002.
    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 index 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. We are 
proposing to update the regional standards based on discharges for 
urban hospitals' cost reporting periods that began during FY 2001 (that 
is, October 1, 2000 through September 30, 2001). That is the latest 
year for which we have complete discharge data available.
    Therefore, we are proposing 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, 2002, must have as the number of discharges for its cost reporting 
period that began during FY 2001 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, as indicated in the 
following table:

------------------------------------------------------------------------
                                                             Number of
                         Region                             discharges
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT).................           6,905
2. Middle Atlantic (PA, NJ, NY).........................           8,648
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)..           8,914
4. East North Central (IL, IN, MI, OH, WI)..............           8,040
5. East South Central (AL, KY, MS, TN)..................           6,748
6. West North Central (IA, KS, MN, MO, NE, ND, SD)......           5,696
7. West South Central (AR, LA, OK, TX)..................           6,220
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)............           9,167
9. Pacific (AK, CA, HI, OR, WA).........................           7,053
------------------------------------------------------------------------

    We note that the median number of discharges for hospitals in each 
census region is greater than the national standard of 5,000 
discharges. Therefore, 5,000 discharges is the minimum criterion for 
all hospitals. These numbers will be revised in the final rule based on 
the latest FY 2001 cost report data.
    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, 2002, must have at least 3,000 discharges for its cost 
reporting period that began during FY 2001.

[[Page 31461]]

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

1. Background
    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 for a Medicare discharge to 
reflect the higher indirect operating costs of teaching hospitals 
relative to nonteaching hospitals. The existing 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 on the 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 1886(d)(5)(B)(ii)(VII) 
of the Act provides that, for discharges occurring during FY 2003 and 
thereafter, the ``c'' variable, or formula multiplier, is 1.35. The 
formula multiplier of 1.35 represents a 5.5-percent increase in IME 
payment for every 10-percent increase in the resident-to-bed ratio.
2. Temporary Adjustments to the FTE Cap To Reflect Residents Affected 
by Residency Program Closure: Resident-to-Bed Ratio for Displaced 
Residents (Secs. 412.105(a) and (f)(1)(ix))
    In the August 1, 2001 hospital inpatient prospective payment system 
final rule (66 FR 39899), we expanded the policy at existing 
Sec. 413.86(g)(8) (proposed to be redesignated as Sec. 413.86(g)(9) in 
this proposed rule), which allows a temporary adjustment to a 
hospital's FTE cap when a hospital trains additional residents because 
of another hospital's closure, to also allow a temporary adjustment 
when a hospital trains residents displaced by the closure of another 
hospital's residency program (but the hospital itself remains open). We 
revised regulations at existing Sec. 413.86(g)(8) to state 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. We 
defined ``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. The methodology for 
adjusting the caps for the ``receiving'' hospital and the ``hospital 
that closed its program'' as they apply to the IME adjustment and 
direct GME payments is set forth in the regulations at existing 
Secs. 412.105(f)(1)(ix) and 413.86(g)(8)(iii), respectively.
    In the August 1, 2001 rule, we noted a commenter who requested that 
CMS further revise the regulations to grant temporary relief to 
hospitals in calculating the IME adjustment with regard to application 
of the resident-to-bed ratio cap (66 FR 39900). The commenter believed 
that while the cap on the number of residents has been temporarily 
adjusted, if the receiving hospital is not allowed to also adjust its 
resident-to-bed ratio in the prior year, the lower resident-to-bed 
ratio from the prior year would act to reduce the IME payments to the 
receiving hospital. The commenter suggested that, similar to the 
exception for residents in hospitals that begin new programs under 
Sec. 412.105(a)(1), an adjustment should be made to the prior year's 
FTE residents equal to the increase in the current year's FTEs that is 
attributable to the transferred residents. In response to the 
commenter, we stated that we had decided not to allow the exclusion of 
these displaced residents in applying the resident-to-bed ratio cap. We 
explained that, while we believed that the receiving hospital may be 
held to a lower cap in the first year of training the displaced 
residents, the receiving hospital would benefit from the higher cap in 
the subsequent years as the displaced residents complete their training 
and leave that hospital. However, we indicated that we would consider 
suggestions for possible future changes to this policy.
    We have revisited this policy and now realize that our rationale 
for not allowing the adjustment for displaced residents to the 
resident-to-bed ratio cap may have been faulty. We initially believed 
that, in the year following the last year in which displaced residents 
trained at the receiving hospital, the receiving hospital would benefit 
from the higher resident-to-bed ratio cap. However, we have determined 
that, while it is correct that the hospital will have a higher 
resident-to-bed ratio cap because of the higher number of displaced 
residents in the prior year, the receiving hospital's FTE count 
decreases as the displaced residents finish their training. Therefore, 
the receiving hospital would not need a higher resident-to-bed ratio 
cap to accommodate the remaining FTEs. Consequently, the higher 
resident-to-bed ratio cap in fact would not benefit the receiving 
hospital. Thus, we are now proposing to allow the exclusion of 
residents displaced by either the closure of another hospital's program 
or another hospital's closure in applying the resident-to-bed ratio 
cap. Specifically, assuming a hospital is eligible to receive a 
temporary adjustment to its FTE cap as described in existing 
Sec. 413.86(g)(8), we are proposing that, solely for purposes of 
applying the resident-to-bed ratio cap in the first year in which the 
receiving hospital is training the displaced residents, the receiving 
hospital may adjust the numerator of the prior year's resident-to-bed 
ratio by the number of FTE residents that has caused the receiving 
hospital to exceed its FTE cap. (We note that this adjustment to the 
resident-to-bed ratio cap does not apply to changes in bed size). In 
the years subsequent to the first year in which the receiving hospital 
takes in the displaced residents, we believe an adjustment to the 
numerator of the prior year's resident-to-bed ratio is unnecessary 
because the receiving hospital's actual FTE count in those years would 
either stay the same or, as the displaced residents complete their 
training or leave that hospital, decrease each year. If all other 
variables remain constant, an increase in the current year's resident-
to-bed ratio will establish a higher cap for the following year. In the 
second and subsequent years of training the displaced residents, the 
receiving hospital's resident-to-bed ratio for the current year would 
not be higher than the prior year's ratio and thus would not be limited 
by the resident-to-bed ratio cap.
    In the cost reporting period following the departure of the last 
displaced residents, when the temporary FTE cap adjustment is no longer 
applicable, we are proposing that, solely for purposes of applying the 
resident-to-bed ratio cap, the resident-to-bed ratio be calculated as 
if the displaced residents had not trained at the receiving hospital in 
the prior year. In other words, in the year that the hospital is no 
longer training displaced residents, the attendant FTEs should be 
removed from the numerator of the resident-to-bed ratio from the prior 
year (that is, the resident-to-bed ratio cap). We believe that because 
we are proposing to allow the adjustment to the resident-to-bed ratio 
cap in the first year in which the receiving hospital trains displaced 
residents, it is equitable to remove those FTEs when calculating the 
resident-to-bed ratio cap after all the displaced

[[Page 31462]]

residents have completed their training at the receiving hospital.
    The following is an example of how the receiving hospital's IME 
resident-to-bed ratio cap would be adjusted for displaced residents 
coming from either a closed hospital or a closed program:
    Example: Hospital A has a family practice program with 3 residents. 
On June 30, 2002, Hospital A closes. Hospital B, which also has a 
family practice program, agrees to continue the training of Hospital 
A's residents beginning July 1, 2002. Its fiscal year end is June 30. 
As of July 1, 2002, the 3 residents displaced by the closure of 
Hospital A include 1 PGY1 resident, 1 PGY2 resident, and 1 PGY3 
resident. In addition, Hospital B has 5 of its own residents, an IME 
FTE resident cap of 5, and 100 beds. Subject to the criteria under 
existing Sec. 413.86(g)(8), Hospital B's FTE cap is temporarily 
increased to 8 FTEs. According to the proposed policy stated above, 
Hospital B's resident-to-bed ratio and resident-to-bed ratio cap would 
be determined as follows:

July 1, 2002 through June 30, 2003
     Resident-to-bed ratio: 5 FTEs + 3 displaced FTEs / 100 
beds = .08 (line 3.18 of Worksheet E, Part A of the Medicare cost 
report, Form CMS 2552-96).


    (Note:
    For purposes of applying the rolling average calculation at 
Sec. 412.105(f)(1)(v) to this example, it is assumed that Hospital B 
had 5 FTE residents in both the prior and the penultimate cost 
reporting periods. Therefore, 5 FTEs are used in the numerator of 
the resident-to-bed ratio. Under Sec. 412.105(f)(1)(v), displaced 
residents are added to the receiving hospital's rolling average FTE 
count in each year that the displaced residents are training at the 
receiving hospital.)


     Resident-to-bed ratio cap: 5 FTEs (from fiscal year end 
June 30, 2002) + 3 displaced FTEs (from fiscal year end June 30, 2003) 
/ 100 beds = .08 (line 3.19 of Worksheet E, Part A of Form CMS 2552-
96).
     The lower of the resident-to-bed ratio from the current 
year (.08) or the resident-to-bed ratio cap from the prior year (.08) 
is used to calculate the IME adjustment. Therefore, Hospital B would 
use a resident-to-bed ratio of .08 (line 3.20 of Worksheet E, Part A of 
Form CMS 2552-96).

July 1, 2003 through June 30, 2004
    The PGY3 displaced resident has completed his or her family 
practice training on June 30, 2003 and has left Hospital B. Hospital B 
continues to train a displaced (now) PGY2 resident, and a displaced 
(now) PGY3 resident.
     Resident-to-bed ratio: 5 FTEs + 2 displaced FTEs / 100 
beds = .07 (line 3.18 of Worksheet E, Part A of Form CMS 2552-96).
     Resident-to-bed ratio cap: 5 FTEs (from fiscal year end 
June 30, 2003) + 3 displaced FTEs (from fiscal year end June 30, 2003) 
/ 100 beds = .08 (line 3.19 of Worksheet E, Part A of Form CMS 2552-
96).
     The lower of the resident-to-bed ratio from the current 
year (.07) or the resident-to-bed ratio cap from the prior year (.08) 
is used to calculate the IME adjustment. Hospital B would use a 
resident-to-bed ratio of .07 (line 3.20 of Worksheet E, Part A of Form 
CMS 2552-96).

July 1, 2004 through June 30, 2005
    Another of the remaining displaced residents has completed his or 
her family practice training on June 30, 2004 and has left Hospital B. 
Hospital B continues to train one displaced (now) PGY3 resident.
     Resident-to-bed ratio: 5 FTEs + 1 displaced FTE / 100 beds 
= .06 (line 3.18 of Worksheet E, Part A of Form CMS 2552-96).
     Resident-to-bed ratio cap: 5 FTEs (from fiscal year end 
June 30, 2004) + 2 displaced FTEs (from fiscal year end June 30, 2004) 
/ 100 beds = .07 (line 3.19 of Worksheet E, Part A of Form CMS 2552-
96).
     The lower of the resident-to-bed ratio from the current 
year (.06) or the resident-to-bed ratio cap from the prior year (.07) 
is used to calculate the IME adjustment. Hospital B would use a 
resident-to-bed ratio of .06 (line 3.20 of Worksheet E, Part A of Form 
CMS 2552-96).

July 1, 2005 through June 30, 2006
    The last displaced resident has completed his or her family 
practice training on June 30, 2005 and has left Hospital B. Hospital B 
no longer trains any displaced residents, and, therefore, the last 
displaced resident is removed from the numerator of the resident-to-bed 
ratio cap.
     Resident-to-bed ratio: 5 FTEs + 0 displaced FTEs / 100 
beds = .05
     Resident-to-bed ratio cap: 5 FTEs (from fiscal year end 
June 30, 2005) + 0 displaced FTEs (subtract 1 displaced FTE from FYE 
June 30, 2005) / 100 beds = .05
     The lower of the resident-to-bed ratio from the current 
year (.05) or the resident-to-bed ratio cap from the prior year (.05) 
is used to calculate the IME adjustment. Hospital B would use a 
resident-to-bed ratio of .05.
    We are proposing that this exception to the resident-to-bed ratio 
cap for residents coming from a closed hospital or a closed program 
would be effective for cost reporting periods beginning on or after 
October 1, 2002. We are proposing to revise Sec. 412.105(a)(1) 
accordingly.
3. Counting Beds for the IME and DSH Adjustments (Sec. 412.105(b) and 
Sec. 412.106(a)(l)(i))
    As discussed under section V.E.2. of this proposed rule, the 
regulations for determining the number of beds to be used in 
calculating the resident-to-bed ratio for the IME adjustment are 
located at Sec. 412.105(b). These regulations also are used to 
determine the number of beds for other purposes, including calculating 
the DSH adjustment at Sec. 412.106(a)(l)(i). Section 412.105(b) 
specifies that the number of beds in a hospital is determined by 
counting the number of available bed days during the cost reporting 
period and dividing that number by the number of days in the cost 
reporting period. The number of available bed days does not include 
beds or bassinets in the healthy newborn nursery, custodial care beds, 
or beds in excluded distinct part hospital units.
    Section 2405.3G of Part I of the Medicare Provider Reimbursement 
Manual (PRM) further defines ``available'' beds. Specifically, section 
2405.3G states that an available bed is a bed that is permanently 
maintained and is available for use to lodge inpatients. However, there 
has been some uncertainty concerning the application of this definition 
of ``available.'' For example, a question arises as to whether beds in 
rooms or entire units that are unoccupied for extended periods of time 
should continue to be counted on the basis that, if there would ever be 
a need, they could be put into use.
    Counting the number of beds in a hospital is intended to measure 
the size of a hospital's routine acute care inpatient operations. While 
hospitals necessarily maintain some excess capacity, we believe there 
is a point where excess capacity may distort the bed count. Therefore, 
we are proposing to revise our policy concerning the determination of a 
hospital's bed size to exclude beds that represent an excessive level 
of unused capacity. We believe this proposed refinement of our bed 
counting policy would better capture the size of a hospital's inpatient 
operations as described above.
    We analyzed Medicare hospital data and found that, among hospitals 
that have between 100 and 130 beds, hospitals receiving DSH payments 
have lower occupancy rates than similar hospitals not receiving DSH 
payments. Because DSH payments are higher for urban hospitals with more 
than 100

[[Page 31463]]

beds, there may be an incentive for these hospitals to maintain excess 
capacity in order to qualify for those higher payments. Among 189 urban 
hospitals in this bed-size range that did not receive DSH payments 
during FY 1999, the average occupancy rate was 55 percent. However, 
among 294 urban hospitals in this bed-size range that did receive DSH 
payments during FY 1999, the average occupancy rate was 47 percent. 
Twenty-five percent of this group of hospitals (those receiving DSH 
payments) had occupancy rates below 35 percent. Among the hospitals not 
receiving DSH payments, 25 percent had occupancy rates below 43 
percent. We believe this is indicative of a tendency among some small 
urban hospitals to maintain excess capacity in order to qualify for 
higher DSH payments. Therefore, we are proposing that if a hospital's 
reported bed count results in an occupancy rate (average daily census 
of patients divided by number of beds) below 35 percent, the applicable 
bed count, for purposes of establishing the number of available beds 
for that hospital, would exclude beds that would result in an average 
annual occupancy rate below 35 percent (proposed Sec. 412.105(b)(3)).
    For example, if a hospital reports 105 beds for a cost reporting 
period, but has an average daily census of 26 patients for that same 
cost reporting period, its occupancy rate equals 24.8 percent (that is, 
26/105). Because its occupancy rate is below the proposed minimum 
threshold of 35 percent, its maximum available bed count would be 74, 
which is the number of beds that would result in an occupancy rate of 
35 percent, given an average daily census of 26 patients (that is, 
26/.35).
    We would otherwise continue to determine a hospital's bed size 
using existing regulations and program manual instructions, including 
the application of the available bed policy.
    Following are the steps a hospital would undertake in determining 
its number of beds in a cost reporting period under our proposed 
policy:
    Step 1: Determine the number of available beds using the existing 
regulations at Sec. 412.105(b) and PRM instructions.
    Step 2: Determine the average daily census by dividing the total 
number of inpatient acute care days in the hospital by the number of 
days in the cost reporting period.
    Step 3: Divide the average daily census determined in step 2 by 35 
percent.
    Step 4: Use the lower of the number of beds as determined under 
step 1, or the result of step 3 for purposes of the IME and DSH 
calculations.
    We believe that this proposed policy more accurately indicates the 
size of a hospital's operations. We are proposing to specify under 
proposed Sec. 412.105(b)(3) that if a hospital's reported bed count 
results in an occupancy rate below 35 percent, the applicable bed count 
for that hospital would be the number of beds that would result in an 
occupancy rate of 35 percent. We are proposing to make this proposed 
policy effective for discharges occurring on or after October 1, 2002.

F. Medicare-Dependent, Small Rural Hospitals: Ongoing Review of 
Eligibility Criteria (Sec. 412.108(b))

    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 hospitals (MDHs). MDHs 
are eligible for a special payment adjustment under the acute care 
hospital inpatient prospective payment system. Initially, in order to 
be classified as an MDH, a hospital must have met all of the following 
criteria:
     The hospital is located in a rural area (as defined in 
Sec. 412.63(b);
     The hospital has 100 or fewer beds (as defined at 
Sec. 412.105(b)) during the cost reporting period;
     The hospital is not classified as an SCH (as defined at 
Sec. 412.92); and
     The hospital has no less than 60 percent of its inpatient 
days or discharges attributable to inpatients receiving Medicare Part A 
benefits during its cost reporting period beginning in FY 1987.
    MDHs were eligible for a special payment adjustment under the acute 
care hospital inpatient 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 based on FY 1982 costs 
per discharge.
     The updated hospital-specific rate based on FY 1987 costs 
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. The MDH provision expired 
effective with cost reporting periods beginning on or after October 1, 
1994.
    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 before October 1, 2006.
    As specified in the June 13, 2001 interim final rule with comment 
period (66 FR 32172) and finalized in the August 1, 2001 final rule (66 
FR 39883), section 212 of Public Law 106-554 provided that, effective 
with cost reporting periods beginning on or after April 1, 2001, a 
hospital has 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 (section 1886(d)(5)(G)(iv)(IV) of the Act). 
According to section 1886(d)(5)(G)(iv)(IV) of the Act, 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.
    We would like to point out that cost reports undergo different 
levels of review. For example, some cost reports are settled with a 
desk review; others, through a full field audit. We believe the 
intention of the law is to provide hospitals the ability to qualify for 
MDH status based on their most recent settled cost reporting periods, 
each of which undergoes a level of audit in its settlement.
    Hospitals that qualify under section 1886(d)(5)(G)(iv)(IV) of the 
Act are subject to the other provisions already in place for MDHs. That 
is, all MDHs are paid using the payment methodology as defined in 
Sec. 412.108(c) and may be eligible for the volume decrease provision 
as defined in Sec. 412.108(d).
    Under existing classification procedures at Sec. 412.108(b), a 
hospital must submit a written request to its fiscal intermediary to be 
considered for

[[Page 31464]]

MDH status based on at least two of its three most recently audited 
cost reporting periods for which the Secretary has a settled cost 
report (as specified in Sec. 412.108(a)(1)(iii)(c)). The fiscal 
intermediary will make its determination and notify the hospital within 
90 days from the date it receives the hospital's request and all of the 
required documentation. The intermediary's determination is subject to 
review under 42 CFR Part 405, Subpart R. MDH status is effective 30 
days after the date of written notification of approval.
    We are proposing to clarify and to codify in the regulations 
(proposed Sec. 412.108(b)(4)) that an approved classification as an MDH 
remains in effect unless there is a change in the circumstances under 
which the classification was approved. That is, in order to maintain 
its eligibility for MDH status, a hospital must continue to be a small 
(100 or fewer beds), rural hospital, with no less than 60 percent 
Medicare inpatient days or discharges during either its cost reporting 
period beginning in FY 1987 or during at least two of its three most 
recently settled cost reporting periods.
    We also are proposing to clarify and to codify in the regulations 
(proposed Sec. 412.108(b)(5)) that the fiscal intermediary will 
evaluate on an ongoing basis whether or not a hospital continues to 
qualify for MDH status. This proposed clarification would include 
evaluating whether or not a hospital that qualified for MDH status 
under section 1886(d)(5)(G)(iv)(IV) of the Act continues to qualify for 
MDH status based on at least two of its three most recently settled 
cost reporting periods.
    In addition, we are proposing, (proposed Sec. 412.108(b)(6)) that 
if a hospital loses its MDH status, that change in status would become 
effective 30 days after the fiscal intermediary provides written 
notification to the hospital that it no longer meets the MDH criteria. 
If the hospital would like to be considered for MDH status after 
another cost reporting period has been audited and settled, we are 
proposing to require that the hospital must reapply by submitting a 
written request to its fiscal intermediary (proposed 
Sec. 412.108(b)(7)). An MDH that continues to meet the criteria would 
not have to reapply.

G. Eligibility Criteria for Reasonable Cost Payments to Rural Hospitals 
for Nonphysician Anesthetists (Sec. 412.113(c))

    Currently, a rural hospital can qualify and be paid on a reasonable 
cost basis for qualified nonphysician anesthetists (certified 
registered nurse anesthetists (CRNAs) and anesthesiologist assistants) 
services for a calendar year beyond 1990 and subsequent years as long 
as it can establish before January 1 of that year that it did not 
provide more than 500 surgical procedures requiring anesthesia 
services, both inpatient and outpatient.
    In the September 1, 1983 interim final rule with comment period 
that implemented the acute care hospital inpatient prospective payment 
system, we established the general policy to include, under that 
prospective payment system, inpatient hospital services furnished 
incident to a physician's service, with a time-limited exception for 
the inpatient hospital services of anesthetists (48 FR 39794). The 
purpose of this exception, which originally was for cost reporting 
periods beginning before October 1, 1986, was that the practice of 
physician-employer and anesthetist-employee was so widespread that we 
believed ``it would be disruptive of medical practice and adverse to 
the quality of patient care to require all such contracts to be 
renegotiated in the limited time available before the implementation of 
the prospective payment system.''
    Section 2312 of Public Law 98-369 provided for reimbursement to 
hospitals on a reasonable cost basis as a pass-through for the costs 
that hospitals incur in connection with 27 the services of CRNAs.\3\ 
Section 2312(c) provided that the amendment was effective for cost 
reporting periods beginning on or after October 1, 1984, and before 
October 1, 1987.
---------------------------------------------------------------------------

    \3\ We noted in the August 31, 1984 final rule that section 2312 
and the Conference Report used the term ``CRNA'' throughout. 
However, we believed it was Congressional intent to apply this pass-
through payment amount to the services of all qualified hospital-
employed nonphysician anesthetists (49 FR 34748).
---------------------------------------------------------------------------

    Section 9320 of Public Law 99-509 (which established a fee schedule 
for the services of nurse anesthetists) amended section 2312(c) of 
Public Law 98-369 by extending the pass-through provision for cost 
reporting periods beginning before January 1, 1989. Section 608 of 
Public Law 100-485 limited the pass-through provision effective during 
1989, 1990, and 1991, to hospitals meeting the following criteria:
     As of January 1, 1988, the hospital employed or contracted 
with a certified nonphysician anesthetist;
     In 1987, the hospital had a volume of surgical procedures 
(including inpatient and outpatient procedures) requiring anesthesia 
services that did not exceed 250 (or such higher number as the 
Secretary determines to be appropriate); and
     Each certified nonphysician anesthetist employed by, or 
under contract with, the hospital has agreed not to bill under Part B 
of Medicare for professional services furnished by the anesthetist at 
the hospital.
    Subsequently, section 6132 of Public Law 101-239 amended section 
608 of Public Law 100-458 by raising the established 250-procedure 
threshold to 500 procedures (effective for anesthesia services 
furnished on or after January 1, 1990), and extended the cost pass-
through indefinitely. However, section 6132 of Public Law 101-239 left 
intact the requirement that the hospital must have not exceeded a 
maximum number of surgical procedures (effectively raised to 500), both 
inpatient and outpatient, requiring anesthesia services during 1987. 
Also, the statutory authority for the Secretary to adopt such other 
appropriate maximum threshold volume of procedures as determined 
appropriate was not affected by section 6132.
    In light of the age of this provision, we undertook to reexamine 
the appropriateness of the current 500-procedure threshold. 
Nonphysician anesthetists who are not employed by or have a contractual 
relationship with a hospital paid under this provision may receive 
payments under a fee schedule. Payments under the fee schedule are 
generally somewhat lower than those made on a reasonable cost basis. 
Therefore, hospitals that exceed 500 procedures may have difficulty 
retaining access to nonphysician anesthetists' services because cost 
reimbursement is unavailable. According to data from the American 
Association of Nurse Anesthetists (AANA), the average total annual 
compensation for a CRNA in 2001 was approximately $155,000. The AANA 
estimates that, based on payments under the Medicare fee schedule, a 
CRNA would have to provide at least 800 anesthesia procedures to reach 
this average level of compensation.
    The statute provides the Secretary with the authority to determine 
the appropriateness of the volume threshold, in part, so that changes 
necessary to meet the needs of rural hospitals can be made. As we have 
found that hospitals that exceed the 500 surgical procedures may have 
difficulty in retaining access to nonphysician anesthetists' services, 
we believe that the appropriate maximum threshold for surgical 
procedures should be raised in order for the payment exception to apply 
to those hospitals most in need of this payment treatment. Based upon 
the data available to us concerning the best

[[Page 31465]]

estimates of average total compensation to a CRNA, we believe that the 
maximum volume threshold for surgical procedures requiring anesthesia 
services should be raised to 800. Therefore, to ensure continued access 
to nonphysician anesthetists' services in rural hospitals, we are 
proposing to revise Secs. 412.113(c)(2)(ii) and (c)(2)(iii) to raise 
the 500-procedure threshold to 800 procedures.

H. Medicare Geographic Classification Review Board (MGCRB) 
Reclassification Process (Secs. 412.230, 412.232, and 412.273)

    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.
1. Withdrawals, Teminations, and Cancellations
    Under Sec. 412.273(a) of our regulations, 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 acute care hospital 
inpatient prospective payment system for the upcoming fiscal year (for 
example, this proposed rule for FY 2003). In the August 1, 2001 final 
rule, we specified that, for purposes of implementing section 304 of 
Public Law 106-554, the withdrawal procedures and the applicable 
timeframes in the existing regulations would apply to hospitals that 
receive 3-year reclassification for wage index purposes (66 FR 39886). 
Once effective, a withdrawal means that the hospital would not be 
reclassified for purposes of the wage index for FY 2003 (and would not 
receive continued reclassification for FYs 2004 and 2005), unless the 
hospital subsequently cancels its withdrawal.
    Consistent with section 1886(d)(10)(D)(v) of the Act, a hospital 
may terminate its approved 3-year reclassification during the second or 
third years (Sec. 412.273(b)). This is a separate action from a 
reclassification withdrawal that occurs in accordance with the 
timeframes described above. Currently, in order to terminate an 
approved 3-year reclassification, we 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 hospital inpatient prospective payment 
system (Sec. 412.273(b)(1)(i)). A termination, unless subsequently 
cancelled, is effective for the full fiscal years remaining in the 3-
year period.
    We also provided that a hospital may apply for reclassification to 
a different area for the year corresponding to the second or third year 
of the reclassification (that is, an area different from the one to 
which it was originally reclassified) and, if successful, the 
reclassification would be for 3 years. Since the publication of the 
final rule, we received an inquiry regarding a situation where a 
hospital with an existing 3-year wage index reclassification 
successfully reclassifies to a different area, then withdraws from that 
second reclassification within the allowable timeframe for withdrawals. 
This scenario raises several issues not specifically addressed in the 
August 1, 2001 final rule, which we are proposing to clarify in this 
proposed rule.
    For example, the question arises, at what point does a hospital's 
termination of a 3-year reclassification become effective when a 
hospital applies for reclassification to another area? As noted above, 
the August 1, 2001 final rule specified that a hospital must file a 
written request with the MGCRB within 45 days of publication of the 
annual proposed rule to terminate the reclassification. However, the 
rules do not specify at what point a previous 3-year reclassification 
is terminated when a hospital applies for reclassification to another 
area in subsequent years. One might conclude that an application for a 
wage index reclassification to another area constitutes a written 
notification of a hospital's intent to terminate an existing 3-year 
reclassification. Under this scenario, however, if the application to 
the second area were denied, it would then be necessary for the 
hospital to formally cancel the termination of its reclassification to 
the first area within 45 days of publication of the proposed rule to 
avoid a lapse in reclassification status the following year. Therefore, 
we are proposing to clarify, in Sec. 412.273(b)(2)(iii), that, in a 
situation where a hospital with an existing 3-year wage index 
reclassification applies to be reclassified to another area, its 
existing 3-year reclassification will be terminated when a second 3-
year wage index reclassification goes into effect for payments for 
discharges on or after the following October 1. In such a case, it will 
not be necessary for the hospital to submit a separate written notice 
of its intent to terminate its existing 3-year reclassification. Of 
course, a hospital also may still terminate an existing 3-year 
reclassification through written notice to the MGCRB, regardless of 
whether it successfully reclassifies to a different area.
    The scenario of a hospital with an existing 3-year reclassification 
seeking reclassification to a second area raises another issue. If the 
hospital's request is approved by the MGCRB, but the hospital withdraws 
from that successful reclassification and ``falls back'' to its 
original 3-year reclassification, does the hospital retain the right to 
cancel that withdrawal the next year? In this way, a hospital could 
accumulate multiple reclassifications from which it could choose in any 
given year through canceling prior withdrawals or terminations to one 
area and withdrawing or terminating reclassifications to other areas.
    We do not believe section 304 of Public Law 106-554 was intended to 
be used in such a manner. Therefore, we are proposing to clarify 
existing policy that a previous 3-year reclassification may not be 
reinstated after a subsequent 3-year reclassification to another area 
takes effect. This would mean that a hospital that is reclassified to 
an area for purposes of the wage index may have only one active 3-year 
reclassification at a time. Once a 3-year reclassification to a second 
area becomes effective, a previously terminated 3-year reclassification 
may not be reinstated by terminating or withdrawing the 
reclassification to the second area and then canceling the termination 
or withdrawal of the reclassification to the first area.
    As we stated in the August 1, 2001 final rule, we believe the 3-
year wage index reclassification policy was intended to provide 
consistency and predictability in hospital reclassifications and the 
wage index data. Allowing hospitals multiple reclassification options 
to choose from would create a situation where many hospitals move in 
unpredictable ways between the proposed and final rules based on their 
calculation of which of several areas would yield the highest wage 
index. This would reduce the predictability of the system, hampering 
the ability of the majority of hospitals to

[[Page 31466]]

adequately project their future revenues. Therefore, we are proposing 
to amend Sec. 412.273(b)(2)(ii) to provide that, once a 3-year 
reclassification becomes effective, a hospital may no longer cancel a 
withdrawal or termination of another 3-year reclassification, even 
within 3 years from the date of such withdrawal or termination. We are 
also proposing a technical correction to Sec. 412.273(b)(2)(i) to 
correct the terminology regarding canceling (rather than terminating) a 
withdrawal.
    Finally, the August 1, 2001 final rule did not specifically 
describe the process to cancel a withdrawal or termination. Therefore, 
we are proposing to add a new Sec. 412.273(d) (existing paragraph (d) 
would be redesignated as paragraph (e)) to describe the process whereby 
a hospital may cancel a previous withdrawal or termination of a 3-year 
wage index reclassification. Specifically, a hospital may cancel a 
previous withdrawal or termination by submitting written notice of its 
intent to the MGCRB no later than the deadline for submitting 
reclassification applications for reclassifications effective at the 
start of the following fiscal year (Sec. 412.256(a)(2)).
2. Effect of Change of Ownership on Hospital Reclassifications
    Sections 412.230(e)(2)(ii) and 412.232(d)(2)(ii) provide that, for 
reclassifications effective beginning FY 2003, a hospital must provide 
a 3-year average of its average hourly wages using wage survey data 
from the CMS hospital wage survey used to construct the wage index in 
effect for prospective payment purposes.
    As discussed in the August 1, 2001 final rule, we received a 
comment suggesting that, for purposes of calculating the 3-year average 
hourly wages, we permit a hospital that has changed ownership the 
option of excluding prior years' wage data submitted by a previous 
owner in order for the new hospital to qualify for reclassification. 
Although we responded to the comment (66 FR 39890), we have now 
determined that there is a need to further clarify our policy regarding 
change of ownership and hospitals that do not accept assignment of the 
previous owner's provider agreement.
    In our response to the comment, we stated that, where a hospital 
has simply changed ownership and the new owners have acquired the 
financial 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. Where this is not the 
case and there is no obligation on the part of the new hospital to 
claim the financial assets or assume the liabilities 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.
    Section 489.18(c) provides that, when there is a change of 
ownership, the existing provider agreement will automatically be 
assigned to the new owner. Our regulations at Sec. 412.230(e)(2) do not 
specifically address the situation of new hospitals seeking to 
reclassify for wage index purposes, in light of the requirement that 
reclassification is based on a 3-year average hourly wage. Therefore, 
we are proposing to revise Sec. 412.230(e)(2), by adding a new 
paragraph (e)(2)(iii), to clarify our existing policy to specify that, 
in situations where a hospital does not accept assignment of the 
existing hospital's provider agreement under Sec. 489.18, the hospital 
would be treated as a new hospital with a new provider number. In that 
case, 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. As we stated in the August 1, 2001 final rule, we 
believe this policy clarification is consistent with how we treat 
hospitals whose ownership has changed for other Medicare payment 
purposes. We are proposing to revise Sec. 412.230 to clarify, under 
proposed new paragraph (e)(2)(iii), that once a new hospital has 
accumulated at least 1 year of wage data using survey data from the CMS 
hospital wage survey used to determine the wage index, it is eligible 
to apply for reclassification on the basis of those data.

I. 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 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 weighted number of full-time 
equivalent (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 in FY 1994 or FY 
1995 have two separate PRAs: 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)(D) 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. For cost 
reporting periods beginning on or after October 1, 2000, and before 
October 1, 2001, the floor PRA is 70 percent of the locality-adjusted, 
updated, weighted average PRA. For cost reporting periods beginning on 
or after October 1, 2001, and before October 1, 2002, section 511 of 
Public Law 106-554 amended the floor PRA to equal 85 percent of the 
locality-adjusted, updated, weighted average PRA. PRAs that are below 
the applicable floor PRA for a particular cost reporting period would 
be adjusted to equal the floor 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

[[Page 31467]]

increased by a reduced inflation factor. Existing regulations at 
Sec. 413.86(e)(4) specify the methodology for calculating each 
hospital's weighted average PRA and the steps for determining whether a 
hospital's PRA will be revised.
2. Determining the Weighted Average PRAs for Newly Participating 
Hospitals (Sec. 413.86(e)(5))
    As stated earlier, under section 1886(h) of the Act and 
implementing regulations, in most cases Medicare pays hospitals for the 
direct costs of GME on the basis of per resident costs in a 1984 base 
year. However, under existing Sec. 413.86(e)(5), if a hospital did not 
have residents in an approved residency training program, or did not 
participate in Medicare during the base period, the hospital's base 
period for its PRA is its first cost reporting period during which the 
hospital participates in Medicare and the residents are on duty during 
the first month of that period. If there are at least three existing 
teaching hospitals with PRAs in the same geographic wage area (MSA), as 
that term is used in 42 CFR Part 412, the fiscal intermediary will 
calculate a PRA based on the lower of the new teaching hospital's 
actual cost per resident in its base period or a weighted average of 
all the PRAs of existing teaching hospitals in the same MSA. There must 
be at least three existing teaching hospitals with PRAs in the MSA for 
this calculation. If there are less than three existing teaching 
hospitals with PRAs within the new teaching hospital's MSA, effective 
for cost reporting periods beginning on or after October 1, 1997, the 
fiscal intermediary uses the updated regional weighted average PRA 
(determined for each of the nine census regions established by the 
Bureau of Census for statistical and reporting purposes) for the new 
teaching hospital's MSA (see 62 FR 46004, August 29, 1997). A new 
teaching hospital is assigned a PRA equal to the lower of its actual 
allowable direct GME costs per resident or the weighted average PRA as 
calculated by the fiscal intermediary. Using a methodology based on a 
weighted average ensures that a new teaching hospital receives a PRA 
that is representative of the costs of training residents within its 
specific geographic wage area.
    Under existing policy, to calculate the weighted average PRA of 
teaching hospitals within a particular MSA, the fiscal intermediary 
begins by determining the base year PRA and the base year FTE count of 
each respective teaching hospital within that MSA. The weighted average 
PRA is (a) the sum of the products of each existing teaching hospital's 
base year PRA in the MSA and its base year FTEs, (b) divided by the sum 
of the base year FTEs from each of those hospitals. While a methodology 
using base year PRAs and FTEs was appropriate and workable in the years 
closely following the implementation of hospital-specific PRAs, it has 
become administratively burdensome for both CMS and the fiscal 
intermediaries to recreate base year information in calculating a 
weighted average. The methodology is particularly problematic in 
instances where there are large numbers of teaching hospitals in an 
MSA.
    In addition, as discussed in section V.I.1. of this proposed rule, 
hospitals that were training nonprimary care residents during FYs 1994 
and 1995 have a distinct nonprimary care PRA, because there was no 
update in the inflation factor for these years (Sec. 413.86(e)(3)(ii)). 
Thus, most teaching hospitals currently have two PRAs: one for primary 
care and obstetrics and gynecology; and one for all other residents. 
(Hospitals that first train residents after FY 1995 only have a single 
PRA, regardless of whether they train primary care or other residents.) 
However, since the current methodology for calculating weighted average 
PRAs is based on data from FY 1984, which was prior to the years during 
which the PRAs were not adjusted for inflation to reflect nonprimary 
care residents, the methodology does not account for all PRAs (both 
primary care and obstetrics and gynecology and nonprimary care) within 
an MSA.
    Accordingly, we are proposing to simplify and revise the weighted 
average PRA methodology under Sec. 413.86(e)(5)(i)(B) to reflect the 
average of all PRAs in an MSA, both primary care and obstetrics and 
gynecology, and nonprimary care. We would continue to calculate a 
weighted average PRA. However, rather than using 1984 base year data, 
we are proposing to use PRAs (both primary care and obstetrics and 
gynecology and nonprimary care) and FTE data from the most recently 
settled cost reports of teaching hospitals in an MSA. We are proposing 
that the intermediary would calculate the weighted average PRA using 
the following steps:
    Step 1: Identify all teaching hospitals (including those serviced 
by another intermediary(ies)) in the same MSA as the new teaching 
hospital.
    Step 2: Identify the respective primary care and obstetrics and 
gynecology FTE counts, the nonprimary care FTE counts, or the total FTE 
count (for hospitals with a single PRA) of each teaching hospital in 
step 1 from the most recently settled cost reports. (Use the FTE counts 
from line 3.07 and line 3.08 of the Medicare cost report, CMS-2552-96, 
Worksheet E-3, Part IV.)
    Step 3: Identify the PRAs (either a hospital's primary care and 
obstetrics and gynecology PRA and nonprimary care PRA, or a hospital's 
single PRA) from the most recently settled cost reports of the 
hospitals in step 1, and update the PRAs using the CPI-U inflation 
factor to coincide with the fiscal year end of the new teaching 
hospital's base year cost reporting period. For example, if the base 
year fiscal year end of a new teaching hospital is December 31, 2003, 
and the most recently settled cost reports of the teaching hospitals 
within the MSA are from the fiscal year ending June 30, 2000, September 
30, 2000, or December 31, 2000, the PRAs from these cost reports would 
be updated for inflation to December 31, 2003.
    Step 4: Calculate the weighted average PRA using the PRAs and FTE 
counts from steps 2 and 3. For each hospital in the calculation:
    (a) Multiply the primary care PRA by the primary care and 
obstetrics and gynecology FTEs.
    (b) Multiply the nonprimary care PRA by the nonprimary care FTEs.
    (c) For hospitals with a single PRA, multiply the single PRA by the 
hospital's total number of FTEs.
    (d) Add the products from steps (a), (b), and (c) for all 
hospitals.
    (e) Add the FTEs from step 3 for all hospitals.
    (f) Divide the sum from step (d) by the sum from step (e). The 
result is the weighted average PRA for hospitals within an MSA.
    The following is an example of how to calculate a weighted average 
PRA under the proposed methodology:

Example

    Assume that new Hospital A has a June 30 fiscal year end and begins 
training residents for the first time on July 1, 2003. Thus, new 
Hospital A's base year for purposes of establishing a PRA is the fiscal 
year ending June 30, 2004. New Hospital A is located in MSA 1234, in 
which three other teaching hospitals exist, Hospital B, Hospital C, and 
Hospital D. These three hospitals also have a fiscal year end of June 
30 and their most recently settled cost reports are for the fiscal year 
ending June 30, 2000. For fiscal year ending June 30, 2000, Hospital B 
has 200 primary care and obstetrics and gynecology FTEs, 150 nonprimary 
care FTEs, and 150 nonprimary care FTEs. Hospital C has 50 primary care 
and obstetrics and gynecology FTEs and 60

[[Page 31468]]

nonprimary care FTEs. Hospital D has 25 FTEs. After updating the PRAs 
for inflation by the CPI-U to June 30, 2004, Hospital B has a primary 
care and obstetrics and gynecology PRA of $120,000 and a nonprimary 
care PRA of $115,000, Hospital C has a primary care and obstetrics and 
gynecology PRA of $100,000 and a nonprimary care PRA of $97,000, and 
Hospital D has a single PRA of $90,000.

(a) Primary care:
Hospital B: $120,000  x  200 FTEs = $24,000,000
Hospital C: $100,000  x  50 FTEs = $5,000,000
(b) Nonprimary care:
Hospital B: $115,000  x  150 FTEs = $17,250,000
Hospital C: $97,000  x  60 FTEs = $5,820,000
(c) Single PRA:
Hospital D: $90,000  x  25 FTEs = $2,250,000
(d) $24,000,000 + 5,000,000 + $17,250,000 + $5,820,000 + $2,250,000 = 
$54,320,000.
(e) 200 + 50 + 150 + 60 + 25 = 485 total FTEs.
(f) $54,320,000/485 FTEs = $112,000, the weighted average PRA for 
MSA1234 for fiscal year ending June 30, 2004.

    New Hospital A's PRA would be the lower of $112,000 or its actual 
base year GME costs per resident.
    We are proposing that this new weighted average calculation would 
be effective for hospitals with direct GME base years that begin on or 
after October 1, 2002.
    In addition, we are taking the opportunity to clarify the language 
under existing Sec. 413.86(e)(5)(i)(B), which relates to calculating 
the weighted average under existing policy. Specifically, existing 
Sec. 413.86(e)(5)(i)(B) states: ``The weighted mean value of per 
resident amounts of all hospitals located in the same geographic wage 
area, as that term is used in the prospective payment system under part 
412 of this chapter, for cost reporting periods beginning in the same 
fiscal years [emphasis added].'' We believe this language could be 
misinterpreted to imply that only those PRAs of hospitals in the same 
geographic wage area (MSA) that have the same fiscal year end as the 
new teaching hospital should be used in the weighted average 
calculation. However, the PRAs of all hospitals within the MSA of the 
new teaching hospital should be used, not just the PRAs of hospitals 
with the same fiscal year end as the new teaching hospital. The 
proposed revision appears under a proposed new Sec. 413.86(e)(5)(i)(c).
3. Aggregate FTE Limit for Affiliated Groups (Secs. 413.86 (b) and 
(g)(7))
    Section 1886(h)(4)(H)(ii) of the Act permits, but does not require, 
the Secretary to prescribe rules that allow institutions that are 
member of the same affiliated group (as defined by the Secretary) to 
elect to apply the FTE resident limit on an aggregate basis. This 
provision allows the Secretary to permit hospitals flexibility in 
structuring rotations within a combined cap when they share residents' 
time. In accordance with the broad authority conferred by the statute, 
we created criteria for defining ``affiliated group'' and ``affiliation 
agreements'' in both the August 29, 1997 final rule (62 FR 45965) and 
the May 12, 1998 final rule (63 FR 26317). Because we have received 
many inquiries from the hospital industry on this policy, we are 
proposing to clarify in regulations the requirements for participating 
in an affiliated group. These requirements are explicitly derived from 
the policy explained in the August 29, 1997 and May 12, 1998 final 
rules.
    Specifically, we are proposing to add under Sec. 413.86(b) a new 
definition of ``Affiliation agreement.'' This new proposed definition 
would state that an affiliation agreement is a written, signed, and 
dated agreement by responsible representatives of each respective 
hospital in an affiliated group (as defined in Sec. 413.86(b)), that 
specifies--
      The term of the agreement, which, at a minimum must be 
one year, beginning on July 1 of a year.
      Each participating hospital's direct and indirect FTE 
cap.
      The annual adjustment to each hospital's FTE caps, for 
both direct GME and IME. This adjustment must reflect the fact that any 
positive adjustment to one hospital's direct and indirect FTE caps must 
be offset by a negative adjustment to the other hospital's (or 
hospitals') direct and indirect FTE caps of at least the same amount.
      The names of the participating hospitals and their 
Medicare provider numbers.
    In addition, we are proposing to add a new Sec. 413.86(g)(5)(iv) 
and a new Sec. 413.86(g)(7) to clarify the requirements for a hospital 
to receive a temporary adjustment to its FTE cap through an affiliation 
agreement. (Existing Sec. 413.86(g)(5)(iv) through (vi) are proposed to 
be redesignated as Sec. 413.86(g)(5)(v) through (vii), respectively; 
and existing Secs. 413.86(g)(7) through (g)(12) are proposed to be 
redesignated as Secs. 413.86(g)(8) through (g)(13), respectively, to 
accommodate these additions.) Specifically, we are proposing that a 
hospital may receive a temporary adjustment to its FTE cap, which is 
subject to the averaging rules, to reflect residents added or 
subtracted because the hospital is participating in an affiliated group 
(as that term is defined under Sec. 413.86(b)). Under this proposed 
provision--
      Each hospital in the affiliated group must submit the 
affiliation agreement (as that term is proposed to be defined under 
Sec. 413.86(b)), to the CMS fiscal intermediary servicing the hospital 
and send a copy to CMS's Central Office no later than July 1 of the 
residency program year during which the affiliation agreement will be 
in effect.
      There must be a rotation of a resident(s) among the 
hospitals participating in the affiliated group during the term of the 
affiliation agreement, such that more than one of the hospitals counts 
the proportionate amount of the time spent by the resident(s) in their 
FTE resident counts. (However, no resident may be counted in the 
aggregate as more than one FTE.) This requirement is intended to ensure 
that the participating hospitals maintain a ``cross-training'' 
relationship during the term of the affiliation agreement.
      The net effect of the adjustments (positive or negative) 
on the affiliated hospitals' aggregate FTE cap for each affiliation 
agreement must not exceed zero.
      If the affiliation agreement terminates for any reason, 
the FTE cap for each hospital in the affiliated group will revert to 
the individual hospital's pre-affiliation FTE cap.
    Except for the proposed new Sec. 413.86(g)(7)(iv) regarding the 
treatment of FTE caps after termination of the affiliation agreement, 
each provision of proposed new Sec. 413.86(g)(7) is explicitly derived 
from policy stated in the May 12, 1998 final rule (63 FR 26336). We are 
proposing to incorporate in regulations policy that was previously 
established under the formal rulemaking process.
    We are proposing a change in policy concerning what happens to each 
participating affiliated hospital's FTE cap when an affiliation 
agreement terminates (proposed new Sec. 413.86(g)(7)(iv)). In the 
preamble of the May 12, 1998 final rule (63 FR 26339), we stated: 
``Each agreement must also specify the adjustment to each respective 
hospital cap in the event the agreement terminates, dissolves, or, if 
the agreement is for a specified time period, for residency training 
years and cost reporting periods subsequent to the

[[Page 31469]]

period of the agreement for purposes of applying the FTE cap on an 
aggregate basis. In the absence of an agreement on the FTE caps for 
each respective institution following the end of the agreement, each 
hospital's FTE cap will be the indirect and direct medical education 
FTE count from each hospital's cost reporting period ending in 1996 and 
the cap will not be applied on an aggregate basis.'' Our purpose for 
allowing hospitals to redistribute their FTE caps (within the limits of 
the aggregate FTE caps) upon the termination of an affiliation was to 
enable hospitals by agreement to more closely reflect the realities of 
the residency rotational arrangement. However, in practice, very few 
hospitals have altered their FTE caps following termination of 
affiliation agreements. Rather, the vast majority of hospitals opted to 
revert to their respective 1996 FTE caps upon the termination of an 
affiliation. In addition, we have found that our existing policy is 
susceptible to the following abusive practice that does not comport 
with our original purpose for allowing redistribution of FTE caps among 
hospitals following termination of an affiliation agreement. We have 
learned of a number of instances in which one hospital (Hospital A) 
affiliated with another hospital (Hospital B) in anticipation of 
Hospital B's closure at some point during the residency program year. 
In these instances, the affiliation agreement was made solely for the 
purpose of obtaining a permanent adjustment to Hospital A's FTE cap 
through the terms of the termination clause. We do not believe these 
permanent FTE cap adjustments that result from hospital closures (or 
any other circumstances) were intended when Congress passed the 
provision on affiliation agreements. As stated above, we believe 
affiliations were meant to provide flexibility for hospitals in the 
rotations of residents where, in the normal course of an affiliation 
between two or more hospitals, the actual number of residents training 
at each hospital may vary somewhat from year to year. Affiliations were 
not intended to be used as a vehicle for circumventing the statutory 
FTE cap on the number of residents. In addition, we have separately 
addressed issues that arise when residents are displaced because of a 
pending hospital closure. We have in place a policy at existing 
Sec. 413.86(g)(8) (proposed to be redesignated as Sec. 413.86(g)(9) in 
this proposed rule) that permits temporary FTE cap adjustments for 
hospitals that take on the training of residents displaced by the 
closure of another hospital.
    Therefore, we are proposing that, effective October 1, 2002, for 
hospitals with affiliation agreements that terminate (for any reason) 
on or after that date, the direct and indirect FTE caps for each 
hospital in the affiliated group will revert back to each individual 
hospital's original FTE cap prior to the affiliation (proposed new 
Sec. 413.86(g)(7)(iv)). This policy would not preclude the 
participating hospitals from entering into additional affiliation 
agreements for later residency years.
    Since this proposed policy would be effective for agreements that 
terminate on or after October 1, 2002, hospitals that have already 
received a permanent FTE cap adjustment from their fiscal 
intermediaries through the existing termination clause policy would 
retain those cap adjustments.
    We also are proposing to make a conforming clarification at 
Sec. 412.105(f)(1)(vi) for purposes of IME payments.
4. Rotating Residents to Other Hospitals
    At existing Sec. 413.86(f), we state, in part, that a hospital may 
count residents training in all areas of the hospital complex; no 
individual may be counted as more than one FTE; and, if a resident 
spends time in more than one hospital or in a nonprovider setting, the 
resident counts as a partial FTE based on the proportion of time worked 
at the hospital to the total time worked (emphasis added). A similar 
policy exists at Secs. 412.105(f)(1)(ii) and (iii) for purposes of 
counting resident FTEs for IME payment. Although these policies 
concerning the counting of the number of FTE residents for IME and 
direct GME payment purposes have been in effect since October 1985, we 
continue to receive questions about whether residents can be counted by 
a hospital for the time during which the resident is rotated to other 
hospitals.
    We would like to clarify that it is longstanding Medicare policy, 
based on language in both the regulations and the statute, to prohibit 
one hospital from claiming the FTEs training at another hospital for 
IME and direct GME payment. This policy applies even when the hospital 
that proposes to count the FTE resident(s) actually incurs the costs of 
training the residents(s) (such as salary and other training costs) at 
another hospital.
    First, section 1886(h)(4)(B) of the Act states that the rules 
governing the direct GME 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.'' In the September 4, 1990 Federal Register (55 FR 36064), we 
stated that '' * * * regardless of which teaching hospital employs a 
resident who rotates among hospitals, each hospital would count the 
resident in proportion to the amount of time spent at its facility.'' 
Therefore, another hospital cannot count the time spent by residents 
training at another hospital. Only the hospital where the residents are 
actually training can count those FTEs for that portion of time. For 
example, if, during a cost reporting year, a resident spends 3 months 
training at Hospital A and 9 months training at Hospital B, Hospital A 
can only claim .25 FTE and Hospital B can only claim .75 FTE. Over the 
course of the entire cost reporting year, the resident would add up to 
1.0 FTE.
    We have been made aware of some instances where an urban hospital 
may incur all the training costs of residents while those residents 
train at a rural hospital, because the rural hospital may not have the 
resources or infrastructure to claim those costs and FTEs on a Medicare 
cost report. However, even in this scenario, the urban hospital is 
precluded from claiming any FTEs for the proportion of time spent in 
training at that rural hospital, or at any other hospital.
    We note, however, that, consistent with the statutory provisions of 
section 1886(d)(5)(B)(iv) of the Act for IME payment and section 
1886(h)(4)(E) of the Act for direct GME payment, a hospital may count 
the time residents spend training in a nonhospital setting if the 
hospital complies with the regulatory criteria at Sec. 413.86(f)(4).

J. Responsibilities of Medicare-Participating Hospitals in Emergency 
Cases (EMTALA)

1. Background
    Sections 1866(a)(1)(I), 1866(a)(1)(N), and 1867 of the Act impose 
specific obligations on Medicare-participating hospitals that offer 
emergency services. These obligations concern individuals who come to a 
hospital emergency department and request examination or treatment for 
medical conditions, and apply to all of these patients, regardless of 
whether or not they are beneficiaries of any program under the Act. 
Section 1867 of the Act sets forth requirements for medical screening 
examinations for medical conditions, as well as necessary stabilizing 
treatment or appropriate transfer. In addition, section 1867 of the Act 
specifically prohibits a delay in providing required screening or 
stabilization services in order to inquire

[[Page 31470]]

about the individual's payment method or insurance status. Section 1867 
of the Act also provides for the imposition of civil monetary penalties 
on hospitals and physicians responsible for the following: (a) 
Negligently failing to appropriately screen a patient seeking emergency 
medical care; (b) negligently failing to provide stabilizing treatment 
to an individual with an emergency medical condition; or (c) 
negligently transferring a patient in an inappropriate manner. (Section 
1867(e)(4) of the Act defines ``transfer'' to include both transfers to 
other health care facilities and cases in which the patient is released 
from the care of the hospital without being moved to another health 
care facility.)
    These provisions, taken together, are frequently referred to as the 
Emergency Medical Treatment and Labor Act (EMTALA), also known as the 
patient antidumping statute. EMTALA was passed in 1986 as part of the 
Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA). As a 
result, many people initially referred to EMTALA as ``COBRA'' or the 
``COBRA antidumping'' statute. Congress enacted these antidumping 
provisions in the Social Security Act because of its concern with an 
``increasing number of reports'' that hospital emergency rooms were 
refusing to accept or treat patients with emergency conditions if the 
patients did not have insurance:
    ``* * * The Committee is most concerned that medically unstable 
patients are not being treated appropriately. There have been reports 
of situations where treatment was simply not provided. In numerous 
other situations, patients in an unstable condition have been 
transferred improperly, sometimes without the consent of the receiving 
hospital.
    ``There is some belief that this situation has worsened since the 
prospective payment system for hospitals became effective. The 
Committee wants to provide a strong assurance that pressures for 
greater hospital efficiency are not to be construed as license to 
ignore traditional community responsibilities and loosen historic 
standards.
    ``[Under the statute] [a]ll participating hospitals with emergency 
departments would be required to provide an appropriate medical 
screening examination for any individual who requests it (or has a 
request made on his behalf) to determine whether an emergency medical 
condition exists or if the patient is in active labor.'' (H.R. Rept. 
No. 99-241, Part 1, 99th Cong., 1st Sess. (1985), p. 27.)
    The regulations implementing section 1867 of the Act are found at 
42 CFR 489.24, Special responsibilities of Medicare hospitals in 
emergency cases. Section 489.24 provides for the following:
     Paragraph (a) requires that when an individual presents to 
a hospital's emergency department and a request is made on the 
individual's behalf for examination or treatment of a medical 
condition, the hospital must provide for an appropriate medical 
screening examination to determine whether or not an emergency medical 
condition exists.
     Paragraph (b) provides the definitions of terms, including 
``comes to the emergency department,'' ``emergency medical condition,'' 
``stabilized,'' and ``to stabilize.''
     Paragraph (c) addresses procedures a hospital must follow 
when it determines that an emergency medical condition exists. If the 
hospital determines that an emergency medical condition exists, the 
hospital must provide for further medical examination and treatment as 
required to stabilize the patient. If the hospital does not have the 
capabilities to stabilize the patient, an appropriate transfer to 
another facility is permitted. A transfer is appropriate when the 
medical benefits of the transfer outweigh the medical risks of the 
transfer and other requirements, specified in the regulation at 
paragraph (d), are met. Also, the hospital may transfer an unstable 
patient who makes an informed written request. Paragraph (c) further 
states that a hospital may not delay an appropriate medical screening 
examination, or further examination or treatment, to inquire about the 
individual's payment method or insurance status.
    In addition, Sec. 489.24 addresses: (a) Restriction of a transfer 
until the individual is stabilized; (b) the responsibilities of the 
receiving hospital; (c) termination of the provider agreement for 
failure to comply with EMTALA requirements; and (d) matters concerning 
consultation with Peer Review Organizations (paragraphs (d) through 
(h), respectively).
    Some EMTALA-related requirements are implemented under regulations 
at Secs. 489.20(l), (m), (q), and (r)(1), (r)(2), and (r)(3). Those 
regulations deal with a hospital's obligations to report the receipt of 
patients that it has reason to believe may have been transferred 
inappropriately; to post signs in the emergency department describing a 
patient's rights to emergency treatment under section 1867 of the Act; 
and to maintain patient records, physician on-call lists, and emergency 
room logs. We are including this brief description for informational 
purposes but, because we are not proposing to change the regulations in 
Sec. 489.20, they will not be discussed further in this document.
    In promulgating these cited regulatory sections and in enforcing 
the provisions of EMTALA, we are aware of the necessary balance between 
the hospital's and a physician's legal duty to provide examination and 
treatment under the statute and the practical realities of the manner 
in which hospitals and medical staffs are organized and operated on a 
day-to-day basis, as well as proper mobilization of resources within 
hospitals in order to comply with these legal duties. Reports of 
overcrowding in hospital emergency departments are common in many parts 
of the country. Within the requirements of EMTALA, individuals should 
be treated at the appropriate site of care.
    Hospitals and physicians have now had over 15 years of experience 
in organizing themselves to comply with the provisions of EMTALA. 
Throughout this section of this proposed rule relating to EMTALA, we 
solicit comments from hospitals, physicians, patients, and beneficiary 
groups on the proposed changes to the EMTALA policies.
2. Special Advisory Bulletin on EMTALA Obligations
    On November 10, 1999, CMS (previously, HCFA) and the Office of the 
Inspector General (OIG) published jointly in the Federal Register a 
Special Advisory Bulletin addressing the requirements of the patient 
antidumping statute and the obligations of hospitals to medically 
screen all patients seeking emergency services and provide stabilizing 
medical treatment as necessary to all patients, including enrollees of 
managed care plans, whose conditions warrant it (64 FR 61353). The 
Special Advisory Bulletin addressed issues of dual staffing of hospital 
emergency rooms by managed care and nonmanaged care physicians, prior 
authorization requirements of some managed care plans, use of advance 
beneficiary notices (ABNs) or other financial responsibility forms, 
handling of individuals' inquiries about financial liability for 
emergency services, and voluntary withdrawal of a treatment request. 
Although it does not amend the Code of Federal Regulations, the Special 
Advisory Bulletin informs individuals of HHS policy regarding 
application of the patient antidumping statute and offers advice on the 
best practices to follow to avoid violation of the requirements imposed 
under that statute.

[[Page 31471]]

    As discussed further in section V.J.4. of this preamble, we are now 
proposing to codify certain policies on prior authorization that are 
currently stated only in the Special Advisory Bulletin. We believe 
these changes in the regulations are needed to ensure uniform and 
consistent application of policy and to avoid any misunderstanding of 
EMTALA requirements by patients, physicians, or hospital employees.
3. EMTALA Provisions in This Proposed Rule
    Recently, a number of questions have been raised about the 
applicability of Sec. 489.24 to specific situations. These questions 
arise in the context of managed care plans' requirements for prior 
authorization, case experiences involving elective procedures, and 
situations when patients have been admitted as inpatients but are not 
stabilized, or later experience a deterioration in their medical 
condition. Some hospitals are uncertain whether various conditions of 
participation found in 42 CFR part 482 apply to these situations or 
whether the EMTALA requirements included in the provider agreement 
regulations at Sec. 489.24 apply, or both. Some representatives of the 
provider community have asked us to reexamine CMS policy on the 
applicability of EMTALA to provider-based departments. Finally, there 
have also been questions concerning the applicability of EMTALA to 
physicians who are ``on call'' and to hospitals that own ambulances 
when those ambulances operate under communitywide emergency medical 
services (EMS) protocols. To help promote consistent application of the 
regulations concerning the special responsibilities of Medicare 
hospitals in emergency cases, we are proposing changes to Sec. 489.24 
to clarify its application to these situations and at the same time 
address concerns about EMTALA raised by the Secretary's Advisory 
Committee on Regulatory Reform. These changes are discussed more fully 
below and include the following:
     We are proposing to change the requirements relating to 
emergency patients presenting at those off-campus outpatient clinics 
that do not routinely provide emergency services. We believe these 
changes would enhance the quality and promptness of emergency care by 
permitting individuals to be referred to appropriately equipped 
emergency facilities close to such clinics.
     We are proposing to clarify when EMTALA applies to both 
inpatients and outpatients. We believe these clarifications would 
enhance overall patient access to emergency services by helping to 
relieve administrative burdens on frequently overcrowded emergency 
departments.
     We are proposing to clarify the circumstances in which 
physicians, particularly specialty physicians, must serve on hospital 
medical staff ``on-call'' lists. We expect these clarifications would 
help improve access to physician services for all hospital patients by 
permitting hospitals local flexibility to determine how best to 
maximize their available physician resources. We are currently aware of 
reports of physicians, particularly specialty physicians, severing 
their relationships with hospitals, especially when those physicians 
belong to more than one hospital medical staff. Physician attrition 
from these medical staffs could result in hospitals having no specialty 
physician service coverage for their patients. Our proposed 
clarification of the on-call list requirement would permit hospitals to 
continue to attract physicians to serve on their medical staffs and 
thereby continue to provide services to emergency room patients.
     We are proposing to clarify the responsibilities of 
hospital-owned ambulances so that these ambulances can be more fully 
integrated with citywide and local community EMS procedures for 
responding to medical emergencies and thus use these resources more 
efficiently for the benefit of these communities.
    We solicit comments on all of these proposed changes.
4. Prior Authorization
    Some managed care plans may seek to pay hospitals for services only 
if the hospitals obtain approval from the plan for the services before 
providing the services. Requirements for this approval are frequently 
referred to as ``prior authorization'' requirements. However, EMTALA 
(specifically, section 1867(h) of the Act and our regulation at 
Sec. 489.24(c)(3)) explicitly prohibit hospitals from delaying 
screening or stabilization services in order to inquire about the 
individual's method of payment or insurance status. Thus, prior 
authorization requirements are a matter of concern because hospitals 
could, in seeking prior authorization from an insurer, present a 
barrier to or delay in the provision of services required by EMTALA.
    After review of these considerations, we believe that our existing 
policy will best implement the intent of the statute by prohibiting a 
participating hospital from seeking authorization from the individual's 
insurance company for screening services or services required to 
stabilize an emergency medical condition until after the hospital has 
provided the appropriate medical screening examination required by 
EMTALA to the patient and has initiated any further medical examination 
and treatment that may be required to stabilize the patient's emergency 
medical condition.
    We are soliciting comments as to whether the regulations should be 
further revised to state that the hospital may seek other information 
(apart from information about payment) from the insurer about the 
individual, and may seek authorization for all services concurrently 
with providing any stabilizing treatment, as long as doing so does not 
delay required screening and stabilization services.
    In addition, we are proposing to specify that an emergency 
physician is not precluded from contacting the patient's physician at 
any time to seek advice regarding the patient's medical history and 
needs that may be relevant to the medical screening and treatment of 
the patient, as long as this consultation does not inappropriately 
delay required screening or stabilization services.
    As explained earlier, this policy was stated in a Special Advisory 
Bulletin published jointly by CMS (then HCFA) and the OIG. However, we 
are now proposing to clarify existing language at Sec. 489.24(c)(3) 
(proposed to be redesignated as paragraph (d)(4)) in this proposed rule 
to include this policy in the regulations.
5. Hospital Responsibility for Communication With Medicare+Choice 
Organizations Concerning Post-Stabilization Care Services
    Section 422.113 of our existing regulations establishes rules 
concerning the responsibility of Medicare+Choice organizations for 
emergency and post-stabilization care services provided to 
Medicare+Choice enrollees (65 FR 40170, June 29, 2000). Under 
Sec. 422.113(c)(2), a Medicare+Choice organization is financially 
responsible for post-stabilization care under certain circumstances, 
including situations in which the organization cannot be contacted or 
does not respond timely to a hospital's request for preapproval of this 
care.
    It has come to our attention that, in some instances, hospitals may 
have failed to contact Medicare+Choice organizations on a timely basis 
to seek authorization for post-stabilization services. In such a case, 
the Medicare+Choice organization does not

[[Page 31472]]

have the opportunity provided for under the regulations to decide 
whether to approve the provision of post-stabilization services at the 
hospital where the emergency services were provided, or to require that 
the enrollee instead be transferred to another hospital for such 
services. Therefore, we are proposing to add a new paragraph (d)(6) 
under Sec. 489.24 to specify that a hospital must promptly contact the 
Medicare+Choice organization after a Medicare+Choice enrollee who is 
treated for an emergency medical condition is stabilized.
6. Clarification of ``Comes to the Emergency Department''
    Section 1867(a) of the Act and our regulations at Sec. 489.24(a) 
provide, in part, that if any individual comes to the emergency 
department of a hospital and a request is made on that individual's 
behalf for examination or treatment of a medical condition, the 
hospital must provide an appropriate medical screening examination 
within the capability of the hospital's emergency department. If the 
hospital determines that such an individual has an emergency medical 
condition, the hospital is further obligated to provide either 
necessary stabilizing treatment or an appropriate transfer. 
Occasionally, questions have arisen as to whether these EMTALA 
requirements apply to situations in which a patient comes to a 
hospital, but does not present to the hospital's emergency department. 
We are proposing to clarify under what circumstances a hospital is 
obligated under EMTALA to screen, stabilize, or transfer an individual 
who comes to a hospital, presenting either at its dedicated emergency 
department, as proposed to be defined below, or elsewhere on hospital 
property, seeking examination or treatment.
    Sometimes individuals come to hospitals seeking examination or 
treatment for medical conditions that could be emergency medical 
conditions, but present for examination or treatment at areas of the 
hospital other than the emergency department. For example, a woman in 
labor may go directly to the labor and delivery department of a 
hospital or a psychiatric outpatient experiencing a psychiatric crisis 
may present at the psychiatry department. In the June 22, 1994 final 
rule (59 FR 32098), we defined ``comes to the emergency department'' at 
Sec. 489.24(b) to clarify that a hospital's EMTALA obligations are 
triggered whenever an individual presents on hospital property in this 
manner in an attempt to gain access to the hospital for emergency care 
and requests examination or treatment for an emergency medical 
condition. At the time we adopted this interpretation of ``comes to the 
emergency department,'' we explained:
    ``We believe that section 1867 of the Act also applies to all 
individuals who attempt to gain access to the hospital for emergency 
care. An individual may not be denied services simply because the 
person failed to actually enter the facility's designated emergency 
department.'' (59 FR 32098)
    We repeated this standard for situations in which a hospital 
becomes bound to meet EMTALA's screening and stabilization or transfer 
requirements with respect to individuals who present on hospital 
property in an attempt to gain access to the hospital for emergency 
care, but outside of a hospital's emergency department, in 
interpretative guidelines published in the State Operations Manual:
    ``If an individual arrives at a hospital and is not technically in 
the emergency department, but is on the premises (including the parking 
lot, sidewalk and driveway) of the hospital and requests emergency 
care, he or she is entitled to a medical screening examination.'' 
(State Operations Manual Appendix V--Responsibilities of Medicare 
Participating Hospitals in Emergency Cases, V-16)
    Thus, an individual can ``come to the emergency department,'' 
creating an EMTALA obligation on the part of the hospital, in one of 
two ways: The individual can present at a hospital's dedicated 
emergency department (as proposed to be defined below) and request 
examination or treatment for a medical condition; or the individual can 
present elsewhere on hospital property in an attempt to gain access to 
the hospital for emergency care (that is, at a location that is on 
hospital property but is not part of a dedicated emergency department), 
and request examination or treatment for what may be an emergency 
medical condition.
    Because of the need to clarify the applicability of EMTALA to a 
particular individual depending on where he or she presents on hospital 
property in order to obtain emergency care, we are proposing to define 
``dedicated emergency department.'' ``Dedicated emergency department'' 
would mean a specially equipped and staffed area of the hospital that 
is used a significant portion of the time for the initial evaluation 
and treatment of outpatients for emergency medical conditions, as 
defined in Sec. 489.24(b), and is either located: (1) On the main 
hospital campus; or (2) off the main hospital campus and is treated by 
Medicare under Sec. 413.65(b) as a department of the hospital. The 
EMTALA statute was intended to apply to individuals presenting to a 
hospital for emergency care services. Accordingly, we believe it is 
irrelevant whether the dedicated emergency department is located on or 
off the hospital main campus, as long as the individual is presenting 
to ``a hospital'' for those services. Therefore, we are proposing in 
our definition of ``dedicated emergency department'' that such a 
department may be located on the main hospital campus, or it may be a 
department of the hospital located off the main campus. (We note that 
this proposed definition would encompass not only what is generally 
thought of as a hospital's ``emergency room,'' but would also include 
other departments of hospitals, such as labor and delivery departments 
and psychiatric units of hospitals, that provide emergency or labor and 
delivery services, or both, or other departments that are held out to 
the public as an appropriate place to come for medical services on an 
urgent, nonappointment basis.)
    We are soliciting public comment on whether this proposed 
definition should more explicitly define what is a ``dedicated 
emergency department.'' Specifically, we are seeking comment on whether 
a ``significant portion of the time'' should be defined more 
objectively; for example, in terms of some minimum number or minimum 
percentage of patients (20, 30, 40 percent or more of all patients 
seen) presenting for emergency care at a particular area of the 
hospital in order for it to qualify as a ``dedicated emergency 
department.'' As an alternative, we could also consider a qualifying 
criteria that is based on determining whether the facility is used 
``regularly'' for the evaluation or treatment of emergency medical 
conditions. Similarly, we are seeking comments on how we could define 
``regularly'' more objectively in our consideration of this 
alternative. We further seek comments from hospitals, physicians, and 
others on how hospitals currently organize themselves to react to 
situations in which individuals come to a hospital requesting a 
screening examination or medical treatment, or both.
    This proposed rule would clarify for hospitals that they must 
provide at least a medical screening examination to all individuals who 
present to an area of a hospital meeting the definition of dedicated 
emergency department and request examination or treatment for a medical 
condition, or have such a request made on their behalf. As we explain 
in section V.J.7. of this preamble, individuals who present to an

[[Page 31473]]

area of a hospital other than a dedicated emergency department on 
hospital property must receive a medical screening examination under 
EMTALA, only when the individual requests examination or treatment for 
what may be an emergency medical condition, or has such a request made 
on his or her behalf, as provided in the proposed changes to 
Sec. 489.24(b) in this proposed rule.
7. Applicability of EMTALA: Individual Comes to the Dedicated Emergency 
Department for Nonemergency Services
    We sometimes receive questions as to whether EMTALA's requirements 
apply to situations in which an individual comes to a hospital's 
dedicated emergency department, but no request is made on the 
individual's behalf for emergency medical evaluation or treatment. In 
view of the specific language of section 1867 of the Act and the 
discussion in section V.J.6. of this proposed rule, which proposes to 
define a hospital's dedicated emergency department as a specially 
equipped and staffed area of the hospital that is used a significant 
portion of the time for the initial evaluation and treatment of 
outpatients for emergency medical conditions located on the main 
hospital campus or at an off-campus department of the hospital, we 
believe that a hospital must be seen as having an EMTALA obligation 
with respect to any individual who comes to the dedicated emergency 
department, if a request is made on the individual's behalf for 
examination or treatment for a medical condition, whether or not the 
treatment requested is explicitly for an emergency condition. A request 
on behalf of the individual would be considered to exist if a prudent 
layperson observer would believe, based on the individual's appearance 
or behavior, that the individual needs examination or treatment for a 
medical condition. This does not mean, of course, that all EMTALA 
screenings must be equally extensive. The statute plainly states that 
the objective of the appropriate medical screening examination is to 
determine whether or not an emergency medical condition exists. 
Therefore, hospitals are not obligated to provide screening services 
beyond those needed to determine that there is no emergency.
    In general, a medical screening examination is the process required 
to reach, with reasonable clinical confidence, a determination about 
whether a medical emergency does or does not exist. We expect that in 
most cases in which a request is made for medical care that clearly is 
unlikely to involve an emergency condition, an individual's statement 
that he or she is not seeking emergency care, together with brief 
questioning by qualified medical personnel, would be sufficient to 
establish that there is no emergency condition and that the hospital's 
EMTALA obligation would thereby be satisfied.
    To clarify our policy in this area, we are proposing to redesignate 
paragraphs (c) through (h) of Sec. 489.24 as paragraphs (d) through (i) 
(we are proposing to remove existing paragraph (i), as explained in 
section V.J.10. of this preamble) and to add a new paragraph (c) to 
state that if an individual comes to a hospital's dedicated emergency 
department and a request is made on his or her behalf for examination 
or treatment for a medical condition, but the nature of the request 
makes it clear that the medical condition is not of an emergency 
nature, the hospital is required only to perform such screening as 
would be appropriate for any individual presenting in that manner, to 
determine that the individual does not have an ``emergency medical 
condition'' as defined in paragraph (b). (See example 1 below.)

    Example 1: A woman walks up to the front desk of a hospital's 
emergency room, a dedicated emergency department, and tells the 
hospital employee attending the front desk that she had a wound 
sutured several days earlier and was directed by her doctor to have 
the sutures removed that day. The front desk attendant registers the 
woman according to the hospital's normal registration procedure and 
directs the woman to the waiting area. An emergency nurse, who has 
been designated by the hospital as a ``qualified medical person'' 
(as provided for in existing Sec. 489.24(a)), calls the woman into 
the examination area of the emergency room. The nurse asks the woman 
if she has experienced any discomfort or noticed any problems in the 
area sutured. The woman explains that she is feeling fine, and the 
wound is not causing her any discomfort, but that her doctor had 
directed her a week ago to have the sutures removed that day. The 
nurse physically inspects the sutures and determines that the wound 
is healing appropriately. The nurse explains to the woman that she 
does not have an emergency medical condition and may direct the 
woman to an outpatient clinic where nonemergency personnel will 
provide the services the woman has requested.

    Application: In this case, the woman presented at the hospital's 
dedicated emergency department and requested examination or treatment 
for a medical condition--specifically, she asked that her sutures be 
removed. Therefore, the hospital is bound under section 1867(a) of the 
Act to provide her a medical screening examination in order to 
determine whether or not she has an emergency medical condition. The 
actions of the nurse, ``a qualified medical person,'' constitute an 
appropriate medical screening examination under EMTALA because the 
nurse has determined, with reasonable clinical confidence, that the 
woman has no emergency medical condition. This appropriate medical 
screening examination fully satisfies the hospital's EMTALA obligations 
as to that woman; because the screening examination revealed no 
emergency medical condition, the hospital properly referred the woman 
to an outpatient clinic for nonemergency care.
8. Applicability of EMTALA: Individual Presents at an Area of the 
Hospital on the Hospital's Main Campus Other Than the Dedicated 
Emergency Department
    Routinely, individuals come to hospitals as outpatients for many 
nonemergency medical purposes, and if such an individual initially 
presents at an on-campus area of the hospital other than a dedicated 
emergency department, we would expect that the individual typically 
would not be seeking emergency care. Under most of these circumstances, 
EMTALA would therefore not apply (this concept is further discussed in 
section V.J.8. of this preamble). A hospital would, however, incur an 
EMTALA obligation with respect to an individual presenting at that area 
who requests examination or treatment for what may be an emergency 
medical condition, or had such a request made on his or her behalf. 
This policy would not require that an emergency medical condition be 
found, upon subsequent medical examination, to exist. Rather, EMTALA is 
triggered in on-campus areas of the hospital other than a dedicated 
emergency department where, in an attempt to gain access to the 
hospital for emergency care, an individual comes to a hospital and 
requests an examination or treatment for a medical condition that may 
be an emergency.
    We are proposing to specify in the regulations that such a request 
would be considered to exist if the individual requests examination or 
treatment for what the individual believes to be an emergency medical 
condition. Where there is no actual request because, for example, the 
individual is unaccompanied and is physically incapable of making a 
request, the request from the individual would be considered to exist 
if a prudent layperson observer would believe, based upon the 
individual's appearance or behavior, that the individual needs 
emergency examination or treatment. We believe this proposed policy is 
appropriate because it would not be

[[Page 31474]]

consistent with the intent of section 1867 of the Act to deny its 
protections to those individuals whose need for emergency services 
arises upon arrival on hospital on-campus property at the hospital's 
main campus but have not been presented to the dedicated emergency 
department.
    Under the proposed policies discussed above, a request for 
examination or treatment by an individual presenting for what may be an 
emergency medical condition at an on-campus area of the hospital other 
than the dedicated emergency department would not have to be expressed 
verbally in all cases, but in some cases should be inferred from what a 
prudent layperson observer would conclude from an individual's 
appearance or behavior. While there may be a request (either through 
the individual or a prudent layperson), thereby triggering an EMTALA 
obligation on the part of the hospital, this policy does not mean that 
the hospital must maintain emergency medical screening or treatment 
capabilities in each department or at each door of the hospital, nor 
anywhere else on hospital property other than the dedicated emergency 
department. If an individual presents at an on-campus area of the 
hospital other than the dedicated emergency department in an attempt to 
gain access to the hospital for emergency care, EMTALA would mandate 
that the hospital (as a whole) would provide for screening and 
stabilizing the individual. For example, upon presentation of an 
individual requesting emergency care, if the department to which the 
individual presents cannot readily provide screening and, if needed, 
stabilization services, the department may arrange for appropriate 
staff to provide these services. Care required to be provided under 
EMTALA should be provided in the most appropriate setting, as 
determined by the hospital.

    Example 2: An individual bleeding profusely from a severe scalp 
laceration enters a hospital through the main entry for hospital 
visitors, and says to one of the receptionists: ``I need help.'' The 
receptionist sees that the individual's head is bleeding and, noting 
his request, arranges to have the individual taken to the dedicated 
emergency department. Minutes later, the staff from the emergency 
department arrive and transport the individual to the hospital's 
emergency department to complete the screening and to give any 
necessary stabilizing treatment.

    Application: The individual presented at an on-campus area of the 
hospital other than the dedicated emergency department (in this case, 
the main entry for hospital visitors), with his head bleeding 
profusely, asking for help. The receptionist, a prudent layperson 
observing the individual, believed that the individual was seeking 
emergency examination or treatment, thereby triggering an EMTALA 
obligation on the part of the hospital. (We note that EMTALA would have 
been triggered even if no verbal request had been made, since the 
individual's appearance indicated the clear possibility of an emergency 
medical condition.) Since the main entry for hospital visitors did not 
have emergency examination or treatment capabilities, the receptionist 
appropriately called the hospital's emergency department to summon 
emergency department staff to provide emergency care for that 
individual. Once the emergency department staff arrived and transported 
the individual to the hospital's emergency department, and provided him 
with the emergency care needed and stabilized the individual, the 
hospital had satisfied its EMTALA obligation to that individual.
    Again, we solicit comments from hospitals and physicians that give 
examples of ways in which hospitals presently react to situations such 
as for the example noted above.
    Most individuals who come to hospitals as outpatients come for many 
nonemergency purposes; under most circumstances, EMTALA would not 
apply. We are proposing that EMTALA would not apply to such an 
individual who then experiences what may be an emergency medical 
condition if the individual is an outpatient (as that term is defined 
at 42 CFR Sec. 410.2) who has come to the hospital outpatient 
department for the purpose of keeping a previously scheduled 
appointment. We would consider such an individual to be an outpatient 
if he or she has begun an encounter (as that term is defined at 
Sec. 410.2) with a health professional at the outpatient department. 
Because such individuals are patients of the hospital already, that is, 
they have a previously established relationship with the hospital, and 
have come to the hospital for previously scheduled medical 
appointments, we believe it is inappropriate that they be considered to 
have ``come to the hospital'' for purposes of EMTALA. However, we note 
that such an outpatient under this proposal who experiences what may be 
an emergency medical condition after the start of an encounter with a 
health professional would have all protections afforded to patients of 
a hospital under the Medicare hospital conditions of participation (as 
discussed in section V.J.13. of this proposed rule). Hospitals that 
fail to provide treatment to these patients could face termination of 
their Medicare provider agreements for a violation of the conditions of 
participation. In addition, as patients of a health care provider, 
these individuals are accorded protections under State statutes or 
common law as well as under general rules of ethics governing the 
medical professions.

    Example 3: A patient who had been discharged from inpatient 
status following knee replacement surgery comes to the hospital 
outpatient department for a physical therapy session which had been 
scheduled 2 weeks earlier. While undergoing therapy, the patient 
complains of chest pains and lightheadedness. Acting under protocols 
established by the hospital, staff of the outpatient department 
contact the hospital's dedicated emergency department, which 
dispatches appropriate personnel to the department. The patient is 
taken to the hospital's dedicated emergency department for 
examination. Upon arrival in the dedicated emergency department, she 
is given a medical screening examination, which reveals that she has 
an emergency medical condition related to coronary artery disease. 
She is stabilized in the dedicated emergency department and is 
released to the care of her daughter.

    Application: In this case, the individual is an outpatient. While 
she is in a physical therapy session in an outpatient department of the 
hospital, she experiences what may be an emergency medical condition--
chest pains and lightheadedness. This outpatient is under the care of 
the hospital; she is in a previously scheduled physical therapy 
appointment and clearly has a previously established relationship with 
the hospital. In addition, the encounter with hospital staff has begun 
since her condition arose while she was undergoing therapy. Therefore, 
although the individual may be experiencing what may be an emergency 
medical condition, the hospital is not obligated under EMTALA. However, 
the hospital appropriately provided treatment for this patient, as 
required under the Medicare conditions of participation (specifically, 
42 CFR Sec. 482.55, which requires the hospital to fulfill its 
condition of participation responsibility for emergency care by 
contacting the hospital's dedicated emergency department and providing 
care to the individual through staff of that department). We solicit 
comments from hospitals and physicians as to what current practices are 
when an outpatient with a previously scheduled appointment experiences 
an emergency medical condition.
    We are proposing to retitle the definition of ``property'' at 
Sec. 489.24(b) to ``hospital property'' and relocate it as a

[[Page 31475]]

separate definition. In addition, we are proposing to clarify which 
areas and facilities are not considered hospital property.
9. Scope of EMTALA Applicability to Hospital Inpatients
    While most issues regarding EMTALA arise in connection with 
ambulatory patients, questions have occasionally been raised about 
whether EMTALA applies to inpatients. In late 1998, the United States 
Supreme Court considered a case (Roberts v. Galen of Virginia) that 
involved, in part, the question of whether EMTALA applies to inpatients 
in a hospital. In the context of that case, the United States Solicitor 
General advised the Supreme Court that the Department of Health and 
Human Services (DHHS) would develop a regulation clarifying its 
position on that issue. After reviewing the issue in the light of the 
EMTALA statute, we are proposing that EMTALA would apply to inpatients 
only under limited circumstances, as described in the following 
paragraphs.
    As noted earlier, once a hospital has incurred an EMTALA obligation 
with respect to an individual, that obligation continues while the 
individual remains at the hospital, so that any transfer to another 
medical facility or discharge of the individual must be in compliance 
with the rules restricting transfer until the individual is stabilized 
under existing Sec. 489.24(d). In many cases, medical judgment will 
dictate that a patient be admitted to the hospital for further 
treatment on an inpatient basis because the patient's emergency medical 
condition has not yet been stabilized.
    In these cases, the hospital continues to be obligated under 
section 1867, irrespective of the inpatient admission. Admitting an 
individual whose emergency medical condition has not been stabilized 
does not relieve the hospital of further responsibility to the 
individual under this section. An individual's emergency medical 
condition will be considered to have been stabilized only when the 
criteria in Sec. 489.24(b) are met; that is, the individual's condition 
must be such that no material deterioration of the condition is likely, 
within reasonable medical probability, to result from or occur during a 
transfer of the individual from the facility or, if the patient is a 
pregnant woman who is having contractions, that the woman has delivered 
the child and the placenta.
    Consistent with the above policy, we emphasize that an admission to 
inpatient status cannot be used to evade EMTALA responsibilities. 
Indeed, permitting inpatient admission to end EMTALA obligations would 
provide an obvious means of circumventing these requirements that would 
seemingly contradict the point of the statute to protect emergency 
patient health and safety. This point should be particularly evident in 
the case of a woman in labor, a central focus of the statute. Such 
women are frequently admitted, and the statute clearly contemplated 
protecting them until completion of the delivery (that is, 
stabilization). In addition, if an inpatient who had been admitted from 
the dedicated emergency department with an unstabilized emergency 
medical condition was never stabilized as an inpatient and is 
transferred, we would still apply EMTALA in reviewing the transfer. In 
this context, stability for transfer reflects a complex medical 
judgment that can be made only based on review of all relevant 
information in each particular case, including all conditions that 
could cause the patient to be medically unstable. A patient who goes in 
and out of apparent stability with sufficient rapidity or frequency 
would not be considered ``stabilized'' within the meaning of 
Sec. 489.24; transient stability of such a patient does not relieve the 
hospital of its EMTALA obligation. Such a patient would continue to be 
covered by EMTALA until the patient's overall medical stability with 
respect to all conditions is achieved.
    Except for the limited circumstances described above, we are 
proposing to clarify that EMTALA does not apply to hospital inpatients. 
We believe EMTALA does not apply to hospital inpatients because we 
interpret section 1867 of the Act by reading the statutory language as 
a whole, with the requirements of paragraphs (b), ``Necessary 
Stabilizing Treatment for Emergency Medical Conditions and Labor,'' and 
(c), ``Restricting Transfer Until Individual is Stabilized,'' applying 
only to those individuals who satisfy the threshold requirement of 
coming to the hospital and requesting emergency care (as interpreted in 
this proposed regulation). This interpretation is based upon the 
statutory language and the legislative history. First, the Congress 
defined ``emergency medical condition'' at section 1867(e)(1) of the 
Act by referring solely to ``acute symptoms,'' which are self-
identified, and did not mention other potentially relevant indications, 
in particular, signs or objective data. ``Signs'' are observable 
findings that are identified or confirmed by a clinician based on 
examination and use of objective data (for example, physiologic 
measurements, x-ray results). When a patient's condition deteriorates 
in the inpatient setting, awareness of a situation potentially 
requiring emergency care is based on any symptoms, signs, and objective 
data, reflecting a situation that is not captured by the targeted 
definition at section 1867(e)(1) of the Act. If the Congress had 
intended EMTALA to apply to transfers at any time during an inpatient 
stay, it would not have used a definition of emergency medical 
condition that focuses exclusively on symptoms and that uniquely 
defines the individual's status at the time of his or her initial 
presentation to the hospital, not his or her status as an inpatient. 
Furthermore, the definition of ``appropriate transfer'' in paragraph 
(c)(2) of section 1867 of the Act includes a variety of terms 
(observation, signs, symptoms, preliminary diagnosis) associated with 
patient information that is gathered at the initial stage of clinical 
intervention, when the course of treatment is just beginning. Thus, it 
would appear to be clear that the authors of this legislation 
understood the precise meanings of these clinical terms and utilized 
them accordingly. Further indication that Congress intended this result 
is the language in section 1867(b)(1)(A) of the Act (stabilization), 
which requires that the hospital provide ``for such further medical 
examination'' as necessary to stabilize. Congress' use of the word 
``further'' acknowledges that there was some initial treatment that 
occurred in the emergency department.
    In addition, the legislative history of EMTALA is replete with 
references to the problem of individuals denied emergency medical care 
at hospital emergency rooms, whereas there is no explicit reference to 
similar problems faced by hospital inpatients. (See, for example, 131 
Cong. Rec. 28.587 and 28.588 (1985)). When the Congress considered the 
need for EMTALA legislation, it noted that Medicare-participating 
hospitals were bound to meet hospital conditions of participation, but 
that no specific requirements then existed for appropriate treatment of 
emergency patients. (See H.R. Rept. No. 241 (I)(1985), reprinted in 
1986 U.S.C.C.A.N. 579, 605.) Arguably, the Congress also considered 
other protections available to hospital inpatients (for example, 
private causes of action).
    This interpretation that EMTALA was not intended to apply to 
transfers at any time during an inpatient's stay is further supported 
by the language of the appropriate transfer provisions of section 
1867(c) of the Act. While that paragraph does refer to individuals at a

[[Page 31476]]

``hospital,'' rather than individuals at an ``emergency department,'' 
the same paragraph also makes reference to actions to be taken by ``a 
physician * * * physically present in the emergency department.'' This 
explicit mention of a hospital emergency department, even in a 
paragraph that generally cites an individual at a ``hospital,'' 
supports the view that EMTALA was not intended to apply to admitted 
inpatients who may become unstable subsequent to admission, but only to 
patients who initially come to the hospital's emergency department with 
an emergency medical condition, and only until the condition has been 
stabilized. Finally, we note that once a hospital admits an individual 
as a patient, that hospital has a variety of other legal, licensing, 
and professional obligations with respect to the continued proper care 
and treatment of such patients.
    a. Admitted Emergency Patients. A related issue concerns whether a 
hospital may satisfy its EMTALA obligations to an admitted emergency 
inpatient only by effectuating an actual stable discharge or 
appropriate transfer. We are proposing to clarify that even when an 
admitted emergency patient is not actually transferred, a determination 
may be made as to whether or not the patient has been stabilized such 
that he or she could be transferred at a certain point without likely 
material deterioration of the patient's condition, as defined in 
section 1867(e)(3)(B) of the Act. Under our proposed policy, if the 
admitted emergency patient could have been transferred as ``stable'' 
under the statute and the period of stability is documented by relevant 
clinical data in the patient's medical record, the hospital has 
satisfied its EMTALA obligation by meeting the statutory requirement of 
providing stabilizing treatment to the point of stability for transfer, 
and the hospital's obligation under EMTALA ends, even though the 
patient may remain in inpatient status at the hospital. If, after 
stabilization, the individual who was admitted as an inpatient again 
has an apparent decline of his or her medical condition, either as a 
result of the injury or illness that created the emergency for which he 
or she initially came to the dedicated emergency department or as a 
result of another injury or illness, the hospital must comply with the 
conditions of participation under 42 CFR Part 482, but has no further 
responsibility under EMTALA with respect to the individual.
    We also note that, just because a hospital may stabilize a patient 
for purposes of ending its EMTALA obligation to that patient, this does 
not relieve the hospital of any further health and safety obligations 
as to that patient under the Medicare program. While they remain 
patients in that hospital, these patients are still protected by a 
number of Medicare health and safety standards (conditions of 
participation), as explained further below. In addition, as explained 
above, nothing under EMTALA in any way changes a hospital's other 
legal, licensing, and professional obligations with respect to the 
continued proper care and treatment of its patients.

    Example 4: A patient comes to Hospital C's emergency department 
and requests treatment for an emergency medical condition. The 
patient knows he has severe heart disease and his chest pains have 
become more frequent. The patient receives an appropriate medical 
screening examination and is found to have an emergency medical 
condition, as indicated by a pain pattern and EKG abnormalities 
consistent with unstable angina. Stabilizing treatment in the 
emergency department on an outpatient basis, consisting of oxygen, 
nitrates and heparin, is initiated.
    After several hours of outpatient care, the emergency physician 
determines that the patient is still not stable for purposes of 
discharge to his home. The emergency physician concludes that the 
patient can be treated most effectively by being admitted to 
Hospital C where he is currently being treated as an outpatient. The 
patient is admitted as an inpatient for further treatment. The 
attending physician knows that patients with indications for 
coronary angioplasty are usually transferred to Hospital D in 
another city because Hospital D has specialized capabilities that 
are unavailable at admitting Hospital C. A trip to Hospital D 
typically requires 2 hours travel by ground ambulance. The physician 
determines that the patient is stable for purposes of this type of 
transfer; that is, such a transfer is not likely to result in a 
material deterioration of the patient's condition, and documents 
relevant clinical data in the patient's medical record. Even though 
patients with this degree of coronary arterial disease and acute 
infarction risk are usually transferred, the patient opposes 
transfer and wants to remain in the local community. In accordance 
with the wishes of the patient and his family, the attending 
physician agrees to treat the patient in Hospital C while informing 
the patient of the risks involved.

    Application: In this situation, the admitted patient is not stable 
for purposes of discharge to his home but the attending physician 
determined that the patient is stable for the type of transfer usually 
undertaken by Hospital C for patients with unstable angina considered 
for angioplasty. This stabilization, which is documented by relevant 
clinical data in the patient's medical record, ends Hospital C's EMTALA 
obligation to the patient, and that obligation would not be reinstated 
by any subsequent deterioration in the patient's condition.
    We are proposing to redesignate paragraph (c) of Sec. 489.24 as 
paragraph (d), and include these stabilization requirements under a new 
proposed Sec. 489.2(d)(2). (Proposed redesignated paragraph (d) would 
be revised further as explained in section V.K.9.b. of this preamble.)
    b. Admitted Elective (Nonemergency) Patients. Most hospital 
admissions do not consist of emergency cases. In most cases, a patient 
who comes to the hospital and requests admission does so to obtain 
elective (nonemergency) diagnosis or treatment for a medical condition. 
Questions have arisen, however, as to whether a hospital would be bound 
under EMTALA in the situation in which an admitted nonemergency 
inpatient experiences a deterioration of his or her medical condition.
    Under our interpretation of section 1867 of the Act as described 
above, we believe EMTALA was intended to provide protection to patients 
coming to a hospital to seek care for an emergency condition. 
Therefore, we believe that the EMTALA requirements do not extend to 
admitted nonemergency inpatients. These patients are protected by a 
number of the Medicare hospital conditions of participation, as 
explained further under section V.K.13. of this preamble. These 
patients are further protected by a hospital's other legal, licensing, 
and professional obligations with respect to the continued proper care 
and treatment of its patients.
    We are proposing to also include these requirements under the 
proposed redesignated Sec. 489.24(d)(2).
10. Applicability of EMTALA to Provider-Based Entities
    On April 7, 2000, we published a final rule specifying the criteria 
that must be met for a determination regarding provider-based status 
(65 FR 18504). The regulations in that the April 2000 final rule were 
subsequently revised to incorporate changes mandated by section 404 of 
Public Law 106-554 (66 FR 59856, November 30, 2001). However, those 
revisions did not substantively affect hospitals' obligations with 
respect to off-campus departments.
    a. Applicability of EMTALA to Off-Campus Hospital Departments. In 
the April 7, 2000 final rule (65 FR 18504), we also clarified the 
applicability of EMTALA to hospital departments not located on the main 
provider campus. At that time, we revised Sec. 489.24 to include a new 
paragraph (i) to specify the antidumping obligations of hospitals

[[Page 31477]]

with respect to individuals who come to off-campus hospital departments 
for the examination or treatment of a potential emergency medical 
condition. As explained in the preamble to the April 7, 2000 final 
rule, we made this change because we believed it was consistent with 
the intent of section 1867 of the Act to protect individuals who 
present on hospital property (including off-campus hospital property) 
for emergency medical treatment. Since publication of the April 7, 2000 
final rule, it has become clear that many hospitals and physicians 
continue to have significant concerns with our policy on the 
applicability of EMTALA to these off-campus locations. After further 
consideration, we are proposing to clarify the scope of EMTALA's 
applicability in this scenario to those off-campus departments that are 
treated by Medicare under Sec. 413.65(b) to be departments of the 
hospital, and that are equipped and staffed areas that are used a 
significant portion of the time for the initial evaluation and 
treatment of outpatients for emergency medical conditions. That is, we 
are proposing to narrow the applicability of EMTALA to only those off-
campus departments that are ``dedicated emergency departments'' as 
defined in proposed revised Sec. 489.24(b).
    This proposed definition would include such departments whether or 
not the words ``emergency room'' or ``emergency department'' were used 
by the hospital to identify the departments. The definition would also 
be interpreted to encompass those off-campus hospital departments that 
would be perceived by a prudent layperson as appropriate places to go 
for emergency care. Therefore, we are proposing to revise the 
definition of ``Hospital with an emergency department'' at 
Sec. 489.24(b) to account for these off-campus dedicated emergency 
departments and to also amend the definition of ``Comes to the 
emergency department'' at Sec. 489.24(b) to include this same language. 
We believe this proposed change would enhance the quality of emergency 
care by facilitating the prompt delivery of emergency care in those 
cases, thus permitting individuals to be referred to nearby facilities 
with the capacity to offer appropriate emergency care.
    In general, we expect that off-campus departments that meet the 
proposed definitions stated above would in practice be functioning as 
``off-campus emergency departments.'' Therefore, we believe it is 
reasonable to expect the hospital to assume, with respect to these off-
campus departments, all EMTALA obligations that the hospital must 
assume with respect to the main hospital campus emergency department. 
For instance, the screening and stabilization or transfer requirements 
described in section V.K.1. of this preamble (``Background'') would 
extend to the off-campus emergency departments, as well as to any such 
departments on the main hospital campus.
    In conjunction with this proposed change in the extent of EMTALA 
applicability with respect to off-campus facilities, we are also 
proposing to delete all of existing Sec. 489.24(i), which, as noted 
above, was established in the April 7, 2000 final rule. We are 
proposing to delete this paragraph in its entirety because its primary 
purpose is to describe a hospital's EMTALA obligations with respect to 
patients presenting to off-campus departments that do not routinely 
provide emergency care. Under the proposals outlined above, however, a 
hospital would have no EMTALA obligation with respect to individuals 
presenting to such departments. Therefore, it would no longer be 
necessary to impose the requirements in existing Sec. 489.24(i). Even 
though off-campus provider-based departments that do not routinely 
offer services for emergency medical conditions would not be subject to 
EMTALA, some individuals may occasionally come to them to seek 
emergency care. Under such circumstances, we believe it would be 
appropriate for the department to call an emergency medical service 
(EMS) if it is incapable of treating the patient, and to furnish 
whatever assistance it can to the individual while awaiting the arrival 
of EMS personnel. Consistent with the hospital's obligation to the 
community and similar to our requirements under Sec. 482.12(f)(2) that 
apply to hospitals that do not provide emergency services, we would 
expect the hospital to have appropriate protocols in place for dealing 
with individuals who come to off-campus nonemergency facilities to seek 
emergency care. To clarify a hospital's responsibility in this regard, 
we are proposing to revise Sec. 482.12(f) by adding a new paragraph (3) 
to state that if emergency services are provided at the hospital but 
are not provided at one or more off-campus departments of the hospital, 
the governing body of the hospital must assure that the medical staff 
of the hospital has written policies and procedures in effect with 
respect to the off-campus department(s) for appraisal of emergencies 
and referral when appropriate. (We note that, in a separate document 
(62 FR 66758, December 16, 1997), we proposed to relocate the existing 
Sec. 482.12(f) requirement to a new section of Part 482. Any change to 
the existing Sec. 482.12(f) that is adopted as a result of the proposal 
described above will be taken into account in finalizing the December 
19, 1997 proposal.) However, the hospital would not incur an EMTALA 
obligation with respect to the individual.
    In summary, we are proposing in existing Sec. 489.24(b) to revise 
the definitions of ``comes to the emergency department'' and ``hospital 
with an emergency department'', and to include these off-campus 
departments in our new definition of ``dedicated emergency 
department.'' We welcome comments on whether this new term is needed or 
if the term ``emergency department'' could be defined more broadly to 
encompass other departments that provide urgent or emergent care 
services. We are proposing to delete all of existing Sec. 489.24(i) and 
to make conforming revisions to Sec. 413.65(g)(1).
    b. On-Campus Provider-Based Applicability. At existing 
Sec. 413.65(g)(1), we state, in part, that if any individual comes to 
any hospital-based entity (including an RHC) located on the main 
hospital campus, and a request is made on the individual's behalf for 
examination or treatment of a medical condition, the entity must comply 
with the antidumping rules at Sec. 489.24. Since provider-based 
entities, as defined in Sec. 413.65(b), are not under the certification 
and provider number of the main provider hospital, this language, read 
literally, would appear to impose EMTALA obligations on providers other 
than hospitals, a result that would not be consistent with section 
1867, which restricts EMTALA applicability to hospitals. To avoid 
confusion on this point and to prevent any inadvertent extension of 
EMTALA requirements outside the hospital setting, we are proposing to 
clarify that EMTALA applies in this scenario to only those departments 
on the hospital's main campus that are provider-based; EMTALA would not 
apply to provider-based entities (such as RHCs) that are on the 
hospital campus.
    In addition, we are proposing in Sec. 489.24(b) to revise the 
definition of ``Comes to the emergency department'' to include an 
individual who presents on hospital property, in which ``hospital 
property'' is in part defined as ``the entire main hospital campus as 
defined at Sec. 413.65(b) of this chapter, including the parking lot, 
sidewalk, and driveway, but excluding other areas or structures that 
may be located within 250 yards of the hospital's main building but are 
not part of the hospital, such as physician offices, RHCs, SNFs, or 
other entities

[[Page 31478]]

that participate separately in Medicare, or restaurants, shops, or 
other nonmedical facilities.'' We are specifically seeking comments on 
this proposed revised definition. Generally, this proposed language 
would clarify that EMTALA does not apply to provider-based entities, 
whether or not they are located on a hospital campus. This language is 
also consistent with our policy as stated in questions and answers 
published on the CMS website: www.cms.gov (CMS EMTALA guidance, 7/20/
01, Q/A # 1) that clarifies that EMTALA does not apply to other areas 
or structures located on the hospital campus that are not part of the 
hospital, such as fast food restaurants or independent medical 
practices.
    If this proposed change limiting EMTALA applicability to only those 
on-campus departments of the hospital becomes finalized, we believe 
that if an individual comes to an on-campus provider-based entity or 
other area or structure on the campus not applicable under the new 
policy and presents for emergency care, it would be appropriate for the 
entity to call the emergency medical service if it is incapable of 
treating the patient, and to render whatever assistance it can to the 
individual while awaiting the arrival of emergency medical service 
personnel. However, the hospital on whose campus the entity is located 
would not incur an EMTALA obligation with respect to the individual.
    We welcome comments from providers and other interested parties on 
the proper or best way to organize hospital resources to react to 
situations on campus where an individual patient or prospective patient 
requires immediate medical attention.
    We are proposing in Sec. 489.24(b) to revise the definition of 
``Comes to emergency department'' (specifically, under proposed new 
paragraph (1)) and make conforming changes at Sec. 413.65(g)(1).
11. EMTALA and On-Call Requirements
    We have frequently received inquiries concerning the applicability 
of EMTALA for physicians on call. We believe there are a number of 
misconceptions in the provider industry concerning the extent to which 
EMTALA requires physicians to provide on-call coverage. Therefore, we 
are including a section in this preamble that clarifies what kinds of 
obligations physicians have to provide on-call coverage under EMTALA.
    Section 1866(a)(1)(I)(iii) of the Act states, as a requirement for 
participation in the Medicare program, that hospitals must keep a list 
of physicians who are on call for duty after the initial examination to 
provide treatment necessary to stabilize an individual with an 
emergency medical condition. If a physician on the list is called by a 
hospital to provide emergency screening or treatment and either fails 
or refuses to appear within a reasonable period of time, the hospital 
and that physician may be in violation of EMTALA as provided for under 
section 1867(d)(1)(C) of the Act.
    The CMS State Operations Manual (SOM) further clarifies a 
hospital's responsibility for the on-call physician. The SOM (Appendix 
V, page V-15, Tag A404) states:
     Each hospital has the discretion to maintain the on-call 
list in a manner to best meet the needs of its patients.
     Physicians, including specialists and subspecialists (for 
example, neurologists), are not required to be on call at all times. 
The hospital must have policies and procedures to be followed when a 
particular specialty is not available or the on-call physician cannot 
respond because of situations beyond his or her control.
    Thus, hospitals are required to maintain a list of physicians on 
call at any one time and physicians or hospitals, or both, may be 
responsible under the EMTALA statute to provide emergency care if a 
physician who is on the on-call list fails to or refuses to appear 
within a reasonable period of time. However, Medicare does not set 
requirements on how frequently a hospital's staff of on-call physicians 
are expected to be available to provide on-call coverage. We are aware 
that practice demands in treating other patients, conferences, 
vacations, days off, and other similar factors must be considered in 
determining the availability of staff. We also are aware that some 
hospitals, particularly those in rural areas, have stated that they 
incur relatively high costs of compensating physician groups for 
providing on-call coverage to their emergency departments, and that 
doing so can strain their already limited financial resources. CMS 
allows hospitals flexibility to comply with EMTALA obligations by 
maintaining a level of on-call coverage that is within their 
capability.
    We understand that some hospitals exempt senior medical staff 
physicians from being on call. This exemption is typically written into 
the hospital's medical staff bylaws or the hospital's rules and 
regulations, and recognizes a physician's active years of service (20 
or more years) or age (that is, 60 years of age or older), or a 
combination of both. We wish to clarify that providing such exemptions 
to members of hospitals' medical staff does not necessarily violate 
EMTALA. On the contrary, we believe that the hospital is responsible 
for maintaining an on-call list in a manner that best meets the needs 
of its patients as long as the exemption does not affect patient care 
adversely. Thus, CMS allows hospitals flexibility in the utilization of 
their emergency personnel.
    We also note that there is no predetermined ``ratio'' that CMS uses 
to identify how many days that a hospital must provide medical staff 
on-call coverage based on the number of physicians on staff for that 
particular specialty. In particular, CMS has no rule stating that 
whenever there are at least three physicians in a specialty, the 
hospital must provide 24 hour/7 day coverage. Generally, in determining 
EMTALA compliance, CMS will consider all relevant factors, including 
the number of physicians on staff, other demands on these physicians, 
the frequency with which the hospital's patients typically require 
services of on-call physicians, and the provisions the hospital has 
made for situations in which a physician in the specialty is not 
available or the on-call physician is unable to respond.

    Example 5: Hospital D has 75 beds and is located in a rural 
area. The hospital provides on-call coverage of orthopedic services 
on all weekdays and the first 3 weekends of each month. On the 
fourth weekend of one month, an individual presents at Hospital D's 
dedicated emergency department and requests examination for a 
medical condition. The emergency physician on duty screens the 
individual and finds that she has an orthopedic emergency medical 
condition requiring the services of an orthopedist. Hospital D does 
not have on-call orthopedic physician coverage on this date and, 
therefore, transfers the individual to an urban hospital 20 miles 
away for necessary treatment. The transfer is arranged in accordance 
with procedures that Hospital D has for meeting patient needs when a 
particular specialty is not available or the physician cannot 
respond for reasons beyond his or her control.
    Analysis: Hospital D incurred an EMTALA obligation when the 
individual presented at Hospital D's dedicated emergency department and 
requested examination for a medical condition. At that time, Hospital D 
did not have on-call coverage to provide necessary stabilizing 
treatment for what was an orthopedic emergency medical condition, even 
though an orthopedic physician was on-call at other times. The 
emergency physician at Hospital D weighed the risks involved to 
transfer the individual to an urban hospital with capabilities to treat 
the individual and found that it would be more beneficial to the 
individual to transfer him or her

[[Page 31479]]

to the urban hospital 20 miles away, than to provide screening and 
stabilizing treatment within Hospital D's capabilities (which, at that 
time, did not include orthopedic services). Hospital D has satisfied 
its EMTALA obligation by providing screening services within its 
capability, followed by an appropriate transfer, under procedures 
developed in advance. To clarify our policies on EMTALA requirements 
regarding the availability of on-call physicians, we are proposing to 
add to Sec. 489.24 a new paragraph (j) to specify that each hospital 
has the discretion to maintain the on-call list in a manner to best 
meet the needs of its patients. This paragraph would further specify 
that physicians, including specialists and subspecialists (for example, 
neurologists), are not required to be on call at all times, and that 
the hospital must have policies and procedures to be followed when a 
particular specialty is not available or the on-call physician cannot 
respond because of situations beyond his or her control.
12. EMTALA Applicability to Hospital-Owned Ambulances
    We stated in the June 22, 1994 final rule (59 FR 32098) that if an 
individual is in an ambulance owned and operated by a hospital, the 
individual is considered to have come to the hospital's emergency 
department, even if the ambulance is not on hospital property. This 
policy, currently set forth at Sec. 489.24(b), was necessary because we 
were concerned that some hospitals that owned and operated ambulances 
at that time were transporting individuals who had called for an 
ambulance to other hospitals, thereby evading their EMTALA 
responsibilities to the individuals.
    Concerns have since been raised by the provider industry about 
applications of this policy to ambulances that are owned by hospitals 
but are operating under communitywide EMS protocols that may require 
the hospital-owned and other ambulances to transport individuals to 
locations other than the hospitals that own the ambulances. For 
instance, we understand that some community protocols require 
ambulances to transport individuals to the nearest hospital to the 
patient geographically, whether or not that hospital owns the 
ambulance.
    To avoid imposing requirements that are inconsistent with local EMS 
requirements, we are proposing to clarify, at proposed revised 
Sec. 489.24(b) in the definition of ``Comes to the emergency 
department'', an exception to our existing rule requiring EMTALA 
applicability to hospitals that own and operate ambulances. Our 
proposal would account for hospital-owned ambulances operating under 
communitywide EMS protocols. Under our proposal, the rule on hospital-
owned ambulances and EMTALA does not apply if the ambulance is 
operating under a communitywide EMS protocol that requires it to 
transport the individual to a hospital other than the hospital that 
owns the ambulance. In this case, the individual is considered to have 
come to the emergency department of the hospital to which the 
individual is transported, at the time the individual is brought onto 
hospital property.
13. Conditions of Participation for Hospitals
    We are reminding hospitals and others that while this proposed 
regulation would make it clear that stabilizing an emergency inpatient 
relieves the hospital of its EMTALA obligations, it does not relieve 
the hospital of all further responsibility for the patient who is 
admitted or indicate that the hospital is thus free to improperly 
discharge or transfer him or her to another facility. Inpatients who 
experience acute medical conditions receive protections under the 
hospital conditions of participation, which are found at 42 CFR part 
482. In addition, as noted earlier in this preamble, we believe that 
outpatients who experience what may be an emergency medical condition 
after the start of an encounter with a health professional would have 
all protections afforded to patients of a hospital under the Medicare 
conditions of participation. There are six conditions of participation 
that provide these protections: emergency services, governing body, 
discharge planning, quality assurance, medical staff, and outpatient 
services. We are not proposing in this proposed rule to make changes to 
any of the conditions of participation.
    If a hospital inpatient develops an acute medical condition and the 
hospital is one that provides emergency services, the hospital is 
required to ensure that it meets the emergency needs of the patient in 
accordance with accepted standards of practice. Similarly, regardless 
of whether the hospital provides emergency services, if an inpatient 
develops an acute medical condition, the governing body condition of 
participation (Sec. 482.12(f)(2), which applies to all Medicare-
participating hospitals) would apply. This condition of participation 
requires that the hospital governing body must ensure that the medical 
staff has written policies and procedures for appraisal of emergencies, 
initial treatment, and referral when appropriate.
    The discharge planning condition of participation (Sec. 482.43, 
which applies to all Medicare-participating hospitals) requires 
hospitals to have a discharge planning process that applies to all 
patients. This condition of participation ensures that patient needs 
are identified and that transfers and referrals reflecting adequate 
discharge planning are made by the hospital. If an inpatient develops 
an acute medical condition and the hospital either does not offer 
emergency services or does not have the capability to provide necessary 
treatment, a transfer to another hospital with the capabilities to 
treat the emergency medical condition could be warranted. Hospitals are 
required to meet the discharge planning condition of participation in 
carrying out such a transfer.
    The hospital condition of participation governing medical staff 
(Sec. 482.22) requires that the hospital have an organized medical 
staff that operates under bylaws approved by the governing body and is 
responsible to the governing body for the quality of medical care 
provided to patients by the hospital. Should the medical staff not be 
held accountable to the governing body for problems regarding a lack of 
provision of care to an inpatient who develops an emergency medical 
condition, this lack of accountability may be reviewed under the 
medical staff condition of participation, as well, and may result in a 
citation of noncompliance at the medical staff condition level for the 
hospital.
    Finally, the quality assurance condition of participation 
(Sec. 482.21, which applies to all Medicare-participating hospitals) 
requires the governing body to ensure that there is an effective, 
hospital-wide quality assurance program to evaluate the provision of 
patient care. In order to comply with this condition of participation, 
the hospital must evaluate the care it provides hospital-wide. 
Complaints regarding a lack of provision of care to an inpatient who 
develops an emergency medical condition must be addressed under the 
hospital's quality assurance program and may be reviewed under the 
quality assurance condition of participation.
    A hospital's failure to meet the conditions of participation 
requirements cited above may result in a finding of noncompliance at 
the condition level for the hospital and lead to termination of the 
hospital's Medicare provider agreement.

[[Page 31480]]

K. Provider-Based Entities

1. Background
a. The April 7, 2000 Final Rule
    Since the beginning of the Medicare program, some providers, which 
we refer to as ``main providers,'' have functioned as a single entity 
while owning and operating multiple provider-based departments, 
locations, and facilities that were treated as part of the main 
provider for Medicare purposes. Having clear criteria for provider-
based status is important because this designation can result in 
additional Medicare payments for services furnished at the provider-
based facility, and may also increase the coinsurance liability of 
Medicare beneficiaries for those services.
    In the April 7, 2000 Federal Register (65 FR 18504), we published a 
final rule specifying the criteria that must be met for a determination 
regarding provider-based status. The regulations at Sec. 413.65(a)(2) 
define provider-based status as ``the relationship between a main 
provider and a provider-based entity or a department of a provider, 
remote location of a hospital, or satellite facility, that complies 
with the provisions of this section.'' The regulations at existing 
Sec. 413.65(b)(2) state that before a main provider may bill for 
services of a facility as if the facility is provider-based, or before 
it includes costs of those services on its cost report, the facility 
must meet the criteria listed in the regulations at Sec. 413.65(d). 
Among these criteria are the requirements that the main provider and 
the facility must have common licensure (when appropriate), the 
facility must operate under the ownership and control of the main 
provider, and the facility must be located in the immediate vicinity of 
the main provider.
    The effective date of these regulations was originally October 10, 
2000, but was subsequently delayed and is now in effect for new 
facilities or organizations for cost reporting periods beginning on or 
after January 10, 2001, as explained further below. Program 
instructions on provider-based status issued before that date, found in 
Section 2446 of the Provider Reimbursement Manual, Part 1 (PRM-1), 
Section 2004 of the Medicare State Operations Manual (SOM), and CMS 
Program Memorandum (PM) A-99-24, will apply to any facility for periods 
before the new regulations become applicable to it. (Some of these 
instructions will not be applied because they have been superseded by 
specific legislation on provider-based status, as described in section 
V.K.3. of this preamble).
b. Frequently Asked Questions Regarding Provider-Based Issues
    Following publication of the April 7, 2000 final rule, we received 
many requests for clarification of policies on specific issues related 
to provider-based status. In response, we published a list of 
``Frequently Asked Questions'' and the answers to them on the CMS 
website at www.hcfa.gov/medlearn/provqa.htm. (This document can also be 
obtained by contacting any of the CMS (formerly, HCFA) Regional 
Offices.) These questions and answers did not revise the regulatory 
criteria, but do provide subregulatory guidance for their 
implementation.
c. Medicare, Medicaid, and SCHIP Benefits Improvement and Protection 
Act of 2000 (Public Law 106-554)
    On December 21, 2000, the Medicare, Medicaid, and SCHIP Benefits 
Improvement and Protection Act (BIPA) of 2000 (Public Law 106-554) was 
enacted. Section 404 of BIPA contains provisions that significantly 
affect the provider-based regulations at Sec. 413.65. Section 404 
includes a grandfathering provision for facilities treated as provider-
based on October 1, 2000; alternative criteria for meeting the 
geographic location requirement; and criteria for temporary treatment 
as provider-based.
(1) Two-Year ``Grandfathering''
    Under section 404(a) of BIPA, any facilities or organizations that 
were ``treated'' as provider-based in relation to any hospital or CAH 
on October 1, 2000, will continue to be treated as such until October 
1, 2002. For the purpose of this provision, we interpret ``treated as 
provider-based'' to include those facilities with formal CMS 
determinations, as well as those facilities without formal CMS 
determinations that were being paid as provider-based as of October 1, 
2000. As a result, existing provider-based facilities and organizations 
may retain that status without meeting the criteria in the existing 
regulations under Secs. 413.65(d), (e), (f), and (h) until October 1, 
2002. These provisions concern provider-based status requirements, 
joint ventures, management contracts, and services under arrangement. 
Thus, the provider-based facilities and organizations affected under 
section 404(a) of BIPA are not required to submit an application for or 
obtain a provider-based status determination in order to continue 
receiving reimbursement as provider-based during this period.
    These provider-based facilities and organizations are not exempt 
from the EMTALA responsibilities of provider-based facilities and 
organizations set forth at Sec. 489.24, which we are proposing to 
revise as discussed above, or from the other obligations of hospital 
outpatient departments and hospital-based entities in existing 
Sec. 413.65(g), such as the responsibility of off-campus facilities to 
provide written notices to Medicare beneficiaries of coinsurance 
liability. These rules are not preempted by the grandfathering 
provisions of section 404 of BIPA because they do not set forth 
criteria that must be met for provider-based status as a department of 
a hospital, but instead identify responsibilities that flow from that 
status. These responsibilities become effective for hospitals on the 
first day of the hospital's cost reporting period beginning on or after 
January 10, 2001.
(2) Geographic Location Criteria
    Section 404(b) of BIPA provides that those facilities or 
organizations that are not included in the grandfathering provision at 
section 404(a) are deemed to comply with the ``immediate vicinity'' 
requirements of the existing regulations under Sec. 413.65(d)(7) if 
they are located not more than 35 miles from the main campus of the 
hospital or CAH. Therefore, those facilities located within 35 miles of 
the main provider satisfy the immediate vicinity requirement as an 
alternative to meeting the ``75/75 test'' under existing 
Sec. 413.65(d)(7).
    In addition, BIPA provides that certain facilities or organizations 
are deemed to comply with the requirements for geographic proximity 
(either the ``75/75 test'' or the ``35-mile test'') if they are owned 
and operated by a main provider that is a hospital with a 
disproportionate share adjustment percentage greater than 11.75 percent 
and is (1) owned or operated by a unit of State or local government, 
(2) a public or private nonprofit corporation that is formally granted 
governmental powers by a unit of State or local government, or (3) a 
private hospital that has a contract with a State or local government 
that includes the operation of clinics of the hospital to ensure access 
in a well-defined service area to health care services for low-income 
individuals who are not entitled to benefits under Medicare or 
Medicaid.
    These geographic location criteria will continue indefinitely. 
While those facilities or organizations treated as provider-based on 
October 1, 2000 are covered by the 2-year grandfathering

[[Page 31481]]

provision noted above, the geographic location criteria at section 
404(b) of BIPA and the existing regulations at Sec. 413.65(d)(7) will 
apply to facilities or organizations not treated as provider-based as 
of that date, effective with the hospital's cost reporting period 
beginning on or after January 10, 2001. On October 1, 2002, the 
statutory moratorium on application of these criteria to the 
grandfathered facilities will expire. In this proposed rule, we are 
proposing a further delay, as discussed below.
(3) Criteria for Temporary Treatment as Provider-Based
    Section 404(c) of BIPA also provides that a facility or 
organization that seeks a determination of provider-based status on or 
after October 1, 2000, and before October 1, 2002, shall be treated as 
having provider-based status for any period before a determination is 
made. Thus, recovery for overpayments will not be made retroactively 
once a request for a determination during that time period has been 
made. For hospitals that do not qualify for grandfathering under 
section 404(a) of BIPA, a request for provider-based status should be 
submitted to the appropriate CMS Regional Office. Until a uniform 
application is available, at a minimum, the request should include the 
identity of the main provider and the facility or organization for 
which provider-based status is being sought and supporting 
documentation for purposes of applying the provider-based status 
criteria in effect at the time the application is submitted. Once such 
a request has been submitted on or after October 1, 2000, and before 
October 1, 2002, CMS will treat the facility or organization as being 
provider-based from the date it began operating as provider-based until 
the effective date of a CMS determination that the facility or 
organization is not provider-based.
    Facilities requesting a provider-based status determination on or 
after October 1, 2002, will not be covered by the provision concerning 
temporary treatment as provider-based in section 404(c) of BIPA. Thus, 
as stated in Sec. 413.65(n), the CMS Regional Offices will make 
provider-based status effective as of the earliest date on which a 
request for determination has been made and all requirements for 
provider-based status in effect as of the date of the request are shown 
to have been met, not on the date of the formal CMS determination. 
Under existing regulations at Sec. 413.65(j), if a facility or 
organization does not qualify for provider-based status and CMS learns 
that the provider has treated the facility or organization as provider-
based without having obtained a provider-based determination under 
applicable regulations, CMS will review all payments and may seek 
recovery for overpayments, including overpayments made for the period 
of time between submission of the request or application for provider-
based status and the issuance of a formal CMS determination. (As 
explained in the previous paragraph, such retroactive recovery of 
payments would not be made for any period to the extent it is 
prohibited by section 404(c) of BIPA.)
d. The August 24, 2001 and November 30, 2001 Published Regulations
    In August 24, 2001 Federal Register (66 FR 44672), we proposed to 
revise the provider-based regulations to reflect the changes mandated 
by section 404 of BIPA and to make other technical and clarifying 
changes in those regulations. In the November 30, 2001 Federal Register 
(66 FR 59856), following consideration of public comments received on 
the August 24, 2001 proposal, we published a final rule that revised 
the provider-based regulations. However, the only substantive changes 
in the provider-based regulations were those required by the BIPA 
legislation.
2. Proposed Changes
    In the preamble to the proposed rule published on August 24, 2001 
(66 FR 44709), we stated our intent to reexamine the EMTALA regulations 
and, in particular, to reconsider the appropriateness of applying 
EMTALA to off-campus locations. We announced that we planned to review 
these regulations with a view toward ensuring that these locations are 
treated in ways that are appropriate to the responsibility for EMTALA 
compliance of the hospital as a whole. We also pointed out that, at the 
same time, we want to ensure that those departments that Medicare pays 
as hospital-based departments are appropriately integrated with the 
hospital as a whole.
    In addition, since the statutory grandfathering provision in the 
BIPA legislation remains in effect only until October 1, 2002, many 
hospital representatives have contacted CMS to request more guidance 
because they are concerned that their facilities are not in compliance 
with existing regulations and would not be able to continue billing as 
provider-based once the grandfathering provision expires. These 
hospital representatives are also concerned that the organizational and 
contractual changes needed to meet current provider-based requirements 
could take several months to complete. Moreover, resolution of some of 
the issues surrounding the provider-based regulations is needed in 
order to allow development of a uniform application form to enable the 
CMS Regional Offices to efficiently process the multitudes of requests 
for provider-based determinations that we expected as the 
grandfathering period expires.
    To address the provider-based issues raised by the hospital 
industry and to allow for an orderly and uniform implementation 
strategy once grandfathering ends, we are proposing the following 
regulatory changes:
a. Scope of Provider-Based Requirements (Sec. 413.65(a))
    Since publication of the April 2000 final rule, we have received 
many questions about which specific facilities or organizations are 
subject to the provider-based requirements. In the ``Frequently Asked 
Questions'' posted on the CMS website, we identified a number of 
facility types for which provider-based determinations would not be 
made, since such determinations would not affect either Medicare 
payment or Medicare beneficiary liability or scope of benefits. The 
regulations at Sec. 413.65(a) were further revised to incorporate the 
exclusion of these facility types from review under the provider-based 
criteria. We now are proposing to further revise Sec. 413.65(a)(1)(ii) 
to state that provider-based determinations will not be made with 
respect to independent diagnostic testing facilities that furnish only 
services paid under a fee schedule, such as facilities that furnish 
only screening mammography services, as defined in section 1861(jj) of 
the Act, facilities that furnish only clinical diagnostic laboratory 
tests, or facilities that furnish only some combination of these 
services. A provider-based determination would not be appropriate for a 
facility that furnishes only screening mammography because of a change 
made by section 104 of BIPA. That legislation, which amended section 
1848(j)(3) of the Act, mandates that all payment for screening 
mammography services furnished on or after January 1, 2000, be made 
under the Medicare Physician Fee Schedule (MPFS). Under the MPFS 
methodology, Medicare payment for the service, regardless of the 
setting in which it is furnished, is set at the lesser of the fee 
schedule amount or the actual charge; and no Part B deductible applies. 
Regardless of the setting, Part B coinsurance is assessed at 20 percent 
of the lesser of the fee schedule amount or the actual charge. Because 
the status of a facility as provider-based or freestanding would

[[Page 31482]]

not affect the amount of Medicare or Medicaid payment, the 
beneficiary's scope of benefits, or the beneficiary's liability for 
coinsurance or deductible amounts, it is not necessary to make a 
provider-based determination regarding facilities that furnish only 
screening mammography. We are also proposing to revise 
Sec. 413.65(a)(1)(ii) by adding a new paragraph (J) to state that we 
will not make provider-based determinations with respect to departments 
of providers (for example, laundry or medical records departments) that 
do not furnish types of health care services for which separate payment 
could be claimed under Medicare or Medicaid. (Such services frequently 
are referred to as ``billable'' services.) As explained more fully 
below, we would not make determinations with respect to these 
departments because their status (that is, whether they are provider-
based or not) would have no impact on Medicare or Medicaid payment or 
on the scope of benefits or beneficiary liability under either program.
    Despite the previous clarifications described above, providers, 
associations, and their representatives have continued to state that 
they are confused as to which facilities or organizations will be the 
subject of provider-based determinations.
    In this document, we are proposing to further clarify the types of 
facilities that are subject to the provider-based rules, by making 
several changes to the definitions of key terms in Sec. 413.65(a)(2). 
First, we are proposing to revise the definition of ``department of a 
provider'' to remove the reference to a physician office as being a 
department of a provider. While a hospital outpatient department, in 
fact, may furnish services that are clinically indistinguishable from 
those of physician offices, physician offices and provider departments 
are paid through separate methods under Medicare and beneficiaries may 
be liable for different coinsurance amounts. Thus, it is essential to 
distinguish between these facility types, and we believe avoiding 
confusion on this issue requires us to remove the reference to a 
hospital department as a physician office.
    We also are proposing to revise Sec. 413.65(a)(2) to state that a 
``department of a provider'', ``provider-based entity'', or ``remote 
location of a hospital'' comprises both the specific physical facility 
that serves as the site of services of a type for which separate 
payment could be claimed under the Medicare or Medicaid programs, and 
the personnel and equipment needed to deliver the services at that 
facility. We believe this change would help to clarify that we would 
make determinations with respect to entities considered in their role 
as sources of health care services and not simply as physical 
locations. We also wish to clarify that we do not intend to make 
provider-based determinations with respect to various organizational 
components or units of providers that may be designated as 
``departments'' or ``organizations'' but do not themselves furnish 
types of services for which separate payment could be claimed under 
Medicare or Medicaid. Examples of components for which we would not 
make provider-based determinations include the medical records, 
housekeeping, and security departments of a hospital. Such departments 
do perform functions that are essential to the provision of inpatient 
and outpatient hospital services, but the departments do not provide 
health care services for which Medicare or Medicaid benefits are 
provided under title XVIII or title XIX of the Act, and for which 
separate payment therefore could be claimed, assuming certification and 
other applicable requirements were met, to one or both programs. 
Therefore, neither Medicare or Medicaid program liability nor 
beneficiary liability or scope of benefits would be affected by the 
ability or inability of these departments to qualify as ``provider-
based.'' (We also would not make a provider-based determination with 
respect to any facility or organization that furnishes only types of 
health care services for which separate payment could be claimed under 
either Medicare or Medicaid, even if the facility or organization met 
all requirements for provider-based status. For example, if a hospital 
that is not eligible for DSH payments under Medicare or Medicaid or for 
IME payments under Medicare were to establish a dedicated facility 
providing only types of cosmetic surgery or experimental therapies that 
could not be covered under either Medicare or Medicaid, no 
determination would be made with respect to that facility.)
    By contrast, Medicare or Medicaid payment (or both) to hospital 
departments that provide diagnostic or therapeutic radiology services 
to outpatients, or primary care, ophthalmology, or other specialty 
services to outpatients are affected by provider-based status, as would 
beneficiary liability for Medicare coinsurance amounts. Therefore, we 
would make provider-based determinations for these departments.
    Similarly, if two acute care hospitals that have approved graduate 
medical education (GME) programs were to merge to form a single, 
multicampus hospital consisting of the main hospital campus and a 
remote location, it would be appropriate to make a determination as to 
whether the remote location is provider-based with respect to the main 
hospital campus. Such a determination would be needed because each 
hospital with an approved residency training program has its own 
hospital-specific cap on the number of residents (or FTE cap), its own 
PRA, and its own Medicare utilization used for purposes of receiving 
Medicare GME payments. A merger of the two hospitals would aggregate 
the two hospitals' individual FTE caps into a merged FTE cap under the 
main hospital's provider number, and would require recalculation of the 
hospital's PRA and a merging of these entities' respective Medicare 
utilization, resulting in a level of Medicare GME payment to the merged 
hospital that exceeds the sum of the payments that would be made to 
each hospital as separate entities. Thus, a provider-based 
determination would be appropriate and necessary in such a case, even 
though payment for services by both facilities would be made under the 
Medicare acute care hospital inpatient prospective payment system.
    In deciding whether to make a provider-based determination with 
respect to a particular facility, it would not be significant that the 
facility might have a low rate of Medicare utilization, might be 
utilized by only Medicare or only Medicaid patients, or might not have 
admitted any Medicare or Medicaid patients in a particular period. The 
fact that the facility furnishes types of services that are billable 
under Medicare or Medicaid, or both, would be sufficient to make a 
determination appropriate.
    We are proposing to retain the rules that a department of a 
provider or a remote location of a hospital (such as, for example, one 
campus of a multicampus hospital) may not by itself be qualified to 
participate in Medicare as a provider under the regulations on provider 
agreements in Sec. 489.2, and the Medicare conditions of participation 
do not apply to a department as an independent entity. However, we are 
proposing to delete the requirement at Sec. 413.65(a)(2) that such a 
department may not be licensed to provide services in its own right. 
Some States require separate licensing of facilities that Medicare 
would treat as a department of a hospital or other provider. In these 
States, we would not require a common license. We would retain the 
provision that, for purposes of Part 413, the term ``department of a 
provider'' does not

[[Page 31483]]

include an RHC or, except as specified in Sec. 413.65(m), an FQHC.
    Questions have arisen regarding whether the provider-based criteria 
in Sec. 413.65 are applicable in determining payment for ambulance 
services. Medicare is converting payment for ambulance services to a 
fee schedule, as described in a final rule published on February 27, 
2002 (67 FR 9100). The ambulance fee schedule is effective April 1, 
2001, and involves a transition period. During this transition period, 
the status of an ambulance supplier as provider-based could influence 
the amount of Medicare payment. However, the specific provider-based 
criteria in Sec. 413.65 were not developed for ambulance suppliers, and 
we believe that many of these criteria could not reasonably be applied 
to them. Therefore, we are not proposing to apply the criteria at 
Sec. 413.65 to ambulance services.
b. Further Delay in Effective Date of Provider-Based Rules
    As noted earlier, Sec. 413.65(b) was recently revised to reflect 
the ``grandfathering'' provision in section 404(a)(1) of BIPA. Under 
that provision, if a facility was treated as provider-based in relation 
to a hospital or CAH on October 1, 2000, it will continue to be 
considered provider-based in relation to that hospital or CAH until 
October 1, 2002.
    It now appears likely that any new provider-based rules that may be 
adopted as the result of this rulemaking effort will not be published 
in final before mid-summer of 2002. To allow hospitals and other 
facilities the time they need to make contractual and organizational 
changes to comply with the new rules, and to ensure that CMS Regional 
Offices and contractors are able to provide for an orderly transition 
to the new provider-based rules, we believe an additional delay in the 
effective date of the provider-based criteria is needed. Therefore, we 
are proposing to revise Sec. 413.65(b)(2) to state that if a facility 
was treated as provider-based in relation to a hospital or CAH on 
October 1, 2000, it will continue to be considered provider-based in 
relation to that hospital or CAH until the start of the hospital's 
first cost reporting period beginning on or after July 1, 2003. We are 
proposing to further provide that the requirements, limitations, and 
exclusions specified in Sec. 413.65(d) through (j) (as proposed to be 
redesignated) will not apply to that hospital or CAH for that facility 
until the start of the hospital's first cost reporting period beginning 
on or after July 1, 2003. For purposes of paragraph (b)(2), a facility 
would be considered as having been provider-based on October 1, 2000, 
if on that date it either had a written determination from CMS that it 
was provider-based, or was billing and being paid as a provider-based 
department or entity of the hospital. We are proposing to make the new 
requirements effective on October 1, 2002, with respect to provider-
based status for facilities not qualifying for the grandfathering 
provision.
c. Revision of Application Requirement
    Existing regulations at Sec. 413.65(b)(2) establish an explicit 
application requirement for all facilities seeking provider-based 
status, except for grandfathered facilities and those treated as 
provider-based pending a determination on an application filed on or 
after October 1, 2000, and before October 1, 2002. Under existing 
Sec. 413.65(b)(3), a main provider or a facility must contact CMS, and 
the facility must be determined by CMS to be provider-based, before the 
main provider bills for services of the facility as if the facility 
were provider-based, or before it includes costs of those services on 
its cost report. Many providers and provider representatives have 
expressed concern that the requirement to file an application will 
increase paperwork burden for hospitals unnecessarily. In response to 
these concerns, we are proposing to revise the application requirements 
as follows:
    First, we would delete the existing application requirement under 
Sec. 413.65(b)(3). We are proposing to revise this section to state 
that except where payment is required to be made under BIPA, as 
specified in proposed revised Sec. 413.65(b)(2) and (b)(5), if a 
potential main provider seeks an advance determination of provider-
based status for a facility that is located on the main campus of the 
potential main provider, the provider would be required to submit an 
attestation stating that its facility meets the criteria in 
Sec. 413.65(d) and, if it is a hospital, also attest that its facility 
will fulfill the obligations of hospital outpatient departments and 
hospital-based entities, as described in proposed Sec. 413.65(g). The 
provider also would be required to maintain documentation of the basis 
for its attestations and to make that documentation available to CMS 
upon request. We note that, under our proposal, there would no longer 
be an explicit requirement that a provider-based approval be obtained 
before a facility is treated as provider-based for billing or cost 
reporting purposes. However, under the proposed revisions to existing 
Sec. 413.65(k) (Correction of errors) as described below, CMS would 
provide a delay in the effective date for any facility that is found 
not to meet the provider-based criteria following a previous advance 
determination, if the reason the provider-based criteria are not met is 
a material change in the provider-facility relationship that was 
properly reported to CMS. The removal of provider-based status would be 
effective as of the first cost reporting period following notification 
of the redetermination, but not less than 6 months after the date of 
notification.
    We are further proposing that if the facility is not located on the 
main campus of the potential main provider, the provider that wishes to 
obtain an advance determination of provider-based status would be 
required to submit an attestation stating that its facility meets the 
criteria in proposed revised Secs. 413.65(d) and (e) and, if the 
facility is operated as a joint venture or under a management contract, 
the requirements in proposed Secs. 413.65(f) and (h), as applicable. If 
the potential main provider is a hospital, the hospital also would be 
required to attest that it will fulfill the obligations of hospital 
outpatient departments and hospital-based entities described in 
proposed revised Sec. 413.65(g). The provider seeking such an advance 
determination would be required to supply documentation of the basis 
for its attestations to CMS at the time it submits its attestations. We 
believe the use of a self-attestation process would strike an 
appropriate balance between the legitimate interests of hospitals in 
reducing paperwork and reporting, and the equally legitimate need of 
CMS to ensure proper accountability for compliance with the 
qualification requirements for a status that typically leads to a 
higher level of Medicare or Medicaid payment.
    We note that, under these proposed revisions to the application 
procedures at Sec. 413.65(b), a hospital would not be explicitly 
required to submit an application and receive a provider-based 
determination for a facility before the time at which the hospital may 
bill for services at that facility as provider-based. However, we are 
considering, alternatively, retaining the existing regulations at 
Sec. 413.65(b)(2) which state that, except where payment is required to 
be made under BIPA as specified in proposed revised Secs. 413.65(b)(2) 
and (b)(5), hospitals are explicitly required to submit provider-based 
applications, and to withhold billing as provider-based until CMS 
determines that a facility meets the provider-based rules. We are 
soliciting comments on the

[[Page 31484]]

appropriateness of this or other alternative application procedures.
d. Requirements Applicable to All Facilities or Organizations
    Under existing Sec. 413.65, all facilities seeking provider-based 
status with respect to a hospital or other main provider must meet a 
common set of requirements. These include requirements relating to 
common licensure (paragraph (d)(1)), operation under the ownership and 
control of the main provider (paragraph (d)(2)), administration and 
supervision (paragraph (d)(3)), integration of clinical services 
(d)(4)), financial integration (paragraph (d)(5)), public awareness 
(paragraph (d)(6)), and location in the immediate vicinity of the main 
provider (paragraph (d)(7)). (In addition, as described more fully 
below, specific rules applicable to all facilities rule out provider-
based status for facilities operated as joint ventures by two or more 
providers (paragraph (e)) and limit the types of management contracts 
that facilities seeking provider-based status may operate under 
(paragraph (f)).)
    Since publication in final of the existing provider-based rules in 
April 2000, hospitals and other providers have expressed concern that 
the requirements outlined above are overly restrictive and do not allow 
them enough flexibility to enter into appropriate business arrangements 
with other facilities. We understand these concerns, and agree that 
Medicare rules should not restrict legitimate business arrangements 
that do not lead to abusive practices or disadvantage Medicare 
beneficiaries. At the same time, we believe our existing rules provide 
a high level of assurance that a facility complying with them is, in 
fact, an integral and subordinate part of the facility with which it is 
based, and do not accord provider-based status to facilities that are 
not integral and subordinate to a main provider, but in fact have only 
a nominal relationship with that provider.
    After considering all comments received on these issues, we believe 
that further changes in the provider-based rules would be appropriate. 
In particular, we agree with those who argue that a facility's or 
organization's location relative to the main campus of the provider is 
relevant to the integration that is likely to exist between the 
facility or organization and the main provider. For example, if a 
facility or organization is located on the main campus of a provider, 
is operated under the main provider's State license, is medically and 
financially integrated with that provider, and is held out to the 
public and other payers as a part of that provider, we believe the 
necessary degree of integration of the facility or organization into 
the main provider can be assumed to exist. We also are concerned that 
further prescribing the types of management contracts or other business 
arrangements that may exist between the main provider and the facility 
or organization would unnecessarily restrict its flexibility to 
establish cost-effective agreements without significantly enhancing the 
integration of the facility or organization into the main provider. 
Therefore, we are proposing to simplify the requirements applicable to 
facilities or organizations located on the campus of the main provider 
(as campus is defined in existing regulations at Sec. 413.65(a)(2)). 
Under our proposal, all facilities seeking provider-based status, 
including both on-campus and off-campus facilities, would be required 
to comply with the existing requirements regarding licensure, clinical 
services integration, financial integration, and public awareness. 
(These requirements are currently codified at Secs. 413.65(d)(1), 
(d)(4), (d)(5), and (d)(6) and, under this proposed rule, would be 
redesignated as paragraphs (d)(1) through (d)(4), respectively, of 
Sec. 413.65.)
    With respect to financial integration, existing regulations at 
Sec. 413.65(d)(5) require that the financial operations of the facility 
or organization be fully integrated within the financial system of the 
main provider, as evidenced by shared income and expenses between the 
main provider and the facility or organization. The regulations also 
require that costs of a provider-based facility or organization be 
reported in a cost center of the provider, and that the financial 
status of any provider-based facility or organization be incorporated 
and readily identified in the main provider's trial balance.
    Some hospital representatives have questioned the appropriateness 
of requiring that the costs of a remote location of a hospital be 
reported in a single cost center, noting that such costs ordinarily 
would appear in multiple cost centers of the main provider, with (for 
example) employee health and welfare costs of the remote location being 
included in the corresponding cost center of the main provider. In 
recognition of this concern, we are proposing to revise the requirement 
to state that the costs of a facility or organization that is a 
hospital department must be reported in a cost center of the provider, 
and that costs of a provider-based facility or organization other than 
a hospital department must be reported in the appropriate cost center 
or cost centers of the main provider.
    Paragraph (d) of Sec. 413.65 would be retitled ``Requirements 
applicable to all facilities or organizations'' and, as indicated by 
its revised title, would set forth those core requirements that any 
facility or organization would have to meet to qualify for provider-
based status.
    We are proposing to delete from this paragraph (d) the requirements 
in existing paragraphs (d)(2) and (d)(3) relating to operation under 
the ownership and control of the main provider and administration and 
supervision because we are proposing to no longer apply these 
requirements to on-campus facilities or organizations. These 
requirements would be moved to paragraph (e) as described below to 
reflect the proposed limitation of their applicability to off-campus 
departments. The core requirements for all facilities or organizations, 
including facilities located on the main campus, also would not include 
the requirement regarding location in the immediate vicinity of the 
main provider (existing Sec. 413.65(d)(7)). Because any facilities or 
organizations located on the campus of the main provider automatically 
meet the requirement regarding location in the immediate vicinity 
(existing Sec. 413.65(d)(7)), the requirement is only of relevance to 
off-campus facilities or organizations. For clarity, we are proposing 
to relocate the requirement to paragraph (e) as described below.
    We also are proposing to require, in paragraph (d)(5) of 
Sec. 413.65, all hospital outpatient departments and hospital-based 
entities, including those located on campus and those located off the 
campus of the main provider hospital, to fulfill the obligations 
currently codified and proposed to be retained at Sec. 413.65(g) in 
order to qualify for provider-based status. (Fulfillment of these 
obligations is currently required under Sec. 413.65(g).) As explained 
further below, we also are proposing other changes to paragraph (g).
e. Additional Requirements Applicable to Off-Campus Facilities or 
Organizations
    We recognize that facilities or organizations located off the main 
provider campus may also be sufficiently integrated with the main 
provider to justify provider-based designation. However, the off-campus 
location of the facilities or organizations may make such integration 
harder to achieve, and such integration should not simply be presumed 
to exist. Therefore, to ensure that off-campus facilities or 
organizations seeking

[[Page 31485]]

provider-based status are appropriately integrated, we are proposing to 
retain for these facilities or organizations certain requirements that 
we are proposing to remove for on-campus facilities or organizations. 
These requirements are set forth in proposed new Sec. 413.65(e). The 
requirements set forth in proposed paragraphs (e)(1), (e)(2), and 
(e)(3) include the requirements on operation under the ownership and 
control of the main provider (existing Sec. 413.65(d)(2)), 
administration and supervision (existing Sec. 413.65(d)(3)), and 
location (existing Sec. 413.65(d)(7)). We also are proposing to include 
language in proposed new Sec. 413.65(e) to state more clearly that a 
facility or organization seeking provider-based status must be located 
in the same State or, when consistent with the laws of both States, in 
adjacent States.
f. Joint Ventures
    Consistent with our views as expressed earlier in this preamble 
regarding the assumption that a higher degree of integration can be 
presumed for on-campus facilities or organizations and in recognition 
of the need to promote reasonable cooperation among providers and avoid 
costly duplication of specialty services, we are proposing to revise 
the regulations on joint ventures (currently set forth under 
Sec. 413.65(e)) to limit their scope to facilities or organizations not 
located on the campus of any potential main provider. Specifically, we 
would redesignate Sec. 413.65(e) as Sec. 413.65(f) and revise it to 
state that a facility or organization that is not located on the campus 
of the potential main provider cannot be considered provider-based if 
the facility or organization is owned by two or more providers engaged 
in a joint venture. We also are proposing to make minor changes to the 
second sentence of the redesignated paragraph (f) to clarify its 
meaning.
g. Clarification of Obligations of Hospital Outpatient Departments and 
Hospital-Based Entities
    Existing regulations impose specific obligations for hospital 
outpatient departments and hospital-based entities, but do not specify 
the sanction that applies if the facility or organization does not 
fulfill its obligations. To clarify policy on this issue and emphasize 
the importance of compliance with the requirements in this area, we are 
proposing to revise existing Sec. 413.65(g) to state that to qualify 
for provider-based status in relation to a hospital, a facility or 
organization must comply with these requirements. In regard to these 
obligations, we are proposing to make three changes in existing 
413.65(g). First, for reasons explained in section V.J. of this 
preamble, we are proposing to revise paragraph (g)(1) by deleting the 
second sentence of that paragraph. In paragraph (g)(2), we are 
proposing to delete the reference to site-of-service reductions and 
instead refer to more accurately determined physician payment amounts, 
in order to more accurately describe how payment under the physician 
fee schedule is determined. In addition, we are proposing to revise the 
first sentence of paragraph (g)(7) to clarify that the notice 
requirements in it do not apply where a beneficiary is examined or 
treated for a medical condition in compliance with the antidumping 
rules in Sec. 489.24. This clarification is needed because we believe 
it would be a violation of the antidumping requirements if examination 
or treatment required under Sec. 489.24 was delayed in order to permit 
notification of the beneficiary or the beneficiary's authorized 
representative. We would further revise Sec. 413.65(g)(7) to state that 
notice is required once the beneficiary has been appropriately screened 
and the existence of an emergency has been ruled out or the emergency 
condition has been stabilized.
h. Management Contracts
    Under existing regulations, facilities or organizations operated 
under management contracts may be considered provider-based only if 
they meet specific requirements in Sec. 413.65(f) (proposed to be 
redesignated as Sec. 413.65(h)). In particular, staff of the facility 
or organization, other than management staff, may not be employed by 
the management company but must be employed either by the provider or 
by another organization, other than the main provider, which also 
employs the staff of the main provider. Under existing regulations, 
these requirements apply equally to on-campus and off-campus facilities 
or organizations.
    Consistent with our intent to simplify provider-based requirements 
for on-campus facilities or organizations, we are proposing to restrict 
the applicability of proposed redesignated paragraph (h) to off-campus 
facilities or organizations. In addition, we are proposing two 
additional changes that we believe are needed to respond to questions 
that are raised frequently about the regulation. First, we would 
specify that a facility or organization operated under a management 
contract may be considered provider-based only if the main provider (or 
an organization that also employs the staff of the main provider and 
that is not the management company) employs the staff of the facility 
or organization who are directly involved in the delivery of patient 
care, except for management staff and staff who furnish patient care 
services of a type that would be paid for by Medicare under a fee 
schedule established by regulations at 42 CFR Part 414. We would not 
specify who may employ other support staff, such as maintenance or 
security personnel, and who are not directly involved in providing 
patient care, nor would we require licensed professional caregivers 
such as physicians, physician assistants, or certified registered nurse 
anesthetists to become provider employees. We also are proposing to 
revise the regulations to clarify at Sec. 413.65(h)(2) that so-called 
``leased'' employees (that is personnel who are actually employed by 
the management company but provide services for the provider under a 
staff leasing arrangement) are not considered to be employees of the 
provider for purposes of this provision.
i. Inappropriate Treatment of a Facility or Organization as Provider-
Based
    Below we describe the steps that we would take if we discover that 
a facility is billing as provider-based without having requested a 
determination, or if the facility received a provider-based 
determination but the main provider did not inform CMS of a subsequent 
material change that affected the provider-based status of its 
facility.
(1) Inappropriate Billing
    The existing regulations at Sec. 413.65(i) state that if we 
discover that a provider is billing inappropriately, we will recover 
the difference between the amount of payments that actually were made 
and the amount of payments that CMS estimates should have been made in 
the absence of a determination of provider-based status. Existing 
Sec. 413.65(j)(2) states that we would adjust future payments to 
approximate as closely as possible the amounts that would be paid, in 
the absence of a provider-based determination, if all other 
requirements for billing are met. In addition, existing 
Sec. 413.65(j)(5) describes a procedure under which CMS would continue 
payments to a provider for services of a facility or organization that 
had been found not to be provider-based, at an adjusted rate calculated 
as described in existing paragraph (j)(2), for up to 6 months in order 
to permit the facility or organization adequate time to meet applicable 
enrollment and other billing requirements. While CMS is not legally 
obligated to continue payments in this matter, we believe it would be

[[Page 31486]]

appropriate to do so, on a time-limited basis, to allow for an orderly 
transition to either provider-based or freestanding status for the 
facility and to avoid disruption in the delivery of services to 
patients, particularly Medicare patients, who may be relying on the 
facility for their medical care.
    We are proposing to adopt a policy concerning recoupment and 
continuation of payment that closely parallels the policy stated in 
existing regulations at Sec. 413.65(j). Under proposed 
Sec. 413.65(j)(1), if CMS learns that a provider has treated a facility 
or organization as provider-based and the provider did not request an 
advance determination of provider-based status from CMS under proposed 
Sec. 413.65(b)(3), and CMS determines that the facility or organization 
did not meet the requirements for provider-based status under proposed 
Sec. 413.65(d) through (i), as applicable (or, in any period before the 
effective date of these regulations, the provider-based requirements in 
effect under Medicare program regulations or instructions), CMS would 
take several actions. First, we are proposing to issue notice to the 
provider, in accordance with proposed paragraph (j)(3), that payments 
for past cost reporting periods may be reviewed and recovered as 
described in proposed paragraph (j)(2)(ii), that future payments for 
services in or at the facility or organization will be adjusted as 
described in proposed paragraph (j)(4), and that continued payments to 
the provider for services of the facility or organization will be made 
only in accordance with proposed paragraph (j)(5). In addition, as 
detailed in proposed Sec. 413.65(j)(1)(ii), CMS would, except for 
providers protected under section 404(a) or (c) of BIPA (implemented at 
Sec. 413.65(b)(2) and (b)(5)) or the exception for good faith effort at 
existing Sec. 413.65(i)(2) and (i)(3)), recover the difference between 
the amount of payments that actually was made to that provider for 
services at the facility or organization and an estimate of the 
payments that CMS would have made to that provider for services at the 
facility or organization in the absence of compliance with the 
requirements for provider-based status. We are proposing to make 
recovery for all cost reporting periods subject to reopening in 
accordance with Secs. 405.1885 and 405.1889. Also, we are proposing to 
adjust future payments to approximate the amounts that would be paid 
for the same services furnished by a freestanding facility.
    Recovery of past payments would be limited in certain 
circumstances. If a provider did not request a provider-based 
determination for a facility by October 1, 2002, but is included in the 
grandfathering period under Sec. 413.65(b)(2), we are proposing to 
recoup all payments subject to the reopening rules at Secs. 405.1885 
and 405.1889, but not for any period before the provider's cost 
reporting period beginning on or after July 1, 2003.
(2) Good Faith Effort
    We are proposing to retain the existing exception for good faith 
effort (proposed redesignated Sec. 413.65(j)(2)). Under this exception, 
we would not recover any payments for any period before the beginning 
of the hospital's first cost reporting period beginning on or after 
January 10, 2001 (the effective date of the existing provider-based 
regulations for providers not grandfathered under Sec. 413.65(b)(2)) if 
during all of that period--
     The requirements regarding licensure and public awareness 
at Sec. 413.65(d)(1) and proposed redesignated (d)(4) were met;
     All facility services were billed as if they had been 
furnished by a department of a provider, a remote location of a 
hospital, a satellite facility, or a provider-based entity of the main 
provider; and
     All professional services of physicians and other 
practitioners were billed with the correct site-of-service indicator, 
as described at proposed redesignated and revised Sec. 413.65(h)(2).
    Under proposed Sec. 413.65(j)(5), CMS would continue payment to a 
provider for services of a facility or organization for a limited 
period of time, in order to allow the facility or organization or its 
practitioners to meet necessary enrollment and other requirements for 
billing on a freestanding basis. Specifically, the notice of denial of 
provider-based status sent to the provider would ask the provider to 
notify CMS in writing, within 30 days of the date the notice is issued, 
as to whether the provider intends to seek an advance determination of 
provider-based status for the facility or organization, or whether the 
facility or organization (or, where applicable, the practitioners who 
staff the facility or organization) will be seeking to enroll and meet 
other requirements to bill for services as a freestanding facility. If 
the provider indicates that it will not be seeking an advance 
determination or that the facility or organization or its practitioners 
will not be seeking to enroll, or if CMS does not receive a response 
within 30 days of the date the notice was issued, all payments under 
proposed paragraph (j)(5) would end as of the 30th day after the date 
of notice. If the provider indicates that it will be seeking an advance 
determination, or that the facility or organization or its 
practitioners will be seeking to meet enrollment and other requirements 
for billing for services in a freestanding facility, payment for 
services of the facility or organization would continue, at the 
adjusted amount described in proposed paragraph (j)(4) for as long as 
is required for all billing requirements to be met (but not longer than 
6 months). Continued payment would be allowed only if the provider or 
the facility or organization or its practitioners submits, as 
applicable, a complete request for an advance provider-based 
determination or a complete enrollment application and provide all 
other required information within 90 days after the date of notice; and 
the facility or organization or its practitioners furnishes all other 
information needed by CMS to process the request for provider-based 
status or, as applicable, the enrollment application and verify that 
other billing requirements are met. If the necessary applications or 
information are not provided, CMS would terminate all payment to the 
provider, facility, or organization as of the date CMS issues notice 
that necessary applications or information have not been submitted.
j. Temporary Treatment as Provider-Based and Correction of Errors
    Under proposed revised Sec. 413.65(k), we would specify the 
procedures for payment for the period between the time a request is 
submitted until a provider-based determination is made, and the steps 
we would take if we discover that a facility for which a provider 
previously received a provider-based determination no longer meets the 
requirements for provider-based status.
    First, we are proposing that, if a provider submits a complete 
request for a provider-based determination for a facility that has not 
previously been found by CMS to have been inappropriately treated as 
provider-based under proposed revised Sec. 413.65(j), the provider may 
bill and be paid for services at the facility as provider-based from 
the date of the application until the date that we determine that the 
facility or organization does not meet the provider-based rules under 
Sec. 413.65. If CMS determines that the requirements for provider-based 
status are not met, CMS will recover the difference between the amount 
of payments that actually was made since the date the complete request 
for a provider-based determination was submitted and the amount of 
payments that CMS estimates

[[Page 31487]]

should have been made in the absence of compliance with the provider-
based requirements. We would consider a request ``complete'' only if it 
included all information we need to make an advance determination of 
provider-based status under Sec. 413.65(b)(3).
    Second, similar to what we specify in existing Sec. 413.65(k), if 
we determine that a facility or organization that previously received a 
provider-based determination no longer qualifies for provider-based 
status, and the failure to qualify for provider-based status resulted 
from a material change in the relationship between the provider and the 
facility or organization that the provider reported to CMS as is 
required under Sec. 413.65(c), treatment of the facility or 
organization as provider-based ceases with the date that CMS determines 
that the facility or organization no longer qualifies for provider-
based status.
    Third, if we determine that a facility or organization that had 
previously received a provider-based determination no longer qualifies 
for provider-based status, and if the failure to qualify for provider-
based status resulted from a material change in the relationship 
between the provider and the facility or organization that the provider 
did not report to CMS, as required under Sec. 413.65(c), we are 
proposing to take the actions with respect to notice to the provider, 
adjustment of payments, and continuation of payment described in 
proposed paragraphs (j)(3), (j)(4), and (j)(5). In short, we would 
treat such cases in the same way as if the provider had never obtained 
an advance determination. However, with respect to recovery of past 
payments for providers included in the grandfathering provision at 
proposed revised Sec. 413.65(b)(2), we would not recover payments for 
any period before the provider's first cost reporting period beginning 
on or after July 1, 2003.
    Also, we are proposing that the exception for good faith effort 
concerning recovery of overpayments under proposed revised 
Secs. 413.65(j)(2) described above would apply to any period before the 
beginning of the hospital's first cost reporting period beginning on or 
after January 10, 2001.
k. Technical Amendments
    We are proposing to correct a typographical error in the heading of 
paragraph (m) of Sec. 413.65 so that it reads ``FQHCs and `look alikes' 
''.
    In paragraph (n) of Sec. 413.65, we are proposing to add a cross-
reference to the requirements for provider-based status described in 
paragraph (b), for purposes of specifying the effective date of 
provider-based status.

L. CMS Authority Over Reopening of Intermediary Determinations and 
Intermediary Hearing Decisions on Provider Reimbursement

    Our existing regulations provide various means for the reopening 
and revision of an intermediary determination or an intermediary 
hearing decision on provider reimbursement by the fiscal intermediary 
or the intermediary hearing officer(s) responsible for the 
determination or the hearing decision, respectively. (In this 
discussion, we will use the term ``intermediary'' to refer to, as 
applicable, the intermediary responsible for an intermediary 
determination (see Secs. 405.1801(a) and 405.1803) or the intermediary 
hearing officer or panel of intermediary hearing officers responsible 
for an intermediary hearing decision (see Secs. 405.1817 and 
405.1831.)) Section 405.1885(a) provides that an intermediary ``may'' 
reopen an intermediary determination or an intermediary hearing 
decision, on its own initiative or at the request of a provider, within 
3 years of the date of the notice of the intermediary determination or 
intermediary hearing decision. However, while Sec. 405.1885(a) provides 
the intermediary with some discretion about whether to reopen an 
intermediary determination or an intermediary hearing decision, we have 
always considered the intermediary's discretion to be limited by any 
directives that may be issued by CMS. Thus, although Sec. 405.1885(a) 
provides that the intermediary ``may'' reopen, that provision neither 
states nor implies that the Secretary lacks authority to direct the 
intermediary to reopen or not reopen a specific matter. Furthermore, 
CMS has prescribed, in Medicare Provider Reimbursement Manual, Part I 
(``PRM''), section 2931.2, criteria that guide the intermediary's 
reopening actions under ``405.1885(a) in the absence of a particular 
directive from CMS. Also, given that the intermediaries are CMS' 
contractors, we have always believed that, under basic principles of 
agency law, we have inherent authority to direct the actions of our own 
agents with respect to reopening matters under ``405.1885(a), just as 
for any other aspect of program administration. See also 42 U.S.C. 
1395h and 1395kk(a); and 42 CFR 421.1(c), 421.5(b), 421.100(f), 
421.124(a), and 421.126(b).
    Under Sec. 405.1885(b), an intermediary determination or an 
intermediary hearing decision ``shall be reopened and revised by the 
intermediary if, within the aforementioned 3-year period, the Centers 
for Medicare & Medicaid Services notifies the intermediary that such 
determination or decision is inconsistent with the applicable law, 
regulations, or general instructions issued by the Centers for Medicare 
& Medicaid Services.'' We have always considered the CMS notice, which 
is a precondition of mandatory intermediary reopening under 
Sec. 405.1885(b), to be one in which we explicitly direct the 
intermediary to reopen. We have never considered a notice or other 
document from CMS that only states or implies that an intermediary 
determination or an intermediary hearing decision is inconsistent with 
law, regulations, CMS ruling, or CMS general instructions, sufficient 
to require intermediary reopening under Sec. 405.1885(b). Moreover, our 
understanding has always been that the phrase ``law, regulations, or 
general instructions'' in Sec. 405.1885(b) refers to the legal 
provisions in effect, as we understand such legal provisions, at the 
time the intermediary rendered the determination or hearing decision. 
Conversely, we have never considered changes in, or judicial 
explications of, ``law, regulations, or general instructions,'' that 
occur after the intermediary rendered the determination or hearing 
decision, sufficient to require intermediary reopening under 
Sec. 405.1885(b). Also, Sec. 405.1885(b) refers to the Secretary's 
agreement with an intermediary; we believe such agreement requires the 
intermediary to apply the law, regulations, CMS rulings, and CMS 
general instructions in effect, as we understand such legal provisions, 
when the intermediary determination or hearing decision was rendered. 
Accordingly, we have not instructed intermediaries to reopen and 
recover reimbursement, or to reopen and award additional reimbursement, 
due to a subsequent change in law or policy, whether the subsequent 
change is made in response to judicial precedent or otherwise.
    Section 405.1885(c) provides: ``Jurisdiction for reopening a 
determination or decision rests exclusively with that administrative 
body that rendered the last determination or decision.'' We have always 
interpreted Sec. 405.1885(c) to provide that authority to reopen an 
intermediary determination or an intermediary hearing decision is 
vested exclusively with the responsible intermediary, as distinct from 
the Provider Reimbursement Review Board (PRRB) and the Administrator of 
CMS (in the context of reviewing PRRB

[[Page 31488]]

decisions (see Sec. 405.1875)) which may not reopen an intermediary 
determination or hearing decision and may not review an intermediary's 
denial of reopening. However, we have never considered the 
intermediary's authority to reopen an intermediary determination or 
hearing decision, which is exclusive under Sec. 405.1885(c) only as to 
the PRRB and the Administrator of CMS (in the context of reviewing PRRB 
decisions), to limit CMS' authority to direct the actions of its own 
agents with respect to reopening matters. See Your Home Visiting Nurse 
Services, Inc. v. Shalala, 525 U.S. 449, 452-53 (1999). (Section 
405.1885(c) divests the PRRB of ``appellate jurisdiction to review the 
intermediary's refusal'' to reopen, but does not limit the Secretary's 
authority to direct an intermediary's ``original jurisdiction'' in the 
reopening area). As discussed previously, the regulations do not 
constrain CMS' authority to direct the intermediary to reopen or not 
reopen a specific matter; instead, CMS has placed generally applicable 
limits on the intermediary's discretion through the reopening criteria 
prescribed in section 2931.2 of the PRM. In addition, we have always 
believed that, under basic principles of agency law, the intermediary's 
discretion over a particular reopening matter is no less circumscribed 
by any directives that may be issued by CMS than would be the case for 
any other aspect of program administration.
    Two recent court decisions conflict with our longstanding 
interpretation of the forgoing provisions of the reopening regulations. 
In Monmouth Medical Center v. Thompson, 257 F.3d 807 (D.C. Cir. 2001), 
the court found that a statement in a CMS ruling, changing CMS' 
interpretation of the statute in response to circuit court precedent, 
constituted a directive to the intermediary under Sec. 405.1885(b) to 
reopen, notwithstanding an explicit directive in the CMS ruling that 
the change in interpretation was to be applied only prospectively. The 
court ordered the intermediary to reopen over the Secretary's 
objection. We disagree with the court's decision, which we believe does 
not comport with our settled interpretation (discussed above) of 
Sec. 405.1885(b). Therefore, we are proposing to revise 
Sec. 405.1885(b) to make clear that, in order to trigger the 
intermediary's obligation to reopen, the notice from CMS to the 
intermediary must explicitly direct the intermediary to reopen based on 
a finding that an intermediary determination or an intermediary hearing 
decision is inconsistent with the law, regulations, CMS ruling, or CMS 
general instructions in effect, and as we understood those legal 
provisions, at the time the determination or decision was rendered. We 
are also proposing to clarify Sec. 405.1885 to reflect our longstanding 
interpretation (discussed above) that a change of legal interpretation 
or policy by CMS in a regulation, CMS ruling, or CMS general 
instruction, whether made in response to judicial precedent or 
otherwise, is not a basis for reopening an intermediary determination 
or an intermediary hearing decision under this section.
    The Monmouth Medical Center decision was followed in Bartlett 
Memorial Medical Center v. Thompson, 171 F. Supp. 2d 1215 (W.D. Okla. 
2001). In a subsequent order in the Bartlett Memorial Medical Center 
case, the court concluded that a CMS ruling, which prohibited 
intermediary reopening on a particular reimbursement issue, improperly 
interfered with the intermediary's discretion under Sec. 405.1885(c) 
over provider requests for reopening under Sec. 405.1885(a). 
Accordingly, the court ordered the intermediary to act on the provider 
reopening requests without regard to the CMS ruling or any other 
involvement of the Secretary. We disagree with the court's decision, 
which we believe is contrary to our settled interpretation (discussed 
above) of Sec. 405.1885(a) and (c). We believe the court's decision is 
also inconsistent with CMS' inherent authority to direct the activities 
of its own contractor-agents, the fiscal intermediaries, with respect 
to particular reopening matters, just as with any other aspect of 
program administration. Therefore, we are proposing, in a new paragraph 
(e) of Sec. 405.1885 (the existing paragraph is proposed to be 
redesignated as paragraph (f)), to clarify that, notwithstanding an 
intermediary's discretion to reopen or not reopen under paragraphs (a) 
and (c) of Sec. 405.1885, CMS may direct an intermediary to reopen, or 
not to reopen, an intermediary determination or an intermediary hearing 
decision in accordance with paragraphs (a) and (c) of this section. To 
illustrate our proposal, revised Sec. 405.1885(e) would clarify that 
CMS has full authority to direct an intermediary to reopen, or not to 
reopen, an intermediary determination or an intermediary hearing 
decision under Sec. 405.1885(a) and (c) based on the reopening criteria 
of ``new and material evidence'' or ``clear and obvious error.'' See 
PRM Sec. 2931.2.

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

A. Background

    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 43358), 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).
    Federal fiscal year (FY) 2001 was the last year of the 10-year 
transition period established to phase in the prospective payment 
system for hospital capital-related costs. Beginning in FY 2001, 
capital prospective payment system payments were based solely on the 
Federal rate for the vast majority of hospitals. 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  (Geographic Adjustment 
Factor(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 also may receive outlier payments for those cases that 
qualify under the thresholds established for each fiscal year that are 
specified in Sec. 412.312(c) of existing regulations. (Refer to the 
August 1, 2001 final rule (66 FR 39910) for 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 
both during and after the transition period, and the policy for 
providing special exceptions.)

B. New Hospitals

    Under the prospective payment system for capital-related costs, at 
Sec. 412.300(b), a new hospital is defined as a hospital that is newly 
participating in the Medicare program (under current or previous 
ownership) for less than 2 years (see 56 FR 43418, August 30,

[[Page 31489]]

1991). During the 10-year transition period, under Sec. 412.324(b), a 
new hospital was exempt from capital prospective payment system for its 
first 2 years of operation and was paid 85 percent of its reasonable 
costs during that period. Effective with its third cost reporting 
period, a new hospital was paid under the appropriate transition 
methodology (either hold-harmless or fully prospective) for the 
remainder of the transition period. (If the hold-harmless methodology 
was applicable, hold-harmless payments would be made for 8 years, even 
if they extend beyond the 10-year transition period, which ended 
beginning with cost reporting periods beginning during FY 2002.)
    This payment provision was implemented to provide special 
protection to new hospitals during the transition period in response to 
concerns that prospective payments under a DRG system may not be 
adequate initially to cover the capital costs of newly built hospitals. 
These hospitals may not have sufficient occupancy in those initial 2 
years and may have incurred significant capital startup costs, so that 
capital prospective payment system payments may not be sufficient. For 
instance, hospitals newly participating in the Medicare program may not 
initially have adequate Medicare utilization. Because capital 
prospective payment system payments are made on a per discharge basis, 
a hospital only receives payments for its capital-related costs upon 
discharge of its Medicare patients. In addition, these hospitals did 
not have an opportunity to reserve previous years' capital prospective 
payment system payments to finance capital projects.
    While the regulations provided for payments based on a percentage 
of costs for new hospitals for the first 2 years during the 10-year 
transition period, no provision was made for new hospitals once the 10-
year transition was completed. However, we believe that the rationale 
for the policy applies equally to new hospitals even after the 
completion of the 10-year transition period. Accordingly, we are 
proposing, under Sec. 412.304(c)(2), to provide special payment to new 
hospitals for cost reporting periods beginning on or after October 1, 
2002. That is, we would pay new hospitals, as defined under 
Sec. 412.300(b), 85 percent of their reasonable costs for their first 2 
years of operation. Effective with their third year of operation, a new 
hospital would be paid based on the Federal rate (that is, the same 
methodology used to pay all other hospitals subject to the capital 
prospective payment system). We believe this proposal would provide for 
more appropriate payments to new hospitals for their capital-related 
costs since initial capital expenditures may reasonably exceed the 
capital prospective payment system per discharge payment based on the 
Federal rate. The capital prospective payment Federal rate is based on 
industry-wide average capital costs rather than the experience of a new 
hospital. We believe this proposed policy would allow new hospitals to 
provide efficiency in the delivery of services and still make 
reasonable payments for their capital expenditures.
    As was the case during the 10-year transition period, this proposed 
new hospital exemption would only be available to those hospitals that 
have not received reasonable cost-based payments under the Medicare 
program in the past, and would need special protection during their 
initial period of operation. This proposed exemption from the capital 
prospective payment system for the first 2 years of operation would not 
apply to a hospital that is ``new'' as an acute care hospital but that 
has operated in the past (under current or previous ownership) and has 
an historical Medicare asset base. Furthermore, a hospital that 
replaces its entire facility (regardless of a change of ownership) 
would not qualify for the new hospital exemption even though it may 
experience a significant change in its asset base. Thus, in accordance 
with Sec. 412.300(b), a new hospital exemption would not apply in the 
following situations:
     A hospital that builds new or replacement facilities at 
the same or a new location, even if a change of ownership or a new 
leasing arrangement is involved;
     A hospital that closes and then reopens under the same or 
different ownership;
     A hospital that has been in operation for more than 2 
years but has been participating in the Medicare program for less than 
2 years; or
     A hospital that changes status from a prospective payment 
system-excluded hospital (paid under the TEFRA methodology) or another 
hospital prospective payment system (such as the inpatient 
rehabilitation facility prospective payment system) to a hospital that 
is subject to the capital prospective payment system for acute care 
hospitals.

C. Extraordinary Circumstances

    When we implemented the capital prospective payment system in FY 
1992, a number of commenters requested that we provide for a separate 
exceptions payment to account for extraordinary circumstances beyond a 
hospital's control that would require the hospital to make 
unanticipated major capital expenditures (56 FR 43411, August 30, 
1991). In response to the commenters' request, we provided in the 
regulations at Sec. 412.348(f) that a hospital may request an 
additional payment if the hospital incurs unanticipated capital 
expenditures in excess of $5 million due to extraordinary circumstances 
beyond the hospital's control. Extraordinary circumstances include, but 
are not limited to, a flood, a fire, or an earthquake. For more 
detailed information regarding this policy, refer to the August 30, 
1991 Federal Register (56 FR 43411).
    To clarify that this policy regarding additional payments for 
extraordinary circumstances also applies to periods beginning on or 
after October 1, 2001, we are proposing to revise Sec. 412.312 by 
adding a new paragraph (e) to specify that payment is made for 
extraordinary circumstances as provided for in Sec. 412.348(f) for cost 
reporting periods after the transition period, that is, on or after 
October 1, 2001.

D. Restoration of the 2.1 Percent Reduction to the Standard Federal 
Capital Prospective Payment System Payment Rate

    Section 1886(g)(1)(A) of the Act, as amended by section 4402 of 
Public Law 105-33, requires the Secretary to reduce the unadjusted 
standard Federal capital prospective payment system payment rate (and 
the unadjusted hospital-specific rate) by 2.1 percent for discharges on 
or after October 1, 1997, and through September 30, 2002, in addition 
to applying the budget neutrality factor used to determine the Federal 
capital prospective payment system payment rate in effect on September 
30, 1995. The budget neutrality factor effective for September 30, 
1995, was 0.8432 (59 FR 45416). Therefore, application of the budget 
neutrality factor (as specified under section 1886(g)(1)(A) of the Act) 
was equivalent to a 15.68 percent reduction to the unadjusted standard 
Federal capital prospective payment system payment rate and the 
unadjusted hospital-specific rate in effect on September 30, 1997. The 
additional 2.1 reduction to the rates in effect on September 30, 1997 
resulted in a total reduction of 17.78 percent. Accordingly, under the 
statute, the additional 2.1 percent reduction no longer applies to 
discharges occurring after September 30, 2002 (Sec. 412.308(b)(5)). 
Therefore, we are proposing to revise Sec. 412.308(b) to add a new 
paragraph (b)(6) to restore the 2.1 percent reduction to the unadjusted

[[Page 31490]]

standard Federal capital prospective payment system payment rate (as 
provided under Sec. 412.308(c)) for discharges occurring on or after 
October 1, 2002, to the level that it would have been without the 
reduction. (Since FY 2001 was the final year of the 10-year transition 
period, we no longer update the hospital-specific rate and, therefore, 
we also no longer restore the 2.1 percent reduction to that rate as 
provided under Sec. 412.328(e)(1).)
    As described in the August 29, 1997 final rule (62 FR 46012), we 
determined the reduction factor for FY 1998 by deducting both the FY 
1995 budget neutrality factor (0.1568) and the 2.1 percent reduction 
(0.021) from 1 (1- 0.1568-0.021 = 0.8222). We then applied the 0.8222 
to the unadjusted standard Federal rate. Therefore, to determine the 
adjustment factor needed to restore the 2.1 percent reduction, we would 
divide the amount of the adjustment without the 2.1 percent reduction 
(1-0.1568 = 0.8432) by the amount of the adjustment with the 2.1 
percent reduction (0.8222). Accordingly, we are proposing to restore 
the 2.1 percent reduction for discharges occurring on or after October 
1, 2002, under proposed Sec. 413.308(b)(6), by applying a factor of 
1.02554 (0.8432/0.8222) to the unadjusted standard Federal capital 
prospective payment system payment rate under Sec. 412.308(c), that was 
in effect on September 30, 2002.

E. Clarification of Special Exceptions Policy

    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 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 described at Sec. 412.348(g)(4); and 
(2) a project size requirement as described at Sec. 412.348(g)(5). In 
accordance with Sec. 412.348(g)(7), hospitals are eligible to receive 
special exceptions payments for the 10 years after the cost reporting 
year in which they complete their project, which can be no later than 
the hospital's cost reporting period beginning before October 1, 2001.
    During the 10-year capital prospective payment system transition 
period, regular exceptions under Secs. 412.348(b) through (e) paid the 
same as or more (between 70 percent and 90 percent of costs, depending 
on the type of hospital) than the special exceptions provision under 
Sec. 412.348(g) (70 percent for all eligible hospitals). Therefore, it 
was not until cost reporting periods beginning on or after October 1, 
2001 (the end of the transition period) that eligible hospitals could 
actually begin receiving additional payments under the special 
exceptions provision. As we stated in the July 30, 1999 final rule (64 
FR 41528), we believe that, since any substantive changes to this 
policy could have a significant impact, the appropriate forum for 
addressing the special exceptions policy is through the legislative 
process in Congress rather than the regulations process. Since 
hospitals are beginning to receive additional payments under this 
provision, we have received several questions regarding current policy 
at Sec. 412.348(g). Therefore, while we are not proposing any changes 
to the special exceptions policy, we are providing the following 
clarifications to the existing regulations.
    Under Sec. 412.348(g)(1), to be eligible for special exception 
payments, a hospital must be either a sole community hospital (SCH), an 
urban hospital with at least 100 beds that has a disproportionate share 
(DSH) percentage of at least 20.2 percent or qualify for DSH payments 
under Sec. 412.106(c)(2), or a hospital with a combined Medicare and 
Medicaid inpatient utilization of at least 70 percent. Because a 
hospital's SCH status, DSH patient percentage, and combined utilization 
may fluctuate from one cost reporting year to the next, the special 
exceptions eligibility criteria are applied for each cost reporting 
period throughout the 10-year special exceptions period. A hospital 
receives special exceptions payments only for those years in the 10-
year period in which it meets the eligibility requirements in 
Sec. 412.348(g)(1). Therefore, a hospital might be eligible for a 
special exception payment in one year, not be eligible the next year, 
and then subsequently qualify during the 10-year special exceptions 
period.
    The project need criteria in Sec. 412.348(g)(2) also state that a 
hospital must obtain any required approval from a State or local 
planning authority. However, in States where a certificate of need or 
approval is not required by the State or local planning authority, the 
hospital must provide the fiscal intermediary with appropriate 
documentation (such as project plans from the hospital's board of 
directors) that demonstrates that the requirements of 
Sec. 412.348(g)(3) concerning the age of assets test and 
Sec. 412.348(g)(4) concerning the excess capacity test for urban 
hospitals are met. We understand that a State planning authority and a 
hospital may define a project differently. Accordingly, we would allow 
the hospital to use either the definition provided by the project 
within the certificate of need (in States where a certificate of need 
is required), or other appropriate documentation provided from the 
hospital's project plans (such as project plans as specified in the 
minutes of the meetings of the hospital's board of directors).
    In determining a hospital's special exceptions payment amount, as 
described in Sec. 412.348(g)(8), for each cost reporting period, the 
cumulative payments made to the hospital under the capital prospective 
payment system are compared to the cumulative minimum payment levels 
applicable to the hospital for each cost reporting period subject to 
the capital prospective payment system. This comparison is offset by 
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). The 
minimum payment level is 70 percent for all hospitals, regardless of 
class, as set forth in Sec. 412.348(g)(6), for the duration of the 
special exceptions provision.
    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, Sec. 412.348(g)(9) 
requires that hospitals eligible for special exception payments 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). In order for an eligible hospital 
to receive special exception payments, this documentation had 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.

[[Page 31491]]

VII. Proposed Changes for Hospitals and Hospital Units Excluded 
From the Acute Care Hospital Inpatient Prospective Payment System

A. Payments to Excluded Hospitals and Hospital Units (Secs. 413.40(c), 
(d), and (f))

1. Payments to Existing Excluded Hospitals and Hospital Units
    Section 1886(b)(3)(H) of the Act (as amended by section 4414 of 
Public Law 105-33) established caps on the target amounts for certain 
existing hospitals and hospital units excluded from the acute care 
hospital inpatient prospective payment system for cost reporting 
periods beginning on or after October 1, 1997 through September 30, 
2002. For this period, the caps on the target amounts apply to the 
following three classes of excluded hospitals or units: psychiatric 
hospitals and units, rehabilitation hospitals and units, and long-term 
care hospitals.
    In accordance with section 1886(b)(3)(H)(i) of the Act and 
effective for cost reporting periods beginning on or after October 1, 
2002, payments to these classes of existing excluded hospitals or 
hospital units are no longer subject to caps on the target amounts. In 
accordance with existing Secs. 413.40(c)(4)(ii) and (d)(1)(i) and (ii), 
these excluded hospitals and hospital units continue to be paid on a 
reasonable cost basis, and payments are based on their Medicare 
inpatient operating costs, not to exceed the ceiling. The ceiling would 
be computed using the hospital's or unit's target amount from the 
previous cost reporting period updated by the rate-of-increase 
specified in Sec. 413.40(c)(3)(viii) of the regulations.
2. Updated Caps for New Excluded Hospitals and Units
    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. A discussion of how the 
payment limitation was calculated can be found in the August 29, 1997 
final rule with comment period (62 FR 46019); 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). Under the statutory 
methodology, a ``new'' hospital or unit is a hospital or unit that 
falls within one of the three classes of hospitals or units 
(psychiatric, rehabilitation or long-term care) that first receives 
payment as a hospital or unit excluded from the acute care hospital 
inpatient prospective payment system on or after October 1, 1997. The 
amount of payment for a ``new'' hospital or unit would be determined as 
follows:
     Under existing Sec. 413.40(f)(2)(ii), 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 (as estimated by the Secretary) of the target amounts 
for the same class of hospital or unit for cost reporting periods 
ending during FY 1996, updated by the hospital market basket increase 
percentage to the fiscal year in which the hospital or unit first 
receives payments under section 1886 of the Act, as adjusted for 
differences in area wage levels.
     Under existing Sec. 413.40(c)(4)(v), for cost reporting 
periods following the hospital's or unit's first two 12-month cost 
reporting periods, the target amount is equal to the amount determined 
under section 1886(b)(7)(A)(i) of the Act for the third period, updated 
by the applicable hospital market basket increase percentage.
    The proposed amounts included in the following table reflect the 
updated 110 percent of the national median target amounts proposed for 
each class of new excluded hospitals and hospital units for cost 
reporting periods beginning during FY 2003. These figures are updated 
to reflect the proposed projected market basket increase percentage of 
3.4 percent. This projected percentage change in the market basket 
reflects the average change in the price of goods and services 
purchased by hospitals to furnish inpatient hospital services (as 
projected by the CMS Office of the Actuary based on its historical 
experience with the hospital inpatient prospective payment system). 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 2003      FY 2003
                                                  proposed     proposed
      Class of excluded hospital or unit           labor-     nonlabor-
                                                  related      related
                                                   share        share
------------------------------------------------------------------------
Psychiatric...................................       $7,047       $2,801
Long-Term Care................................       17,269        6,866
------------------------------------------------------------------------

    Effective for cost reporting periods beginning on or after October 
1, 2002, this payment limitation is no longer applicable to new 
rehabilitation hospitals and units since they will be paid under the 
inpatient rehabilitation facility prospective payment system.
3. Establishment of a Prospective Payment System for Inpatient 
Rehabilitation Hospitals and Units
    Section 1886(j) of the Act, as added by section 4421(a) of Public 
Law 105-33, provided the phase-in of a case-mix adjusted prospective 
payment system for inpatient hospital services furnished by a 
rehabilitation hospital or a rehabilitation hospital unit (referred to 
in the statute as rehabilitation facilities) for cost reporting periods 
beginning on or after October 1, 2000 and before October 1, 2002, with 
a fully implemented prospective payment 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 a discharge as the payment unit under the prospective 
payment system for inpatient hospital services furnished by 
rehabilitation facilities 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 rehabilitation 
facilities to elect to be paid the full Federal prospective payment 
rather than the transitional period payments specified in the Act.
    On August 7, 2001, we issued a final rule in the Federal Register 
(66 FR 41316) establishing the prospective payment system for inpatient 
rehabilitation facilities, effective for cost reporting periods 
beginning on or after January 1, 2002. Under the inpatient 
rehabilitation prospective payment system, for cost reporting periods 
beginning on or after January 1, 2002, and before October 1, 2002, 
payment will consist of 33\1/3\ percent of the facility-specific 
payment amount (based on the reasonable cost-based reimbursement 
methodology) and 66\2/3\ percent of the adjusted Federal prospective 
payment. For cost reporting periods beginning on or after October 1, 
2002, payment will be based entirely on the Federal prospective payment 
rate determined under the inpatient rehabilitation facility prospective 
payment system.
4. Implementation of a Prospective Payment System for Long-Term Care 
Hospitals
    In accordance with the requirements of section 123 of Public Law 
106-113, as modified by section 307(b) of Public Law 106-554, we are 
proposing (as published in the March 22, 2002 proposed rule (67 FR 
13415)) the establishment of a per discharge, DRG-based prospective 
payment system for long-term care hospitals as described in

[[Page 31492]]

section 1886(d)(1)(B)(iv) of the Act for cost reporting periods 
beginning on or after October 1, 2002. As part of the implementation 
process, we are proposing a 5-year transition period from reasonable 
cost-based reimbursement to the long-term care hospital prospective 
payment system Federal rate. We are also proposing that a long-term 
care hospital may elect to be paid based on 100 percent of the Federal 
prospective rate. Under the March 22, 2002 proposed rule, a blend of 
the reasonable cost-based reimbursement percentage and the prospective 
payment Federal rate percentage would be used to determine a long-term 
care hospital's total payment under the prospective payment system 
during the transition period. We would expect long-term care hospitals 
to be paid under the full Federal prospective rate for cost reporting 
periods beginning on or after October 1, 2006.

B. Criteria for Exclusion of Satellite Facilities from the Hospital 
Inpatient Prospective Payment System

    Existing regulations at 42 CFR 412.22(e) define a hospital-within-
a-hospital as a hospital that occupies space in the same building as 
another hospital, or in one or more entire buildings located on the 
same campus as buildings used by another hospital. Section 412.22(h), 
relating to satellites of hospitals excluded from the acute care 
hospital inpatient prospective payment system, defines a satellite 
facility as a part of a hospital that provides inpatient services in a 
building also used by another hospital, or in one or more entire 
buildings located on the same campus as buildings used by another 
hospital. Section 412.25(e), relating to satellites of excluded 
hospital units, defines a satellite facility as a part of a hospital 
unit that provides inpatient services in a building also used by 
another hospital, or in one or more entire buildings located on the 
same campus as buildings used by another hospital. Because of the 
similarities between the definitions of the two types of satellite 
facilities and the definition of a hospital-within-a-hospital, 
questions have been raised as to whether satellite facilities must meet 
the ``hospital-within-a-hospital'' criteria in Sec. 412.22(e) regarding 
having a governing body, chief medical officer, medical staff, and 
chief executive officer that are separate from those of the hospital 
with which space is shared.
    Although the separateness of satellite facilities of excluded 
hospitals and satellite facilities of excluded units of hospitals is 
not explicitly required under existing regulations, we believe these 
two types of satellite facilities are similar enough to hospitals-
within-hospitals to warrant application of more closely related 
criteria to all of them. Specifically, satellite facilities are like 
hospitals-within-hospitals in that the satellites are physically 
located in acute care hospitals that are paid for their inpatient 
services under the acute care hospital inpatient prospective payment 
system. Moreover, both satellite facilities and hospitals-within-
hospitals provide inpatient hospital care that is paid for at higher 
rates than would apply if the facility were treated by Medicare as a 
part of the acute care hospital.
    In view of these facts, it is important that we establish clear 
criteria for ensuring that these facilities are not merely units of the 
hospitals in which they are located, but are, in fact, organizationally 
and functionally separate from those hospitals. Therefore, we are 
proposing to revise Sec. 412.22(h)(2) to specify that, effective for 
cost reporting periods beginning on or after October 1, 2002, a 
hospital having a satellite facility would qualify for exclusion from 
the acute care hospital inpatient prospective payment system only if 
that satellite facility is not under the authority or control of the 
governing body or chief executive officer of the hospital in which it 
is located, and it furnishes inpatient care through the use of medical 
personnel who are not under the authority or control of the medical 
staff or chief medical officer of the hospital in which it is located. 
We also are proposing to revise Sec. 412.25(e)(2)(iii) to state that, 
effective for cost reporting periods beginning on or after October 1, 
2002, a hospital unit having a satellite facility would qualify for 
exclusion from the acute care hospital inpatient prospective payment 
system only if it is not under the authority or control of the 
governing body or chief executive officer of the hospital in which it 
is located, and it furnishes inpatient care through the use of medical 
personnel who are not under the authority or control of the medical 
staff or chief medical officer of the hospital in which it is located.

C. Critical Access Hospitals (CAHs)

1. Background
    Section 1820 provides for a nationwide Medicare Rural Hospital 
Flexibility Program (MRHF). (MRHF replaced the 7-State Essential Access 
Community Hospital/Rural Primary Care Hospital (EACH/RPCH) program.) 
Under section 1820 of the Act, as amended, certain rural providers may 
be designated as critical access hospitals (CAHs) under the MRHF 
program if they meet qualifying criteria and the conditions for 
designation specified in the statute. Implementing regulations for 
section 1820 of the Act are located at 42 CFR Part 485, Subpart F.
2. Election of Optional Payment Method
    Under existing regulations at 42 CFR 413.70(b), CAHs may elect to 
be paid for services to their outpatients under an optional method. 
Facilities making this election are paid an amount for each outpatient 
visit that is the sum of the reasonable costs of facility services, as 
determined under applicable regulations, and, for professional services 
otherwise payable to the physician or other practitioner, 115 percent 
of the amounts that otherwise would be paid for the services if the CAH 
had not elected payment under the optional method. To enable 
intermediaries to make these payments accurately and to avoid possible 
delays in or duplications of payment, we specify in Sec. 413.70(b)(3) 
that each CAH electing payment under the optional method must inform 
the intermediary in writing of that election annually, at least 60 days 
before the start of the affected cost reporting period (65 FR 47100, 
August 1, 2000, and 66 FR 31272, June 13, 2001).
    Since the publication of this regulation, some CAHs have expressed 
concern that requiring a 60-day advance notice of the election of the 
optional payment method limits their flexibility, and have suggested 
that a shorter advance notice period would be appropriate. We have 
contacted our fiscal intermediaries to obtain feedback on the 
feasibility of changing the period of advance notification, since the 
fiscal intermediaries would need to make appropriate bill processing 
changes to allow any shorter time for notification of election of the 
optional method. Some fiscal intermediaries stated that requiring less 
than 60 days' advance notice is impractical, while others believed that 
needed changes could be made with as little as 2 weeks' advance notice. 
Given the diversity of feedback on this issue and our desire to allow 
CAHs as much flexibility as possible, we are proposing to revise 
Sec. 412.30(b)(3) to allow the required advance notice period to be 
determined by each individual fiscal intermediary for the CAHs it 
services, as long as the required advance notice is not less than 14 
days or more than 60 days before the start of each affected cost 
reporting period.

[[Page 31493]]

3. Use of the Resident Assessment Instrument (RAI) by CAHs
    Among the existing regulations implementing section 1820 of the Act 
are specific conditions that a hospital must meet to be designated as a 
CAH. To help protect the health and safety of Medicare patients who are 
being furnished post-hospital skilled nursing facility (SNF) level of 
care in a CAH, our regulations require CAHs to comply with some, but 
not all, of the Medicare SNF conditions of participation at 42 CFR part 
483, subpart B. Specifically, the regulations at Sec. 485.645(d) 
provide that in order for a CAH to use its beds to provide post-
hospital SNF care, the CAH must be in substantial compliance with nine 
of the SNF requirements contained in part 483, subpart B. Included 
among the nine requirements are requirements for comprehensive 
assessments, comprehensive care plans, and discharge planning as 
specified in Sec. 483.20(b), (k), and (l). (We note that the existing 
Sec. 485.645(d)(6) incorrectly cites these regulation cross-references 
as ``Sec. 483.20(b), (d), and (e).'' When we revised Sec. 483.20 on 
December 23, 1997 (63 FR 53307), we inadvertently did not make 
conforming cross-reference changes in Sec. 485.645(d)(6). In this 
proposed rule, we are proposing to make these conforming cross-
reference changes.) Section 483.20(b) provides that a facility must 
make a comprehensive assessment of a resident's needs using the 
resident assessment instrument (RAI), specified by the State, on all 
its swing-bed patients.
    We have received inquiries regarding the need for CAHs to use the 
RAI for patient assessment and care planning. The inquirers consider 
the RAI a lengthy and burdensome instrument and pointed out that CMS 
currently does not require CAHs to report data from the RAI for quality 
or payment purposes.
    We required former RPCHs to use the RAI for the assessment of 
swing-bed patients to avoid the possibility of negative outcomes that 
might extend the length of stays in these hospitals, which provided 
limited services. In addition, we believed that the use of the RAI 
would help to ensure that patient needs are met when patients are in 
the facility for an extended period of time. Swing-bed hospitals were 
not required to use any patient assessment instrument because we 
believed that the hospital conditions of participation included 
requirements that were appropriate safeguards to protect the health and 
safety of Medicare patients. Currently, the regulations at 
Sec. 483.20(f) require all long-term care facilities to collect and 
submit assessment data from the RAI to the State for quality and 
payment purposes. There are no such collection and submission 
requirements for CAHs.
    We have gathered information from the provider community, State 
surveyors, and staff involved in the development of quality indicators 
and prospective payment system rates for SNFs to determine the 
feasibility of continuing to require CAHs to comply with the 
requirement for use of the RAI for patient assessments. Based on the 
information received, we have determined that there are no specific 
patient benefits involved in requiring CAHs to use the RAI for patient 
assessment purposes.
    In the interest of reducing burden, where possible, and based on 
our analysis of the current significance of the requirement for use of 
the RAI for patient assessments in CAHs, we believe it is appropriate 
to propose the elimination of the requirement for CAHs to complete an 
RAI without jeopardizing patient health and safety. A CAH would still 
be required to capture assessment data for its SNF patients but would 
have the flexibility to document the assessment data in the medical 
record in a manner appropriate for its facility. We believe there are 
sufficient safeguards in the CAH regulations to ensure the health and 
safety of each SNF patient in a CAH. The facility would still be 
required to develop a comprehensive care plan for each SNF patient that 
includes measurable objectives and a timetable to meet a patient's 
medical, nursing, and psychosocial needs that are identified in an 
assessment. Also, a post-discharge plan of care would address post-
hospital care needs of the patient. All of this information 
(assessment, plan of care, and discharge plans) must be maintained in 
the patient's medical record.
    We are proposing to revise Sec. 485.645 to specify that CAHs are 
required to complete a comprehensive assessment, comprehensive care 
plan, and discharge planning in accordance with the requirements of 
Sec. 483.20(b), (k), and (l), except that the CAH is not required to 
use the RAI specified by the State, and is not required to comply with 
the requirements for frequency, scope, and number of assessments 
prescribed in Sec. 413.343(b).

VIII. MedPAC Recommendations

    We have reviewed the March 1, 2002 report submitted by MedPAC to 
Congress and have given it careful consideration in conjunction with 
the proposals set forth in this document. MedPAC's recommendations for 
payments for Medicare inpatient hospital services in its March 2002 
report focused mainly on accounting for changes in input prices for the 
hospital market basket (Recommendation 2A) and on increases in the base 
rate for inpatient hospital services by applying the annual update 
factors (Recommendations 2B-1 and 2B-2).
    In Recommendation 2A, MedPAC recommended that the Secretary should 
use wage and benefit proxies that most closely match the training and 
skill requirements of health care occupations in all input price 
indexes used for updating payments. MedPAC further indicated that, in 
determining index weights, measures specific to the health sector and 
to occupation categories in which health care plays a major role should 
be emphasized. Our proposal to rebase and revise the hospital market 
basket, including cost category weights and price proxies, that is used 
in determining the update factors for payments for inpatient hospital 
services is presented in section IV. of this proposed rule.
    Recommendations 2B-1 and 2B-2 concerning the update factor for 
inpatient hospital operating costs and for hospitals and hospital 
distinct-part units excluded from the acute care hospital inpatient 
prospective payment system are discussed in Appendix C to this proposed 
rule.

IX. 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/pufiles.htm. Data files, and the 
cost for each, are listed below. Anyone wishing to purchase data tapes, 
cartridges, or diskettes should submit a written request along with a 
company check or money order (payable to CMS-PUF) to cover the cost to 
the following address: Centers for Medicare & Medicaid Services, Public 
Use Files, Accounting Division, P.O. Box 7520, Baltimore, Maryland 
21207-0520, (410) 786-3691. Files on the Internet may be downloaded 
without charge.
1. Expanded Modified MedPAR-Hospital (National)
    The Medicare Provider Analysis and Review (MedPAR) file contains 
records

[[Page 31494]]

for 100 percent of Medicare beneficiaries using hospital inpatient 
services in the United States. (The file is a Federal fiscal year file, 
that is, discharges occurring October 1 through September 30 of the 
requested year.) The records are stripped of most data elements that 
would permit identification of beneficiaries. The hospital is 
identified by the 6-position Medicare billing number. The file is 
available to persons qualifying under the terms of the Notice of 
Proposed New Routine Uses for an Existing System of Records published 
in the Federal Register on December 24, 1984 (49 FR 49941), and amended 
by the July 2, 1985 notice (50 FR 27361). The national file consists of 
approximately 11,420,000 records. Under the requirements of these 
notices, an agreement for use of CMS Beneficiary Encrypted Files must 
be signed by the purchaser before release of these data. For all files 
requiring a signed agreement, please write or call to obtain a blank 
agreement form before placing an order. Two versions of this file are 
created each year. They support the following:
     Notice of Proposed Rulemaking (NPRM) published in the 
Federal Register. This file, scheduled to be available by the end of 
April, is derived from the MedPAR file with a cutoff of 3 months after 
the end of the fiscal year (December file).
     Final Rule published in the Federal Register. The FY 2001 
MedPAR file used for the FY 2003 final rule will be cut off 6 months 
after the end of the fiscal year (March file) and is scheduled to be 
available by the end of April.
Media: Tape/Cartridge.
File Cost: $3,655.00 per fiscal year.
Periods Available: FY 1988 through FY 2001.
2. Expanded Modified MedPAR-Hospital (State)
    The State MedPAR file contains records for 100 percent of Medicare 
beneficiaries using hospital inpatient services in a particular State. 
The records are stripped of most data elements that will permit 
identification of beneficiaries. The hospital is identified by the 6-
position Medicare billing number. The file is available to persons 
qualifying under the terms of the Notice of Proposed New Routine Uses 
for an Existing System of Records published in the December 24, 1984 
Federal Register notice, and amended by the July 2, 1985 notice. This 
file is a subset of the Expanded Modified MedPAR-Hospital (National) as 
described above. Under the requirements of these notices, an agreement 
for use of CMS Beneficiary Encrypted Files must be signed by the 
purchaser before release of these data. Two versions of this file are 
created each year. They support the following:
     NPRM published in the Federal Register. This file, 
scheduled to be available by the end of April, is derived from the 
MedPAR file with a cutoff of 3 months after the end of the fiscal year 
(December file).
     Final Rule published in the Federal Register. The FY 2001 
MedPAR file used for the FY 2003 final rule will be cut off 6 months 
after the end of the fiscal year (March file) and is scheduled to be 
available by the end of April.

Media: Tape/Cartridge.
File Cost: $1,130.00 per State per year.
Periods Available: FY 1988 through FY 2001.
3. CMS Wage Data
    This file contains the hospital hours and salaries for FY 1999 used 
to create the proposed FY 2003 prospective payment system wage index. 
The file will be available by the beginning of January for the NPRM and 
the beginning of May for the final rule.

------------------------------------------------------------------------
                                                 Wage data    PPS fiscal
                Processing year                     year         year
------------------------------------------------------------------------
2002..........................................         1999         2003
2001..........................................         1998         2002
2000..........................................         1997         2001
1999..........................................         1996         2000
1998..........................................         1995         1999
1997..........................................         1994         1998
1996..........................................         1993         1997
1995..........................................         1992         1996
1994..........................................         1991         1995
1993..........................................         1990         1994
1992..........................................         1989         1993
1991..........................................         1988         1992
------------------------------------------------------------------------

    These files support the following:
     NPRM published in the Federal Register.
     Final Rule published in the Federal Register.

Media: Diskette/most recent year on the Internet.
File Cost: $165.00 per year.
Periods Available: FY 2003 PPS Update.
4. CMS Hospital Wages Indices (Formerly: Urban and Rural Wage Index 
Values Only)
    This file contains a history of all wage indices since October 1, 
1983.

Media: Diskette/most recent year on the Internet.
File Cost: $165.00 per year.
Periods Available: FY 2003 PPS Update.
5. PPS SSA/FIPS MSA State and County Crosswalk
    This file contains a crosswalk of State and county codes used by 
the Social Security Administration (SSA) and the Federal Information 
Processing Standards (FIPS), county name, and a historical list of 
Metropolitan Statistical Area (MSA).

Media: Diskette/Internet.
File Cost: $165.00 per year.
Periods Available: FY 2003 PPS Update.
6. Reclassified Hospitals New Wage Index (Formerly: Reclassified 
Hospitals by Provider Only)
    This file contains a list of hospitals that were reclassified for 
the purpose of assigning a new wage index. Two versions of these files 
are created each year. They support the following:
     NPRM published in the Federal Register.
     Final Rule published in the Federal Register.
Media: Diskette/Internet.
File Cost: $165.00 per year.
Periods Available: FY 2003 PPS Update.
7. PPS-IV to PPS-XII Minimum Data Set
    The Minimum Data Set contains cost, statistical, financial, and 
other information from Medicare hospital cost reports. The data set 
includes only the most current cost report (as submitted, final 
settled, or reopened) submitted for a Medicare participating hospital 
by the Medicare fiscal intermediary to CMS. This data set is updated at 
the end of each calendar quarter and is available on the last day of 
the following month.
Media: Tape/Cartridge.
File Cost: $770.00 per year.

------------------------------------------------------------------------
                                                  Periods
                                                 beginning    and before
                                                on or after
------------------------------------------------------------------------
PPS-IV........................................     10/01/86     10/01/87
PPS-V.........................................     10/01/87     10/01/88
PPS-VI........................................     10/01/88     10/01/89
PPS-VII.......................................     10/01/89     10/01/90
PPS-VIII......................................     10/01/90     10/01/91
PPS-IX........................................     10/01/91     10/01/92
PPS-X.........................................     10/01/92     10/01/93
PPS-XI........................................     10/01/93     10/01/94
PPS-XII.......................................     10/01/94     10/01/95
------------------------------------------------------------------------

(Note: The PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, and PPS-XVII Minimum 
Data Sets are part of the PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, and PPS-
XVII Hospital Data Set Files (refer to item 9 below).)
8. PPS-IX to PPS-XII Capital Data Set
    The Capital Data Set contains selected data for capital-related 
costs, interest expense and related information and complete balance 
sheet data from the Medicare hospital cost report. The data set 
includes only the most current cost report (as submitted, final settled 
or

[[Page 31495]]

reopened) submitted for a Medicare certified hospital by the Medicare 
fiscal intermediary to CMS. This data set is updated at the end of each 
calendar quarter and is available on the last day of the following 
month.

Media: Tape/Cartridge.
File Cost: $770.00 per year.

------------------------------------------------------------------------
                                                  Periods
                                                 beginning    and before
                                                on or after
------------------------------------------------------------------------
PPS-IX........................................     10/01/91     10/01/92
PPS-X.........................................     10/01/92     10/01/93
PPS-XI........................................     10/01/93     10/01/94
PPS-XII.......................................     10/01/94     10/01/95
------------------------------------------------------------------------

(Note: The PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, and PPS-XVII Capital 
Data Sets are part of the PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, and PPS-
XVII Hospital Data Set Files (refer to item 9 below).)
9. PPS-XIII to PPS-XVII Hospital Data Set
    The file contains cost, statistical, financial, and other data from 
the Medicare Hospital Cost Report. The data set includes only the most 
current cost report (as submitted, final settled, or reopened) 
submitted for a Medicare-certified hospital by the Medicare fiscal 
intermediary to CMS. The data set are updated at the end of each 
calendar quarter and is available on the last day of the following 
month.

Media: Diskette/Internet.
File Cost: $2,500.00.

------------------------------------------------------------------------
                                                  Periods
                                                 beginning    and before
                                                on or after
------------------------------------------------------------------------
PPS-XIII......................................     10/01/95     10/01/96
PPS-XIV.......................................     10/01/96     10/01/97
PPS-XV........................................     10/01/97     10/01/98
PPS-XVI.......................................     10/01/98     10/01/99
PPS-XVII......................................     10/01/99     10/01/00
------------------------------------------------------------------------

10. Provider-Specific File
    This file is a component of the PRICER program used in the fiscal 
intermediary's system to compute DRG payments for individual bills. The 
file contains records for all prospective payment system eligible 
hospitals, including hospitals in waiver States, and data elements used 
in the prospective payment system recalibration processes and related 
activities. Beginning with December 1988, the individual records were 
enlarged to include pass-through per diems and other elements.

Media: Diskette/Internet.
File Cost: $265.00.
Periods Available: FY 2003 PPS Update.
11. CMS Medicare Case-Mix Index File
    This file contains the Medicare case-mix index by provider number 
as published in each year's update of the Medicare hospital inpatient 
prospective payment system. The case-mix index is a measure of the 
costliness of cases treated by a hospital relative to the cost of the 
national average of all Medicare hospital cases, using DRG weights as a 
measure of relative costliness of cases. Two versions of this file are 
created each year. They support the following:
     NPRM published in the Federal Register.
     Final rule published in the Federal Register.

Media: Diskette/most recent year on Internet.
Price: $165.00 per year/per file.
Periods Available: FY 1985 through FY 2001.
12. DRG Relative Weights (Formerly Table 5 DRG)
    This file contains a listing of DRGs, DRG narrative description, 
relative weights, and geometric and arithmetic mean lengths of stay as 
published in the Federal Register. The hard copy image has been copied 
to diskette. There are two versions of this file as published in the 
Federal Register:
     NPRM.
     Final rule.

Media: Diskette/Internet.
File Cost: $165.00.
Periods Available: FY 2003 PPS Update.
13. PPS Payment Impact File
    This file contains data used to estimate payments under Medicare's 
hospital inpatient prospective payment systems for operating and 
capital-related costs. The data are taken from various sources, 
including the Provider-Specific File, Minimum Data Sets, and prior 
impact files. The data set is abstracted from an internal file used for 
the impact analysis of the changes to the prospective payment systems 
published in the Federal Register. This file is available for release 1 
month after the proposed and final rules are published in the Federal 
Register.

Media: Diskette/Internet.
File Cost: $165.00.
Periods Available: FY 2003 PPS Update.
14. AOR/BOR Tables
    This file contains data used to develop the DRG relative weights. 
It contains mean, maximum, minimum, standard deviation, and coefficient 
of variation statistics by DRG for length of stay and standardized 
charges. The BOR tables are ``Before Outliers Removed'' and the AOR is 
``After Outliers Removed.'' (Outliers refers to statistical outliers, 
not payment outliers.) Two versions of this file are created each year. 
They support the following:
     NPRM published in the Federal Register.
     Final rule published in the Federal Register.

Media: Diskette/Internet.
File Cost: $165.00.
Periods Available: FY 2003 PPS Update.
15. Prospective Payment System (PPS) Standardizing File
    This file contains information that standardizes the charges used 
to calculate relative weights to determine payments under the 
prospective payment system. Variables include wage index, cost-of-
living adjustment (COLA), case-mix index, disproportionate share, and 
the Metropolitan Statistical Area (MSA). The file supports the 
following:
     NPRM published in the Federal Register.
     Final rule published in the Federal Register.

Media: Internet.
File cost: No charge.
Periods Available: FY 2003 PPS Update.

    For further information concerning these data tapes, contact the 
CMS Public Use Files Hotline at (410) 786-3691.
    Commenters interested in obtaining or discussing any other data 
used in constructing this rule should contact Stephen Phillips at (410) 
786-4548.

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.
    However, the majority of the collection requirements contained in 
this proposed rule are currently approved.
    Section IX.B.1. below lists the OMB approval numbers and the 
current

[[Page 31496]]

expiration dates for the collection requirements, referenced by 42 CFR 
Part, in this proposed rule that are currently approved. In addition, 
as summarized below, section IX.B.2. of this proposed rule outlines the 
proposed collection requirements referenced in this proposed rule for 
which we are seeking public comment, as required under the PRA of 1995.
1. Currently Approved Requirements

----------------------------------------------------------------------------------------------------------------
                                                OMB approval
       Regulation references in 42 CFR               No.                    Current expiration date
----------------------------------------------------------------------------------------------------------------
Part 412.....................................       0938-0691  September 30, 2002.
                                                    0938-0050  May 31, 2004.
                                                    0938-0573  September 30, 2002.
Part 413.....................................       0938-0050  May 31, 2004.
                                                    0938-0667  October 31, 2002.
                                                    0938-0477  June 30, 2002.
Part 489.....................................       0938-0667  October 31, 2002.
----------------------------------------------------------------------------------------------------------------

2. Proposed Requirements for Public Comment

 Section 412.230  Criteria for an Individual Hospital Seeking 
Redesignation to Another Rural Area or an Urban Area.

Appropriate Wage Data

    As specified in this section, a new hospital must accumulate and 
provide at least 1 year of wage data to CMS for the purposes of 
applying for reclassification. While this collection requirement is 
subject to the PRA, we believe the burden associated with this 
requirement is exempt from the PRA as stipulated under 5 CFR 
1320.3(b)(2) and (b)(3).

Section 413.65  Requirements for a Determination That a Facility or an 
Organization Had Provider-Based Status

Responsibility for Obtaining Provider-Based Determinations

    As summarized in this section, a potential main provider seeking an 
advance determination of provider-based status for a facility that is 
located on the main campus of the potential main provider would be 
required to submit an attestation stating that the facility meets the 
criteria in paragraph (d) of this section and, if it is a hospital, 
also attest that it will fulfill the obligations of hospital outpatient 
departments and hospital-based entities described in paragraph (g) of 
this section. In addition, the provider seeking such an advance 
determination would be required to maintain documentation of the basis 
for its attestations and to make that documentation available to CMS 
upon request.
    We believe the burden associated with these requirements is 
estimated to average 1.5 hours per provider, for approximately 3,000 
providers per year, for an annual burden of 4,500 annual burden hours. 
This estimate is based on fact the providers currently maintain the 
necessary data and that minimal effort would be required to locate and 
review the appropriate data.

Clinical Services

    The clinical services of the facility or organization seeking 
provider-based status and the main provider would be required to 
maintain an unified retrieval system (or cross reference) of the main 
provider for all patient medical records for those patients treated in 
the facility or organization.
    While this collection requirement is subject to the PRA, we believe 
the burden associated with this requirement is exempt from the PRA as 
stipulated under 5 CFR 1320.3(b) (2) and (b)(3).

Section 482.12  Conditions of Participation: Governing Body

Standard: Emergency Services

    If emergency services are provided at the hospital but are not 
provided at one or more off-campus departments of the hospital, the 
governing body of the hospital would be required to assure that the 
medical staff have written policies and procedures in effect with 
respect to the off-campus department(s) for appraisal of emergencies 
and referral when appropriate.
    While this collection requirement is subject to the PRA, we believe 
the burden associated with this requirement is exempt from the PRA as 
stipulated under 5 CFR 1320.3(b)(2) and (b)(3).

Section 489.24  Special Responsibilities of Medicare Hospitals in 
Emergency Cases

Application to Inpatients--Admitted Emergency Patients

    If a hospital admits an individual with an unstable emergency 
medical condition for stabilizing treatment, as an inpatient, and 
stabilizes that individual's emergency medical condition, the period of 
stability would be required to be documented by relevant clinical data 
in the individual's medical record, before the hospital has satisfied 
its special responsibilities under this section with respect to that 
individual.
    While this collection requirement is subject to the PRA, we believe 
the burden associated with this requirement is exempt from the PRA as 
stipulated under 5 CFR 1320.3(b)(2) and (b)(3).
    If you comment on these information collection and recordkeeping 
requirements, please mail copies directly to the following:

Centers for Medicare & Medicaid Services, Office of Information 
Services, Information Technology Investment Management Group, Attn.: 
John Burke, Attn: CMS-1203-P, Room N2-14-26, 7500 Security Boulevard, 
Baltimore, MD 21244-1850.
Office of Information and Regulatory Affairs, Office of Management and 
Budget, Room 10235, New Executive Office Building, Washington, DC 
20503, Attn: Allison Eydt, CMS Desk Officer Attn: CMS-1203-P.

C. Public Comments

    Because of the large number of items of correspondence we normally 
receive on a proposed rule, we are not able to acknowledge or respond 
to them individually. However, in preparing the final rule, we will 
consider all comments concerning the provisions of this proposed rule 
that we receive by the date and time specified in the ``DATES'' section 
of this preamble and respond to those comments in the preamble to that 
rule. We emphasize that section 1886(e)(5) of the Act requires the 
final rule for FY 2003 to be published by August 1, 2002, and we will 
consider only those comments that deal specifically with the matters 
discussed in this proposed rule.

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.

[[Page 31497]]

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 489

    Health facilities, Medicare, Reporting and recordkeeping 
requirements.

    For the reasons stated in the preamble of this proposed rule, 42 
CFR chapter IV is proposed to be amended as follows:

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

    A. Part 405 is amended as follows:
    1. The authority citation for Part 405, Subpart R continues to read 
as follows:

    Authority: Secs. 205, 1102, 1814(b), 1815(a), 1833, 1861(v), 
1871, 1872, 1878, and 1886 of the Social Security Act (42 U.S.C. 
405, 1302, 1395f(b), 1395g(a), 1395l, 1395x(v), 1395hh, 1395ii, 
1395oo, and 1395ww).

    2. Section 405.1885 is amended by revising paragraph (b), 
redesignating paragraph (e) as paragraph (f), and adding a new 
paragraph (e), to read as follows:


Sec. 405.1885  Reopening a determination or decision.

* * * * *
    (b)(1) An intermediary determination or an intermediary hearing 
decision shall be reopened and revised by the intermediary if, within 
the aforementioned 3-year period, CMS--
    (i) Provides notice to the intermediary that the intermediary 
determination or the intermediary hearing decision is inconsistent with 
the applicable law, regulations, CMS ruling, or CMS general 
instructions in effect, and as CMS understood those legal provisions, 
at the time the determination or decision was rendered by the 
intermediary; and
    (ii) Explicitly directs the intermediary to reopen and revise the 
intermediary determination or the intermediary hearing decision.
    (2) A change of legal interpretation or policy by CMS in a 
regulation, CMS ruling, or CMS general instruction, whether made in 
response to judicial precedent or otherwise, is not a basis for 
reopening an intermediary determination or an intermediary hearing 
decision under this section.
* * * * *
    (e) Nothwithstanding an intermediary's discretion to reopen or not 
reopen an intermediary determination or an intermediary hearing 
decision under paragraphs (a) and (c) of this section, CMS may direct 
an intermediary to reopen, or not to reopen, an intermediary 
determination or an intermediary hearing decision in accordance with 
paragraphs (a) and (c) of this section.
* * * * *

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).


Sec. 412.4  [Amended]

    2. In Sec. 412.4 (f)(1), the reference ``paragraph (b) or (c)'' is 
removed and ``paragraph (b)(1) or (c)'' is added in its place.
    3. Section 412.22 is amended by--
    a. Revising the introductory text of paragraph (h)(2).
    b. Republishing the introductory text of paragraph (h)(2)(iii).
    c. Redesignating paragraphs (h)(2)(iii)(A) through (F) as 
paragraphs (h)(2)(iii)(B) through (G), respectively. d. Adding new 
paragraph (h)(2)(iii)(A).


Sec. 412.22  Excluded hospitals and hospital units: General rules.

* * * * *
    (h) Satellite facilities. * * *
    (2) Except as provided in paragraph (h)(3) of this section, 
effective for cost reporting periods beginning on or after October 1, 
1999, a hospital that has a satellite facility must meet the following 
criteria in order to be excluded from the acute care hospital inpatient 
prospective payment systems for any period:
* * * * *
    (iii) The satellite facility meets all of the following 
requirements:
    (A) Effective for cost reporting periods beginning on or after 
October 1, 2002, it is not under the authority or control of the 
governing body or chief executive officer of the hospital in which it 
is located, and it furnishes inpatient care through the use of medical 
personnel who are not under the authority or control of the medical 
staff or chief medical officer of the hospital in which it is located.
* * * * *
    4. Section 412.25 is amended by--
    a. Revising the introductory text of paragraph (e)(2).
    b. Republishing the introductory text of paragraph (e)(2)(iii).
    c. Redesignating paragraphs (e)(2)(iii)(A) through (F) as 
paragraphs (e)(2)(iii)(B) through (G), respectively.
    d. Adding new paragraph (e)(2)(iii)(A).


Sec. 412.25  Excluded hospitals units: Common requirements.

* * * * *
    (e) Satellite facilities. * * *
    (2) Except as provided in paragraph (e)(3) of this section, 
effective for cost reporting periods beginning on or after October 1, 
1999, a hospital that has a satellite facility must meet the following 
criteria in order to be excluded from the acute care hospital inpatient 
prospective payment systems for any period:
* * * * *
    (iii) The satellite facility meets all of the following 
requirements:
    (A) Effective for cost reporting periods beginning on or after 
October 1, 2002, it is not under the authority or control of the 
governing body or chief executive officer of the hospital in which it 
is located, and it furnishes inpatient care through the use of medical 
personnel who are not under the authority or control of the medical 
staff or chief medical officer of the hospital in which it is located.
* * * * *


Sec. 412.63  [Amended]

    5. Section 412.63 is amended by--
    a. In paragraph (x)(2)(i)(A), removing the phrase ``tabulating the 
hospital's data'' and adding in its place ``tabulating its data''.
    b. Removing paragraphs (x)(3) and (x)(4).
    c. Redesignating paragraph (x)(5) as paragraph (x)(3).
    6. Section 412.80 is amended by revising paragraph (a)(2) to read 
as follows:


Sec. 412.80  Outlier cases: General provisions.

    (a) Basic rule. * * *
    (2) Discharges occurring on or after October 1, 1997 and before 
October 1, 2001. For discharges occurring on or after October 1, 1997 
and before October 1, 2001, except as provided in paragraph (b) of this 
section concerning transfers, CMS provides for additional payment, 
beyond standard DRG payments, to a

[[Page 31498]]

hospital for covered inpatient hospital services furnished to a 
Medicare beneficiary if the hospital's charges for covered services, 
adjusted to operating costs and capital costs by applying cost-to-
charge ratios, as described in Sec. 412.84(h), exceed the DRG payment 
for the case, payments for indirect costs of graduate medical education 
(Sec. 412.105), and payments for serving disproportionate share of low-
income patients (Sec. 412.106), plus a fixed dollar amount (adjusted 
for geographic variation in costs) as specified by CMS.
* * * * *
    7. Section 412.92 is amended by revising paragraph (c)(2), to read 
as follows:


Sec. 412.92  Special treatment: Sole community hospitals.

* * * * *
    (c) Terminology. * * *
    (2) The term like hospital means a hospital furnishing short-term, 
acute care. Effective with cost reporting periods beginning on or after 
October 1, 2002, if a hospital seeking sole community hospital 
designation can demonstrate that no more than 3 percent of the services 
it provides overlap with the services provided by a nearby hospital 
that would otherwise be considered a like hospital under this 
definition, CMS will not consider the nearby hospital to be a like 
hospital.
* * * * *
    8. Section 412.105 is amended by--
    A. Republishing the introductory text of paragraph (a).
    B. Revising paragraph (a)(1).
    C. Revising paragraph (b).
    D. Revising paragraph (f)(1)(vi).
    E. Making the following cross-reference changes in paragraph 
(f)(1):
    i. In paragraph (f)(1)(vii), the reference ``Sec. 413.86(g)(12)'' 
is removed and ``Sec. 413.86(g)(13)'' is added in its place.
    ii. In paragraph (f)(1)(viii), the reference ``Sec. 413.86(g)(7)'' 
is removed and ``Sec. 413.86(g)(8)'' is added in its place.
    iii. In paragraph (f)(1)(ix), the reference ``Secs. 413.86(g)(8)(i) 
and (g)(8)(ii) of this subchapter'' is removed and 
``Sec. 413.86(g)(9)(i) and (g)(9)(ii) of this subchapter'' is added in 
its place; the reference ``Secs. 413.86(g)(8)(i) and (g)(8)(iii)(B) of 
this subchapter'' is removed and ``Sec. 413.86(g)(9)(i) and 
(g)(9)(iii)(B) of this subchapter'' is added in its place; and the 
reference ``Secs. 413.86(g)(8)(i) and (g)(8)(iii)(A) of this 
subchapter'' is removed and ``Sec. 413.86(g)(9)(i) and (g)(9)(iii)(A) 
of this subchapter'' is added it its place.
    iv. In paragraph (f)(1)(x), the reference ``Sec. 413.86(g)(12)'' is 
removed and ``Sec. 413.86(g)(13)'' is added in its place; and the 
reference ``Sec. 413.86(g)(11)'' is removed and ``Sec. 413.86(g)(12)'' 
is added in its place.
    v. In paragraph (f)(1)(xi), the reference ``Sec. 413.86(g)(9)'' is 
removed and ``Sec. 413.86(g)(10)'' is added in its place.
    vi. In paragraph (f)(1)(xii), the reference ``Sec. 413.86(g)(10)'' 
is removed and ``Sec. 413.86(g)(11)'' is added in its place.
    The revisions read as follows:


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).
    (i) 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 cost reporting periods beginning on or after October 1, 
1997, and for the special circumstances for closed hospitals or closed 
programs described in paragraph (f)(1)(ix) of this section for cost 
reporting periods beginning on or after October 1, 2002, 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.
    (ii) 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.
    (iii) The exception for closed hospitals and closed programs 
described in paragraph (f)(1)(ix) of this section applies only in the 
first cost reporting period in which the receiving hospital trains the 
displaced full-time equivalent residents.
    (iv) In the cost reporting period following the last year the 
receiving hospital's full-time equivalent cap is adjusted for the 
displaced resident(s), the resident-to-bed ratio cap in paragraph 
(a)(1) of this section is calculated as if the displaced full-time 
equivalent residents had not trained at the receiving hospital in the 
prior year.
* * * * *
    (b) Determination of number of beds. (1) For purposes of this 
section, subject to the provisions of paragraph (b)(2) of this section, 
the number of beds in a hospital is determined by counting the number 
of available bed days during the cost reporting period, not including 
beds or bassinets in the healthy newborn nursery, custodial care beds, 
or beds in excluded distinct part hospital units, and dividing that 
number by the number of days in the cost reporting period.
    (2) Effective for discharges occurring on or after October 1, 2002, 
a hospital's number of beds is equal to the lower of the number of beds 
as determined under paragraph (b)(1) of this section, or the average 
daily census (as determined in accordance with Sec. 412.322(a)(2) of 
this chapter) divided by 35 percent.
* * * * *
    (f) Determining the total number of full-time equivalent residents 
for cost reporting periods beginning on or after July 1, 1991.
    (1) * * *
    (vi) Hospitals that are part of the same affiliated group (as 
defined in Sec. 413.86(b) of this subchapter) may elect to apply the 
limit at paragraph (f)(1)(iv) of this section on an aggregate basis, as 
specified in Sec. 413.86(g)(7) of this chapter.
* * * * *
    9. 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. (1) The fiscal intermediary 
determines whether a hospital meets the criteria specified in paragraph 
(a) of this section.
    (2) A hospital must submit a written request along with qualifying 
documentation to its fiscal intermediary to be considered for MDH 
status based on the criterion under paragraph (a)(1)(iii)(C) of this 
section.
    (3) The fiscal 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.
    (4) A determination of MDH status made by the fiscal intermediary 
is effective 30 days after the date the fiscal intermediary provides 
written notification to the hospital. An approved MDH status 
determination remains in effect unless there is a change in the 
circumstances under which the status was approved.
    (5) The fiscal intermediary will evaluate on an ongoing basis, 
whether or not a hospital continues to qualify for MDH status. This 
evaluation includes an ongoing review to ensure that the hospital 
continues to meet all of the

[[Page 31499]]

criteria specified in paragraph (a) of this section.
    (6) If the fiscal intermediary determines that a hospital no longer 
qualifies for MDH status, the change in status will become effective 30 
days after the date the fiscal intermediary provides written 
notification to the hospital.
    (7) A hospital may reapply for MDH status following its 
disqualification only after it has completed another cost reporting 
period that has been audited and settled. The hospital must reapply for 
MDH status in writing to its fiscal intermediary and submit the 
required documentation.
    (8) If a hospital disagrees with an intermediary's determination 
regarding the hospital's initial or ongoing MDH status, the hospital 
may notify its fiscal intermediary and submit other documentable 
evidence to support its claim that it meets the MDH qualifying 
criteria.
    (9) The fiscal intermediary's initial and ongoing determination is 
subject to review under subpart R of Part 405 of this chapter. The time 
required by the fiscal intermediary to review the request is considered 
good cause for granting an extension of the time limit for the hospital 
to apply for that review.
* * * * *
    10. Section 412.113 is amended by revising paragraphs (c)(2)(ii) 
and (c)(2)(iii) to read as follows:


Sec. 412.113  Other payments.

* * * * *
    (c) Anesthesia services furnished by hospital employed nonphysician 
anesthetists or obtained under arrangements. * * *
    (2) * * *
    (ii) To maintain its eligibility for reasonable cost payment under 
paragraph (c)(2)(i) of this section in calendar years after 1989, a 
qualified hospital or CAH must demonstrate prior to January 1 of each 
respective year that for the prior year its volume of surgical 
procedures requiring anesthesia service did not exceed 500 procedures; 
or, effective October 1, 2002, did not exceed 800 procedures.
    (iii) A hospital or CAH that did not qualify for reasonable cost 
payment for nonphysician anesthetist services furnished in calendar 
year 1989 can qualify in subsequent years if it meets the criteria in 
paragraphs (c)(2)(i)(A), (B), and (D) of this section, and demonstrates 
to its intermediary prior to the start of the calendar year that it met 
these criteria. The hospital or CAH must provide data for its entire 
patient population to demonstrate that, during calendar year 1987 and 
the year immediately preceding its election of reasonable cost payment, 
its volume of surgical procedures (inpatient and outpatient) requiring 
anesthesia services did not exceed 500 procedures, or, effective 
October 1, 2002, did not exceed 800 procedures.
* * * * *
    11. Section 412.230 is amended by adding a new paragraph 
(e)(2)(iii) to read as follows:


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

* * * * *
    (e) Use of urban or other rural area's wage index. * * *
    (2) Appropriate wage data. * * *
    (iii) For purposes of this paragraph (e)(2), if a new owner does 
not accept assignment of the existing hospital's provider agreement in 
accordance with Sec. 489.18 of this chapter, the hospital will be 
treated as a new provider with a new provider number. In this case, the 
wage data associated with the previous owner of the hospital cannot be 
used in calculating the new hospital's 3-year average hourly wage. Once 
a new hospital has accumulated at least 1 year of wage data, it is 
eligible to apply for reclassification on the basis of those data.
* * * * *
    12. Section 412.273 is amended by--
    A. Revising the section heading.
    B. Revising paragraph (b)(2).
    C. Redesignating paragraph (d) as paragraph (e).
    D. Add a new paragraph (d).


Sec. 412.273  Withdrawing an application, terminating an approved 3-
year reclassification, or canceling a previous withdrawal or 
termination.

* * * * *
    (b) Request for termination of approved 3-year wage index 
reclassifications. * * *
    (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 cancel its withdrawal in a subsequent 
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. Once a 3-year reclassification becomes effective, a hospital may 
no longer cancel a withdrawal or termination of another 3-year 
reclassification, regardless of whether the withdrawal or termination 
request is made within 3 years from the date of the withdrawal or 
termination.
    (iii) In a case in which a hospital with an existing 3-year wage 
index reclassification applies to be reclassified to another area, its 
existing 3-year reclassification will be terminated when a second 3-
year wage index reclassification goes into effect for payments for 
discharges on or after the following October 1.
* * * * *
    (d) Process for canceling a previous withdrawal or termination. A 
hospital may cancel a previous withdrawal or termination by submitting 
written notice of its intent to the MGCRB no later than the deadline 
for submitting reclassification applications for the following fiscal 
year, as specified in Sec. 412.256(a)(2).
* * * * *
    13. Section 412.304 is amended by revising paragraph (c) to read as 
follows:


Sec. 412.304  Implementation of the capital prospective payment system.

* * * * *
    (c) Cost reporting periods beginning on or after October 1, 2001.
    (1) General. Except as provided in paragraph (c)(2) of this 
section, for cost reporting periods beginning on or after October 1, 
2001, the capital payment amount is based solely on the Federal rate 
determined under Sec. 412.308(a) and (b) and updated under 
Sec. 412.308(c).
    (2) Payment to new hospitals. For cost reporting periods beginning 
on or after October 1, 2002--
    (i) A new hospital, as defined under Sec. 412.300(b), is paid 85 
percent of its allowable Medicare inpatient hospital capital-related 
costs through its cost report ending at least 2 years after the 
hospital accepts its first patient.
    (ii) For the third year and subsequent years, the hospital is paid 
based on the Federal rate as described under Sec. 412.312.
* * * * *
    14. Section 412.308 is amending by adding a new paragraph (b)(6) to 
read as follows:


Sec. 412.308  Determining and updating the Federal rate.

* * * * *
    (b) Standard Federal rate. * * *
    (6) For discharges occurring on or after October 1, 2002, the 2.1 
percent reduction provided for under paragraph (b)(5) of this section 
is eliminated from the unadjusted standard Federal rate in effect on 
September 30, 2002, used to

[[Page 31500]]

determine the Federal rate each year under paragraph (c) of this 
section.
* * * * *
    15. Section 412.312 is amended by adding a new paragraph (e) to 
read as follows:


Sec. 412.312  Payment based on the Federal rate.

* * * * *
    (e) Payment for extraordinary circumstances. Payment for 
extraordinary circumstances is made as provided for in Sec. 412.348(f) 
for cost reporting periods beginning on or after October 1, 2001.

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

    C. Part 413 is amended as follows:
    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 413.65 is amended by--
    A. Revising paragraph (a)(1)(ii)(G) and adding a new paragraph 
(a)(1)(ii)(J).
    B. Revising the definition of ``Department of a provider'', 
``Provider-based entity'', and ``Remote location of a hospital'' under 
paragraph (a)(2).
    C. Revising paragraphs (b)(2), (b)(3), and (d).
    D. Removing paragraph (j).
    E. Redesignating paragraphs (h) and (i) as paragraphs (i) and (j), 
respectively.
    F. Redesignating paragraph (f) as paragraph (h).
    G. Redesignating paragraph (e) as paragraph (f).
    H. Adding a new paragraph (e).
    I. Revising redesignated paragraph (f).
    J. Revising the introductory text of paragraph (g), and paragraphs 
(g)(1), (g)(2), and (g)(7).
    K. Revising redesignated paragraphs (h), (i), and (j).
    L. Revising paragraph (k).
    M. Revising the heading of paragraph (m).
    N. Revising paragraph (n).


Sec. 413.65  Requirements for a determination that a facility or an 
organization had provider-based status.

    (a) Scope and definitions. (1) Scope. * * *
    (ii) This section does not apply to the following facilities:
* * * * *
    (G) Independent diagnostic testing facilities furnishing only 
services paid under a fee schedule, such as facilities that furnish 
only screening mammography services (as defined in section 1861(jj) of 
the Act), facilities that furnish only clinical diagnostic laboratory 
tests, or facilities that furnish only some combination of these 
services.
* * * * *
    (J) Departments of providers that perform functions necessary for 
the successful operation of the providers but do not furnish services 
of a type for which separate payment could be claimed under Medicare or 
Medicaid (for example, laundry or medical records departments).
    (2) Definitions. * * *
    Department of a provider means a facility or organization that is 
either created by, or acquired by, a main provider for the purpose of 
furnishing health care services of the same type as those furnished by 
the main provider under the name, ownership, and financial and 
administrative control of the main provider, in accordance with the 
provisions of this section. A department of a provider comprises both 
the specific physical facility that serves as the site of services of a 
type for which payment could be claimed under the Medicare or Medicaid 
program, and the personnel and equipment needed to deliver the services 
at that facility. A department of a provider may not by itself be 
qualified to participate in Medicare as a provider under Sec. 489.2 of 
this chapter, and the Medicare conditions of participation do not apply 
to a department as an independent entity. For purposes of this part, 
the term ``department of a provider'' does not include an RHC or, 
except as specified in paragraph (m) of this section, an FQHC.
* * * * *
    Provider-based entity means a provider of health care services, or 
an RHC as defined in Sec. 405.2401(b) of this chapter, that is either 
created by, or acquired by, a main provider for the purpose of 
furnishing health care services of a different type from those of the 
main provider under the name, ownership, and administrative and 
financial control of the main provider, in accordance with the 
provisions of this section. A provider-based entity comprises both the 
specific physical facility that serves as the site of services of a 
type for which payment could be claimed under the Medicare or Medicaid 
program, and the personnel and equipment needed to deliver the services 
at that facility. A provider-based entity may, by itself, be qualified 
to participate in Medicare as a provider under Sec. 489.2 of this 
chapter, and the Medicare conditions of participation do apply to a 
provider-based entity as an independent entity.
* * * * *
    Remote location of a hospital means a facility or an organization 
that is either created by, or acquired by, a hospital that is a main 
provider for the purpose of furnishing inpatient hospital services 
under the name, ownership, and financial and administrative control of 
the main provider, in accordance with the provisions of this section. A 
remote location of a hospital comprises both the specific physical 
facility that serves as the site of services for which separate payment 
could be claimed under the Medicare or Medicaid program, and the 
personnel and equipment needed to deliver the services at that 
facility. The Medicare conditions of participation do not apply to a 
remote location of a hospital as an independent entity. For purposes of 
this part, the term ``remote location of a hospital'' does not include 
a satellite facility as defined in Sec. 412.22(h)(1) and 
Sec. 412.25(e)(1) of this chapter.
    (b) Responsibility for obtaining provider-based determinations. * * 
*
    (2) If a facility was treated as provider-based in relation to a 
hospital or CAH on October 1, 2000, it will continue to be considered 
provider-based in relation to that hospital or CAH until the start of 
the hospital's first cost reporting period beginning on or after July 
1, 2003. The requirements, limitations, and exclusions specified in 
paragraphs (d), (e), (f), (g), (h), and (i), of this section will not 
apply to that hospital or CAH until the start of the hospital's first 
cost reporting period beginning on or after July 1, 2003. For purposes 
of this paragraph (b)(2), a facility is considered as provider-based on 
October 1, 2000 if, on that date, it either had a written determination 
from CMS that it was provider-based, or was billing and being paid as a 
provider-based department or entity of the hospital.
    (3)(i) Except as specified in paragraphs (b)(2) and (b)(5) of this 
section, if a potential main provider seeks an advance determination of 
provider-based status for a facility that is located on the main campus 
of the potential main provider, the provider would be required to 
submit an attestation stating that the facility meets the criteria in 
paragraph (d) of this section and if it is a hospital, also attest that 
it will fulfill the obligations of hospital outpatient departments and

[[Page 31501]]

hospital-based entities described in paragraph (g) of this section. The 
provider seeking such an advance determination would also be required 
to maintain documentation of the basis for its attestations and to make 
that documentation available to CMS upon request.
    (ii) If the facility is not located on the main campus of the 
potential main provider, the provider seeking an advance determination 
would be required to submit an attestation stating that the facility 
meets the criteria in paragraphs (d) and (e) of this section, and if 
the facility is operated as a joint venture or under a management 
contract, the requirements of paragraph (f) or paragraph (h) of this 
section, as applicable. If the potential main provider is a hospital, 
the hospital also would be required to attest that it will fulfill the 
obligations of hospital outpatient departments and hospital-based 
entities described in paragraph (g) of this section. The provider would 
be required to supply documentation of the basis for its attestations 
to CMS at the time it submits its attestations.
* * * * *
    (d) Requirements applicable to all facilities or organizations. Any 
facility or organization for which provider-based status is sought, 
whether located on or off the campus of a potential main provider, must 
meet all of the following requirements to be determined by CMS to have 
provider-based status:
    (1) Licensure. The department of the provider, the remote location 
of a hospital, or the satellite facility and the main provider are 
operated under the same license, except in areas where the State 
requires a separate license for the department of the provider, the 
remote location of a hospital, or the satellite facility, or in States 
where State law does not permit licensure of the provider and the 
prospective department of the provider, the remote location of a 
hospital, or the satellite facility under a single license. If a State 
health facilities' cost review commission or other agency that has 
authority to regulate the rates charged by hospitals or other providers 
in a State finds that a particular facility or organization is not part 
of a provider, CMS will determine that the facility or organization 
does not have provider-based status.
    (2) Clinical services. The clinical services of the facility or 
organization seeking provider-based status and the main provider are 
integrated as evidenced by the following:
    (i) Professional staff of the facility or organization have 
clinical privileges at the main provider.
    (ii) The main provider maintains the same monitoring and oversight 
of the facility or organization as it does for any other department of 
the provider.
    (iii) The medical director of the facility or organization seeking 
provider-based status maintains a reporting relationship with the chief 
medical officer or other similar official of the main provider that has 
the same frequency, intensity, and level of accountability that exists 
in the relationship between the medical director of a department of the 
main provider and the chief medical officer or other similar official 
of the main provider, and is under the same type of supervision and 
accountability as any other director, medical or otherwise, of the main 
provider.
    (iv) Medical staff committees or other professional committees at 
the main provider are responsible for medical activities in the 
facility or organization, including quality assurance, utilization 
review, and the coordination and integration of services, to the extent 
practicable, between the facility or organization seeking provider-
based status and the main provider.
    (v) Medical records for patients treated in the facility or 
organization are integrated into a unified retrieval system (or cross 
reference) of the main provider.
    (vi) Inpatient and outpatient services of the facility or 
organization and the main provider are integrated, and patients treated 
at the facility or organization who require further care have full 
access to all services of the main provider and are referred where 
appropriate to the corresponding inpatient or outpatient department or 
service of the main provider.
    (3) Financial integration. The financial operations of the facility 
or organization are fully integrated within the financial system of the 
main provider, as evidenced by shared income and expenses between the 
main provider and the facility or organization. The costs of a facility 
or organization that is a hospital department are reported in a cost 
center of the provider, costs of a provider-based facility or 
organization other than a hospital department are reported in the 
appropriate cost center or cost centers of the main provider, and the 
financial status of any provider-based facility or organization is 
incorporated and readily identified in the main provider's trial 
balance.
    (4) Public awareness. The facility or organization seeking status 
as a department of a provider, a remote location of a hospital, or a 
satellite facility is held out to the public and other payers as part 
of the main provider. When patients enter the provider-based facility 
or organization, they are aware that they are entering the main 
provider and are billed accordingly.
    (5) Obligations of hospital outpatient departments and hospital-
based entities. In the case of a hospital outpatient department or a 
hospital-based entity, the facility or organization must fulfill the 
obligations of hospital outpatient departments and hospital-based 
entities described in paragraph (g) of this section.
    (e) Additional requirements applicable to off-campus facilities or 
organizations. Except as described in paragraphs (b)(2) and (b)(5) of 
this section, any facility or organization for which provider-based 
status is sought that is not located on the campus of a potential main 
provider must meet both the requirements in paragraph (d) of this 
section and all of the following additional requirements, in order to 
be determined by CMS to have provider-based status.
    (1) Operation under the ownership and control of the main provider. 
The facility or organization seeking provider-based status is operated 
under the ownership and control of the main provider, as evidenced by 
the following:
    (i) The business enterprise that constitutes the facility or 
organization is 100 percent owned by the provider.
    (ii) The main provider and the facility or organization seeking 
status as a department of the provider, a remote location of a 
hospital, or a satellite facility have the same governing body.
    (iii) The facility or organization is operated under the same 
organizational documents as the main provider. For example, the 
facility or organization seeking provider-based status must be subject 
to common bylaws and operating decisions of the governing body of the 
provider where it is based.
    (iv) The main provider has final responsibility for administrative 
decisions, final approval for contracts with outside parties, final 
approval for personnel actions, final responsibility for personnel 
policies (such as fringe benefits or code of conduct), and final 
approval for medical staff appointments in the facility or 
organization.
    (2) Administration and supervision. The reporting relationship 
between the facility or organization seeking provider-based status and 
the main provider must have the same frequency, intensity, and level of 
accountability that exists in the relationship between the main 
provider and one of its existing departments, as evidenced by

[[Page 31502]]

compliance with all of the following requirements:
    (i) The facility or organization is under the direct supervision of 
the main provider.
    (ii) The facility or organization is operated under the same 
monitoring and oversight by the provider as any other department of the 
provider, and is operated just as any other department of the provider 
with regard to supervision and accountability. The facility or 
organization director or individual responsible for daily operations at 
the entity--
    (A) Maintains a reporting relationship with a manager at the main 
provider that has the same frequency, intensity, and level of 
accountability that exists in the relationship between the main 
provider and its existing departments; and
    (B) Is accountable to the governing body of the main provider, in 
the same manner as any department head of the provider.
    (iii) The following administrative functions of the facility or 
organization are integrated with those of the provider where the 
facility or organization is based: billing services, records, human 
resources, payroll, employee benefit package, salary structure, and 
purchasing services. Either the same employees or group of employees 
handle these administrative functions for the facility or organization 
and the main provider, or the administrative functions for both the 
facility or organization and the entity are--
    (A) Contracted out under the same contract agreement; or
    (B) Handled under different contract agreements, with the contract 
of the facility or organization being managed by the main provider.
    (3) Location. The facility or organization is located within a 35-
mile radius of the main campus of the hospital or CAH that is the 
potential main provider, except when the requirements in paragraph 
(e)(3)(i), (e)(3)(ii), or (e)(3)(iii) of this section are met:
    (i) The facility or organization is owned and operated by a 
hospital or CAH that has a disproportionate share adjustment (as 
determined under Sec. 412.106 of this chapter) greater than 11.75 
percent or is described in Sec. 412.106(c)(2) of this chapter 
implementing section 1886(e)(5)(F)(i)(II) of the Act and is--
    (A) Owned or operated by a unit of State or local government;
    (B) A public or nonprofit corporation that is formally granted 
governmental powers by a unit of State or local government; or
    (C) A private hospital that has a contract with a State or local 
government that includes the operation of clinics located off the main 
campus of the hospital to assure access in a well-defined service area 
to health care services for low-income individuals who are not entitled 
to benefits under Medicare (or medical assistance under a Medicaid 
State plan).
    (ii) The facility or organization demonstrates a high level of 
integration with the main provider by showing that it meets all of the 
other provider-based criteria and demonstrates that it serves the same 
patient population as the main provider, by submitting records showing 
that, during the 12-month period immediately preceding the first day of 
the month in which the application for provider-based status is filed 
with CMS, and for each subsequent 12-month period--
    (A) At least 75 percent of the patients served by the facility or 
organization reside in the same zip code areas as at least 75 percent 
of the patients served by the main provider;
    (B) At least 75 percent of the patients served by the facility or 
organization who required the type of care furnished by the main 
provider received that care from that provider (for example, at least 
75 percent of the patients of an RHC seeking provider-based status 
received inpatient hospital services from the hospital that is the main 
provider); or
    (C) If the facility or organization is unable to meet the criteria 
in paragraph (e)(3)(ii)(A) or paragraph (e)(3)(ii)(B) of this section 
because it was not in operation during all of the 12-month period 
described in paragraph (e)(3)(ii) of this section, the facility or 
organization is located in a zip code area included among those that, 
during all of the 12-month period described in paragraph (e)(3)(ii) of 
this section, accounted for at least 75 percent of the patients served 
by the main provider.
    (iv) A facility or organization may qualify for provider-based 
status under this section only if the facility or organization and the 
main provider are located in the same State or, when consistent with 
the laws of both States, in adjacent States.
    (v) An RHC that is otherwise qualified as a provider-based entity 
of a hospital that is located in a rural area, as defined in 
Sec. 412.62(f)(1)(iii) of this chapter, and has fewer than 50 beds, as 
determined under Sec. 412.105(b) of this chapter, is not subject to the 
criteria in paragraphs (e)(3)(i) through (e)(3)(iii) of this section.
    (f) Provider-based status for joint ventures. A facility or 
organization that is not located on the campus of the potential main 
provider cannot be considered provider-based if the facility or 
organization is owned by two or more providers engaged in a joint 
venture. For example, where a hospital has jointly purchased or jointly 
created a facility under joint venture arrangements with one or more 
other providers, and the facility is not located on the campus of the 
hospital or the campus of any other provider engaged in the joint 
venture arrangement, no party to the joint venture arrangement can 
claim the facility as provider-based.
    (g) Obligations of hospital outpatient departments and hospital-
based entities. To qualify for provider-based status in relation to a 
hospital, a facility or organization must comply with the following 
requirements:
    (1) The following departments must comply with the antidumping 
rules of Sec. 489.20(l), (m), (q), and (r) and Sec. 489.24 of this 
chapter:
    (i) Any facility or organization that is located on the main 
hospital campus and is treated by Medicare under this section as a 
department of the hospital; and
    (ii) Any facility or organization that is located off the main 
hospital campus that is treated by Medicare under this section as a 
department of the hospital and is a dedicated emergency department, as 
defined in Sec. 489.24(b) of this chapter.
    (2) Physician services furnished in hospital outpatient departments 
or hospital-based entities (other than RHCs) must be billed with the 
correct site-of-service so that appropriate physician and practitioner 
payment amounts can be determined under the rules of part 414 of this 
chapter.
* * * * *
    (7) When a Medicare beneficiary is treated in a hospital outpatient 
department of hospital-based entity (other than an RHC) that is not 
located on the main provider's campus, and the treatment is not 
required to be provided by the antidumping rules in Sec. 489.24 of this 
chapter, the hospital must provide written notice to the beneficiary, 
before the delivery of services, of the amount of the beneficiary's 
potential financial liability (that is, that the beneficiary will incur 
a coinsurance liability for an outpatient visit to the hospital as well 
as for the physician service, and of the amount of that liability).
    (i) The notice must be one that the beneficiary can read and 
understand.
    (ii) If the exact type and extent of care needed is not known, the 
hospital may furnish a written notice to the patient that explains that 
the beneficiary will incur a coinsurance liability to the hospital that 
he or she would not incur if the facility were not provider-based.

[[Page 31503]]

    (iii) The hospital may furnish an estimate based on typical or 
average charges for visits to the facility, while stating that the 
patient's actual liability will depend upon the actual services 
furnished by the hospital.
    (iv) If the beneficiary is unconscious, under great duress, or for 
any other reason unable to read a written notice and understand and act 
on his or her own rights, the notice must be provided, before the 
delivery of services, to the beneficiary's authorized representative.
    (v) In cases where a hospital outpatient department provides 
examination or treatment that is required to be provided by the 
antidumping rules of Sec. 489.24 of this chapter, notice, as described 
in this paragraph (g)(7), must be given as soon as possible after the 
existence of an emergency has been ruled out or the emergency condition 
has been stabilized.
* * * * *
    (h) Management contracts. A facility or organization that is not 
located on the campus of the potential main provider and otherwise 
meets the requirements of paragraphs (d) and (e) of this section, but 
is operated under management contracts, must also meet all of the 
following criteria:
    (1) The main provider (or an organization that also employs the 
staff of the main provider and that is not the management company) 
employs the staff of the facility or organization who are directly 
involved in the delivery of patient care, except for management staff 
and staff who furnish patient care services of a type that would be 
paid for by Medicare under a fee schedule established by regulations at 
Part 414 of this chapter. ``Leased'' employees (that is, personnel who 
are actually employed by the management company but provide services 
for the provider under a staff leasing or similar agreement) are not 
considered to be employees of the provider for purposes of this 
paragraph.
    (2) The administrative functions of the facility or organization 
are integrated with those of the main provider, as determined under 
criteria in paragraph (e)(2)(iii) of this section.
    (3) The main provider has significant control over the operations 
of the facility or organization as determined under criteria in 
paragraph (e)(2)(ii) of this section.
    (4) The management contract is held by the main provider itself, 
not by a parent organization that has control over both the main 
provider and the facility or organization.
    (i) Furnishing all services under arrangement. A facility or 
organization may not qualify for provider-based status if all patient 
care services furnished at the facility or organization are furnished 
under arrangements.
    (j) Inappropriate treatment of a facility or organization as 
provider-based. (1) Determination and review. If CMS learns that a 
provider has treated a facility or organization as provider-based and 
the provider did not request an advance determination of provider-based 
status from CMS under paragraph (b)(3) of this section and CMS 
determines that the facility or organization did not meet the 
requirements for provider-based status under paragraphs (d) through (i) 
of this section, as applicable (or, in any period before the effective 
date of these regulations, the provider-based requirements in effect 
under Medicare program regulations or instructions), CMS will--
    (i) Issue notice to the provider in accordance with paragraph 
(j)(3) of this section, adjust the amount of future payments to the 
provider for services of the facility or organization in accordance 
with paragraph (j)(4) of this section, and continue payments to the 
provider for services of the facility or organization only in 
accordance with paragraph (j)(5) of this section; and
    (ii) Except as otherwise provided in paragraphs (b)(2), (b)(5), or 
(j)(2) of this section, recover the difference between the amount of 
payments that actually was made and the amount of payments that CMS 
estimates should have been made, in the absence of compliance with the 
provider-based requirements, to that provider for services at the 
facility or organization for all cost reporting periods subject to 
reopening in accordance with Secs. 405.1885 and 405.1889 of this 
chapter.
    (2) Exception for good faith effort. CMS will not recover any 
payments for any period before the beginning of the hospital's first 
cost reporting period beginning on or after January 10, 2001, if, 
during all of that period--
    (i) The requirements regarding licensure and public awareness in 
paragraphs (d)(1) and (d)(4) of this section were met;
    (ii) All facility services were billed as if they had been 
furnished by a department of a provider, a remote location of a 
hospital, a satellite facility, or a provider-based entity of the main 
provider; and
    (iii) All professional services of physicians and other 
practitioners were billed with the correct site-of-service indicator, 
as described in paragraph (g)(2) of this section.
    (3) Notice to provider. CMS will issue written notice to the 
provider that payments for past cost reporting periods may be reviewed 
and recovered as described in paragraph (j)(1)(ii) of this section, and 
that future payments for services in or of the facility or organization 
will be adjusted as described in paragraph (j)(4) of this section.
    (4) Adjustment of payments. CMS will adjust future payments to the 
provider or the facility or organization, or both, to approximate as 
closely as possible the amounts that would be paid for the same 
services furnished by a freestanding facility.
    (5) Continuation of payment. (i) The notice of denial of provider-
based status sent to the provider will ask the provider to notify CMS 
in writing, within 30 days of the date the notice is issued, of whether 
the provider intends to seek an advance determination of provider-based 
status for the facility or organization under paragraph (b)(3) of this 
section or whether the facility or organization (or, where applicable, 
the practitioners who staff the facility or organization) will be 
seeking to enroll and meet other requirements to bill for services in a 
freestanding facility.
    (ii) If the provider indicates that it will not be seeking an 
advance determination for the facility or organization under paragraph 
(b) of this section or that the facility or organization or its 
practitioners will not be seeking to enroll, or if CMS does not receive 
a response within 30 days of the date the notice was issued, all 
payment under this paragraph (j)(5) will end as of the 30th day after 
the date of notice.
    (iii) If the provider indicates that it will be seeking an advance 
determination for the facility or organization under paragraph (b) of 
this section or that the facility or organization or its practitioners 
will be seeking to meet enrollment and other requirements for billing 
for services in a freestanding facility, payment for services of the 
facility or organization will continue, at the adjusted amounts 
described in paragraph (j)(4) of this section, for as long as is 
required for all billing requirements to be met (but not longer than 6 
months) if the provider or the facility or organization or its 
practitioners--
    (A) Submits, as applicable, a complete request for an advance 
determination of provider-based status or a complete enrollment 
application and provide all other required information within 90 days 
after the date of notice; and
    (B) Furnishes all other information needed by CMS to process the 
request for provider-based status or the enrollment application, as 
applicable,

[[Page 31504]]

and verifies that other billing requirements are met.
    (v) If the necessary applications or information are not provided, 
CMS will terminate all payment to the provider, facility, or 
organization as of the date CMS issues notice that necessary 
applications or information have not been submitted.
    (k) Temporary treatment as provider-based and correction of errors. 
(1) If a provider submits a complete request for a provider-based 
determination for a facility or organization that has not previously 
been found by CMS to have been inappropriately treated as provider-
based under paragraph (j) of this section, the provider may bill and be 
paid for services of the facility or organization as provider-based 
from the date of the application until the date that CMS determines 
that the facility or organization does not meet the provider-based 
rules. If CMS subsequently determines that the requirements for 
provider-based status are not met, CMS will recover the difference 
between the amount of payments that actually was made since the date 
the complete request for a provider-based determination was submitted 
and the amount of payments that CMS estimates should have been made in 
the absence of compliance with the provider-based requirements. For 
purposes of this paragraph (k), a complete request is one that includes 
all information needed to permit CMS to make an advance determination 
under paragraph (b)(3) of this section.
    (2) If CMS determines that a facility or organization that had 
previously been determined to be provider-based under paragraph (b) of 
this section no longer qualifies for provider-based status, and the 
failure to qualify for provider-based status resulted from a material 
change in the relationship between the provider and the facility or 
organization that the provider did report to CMS as required under 
paragraph (c) of this section, treatment of the facility or 
organization as provider-based ceases with the date that CMS determines 
that the facility or organization no longer qualifies for provider-
based status.
    (3) If CMS determines that a facility or organization that had 
previously been determined to be provider-based under paragraph (b) of 
this section no longer qualifies for provider-based status, and if the 
failure to qualify for provider-based status resulted from a material 
change in the relationship between the provider and the facility or 
organization that the provider did not report to CMS, as required under 
paragraph (c) of this section, CMS will take the actions with respect 
to notice to the provider, adjustment of payments, and continuation of 
payment described in paragraphs (j)(3), (j)(4), and (j)(5) of this 
section, and will recover past payments to the provider to the extent 
described in paragraph (j)(1)(ii) of this section.
* * * * *
    (m) FQHCs and ``look alikes''. * * *
    (n) Effective date of provider-based status. Provider-based status 
for a facility or organization is effective on the earliest date on 
which a request for provider-based status, as described in paragraph 
(b) of this section, has been made and all of the requirements of this 
part have been met.
    3. Section 413.70 is amended by revising paragraph (b)(3)(i) to 
read as follows:


Sec. 413.70  Payment for services of a CAH.

* * * * *
    (b) Payment for outpatient services furnished by CAH.
* * * * *
    (3) Election to be paid reasonable costs for facility services plus 
fee schedule for professional services. (i) A CAH may elect to be paid 
for outpatient services in any cost reporting period under the method 
described in paragraphs (b)(3)(ii) and (b)(3)(iii) of this section. 
This election must be made in writing, made on an annual basis, and 
delivered to the intermediary servicing the CAH by a date determined by 
that intermediary, which may be no less than 14 days and no more than 
60 days before the start of each affected cost reporting period. An 
election of this payment method, once made for a cost reporting period, 
remains in effect for all of that period and applies to all services 
furnished to outpatients during that period.
* * * * *
    4. Section 413.86 is amended by--
    A. Adding a definition of ``Affiliation agreement'' in alphabetical 
order under paragraph (b).
    B. Revising the last sentence of the introductory text of paragraph 
(e)(5)(i).
    C. Revising paragraph (e)(5)(i)(B).
    D. Adding a new paragraph (e)(5)(i)(C).
    E. Redesignating paragraphs (g)(5)(iv), (g)(5)(v), and (g)(5)(vi) 
as paragraphs (g)(5)(v), (g)(5)(vi), and (g)(5)(vii), respectively.
    F. Republishing the introductory text of paragraph (g)(5) and 
adding a new paragraph (g)(5)(iv).
    G. Redesignating paragraphs (g)(7) through (g)(12) as paragraphs 
(g)(8) through (g)(13), respectively.
    H. Adding a new paragraph (g)(7).
    I. Making the following cross-reference changes:
    i. In redesignated paragraph (g)(5)(vii), ``paragraph (g)(8)'' is 
removed and ``paragraph (g)(9)'' is added in its place.
    ii. In paragraph (g)(6), ``paragraph (g)(12)'' is removed and 
``paragraph (g)(13)'' is added in its place.
    iii. In redesignated paragraphs (g)(8)(iv) and (g)(8)(v), 
``paragraph (g)(7)'' is removed and ``paragraph (g)(8)'' is added in 
its place.
    iv. In redesignated paragraph (g)(9)(i), ``paragraph (g)(8)'' is 
removed and ``paragraph (g)(9)'' is added in its place.
    v. In the introductory text of redesignated paragraph (g)(9)(iii), 
``paragraph (g)(8)(iii)(B)'' is removed and ``paragraph 
(g)(9)(iii)(B)'' is added in its place; and ``paragraph 
(g)(8)(iii)(A)'' is removed and ``paragraph (g)(9)(iii)(A)'' is added 
in its place.
    vi. In redesignated paragraph (g)(9)(iii)(A)(2), ``paragraph 
(g)(8)(iii)(B)(2)'' is removed and ``paragraph (g)(9)(iii)(B)(2)'' is 
added in its place.
    vii. In the introductory text of redesignated paragraph (g)(12), 
``paragraph (g)(11)(i) through (g)(11)(vi)'' is removed and ``paragraph 
(g)(12)(i) through (g)(12)(vi)'' is added in its place.
    The additions and revisions read as follows:


Sec. 413.86  Direct graduate medical education payments.

* * * * *
    (b) Definitions. * * *
    Affiliation agreement means a written, signed, and dated agreement 
by responsible representatives of each respective hospital in an 
affiliated group, as defined in this section, that specifies--
    (1) The term of the agreement (which, at a minimum is one year), 
beginning on July 1 of a year;
    (2) Each participating hospital's direct and indirect FTE caps 
existing at the time of affiliation;
    (3) The adjustment to each hospital's FTE caps in each year that 
the affiliation agreement is in effect, for both direct GME and IME, 
that reflects a positive adjustment to one hospital's direct and 
indirect FTE caps that is offset by a negative adjustment to the other 
hospital's (or hospitals') direct and indirect FTE caps of at least the 
same amount; and
    (4) The names of the participating hospitals and their Medicare 
provider numbers.
* * * * *
    (e) Determining per resident amounts for the base period. * * *
    (5) Exceptions--(i) Base period for certain hospitals. * * * The 
per

[[Page 31505]]

resident amount is based on the lower of the amount specified in 
paragraph (e)(5)(i)(A) or in paragraph (e)(5)(i)(B) of this section, 
subject to the provisions of paragraph (e)(5)(i)(C) of this section.
* * * * *
    (B) Except as specified in paragraph (e)(5)(i)(C) of this section--
    (1) For base periods that begin before October 1, 2002, the updated 
weighted mean value of per resident amounts of all hospitals located in 
the same geographic wage area, as that term is used in the prospective 
payment system under part 412 of this chapter.
    (2) For base periods beginning on or after October 1, 2002, the 
weighted mean value of per resident amounts of all hospitals located in 
the same geographic wage area is calculated using all per resident 
amounts (including primary care and obstetrics and gynecology and 
nonprimary care) and FTE resident counts from the most recently settled 
cost reports of those teaching hospitals.
    (C) If, under paragraph (e)(5)(i)(B)(1) or (e)(5)(i)(B)(2) of this 
section, there are fewer than three existing teaching hospitals with 
per resident amounts that can be used to calculate the weighted mean 
value per resident amount, for base periods beginning on or after 
October 1, 1997, the per resident amount equals the updated weighted 
mean value of per resident amounts of all hospitals located in the same 
census region as that term is used in Sec. 412.62(f)(1)(i) of this 
chapter.
* * * * *
    (g) Determining the weighted number of FTE residents. * * *
    (5) For purposes of determining direct graduate medical education 
payment--
* * * * *
    (iv) Hospitals that are part of the same affiliated group (as 
described under paragraph (b) of this section) may elect to apply the 
limit on an aggregate basis as described under paragraph (g)(7) of this 
section.
* * * * *
    (7) A hospital may receive a temporary adjustment to its FTE cap, 
which is subject to the averaging rules under paragraph (g)(5)(iii) of 
this section, to reflect residents added or subtracted because the 
hospital is participating in an affiliated group (as defined under 
paragraph (b) of this section). Under this provision--
    (i) Each hospital in the affiliated group must submit the 
affiliation agreement, as defined under paragraph (b) of this section, 
to the CMS fiscal intermediary servicing the hospital and send a copy 
to CMS's Central Office no later than July 1 of the residency program 
year during which the affiliation agreement will be in effect.
    (ii) There must be a rotation of a resident(s) among the hospitals 
participating in the affiliated group during the term of the 
affiliation agreement such that more than one of the hospitals count 
the proportionate amount of the time spent by the resident(s) in their 
FTE resident counts. No resident may be counted in the aggregate as 
more than one FTE.
    (iii) The net effect of the adjustments (positive or negative) on 
the affiliated hospitals' aggregate FTE cap for each affiliation 
agreement must not exceed zero.
    (iv) If the affiliation agreement terminates for any reason, the 
FTE cap of each hospital in the affiliated group will revert to the 
individual hospital's pre-affiliation FTE cap that is determined under 
the provisions of paragraph (g)(4) of this section.
* * * * *

PART 482--CONDITIONS FOR PARTICIPATION FOR HOSPITALS

    D. Part 482 is amended as follows:
    1. The authority citation for part 482 continues to read as 
follows:

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1320 and 1395hh).

    2. Section 482.12 is amended by adding a new paragraph (f)(3), to 
read as follows:


Sec. 482.12  Condition of participation: Governing body.

* * * * *
    (f) Standard: Emergency services. * * *
    (3) If emergency services are provided at the hospital but are not 
provided at one or more off-campus departments of the hospital, the 
governing body of the hospital must assure that the medical staff has 
written policies and procedures in effect with respect to the off-
campus department(s) for appraisal of emergencies and referral when 
appropriate.

PART 485--CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS

    E. 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 
1396hh).

    2. In Sec. 485.645, the introductory text of paragraph (d) is 
republished and paragraph (d)(6) is revised, to read as follows.


Sec. 485.645  Special requirements for CAH providers of long-term care 
services (``swing-beds'').

* * * * *
    (d) SNF services. The CAH is substantially in compliance with 
following SNF requirements contained in subpart B of part 483 of this 
chapter.
* * * * *
    (6) Comprehensive assessment, comprehensive care plan, and 
discharge planning (Sec. 483.20(b), (k), and (l) of this chapter, 
except that the CAH is not required to use the resident assessment 
instrument (RAI) specified by the State that is required under 
Sec. 483.20(b), or to comply with the requirements for frequency, 
scope, and number of assessments prescribed in Sec. 413.343(b) of this 
chapter).
* * * * *

PART 489--PROVIDER AGREEMENTS AND SUPPLIER APPROVAL

    F. Part 489 is amended as follows:
    1. The authority citation for part 489 continues to read as 
follows:

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

    2. Section 489.24 is amended by--
    A. Revising paragraph (a).
    B. Republishing the introductory text of paragraph (b) and revising 
the definitions of ``Comes to the emergency department'' and ``Hospital 
with an emergency department''.
    C. Adding definitions of ``Dedicated emergency department'', 
``Hospital property'', and ``Patient'' in alphabetical order under 
paragraph (b).
    D. Under the definition of ``Emergency medical condition'' under 
paragraph (b), redesignating paragraphs (i), (i)(A), (i)(B), (i)(C), 
(ii), (ii)(A), and (ii)(B) as paragraphs (1), (1)(i), (1)(ii), 
(1)(iii), (2), (2)(i), and (2)(ii), respectively.
    E. Under the definition of ``Participating hospital'' under 
paragraph (b), redesignating paragraphs (i) and (ii) as paragraphs (1) 
and (2), respectively.
    F. Under the definitions of ``Stabilized'' and ``To stabilize'' 
under paragraph (b), ``paragraph (i)'' is removed and ``paragraph (1)'' 
is added in its place; and ``paragraph (ii)'' is removed and 
``paragraph (2)'' is added in its place.
    G. Removing paragraph (i); and redesignating paragraph (c) through 
(h) as paragraphs (d) through (i), respectively.
    H. Adding a new paragraph (c).
    I. Revising newly redesignated paragraph (d).
    J. Adding a new paragraph (j).

[[Page 31506]]

    K. Making the following cross-reference changes:
    i. In redesignated paragraph (e)(1)(i), ``paragraph (d)(2)'' is 
removed and ``paragraph (e)(2)'' is added in its place.
    ii. In redesignated paragraph (e)(1)(ii)(C), ``paragraph 
(d)(1)(ii)(B)'' is removed and ``paragraph (e)(1)(ii)(B)'' is added in 
its place.
    iii. In redesignated paragraph (e)(2)(iii), ``paragraph 
(d)(1)(ii)'' is removed and ``paragraph (e)(1)(ii)'' is added in its 
place.
    iv. In redesignated paragraph (e)(2)(iii), ``paragraph (f)'' is 
removed and ``paragraph (g)'' is added in its place.
    v. In redesignated paragraph (e)(3), ``paragraph (d)(1)(ii)(C)'' is 
removed and ``paragraph (e)(1)(ii)(C) is added in its place.
    vi. In redesignated paragraph (g), ``paragraph (a) through (e)'' is 
removed and ``paragraphs (a) through (f)'' is added in its place.
    vii. In redesignated paragraph (h)(1), ``paragraph (g)(3)'' is 
removed and ``paragraph (h)(3)'' is added in its place; and ``paragraph 
(g)(2)(iv) and (v)'' is removed and ``paragraphs (h)(2)(iv) and (v)'' 
is added in its place.
    viii. In redesignated paragraph (h)(2) introductory text, 
``paragraph (g)(1)'' is removed and ``paragraph (h)(1)'' is added in 
its place.
    ix. In redesignated paragraph (h)(2)(iii)(B), ``paragraph 
(g)(2)(iii)(A)'' is removed and ``paragraph (h)(2)(iii)(A)'' is added 
in its place.
    x. In redesignated paragraph (h)(2)(vi), ``paragraph (g)(2)(v)'' is 
removed and ``paragraph (h)(2)(v)'' is added in its place.
    xi. In redesignated paragraph (h)(4), ``paragraph (g)'' is removed 
and ``paragraph (h)'' is added in its place; and ``paragraph 
(g)(2)(v)'' is removed and ``paragraph (h)(2)(v)'' is added in its 
place.
    The additions and revisions read as follows:


Sec. 489.24  Special responsibilities of Medicare hospitals in 
emergency cases.

    (a) Application. In the case of a hospital that has an emergency 
department, if an individual (whether or not eligible for Medicare 
benefits and regardless of ability to pay) ``comes to the emergency 
department'', as defined in paragraph (b) of this section, the hospital 
must--
    (1) Provide an appropriate medical screening examination within the 
capability of the hospital's emergency department, including ancillary 
services routinely available to the emergency department, to determine 
whether or not an emergency medical condition exists. The examination 
must be conducted by an individual(s) determined qualified by hospital 
bylaws or rules and regulations and who meet the requirements of 
Sec. 482.55 of this chapter concerning emergency services personnel and 
direction; and
    (2) If an emergency medical condition is determined to exist, 
provide any necessary stabilizing treatment, as defined in paragraph 
(d) of this section, or an appropriate transfer as defined in paragraph 
(e) of this section.
    (b) Definitions. As used in this subpart--
* * * * *
    Comes to the emergency department means, with respect to an 
individual who is not a patient, the individual--
    (1) Has presented at a hospital's dedicated emergency department, 
as defined in this section, and requests examination or treatment for a 
medical condition, or has such a request made on his or her behalf. In 
the absence of such a request by or on behalf of the individual, a 
request on behalf of the individual will be considered to exist if a 
prudent layperson observer would believe, based on the individual's 
appearance or behavior, that the individual needs examination or 
treatment for a medical condition;
    (2) Has presented on hospital property, as defined in this section, 
other than the dedicated emergency department, and requests examination 
or treatment for what may be an emergency medical condition, or has 
such a request made on his or her behalf (except for certain 
outpatients as specified in paragraph (d)(3) of this section). In the 
absence of such a request by or on behalf of the individual, a request 
on behalf of the individual will be considered to exist if a prudent 
layperson observer would believe, based on the individual's appearance 
or behavior, that the individual needs emergency examination or 
treatment;
    (3) Is in an ambulance owned and operated by the hospital for 
presentation for examination and treatment for a medical condition at a 
hospital's dedicated emergency department, even if the ambulance is not 
on hospital grounds. This provision does not apply if the ambulance is 
operating under communitywide EMS protocols that direct it to transport 
the individual to a hospital other than the hospital that owns the 
ambulance; for example, to the nearest hospital. In this latter case, 
the individual is considered to have come to the emergency department 
of the hospital to which the individual is transported, at the time the 
individual is brought onto hospital property; or
    (4) Is in a nonhospital-owned ambulance on hospital property for 
presentation for examination and treatment for a medical condition at a 
hospital's dedicated emergency department. An individual in a 
nonhospital-owned ambulance off hospital property is not considered to 
have come to the hospital's emergency department, even if a member of 
the ambulance staff contacts the hospital by telephone or telemetry 
communications and informs the hospital that they want to transport the 
individual to the hospital for examination and treatment. In the latter 
circumstance, the hospital may deny access if it is in ``diversionary 
status,'' that is, it does not have the staff or facilities to accept 
any additional emergency patients. If, however, the ambulance staff 
disregards the hospital's instructions and transports the individual 
onto hospital property, the individual is considered to have come to 
the emergency department.
    Dedicated emergency department means a specially equipped and 
staffed area of the hospital that is used a significant portion of the 
time for the initial evaluation and treatment of outpatients for 
emergency medical conditions, as defined in this section, and that is 
located--
    (1) On the main hospital campus; or
    (2) Off the main hospital campus and is treated by Medicare under 
Sec. 413.65(b) of this chapter as a department of the hospital.
* * * * *
    Hospital property means the entire main hospital campus as defined 
in Sec. 413.65(b) of this chapter, including the parking lot, sidewalk, 
and driveway, but excluding other areas or structures that are located 
within 250 yards of the hospital's main building but are not part of 
the hospital, such as physician offices, rural health centers, skilled 
nursing facilities, or other entities that participate separately under 
Medicare, or restaurants, shops, or other nonmedical facilities.
    Hospital with an emergency department means a hospital that offers 
services for emergency medical conditions (as defined in this paragraph 
(b)) within its capability to do so, including a hospital that offers 
these services at locations other than its main hospital campus.
* * * * *
    Patient, for purposes of this section, means an individual who is 
either an outpatient as defined in Sec. 410.2 of this chapter, or is 
receiving inpatient hospital services as defined in Sec. 409.10(b) of 
this chapter.
* * * * *

[[Page 31507]]

    (c) Use of dedicated emergency department for nonemergency 
services. If an individual comes to a hospital's dedicated emergency 
department and a request is made on his or her behalf for examination 
or treatment for a medical condition, but the nature of the request 
makes it clear that the medical condition is not of an emergency 
nature, the hospital is required only to perform such screening as 
would be appropriate for any individual presenting in that manner, to 
determine that the individual does not have an emergency medical 
condition.
    (d) Necessary stabilizing treatment for emergency medical 
conditions.--(1) General. If any individual (whether or not eligible 
for Medicare benefits) comes to a hospital and the hospital determines 
that the individual has an emergency medical condition, the hospital 
must provide either--
    (i) Within the capabilities of the staff and facilities available 
at the hospital, for further medical examination and treatment as 
required to stabilize the medical condition; or
    (ii) For transfer of the individual to another medical facility in 
accordance with paragraph (e) of this section.
    (2) Application to inpatients--admitted emergency patients.
    (i) When an individual has been screened under paragraph (a) of 
this section and found to have an emergency medical condition, and the 
individual has not been stabilized as defined in paragraph (b) of this 
section, the provisions of this section would apply, even if the 
hospital admits the patient as an inpatient. Admitting an individual 
whose emergency medical condition has not been stabilized does not 
relieve the hospital of further responsibility to the individual under 
this section.
    (ii) If a hospital admits an individual with an unstable emergency 
medical condition for stabilizing treatment, as an inpatient, 
stabilizes that individual's emergency medical condition, and this 
period of stability is documented by relevant clinical data in the 
individual's medical record, the hospital has satisfied its special 
responsibilities under this section with respect to that individual. If 
the patient is stable for a transfer of the type usually undertaken 
with respect to patients having the same medical conditions, the 
hospital's special responsibilities under this section are satisfied, 
even if no transfer occurs and the individual remains at the hospital 
as an inpatient for followup care. If, after stabilization, the 
individual who was admitted as an inpatient again has an apparent 
decline of his or her medical condition, either as a result of the 
injury or illness that created the emergency for which he or she 
initially came to the dedicated emergency department or as a result of 
another injury or illness, the hospital must comply with the conditions 
of participation for hospitals under part 482 of this chapter but has 
no further responsibility under this section with respect to the 
individual.
    (iii) A hospital has no responsibility under this section with 
respect to an inpatient who was admitted for elective (nonemergency) 
diagnosis or treatment. If such an inpatient has an abrupt 
deterioration of his or her medical condition after admission, the 
hospital must comply with the conditions of participation for hospitals 
under part 482 of this chapter and is not required to comply with the 
special responsibilities of this section.
    (3) Refusal to consent to treatment. A hospital meets the 
requirements of paragraph (d)(1)(i) of this section with respect to an 
individual if the hospital offers the individual the further medical 
examination and treatment described in that paragraph and informs the 
individual (or a person acting on the individual's behalf) of the risks 
and benefits to the individual of the examination and treatment, but 
the individual (or a person acting on the individual's behalf) refuses 
to consent to the examination and treatment. The medical record must 
contain a description of the examination, treatment, or both if 
applicable, that was refused by or on behalf of the individual. The 
hospital must take all reasonable steps to secure the individual's 
written informed refusal (or that of the person acting on his or her 
behalf). The written document should indicate that the person has been 
informed of the risks and benefits of the examination or treatment, or 
both.
    (4) Delay in examination or treatment. (i) A participating hospital 
may not delay providing an appropriate medical screening examination 
required under paragraph (a) of this section or further medical 
examination and treatment required under paragraphs (d)(1) and (d)(2) 
of this section in order to inquire about the individual's method of 
payment or insurance status.
    (ii) A participating hospital may not seek, or direct a patient to 
seek, authorization from the individual's insurance company for 
screening or stabilization services to an individual until after the 
hospital has provided the appropriate medical screening examination 
required under paragraph (a) of this section, and initiated any further 
medical examination and treatment that may be required to stabilize the 
emergency medical condition under paragraphs (d)(1) and (d)(2) of this 
section.
    (iii) An emergency physician is not precluded from contacting the 
patient's physician at any time to seek advice regarding the patient's 
medical history and needs that may be relevant to the medical treatment 
and screening of the patient, as long as this consultation does not 
inappropriately delay services required under paragraph (a) or 
paragraphs (d)(1) and (d)(2) of this section.
    (5) Refusal to consent to transfer. A hospital meets the 
requirements of paragraph (d)(1)(ii) of this section with respect to an 
individual if the hospital offers to transfer the individual to another 
medical facility in accordance with paragraph (e) of this section and 
informs the individual (or a person acting on his or her behalf) of the 
risks and benefits to the individual of the transfer, but the 
individual (or a person acting on the individual's behalf) refuses to 
consent to the transfer. The hospital must take all reasonable steps to 
secure the individual's written informed refusal (or that of a person 
acting on his or her behalf). The written document must indicate the 
person has been informed of the risks and benefits of the transfer and 
state the reasons for the individual's refusal. The medical record must 
contain a description of the proposed transfer that was refused by or 
on behalf of the individual.
    (6) Hospital responsibility for communication with Medicare+Choice 
organizations after stabilization of an emergency medical condition. 
When an enrollee of a Medicare+Choice organization who is treated for 
an emergency medical condition is stabilized and needs further hospital 
care, the hospital must promptly contact the Medicare+Choice 
organization to obtain preapproval of the further hospital care, 
consistent with the provisions of Sec. 422.113 of this chapter.
* * * * *
    (j) Availability of on-call physicians. Each hospital must maintain 
an on-call list of physicians on its medical staff in a manner that 
best meets the needs of the hospital's patients. Physicians, including 
specialists and subspecialists, are not required to be on call at all 
times. The hospital must have written policies and procedures in place 
to respond to situations in which a particular specialty is not 
available or the on-call physician cannot respond because of 
circumstances beyond the physician's control.

(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance)



[[Page 31508]]


    Dated: April 24, 2002.
Thomas A. Scully,
Administrator, Centers for Medicare & Medicaid Services.
    Dated: April 26, 2002.
Tommy G. Thompson,
Secretary.

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

Addendum--Proposed Schedule of Standardized Amounts Effective with 
Discharges Occurring On or After October 1, 2002 and Update Factors and 
Rate-of-Increase Percentages Effective With Cost Reporting Periods 
Beginning On or After October 1, 2002

I. Summary and Background

    In this Addendum, we are setting forth the proposed amounts and 
factors for determining prospective payment rates for Medicare 
hospital inpatient operating costs and Medicare hospital inpatient 
capital-related costs. We are also setting forth proposed rate-of-
increase percentages for updating the target amounts for hospitals 
and hospital units excluded from the acute care hospital inpatient 
prospective payment system.
    For discharges occurring on or after October 1, 2002, except for 
SCHs, MDHs, and hospitals located in Puerto Rico, each hospital's 
payment per discharge under the acute care hospital inpatient 
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 costs per discharge; 
the updated hospital-specific rate based on FY 1987 costs per 
discharge; or 75 percent of the updated hospital-specific rate based 
on FY 1996 costs per discharge, plus the greater of 25 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 costs 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 
costs 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 
proposing to make changes in the determination of the prospective 
payment rates for Medicare inpatient operating costs for FY 2003. 
The changes, to be applied prospectively effective with discharges 
occurring on or after October 1, 2002, would affect the calculation 
of the Federal rates. In section III. of this Addendum, we discuss 
our proposed changes for determining the prospective payment rates 
for Medicare inpatient capital-related costs for FY 2003. Section 
IV. of this Addendum sets forth our proposed changes for determining 
the rate-of-increase limits for hospitals excluded from the 
prospective payment system for FY 2003. The tables to which we refer 
in the preamble to this final rule are presented at the end of this 
Addendum in section V.

II. Proposed Changes to Prospective Payment Rates for Hospital 
Inpatient Operating Costs for FY 2003

    The basic methodology for determining prospective payment rates 
for hospital inpatient operating costs is set forth at Sec. 412.63. 
The basic methodology for determining the prospective payment rates 
for hospital 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.
    In summary, the proposed standardized amounts set forth in 
Tables 1A and 1C of section V. 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 the proposed DRG recalibration 
and wage index update and changes are budget neutral, 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 the effects of geographic 
reclassification are budget neutral, as provided for in section 
1886(d)(8)(D) of the Act, by removing the FY 2002 budget neutrality 
factor and applying a revised factor;
     An adjustment to apply the new outlier offset by 
removing the FY 2002 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) 
contained a detailed explanation of how base-year cost data were 
established in the initial development of standardized amounts for 
the acute care hospital inpatient prospective payment system.
    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 require 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 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 acute care hospital inpatient 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 acute care 
hospital inpatient prospective payment system. As discussed in 
section IV. of the preamble to this proposed rule, we are proposing 
to revise the labor share of the standardized amount (the proportion 
adjusted by the wage index) to be 72.5 percent. The average labor 
share in Puerto Rico is 71.3 percent. We are proposing to revise the 
discharge-weighted national standardized amount for Puerto Rico to 
reflect the proportion of discharges in large urban and other areas 
from the FY 2001 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

[[Page 31509]]

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 the latest available population estimates published by 
the Bureau of the Census, 63 areas meet the criteria to be defined 
as large urban areas for FY 2003. 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 proposing to update the large 
urban areas' and the other areas' average standardized amounts for 
FY 2003 using the applicable percentage increases specified in 
section 1886(b)(3)(B)(i) of the Act. Section 1886(b)(3)(B)(i)(XVIII) 
of the Act specifies that the update factor for the standardized 
amounts for FY 2003 is equal to the market basket percentage 
increase minus 0.55 percentage points for hospitals in all areas.
    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 2003 is 3.3 percent. Thus, for FY 
2003, 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 2002 standardized 
amounts to remove the effects of the FY 2002 geographic 
reclassifications and outlier payments before applying the FY 2003 
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 2003.
    Although the update factors for FY 2003 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 2003 for both 
prospective payment hospitals and hospitals excluded from the 
prospective payment system. For general information purposes, we 
have included the report to Congress as Appendix B to this proposed 
rule. Our proposed recommendation on the update factors (which is 
required by sections 1886(e)(4)(A) and (e)(5)(A) of the Act) is set 
forth as Appendix C to this proposed 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. However, 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 payments to hospitals are affected by 
factors other than average case weight. Therefore, as we have done 
in past years, we are proposing to make a budget neutrality 
adjustment to ensure that the requirement of section 
1886(d)(4)(C)(iii) of the Act is met.
    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.
    We note, however, that 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. This provision is 
required by section 4410(b) of Public Law 105-33 to be budget 
neutral.
    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 2001 discharge data to simulate payments and 
compared aggregate payments using the FY 2002 relative weights and 
wage index to aggregate payments using the proposed FY 2003 relative 
weights and wage index. The same methodology was used for the FY 
2002 budget neutrality adjustment. Based on this comparison, we 
computed a proposed budget neutrality adjustment factor equal to 
1.001026. 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 1.002689. These budget 
neutrality adjustment factors are applied to the standardized 
amounts without removing the effects of the FY 2002 budget 
neutrality adjustments. 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 are proposing to apply these same adjustment 
factors to the hospital-specific rates that are effective for cost 
reporting periods beginning on or after October 1, 2002. (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 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 acute care hospital inpatient 
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 2001 discharge data to simulate payments, and compared 
total prospective payments (including IME and DSH payments) prior to 
any reclassifications to total prospective payments after 
reclassifications. Based on these simulations, we are applying a 
proposed adjustment factor of 0.990536 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 2002 budget neutrality 
adjustment factor. We note that the proposed FY 2003 adjustment 
reflects wage index and standardized amount reclassifications 
approved by the MGCRB or the Administrator as of February 28, 2002, 
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 occur as a result of appeals and 
reviews of the MGCRB decisions for FY 2003 or from a hospital's 
request for the withdrawal of a reclassification request for FY 2003 
will be reflected in the final budget neutrality adjustment required 
under section 1886(d)(8)(D) of the Act and published in the final 
rule for FY 2003.

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). To 
qualify for outlier payments, a case must have costs above a 
threshold amount. To determine whether the costs of a case exceed 
the threshold, a hospital's cost-to-charge ratio is applied to the 
total covered charges for the case to convert the charges to costs. 
Payments for eligible cases are then made based on a marginal cost 
factor, which is a percentage of the costs above the threshold.
    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 operating DRG payments plus outlier 
payments. Section 1886(d)(3)(B) of the Act requires the Secretary to 
reduce 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

[[Page 31510]]

1886(d)(9)(B)(iv) of the Act requires the Secretary to reduce 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.
    i. FY 2003 outlier thresholds. For FY 2002, the threshold was 
equal to the prospective payment rate for the DRG plus any IME and 
DSH payments plus $21,025. 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 2003, we are proposing to establish a fixed loss cost 
outlier threshold equal to the prospective payment rate for the DRG 
plus any IME and DSH payments, and any add-on payments for new 
technology, plus $33,450. This single threshold would be applicable 
to qualify for both operating and capital outlier payments. We are 
proposing to maintain the marginal cost factor for cost outliers at 
80 percent.
    To calculate the proposed FY 2003 outlier thresholds, we 
simulated payments by applying proposed FY 2003 rates and policies 
to the December 2001 update of the FY 2001 MedPAR file and the 
December 2001 update of the Provider-Specific File. Therefore, it is 
necessary to inflate the charges on the MedPAR claims by 2 years.
    Previously, inflation factors have been calculated by measuring 
the percent change in costs using the two most recent available cost 
report files. For example, the FY 2002 threshold was determined 
using the rate of cost increase measured using costs from hospitals' 
FY 1998 and FY 1999 cost reports. However, at the time of this 
proposed rule, the FY 2000 cost reports are not available to produce 
an updated cost inflation factor due to processing delays associated 
with implementing the hospital outpatient prospective payment 
system.
    Rather than use the rate of cost increase from hospitals' FY 
1998 and FY 1999 cost reports to project the rate of increase from 
FY 2001 to FY 2003, we are proposing to use a 3-year moving average 
of the rate of change in prior years to estimate the annual rates of 
increase from FY 2001 to FY 2003. The calculation is shown in the 
table below.
    For example, the rate of change in cost per case from 1998 to 
1999 was 1.0242 percent. This rate of change is then subtracted by 
the rate of change from 1997 to 1998 (1.0237) to calculate a 
difference in change of 0.005. A 3-year average of the annual rates 
of change was then computed based on the difference in the percent 
changes from the 3 most recent prior years. The difference in change 
for 1997 to 1998 is then averaged with the differences for 1996 to 
1997, and for 1995 to 1996, to calculate a 3-year average of 0.0180. 
To project percent changes in costs for FY 2000 through FY 2003, the 
average of the differences in the percent changes for the 3 most 
recent years (0.0180) was added to the percent change in cost per 
case for the previous year (1.0242) to estimate the percent change 
in costs between fiscal years. This proposed methodology resulted in 
an estimated change of 1.066 (6.6 percent increase) for FY 2001 to 
FY 2002 and 1.079 (7.9 percent increase) for FY 2002 to FY 2003.

----------------------------------------------------------------------------------------------------------------
                                                                                                        3-year
                                                                             Rate of                    moving
                  Cost reports begin in FY                     Cost/case    change in    Difference   average of
                                                                             cost per    in change   differences
                                                                               case                    in change
----------------------------------------------------------------------------------------------------------------
1995........................................................      5818.50  ...........  ...........  ...........
1996........................................................      5644.52       0.9701  ...........  ...........
1997........................................................      5666.03       1.0038       0.0337  ...........
1998........................................................      5800.34       1.0237       0.0199  ...........
1999........................................................      5940.85       1.0242       0.0005  ...........
2000........................................................  ...........       1.0423       0.0180       0.0180
2001........................................................  ...........       1.0551       0.0128       0.0128
2002........................................................  ...........       1.0655       0.0105       0.0105
2003........................................................  ...........       1.0793       0.0138       0.0138
----------------------------------------------------------------------------------------------------------------

    Based on this proposed methodology, we are proposing a 2-year 
cost inflation factor of 15.0 percent to inflate FY 2001 charges to 
FY 2003, determined by multiplying the annual projected inflation 
factors for FYs 2002 and 2003 of 1.0655 and 1.0793.
    Using FY 2001 cases now available, our analysis indicates that 
this 3-year moving average methodology would have resulted in FY 
2002 outlier payments very close to 5.1 percent of total operating 
DRG payments and outlier payments (the current projection of FY 2002 
outlier payments is 6.8 percent of total DRG and outlier payments--
see discussion below). We intend to update our analysis of FY 2002 
outlier payments using actual FY 2002 claims available through March 
2002 prior to publishing the final rule by August 1.
    We want to emphasize that we are making this proposal due to the 
unavailability of the FY 2000 cost reports. If the proposed 
methodology is ultimately adopted in the final rule for FY 2003, 
this would not necessarily mean that we would apply the same 
methodology in future fiscal years when updated cost report 
information becomes available.
    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 operating DRG payments plus outlier payments. In 
accordance with section 1886(d)(3)(B), we reduced the proposed FY 
2003 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 hospital 
inpatient operating costs and hospital 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 proposed thresholds 
for FY 2003 would result in outlier payments equal to 5.1 percent of 
operating DRG payments and 5.4 percent of capital payments based on 
the Federal rate.
    The proposed outlier adjustment factors to be applied to the 
standardized amounts for FY 2003 are as follows:

------------------------------------------------------------------------
                                             Operating
                                           standardized       Capital
                                              amounts      Federal rate
------------------------------------------------------------------------
National................................        0.949004        0.945957
Puerto Rico.............................        0.982910        0.980994
------------------------------------------------------------------------

    We apply the outlier adjustment factors after removing the 
effects of the FY 2002 outlier adjustment factors on the 
standardized amounts.
    To determine whether a case qualifies for outlier payments, we 
apply hospital-specific cost-to-charge ratios to the total covered 
charges for the case. Operating and capital costs for the case are 
calculated separately by applying separate operating and capital 
cost-to-charge ratios, then these costs are combined to compare with 
the fixed-loss outlier threshold.
    For those hospitals for which the fiscal intermediary computes 
operating cost-to-charge ratios lower than 0.200 or greater than 
1.262, or capital cost-to-charge ratios lower than 0.012 or greater 
than 0.167, statewide average ratios would be used to calculate 
costs to determine whether a hospital qualifies for outlier 
payments.\1\ Table 8A in section V. of this Addendum contains the 
proposed statewide average operating cost-to-charge ratios for urban 
hospitals and for rural hospitals for which the fiscal intermediary 
is unable to compute a hospital-specific cost-to-charge ratio within 
the above range. These statewide average ratios would replace the

[[Page 31511]]

ratios published in the August 1, 2001 final rule (66 FR 40083). 
Table 8B contains comparable statewide average capital cost-to-
charge ratios. We note that the cost-to-charge ratios in Tables 8A 
and 8B would be used during FY 2003 when hospital-specific cost-to-
charge ratios based on the latest settled cost report are either not 
available or are outside the three standard deviations range.
---------------------------------------------------------------------------

    \1\ 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.
---------------------------------------------------------------------------

    iii. FY 2001 and FY 2002 outlier payments. In the August 1, 2001 
final rule (66 FR 39942), we stated that, based on available data, 
we estimated that actual FY 2001 outlier payments would be 
approximately 6.2 percent of actual total DRG payments. This was 
computed 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). That is, the 
estimate of actual outlier payments did not reflect actual FY 2001 
bills but instead reflected the application of FY 2001 rates and 
policies to available FY 2000 bills.
    Our current estimate, using available FY 2001 bills, is that 
actual outlier payments for FY 2001 were approximately 7.6 percent 
of actual total DRG payments. Thus, the data indicate that, for FY 
2001, the percentage of actual outlier payments relative to actual 
total payments is higher than we projected before FY 2001 (and thus 
exceeds the percentage by which we reduced the standardized amounts 
for FY 2001). Nevertheless, consistent with the policy and statutory 
interpretation we have maintained since the inception of the acute 
care hospital inpatient prospective payment system, we do not plan 
to recoup money and make retroactive adjustments to outlier payments 
for FY 2001. We note that the MedPAR file for FY 2001 discharges 
continues to be updated, and we will update our estimate of actual 
FY 2001 outlier payments as a percentage of total payments in the 
final rule.
    We currently estimate that actual outlier payments for FY 2002 
will be approximately 6.8 percent of actual total DRG payments, 1.7 
percentage points higher than the 5.1 percent we projected in 
setting outlier policies for FY 2002. This estimate is based on 
simulations using the December 2001 update of the Provider-Specific 
File and the December 2001 update of the FY 2001 MedPAR file 
(discharge data for FY 2001 bills). We used these data to calculate 
an estimate of the actual outlier percentage for FY 2002 by applying 
FY 2002 rates and policies to available FY 2001 bills.

5. FY 2003 Standardized Amounts

    The adjusted standardized amounts are divided into labor and 
nonlabor portions. Table 1A contains the two national standardized 
amounts that we are proposing to be applicable to all hospitals, 
except hospitals in Puerto Rico. As described in section II.A.1. of 
this Addendum, we are proposing to revise the labor share of the 
national standardized amount from 71.1 percent to 72.5 percent.
    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. The labor 
share applied to the Puerto Rico standardized amount is 71.3 
percent.

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 are proposed to 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 proposed 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 
national and Puerto Rico prospective payment rates, respectively, 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 proposed FY 
2003 wage index. The proposed wage index is set forth in Tables 4A, 
4B, 4C, and 4F of this Addendum. In section IV. of this preamble we 
discuss our proposed revised estimate of the labor-related portion 
of the standardized amounts.

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 2003, we are proposing to adjust 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. If the Office of Personnel Management releases 
revised cost-of-living adjustment factors before July 1, 2002, we 
will publish them in the final rule and use them in determining FY 
2003 payments.

 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 V. of this Addendum 
contains the relative weights that we are proposing to use for 
discharges occurring in FY 2003. These factors have been 
recalibrated as explained in section II. of the preamble.

D. Calculation of Prospective Payment Rates for FY 2003

General Formula for Calculation of Prospective Payment Rates for FY 
2003

    The operating prospective payment rate for all hospitals paid 
under the acute-care, short-term inpatient prospective payment 
system located outside of Puerto Rico, except SCHs and MDHs, equals 
the Federal rate based on the amounts in Table 1A.
    For FY 2003, 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, 75 percent of 
the updated hospital-specific rate based on FY 1996 cost per 
discharge, plus the greater of 25 percent of the updated FY 1982 or 
FY 1987 hospital-specific rate, or 25 percent of the Federal rate. 
Section 1886(b)(3) of the Act, as amended, allows 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 proposed prospective payment rate for Puerto Rico equals 50 
percent of the Puerto Rico rate plus 50 percent of the national rate 
from Table 1C.

1. Federal Rate

    For discharges occurring on or after October 1, 2002 and before 
October 1, 2003, except for SCHs, MDHs, and hospitals in Puerto 
Rico, payment under the acute-care inpatient prospective payment 
system 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 location of the hospital (large urban or other) (see 
Table 1A in section V. 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 or the area to which the hospital is 
reclassified (see Tables 4A, 4B, and 4C of section V. of this 
Addendum).
    Step 3--For hospitals in Alaska and Hawaii, multiply the 
nonlabor-related

[[Page 31512]]

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 
V. of this Addendum).

2. Hospital-Specific Rate (Applicable Only to SCHs and MDHs)

a. Calculation of Hospital-Specific Rate

    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 costs per discharge, the updated hospital-
specific rate based on FY 1987 costs per discharge, or, for FY 2003, 
75 percent of the updated hospital-specific rate based on FY 1996 
costs per discharge, plus the greater of 25 percent of the updated 
FY 1982 or FY 1987 hospital-specific rate or 25 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 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). In 
addition, for both SCHs and MDHs, the hospital-specific rate is 
adjusted by the budget neutrality adjustment factor (that is, by 
1.001026) 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 
would be paid for its discharges beginning on or after October 1, 
2002.

b. Updating the FY 1982, FY 1987, and FY 1996 Hospital-Specific Rates 
for FY 2003

    We are proposing to increase 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 2003. 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 2003, 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 2003, is the market 
basket rate of increase minus 0.55 percentage points.

3. General Formula for Calculation of Prospective Payment Rates for 
Hospitals Located in Puerto Rico Beginning On or After October 1, 2002 
and Before October 1, 2003

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 V. 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 V. 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 V. 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 V. 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. Proposed Changes to Payment Rates for Acute Care Hospital 
Inpatient Capital-Related Costs for FY 2003

    The prospective payment system for acute care 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, acute care hospital inpatient capital-related costs 
were 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 in regulations at Secs. 412.308 
through 412.352. Below we discuss the factors that we are proposing 
to use to determine the capital Federal rate for FY 2003, which will 
be effective for discharges occurring on or after October 1, 2002. 
The 10-year transition period ended with hospital cost reporting 
periods beginning on or after October 1, 2001 (FY 2002). Therefore, 
for cost reporting periods beginning in FY 2002, all hospitals 
(except ``new'' hospitals under Sec. 412.324(b) and under proposed 
Sec. 412.304(c)(2)) are 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. As we explained in section VI.D. of the 
preamble of this proposed rule, 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 during the 10-year 
transition period, we developed a dynamic model of Medicare 
inpatient capital-related costs, that is, a model that projected 
changes in Medicare inpatient capital-related costs over time. With 
the expiration of the budget neutrality provision, the capital cost 
model was only used to estimate the regular exceptions payment 
adjustment and other factors. As we explained in the August 1, 2001 
final rule (66 FR 39911), beginning in FY 2003 an adjustment for 
regular exceptions is no longer necessary because regular exception 
payments were only made for cost reporting periods beginning on or 
after October 1, 1991, and before October 1, 2001 (see 
Sec. 412.348(b)). Since payments are no longer being made under the 
regular exceptions policy in FY 2003, we are no longer using the 
capital cost model. The capital cost model and its application 
during the transition

[[Page 31513]]

period are described in Appendix B of the August 1, 2001 final rule 
(66 FR 40099).
    In accordance with section 1886(d)(9)(A) of the Act, under the 
prospective payment system for acute care hospital 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 acute care hospital 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 Hospital Inpatient Capital-Related 
Prospective Payment Rate Update

    In the August 1, 2001 final rule (66 FR 39947), we established a 
Federal rate of $390.74 for FY 2002. As a result of the changes we 
are proposing to the factors used to establish the Federal rate in 
this addendum, the proposed FY 2003 Federal rate is $408.90.
    In the discussion that follows, we explain the factors that were 
used to determine the proposed FY 2003 Federal rate. In particular, 
we explain why the FY 2003 Federal rate has increased 4.6 percent 
compared to the FY 2002 Federal rate (published in the August 1, 
2001 final rule (66 FR 39947)). We also estimate aggregate capital 
payments will increase by 5.72 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 more than last year (4.27 percent) mostly due 
to the restoration of the 2.1 percent reduction to the capital 
Federal rate (see section VI.D. of the preamble of this proposed 
rule).
    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 2003 compared to FY 2002.

1. Standard Federal Rate Update

a. Description of the Update Framework

    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 (CIPI) and other factors. The 
update framework consists of a 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 update factor for FY 2003 under that framework is 1.1 
percent. This update factor is based on a projected 0.7 percent 
increase in the CIPI, a 1.0 percent adjustment for intensity, a 0.0 
percent adjustment for case-mix, a --0.3 percent adjustment for the 
FY 2001 DRG reclassification and recalibration, and a forecast error 
correction of -0.3 percent. We explain the basis for the FY 2003 
CIPI projection in section III.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 acute care hospital inpatient 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 2001 DRG reclassification and recalibration as 
part of our FY 2003 update recommendation.) We have adopted this 
case-mix index adjustment in the capital update framework as well.
    For FY 2003, we are projecting a 1.0 percent total increase in 
the case-mix index. We estimate that real case-mix increase will 
equal 1.0 percent in FY 2003. Therefore, the net adjustment for 
case-mix change in FY 2003 is 0.0 percentage points.
    We estimate that FY 2001 DRG reclassification and recalibration 
will result in a 0.3 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 -0.3 percent adjustment for DRG 
reclassification and recalibration in the update recommendation for 
FY 2003.
    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 2001 update. That is, current historical data indicate that 
the forecasted FY 2001 CIPI used in calculating the FY 2001 update 
factor (0.9 percent) overstated the actual realized price increases 
(0.6 percent) by 0.3 percentage points. This over-prediction was due 
to prices from municipal bond yields declining faster than 
originally expected. Therefore, we are making a -0.3 percent 
adjustment for forecast error in the update for FY 2003.
    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 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

[[Page 31514]]

increase in intensity to allow for within-DRG severity increases and 
the adoption of quality-enhancing technology.
    For FY 2003, we have developed a Medicare-specific intensity 
measure based on a 5-year average, using FY 1997 through 2001 data. 
In determining case-mix constant intensity, we found that observed 
case-mix increase was 0.3 percent in FY 1997, -0.4 percent in FY 
1998, -0.3 percent in FY 1999, -0.7 in FY 2000, and -0.3 percent in 
FY 2001. Past studies of case-mix change by the RAND Corporation 
(``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)) suggest 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 1997 through 
FY 2001. Since we did not find an increase in case-mix outside of 
the range of 1.0 to 1.4 percent, we believe that all of the observed 
case-mix increase for FYs 1997 through 2001 is real. Therefore, 
there was no need to employ the upper bound of 1.0 and 1.4 supported 
by the RAND study as we have done in the past since we did not find 
an increase in case-mix that 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. We 
estimate that case-mix constant intensity increased by an average of 
1.0 percent during FYs 1997 through 2001, for a cumulative increase 
of 5.2 percent, given estimates of real case-mix of 0.3 percent for 
FY 1997, -0.4 percent for FY 1998, -0.3 percent for FY 1998, -0.7 
percent for FY 2000, and -0.3 percent for FY 2001. Since we estimate 
that intensity has increased during that period, we are recommending 
a 1.0 percent intensity adjustment for FY 2003.
    Above we described the basis of the components used to develop 
the proposed 1.1 percent capital update factor for FY 2003 as shown 
in Table 1 below.

  Table 1.--CMS's Proposed FY 2003 Update Factor to the Capital Federal
                                 Rate--
------------------------------------------------------------------------
 
------------------------------------------------------------------------
Capital Input Price Index.......................................     0.7
Intensity:                                                           1.0
Case-Mix Adjustment Factors:
  Projected Case-Mix Change.....................................    -1.0
  Real Across DRG Change........................................     1.0
                                                                 -------
    Subtotal....................................................     0.0
                                                                 =======
Effect of FY 2001 Reclassification and Recalibration............    -0.3
Forecast Error Correction.......................................    -0.3
                                                                 -------
  Total Proposed Update.........................................     1.1
------------------------------------------------------------------------

b. Comparison of CMS and MedPAC Update Recommendations

    In the past, MedPAC has included an update recommendation for 
capital prospective payment system payments in a Report to Congress. 
In its March 2001 report, MedPAC presented a combined operating and 
capital update for hospital inpatient prospective payment systems 
for FY 2002. Currently, section 1886(b)(3)(B)(i)(XVIII) of the Act 
sets forth the FY 2003 percentage increase in prospective payment 
system operating cost standardized amounts. The prospective payment 
system capital update is set at the discretion of the Secretary 
under the framework outlined in Sec. 412.308(c)(1). In its March 
2002 Report to Congress, MedPAC did not make an update 
recommendation for capital prospective payment system payments. 
MedPAC states that, with the two updates (operating and capital) 
remaining separate, it focused on the operating update since it 
involves more money (92 percent of hospital's Medicare costs) and it 
commands the most attention in Congress (page 65).

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, 2001 final rule, we estimated that outlier 
payments for capital in FY 2002 would equal 5.76 percent of 
inpatient capital-related payments based on the Federal rate (66 FR 
39948). Accordingly, we applied an outlier adjustment factor of 
0.9424 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 5.40 percent of inpatient capital-
related payments based on the Federal rate in FY 2003. Therefore, we 
are proposing an outlier adjustment factor of 0.9460 to the Federal 
rate. Thus, the projected percentage of capital outlier payments to 
total capital standard payments for FY 2003 is lower than the 
percentage for FY 2002.
    The outlier reduction factors are not built permanently into the 
rates; that is, they are not applied cumulatively in determining the 
Federal rate. Therefore, the net proposed change in the outlier 
adjustment to the Federal rate for FY 2003 is 1.0038 (0.9460/
0.9424). The outlier adjustment increases the proposed FY 2003 
Federal rate by 0.38 percent compared with the FY 2002 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.
    Since we implemented a separate geographic adjustment factor for 
Puerto Rico, we apply separate budget neutrality adjustments for the 
national geographic adjustment factor and the Puerto Rico geographic 
adjustment factor. We apply 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.
    In the past, we used the actuarial capital cost model (described 
in Appendix B of the August 1, 2001 final rule (66 FR 40099)) to 
estimate the aggregate payments that would have been made on the 
basis of the Federal rate with and without changes in the DRG 
classifications and weights and in the GAF to compute the adjustment 
required to maintain budget neutrality for changes in DRG weights 
and in the GAF. During the transition period, the capital cost model 
was also used to estimate the regular exceptions payment adjustment 
factor. As we explain below in section III.A.4. of this Addendum, 
beginning in FY 2003 an adjustment for regular exceptions is no 
longer necessary. Therefore, we are no longer using the capital cost 
model. Instead, we are using historical data based on hospitals' 
actual cost experiences to determine the exceptions adjustment 
factor for special exception payments.
    To determine the proposed factors for FY 2003, we compared 
(separately for the national rate and the Puerto Rico rate) 
estimated aggregate Federal rate payments based on the FY 2002 DRG 
relative weights and the FY 2002 GAF to estimated aggregate Federal 
rate payments based on the FY 2003 relative weights and the FY 2003 
GAF. For FY 2002, the budget neutrality adjustment factors were 
0.9927 for the national rate and 0.9916 for the Puerto Rico rate 
(see the August 1, 2001 final rule (66 FR 40101)). In making the 
comparison, we set the regular and special exceptions reduction 
factors to 1.00.
    To achieve budget neutrality for the changes in the national 
GAF, we propose to apply an incremental budget neutrality adjustment 
of 0.9990 for FY 2003 to the previous cumulative FY 2002 adjustment 
of (0.9927), yielding a proposed cumulative adjustment of 0.9917 
through FY 2003. For the Puerto Rico GAF, we propose to apply an 
incremental budget neutrality adjustment of 1.0080 for FY 2003 to 
the previous cumulative FY 2002 adjustment (0.9916), yielding a 
proposed cumulative adjustment of 0.9996 through FY 2003.
    We then compared estimated aggregate Federal rate payments based 
on the FY 2002 DRG relative weights and the FY 2002 GAF to estimated 
aggregate Federal rate payments based on the proposed FY 2003 DRG 
relative weights and the FY 2003 GAF. The proposed incremental 
adjustment for DRG

[[Page 31515]]

classifications and changes in relative weights is 1.0034 nationally 
and for Puerto Rico. The proposed cumulative adjustments for DRG 
classifications and changes in relative weights and for changes in 
the GAF through FY 2003 are 0.9951 nationally and 1.0030 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                                  DRG                                                        DRG
                                      Geographic  reclassifications                Cumulative    Geographic  reclassifications
                                      adjustment         and           Combined                  adjustment         and           Combined    Cumulative
                                        factor      recalibration                                  factor      recalibration
--------------------------------------------------------------------------------------------------------------------------------------------------------
1992...............................  ...........  .................  ...........      1.00000   ...........  .................  ...........  ...........
1993...............................  ...........  .................      0.99800      0.99800   ...........  .................  ...........  ...........
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\ 0.99771     \3\ 1.00009     \3\ 0.99780      0.99922   \3\ 1.00365     \3\ 1.00009     \3\ 1.00374      1.00508
2002...............................  \4\ 0.99666     \4\ 0.99668     \4\ 0.99335      0.99268   \4\ 0.98991     \4\ 0.99668     \4\ 0.99662      0.99164
2003...............................  \5\ 0.99902     \5\ 1.00342     \5\ 1.00244  \5\ 0.99510   \5\ 1.00804     \5\ 1.00342     \5\ 1.01149  \5\ 1.00303
 
--------------------------------------------------------------------------------------------------------------------------------------------------------
\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.
\5\ Proposed factors for FY 2003.

    The methodology used to determine the proposed recalibration and 
geographic (DRG/GAF) budget neutrality adjustment factor for FY 2003 
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 GAF (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, indirect medical education payments, or the large urban 
add-on payments.
    For FY 2002, we calculated a GAF/DRG budget neutrality factor of 
0.9934. For FY 2003, we are proposing a GAF/DRG budget neutrality 
factor of 1.0024. 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. The 
proposed incremental change in the adjustment from FY 2002 to FY 
2003 is 1.0024. The proposed cumulative change in the rate due to 
this adjustment is 0.9951 (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, FY 2002, and the proposed incremental factor for 
FY 2003: 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  x  1.0024 = 
0.9951).
    This proposed factor accounts for DRG reclassifications and 
recalibration and for changes in the GAF. It also incorporates the 
effects on the GAF of FY 2003 geographic reclassification decisions 
made by the MGCRB compared to FY 2002 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 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 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 actuarial 
capital cost model originally developed for determining budget 
neutrality (described in Appendix B of the August 1, 2001 final rule 
(66 FR 40099)) to determine the exception adjustment factor, which 
was applied to both the Federal and hospital-specific rates.
    An adjustment for regular exceptions is no longer necessary in 
determining the proposed FY 2003 capital Federal rate because, in 
accordance with Sec. 412.348(b), regular exception payments were 
only made for cost reporting periods beginning on or after October 
1, 1991 and before October 1, 2001. Accordingly, as we explained in 
the August 1, 2001 final rule (66 FR 39949), in FY 2003 and later, 
no payments will be made under the regular exceptions provision. 
However, in accordance with Sec. 412.308(c), we still need to 
compute a budget neutrality adjustment for special exception 
payments under Sec. 412.348(g). We describe our methodology for 
determining the special exceptions adjustment used in establishing 
the FY 2003 proposed capital Federal rate below.
    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 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 as described at Sec. 412.348(g)(4); (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).
    As we explained in the August 1, 2001 final rule (66 FR 39912 
through 39914), 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

[[Page 31516]]

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 the 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, 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 
estimated project-size by using the fixed capital acquisitions shown 
on Worksheet A7 from the following HCRIS cost reports updated 
through December 2001.

------------------------------------------------------------------------
                                         Cost reports  periods beginning
               PPS year                             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 added together the fixed acquisitions from sequential pairs of 
cost reports to determine project size. Under Sec. 412.348(g)(5), 
the hospital's project cost must be at least $200 million or 100 
percent of its operating cost during the first 12-month cost 
reporting period beginning on or after October 1, 1991. We 
calculated 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 did not 
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 decided to 
model 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 
ignored 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 payment, 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).
    Our modeling of special exception payments for FY 2003 produced 
the following results:

------------------------------------------------------------------------
                                                              Special
                                             Number of     exceptions as
                                             hospitals     a fraction of
               Cost report                 eligible for       capital
                                              special       payments to
                                            exceptions     all hospitals
------------------------------------------------------------------------
PPS IX..................................  ..............  ..............
PPS X...................................  ..............  ..............
PPS XI..................................               2  ..............
PPS XII.................................               6          0.0002
PPS XIII................................               8          0.0001
PPS XIV.................................              16          0.0003
PPS XV..................................              20          0.0011
PPS XVI.................................              28          0.0019
------------------------------------------------------------------------

    We note that 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, and therefore, we 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 could be approximately 
0.0040.
    Because special exceptions are budget neutral, we propose to 
offset the proposed Federal capital rate by 0.40 percent for special 
exceptions for FY 2003. Therefore, the proposed exceptions 
adjustment factor for special exception payments would equal 0.9960 
(1 - 0.0040) to account for special exception payments in FY 2003. 
We will revise this projection of the special exception adjustment 
factor in the final rule based on the latest available data.
    For FY 2002, we estimated that total (regular and special) 
exceptions payments would equal 0.71 percent of aggregate payments 
based on the Federal rate. Therefore, we applied an exceptions 
reduction factor of 0.9929 (1-0.0071) in determining the Federal 
rate. As we stated above, we estimate that exceptions payments for 
FY 2003 will equal 0.40 percent of aggregate payments based on the 
Federal rate. Therefore, we are proposing an exceptions payment 
reduction factor of 0.9960 (1-0.0040) to the Federal rate for FY 
2003. The proposed exceptions reduction factor for FY 2003 is 0.31 
percent higher than the factor for FY 2002 published in the August 
1, 2001 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. Therefore, the proposed net change in 
the exceptions adjustment to the FY 2003 Federal rate is 0.9960/
0.9929, or 1.0031.

5. Special Adjustment To Restore the 2.1 Percent Reduction to the 
Standard Federal Capital Prospective Payment System Payment Rate

    As we explained in section VI.D. of the preamble of this 
proposed rule, section 1886(g)(1)(A) of the Act, as amended by 
section 4402 of Public Law 105-33, requires the Secretary to reduce 
the unadjusted standard Federal capital prospective payment system 
payment rate by 2.1 percent for discharges on or after October 1, 
1997, and through September 30, 2002. Therefore, under the statute 
the additional 2.1 percent reduction no longer applies to discharges 
occurring after September 30, 2002. Accordingly, we are proposing to 
revise Sec. 412.308(b) to restore the 2.1 percent reduction to the 
unadjusted standard Federal capital prospective payment system 
payment rate for discharges occurring on or after October 1, 2002 to 
the level that it would have been without the reduction.
    As we state in section VI.D. of the preamble of this proposed 
rule and in the August 29, 1997 final rule (62 FR 46012), we applied 
a factor of 0.8222 in FY 1998 to account for both the reduction 
equal to the FY 1995 budget neutrality factor (0.1568) and the 2.1 
percent reduction (0.021) provided for under section 4402 of Public 
Law 105-33. In order to determine the adjustment factor needed to 
restore the 2.1 percent reduction, we would divide the amount of the 
adjustment without the 2.1 percent reduction (1- 0.1568 = 0.8432) by 
the amount of the adjustment with the 2.1 percent reduction 
(0.8222). Therefore, we are proposing to apply a factor of 1.02554 
(0.8432/0.8222) to the unadjusted FY 2002 standard Federal capital 
prospective payment system payment rate to restore the 2.1 percent 
reduction for discharges occurring on or after October 1, 2002.

6. Standard Capital Federal Rate for FY 2003

    For FY 2002, the capital Federal rate was $390.74. For FY 2003, 
we are proposing a capital Federal rate of $408.90. The proposed 
Federal rate for FY 2003 was calculated as follows:
     The proposed FY 2003 update factor is 1.0110; that is, 
the update is 1.10 percent.
     The proposed FY 2003 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 1.0024.
     The proposed FY 2003 outlier adjustment factor is 
0.9460.
     The proposed FY 2003 exceptions payments adjustment 
factor is 0.9960.
     The proposed special adjustment factor for FY 2003 to 
restore the 2.1 percent reduction to the standard Federal rate is 
1.0255.

[[Page 31517]]

    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 are proposing to make 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 proposed 
factors and adjustments for FY 2003 affected the computation of the 
proposed FY 2003 Federal rate in comparison to the FY 2002 Federal 
rate. The proposed FY 2003 update factor has the effect of 
increasing the Federal rate by 1.10 percent compared to the FY 2002 
Federal rate, while the proposed geographic and DRG budget 
neutrality factor has the effect of increasing the Federal rate by 
0.24 percent. The proposed FY 2003 outlier adjustment factor has the 
effect of increasing the Federal rate by 0.38 percent compared to 
the FY 2002 Federal rate. The proposed FY 2003 exceptions reduction 
factor has the effect of increasing the Federal rate by 0.31 percent 
compared to the exceptions reduction for FY 2002. The proposed 
special adjustment factor for FY 2003 to restore the 2.1 percent 
reduction to the standard Federal rate has the effect of increasing 
the Federal rate by 2.55 percent compared to the FY 2002 Federal 
rate. The combined effect of all the proposed changes is to increase 
the Federal rate by 4.65 percent compared to the FY 2002 Federal 
rate.

          Comparison of Factors and Adjustments: FY 2002 Federal Rate and Proposed FY 2003 Federal Rate
----------------------------------------------------------------------------------------------------------------
                                                                           Proposed FY                 Percent
                                                                FY 2002        2003        Change       change
----------------------------------------------------------------------------------------------------------------
Update factor \1\...........................................       1.0130       1.0110       1.0110         1.10
GAF/DRG Adjustment Factor \1\...............................       0.9934       1.0024       1.0024         0.24
Outlier Adjustment Factor \2\...............................       0.9424       0.9460       1.0038         0.38
Exceptions Adjustment Factor \2\............................       0.9929       0.9960       1.0031         0.31
Special Adjustment \3\......................................          N/A       1.0255       1.0255         2.55
Federal Rate................................................      $390.74      $408.90       1.0465        4.65
----------------------------------------------------------------------------------------------------------------
\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 2002 to FY 2003 resulting from the application of the 1.0024 GAF/DRG
  budget neutrality factor for FY 2003 is 1.0024.
\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 2003 outlier reduction factor is 0.9460/0.9424, or 1.0038.
\3\ Section 1886(g)(1)(A) of the Act requires, for discharges on or after October 1, 1997, and through September
  30, 2002, the Secretary to reduce the unadjusted standard Federal capital prospective payment system payment
  rate by 2.1 percent. Thus, the 2.1 percent reduction no longer applies to discharges occurring after September
  30, 2002, and we are proposing to restore the 2.1 percent reduction by applying a factor of 1.0255 (see
  section VI.D. of the preamble of this proposed rule).

7. 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. As we stated in section III.A.4. of 
this Addendum, for Puerto Rico the proposed GAF budget neutrality 
factor is 1.0080, while the proposed DRG adjustment is 1.0034, for a 
proposed combined cumulative adjustment of 1.0115.
    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 2002, before application of the GAF, the special rate for 
Puerto Rico hospitals was $187.73. With the changes we are proposing 
to the factors used to determine the rate, the proposed FY 2003 
special rate for Puerto Rico is $199.70.

B. Calculation of Inpatient Capital-Related Prospective Payments 
for FY 2003

    With the end of the capital prospective payment system 
transition period in FY 2001, all hospitals (except ``new'' 
hospitals under Sec. 412.324(b) and under proposed 
Sec. 412.304(c)(2)) are paid based on 100 percent of the Federal 
rate in FY 2003. 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 2003, 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 
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. The outlier thresholds for FY 2003 are in 
section II.A.4.c. of this Addendum. For FY 2003, 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 $33,450.
    An eligible hospital may also 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 as 
described at Sec. 412.348(g)(4); 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 or qualify 
for DSH payments under Sec. 412.106(c)(2), 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

[[Page 31518]]

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. 
Under Sec. 412.348(g)(6), the minimum payment level is 70 percent 
for all eligible hospitals.
    During the transition period, new hospitals (as defined under 
Sec. 412.300) were exempt 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. Effective with the 
third year of operation through the remainder of the transition 
period, under Sec. 412.324(b) we paid the hospital under the 
appropriate transition methodology. If the hold-harmless methodology 
was 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. As discussed in 
section VI.B. of the preamble of this proposed rule, we are 
proposing under Sec. 412.304(c)(2) to pay new hospitals 85 percent 
of their reasonable costs during the first 2 years of operation. 
Effective with the third year of operation through the remainder of 
the transition period, we would pay the hospital based on 100 
percent of the capital Federal (that is, the same methodology used 
to pay all other hospitals subject to capital prospective payment 
system).

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.
    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. The CIPI was last rebased to FY 
1992 in the August 30, 1996 final rule (61 FR 46196). In this 
proposed rule, we are proposing to revise and rebase the CIPI to a 
FY 1997 base year to reflect the more recent structure of capital 
costs. For further details on the proposed rebasing and revision of 
the CIPI, see section IV.B. of this proposed rule.

2. Forecast of the CIPI for Federal Fiscal Year 2003

    We are forecasting the proposed CIPI to increase 0.7 percent for 
FY 2003. This reflects a projected 1.3 percent increase in vintage-
weighted depreciation prices (building and fixed equipment, and 
movable equipment) and a 2.7 percent increase in other capital 
expense prices in FY 2003, partially offset by a 2.2 percent decline 
in vintage-weighted interest rates in FY 2003. The weighted average 
of these three factors produces the 0.7 percent increase for the 
CIPI as a whole.

IV. Proposed 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 acute care hospital inpatient 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).
    Under existing Sec. 413.40(c)(4)(iii)(B), for cost reporting 
periods beginning and during FYs 1998 and through 2002, 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 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 hospitals 
for hospitals and hospital 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.
    Under existing Secs. 413.40(c)(4)(ii) and (d)(1)(i) and (ii), 
effective for cost reporting periods beginning during FY 2003, 
payments to existing excluded hospitals and hospital units will no 
longer be subject to a 75th percentile cap. These excluded hospitals 
and hospital units will be paid based on their aggregate Medicare 
inpatient operating costs, which may not exceed their ceiling. The 
ceiling on a hospital's or hospital unit's aggregate Medicare 
inpatient operating costs would be computed using the hospital's or 
hospital unit's target amount from the previous cost reporting 
period updated using the rate-of-increase percentage specified in 
Sec. 413.40(c)(3)(viii) and multiplied by the total number of 
Medicare discharges.
    Section 1886(b)(3)(B) of the Act, as implemented in regulations 
at Sec. 413.40(c)(3)(viii), provides that, for cost reporting 
periods beginning on or after October 1, 2002, the update factor for 
a hospital or hospital unit is the percentage increase projected by 
the hospital market basket index. The most recent proposed projected 
forecast of the market basket percentage increase for FY 2003 for 
hospitals and hospital units excluded from the acute care hospital 
inpatient prospective payment system is 3.4 percent. This proposed 
percentage change is made by CMS'' Office of the Actuary and 
reflects the average change in the price of goods and services 
purchased by hospitals to furnish inpatient hospital care. 
Therefore, we are proposing that the update to a hospital's target 
amount for its cost reporting period beginning in FY 2003 would be 
3.4 percent.
    As discussed in section VII. of the preamble of this proposed 
rule, we are proposing to make an adjustment to the updated cap on 
the target amounts per discharge for each class of new excluded 
hospitals and hospital units for cost reporting periods beginning 
during FY 2003, using the prospective payment system wage index 
without taking into account the reclassifications under sections 
1886(d)(8)(B) and (d)(10) of the Act. 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.
    Regulations at Sec. 413.40(f)(2)(ii) specify the payment 
methodology for new hospitals and hospital units, effective October 
1, 1997.
    For cost reporting periods beginning in FY 2003, the proposed 
caps are as follows:

------------------------------------------------------------------------
                                                  FY 2003      FY 2003
                                                  proposed     proposed
      Class of excluded hospital or unit           labor-     nonlabor-
                                                  related      related
                                                   share        share
------------------------------------------------------------------------
Psychiatric...................................       $7,047       $2,801
Long-Term Care................................       17,269        6,866
------------------------------------------------------------------------

    Effective for cost reporting periods beginning on or after 
October 1, 2002, this payment limitation is no longer applicable to 
new rehabilitation hospitals and units since they will be paid under 
the inpatient rehabilitation facility prospective payment system.
    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.

V. Tables

    This section contains the tables referred to throughout the 
preamble to this proposed rule and in this Addendum. For purposes of 
this proposed rule, and to avoid confusion, we have retained the 
designations of Tables 1 through 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, 8B, 9, and 10 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

[[Page 31519]]

Table 1D--Capital Standard Federal Payment Rate
Table 2--Hospital Average Hourly Wage for Federal Fiscal Years 2001 
(1997 Wage Data), 2002 (1998 Wage Data), and 2003 (1999 Wage Data) 
Wage Indexes and 3-Year Average of Hospital Average Hourly Wages
Table 3A--3-Year Average Hourly Wage for Urban Areas
Table 3B--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 2001 MedPAR Update 12/01 GROUPER V19.0
Table 7B--Medicare Prospective Payment System Selected Percentile 
Lengths of Stay FY 2001 MedPAR Update 12/01 GROUPER V20.0
Table 8A--Statewide Average Operating Cost-to-Charge Ratios for 
Urban and Rural Hospitals (Case Weighted) March 2002
Table 8B--Statewide Average Capital Cost-to-Charge Ratios (Case 
Weighted) March 2002
Table 9--Hospital Reclassifications and Redesignations by Individual 
Hospital--FY 2003
Table 10--Mean and Standard Deviations by Diagnosis-Related Groups 
(DRGs)--FY 2003

   Table 1A.--National Adjusted Operating Standardized Amounts, Labor/
                                Nonlabor
------------------------------------------------------------------------
          Large urban areas                       Other areas
------------------------------------------------------------------------
  Labor-related     Nonlabor-related    Labor-related   Nonlabor-related
------------------------------------------------------------------------
      $3,099.62          $1,175.71          $3,050.55         $1,157.10
------------------------------------------------------------------------


               Table 1C.--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor
----------------------------------------------------------------------------------------------------------------
                                                         Large Urban Areas                  Other Areas
                                                 ---------------------------------------------------------------
                                                       Labor         Nonlabor          Labor         Nonlabor
----------------------------------------------------------------------------------------------------------------
National........................................       $3,073.03       $1,165.63       $3,073.03       $1,165.63
Puerto Rico.....................................        1,475.56          593.94        1,452.19          584.54
----------------------------------------------------------------------------------------------------------------


            Table 1D.--Capital Standard Federal Payment Rate
------------------------------------------------------------------------
                                                               Rate
------------------------------------------------------------------------
National................................................         $408.90
Puerto Rico.............................................         $199.70
------------------------------------------------------------------------

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

** Based on the sum of the salaries and hours computed for Federal FYs 
2001, 2002, and 2003.

[[Page 31519]]



Table 2.--Hospital Average Hourly Wage for Federal Fiscal Years 2001 (1997 Wage Data), 2002 (1998 Wage Data) and
             2003 (1999 Wage Data) Wage Indexes and 3-Year Average of Hospital Average Hourly Wages
----------------------------------------------------------------------------------------------------------------
                                                      Average         Average         Average         Average
                  Provider No.                      hourly wage     hourly wage     hourly wage    hourly** wage
                                                      FY 2001         FY 2002         FY 2003         (3 yrs)
----------------------------------------------------------------------------------------------------------------
010001..........................................         16.4088         17.4467         17.7070         17.1977
010004..........................................         17.9732         19.0010         20.1613         19.0027
010005..........................................         17.5985         18.6554         21.5442         19.2074
010006..........................................         16.7480         17.6115         18.6118         17.6922
010007..........................................         15.4798         15.6788         16.0781         15.7477
010008..........................................         14.7443         17.4728         19.0182         17.0908
010009..........................................         18.7731         18.4979         19.7272         18.9866
010010..........................................         16.4468         16.4664         17.7348         16.9045
010011..........................................         20.7972         22.4292         24.7067         22.5297
010012..........................................         17.7171         15.8686         20.3948         17.8168
010015..........................................         15.4510         19.1178         19.8205         18.1040
010016..........................................         17.2473         20.2198         20.4139         19.2448
010018..........................................         17.6449         18.9388         19.5519         18.7214
010019..........................................         16.3493         17.0856         17.4615         16.9602
010021..........................................         16.2919         15.1241               *         15.7091

[[Page 31520]]

 
010022..........................................         18.5879         17.6435         22.2036         19.2378
010023..........................................         16.1025         16.3209         18.4567         16.9929
010024..........................................         16.2900         15.9034         17.0372         16.4149
010025..........................................         15.1356         15.1548         16.9733         15.7569
010027..........................................         11.7900         16.8595         16.5157         14.5941
010029..........................................         17.6461         18.3605         19.1001         18.3671
010031..........................................         18.7835         18.6402         19.2612         18.9043
010032..........................................         12.5995         15.3590         16.3967         14.8530
010033..........................................         20.3923         21.2986         21.8375         21.1715
010034..........................................         15.0959         15.3639         14.9379         15.1325
010035..........................................         20.1853         15.9439         20.8498         18.7765
010036..........................................         17.8140         17.7166         18.1325         17.8864
010038..........................................         18.2671         19.6098         19.6887         19.2225
010039..........................................         20.1045         20.3406         21.1309         20.5522
010040..........................................         18.9376         20.0983         20.4032         19.7634
010043..........................................         30.7489         18.6640         18.1128         21.1242
010044..........................................         22.0091         24.0265         23.4575         23.1128
010045..........................................         15.2200         17.0417         18.7569         16.8822
010046..........................................         17.3970         18.9737         18.8741         18.4218
010047..........................................         13.3521         15.4190         13.4130         14.0833
010049..........................................         14.7590         15.5246         16.3349         15.5762
010050..........................................         18.5163         17.9830         20.3028         18.9035
010051..........................................         11.9275         11.8108         12.3280         12.0151
010052..........................................         16.5486         18.0653         19.8289         18.3581
010053..........................................         14.6267         15.5649         15.4156         15.2353
010054..........................................         18.5103         19.4955         20.9656         19.7134
010055..........................................         18.9526         18.8590         19.4959         19.1060
010056..........................................         19.2175         19.6577         20.5645         19.7867
010058..........................................         16.1702         16.9715         16.1265         16.4288
010059..........................................         19.1286         18.8020         19.1270         19.0199
010061..........................................         14.9547         14.5003         18.5320         15.9823
010062..........................................         14.7732         12.3259               *         13.4892
010064..........................................         20.4139         19.5256         20.6628         20.1862
010065..........................................         16.4049         16.8752         18.8957         17.4231
010066..........................................         15.4317         13.1559         14.8904         14.4355
010068..........................................         12.0525         18.6925         23.4322         17.0157
010069..........................................         13.8636         14.7211         15.4497         14.6885
010072..........................................         14.9526         16.2339         16.5652         15.9117
010073..........................................         13.8601         14.1273         13.5594         13.8482
010078..........................................         17.9202         18.1363         18.5127         18.1930
010079..........................................         16.4421         17.0648         16.8045         16.7705
010081..........................................         18.9474         17.2996               *         18.1637
010083..........................................         16.8933         18.0312         18.4282         17.8382
010084..........................................         18.4965         18.7769         19.8773         19.0316
010085..........................................         18.4744         19.9023         21.3593         19.9065
010086..........................................         16.6694         16.5711         16.8886         16.7103
010087..........................................         19.0033         18.0567         18.6860         18.6208
010089..........................................         16.8042         17.7800         19.5697         18.0246
010090..........................................         18.3866         18.9445         19.5635         18.9671
010091..........................................         13.9405         17.0799         17.1775         15.9756
010092..........................................         16.9900         17.8144         18.5703         17.8203
010095..........................................         12.4525         12.2597         13.7865         12.8381
010097..........................................         13.0413         12.7286         14.2675         13.3206
010098..........................................         15.9165         14.0300         15.5763         15.1201
010099..........................................         15.9874         15.5619         15.9232         15.8146
010100..........................................         17.2011         17.9430         18.3755         17.8826
010101..........................................         15.3859         14.4625         18.7988         16.0267
010102..........................................         13.7933         13.8136         15.7777         14.4205
010103..........................................         17.9358         17.7242         22.2456         19.1327
010104..........................................         17.7126         16.8457         22.0038         18.6396
010108..........................................         17.9017         19.4617         19.1596         18.8606
010109..........................................         15.3107         14.6752         15.9627         15.2873
010110..........................................         15.6317         15.8283         15.5817         15.6824

[[Page 31521]]

 
010112..........................................         15.1401         16.8271         15.6041         15.8270
010113..........................................         16.9683         16.8936         18.2706         17.3693
010114..........................................         15.2454         17.0760         19.0678         17.1007
010115..........................................         14.6268         14.2261         15.3510         14.7053
010118..........................................         18.8477         17.0834         17.4620         17.7157
010119..........................................         18.8024         19.3942         19.4672         19.3127
010120..........................................         17.2336         18.2567         18.9975         18.1726
010121..........................................         14.6444         14.5262         15.2345         14.7784
010123..........................................         16.7344         19.2140               *         17.9083
010124..........................................         16.2846         16.7465               *         16.5122
010125..........................................         15.5304         16.0136         16.5117         16.0174
010126..........................................         19.5710         19.1065         19.5933         19.4288
010127..........................................         19.5190         18.2786               *         18.9233
010128..........................................         14.5056         14.4322         15.1184         14.6873
010129..........................................         14.7286         16.1733         16.7609         15.8741
010130..........................................         16.6809         19.5573         17.4614         17.7942
010131..........................................         17.8260         20.1883         19.0492         18.9966
010134..........................................         18.8835         19.9856         18.5179         19.1797
010137..........................................         12.1217         20.5828         21.3573         17.6481
010138..........................................         12.8675         14.5254         14.1369         13.8739
010139..........................................         19.0001         20.4331         20.5708         19.9541
010143..........................................         16.7911         17.6212         18.8903         17.7663
010144..........................................         17.1320         18.2040         18.7743         18.0281
010145..........................................         20.8434         20.5895         20.8110         20.7460
010146..........................................         18.5198         19.1415         18.3666         18.6687
010148..........................................         12.2214         15.8349         16.6251         14.5873
010149..........................................         18.6333         18.0156         19.0199         18.5806
010150..........................................         17.8951         18.9359         19.4819         18.7907
010152..........................................         17.8306         18.7677         19.8695         18.8444
010155..........................................          9.0300         15.0689         13.6136         11.6435
010157..........................................               *               *         18.0689         18.0689
010158..........................................         17.3227         18.3957         18.8358         18.2136
010159..........................................               *               *         20.4419         20.4419
020001..........................................         28.1747         28.0394         28.6292         28.2864
020002..........................................         24.5815         25.1987         28.2759         25.9928
020004..........................................         30.5667         25.4679         26.5088         27.6844
020005..........................................         30.2920         29.2378         35.0860         31.4575
020006..........................................         31.2404         28.1417         33.0843         30.7594
020007..........................................         27.8319         32.3852         27.7269         28.9902
020008..........................................         29.4146         30.8691         31.8715         30.7301
020009..........................................         20.1930         18.4660         18.5594         19.0476
020010..........................................         23.6727         22.7559         23.7275         23.3859
020011..........................................         30.4727         28.0658         27.5062         28.6155
020012..........................................         24.8543         25.5320         26.7586         25.6982
020013..........................................         23.8847         28.1557         29.5646         26.9336
020014..........................................         27.3823         24.5875               *         25.9860
020017..........................................         26.8319         28.0572         28.8752         27.9519
020024..........................................         24.0872         25.3205         25.5933         25.0276
020025..........................................         21.7557         20.2583         29.4375         23.2312
030001..........................................         20.3673         21.7869         22.8996         21.6709
030002..........................................         21.5977         21.8375         23.1450         22.2070
030003..........................................         23.4833         22.6804         23.9849         23.3723
030004..........................................         14.0711         15.5478         13.8452         14.3965
030006..........................................         18.2668         20.0273         20.5019         19.5831
030007..........................................         19.6708         21.5169         22.2473         21.1843
030008..........................................         22.2758         22.2190               *         22.2524
030009..........................................         18.1794         18.7557         19.1258         18.6629
030010..........................................         19.0907         19.5123         19.8496         19.4665
030011..........................................         19.2973         19.4310         19.8141         19.5088
030012..........................................         18.9918         20.6585         21.1099         20.2847
030013..........................................         20.7458         20.0535         19.9517         20.2223
030014..........................................         19.9315         19.7966         20.0568         19.9241
030016..........................................         19.3967         19.4785         22.2526         20.4395

[[Page 31522]]

 
030017..........................................         22.8765         21.7938         23.1702         22.6064
030018..........................................         20.2032         20.8980         21.8067         20.9825
030019..........................................         21.7005         21.2540         22.0341         21.6682
030022..........................................         19.2966         19.5794         22.3351         20.3379
030023..........................................         23.6697         24.1678         25.4626         24.5066
030024..........................................         22.2541         23.6009         23.5218         23.1550
030025..........................................         12.7254         11.9894         20.2690         14.6291
030027..........................................         15.7554         17.6555         18.5500         17.3221
030030..........................................         20.8303         21.6932         23.1280         21.8856
030033..........................................         20.0044         20.2820         20.3034         20.1983
030034..........................................         16.8241         20.8689         19.5578         19.0205
030035..........................................         19.2781         20.0226         20.5339         19.9127
030036..........................................         20.7567         21.6371         22.2690         21.5890
030037..........................................         22.8266         23.7615         23.7325         23.4266
030038..........................................         22.6776         22.9822         23.4477         23.0337
030040..........................................         18.5456         19.7636         19.3706         19.2127
030041..........................................         15.8921         18.8717         18.4750         17.5529
030043..........................................         20.9341         20.5598         18.7843         19.9580
030044..........................................         16.8649         17.6575         18.6781         17.7554
030047..........................................         22.6401         21.4412         22.7385         22.2630
030049..........................................         19.0881         19.3580         19.7315         19.3525
030054..........................................         15.3338         15.0657         15.7973         15.4130
030055..........................................         16.3613         20.2991         20.8373         19.1429
030059..........................................         24.0465         22.6279         27.3929         24.5505
030060..........................................         19.2461         18.6313         19.5021         19.1145
030061..........................................         18.9063         19.9047         21.1013         19.9959
030062..........................................         17.6738         18.7172         19.2670         18.6035
030064..........................................         19.5673         20.3837         21.6435         20.5204
030065..........................................         20.5130         20.7838         22.2846         21.2496
030067..........................................         14.4446         17.2778         17.6414         16.3935
030068..........................................         17.3614         17.7208         18.9718         18.0528
030069..........................................         19.0961         21.0936         23.4902         21.1503
030080..........................................         20.5144         20.6581         21.2079         20.8105
030083..........................................         23.3355         23.5229         23.2965         23.3842
030085..........................................         21.0954         20.8690         21.4417         21.1505
030086..........................................         19.5436               *               *         19.5436
030087..........................................         21.4084         21.9465         23.1339         22.1276
030088..........................................         19.8682         20.5340         21.4201         20.6453
030089..........................................         20.4019         20.9516         22.0850         21.2122
030092..........................................         20.6986         21.8308         19.4627         20.4899
030093..........................................         19.7262         20.4314         21.7195         20.6797
030094..........................................         21.6218         22.8123         21.8049         22.0984
030095..........................................         13.7293         13.7664         20.5222         15.2252
030099..........................................         16.1541         18.2263         19.8092         18.2768
030100..........................................               *         23.7609         23.5868         23.6643
030101..........................................               *         19.2547         21.1029         20.2450
030102..........................................               *         18.2413         21.5405         19.8425
030103..........................................               *               *         15.0859         15.0859
030104..........................................               *               *         32.8668         32.8668
040001..........................................         15.1624         16.9178         16.3882         16.1463
040002..........................................         13.0592         15.1107         16.1353         14.6990
040003..........................................         14.2089         15.5740         15.5186         15.0890
040004..........................................         17.8476         17.9034         19.0105         18.2433
040005..........................................         13.2597         11.1318         16.5465         13.4890
040007..........................................         21.9583         18.6998               *         20.1466
040008..........................................         15.3040         14.7985         20.2121         16.6104
040010..........................................         18.6023         19.4913         19.8251         19.3459
040011..........................................         14.5319         16.0995         17.1337         15.8295
040014..........................................         17.6340         18.1434         19.3996         18.3693
040015..........................................         16.5891         15.5207         17.4003         16.5312
040016..........................................         19.0295         20.2321         19.8087         19.7068
040017..........................................         13.5098         15.4736         16.5602         15.1870
040018..........................................         17.6027         18.7463         18.8203         18.3807

[[Page 31523]]

 
040019..........................................         22.6769         23.4163         21.0465         22.2688
040020..........................................         16.4827         18.9844         17.6056         17.6157
040021..........................................         17.6398         19.6835         21.3321         19.4636
040022..........................................         17.0397         20.8281         19.2393         18.9742
040024..........................................         14.4541         17.6607         15.0590         15.6850
040025..........................................         11.5079         13.4705         14.8071         13.1413
040026..........................................         19.5563         19.7924         21.0143         20.1201
040027..........................................         16.0975         17.4431         17.7161         17.1113
040028..........................................         14.6584         13.9946         15.2850         14.6612
040029..........................................         17.8787         21.1370         22.5094         20.5216
040030..........................................         13.5428         11.2402         16.5488         13.3388
040032..........................................         13.7030         13.2872         13.8013         13.5932
040035..........................................         12.8300         10.9569         11.0611         11.5521
040036..........................................         18.9757         20.2012         21.1066         20.1370
040037..........................................         14.6559         14.0941         15.4984         14.7015
040039..........................................         14.3576         14.7177         14.8433         14.6458
040040..........................................         18.0895         19.1984         19.6704         18.9937
040041..........................................         15.9896         16.4624         17.7783         16.7177
040042..........................................         15.2142         15.2057         16.6875         15.6976
040044..........................................         12.6275         13.3501         17.1869         14.3743
040045..........................................         14.9429         16.2469         16.6648         15.9379
040047..........................................         16.8654         17.5336         18.6295         17.6726
040050..........................................         13.3818         14.0036         14.2087         13.8730
040051..........................................         15.8627         16.6039         18.0487         16.8084
040053..........................................         16.3610         15.0219         14.1508         15.1659
040054..........................................         15.3219         14.2577         16.5217         15.3669
040055..........................................         17.1269         18.0414         16.6283         17.2760
040058..........................................         17.6766         16.4278         19.3124         17.6534
040060..........................................         12.8148         17.9805         15.4220         15.0376
040062..........................................         18.2048         17.8902         19.4255         18.5267
040064..........................................         10.7255         11.5029         13.3479         11.7813
040066..........................................         18.3377         19.7144         18.7831         18.9326
040067..........................................         14.6014         14.4741         15.0081         14.6924
040069..........................................         17.5052         17.0026         18.9754         17.8560
040070..........................................         16.9027         16.9700         18.6066         17.5468
040071..........................................         16.9610         17.6144         18.0874         17.5370
040072..........................................         16.0895         17.4960         21.3094         18.1882
040074..........................................         18.3224         18.7542         20.8465         19.2921
040075..........................................         13.3623         14.0975         14.6681         14.0257
040076..........................................         19.0732         20.5840         21.8010         20.4612
040077..........................................         12.9211         13.9114         14.7230         13.8164
040078..........................................         18.7600         18.5821               *         18.6754
040080..........................................         19.2461         19.3707         22.8153         20.3838
040081..........................................         11.3169         11.1332         12.4796         11.6373
040082..........................................         16.2152         15.1331         16.4840         15.9329
040084..........................................         17.2613         17.7295         18.3410         17.7584
040085..........................................         16.8957         16.5216         14.1782         15.7843
040088..........................................         17.9636         17.1624         18.2831         17.7943
040090..........................................         17.8282         19.0824         16.6619         17.8476
040091..........................................         19.8700         20.1378         20.2904         20.1018
040093..........................................         12.3537         13.9741         14.7132         13.5635
040100..........................................         14.7587         15.6833         16.9558         15.9133
040105..........................................         15.3319         14.3896         14.8936         14.8814
040106..........................................         15.6545         18.1341         19.0936         17.8001
040107..........................................         18.8120         17.8628         20.6852         19.1446
040109..........................................         14.6266         16.6278         16.2496         15.8538
040114..........................................         18.8743         21.1231         21.3826         20.4184
040116..........................................         20.2716               *               *         20.2716
040118..........................................         19.3720         18.2123         19.6248         19.0444
040119..........................................         15.5338         16.9407         18.5876         17.0324
040124..........................................         19.1349         19.2889               *         19.2100
040126..........................................         12.5368         11.6517         16.3391         13.4177
040132..........................................         17.5179         10.3875               *         13.5846

[[Page 31524]]

 
040134..........................................         18.0787         19.0185         22.1291         19.8434
040135..........................................         22.6761         23.0084               *         22.8797
040136..........................................               *               *         21.4139         21.4139
050002..........................................         37.8295         36.9630         30.2629         34.5243
050006..........................................         19.5594         18.2061         22.4890         20.0298
050007..........................................         30.7126         30.8676         31.6270         31.0595
050008..........................................         26.2458         26.3682         28.2021         26.8667
050009..........................................         26.8159         28.4734         28.3021         27.8816
050013..........................................         23.2201         28.0569         27.2552         25.9477
050014..........................................         22.8478         23.6745         25.1664         23.9039
050015..........................................         26.2481         27.7731         28.2204         27.4404
050016..........................................         20.5566         21.2045         22.7014         21.5040
050017..........................................         23.9625         25.6178         25.7403         25.1023
050018..........................................         15.4721         15.2903         16.4211         15.7749
050021..........................................         25.8966               *               *         25.8966
050022..........................................         24.0318         24.5254         26.2574         24.9836
050024..........................................         21.3989         22.4274         21.5230         21.7688
050025..........................................         23.3896         24.8245         26.0161         24.7262
050026..........................................         27.8736         23.1904         23.4651         24.6800
050028..........................................         16.4671         17.6138         17.9421         17.3234
050029..........................................         25.1259         24.6839         26.6783         25.4673
050030..........................................         20.9812         21.5621         21.8639         21.4881
050032..........................................         25.2010         24.3598         24.4176         24.6502
050033..........................................         24.9328         32.0179         31.1768         29.1633
050036..........................................         21.2420         21.8239         24.1361         22.4423
050038..........................................         28.6528         29.9698         32.1757         30.1303
050039..........................................         22.7117         22.8288         23.8122         23.1279
050040..........................................         32.1287         30.2607         30.1153         30.8697
050042..........................................         24.8067         24.5260         25.4903         24.9502
050043..........................................         32.9958         33.8255         38.8988         35.0749
050045..........................................         19.8831         21.1474         21.0356         20.7131
050046..........................................         25.3185         25.2005         25.3067         25.2745
050047..........................................         29.9255         29.9580         31.6959         30.5375
050051..........................................         17.8945         18.7809         17.9266         18.1624
050054..........................................         20.7212         22.0982         19.2395         20.6257
050055..........................................         29.3984         29.2730         32.0923         30.2190
050056..........................................         27.4321         23.8396         24.7994         25.2478
050057..........................................         21.1554         20.7420         21.7403         21.2220
050058..........................................         23.1641         23.3009         24.8366         23.7800
050060..........................................         20.7747         20.5450         21.9971         21.2660
050061..........................................         23.5454         24.5488         23.9906         24.0316
050063..........................................         24.8851         25.7593         25.5798         25.3924
050065..........................................         24.0420         24.6290         27.6677         25.3130
050066..........................................         16.5725         16.1649         26.3920         18.5257
050067..........................................         23.1966         25.8857         22.1250         23.5170
050068..........................................         20.6851         19.3615         19.2325         19.8460
050069..........................................         25.9420         24.6153         25.8560         25.4593
050070..........................................         32.5166         34.0721         36.4136         34.4086
050071..........................................         33.1850         34.4367         36.4834         34.7318
050072..........................................         33.2858         39.7321         36.1146         36.2550
050073..........................................         33.3922         32.8555         36.1054         34.1118
050075..........................................         33.9095         33.7160         37.8104         35.1272
050076..........................................         27.7797         33.9752         37.0415         32.6495
050077..........................................         24.1019         24.1404         25.3481         24.5518
050078..........................................         23.0736         24.3150         22.6776         23.3158
050079..........................................         33.2432         30.0167         36.5455         33.0896
050082..........................................         22.1009         23.7617         23.7718         23.2042
050084..........................................         23.5866         25.4517         25.1155         24.6796
050088..........................................         20.8406         24.9641         25.2282         23.4877
050089..........................................         20.9117         22.8450         23.4120         22.3589
050090..........................................         23.4097         24.6070         25.4545         24.4799
050091..........................................         25.2792         23.7713               *         24.5189
050092..........................................         16.7969         17.1211         17.1883         17.0299

[[Page 31525]]

 
050093..........................................         25.2130         25.6647         27.1820         26.0418
050095..........................................         33.6718         30.4847         29.2226         31.0314
050096..........................................         20.0487         22.7394         22.5034         21.6293
050097..........................................         16.7054         22.5991         24.2548         20.5747
050099..........................................         24.8091         25.3722         26.2363         25.4947
050100..........................................         29.8758         25.2031         23.9877         26.2195
050101..........................................         31.0264         31.8957         32.7594         31.9069
050102..........................................         22.2937         24.0014         22.6741         22.9916
050103..........................................         24.7932         25.4133         23.5946         24.5653
050104..........................................         25.5797         26.9726         25.4575         26.0072
050107..........................................         21.2690         22.2019         22.2746         21.9397
050108..........................................         23.5564         25.1758         25.6983         24.8127
050110..........................................         20.1870         19.9589         21.3399         20.4921
050111..........................................         21.5487         20.7897         21.0813         21.1480
050112..........................................         25.3015         26.8182         28.3676         26.8364
050113..........................................         28.8420         28.5224         32.3967         30.0407
050114..........................................         24.7286         26.6757         27.6486         26.3583
050115..........................................         21.3291         23.0182         24.3748         22.9340
050116..........................................         25.2130         24.9196         27.0331         25.6442
050117..........................................         23.3612         22.2123         23.0697         22.8657
050118..........................................         23.7698         23.7129         24.9094         24.1342
050121..........................................         19.5252         18.7272         18.8430         19.0230
050122..........................................         26.3172         26.9546         26.9193         26.7318
050124..........................................         22.7736         24.5069         23.9379         23.7017
050125..........................................         29.6147         32.0230         33.3290         31.6254
050126..........................................         23.9247         24.6752         26.9718         25.2082
050127..........................................         22.1937         20.9027         20.5928         21.0815
050128..........................................         25.7240         26.6132         26.2519         26.1998
050129..........................................         26.5030         24.0108         23.2118         24.4255
050131..........................................         31.0732         32.5462         33.0980         32.2202
050132..........................................         24.0834         24.0173         24.1583         24.0881
050133..........................................         24.9746         23.2093         23.9479         23.9946
050135..........................................         23.2361         24.7157         23.2750         23.7026
050136..........................................         24.7921         24.7280         28.0754         25.7753
050137..........................................         32.6507         32.9192         33.7489         33.1070
050138..........................................         37.3286         38.1584         40.8912         38.7884
050139..........................................         32.9351         31.4984         35.1492         33.0424
050140..........................................         34.1499         32.7609         36.7096         34.4570
050144..........................................         27.8751         27.4069               *         27.6480
050145..........................................         32.3857         34.5185         37.5003         34.7881
050148..........................................         21.9211         20.0971         21.1622         21.0247
050149..........................................         24.6078         26.8674         25.8880         25.7652
050150..........................................         24.9073         24.6596         25.9494         25.1761
050152..........................................         34.0766         33.3305         33.1217         33.4979
050153..........................................         30.5714         32.3389         32.1256         31.7026
050155..........................................         21.0257         25.3354         23.2118         23.0854
050158..........................................         27.5623         28.6071         28.9764         28.3557
050159..........................................         23.2912         22.5313         26.6139         23.7086
050167..........................................         21.9128         21.8796         21.9596         21.9174
050168..........................................         23.3511         25.1937         27.1971         25.2088
050169..........................................         22.3888         24.8407         24.7737         23.9439
050170..........................................         23.9574         24.3654         27.9459         25.2622
050172..........................................         20.1841         19.6120         22.0400         20.6111
050173..........................................         24.5545         24.8694               *         24.7049
050174..........................................         30.2140         30.2775         31.6888         30.7398
050175..........................................         27.2806         24.7548         26.0146         25.8419
050177..........................................         21.7943         21.1396         22.5039         21.8034
050179..........................................         21.7175         23.8868         22.8941         22.7755
050180..........................................         31.8947         33.3257         34.0900         33.1860
050183..........................................         20.3638               *               *         20.3638
050186..........................................         22.4155         23.6288         25.0791         23.7560
050188..........................................         28.0918         28.2364         30.6007         29.0015
050189..........................................         22.8687         27.4071         28.3295         26.4046

[[Page 31526]]

 
050191..........................................         20.8321         25.3516         29.2992         25.0950
050192..........................................         18.6701         14.1996         19.0400         17.0362
050193..........................................         22.6316         24.9444         25.5294         24.3542
050194..........................................         29.7371         29.5678         28.5389         29.2648
050195..........................................         35.5621         36.9068         39.1617         37.2637
050196..........................................         18.5180         18.2411         19.4304         18.7370
050197..........................................         35.7449         32.4030         34.6750         34.1639
050204..........................................         23.6105         22.7099         23.0192         23.1063
050205..........................................         23.6831         24.1691         24.1275         23.9917
050207..........................................         21.6214         22.9941         23.4210         22.6876
050211..........................................         31.6084         31.7280         33.2481         32.1766
050213..........................................         21.4806         21.4951               *         21.4880
050214..........................................         21.7335         24.0276         21.1480         22.2422
050215..........................................         29.8563         35.0459         31.6895         32.1029
050217..........................................         19.6010         20.2042         21.3026         20.3986
050219..........................................         21.7444         21.2458         21.7637         21.5978
050222..........................................         27.4809         23.3563         23.0670         24.3640
050224..........................................         23.5316         23.5101         24.8431         23.9839
050225..........................................         23.3480         21.6820         22.0981         22.3835
050226..........................................         27.7315         24.4443         26.1959         26.0496
050228..........................................         34.0711         34.2596         36.0632         34.7751
050230..........................................         27.7357         26.6291         26.7963         27.0820
050231..........................................         26.1508         26.7321         26.8977         26.6061
050232..........................................         24.3072         24.5245         25.8640         24.8981
050234..........................................         25.7035         24.6126         25.0104         25.0823
050235..........................................         25.2527         27.0922         26.0323         26.1239
050236..........................................         26.9803         25.9458         27.7406         26.8805
050238..........................................         24.2922         24.5823         25.1796         24.6748
050239..........................................         22.6625         23.2711         24.9463         23.6289
050240..........................................         26.3657         26.7620               *         26.5501
050241..........................................         26.3740         29.8345               *         27.9992
050242..........................................         31.1576         32.0829         32.9875         32.0689
050243..........................................         28.9635         26.4627         26.0256         27.1221
050245..........................................         23.8124         23.2716         27.5920         24.8781
050248..........................................         26.2015         27.6457         28.4413         27.4692
050251..........................................         21.6574         23.6360         27.9531         24.2057
050253..........................................         16.0701         16.7540         21.0399         17.6028
050254..........................................         19.3126         20.1176         22.3414         20.6227
050256..........................................         23.6887         23.4835         25.1104         24.1533
050257..........................................         15.2306         17.2596         15.6379         16.0441
050260..........................................         23.2421         27.4234         30.1623         26.5840
050261..........................................         20.0552         20.1040         19.4649         19.8596
050262..........................................         28.8785         29.5550         30.8866         29.7520
050264..........................................         32.1312         36.0331         32.8689         33.6109
050267..........................................         26.2264         26.0401         27.8393         26.6370
050270..........................................         24.0439         25.3757         26.4092         25.2781
050272..........................................         22.4247         23.0587         23.3443         22.9405
050274..........................................         20.0422               *               *         20.0422
050276..........................................         29.8624         33.3302         34.0633         32.3736
050277..........................................         20.0520         26.0822         23.6065         23.0165
050278..........................................         24.7787         23.9289         24.9699         24.5628
050279..........................................         20.8444         21.8949         22.2776         21.6332
050280..........................................         25.2149         25.6651         26.3392         25.7541
050281..........................................         19.6888         24.2251         25.2699         22.9927
050282..........................................         28.8261         25.4428         26.4698         26.9213
050283..........................................         29.7734         31.7669         32.3270         31.3481
050286..........................................         16.5708         19.4241         20.6191         18.4349
050289..........................................         34.1393         30.4750         32.2125         32.1522
050290..........................................         28.6231         29.6796         31.5000         29.9312
050291..........................................         30.2748         29.4029         30.9334         30.2109
050292..........................................         21.6243         20.8410         21.4357         21.2903
050293..........................................         22.2963         24.1875               *         23.1602
050295..........................................         21.2892         21.7883         24.5917         22.5802

[[Page 31527]]

 
050296..........................................         27.2948         28.3906         30.0984         28.6215
050298..........................................         24.4477         23.2006         22.4000         23.3022
050299..........................................         26.4543         25.5035         24.6751         25.5099
050300..........................................         23.5116         25.9228         26.0298         25.2222
050301..........................................         22.5201         21.1403         24.7987         22.7770
050305..........................................         34.5185         36.7908         36.6981         36.0318
050307..........................................         17.2147               *               *         17.2147
050308..........................................         29.3803         28.9284         28.5759         28.9478
050309..........................................         23.7884         25.3515         25.5221         24.8819
050312..........................................         26.7617         26.0015         26.0172         26.2525
050313..........................................         21.7577         25.6827         28.9126         25.5297
050315..........................................         24.7086         22.7359         25.8372         24.4689
050317..........................................         21.6937               *               *         21.6937
050320..........................................         30.4101         32.4809         31.6571         31.4911
050324..........................................         26.6049         25.3694         26.8313         26.2820
050325..........................................         24.4862         23.6327         22.6353         23.5919
050327..........................................         23.9484         25.6450               *         24.7970
050329..........................................         19.7455         21.6984         24.2134         21.8073
050331..........................................         22.2536         25.0230         25.2110         24.0855
050333..........................................         19.4589         19.1449         14.1808         17.2305
050334..........................................         34.2330         34.2557         34.3956         34.2968
050335..........................................         23.0258         22.9926         22.9335         22.9822
050336..........................................         20.7979         21.3402         18.9187         20.3375
050342..........................................         20.1841         20.8255         22.4356         21.1404
050343..........................................         17.2085               *               *         17.2085
050348..........................................         23.8779         25.1085         29.3364         26.0263
050349..........................................         14.9754         15.0667         15.4536         15.1663
050350..........................................         24.8340         26.4161         27.2368         26.1456
050351..........................................         25.4791         24.8121         25.2436         25.1768
050352..........................................         26.1380         26.4262         27.7489         26.7934
050353..........................................         23.0564         23.2699         24.1009         23.4992
050355..........................................         17.2778         21.0969               *         18.6280
050357..........................................         22.6545         24.5345         24.3540         23.9188
050359..........................................         17.7907         21.7548         19.6236         19.5994
050360..........................................         31.3526         31.7583         33.3592         32.1693
050366..........................................         23.7528         19.6823         22.0442         21.7233
050367..........................................         28.2805         30.7328         31.7487         30.2799
050369..........................................         27.0548         26.2234         26.6627         26.6233
050373..........................................         26.9776         27.8275         29.9749         28.1900
050376..........................................         26.5840         28.0990         28.4026         27.6603
050377..........................................         17.1764         17.0012               *         17.1127
050378..........................................         25.9810         26.9101         27.8389         26.9067
050379..........................................         15.2022         18.4278               *         16.6705
050380..........................................         31.4343         31.9578         31.5137         31.6362
050382..........................................         26.1398         25.9244         26.3968         26.1598
050385..........................................         24.6083               *         27.1692         25.6464
050388..........................................         19.1512         22.0122         17.6762         19.5684
050390..........................................         25.0426         24.2700         25.8556         25.0345
050391..........................................         18.9266         20.0615         19.0832         19.3414
050392..........................................         21.6729         22.9430         24.9003         23.1073
050393..........................................         25.6964         24.1981         25.4028         25.0965
050394..........................................         23.0604         23.1526         23.1641         23.1275
050396..........................................         24.0636         25.3729         25.7580         25.0612
050397..........................................         20.2601         20.6397         23.3212         21.1533
050401..........................................         20.7473         18.4593               *         19.5658
050404..........................................         17.3396         15.9839         16.4845         16.6030
050406..........................................         17.3016         17.8596         21.5282         18.7226
050407..........................................         29.9642         30.8346         32.0753         30.9310
050410..........................................         17.6769         19.8508         17.1718         18.1805
050411..........................................         34.8899         33.1943         33.1718         33.7076
050414..........................................         24.2060         25.9723         24.4936         24.8800
050417..........................................         21.5739         23.3005         23.3862         22.7800
050419..........................................         23.7584         23.4936         25.1449         24.1188

[[Page 31528]]

 
050420..........................................         22.3166         23.5438         26.4201         24.1207
050423..........................................         17.3771         21.3552         24.8113         20.9574
050424..........................................         22.8350         24.0727         25.9378         24.3139
050425..........................................         32.8364         35.3712         33.7276         33.9997
050426..........................................         25.2453         29.0120         27.4428         27.1541
050427..........................................         20.1674         16.4330               *         17.9553
050430..........................................         23.8788         21.2275         25.2322         23.4217
050432..........................................         24.4133         24.5630         26.0686         25.0170
050433..........................................         17.4643         18.9021         17.7980         18.0325
050434..........................................         19.7591               *         24.0017         21.7788
050435..........................................         25.6676         23.3426         22.2458         23.7166
050436..........................................         14.8121               *               *         14.8121
050438..........................................         25.0138         23.2583         25.3763         24.5467
050440..........................................         23.5167         22.5400         25.4767         23.8254
050441..........................................         28.9804         31.8774         33.4696         31.2892
050443..........................................         19.9020         17.2875         16.8897         17.9266
050444..........................................         21.4533         22.4530         22.6469         22.1781
050446..........................................         20.4908         22.3422         20.3611         21.0344
050447..........................................         17.9751         18.9851         24.4339         20.7186
050448..........................................         19.7046         21.7718         22.6612         21.3755
050449..........................................         23.8001         23.4614               *         23.6286
050454..........................................         28.7432         30.0792         30.3063         29.7856
050455..........................................         20.1643         19.8577         20.5575         20.1952
050456..........................................         20.1254         18.1585         17.5846         18.4965
050457..........................................         34.4949         32.1910         33.5750         33.4045
050464..........................................         25.3292         25.7710         25.8092         25.6421
050468..........................................         23.3050         22.2926         22.9771         22.8607
050469..........................................         23.8759         24.5205               *         24.1896
050470..........................................         16.0292         16.0805         15.7765         15.9567
050471..........................................         25.6172         27.1597         29.4705         27.3360
050476..........................................         22.4754         24.0253         25.9458         24.2592
050477..........................................         27.9595         27.5819         30.8781         28.6932
050478..........................................         24.5401         26.3306         28.1829         26.3141
050481..........................................         28.9722         27.7973         28.5320         28.4396
050482..........................................         18.1217         16.0114         21.6091         18.2297
050483..........................................         22.7182               *               *         22.7182
050485..........................................         24.1983         24.6906         23.9507         24.2714
050488..........................................         34.6939         31.7481         33.8291         33.4344
050491..........................................         26.8703         27.4600         27.7412         27.3548
050492..........................................         19.5457         20.5030         23.4977         21.2468
050494..........................................         29.2621         29.1296         30.2875         29.5621
050496..........................................         32.5168         34.9704         32.7474         33.3456
050497..........................................         13.8110         15.4115               *         14.5264
050498..........................................         24.9677         26.1716         27.6099         26.2387
050502..........................................         22.3788         25.3701         27.2724         24.9510
050503..........................................         24.4069         23.3745         25.7668         24.5458
050506..........................................         25.0845         25.0333         27.1555         25.7636
050510..........................................         33.3774         33.7481         36.2548         34.4910
050512..........................................         35.3581         34.4368         36.0785         35.2923
050515..........................................         35.3419         33.7321         37.3440         35.4231
050516..........................................         24.7992         26.1969         25.1778         25.3919
050517..........................................         20.9550         22.0985         23.6067         22.1150
050522..........................................         35.3784         36.2127         37.0295         36.1638
050523..........................................         27.0544         31.2522         32.1272         30.1439
050526..........................................         23.8099         26.4014         27.9306         26.0042
050528..........................................         19.0611         18.9155         21.1741         19.7510
050531..........................................         22.7308         21.3948               *         22.0804
050534..........................................         24.0700         24.0001         24.4038         24.1576
050535..........................................         25.4215         26.8511         27.7626         26.6201
050537..........................................         22.2256         24.0354         26.2342         24.2063
050539..........................................         20.7129         23.3846         23.6244         22.6500
050541..........................................         34.4573         36.6149         37.0551         36.1147
050542..........................................         16.0892         17.7737         21.8129         18.4625

[[Page 31529]]

 
050543..........................................         22.3994         21.6795         22.4134         22.1708
050545..........................................         26.3304         31.7280         33.6302         29.6054
050546..........................................         26.1949         38.8087         39.4266         31.5013
050547..........................................         26.8305         37.7681         37.7633         31.6990
050548..........................................         28.8083         29.8516         30.3336         29.5564
050549..........................................         27.2765         28.9615         30.0948         28.8364
050550..........................................         24.8048         25.6588               *         25.2235
050551..........................................         25.4652         24.8084         25.9619         25.4069
050552..........................................         21.5216         20.3239         20.6068         20.8970
050557..........................................         21.1243         22.2562         23.8340         22.4197
050559..........................................         23.5759         24.7866         26.3799         24.8811
050561..........................................         34.5791         33.4423         34.2065         34.0632
050564..........................................         23.5922         24.2091               *         23.9025
050565..........................................         23.7829         20.8349               *         22.1110
050566..........................................         17.4423         22.3448         21.7712         20.6000
050567..........................................         24.6454         25.0787         26.2588         25.3566
050568..........................................         19.5816         20.5376         21.9313         20.7038
050569..........................................         26.5479         27.3429         27.3294         27.0680
050570..........................................         25.2294         25.8619         26.8965         26.0357
050571..........................................         26.2039         24.0154         24.6237         24.9296
050573..........................................         24.9644         25.6589         25.9380         25.5333
050575..........................................         19.5611         20.7090         27.8579         22.3375
050577..........................................         25.1549         23.5487         25.2861         24.6231
050578..........................................         28.5379         28.9009         32.0554         29.7756
050579..........................................         30.4952         29.9348         32.0245         30.8151
050580..........................................         25.9004         24.6962         22.7522         24.4365
050581..........................................         23.8584         24.9807         26.0580         24.9311
050583..........................................         24.3987         25.8800         26.2664         25.5050
050584..........................................         21.2366         19.5805         24.5294         21.6929
050585..........................................         25.9426         24.2824         26.4446         25.5528
050586..........................................         23.4079         23.1850               *         23.3000
050588..........................................         25.3094         24.5472         27.0506         25.7065
050589..........................................         24.8698         23.8880         23.7918         24.1317
050590..........................................         22.4480         24.4797         25.7756         24.1986
050591..........................................         23.9412         25.0209         26.7662         25.1993
050592..........................................         21.1745         22.1174         23.8267         22.4222
050594..........................................         27.1584         27.7002         28.7415         27.8366
050597..........................................         22.8523         23.3280         23.1209         23.0979
050598..........................................         24.3597         23.9202         25.1622         24.5206
050599..........................................         29.1221         26.0892         26.3782         27.1542
050601..........................................         31.8670         29.7417         29.7734         30.4482
050603..........................................         23.3390         21.7031         24.9032         23.2638
050604..........................................         34.0461         35.4034         36.4669         35.3805
050608..........................................         18.0947         18.1664         20.7987         18.9517
050609..........................................         34.9935         33.5028         34.8949         34.4263
050613..........................................         23.3835         30.2413         34.9980         28.8691
050615..........................................         23.8815         27.5682         25.8698         25.6901
050616..........................................         22.7437         24.9843         25.0016         24.2299
050618..........................................         21.6509         21.4895         22.3548         21.8584
050623..........................................         29.1806         27.5832         28.6475         28.4545
050624..........................................         22.7148         26.4659         22.4030         23.6850
050625..........................................         26.4849         27.5816         28.1438         27.4404
050630..........................................         23.9159         24.2120         25.1453         24.4580
050633..........................................         23.1918         25.4283         27.8165         25.4720
050636..........................................         21.2618         23.5257         25.0214         23.2191
050638..........................................         18.2859         18.2159         15.6375         17.1599
050641..........................................         21.8315         17.1258         17.9379         18.6266
050644..........................................         22.3456         22.1489               *         22.2474
050661..........................................         19.6780               *               *         19.6780
050662..........................................         26.9606         35.0989         38.9592         31.5421
050663..........................................         30.6591         24.9110         22.7770         25.2271
050667..........................................         24.9979         27.5045         26.9236         26.1684
050668..........................................         42.0974         61.7751         57.8627         51.0207

[[Page 31530]]

 
050670..........................................         20.0152         24.6101         24.1626         22.6855
050674..........................................         34.7380         32.4807         33.7845         33.5929
050675..........................................         15.6794               *               *         15.6794
050676..........................................         18.6672         20.2087         16.3948         18.3663
050677..........................................         35.6503         33.6070         34.0936         34.4139
050678..........................................         26.8741         22.7756         25.2143         24.8560
050680..........................................         28.0584         31.4839         31.9166         30.4823
050682..........................................         26.2882         17.3566         19.8107         20.5443
050684..........................................         22.3398         23.3697         24.2792         23.3071
050685..........................................         31.1725         35.1307         30.4194         32.1391
050686..........................................         35.2631         33.4420         34.8278         34.4753
050688..........................................         30.6635         31.0648         34.9936         32.8691
050689..........................................         30.7295         30.9399         34.0571         31.9763
050690..........................................         32.8204         34.8112         36.7516         34.8707
050693..........................................         26.8265         25.5662         29.1213         27.1699
050694..........................................         23.2293         23.5572         25.1964         23.9614
050695..........................................         21.1377         24.4301         26.2838         24.0169
050696..........................................         28.0015         28.3291         29.6685         28.6563
050697..........................................         21.1566         18.2338         24.1116         21.0055
050698..........................................               *               *         24.9559         24.9559
050699..........................................         25.7843         17.5296         23.4611         21.9391
050701..........................................         22.6959         24.3055         26.4901         24.3588
050704..........................................         22.8716         22.7618         25.6565         23.8031
050707..........................................         26.2732         27.8958         28.2637         27.6356
050708..........................................         22.7821         24.8647         24.5606         24.0910
050709..........................................         21.9598         19.4977         21.8770         21.0737
050710..........................................         26.9060         27.5828         30.5918         28.4895
050713..........................................         17.7259         16.8538         18.2822         17.6031
050714..........................................         28.9314         30.1925         30.3290         29.7818
050717..........................................         25.9534         28.7973         31.5021         28.6924
050718..........................................         17.6062         18.0940         22.5989         19.6750
050719..........................................         25.5508         23.0833               *         23.8495
050720..........................................               *         25.8677               *         25.8677
050723..........................................               *               *         32.0291         32.0291
060001..........................................         21.3659         21.1819         20.6781         21.0801
060003..........................................         19.8023         20.4682         21.9043         20.7102
060004..........................................         22.8750         21.4496         22.9265         22.4496
060006..........................................         19.3651         20.0213         21.0003         20.1579
060007..........................................         17.4682         18.2977         19.3071         18.3452
060008..........................................         18.0333         18.4590         18.7097         18.3997
060009..........................................         21.4312         22.7164         23.9272         22.7121
060010..........................................         24.0872         23.6827         24.7332         24.1778
060011..........................................         23.4366         22.3458         22.2058         22.6927
060012..........................................         20.1442         19.4932         21.2980         20.3114
060013..........................................         22.7346         19.1256         23.5248         21.7755
060014..........................................         24.2459         24.3210         25.7689         24.7914
060015..........................................         20.9773         23.2469         23.6015         22.5801
060016..........................................         16.4707         20.2408         20.2361         18.8056
060018..........................................         20.3183         21.5083         21.8478         21.1863
060020..........................................         18.3099         18.8985         19.4966         18.9093
060022..........................................         21.0558         21.0830         22.6052         21.6192
060023..........................................         19.2373         21.5475         22.6480         21.1568
060024..........................................         21.9955         22.9185         23.5154         22.8418
060027..........................................         20.9846         22.0713         21.7571         21.6190
060028..........................................         23.2065         23.1792         24.2985         23.5665
060029..........................................         20.8585         18.2938         19.8498         19.6763
060030..........................................         20.5002         20.3452         18.0264         19.6163
060031..........................................         21.1649         22.5067         23.3995         22.3074
060032..........................................         23.4162         22.8123         24.2216         23.4772
060033..........................................         15.9085         16.0760         17.8514         16.5805
060034..........................................         22.4791         23.2816         23.4859         23.0898
060036..........................................         15.0698         18.5988         18.6521         17.3368
060037..........................................         15.5611         15.4513         15.7495         15.5902

[[Page 31531]]

 
060038..........................................         14.0791         14.3249         16.6525         15.2260
060041..........................................         14.8934         19.1263         19.0282         17.3424
060042..........................................         19.1892         20.8597         19.3967         19.6496
060043..........................................         13.6717         13.4443         15.4073         14.1048
060044..........................................         19.7039         20.8673         21.3102         20.6215
060046..........................................         19.4567         22.2699         22.6819         21.4974
060047..........................................         15.8770         17.1534         17.9173         16.9143
060049..........................................         21.7797         23.0613         25.9592         23.6523
060050..........................................         18.2238         19.0832               *         18.6522
060052..........................................         13.4210         14.8729         16.0543         14.6462
060053..........................................         15.9806         18.0232         19.4746         17.7396
060054..........................................         22.8985         20.4160         19.7753         20.9273
060056..........................................         18.2831         18.1263         21.9586         19.5606
060057..........................................         26.4046         25.4185         24.6599         25.4808
060058..........................................         15.4856         13.8539         16.4504         15.2822
060060..........................................         15.6469         15.6018         19.4418         16.7387
060062..........................................         17.2991         16.8640         17.1032         17.1033
060064..........................................         21.2207         22.7797               *         22.0259
060065..........................................         21.6305         24.5572         23.7809         23.3223
060066..........................................         16.3485         17.2537         17.5556         16.9855
060070..........................................         17.3184         18.8960         19.2220         18.4993
060071..........................................         17.5987         17.4068         17.6452         17.5489
060073..........................................         15.7860         17.0846         18.4971         17.0767
060075..........................................         24.1550         23.8724         25.0552         24.3665
060076..........................................         24.8732         20.3265         22.9203         22.6621
060085..........................................         13.6277         14.3409         10.9724         12.8943
060088..........................................         25.2786         13.7174         18.1570         17.7609
060090..........................................         22.2974         16.3760         16.5321         18.2600
060096..........................................         21.9623         20.8937         21.9951         21.6204
060100..........................................         23.5986         23.9305         24.1341         23.8807
060103..........................................         24.8151         23.5083         24.4962         24.2301
060104..........................................         22.2295         21.1820         24.4248         22.5603
060107..........................................         14.2698         21.9221               *         16.3130
060108..........................................               *               *         19.1327         19.1327
060109..........................................               *               *         27.3180         27.3180
070001..........................................         26.0878         26.3596         27.7441         26.7515
070002..........................................         26.2801         26.1768         26.6881         26.3761
070003..........................................         25.6949         27.5200         28.1721         27.1059
070004..........................................         22.4871         24.2567         25.4310         24.0188
070005..........................................         26.6483         26.9151         27.6733         27.0706
070006..........................................         27.5674         28.6413         33.6291         30.1330
070007..........................................         26.9505         26.3313         28.0875         27.1381
070008..........................................         23.0227         24.2971         25.1362         24.0979
070009..........................................         24.6201         24.1871         24.9408         24.5838
070010..........................................         26.2354         29.2194         28.3168         27.8716
070011..........................................         23.3638         23.0883         24.8206         23.7802
070012..........................................         23.0321         28.8067               *         25.4962
070015..........................................         23.8240         28.1204         29.2693         27.0233
070016..........................................         24.9148         24.4633         28.4833         25.9349
070017..........................................         26.2923         26.0424         27.5515         26.5441
070018..........................................         28.0689         30.6864         32.6301         30.4394
070019..........................................         25.7283         24.9249         26.2348         25.6326
070020..........................................         23.9987         25.9964         26.6203         25.5573
070021..........................................         25.2978         26.3043         29.4596         26.9916
070022..........................................         26.5691         26.9111         26.9907         26.8202
070024..........................................         25.2983         24.8948         26.2173         25.4902
070025..........................................         25.1315         25.4345         27.3592         25.9673
070027..........................................         23.6412         26.8450         25.8163         25.4005
070028..........................................         24.6788         25.7492         26.7286         25.7052
070029..........................................         22.0080         23.9682         23.8427         23.2454
070030..........................................         28.9117         22.1578               *         25.8929
070031..........................................         23.4419         24.1198         25.6347         24.3735
070033..........................................         30.4214         31.4736         32.8256         31.5451

[[Page 31532]]

 
070034..........................................         28.9200         29.4916         30.0480         29.4611
070035..........................................         23.0869         24.1423         24.1838         23.7950
070036..........................................         28.8400         29.9470         31.2961         29.9831
070038..........................................               *               *         26.3126         26.3126
070039..........................................         22.9032         22.3356               *         22.7640
080001..........................................         25.4836         24.8833         26.8887         25.7287
080002..........................................         19.6011         20.1965         20.9385         20.3062
080003..........................................         22.1856         23.1275         24.8200         23.2380
080004..........................................         21.9391         22.9706         21.7344         22.1849
080006..........................................         20.0792         22.6671         20.8203         21.1329
080007..........................................         19.6213         21.3746         21.1211         20.7477
090001..........................................         21.7526         21.5751         23.0365         22.1027
090002..........................................         19.4191         21.5726         20.6550         20.5048
090003..........................................         22.1090         23.1268         26.6720         23.7360
090004..........................................         24.3367         25.5054         25.9717         25.2072
090005..........................................         23.8620         26.3074         26.6217         25.5545
090006..........................................         20.8675         22.0957         22.6250         21.8452
090007..........................................         22.1973         29.2840         26.7809         26.4132
090008..........................................         20.2166         25.2708               *         22.7566
090010..........................................         24.1287         23.6616         25.9373         24.5182
090011..........................................         27.4781         26.6349         28.0948         27.4100
100001..........................................         19.5796         20.2157         21.9071         20.5375
100002..........................................         20.7136         21.0222         21.5772         21.1199
100004..........................................         14.6283         15.4149         16.1638         15.4361
100006..........................................         20.1133         21.2293         20.9190         20.7854
100007..........................................         21.7242         22.1590         22.5317         22.1527
100008..........................................         20.4980         20.8381         21.6416         21.0118
100009..........................................         22.6419         22.1741         21.3298         22.0295
100010..........................................         21.9078         23.0637         23.9582         22.9492
100012..........................................         19.6177         20.4659         21.7527         20.6367
100014..........................................         19.8023         19.5770         21.7358         20.3525
100015..........................................         18.4779         18.0654         18.9383         18.4860
100017..........................................         19.0608         19.8655         20.0861         19.6893
100018..........................................         21.0332         21.6388         22.5429         21.7594
100019..........................................         22.6152         23.5462         28.2362         24.8745
100020..........................................         21.3848         20.7816         21.7421         21.3134
100022..........................................         26.4094         26.5695         27.4235         26.7855
100023..........................................         19.9739         19.1787         20.2034         19.7906
100024..........................................         21.8791         22.1332         22.9872         22.3458
100025..........................................         18.7774         19.4529         20.1360         19.4381
100026..........................................         20.5641         20.9461         21.3742         20.9788
100027..........................................         19.1481         14.7916         20.5889         17.6926
100028..........................................         19.3757         19.3371         19.7475         19.4900
100029..........................................         20.8745         20.8950         22.2553         21.3244
100030..........................................         22.8204         20.5952         20.4996         21.1231
100032..........................................         19.8127         19.7451         20.6543         20.0503
100034..........................................         17.8743         19.5282         20.1214         19.1092
100035..........................................         20.1540         23.8117         21.2830         21.7761
100038..........................................         23.3578         24.5864         24.9548         24.3305
100039..........................................         21.5297         21.7861         23.3111         22.2259
100040..........................................         19.0449         18.6321         18.7546         18.8065
100043..........................................         18.7993         18.8206         20.7414         19.4322
100044..........................................         21.4764         22.7236         22.4824         22.2380
100045..........................................         20.9216         21.0228         22.8096         21.6136
100046..........................................         21.6207         21.3028         23.8909         22.2917
100047..........................................         20.0114         20.6068         21.4971         20.7134
100048..........................................         15.0584         15.7790         17.3663         16.1388
100049..........................................         18.8535         19.1025         20.9490         19.6376
100050..........................................         17.2377         17.9039         17.8960         17.6845
100051..........................................         23.1273         17.9453         19.3264         19.7334
100052..........................................         17.9537         18.1780         17.9957         18.0416
100053..........................................         20.1724         19.6800         21.6634         20.4905
100054..........................................         23.5491         21.1518         20.8078         21.8397

[[Page 31533]]

 
100055..........................................         18.0547         18.8760         19.1324         18.6804
100056..........................................         25.7863         21.8506         23.1737         23.6729
100057..........................................         19.9712         19.5319         22.3406         20.5479
100060..........................................         23.2561         23.5997               *         23.4313
100061..........................................         22.1133         22.9176         24.4704         23.1202
100062..........................................         19.4370         21.4424         21.9054         21.0072
100063..........................................         19.2629         18.4642         19.0908         18.9473
100067..........................................         18.0877         18.4851         18.5405         18.3328
100068..........................................         19.9305         19.8308         19.9648         19.9094
100069..........................................         16.8271         17.3666         18.5789         17.6344
100070..........................................         18.7408         20.0381         20.9592         19.7991
100071..........................................         17.5451         17.7234         20.7461         18.6293
100072..........................................         21.0225         20.5968         22.0317         21.2423
100073..........................................         21.1898         22.2812         22.2425         21.9197
100075..........................................         18.3688         19.4480         20.4664         19.4104
100076..........................................         17.8733         17.8612         18.4815         18.0825
100077..........................................         22.3438         19.0640         16.8641         17.3061
100078..........................................         18.4499         19.2891         14.4191         17.3311
100080..........................................         22.1966         22.7153         21.3374         22.0479
100081..........................................         14.8313         15.4253         16.5149         15.5681
100082..........................................         18.8998               *               *         18.8998
100084..........................................         22.3674         22.7009         24.5682         23.2945
100085..........................................         22.1231               *               *         22.1231
100086..........................................         21.6997         23.3718         24.3067         23.1462
100087..........................................         23.6090         23.6562         21.2831         22.8681
100088..........................................         20.3693         20.5566         20.0598         20.3349
100090..........................................         19.1479         19.7695         21.0431         20.0438
100092..........................................         17.9216         20.1760         20.5186         19.5588
100093..........................................         16.5128         16.8422         18.7153         17.3704
100098..........................................         19.2427         20.8315         21.1723         20.4066
100099..........................................         15.7823         15.7591         16.5624         16.0147
100102..........................................         18.9701         19.7673         19.0195         19.2464
100103..........................................         17.2364         18.7844         20.6957         18.8771
100105..........................................         21.6604         21.8268         22.7793         22.1049
100106..........................................         17.2527         17.4958         21.4342         18.9189
100107..........................................         20.1281         20.0719         21.7553         20.6632
100108..........................................         19.9593         20.1125         18.4127         19.5107
100109..........................................         20.8440         20.8370         20.5973         20.7560
100110..........................................         20.8995         20.1853         22.2354         21.1342
100112..........................................         25.2570         15.2128         16.2109         17.7240
100113..........................................         23.2020         21.3489         22.7264         22.3351
100114..........................................         21.6262         22.8178         22.5326         22.3196
100117..........................................         20.7624         20.6962         21.3007         20.9256
100118..........................................         22.8702         20.7323         21.4486         21.6456
100121..........................................               *         18.5842         18.8073         18.6952
100122..........................................         19.8783         19.2643         24.9765         21.2147
100124..........................................         17.0713         20.4022               *         18.7024
100125..........................................         18.9535         19.6097         20.3232         19.6414
100126..........................................         19.5413         19.3103         21.4349         20.0428
100127..........................................         19.9860         19.2122         20.4778         19.8925
100128..........................................         20.1536         22.8826         23.5835         22.0798
100129..........................................         19.1936               *               *         19.1936
100130..........................................         18.6751         20.0947         21.0023         19.9341
100131..........................................         23.4373         23.1622         24.1745         23.6099
100132..........................................         18.1167         18.7863         19.0747         18.6426
100134..........................................         15.1764         15.9733         16.9302         15.9832
100135..........................................         18.8253         19.1865         19.7675         19.2758
100137..........................................         18.6955         19.5562         20.9015         19.8112
100138..........................................         17.1373         14.9539         14.9760         15.5324
100139..........................................         15.6514         15.2532         15.7378         15.5541
100140..........................................         17.1389         19.0584         20.1703         18.8122
100142..........................................         19.6815         18.4113         17.7250         18.5714
100144..........................................         12.2877               *               *         12.2877

[[Page 31534]]

 
100146..........................................         18.1267         21.3359         21.9435         20.4800
100147..........................................         14.6616         15.2348         17.1566         15.6835
100150..........................................         21.2807         21.5057         25.4269         22.5635
100151..........................................         21.6087         23.8489         26.6143         24.0945
100154..........................................         20.0015         20.4068         21.6715         20.7094
100156..........................................         19.4980         18.4779         20.0348         19.3485
100157..........................................         22.6744         22.6195         24.2188         23.1792
100159..........................................         10.2793         10.7818         15.0633         11.7916
100160..........................................         20.5581         23.3121         22.6942         22.2030
100161..........................................         22.2994         22.3053         22.6534         22.4189
100162..........................................         20.1411         20.3110         20.4188         20.2955
100165..........................................         19.0388         22.6622               *         21.0526
100166..........................................         20.0250         21.2309         22.2379         21.1128
100167..........................................         23.4075         23.2969         25.6873         24.1145
100168..........................................         20.1994         20.3167         23.0121         21.2144
100169..........................................         20.9506         20.3017         21.6397         20.9720
100170..........................................         18.5088         19.3005         21.2469         19.5894
100172..........................................         14.3446         14.8826         15.7827         14.9994
100173..........................................         18.5662         17.1337         18.3828         18.0289
100174..........................................         26.1826         21.9807               *         24.0224
100175..........................................         18.1692         20.5442         21.2532         20.0936
100176..........................................         22.8604         24.3089         24.6595         23.9677
100177..........................................         24.4296         24.4284         26.4489         25.1965
100179..........................................         22.3015         23.0849         23.9633         23.1372
100180..........................................         20.2130         21.5388         22.6895         21.4521
100181..........................................         23.0800         18.9510         17.9048         19.7877
100183..........................................         24.6121         23.0654         22.2063         23.2470
100187..........................................         20.2533         20.8535         21.4988         20.8818
100189..........................................         21.3147         26.5962         27.1295         24.9742
100191..........................................         19.9879         21.0647         21.7024         20.8988
100199..........................................         21.7193               *               *         21.7193
100200..........................................         22.4579         23.8729         24.8878         23.7939
100204..........................................         20.8995         20.2193         20.8626         20.6601
100206..........................................         19.5710         20.1171         20.3436         20.0192
100208..........................................         21.2117         20.7029         20.4678         20.8077
100209..........................................         22.4577         23.3903         22.5915         22.8006
100210..........................................         21.3575         21.8545         23.0431         22.0260
100211..........................................         20.6427         20.7516         21.6367         21.0021
100212..........................................         21.1187         21.1263               *         21.1225
100213..........................................         20.6558         21.1818         21.9371         21.2709
100217..........................................         20.5909         22.7335         22.7116         21.9737
100220..........................................         21.2796         21.8246         22.3283         21.7592
100221..........................................         17.3965         21.2321         23.2263         20.3743
100223..........................................         20.6302         20.2233         21.3859         20.7713
100224..........................................         20.0251         21.8628         21.9515         21.2530
100225..........................................         20.6802         21.5059         22.4619         21.5424
100226..........................................         20.6858         21.8808         22.4084         21.7019
100228..........................................         21.3168         20.8810         23.4697         21.8662
100229..........................................         19.6908         18.2350         19.7259         19.2271
100230..........................................         20.5051         22.5650         23.4169         22.2637
100231..........................................         17.9226         18.7526         21.1128         19.1318
100232..........................................         19.3491         19.8002         19.9125         19.6887
100234..........................................         20.9104         21.6360         23.4761         21.9136
100235..........................................         17.1622               *               *         17.1622
100236..........................................         20.3766         20.6942         21.5316         20.8545
100237..........................................         22.0865         23.2408         23.2712         22.8481
100238..........................................         19.6367         20.8252         22.8488         21.0709
100239..........................................         21.3193         19.4481         23.0048         21.1692
100240..........................................         20.4340         21.0606         21.3495         20.9700
100241..........................................         14.7224         17.1063         14.1059         15.3322
100242..........................................         17.9260         18.6938         18.9062         18.5149
100243..........................................         21.2644         20.8041         22.4644         21.5426
100244..........................................         18.6227         20.5352         21.2521         20.2154

[[Page 31535]]

 
100246..........................................         19.6376         21.9247         23.5171         21.5681
100248..........................................         20.7007         21.2988         21.8086         21.2951
100249..........................................         19.2808         18.1397         18.4932         18.6366
100252..........................................         17.7778         19.8079         22.0976         19.8858
100253..........................................         21.3232         22.4778         22.6517         22.1811
100254..........................................         19.6598         19.5523         19.5050         19.5721
100255..........................................         25.2119         21.0284         20.7228         22.1421
100256..........................................         20.9356         21.2786         22.0528         21.4173
100258..........................................         21.3501         20.0300         22.0790         21.1494
100259..........................................         20.3815         21.1160         21.4991         21.0228
100260..........................................         21.0506         24.9183         21.1292         22.2409
100262..........................................         20.0433         21.0927         22.7137         21.2022
100264..........................................         19.1556         19.9491         21.5104         20.1857
100265..........................................         18.8301         18.2291         20.2365         19.1431
100266..........................................         18.2993         19.3623         20.2821         19.3534
100267..........................................         20.1141         21.7430         21.7446         21.2105
100268..........................................         23.9249         24.0538         23.6367         23.8643
100269..........................................         21.6724         22.5114         26.0271         23.4143
100270..........................................         15.1462         16.7148         20.8217         17.5380
100271..........................................         20.4824         20.8695         21.9823         21.1576
100275..........................................         20.9188         21.4904         23.2088         21.8580
100276..........................................         22.3646         24.1022         24.8251         23.8061
100277..........................................         16.6255         19.7241         14.9157         16.6327
100279..........................................         22.9095         22.5879         21.1094         22.2253
100280..........................................         17.3676         18.1972         19.0157         18.2076
100281..........................................         22.4392         23.0142         23.4729         23.0255
100282..........................................         19.1978         18.4884         20.9256         19.5516
100284..........................................               *         18.9448         18.4204         18.6867
110001..........................................         19.1971         20.1150         22.3072         20.5112
110002..........................................         17.1406         19.5158         20.2149         18.9927
110003..........................................         18.1168         17.1450         18.2792         17.8514
110004..........................................         19.5591         19.7733         20.6096         19.9776
110005..........................................         17.7348         22.4568         21.8105         20.9768
110006..........................................         20.7820         21.0601         21.9525         21.2769
110007..........................................         21.9505         25.2523         26.3143         24.5085
110008..........................................         22.0081         18.5265         19.9606         20.1468
110009..........................................         16.3069         17.4306         16.6452         16.8052
110010..........................................         23.3213         23.9104         25.1930         24.1454
110011..........................................         18.6144         18.9823         20.4028         19.3209
110013..........................................         16.2811         18.9160         16.7833         17.3444
110014..........................................         16.0658         18.1787         18.4463         17.4976
110015..........................................         21.2146         20.9926         21.2600         21.1563
110016..........................................         22.5321         14.2398         14.7571         16.4041
110017..........................................         13.1960         22.2537         21.2970         19.1377
110018..........................................         19.6064         22.1480         22.3933         21.3958
110020..........................................         18.3147         19.4617         20.9687         19.5535
110023..........................................         21.1994         22.0546               *         21.6186
110024..........................................         20.7297         20.7345         21.3945         20.9529
110025..........................................         19.5749         20.4232         20.2493         20.0573
110026..........................................         17.2977         16.2484         16.6320         16.7325
110027..........................................         16.0642         14.7081         19.8976         16.6619
110028..........................................         20.1547         29.1670         28.1695         25.3235
110029..........................................         20.2906         21.2150         21.3492         20.9560
110030..........................................         18.8105         19.6412         20.4656         19.6568
110031..........................................         19.9482         20.0553         20.9219         20.3082
110032..........................................         15.7349         18.2014         19.2685         17.6324
110033..........................................         22.1879         25.6335         23.1939         23.6010
110034..........................................         19.6055         19.5554         23.0724         20.6505
110035..........................................         19.3795         22.7950         21.8646         21.4160
110036..........................................         22.2498         24.9234         25.1127         24.0254
110038..........................................         17.7060         17.7396         18.4508         17.9715
110039..........................................         20.6011         20.4998         18.9817         19.9578
110040..........................................         17.0743         16.8083         17.7798         17.2164

[[Page 31536]]

 
110041..........................................         18.8035         20.2755         20.1398         19.7378
110042..........................................         24.0153         25.2331         25.0535         24.7832
110043..........................................         20.1016         20.6150         21.2714         20.6367
110044..........................................         16.3624         17.2087         17.5905         17.0642
110045..........................................         20.2498         21.3049         20.6934         20.7294
110046..........................................         19.7377         21.4905         22.8820         21.3991
110048..........................................         16.3148         15.6113         18.8751         16.8775
110049..........................................         16.1817         16.8639         17.1396         16.7155
110050..........................................         20.7619         19.2291         18.9048         19.6044
110051..........................................         17.0070         17.2292         17.2050         17.1503
110054..........................................               *         20.0549         20.5698         20.3256
110056..........................................         15.6202         17.7959         16.0362         16.5039
110059..........................................         16.6678         16.7990         17.8076         17.0958
110061..........................................         15.0367         16.3557         17.4601         16.2796
110062..........................................         18.8019         17.0053         17.9421         17.8940
110063..........................................         16.9612         18.5071         18.0256         17.8146
110064..........................................         18.9515         19.1203         18.8578         18.9772
110065..........................................         15.6771         16.3546         16.9829         16.3529
110066..........................................         21.0207         22.4189         23.4554         22.2503
110069..........................................         19.3109         20.9575         21.1513         20.4832
110070..........................................         21.0227         17.3438         19.6361         19.3058
110071..........................................         14.5984         18.8321         21.5042         17.7757
110072..........................................         12.7877         12.7625         13.6626         13.0734
110073..........................................         15.4261         16.4658         17.9372         16.5696
110074..........................................         21.3945         22.3769         24.4924         22.7969
110075..........................................         18.5199         20.1757         20.1604         19.6679
110076..........................................         21.2867         21.9798         23.6127         22.2999
110078..........................................         22.3718         24.0893         25.9119         24.1213
110079..........................................         21.0593         22.1070         22.3641         21.8325
110080..........................................         18.4768         19.1839         19.4635         19.0419
110082..........................................         23.8768         24.3140         22.7015         23.5986
110083..........................................         23.1219         23.1463         22.2609         22.8147
110086..........................................         18.2815         16.6374         19.0164         17.9653
110087..........................................         21.7773         22.7069         24.0994         22.9041
110089..........................................         18.5587         19.3855         19.0453         18.9917
110091..........................................         19.5114         21.5328         23.7110         21.5509
110092..........................................         17.3479         16.9725         15.9178         16.7054
110093..........................................               *         16.9827               *         16.9827
110094..........................................         14.5641         16.9503         16.8890         16.0918
110095..........................................         16.4670         17.1195         17.4302         17.0118
110096..........................................         16.8541         17.4157         18.0418         17.4444
110097..........................................         15.5811         17.4558         17.8454         16.7969
110098..........................................         16.3532         16.0597         16.7800         16.4135
110100..........................................         18.6978         19.0764         18.6822         18.8175
110101..........................................         10.8187         18.8491         13.8787         13.5799
110103..........................................         13.6842         21.1837         21.5683         17.7316
110104..........................................         15.7781         15.9431         16.6322         16.1150
110105..........................................         16.8909         16.7775         18.1306         17.2936
110107..........................................         19.3609         19.3897         21.0863         19.9482
110108..........................................         19.7938         25.2161         20.1140         21.3451
110109..........................................         15.9359         16.4031         16.5977         16.3157
110111..........................................         18.5108         18.3951         18.4274         18.4433
110112..........................................         19.0619         19.8986         18.9574         19.2821
110113..........................................         16.8179         15.9532         16.0942         16.2556
110114..........................................         14.6888         16.4812         16.8297         16.0087
110115..........................................         43.9427         22.5049         26.5759         28.7027
110118..........................................         20.5368         19.7509         17.5714         19.1118
110120..........................................         15.2589         17.7452         18.4738         17.1958
110121..........................................         16.2711         19.3643         18.8744         18.1723
110122..........................................         21.1385         21.1469         20.4922         20.9166
110124..........................................         17.5732         18.3366         19.4093         18.3953
110125..........................................         19.1311         18.0090         19.4207         18.8387
110127..........................................         14.6143         20.3765         16.1107         17.0392

[[Page 31537]]

 
110128..........................................         18.1845         18.0835         19.5450         18.6049
110129..........................................         18.9388         19.0001         20.8935         19.6183
110130..........................................         16.0580         14.6011         16.6915         15.7591
110132..........................................         16.0419         16.3943         17.1820         16.5355
110134..........................................         12.5723         19.8639         19.0305         17.6901
110135..........................................         17.4380         17.3504         15.6668         16.7018
110136..........................................         18.0639         16.9629         20.7827         18.4333
110140..........................................         17.8870         17.7915               *         17.8447
110141..........................................         13.2501         14.4935         13.2710         13.6692
110142..........................................         14.6144         13.9525         14.1203         14.2070
110143..........................................         20.1603         22.5926         22.4254         21.8082
110144..........................................         16.8685         17.5112         17.5678         17.2876
110146..........................................         16.1316         17.1835         17.5940         17.0117
110149..........................................         17.7535         32.1975         25.2525         24.0956
110150..........................................         20.2644         21.2909         22.4899         21.3508
110152..........................................         15.3996         15.1324         16.3837         15.6496
110153..........................................         19.2744         20.5068         20.6972         20.1497
110154..........................................         14.9636         17.3761         16.5286         16.2471
110155..........................................         15.5306         16.5146         16.4756         16.1555
110156..........................................         14.7477         16.3876         16.0759         15.7007
110161..........................................         21.7153         22.2861         24.5776         22.9656
110163..........................................         20.4202         18.6637         20.0673         19.6918
110164..........................................         20.2074         21.2160         22.5865         21.3587
110165..........................................         21.2577         20.8030         22.5604         21.5831
110166..........................................         20.5882         20.5049         22.3657         21.1057
110168..........................................         20.6646         21.8058         22.2537         21.6267
110169..........................................         20.6385         22.6648         23.3750         21.9474
110171..........................................         23.7893         25.5296         24.5313         24.5760
110172..........................................         23.3730         23.6803         24.7005         23.9332
110174..........................................         13.7339         14.6199               *         14.1346
110177..........................................         20.7187         21.2796         22.7831         21.6138
110178..........................................         18.8306               *               *         18.8306
110179..........................................         22.7841         22.0767         24.3673         23.0370
110181..........................................         14.0941         12.9798         13.9591         13.6986
110183..........................................         23.3826         22.5148         24.2899         23.3905
110184..........................................         22.1970         22.1920         22.2761         22.2235
110185..........................................         16.7246         17.7925         17.3330         17.2705
110186..........................................         17.4287         18.3178         19.7172         18.4775
110187..........................................         20.1154         19.8419         22.8248         20.9454
110188..........................................         24.8376         23.7032         21.9945         23.3633
110189..........................................         22.2715         20.8786         19.3335         20.7205
110190..........................................         18.5728         18.3649         20.7292         19.1518
110191..........................................         20.2033         21.4033         21.3404         21.0040
110192..........................................         21.4951         21.0486         22.9684         21.8761
110193..........................................         20.6380         20.7867         22.1392         21.1880
110194..........................................         15.1480         14.8115         15.8129         15.2645
110195..........................................         13.9135         12.7261         10.9444         12.3540
110198..........................................         24.1999         24.8646         24.8275         24.6410
110200..........................................         18.1862         17.7744         17.9631         17.9701
110201..........................................         20.4699         20.9497         21.9313         21.1039
110203..........................................         26.8148         22.7453         24.2062         24.5686
110204..........................................         19.7317         30.7342         35.3699         24.8432
110205..........................................         21.1435         21.3617         20.1405         20.8862
110207..........................................         12.9727         14.7154         14.6045         14.1130
110208..........................................         15.1742         15.6161         15.0350         15.2676
110209..........................................         17.9190         18.6404         20.0629         18.7585
110211..........................................         20.9372         26.9151         20.1024         22.3126
110212..........................................         11.8545         14.3790         15.8420         13.8932
110213..........................................         14.3651               *               *         14.3651
110215..........................................         20.1928         18.1539         21.0263         19.7770
110216..........................................               *         27.1878               *         27.1878
120001..........................................         27.9213         29.0427         29.4126         28.7754
120002..........................................         25.0744         25.2021         23.5667         24.5781

[[Page 31538]]

 
120003..........................................         25.9059         23.9115         24.6238         24.8142
120004..........................................         23.9208         24.8632         26.1398         24.8838
120005..........................................         23.3975         24.1662         22.3213         23.2601
120006..........................................         25.0895         25.8943         26.0904         25.6667
120007..........................................         22.7200         22.8772         22.7179         22.7718
120009..........................................         17.4693         16.4485         16.7630         16.8820
120010..........................................         25.1480         24.1923         24.9089         24.7414
120011..........................................         35.0582         37.2759         35.2051         35.8314
120012..........................................         23.1144         21.8507         22.0371         22.3824
120014..........................................         22.8866         24.1208         25.3557         24.0761
120015..........................................         32.9906         42.6465               *         37.0469
120016..........................................         27.9127         45.1899         43.5083         34.2774
120018..........................................         24.5031         31.1879               *         26.7466
120019..........................................         22.9341         25.5659         23.8535         24.0876
120021..........................................         23.4508         23.1839               *         23.3291
120022..........................................         21.7868         19.2614         17.3744         19.4456
120024..........................................         29.4808         32.2514               *         30.1443
120025..........................................         20.1065         50.6376         40.1332         25.3493
120026..........................................         26.0787         25.1314         25.7023         25.6323
120027..........................................         24.7255         24.4535         23.1434         24.0841
120028..........................................         27.5023         27.0897         27.5365         27.3898
130001..........................................         18.8471         17.6306         19.6328         18.7161
130002..........................................         16.6620         16.9867         18.5746         17.4270
130003..........................................         21.7313         22.3430         23.0994         22.4005
130005..........................................         20.7169         21.2386         22.6364         21.5043
130006..........................................         19.3392         20.4614         21.4640         20.4603
130007..........................................         20.8338         21.8107         22.0894         21.5806
130008..........................................         12.5506         13.6018         19.3392         14.7112
130009..........................................         19.1837         15.9701         16.8563         17.2592
130010..........................................         17.6795         17.5119         17.7826         17.6635
130011..........................................         20.5031         20.1147         22.1125         20.9248
130012..........................................         22.9813         24.9976         24.2451         24.1243
130013..........................................         17.4038         15.1129         22.6624         18.2887
130014..........................................         18.9769         19.2107         19.7560         19.3379
130015..........................................         15.7233         18.5913         16.4136         16.7965
130016..........................................         17.3942         19.0516         20.1220         18.8309
130017..........................................         17.1710         19.6875         19.9511         18.7336
130018..........................................         19.7368         19.8425         20.1934         19.9339
130019..........................................         18.6648         19.1711         19.5147         19.0953
130021..........................................         12.8588         15.6155         14.3089         14.2489
130022..........................................         16.5270         18.9127         19.7814         18.3410
130024..........................................         19.3634         19.0703         19.9934         19.4905
130025..........................................         17.5213         16.4627         17.5989         17.2009
130026..........................................         21.5934         21.8106         23.2093         22.2042
130027..........................................         21.4279         20.5344         19.0911         20.3739
130028..........................................         19.1093         20.9674         18.1205         19.2837
130029..........................................         18.4263         18.7694         22.9243         19.6491
130030..........................................         17.8440         17.5759         18.5827         17.9732
130031..........................................         16.2397         16.7766         20.4146         17.4242
130034..........................................         16.9873         18.9483         20.5802         18.9102
130035..........................................         19.3478         20.7770         16.9671         19.1314
130036..........................................         13.7933         13.6362         15.1590         14.2304
130037..........................................         18.8071         18.6856         19.2108         18.9127
130043..........................................         16.5102         16.7904         17.6920         16.9853
130044..........................................         17.8160         13.4513         16.7797         15.8094
130045..........................................         16.0990         19.0208         17.5152         17.4280
130048..........................................         16.0899         16.7900               *         16.4201
130049..........................................         20.3129         22.4440         22.0520         21.6192
130054..........................................         17.2729         17.7085         16.4675         17.1120
130056..........................................         14.6862         20.9476         28.8008         19.9051
130060..........................................         21.8662         22.7399         23.2512         22.6187
130061..........................................         15.4006         14.7394               *         15.1267
130062..........................................         16.5672         19.8157         19.8264         18.8380

[[Page 31539]]

 
130063..........................................         15.9441         18.8024         18.4797         18.1425
140001..........................................         16.3372         17.7990         17.7421         17.2408
140002..........................................         19.0248         19.9284         20.9959         19.9709
140003..........................................         21.2886         17.8595         18.0163         18.9220
140004..........................................         15.7042         17.4574         19.0486         17.4249
140005..........................................         11.6127         12.3002         12.4144         12.1009
140007..........................................         22.9799         23.8585         25.0105         23.9811
140008..........................................         21.6548         22.1111         24.2779         22.6707
140010..........................................         31.8207         28.5635         26.6836         28.8200
140011..........................................         17.8676         18.6164         18.4052         18.3022
140012..........................................         23.0653         21.4374         22.5885         22.3529
140013..........................................         18.3060         19.6722         20.3147         19.4284
140014..........................................         22.4737         21.4042         22.2944         22.0537
140015..........................................         16.6735         17.6805         20.3540         18.1726
140016..........................................         13.1278         14.4938         15.4454         14.3266
140018..........................................         22.3070         22.4132         23.4595         22.7307
140019..........................................         16.6548         16.4254         16.1180         16.3909
140024..........................................         16.8271         15.3782         16.1032         16.1040
140025..........................................         16.9462         18.5135         21.7775         18.9319
140026..........................................         16.6612         18.3220         19.7839         18.2263
140027..........................................         18.7553         19.2149         20.5980         19.5140
140029..........................................         22.8322         26.0833         28.0683         25.6669
140030..........................................         21.9475         23.1760         25.2828         23.5549
140031..........................................         19.5731         17.6067         16.9650         17.9987
140032..........................................         18.1058         19.0383         19.8033         18.9961
140033..........................................         24.1722         25.1639         22.8705         24.0049
140034..........................................         19.5278         19.8792         19.7711         19.7256
140035..........................................         15.2649         15.5040         17.4514         16.0631
140036..........................................         18.5771         19.1076         21.2366         19.6677
140037..........................................         13.0764         14.1083         14.3082         13.8255
140038..........................................         18.3035         18.4948         19.8197         18.8624
140040..........................................         19.9267         16.7450         18.0342         18.2044
140041..........................................         17.6582         18.5952         18.8042         18.3411
140042..........................................         15.4095         15.8892         16.1157         15.8051
140043..........................................         19.4683         20.1176         21.7356         20.4389
140045..........................................         15.5807         17.7799         17.4261         16.8835
140046..........................................         18.9763         18.6371         20.0859         19.2505
140047..........................................         17.1539         13.3610         16.6672         15.5612
140048..........................................         24.0913         23.9545         22.5870         23.5490
140049..........................................         28.4958         26.9483         27.0250         27.5281
140051..........................................         23.8264         24.0796         24.6964         24.2137
140052..........................................         19.6409         17.9571         21.0450         19.4727
140053..........................................         19.1892         19.9620         20.5244         19.8722
140054..........................................         22.1921         23.1576         23.9416         23.0858
140055..........................................         16.3404         14.3603         15.8756         15.4931
140058..........................................         17.4927         18.6861         19.1199         18.4367
140059..........................................         15.0195               *         18.2593         16.6820
140061..........................................         17.3012         18.2039         18.4264         17.9767
140062..........................................         28.0877         28.5304         28.6390         28.4255
140063..........................................         25.3641         29.1453         25.8203         26.5945
140064..........................................         19.1023         18.9379         19.6954         19.2477
140065..........................................         24.1128         25.3336         25.5939         25.0012
140066..........................................         17.3902         13.6491         15.4818         15.3710
140067..........................................         19.3267         19.5292         20.7511         19.8509
140068..........................................         19.9691         21.6188         21.6089         21.0342
140069..........................................         16.7544         17.3879         17.7785         17.3221
140070..........................................         22.9678         22.7153         25.2646         23.5870
140074..........................................         19.3504         21.6052         22.2604         20.9581
140075..........................................         21.6313         21.6434         21.0968         21.4950
140077..........................................         17.5305         17.3647         17.3236         17.4081
140079..........................................         23.3020         23.6928         22.7046         23.2149
140080..........................................         21.0739         22.1968         22.0682         21.7613
140081..........................................         16.2247         16.9808         18.1746         17.0842

[[Page 31540]]

 
140082..........................................         23.8960         29.7262         26.5960         26.4591
140083..........................................         19.3145         21.0330         18.0664         19.5127
140084..........................................         20.9709         22.3467         22.0706         21.7924
140086..........................................         18.3803         19.1613         19.1815         18.9175
140087..........................................         16.1009         17.1147         21.4593         18.0959
140088..........................................         25.2369         25.4176         26.5258         25.7146
140089..........................................         17.6366         18.3157         19.3230         18.4019
140090..........................................         26.4325         26.9364         28.0530         26.9854
140091..........................................         20.9018         21.9322         22.9565         21.9272
140093..........................................         18.2899         20.1528         20.7564         19.6330
140094..........................................         21.4709         21.9383         22.8892         22.0901
140095..........................................         24.0549         24.2859         23.8834         24.0755
140097..........................................         17.5081         21.1719         21.8418         20.1374
140100..........................................         21.3581         23.1399         23.8226         22.7460
140101..........................................         21.5473         21.4211         23.1418         22.0459
140102..........................................         17.1500         17.5729         18.6328         17.7567
140103..........................................         19.2783         18.1303         16.2009         17.8612
140105..........................................         22.6573         22.8944         23.8258         23.1227
140107..........................................         13.7533         11.8383         11.5827         12.2495
140108..........................................         25.4742         26.9971         27.9140         26.8421
140109..........................................         15.7465         14.5498         15.9178         15.3965
140110..........................................         19.1822         19.2888         20.9631         19.8004
140112..........................................         17.6856         17.6974         18.1119         17.8311
140113..........................................         19.0592         19.5584               *         19.3069
140114..........................................         21.1639         21.0976         22.9844         21.7634
140115..........................................         21.1926         21.0433         20.7660         21.0012
140116..........................................         23.1177         23.8993         27.8888         25.1841
140117..........................................         21.5671         21.4876         22.0889         21.7249
140118..........................................         23.5952         24.3260         25.3249         24.4123
140119..........................................         29.1419         27.9145         30.6468         29.2072
140120..........................................         18.0743         17.9716         18.5685         18.2090
140121..........................................         16.0397         16.6993         16.2607         16.3273
140122..........................................         24.6470         26.1270         26.7344         25.7959
140124..........................................         27.1906         27.9813         30.2658         28.3904
140125..........................................         17.6759         16.9516         17.8190         17.4826
140127..........................................         19.8973         20.0489         20.8397         20.2623
140128..........................................         19.4955         23.1327         23.5481         22.1101
140129..........................................         18.2639         20.2868         21.6252         19.9926
140130..........................................         22.2285         23.4298         26.0464         23.9518
140132..........................................         23.5475         23.3054         23.7046         23.5171
140133..........................................         21.4090         21.4166         20.1740         21.0117
140135..........................................         17.8100         17.3985         18.2479         17.8298
140137..........................................         16.8969         18.6330         19.2594         18.2334
140138..........................................         16.7420         17.1968         14.5771         16.0861
140139..........................................         14.0619         11.0397               *         12.4249
140140..........................................         17.8243         17.6845         18.8185         18.1076
140141..........................................         17.5204         19.1097         20.2606         18.9480
140143..........................................         19.1862         19.0810         19.9885         19.4222
140144..........................................         21.3245         22.2864         24.8854         22.7447
140145..........................................         17.5471         18.1788         19.4509         18.3977
140146..........................................         21.9573         19.9704         19.4272         20.3714
140147..........................................         16.1336         18.8049         17.1013         17.2344
140148..........................................         18.6598         18.7730         19.7630         19.0696
140150..........................................         27.3378         24.7976         28.1723         26.6696
140151..........................................         21.3896         20.0310         20.8820         20.7518
140152..........................................         24.6333         25.6011         27.9615         26.0086
140155..........................................         19.9738         20.2778         23.9957         21.3787
140158..........................................         22.7639         22.7988         23.7428         23.1140
140160..........................................         17.7691         17.7921         19.8825         18.5234
140161..........................................         20.0948         20.3799         21.2045         20.5610
140162..........................................         19.6464         20.3452         21.6901         20.5431
140164..........................................         18.7806         18.6589         19.8246         19.1100
140165..........................................         14.9156         14.7223         16.3700         15.3419

[[Page 31541]]

 
140166..........................................         17.5496         18.3833         18.9513         18.2817
140167..........................................         17.1479         17.6525         18.8532         17.9029
140168..........................................         16.6770         17.7453         18.2896         17.5820
140170..........................................         16.1621         16.4107         17.6901         16.7412
140171..........................................         14.1637         15.0237         15.2617         14.8002
140172..........................................         23.8431         23.6262         26.2314         24.4761
140173..........................................         15.1487         16.3924         16.0030         15.8459
140174..........................................         20.5339         35.9320         21.8272         23.9333
140176..........................................         23.2866         24.5338         26.2821         24.7364
140177..........................................         18.2648         15.0827         20.3142         17.5964
140179..........................................         21.1948         21.9859         22.6795         21.9485
140180..........................................         22.4548         22.7996         22.7508         22.6646
140181..........................................         20.8709         21.9864         22.6089         21.8164
140182..........................................         22.0170         28.9515         25.1352         24.9085
140184..........................................         17.8155         17.2401         17.9169         17.6582
140185..........................................         17.6514         18.2867         18.8573         18.2635
140186..........................................         22.7890         23.5034         20.7389         22.2767
140187..........................................         17.9201         18.3331         19.4049         18.5535
140188..........................................         15.2479         16.1907               *         15.6443
140189..........................................         21.0616         20.6627         21.1515         20.9599
140190..........................................         16.3366         17.5263         16.6673         16.8245
140191..........................................         25.8835         25.2628         27.4166         26.1852
140193..........................................         15.8022         17.4057         18.5651         17.2695
140197..........................................         18.6394         19.3774         19.9406         19.3426
140199..........................................         18.3507         18.0450         18.5409         18.3150
140200..........................................         21.5220         21.7680         22.5226         21.9573
140202..........................................         22.1939         23.7955         25.2777         23.7942
140203..........................................         19.9194         21.0848         24.8870         21.9324
140205..........................................         17.4751         20.0784               *         18.5139
140206..........................................         21.3295         22.5109         23.0603         22.2974
140207..........................................         21.9779         22.3905         25.4539         23.1447
140208..........................................         25.9900         26.2527         28.0890         26.7814
140209..........................................         18.1206         20.1557         20.2433         19.4720
140210..........................................         15.6899         14.8248         15.5345         15.3479
140211..........................................         21.8891         22.6265         22.8852         22.4887
140213..........................................         27.0645         24.9892         25.6839         25.9086
140215..........................................         15.9949         15.2893         18.5502         16.5949
140217..........................................         24.8229         25.7329         25.6584         25.3935
140218..........................................         14.9459         14.9851         17.4171         15.7345
140220..........................................         17.6370         17.8450         19.3915         18.3036
140223..........................................         24.9249         24.9017         26.2168         25.3383
140224..........................................         25.8668         32.8292         24.7882         27.5872
140228..........................................         19.6988         20.1688         21.2764         20.3895
140230..........................................         18.0918         18.2983               *         18.1984
140231..........................................         23.9176         24.5019         26.0439         24.9346
140233..........................................         19.4542         21.2333         23.5331         21.4436
140234..........................................         18.9945               *         19.7266         19.3554
140236..........................................               *         12.9253               *         12.9253
140239..........................................         18.8127         20.3745         20.9926         20.0958
140240..........................................         23.6860         24.6949         25.1418         24.5193
140242..........................................         24.5428         25.2317         26.1850         25.3655
140245..........................................         13.4839         14.2481         15.1320         14.2800
140246..........................................         13.4639         11.6267         15.0650         13.2908
140250..........................................         25.0876         23.6449         25.3410         24.6985
140251..........................................         21.4385         21.9435         23.3971         22.2702
140252..........................................         25.2246         25.0220         26.0869         25.4562
140253..........................................         18.5511         19.5858         18.4567         18.8447
140258..........................................         23.2973         25.3622         24.3731         24.3357
140271..........................................         15.5079         12.0079         16.0350         14.2915
140275..........................................         20.1699         23.8171         21.8908         21.8947
140276..........................................         26.6777         25.3134         26.1713         26.0267
140280..........................................         20.2360         18.8300         20.0763         19.6936
140281..........................................         24.0192         25.2719         26.5197         25.2957

[[Page 31542]]

 
140285..........................................         18.1181         18.5916         15.7435         17.3779
140286..........................................         20.3735         26.1290         24.0947         23.4832
140288..........................................         25.2327         24.4331         25.8717         25.1876
140289..........................................         17.1388         18.1747         15.9356         16.9462
140290..........................................         21.1784         22.8590         26.8449         23.6369
140291..........................................         25.0911         24.9537         26.8628         25.6578
140292..........................................         20.8560         21.9950         26.8610         23.2005
140294..........................................         17.7226         17.7301         19.4218         18.2830
140300..........................................         25.3662         27.8436         28.5457         27.2635
150001..........................................         22.8109         24.0620         22.1398         22.9956
150002..........................................         19.3401         20.7651         20.7353         20.3004
150003..........................................         19.7661         20.8636         22.3835         21.0177
150004..........................................         20.3685         21.2449         22.8060         21.4609
150005..........................................         20.6260         21.6806         22.5280         21.6427
150006..........................................         20.8158         20.6523         21.8435         21.1085
150007..........................................         20.1826         20.6635         21.2811         20.6934
150008..........................................         21.4545         21.8457         22.9042         22.0745
150009..........................................         18.7073         19.0030         19.4599         19.0578
150010..........................................         21.7125         20.5570         20.8213         21.0317
150011..........................................         18.3742         18.3275         19.8823         18.8436
150012..........................................         22.4751         22.1402         21.7903         22.1209
150013..........................................         17.0352         16.9327         17.5531         17.1857
150014..........................................         22.0143         21.5168         22.8402         22.1055
150015..........................................         22.5409         21.9037         24.2370         22.8616
150017..........................................         18.7664         19.5339         20.4814         19.6077
150018..........................................         20.4947         21.0496         23.0257         21.5245
150019..........................................         16.6327         17.8585         19.8341         18.0075
150020..........................................         15.1120         16.6600         15.9405         15.8686
150021..........................................         19.5096         21.5944         23.2077         21.4598
150022..........................................         19.1555         17.9222         18.7751         18.6044
150023..........................................         18.3598         19.3412         20.3015         19.3319
150024..........................................         18.4140         19.2295         19.8368         19.1528
150025..........................................         17.7007         20.2750               *         18.8948
150026..........................................         18.8417         22.4978         21.9448         21.0269
150027..........................................         17.3284         18.0335         19.4238         18.2383
150029..........................................         23.0546         23.2454         24.8939         23.7166
150030..........................................         17.9992         19.2406         20.5272         19.2757
150031..........................................         17.2429         18.3463         18.9672         18.2134
150033..........................................         21.8768         22.6741         23.0163         22.5338
150034..........................................         22.1317         23.1533         23.3718         22.8966
150035..........................................         20.4477         21.2374         22.3779         21.3734
150036..........................................         20.8692         21.4567         22.1464         21.5046
150037..........................................         21.7109         24.4611         22.3699         22.8076
150038..........................................         21.2193         22.0572         20.3454         21.1795
150039..........................................         18.4729         19.6215         16.0227         17.8696
150042..........................................         18.1632         20.2221         17.5614         18.5653
150043..........................................         19.0120         20.1741         20.5266         19.8572
150044..........................................         18.4381         19.1309         19.8951         19.1600
150045..........................................         16.8121         18.1670         21.3723         18.7127
150046..........................................         17.6342         18.2543         19.4146         18.4518
150047..........................................         19.7441         22.0145         21.9824         21.1814
150048..........................................         19.3329         19.1648         21.1441         19.9048
150049..........................................         17.0141         18.6451         21.6309         18.9803
150050..........................................         16.8354         17.7354         18.0411         17.5369
150051..........................................         19.0130         19.7257         20.6895         19.8190
150052..........................................         15.8590         17.3750         18.7783         17.3644
150053..........................................         19.1421         18.8632         17.8949         18.6402
150054..........................................         17.3825         18.3916         19.3424         18.3843
150056..........................................         22.4087         21.5774         23.0603         22.3391
150057..........................................         16.5882         16.9736               *         16.7800
150058..........................................         20.8178         22.1409         23.0273         22.0105
150059..........................................         21.2535         22.7360         22.9822         22.3129
150060..........................................         17.0743         18.6159         19.5011         18.4069

[[Page 31543]]

 
150061..........................................         17.3887         19.7968         19.4014         18.8242
150062..........................................         20.5415         20.8274         21.2608         20.9059
150063..........................................         22.0925         22.6525         24.8587         23.1574
150064..........................................         18.1400         20.3865         20.6232         19.7087
150065..........................................         19.8913         21.2153         21.4572         20.8676
150066..........................................         15.3373         19.5313         19.6845         18.2239
150067..........................................         18.2926         18.8862         19.8632         19.0434
150069..........................................         21.5310         23.3969         23.5510         22.9021
150070..........................................         17.9260         18.0827         18.9332         18.3136
150071..........................................         13.4760         13.5111         16.4179         14.3733
150072..........................................         16.2054         15.0765         18.5813         16.5238
150073..........................................         22.2968               *         19.7285         21.0407
150074..........................................         20.4175         20.2305         21.3821         20.6660
150075..........................................         15.5603         16.7532         17.1709         16.4680
150076..........................................         22.9382         22.6424         23.3724         22.9988
150078..........................................         19.2718         19.9668         20.2068         19.8183
150079..........................................         17.2436         18.2051         18.3668         17.9396
150082..........................................         17.5265         17.8381         19.6881         18.3251
150084..........................................         23.2506         24.3107         24.9054         24.1870
150086..........................................         18.9735         18.3838         19.7763         19.0552
150088..........................................         18.9869         20.3366         22.3055         20.5100
150089..........................................         23.8791         22.1725         21.0399         22.2998
150090..........................................         20.7726         21.0945         21.9803         21.2765
150091..........................................         20.4053         22.4640         26.2176         22.8558
150092..........................................         16.7434         16.9179         18.2592         17.3164
150094..........................................         16.5788         17.5244         16.7680         16.9454
150095..........................................         17.1324         19.2749         22.3214         19.5343
150096..........................................         23.2764         20.8204               *         21.9551
150097..........................................         19.3802         19.7751         21.0944         20.1363
150098..........................................         15.0943         15.2829         16.4763         15.6011
150099..........................................         22.4229               *               *         22.4229
150100..........................................         18.4148         19.8066         18.7289         18.9950
150101..........................................         16.4604         20.6209         20.9635         19.3121
150102..........................................         19.7426         23.7180         20.8818         21.3162
150103..........................................         18.4781         18.7036         19.2881         18.8849
150104..........................................         17.6981         20.0765         21.3141         19.7260
150105..........................................         20.0431         22.4412         21.6975         21.3454
150106..........................................         16.1510         16.8714         18.7088         17.2750
150109..........................................         18.8077         19.9066         21.6285         20.0890
150110..........................................         18.6627         21.9336               *         20.0654
150111..........................................         18.4556         19.2355         24.0256         20.3967
150112..........................................         20.4109         20.5253         22.1939         21.0672
150113..........................................         20.3780         19.6603         20.5871         20.2207
150114..........................................         19.5183         17.9877         18.3097         18.6233
150115..........................................         17.4315         18.4844         18.1308         18.0117
150122..........................................         18.7139         17.7867         20.7540         19.0652
150123..........................................         14.1105         14.0508         16.2898         14.8865
150124..........................................         14.6245         15.9487         16.2104         15.6060
150125..........................................         20.6735         21.3311         22.0021         21.3476
150126..........................................         21.3697         20.6857         24.0000         22.0092
150127..........................................         17.1994         17.0052         17.7858         17.3321
150128..........................................         18.5100         19.5576         20.3880         19.4584
150129..........................................         24.7711         28.6211         29.9888         27.3320
150130..........................................         18.1971         18.4846         18.3852         18.3505
150132..........................................         20.1684         20.9443         21.2747         20.8045
150133..........................................         17.3966         18.4250         19.0871         18.2346
150134..........................................         19.2526         19.3632         20.2764         19.6091
150136..........................................         20.1245         21.8097         22.9091         21.6195
150145..........................................         16.6851               *               *         16.6851
150146..........................................               *         19.0204               *         19.0204
160001..........................................         18.6035         19.0085         20.1699         19.2573
160002..........................................         15.9534         16.6003         17.6600         16.7287
160003..........................................         16.0862         16.2208         17.5429         16.6099

[[Page 31544]]

 
160005..........................................         17.6153         17.9405         19.3348         18.3156
160007..........................................         13.2101         15.1738         14.9137         14.4341
160008..........................................         15.9742         16.6193         16.7484         16.4416
160009..........................................         16.8391         17.9886         19.0664         17.9375
160012..........................................         16.4827         16.7112         17.9236         17.0145
160013..........................................         18.3996         18.6304         20.3023         19.1017
160014..........................................         15.9086         16.7146         18.7253         17.0747
160016..........................................         19.6322         19.9747         21.6050         20.4119
160018..........................................         14.5946         15.6141         16.0793         15.4308
160020..........................................         15.4712         15.5384         15.7960         15.6015
160021..........................................         16.5049         16.7617         16.7920         16.6812
160023..........................................         15.0665         15.0099         15.3854         15.1530
160024..........................................         19.7050         19.4764         20.5622         19.9066
160026..........................................         18.8379         19.5260         20.4567         19.6047
160027..........................................         16.3477         16.9417         18.2081         17.1431
160028..........................................         19.9595         21.0000               *         20.4650
160029..........................................         20.4678         21.3457         22.2106         21.3395
160030..........................................         19.9508         19.6182         21.6899         20.4018
160031..........................................         15.2448         16.1267         16.8957         16.0812
160032..........................................         17.3202         18.3168         19.2464         18.2782
160033..........................................         18.8673         18.8859         20.1916         19.3159
160034..........................................         15.0019         16.5957         17.3644         16.3397
160035..........................................         15.2211         16.3991         17.0165         16.0816
160036..........................................         17.8849         17.4558         20.2598         18.5977
160037..........................................         19.0532         19.5045         19.5067         19.3582
160039..........................................         17.4758         17.8647         19.1998         18.1868
160040..........................................         18.1949         18.0667         19.6339         18.6033
160041..........................................         16.7850         17.4435         18.7943         17.7638
160043..........................................         15.6909         14.8564         16.7841         15.7684
160044..........................................         16.7439         17.8323         19.5552         18.0882
160045..........................................         20.1236         20.0611         21.4757         20.5590
160046..........................................         14.5655         16.2737         16.8665         15.8592
160047..........................................         18.3593         19.0787         20.4259         19.2869
160048..........................................         14.6144         15.6856         17.2709         15.7797
160049..........................................         14.5457         15.5673         15.3233         15.1526
160050..........................................         17.4912         17.7878         21.1184         18.6885
160051..........................................         14.6400         16.4261         15.8213         15.6207
160052..........................................         18.0941         21.7647         22.1933         20.7461
160054..........................................         16.1753         16.1981         16.5258         16.3024
160055..........................................         14.7600         15.1674         17.6177         15.8187
160056..........................................         16.1575         17.0172         17.9534         17.0042
160057..........................................         18.1776         19.1378         19.6802         19.0270
160058..........................................         21.1159         22.1061         23.2042         22.1074
160060..........................................         16.0436         17.2825         17.7489         16.9862
160061..........................................         17.3215         17.0938         17.2064         17.2123
160062..........................................         17.8086         17.4388         18.8163         18.0222
160063..........................................         16.8834         16.3583         17.3771         16.8779
160064..........................................         20.5496         22.2131         25.1546         22.5347
160065..........................................         16.9373         17.1043         17.0609         17.0424
160066..........................................         17.1875         17.9971         19.3202         18.1697
160067..........................................         17.8514         16.7833         17.6602         17.4022
160068..........................................         17.9892         19.0572         20.5995         19.2056
160069..........................................         19.7280         19.1640         20.4556         19.7835
160070..........................................         16.7017         18.4588         17.7855         17.6458
160072..........................................         14.9536         14.4141         15.3384         14.9054
160073..........................................         11.8261         11.4997         15.5946         12.7126
160074..........................................         19.5092         17.9513         18.4624         18.6658
160075..........................................         19.4948         18.4613         20.7842         19.5335
160076..........................................         17.9381         17.8824         19.1590         18.2977
160077..........................................         12.8826         13.6658         15.0468         13.8624
160079..........................................         17.6187         18.6333         20.5010         18.9292
160080..........................................         18.6687         19.4925         19.6680         19.2860
160081..........................................         17.0052         17.4466         19.1442         17.8781

[[Page 31545]]

 
160082..........................................         19.6499         19.5322         20.6425         19.9343
160083..........................................         20.6189         19.7542         21.3221         20.5512
160085..........................................         18.0063         21.2557         19.1929         19.4359
160086..........................................         17.3271         17.5308         19.0477         17.9338
160088..........................................         20.2331         22.3655         23.8098         22.1152
160089..........................................         16.9538         17.3449         18.3526         17.5556
160090..........................................         17.1090         17.9614         18.4210         17.8146
160091..........................................         12.8516         14.2573         14.8904         13.9759
160092..........................................         15.5011         17.0633         17.9251         16.7839
160093..........................................         17.7457         18.5675         19.5732         18.6194
160094..........................................         18.7653         17.6094         18.7835         18.3744
160095..........................................         15.1895         15.2722         16.4927         15.6525
160097..........................................         15.9263         16.6790         17.7860         16.8002
160098..........................................         16.3135         16.8670         16.8997         16.6946
160099..........................................         13.9053         15.0880         16.0710         15.0169
160101..........................................         18.3705         18.9788         19.6314         18.9647
160102..........................................         18.8765         20.1161         14.4837         17.6011
160103..........................................         17.0973         18.2741         19.6168         18.2567
160104..........................................         18.8301         17.4829         21.0060         19.1043
160106..........................................         16.9639         17.3474         19.4385         17.8892
160107..........................................         18.0634         18.0097         18.8936         18.3269
160108..........................................         16.0529         16.7779         17.7577         16.8631
160109..........................................         16.5593         17.9873         18.2938         17.5854
160110..........................................         19.1420         20.6215         20.9346         20.2607
160111..........................................         14.1644         14.9965         15.1104         14.7432
160112..........................................         16.8332         17.2450         19.6950         17.9037
160113..........................................         14.7097         15.4834         14.9449         15.0474
160114..........................................         16.1423         16.5006         18.0532         16.8768
160115..........................................         15.8995         16.5654         16.9991         16.4863
160116..........................................         16.9534         16.6993         18.4261         17.3468
160117..........................................         17.9410         18.7615         19.9040         18.8566
160118..........................................         17.2523         19.4472         17.1480         17.8721
160120..........................................         10.5992         15.6789         15.0577         13.1432
160122..........................................         18.9252         18.1469         18.8469         18.6451
160124..........................................         18.0908         19.1600         19.9144         19.0634
160126..........................................         17.8142         19.4903         17.6813         18.2418
160129..........................................         16.7131         17.2112         18.0113         17.3098
160130..........................................         16.0528         15.6666         16.2628         15.9955
160131..........................................         15.4898         16.0424         16.5397         16.0265
160134..........................................         13.4743         15.3012         14.6396         14.4558
160135..........................................         18.2682         18.7711         18.3973         18.4829
160138..........................................         16.8699         17.1491         18.3957         17.4264
160140..........................................         18.4007         18.5630         19.6155         18.8655
160142..........................................         16.2875         18.1467         17.2792         17.2139
160143..........................................         16.6154         17.4497         18.1287         17.4014
160145..........................................         13.9152         16.9092         17.8887         16.1391
160146..........................................         16.6024         17.7010         19.0576         17.7319
160147..........................................         17.4880         19.4041         21.6062         19.3700
160151..........................................         16.8257         17.2177         18.3398         17.4331
160152..........................................         15.6170         15.9500         17.0750         16.1956
160153..........................................         20.2316         21.2085         22.7004         21.3705
170001..........................................         17.9304         17.9218         18.3934         18.0897
170004..........................................         15.0636         16.1442         17.2262         16.1274
170006..........................................         17.2192         17.5982         19.1802         18.0107
170008..........................................         14.9124         16.8412         17.7061         16.4380
170009..........................................         20.7795         23.1349         25.0155         23.0594
170010..........................................         18.7384         19.4584         19.5990         19.2633
170012..........................................         17.8719         18.4432         20.2281         18.8642
170013..........................................         18.6454         19.4667         20.1123         19.4285
170014..........................................         17.9349         18.4931         19.3973         18.6216
170015..........................................         16.5750         17.1302         17.2443         16.9768
170016..........................................         19.2130         20.0675         20.9301         20.0460
170017..........................................         17.7958         19.5994         19.7908         19.0428

[[Page 31546]]

 
170018..........................................         15.2984         15.3237         14.8794         15.1619
170019..........................................         15.2094         16.9362         17.3043         16.4640
170020..........................................         17.3400         18.1325         18.9345         18.1573
170022..........................................         18.5309         19.1888         20.3269         19.3395
170023..........................................         19.1351         19.2441         19.6533         19.3514
170024..........................................         13.6803         14.3604         15.0081         14.3388
170025..........................................         17.8667         18.7182         19.1720         18.5412
170026..........................................         15.0470         14.8974         16.6547         15.5216
170027..........................................         17.3604         17.8690         18.4466         17.8805
170030..........................................         14.6530         15.9282         12.9413         14.4010
170031..........................................         13.9601         14.2151         16.4660         14.7972
170032..........................................         15.6093         16.3449         15.2207         15.7224
170033..........................................         16.4059         19.1952         21.2104         18.9788
170034..........................................         15.8202         16.9586         17.8239         16.8326
170035..........................................         18.5885         17.0945         19.8334         18.5082
170038..........................................         14.7776         13.8582         15.2505         14.6401
170039..........................................         15.8635         17.0774         18.5780         17.1811
170040..........................................         21.6440         21.0617         23.1014         21.8449
170041..........................................         11.7566         12.4488          9.9263         11.2790
170044..........................................         15.3011         17.3254               *         16.3356
170045..........................................         14.0875         25.8331         20.5454         19.8078
170049..........................................         19.9415         20.7921         21.2917         20.7035
170051..........................................         15.0889         16.4851         16.9003         16.1546
170052..........................................         15.0108         15.2283         16.0948         15.4803
170053..........................................         16.5102         14.6133         14.3628         15.2080
170054..........................................         14.4353         14.6354         15.1330         14.7339
170055..........................................         16.9800         18.2607         18.1783         17.7932
170056..........................................         17.0442         18.3550         19.7369         18.3732
170057..........................................         13.0007               *               *         13.0007
170058..........................................         18.6983         19.5415         20.1090         19.4664
170060..........................................         17.3482         18.9853         17.5290         17.8991
170061..........................................         15.6527         15.0258         15.2924         15.3392
170063..........................................         12.8082         14.1185         13.7611         13.4911
170066..........................................         15.5322         16.2891         16.8009         16.1505
170067..........................................         14.7492         14.9921         20.7945         16.7328
170068..........................................         15.1790         17.0022         19.2629         17.0101
170070..........................................         14.2445         14.0627         14.8348         14.3652
170072..........................................         12.6329         12.7709               *         12.7037
170073..........................................         17.5368         17.7056         17.7586         17.6632
170074..........................................         17.5537         17.3699         17.2800         17.4035
170075..........................................         12.4212         13.6816         14.4939         13.5832
170076..........................................         14.5866         14.6109         14.9392         14.7111
170077..........................................         13.5235         13.9104         14.1376         13.8508
170079..........................................         13.5261         11.5902         16.7227         13.6766
170080..........................................         12.6014         14.8293         13.6794         13.6471
170081..........................................         13.8077         14.6823         15.0840         14.5566
170082..........................................         12.8563         13.7462         14.8154         13.7610
170084..........................................         12.5410         13.0519         13.5927         13.0488
170085..........................................         15.4518         17.5422         21.8907         18.4877
170086..........................................         20.4068         19.7182         20.2892         20.1437
170088..........................................         13.4542         13.4860               *         13.4703
170089..........................................         18.8136         15.4860         20.2263         18.3293
170090..........................................         11.9147         10.9444               *         11.4573
170093..........................................         13.5490         14.0276         14.7803         14.0852
170094..........................................         20.1985         21.2035         21.2484         20.8944
170095..........................................         15.5463         15.3532         16.1078         15.6715
170097..........................................         16.4608         17.7540         18.6805         17.6242
170098..........................................         15.5259         16.6210         17.3480         16.4881
170099..........................................         13.6033         14.3370         16.5247         14.7568
170101..........................................         14.5629         18.0143         17.3381         16.4637
170102..........................................         13.6321         14.2447         14.4499         14.1084
170103..........................................         17.2844         17.9530         18.6172         17.9709
170104..........................................         20.6182         21.0049         21.9487         21.1996

[[Page 31547]]

 
170105..........................................         16.5408         16.7403         18.2788         17.1877
170106..........................................         18.5479         17.7467               *         18.0680
170109..........................................         17.2629         16.9782         18.3483         17.5682
170110..........................................         16.9823         18.5731         21.0637         18.8359
170112..........................................         14.3855         15.4049         15.8097         15.1873
170113..........................................         13.9038         14.6486         16.4938         15.0142
170114..........................................         14.4545         16.2645         13.8347         14.7519
170115..........................................         12.6997         12.9216         13.0253         12.8848
170116..........................................         16.8714         18.1830         19.4278         18.1442
170117..........................................         15.7875         16.8237         16.8301         16.4481
170119..........................................         15.1990         15.2708         15.1982         15.2222
170120..........................................         17.6748         17.4917         18.2061         17.7788
170122..........................................         20.0615         21.1769         21.4205         20.8657
170123..........................................         23.1697         23.6534         25.2071         23.9580
170124..........................................         11.1249         15.0596         16.3925         13.8286
170126..........................................         12.8096         13.5736         14.5527         13.6140
170128..........................................         14.8891         14.1676         17.6259         15.4144
170131..........................................         10.1000               *               *         10.1000
170133..........................................         18.0243         18.8119         19.9778         18.9214
170134..........................................         14.1085         14.6799         15.1932         14.6538
170137..........................................         17.8290         19.3118         19.3344         18.8395
170139..........................................         14.1967         14.3001         14.8157         14.4193
170142..........................................               *         17.7134         18.9169         18.3246
170143..........................................         15.6509         16.0415         16.3258         16.0049
170144..........................................         19.0929         20.4392         20.7583         20.0727
170145..........................................         17.1837         19.0142         18.1398         18.1031
170146..........................................         20.9075         21.7919         25.4405         22.7798
170147..........................................         22.3017         17.6717         17.4968         19.0192
170148..........................................         16.9183         19.1942         24.4828         19.5145
170150..........................................         15.5651         15.9072         14.9718         15.4692
170151..........................................         13.8934         14.3668         14.5002         14.2317
170152..........................................         14.9139         15.6423         16.0930         15.5503
170160..........................................         13.7108         14.4732         17.0629         15.0179
170164..........................................         16.6542         17.4072         17.0791         17.0445
170166..........................................         27.5567         12.7507         16.5113         18.0323
170171..........................................         12.5200         13.1792         14.7051         13.3708
170175..........................................         19.0232         20.1907         19.9712         19.7266
170176..........................................         21.3400         23.5043         23.5743         22.8029
170180..........................................         16.6921          8.6352               *         11.8552
170182..........................................         22.2164         21.3454         21.9797         21.8339
170183..........................................         20.3505         19.5182         16.6577         18.5979
170185..........................................               *               *         26.6814         26.6814
170186..........................................               *               *         32.9088         32.9088
180001..........................................         17.9906         20.4885         20.8419         19.8481
180002..........................................         17.9669         17.5798         19.7742         18.4114
180004..........................................         17.2581         17.7149         18.0494         17.6734
180005..........................................         21.1390         22.4634         23.4941         22.1458
180006..........................................         11.4398         10.3400         11.2872         11.0389
180007..........................................         17.6776         17.9491         18.6823         18.0973
180009..........................................         21.4730         21.0608         21.7746         21.4458
180010..........................................         19.1100         19.6311         19.4210         19.3847
180011..........................................         17.1050         19.0526         22.6798         19.8513
180012..........................................         18.7223         19.0646         19.6614         19.1485
180013..........................................         18.2354         19.7418         19.9690         19.3345
180014..........................................         21.4856         21.3361         22.9674         21.8678
180016..........................................         19.8892         21.1458         19.7132         20.2640
180017..........................................         15.4140         15.6583         16.7649         15.9422
180018..........................................         17.1692         15.4892         17.2357         16.6084
180019..........................................         17.3970         17.8285         19.0883         18.1044
180020..........................................         17.7288         18.0111         19.3978         18.3483
180021..........................................         15.4580         17.0618         16.5376         16.3552
180023..........................................         15.8803         17.4717         19.0574         17.4610
180024..........................................         16.1731         16.5040         19.6313         17.2961

[[Page 31548]]

 
180025..........................................         14.1841         15.4180         17.1875         15.5888
180026..........................................         14.6804         15.0118         13.9959         14.5545
180027..........................................         16.4116         17.5286         19.6928         17.8399
180028..........................................         19.5276         15.7005         26.1723         19.5534
180029..........................................         17.7729         17.7248         20.0357         18.4826
180030..........................................         17.3430         17.9543         17.5043         17.5959
180031..........................................         13.9844         13.1848         17.1003         14.4541
180032..........................................         16.8318         17.2784         17.2362         17.1383
180033..........................................         17.7344         15.4131         17.0498         16.6984
180034..........................................         15.3369         16.3991         17.0349         16.2188
180035..........................................         20.1305         21.3666         22.6728         21.3628
180036..........................................         19.8398         20.1860         20.6951         20.2522
180037..........................................         19.9737         21.2184         21.0177         20.7450
180038..........................................         17.7626         18.5923         19.0457         18.4790
180040..........................................         19.5337         21.2229         22.1332         20.9525
180041..........................................         15.0785         16.3699         17.5950         16.3724
180042..........................................         16.7691         17.1519         15.5660         16.4438
180043..........................................         16.8027         14.6526         17.0419         16.0656
180044..........................................         18.5571         19.4984         21.1057         19.7654
180045..........................................         17.7130         20.8455         20.7850         19.9661
180046..........................................         19.2523         21.2080         20.8544         20.4279
180047..........................................         16.2304         18.6938         17.8625         17.5927
180048..........................................         18.3442         17.7816         18.3151         18.1431
180049..........................................         16.4319         16.5459         17.0422         16.6742
180050..........................................         17.8540         17.1493         19.4583         18.1528
180051..........................................         16.3960         17.5441         17.7358         17.2163
180053..........................................         15.9284         15.8994         17.3167         16.3733
180054..........................................         19.4858         20.0946         17.4354         19.0288
180055..........................................         15.2663         15.8422         16.6072         15.8890
180056..........................................         17.0056         17.5881         18.6075         17.7242
180058..........................................         15.9685         14.5355         14.7900         15.0323
180059..........................................         13.3955         14.7032         17.2542         14.9522
180063..........................................         13.1036         12.4448         14.7338         13.4418
180064..........................................         15.2424         15.5066         16.3894         15.6781
180065..........................................         12.0629         11.1934         11.0966         11.4164
180066..........................................         19.2981         19.8956         19.4875         19.5598
180067..........................................         20.6322         20.1712         20.2762         20.3589
180069..........................................         17.7911         16.2916         19.0443         17.6808
180070..........................................         13.1923         15.9362         15.4643         14.7849
180072..........................................         16.9021         17.2347         17.0576         17.0759
180078..........................................         21.1170         21.7116         22.2802         21.7169
180079..........................................         15.1636         15.9048         18.1683         16.3817
180080..........................................         16.4989         16.6428         17.5659         16.9072
180087..........................................         14.9167         15.6089         16.2378         15.5798
180088..........................................         22.0374         22.1774         22.8908         22.3519
180092..........................................         18.2405         18.3597         18.8964         18.5113
180093..........................................         17.0132         17.8492         17.6961         17.5099
180094..........................................         13.5490         13.6233         14.3306         13.8326
180095..........................................         13.8021         13.9050         15.4478         14.3114
180099..........................................         13.3631         13.2991         14.0464         13.5559
180101..........................................         18.4883               *         20.2958         19.4148
180102..........................................         17.9618         18.5240         16.6998         17.7006
180103..........................................         19.8965         20.3490         20.8866         20.3712
180104..........................................         18.9281         19.3922         20.3023         19.5481
180105..........................................         15.2394         16.6997         18.2976         16.6579
180106..........................................         14.3505         15.2895         15.5278         15.0462
180108..........................................         14.8187         14.4740         14.8720         14.7266
180115..........................................         16.7003         16.9096         18.0951         17.2235
180116..........................................         18.0392         18.6077         18.1923         18.2836
180117..........................................         17.7857         23.0192         20.7961         20.3977
180118..........................................         15.8597         16.9250         17.9017         16.8657
180120..........................................         16.1591         15.3115         16.4226         15.9318
180121..........................................         15.0983         20.0494         16.9570         17.2427

[[Page 31549]]

 
180122..........................................         18.5094         18.1930         18.7549         18.4922
180123..........................................         21.0613         21.1067         21.8227         21.3332
180124..........................................         17.4994         18.8487         19.7138         18.6761
180125..........................................         19.6416         14.9314         22.6161         18.1828
180126..........................................         12.9228         14.3551         14.8501         14.0804
180127..........................................         19.2581         17.6365         18.0498         18.2667
180128..........................................         17.6385         18.2817         18.7194         18.2299
180129..........................................         16.8378         22.3536         15.6637         17.9690
180130..........................................         19.8192         20.6450         21.9268         20.8000
180132..........................................         17.7744         19.5884         19.4233         18.9093
180133..........................................         21.6794         21.7800         23.2679         22.2101
180134..........................................         13.1935         14.5387         16.5901         14.7149
180136..........................................         17.3542               *               *         17.3542
180138..........................................         19.3692         20.2102         19.8524         19.8199
180139..........................................         18.7198         20.5350         20.3816         19.9038
180140..........................................         16.8152         15.2719         14.6466         15.5892
180141..........................................         20.9820         23.8930         23.0957         22.5668
180142..........................................               *          20.751               *         20.7510
180143..........................................               *               *         21.3197         21.3197
190001..........................................         17.6832         18.1514         18.8583         18.2414
190002..........................................         19.1924         19.8834         20.6057         19.8935
190003..........................................         19.7749         19.9121         19.5115         19.7281
190004..........................................         17.7710         18.3620         19.6755         18.6227
190005..........................................         17.2422         17.5161         18.6994         17.8286
190006..........................................         17.8036         17.5911         17.7333         17.7115
190007..........................................         13.8189         14.4720         15.8753         14.7770
190008..........................................         18.6664         19.2456         22.4797         20.0804
190009..........................................         15.3555         15.9731         16.0395         15.7936
190010..........................................         16.2805         16.5020         17.7616         16.8604
190011..........................................         15.9534         15.6351         15.7319         15.7701
190013..........................................         16.8181         15.5019         16.7770         16.3476
190014..........................................         17.0959         17.8015         18.6929         17.8513
190015..........................................         18.6266         18.9896         19.7673         19.1223
190017..........................................         16.2393         17.5381         19.8449         17.8836
190018..........................................         15.0668         11.1898         13.1355         13.0348
190019..........................................         18.5257         18.3788         18.6473         18.5189
190020..........................................         17.5256         17.6840         18.7252         17.9732
190025..........................................         18.6369         16.8686         18.1892         17.9111
190026..........................................         18.1622         18.5015         18.8895         18.5256
190027..........................................         17.0827         17.4761         18.3203         17.6149
190029..........................................         16.5239         19.1967         18.7344         18.0923
190034..........................................         16.8503         18.0754         19.2007         18.0146
190036..........................................         20.1780         20.0300         21.1870         20.4494
190037..........................................         17.6945         19.9878         14.1323         17.4581
190039..........................................         19.4713         19.0376         17.8217         18.7156
190040..........................................         21.4634         21.7376         23.0537         22.0787
190041..........................................         17.6646         17.9535         17.2344         17.5871
190043..........................................         15.5580         15.5618         15.5645         15.5614
190044..........................................         17.2892         17.4471         17.6788         17.4765
190045..........................................         21.6107         21.2853         22.0065         21.6574
190046..........................................         19.7964         20.4458         20.2414         20.1666
190048..........................................         16.6683         16.8136         16.6848         16.7218
190049..........................................         17.2280         17.7417         18.5902         17.8611
190050..........................................         16.1980         16.2854         16.9053         16.4718
190053..........................................         13.2159         13.0080         13.4768         13.2412
190054..........................................         19.1738         18.9059         17.7269         18.6351
190059..........................................         15.6942         15.8373         17.8651         16.5018
190060..........................................         14.7186         17.8443         19.9121         17.2297
190064..........................................         20.4482         18.2466         19.9873         19.5473
190065..........................................         20.9927         18.3091         18.3050         19.0764
190071..........................................         14.4827         16.4138         16.3822         15.7772
190077..........................................         15.7805         16.5536         16.8829         16.4072
190078..........................................         14.8826         16.9383         19.5879         16.9873

[[Page 31550]]

 
190079..........................................         17.7120         17.9403         18.1929         17.9449
190081..........................................         15.3198         14.9707         14.7919         15.0273
190083..........................................         18.8895         18.4951         16.2970         17.9487
190086..........................................         15.8694         16.5074         17.6237         16.6689
190088..........................................         20.5531         19.9362         20.4725         20.3095
190089..........................................         13.0503         15.0395         15.2055         14.4221
190090..........................................         16.6664         16.2351         19.8201         17.5803
190095..........................................         16.2287         17.3258         17.3637         16.9543
190098..........................................         20.4897         21.0847         22.5793         21.3421
190099..........................................         19.9018         19.0635         19.0545         19.3385
190102..........................................         20.0300         20.7870         21.0423         20.6389
190103..........................................         12.1389         14.4158         15.6415         14.0050
190106..........................................         18.5813         18.5908         19.9117         19.0267
190109..........................................         15.5767         15.8187         16.3641         15.9327
190110..........................................         15.8052         15.7313         15.2652         15.5956
190111..........................................         19.7514         20.6508         20.2253         20.2164
190112..........................................         21.0232         22.0741         24.2806         22.3499
190113..........................................         12.5777               *         19.0411         16.0667
190114..........................................         12.6366         13.9209         13.4402         13.3357
190115..........................................         20.2473         22.7583         23.7462         22.1782
190116..........................................         15.5481         17.3757         18.3223         17.0452
190118..........................................         14.7876         16.3776         17.8543         16.2736
190120..........................................         13.9591         17.2309         17.6708         16.2867
190122..........................................         15.4793         15.3742         16.7189         15.8764
190124..........................................         20.6222         20.1206         22.8245         21.2142
190125..........................................         20.4517         19.8298         20.1401         20.1511
190128..........................................         20.4688         20.8770         21.1465         20.8466
190130..........................................         15.1467         14.0379         14.5586         14.5812
190131..........................................         20.7565         18.8958         19.7483         19.8133
190133..........................................         13.5383         15.1393         15.7834         14.7342
190134..........................................         12.1749         12.4507               *         12.3182
190135..........................................         21.6875         21.3454         23.1434         22.0401
190136..........................................         12.4091         15.1662         15.6286         14.4513
190140..........................................         14.2256         14.6829         14.8738         14.5954
190142..........................................         15.4861         16.2280         19.0464         16.8845
190144..........................................         16.2068         18.4405         18.3513         17.6419
190145..........................................         15.2345         16.2505         16.4402         15.9754
190146..........................................         21.2825         21.9607         20.6776         21.3057
190147..........................................         14.4345         14.7202         15.2732         14.8106
190148..........................................         16.6337         15.5338         19.4518         17.1031
190149..........................................         17.5997         16.4722         16.5153         16.8165
190151..........................................         14.7333         15.5210         16.2783         15.5127
190152..........................................         22.2070         22.0319         22.7142         22.3160
190156..........................................         15.7478         16.0442         17.6573         16.4812
190158..........................................         20.4637         20.4078         21.6307         20.8104
190160..........................................         17.1003         18.4662         19.3139         18.3349
190161..........................................         15.5737         15.9280         15.7807         15.7581
190162..........................................         20.6143         20.1962         20.9645         20.5966
190164..........................................         15.1783         18.2379         19.0473         17.3930
190167..........................................         16.6681         17.7611         15.5795         16.5709
190170..........................................         14.1750         14.5222         16.2045         15.0173
190173..........................................         23.6398         23.0934               *         23.4298
190175..........................................         19.3625         20.4580         22.2470         20.7017
190176..........................................         24.0574         22.2316         21.7051         22.5987
190177..........................................         18.6715         19.7794         20.3679         19.5997
190178..........................................         11.0657         12.0372               *         11.5413
190182..........................................         20.2855         20.7102         23.1997         21.3232
190183..........................................         16.7671         16.0752         16.7402         16.5275
190184..........................................         17.2044         19.8436         18.6583         18.5582
190185..........................................         20.1444         20.5852         20.5454         20.4315
190186..........................................         18.7568         17.4078         16.7272         17.7093
190190..........................................         17.4642         15.8985         13.7951         15.8564
190191..........................................         20.4975         19.6911         19.7218         19.9785

[[Page 31551]]

 
190196..........................................         17.9225         18.6138         19.1961         18.6202
190197..........................................         19.5569         20.2082         20.5377         20.1371
190199..........................................         16.0637         15.3522         17.8288         16.5088
190200..........................................         22.0391         21.6852         22.3510         22.0311
190201..........................................         18.7079         19.7421         21.5656         20.0412
190202..........................................               *               *         22.4701         22.4701
190203..........................................         21.7350         21.7931         23.0636         22.1708
190204..........................................         21.4624         20.5784         22.9134         21.6176
190205..........................................         19.6587         19.3737         18.8750         19.3122
190206..........................................         21.7012         21.3307         21.7867         21.6067
190207..........................................         20.5082         19.0216         20.7024         20.0851
190208..........................................         20.0065         16.9641         17.6834         18.1192
190218..........................................         19.7518         19.2992         20.7290         19.9128
190231..........................................         15.8287         17.7247               *         16.7208
190236..........................................         19.3395         21.1982         22.5796         21.1124
190238..........................................               *         20.6799               *         20.6799
190239..........................................               *         19.7601               *         19.7601
190240..........................................               *         14.3579         16.0112         15.2482
200001..........................................         18.0527         18.2513         19.9438         18.7634
200002..........................................         19.3629         22.3035         22.3272         21.3905
200003..........................................         16.9566         18.4141         18.8570         18.0991
200006..........................................         17.6586         21.0922         24.1167         20.8621
200007..........................................         18.7992         18.1681         19.4177         18.7699
200008..........................................         21.7489         21.5556         24.2833         22.5897
200009..........................................         22.2280         21.4763         23.2456         22.3157
200012..........................................         18.3484         19.1047         20.9187         19.4746
200013..........................................         18.0566         17.9378         20.2192         18.8221
200016..........................................         18.0866         17.1187         16.2939         17.1580
200017..........................................         17.2930               *               *         17.2930
200018..........................................         18.5397         17.8675         20.6104         19.0069
200019..........................................         19.2348         19.9245         21.3003         20.1669
200020..........................................         22.4526         22.3355         24.8195         23.2627
200021..........................................         19.9133         20.7361         22.4038         21.0287
200023..........................................         16.1707         20.2063               *         18.0379
200024..........................................         19.4329         20.8336         21.2346         20.5158
200025..........................................         20.2259         20.4165         21.6002         20.7762
200026..........................................         18.1194         17.9021         21.4758         18.9050
200027..........................................         18.5659         19.4220         20.2146         19.4316
200028..........................................         19.5708         18.8763         19.9926         19.4914
200031..........................................         16.2217         16.1641         17.3915         16.5880
200032..........................................         18.9315         19.4613         20.8973         19.7659
200033..........................................         21.8634         22.4685         23.6538         22.6396
200034..........................................         20.1519         20.4941         21.3303         20.6756
200037..........................................         18.6713         20.3015         19.7768         19.6048
200038..........................................         23.3851         21.2632         22.9629         22.5227
200039..........................................         19.8589         20.1508         21.0884         20.3830
200040..........................................         19.5503         18.9580         19.5917         19.3665
200041..........................................         19.3563         18.8131         20.3761         19.5462
200043..........................................         16.7224         19.4295         19.8833         18.5621
200050..........................................         20.1214         20.2014         14.6387         17.8681
200051..........................................         22.1525         22.0712               *         22.1031
200052..........................................         17.2099         17.6271         19.9239         18.2260
200055..........................................         18.8422         18.5983         19.4998         18.9700
200062..........................................         17.2273         18.4279         18.4038         18.0038
200063..........................................         19.9331         21.2121         22.5278         21.2360
200066..........................................         17.0289         17.0570         18.7143         17.6294
210001..........................................         20.4841         18.6617         21.5280         20.1745
210002..........................................         19.9219         23.5132         21.1426         21.7024
210003..........................................         20.3446         26.0447         21.6625         22.4257
210004..........................................         24.2909         24.9760               *         24.6345
210005..........................................         21.4929         21.3829         23.8670         22.2506
210006..........................................         18.9436         19.3682         20.8607         19.7283
210007..........................................         23.1007         23.8840         23.4582         23.4837

[[Page 31552]]

 
210008..........................................         21.1768         21.2895         21.0767         21.1826
210009..........................................         20.5447         20.7479         20.8476         20.7179
210010..........................................         18.7197         19.5908         19.7917         19.3735
210011..........................................         21.4862         21.4043         20.0662         20.9726
210012..........................................         20.7203         21.3977         24.0745         21.9907
210013..........................................         19.7288         19.4505         23.1649         20.7921
210015..........................................         16.1912         18.7448         23.9651         19.4078
210016..........................................         23.8739         26.5193               *         25.1634
210017..........................................         18.8928         18.5079         18.2963         18.5724
210018..........................................         22.2135         22.8553         23.6442         22.8975
210019..........................................         19.3046         20.6025         21.5429         20.4724
210022..........................................         22.6389         24.5744         25.6728         24.3137
210023..........................................         23.1950         22.9989         24.4815         23.5799
210024..........................................         20.6011         24.4280         24.7858         23.2181
210025..........................................         19.5876         21.2769         21.4910         20.6428
210026..........................................         12.1348         13.8668         20.7986         14.8993
210027..........................................         17.6855         17.1060         16.2219         17.0429
210028..........................................         19.6408         19.4157         20.4027         19.8293
210029..........................................         21.2167         25.4939         24.7605         23.8903
210030..........................................         21.7403         20.9574         21.9547         21.5644
210031..........................................         16.2299               *               *         16.2299
210032..........................................         17.7228         20.1955         20.0825         19.3625
210033..........................................         20.8053         23.7588         22.8303         22.4103
210034..........................................         15.7322         19.4144         22.6812         19.1023
210035..........................................         20.2731         20.8317         21.6662         20.9231
210037..........................................         18.3072         20.5528         19.2811         19.3731
210038..........................................         23.4971         24.9762         25.9701         24.7755
210039..........................................         19.9901         21.3559         23.3583         21.5884
210040..........................................         21.5014         23.4252         23.1960         22.7040
210043..........................................         19.6474         22.4000         22.9504         21.5561
210044..........................................         22.5781         23.0917         22.9540         22.8695
210045..........................................         11.6086         12.1467         13.5654         12.4021
210048..........................................         23.0537         24.6921         24.9381         24.2387
210049..........................................         19.0821         19.3022         21.1056         19.8459
210051..........................................         22.4335         23.6476         24.8949         23.6510
210054..........................................         22.3559         23.2730         25.1694         23.5831
210055..........................................         29.2539         26.5272         23.8025         26.3168
210056..........................................         19.2662         22.9593         23.8915         21.9932
210057..........................................         23.8289         26.0076               *         24.8719
210058..........................................         22.0753         16.3191         17.4250         18.5418
210059..........................................         22.6766         25.6052               *         23.8855
210060..........................................               *         26.5846         26.4566         26.5245
210061..........................................         17.2240         16.1931         20.8975         18.1853
220001..........................................         21.9369         22.9064         23.4091         22.7509
220002..........................................         24.1285         24.5840         25.3171         24.6486
220003..........................................         16.9246         17.9319         17.6069         17.4814
220006..........................................         22.3085         22.6337         23.5624         22.8309
220008..........................................         24.4691         22.0796         23.0806         23.1592
220010..........................................         21.8582         22.0067         23.8256         22.5598
220011..........................................         26.1827         29.5290         24.8039         26.6476
220012..........................................         32.0829         31.2303         30.4104         31.2159
220015..........................................         22.5773         23.1893         24.1348         23.2890
220016..........................................         23.3750         23.0951         24.5411         23.6644
220017..........................................         22.4605         25.1568         25.9000         24.3877
220019..........................................         19.5613         19.8551         19.9268         19.7870
220020..........................................         21.4152         22.4295         22.5375         22.1352
220023..........................................         16.1885               *               *         16.1885
220024..........................................         21.5363         21.9316         23.8620         22.4506
220025..........................................         20.7882         22.8593         22.8936         22.1783
220028..........................................         22.8036         21.0630         24.0441         22.5673
220029..........................................         23.1509         25.6560         26.3117         25.0100
220030..........................................         18.5441         18.7429         19.3387         18.8705
220031..........................................         30.2430         29.3091         28.3832         29.0231

[[Page 31553]]

 
220033..........................................         20.0695         20.3609         22.3195         20.8616
220035..........................................         21.6396         23.1892         24.5685         23.0612
220036..........................................         24.6470         24.4091         24.9637         24.6635
220038..........................................         22.6518         22.3162         22.4302         22.4673
220041..........................................         23.4720         27.5034         28.6303         26.3941
220042..........................................         25.0779         26.0473         28.4675         26.3871
220046..........................................         22.7068         23.3149         23.8578         23.2791
220049..........................................         26.0025         27.2689         25.2174         26.1330
220050..........................................         22.0144         22.5265         23.3330         22.6222
220051..........................................         21.1033         21.7357         22.4826         21.7398
220052..........................................         23.7650         23.5225         24.4403         23.8995
220053..........................................         19.1280               *               *         19.1280
220055..........................................         21.3743               *               *         21.3743
220057..........................................         25.3902         25.8064         26.2945         25.8083
220058..........................................         19.9369         26.8345         21.6814         22.7654
220060..........................................         28.0843         28.0794         28.1888         28.1190
220062..........................................         20.4685         20.2254         16.0585         19.0019
220063..........................................         20.3951         20.8079         21.7336         21.0041
220064..........................................         22.3260         22.7497         23.8859         22.7342
220065..........................................         20.1364         20.1424         21.5556         20.6267
220066..........................................         20.7826         23.4477         24.5463         22.8901
220067..........................................         26.4443         27.5405         27.9807         27.2636
220070..........................................         19.7528         20.9128         21.0606         20.5677
220071..........................................         25.6184         27.4151         27.4906         26.8301
220073..........................................         25.6025         26.1328         27.4458         26.3872
220074..........................................         25.6390         24.3057         24.8908         24.8286
220075..........................................         22.8057         22.5329         24.5769         23.3112
220076..........................................         22.6668         23.2795         24.1224         23.3492
220077..........................................         25.2646         26.1545         27.1503         26.1736
220079..........................................         22.6256         22.0769         25.7305         22.9418
220080..........................................         21.5238         22.1971         22.9911         22.2508
220081..........................................         29.1726         29.6682         29.6399         29.4983
220082..........................................         21.6726         22.1453         22.9171         22.2513
220083..........................................         23.9156         22.5815         27.2605         24.4264
220084..........................................         23.6641         25.3761         25.8300         24.9680
220086..........................................         23.8705         26.7778         28.7276         26.2967
220088..........................................         22.9067         23.4258         25.0671         23.8081
220089..........................................         23.0965         25.4106         25.3521         24.5662
220090..........................................         22.0041         23.3049         25.0628         23.4549
220092..........................................         18.5239         24.7905               *         20.9405
220095..........................................         21.4831         21.7851         22.4924         21.9294
220098..........................................         21.5906         23.1547         24.7180         23.1447
220100..........................................         25.7077         27.5841         26.8001         26.6854
220101..........................................         25.9204         27.0711         27.9184         26.9502
220104..........................................         28.0021         28.7258               *         28.3658
220105..........................................         21.4129         21.9185         23.2210         22.2352
220106..........................................         25.6577         25.9277         28.1034         26.6044
220108..........................................         21.9115         23.4975         24.5939         23.3257
220110..........................................         28.7071         29.1648         30.2500         29.3820
220111..........................................         23.8066         24.7510         26.7336         25.0953
220116..........................................         26.1662         32.0049         28.4236         28.6928
220119..........................................         23.3216         23.8785         24.4507         23.8686
220123..........................................         25.8994         32.4678         28.8325         29.1153
220126..........................................         22.5218         23.6045         23.8123         23.3172
220133..........................................         25.4596         29.3911         29.8366         28.1948
220135..........................................         25.6522         28.3648         29.6837         27.9677
220153..........................................         22.9592               *               *         22.9592
220154..........................................         22.4770         21.1563         23.3590         22.3695
220163..........................................         29.1143         29.2299         29.3552         29.2328
220171..........................................         24.5553         24.9261         26.9048         25.5207
230001..........................................         19.8020         20.0438         23.3051         20.9963
230002..........................................         22.7991         23.0439         24.3115         23.3442
230003..........................................         19.8420         21.2215         21.6493         20.9088

[[Page 31554]]

 
230004..........................................         23.1036         20.5005         22.4538         21.9617
230005..........................................         18.5644         17.0943         20.5596         18.6769
230006..........................................         19.1041         20.4978         21.1974         20.2494
230007..........................................         15.5538               *               *         15.5538
230012..........................................         15.0803               *               *         15.0803
230013..........................................         20.8018         22.2211         20.0954         21.0266
230015..........................................         20.1104         20.6464         21.9499         20.8811
230017..........................................         22.2822         22.9755         25.7900         23.6501
230019..........................................         22.2622         23.6674         23.8779         23.3381
230020..........................................         22.1280         21.8526         28.8386         23.8749
230021..........................................         18.9636         19.8256         20.5690         19.8347
230022..........................................         18.8006         21.9129         21.7265         20.8153
230024..........................................         23.7326         24.9664         26.2155         24.8592
230027..........................................         14.6950         19.6393         22.5114         18.5396
230029..........................................         19.4911         22.1782         25.2459         22.2502
230030..........................................         18.3916         18.6406         19.1742         18.7416
230031..........................................         19.3162         19.9465         19.4676         19.5690
230032..........................................         21.8845         24.8930         22.5952         23.1148
230034..........................................         19.0473         19.4366         17.9276         18.7511
230035..........................................         17.5109         17.7490         20.5906         18.5317
230036..........................................         23.2119         23.8398         25.2015         24.1096
230037..........................................         20.4747         23.2751         22.7382         22.1469
230038..........................................         23.5251         21.9692         21.4546         22.2952
230040..........................................         21.4393         20.7841         20.2451         20.8039
230041..........................................         20.3131         21.7364         23.2870         21.7251
230042..........................................         22.1043         21.3870         19.8523         21.0979
230046..........................................         25.5696         25.3206         26.1787         25.6837
230047..........................................         21.5381         22.3595         23.7737         22.5475
230053..........................................         25.4968         26.8917         23.3066         25.2933
230054..........................................         20.6963         20.8014         17.6968         19.8741
230055..........................................         20.7932         20.8492         20.8930         20.8452
230056..........................................         16.0766         17.8091         17.3516         17.0331
230058..........................................         20.4165         21.0303         21.6619         21.0283
230059..........................................         19.9240         20.7092         20.5651         20.3916
230060..........................................         19.8021         19.8987         21.0368         20.2439
230062..........................................         17.1540         18.8039         18.2283         18.0500
230063..........................................         20.4171               *               *         20.4171
230065..........................................         22.3459         22.7416         23.3414         22.8607
230066..........................................         22.1768         23.0475         23.2790         22.8376
230069..........................................         23.2076         24.2470         25.0212         24.1384
230070..........................................         20.2505         21.5666         21.1658         21.1081
230071..........................................         22.9052         23.1337         23.6398         23.2244
230072..........................................         20.6944         20.4456         22.6533         21.2484
230075..........................................         20.0545         22.5866         22.3632         21.5991
230076..........................................         24.4547         24.7010         26.7244         25.2068
230077..........................................         21.0178         20.2823         22.6153         21.3059
230078..........................................         17.5577         17.9868         19.1638         18.2565
230080..........................................         19.7687         20.2104         19.1810         19.7086
230081..........................................         19.0345         19.0199         20.0464         19.3283
230082..........................................         18.2992         19.0419         18.2165         18.5095
230085..........................................         20.2096         23.4996         24.5765         22.7898
230086..........................................         18.9420         20.1730         20.1060         19.7404
230087..........................................         18.9034         19.9700         20.6619         19.7714
230089..........................................         23.9100         22.6994         22.7774         23.0814
230092..........................................         20.0145         20.7738         22.2629         21.0588
230093..........................................         20.4655         20.6314         21.0274         20.7091
230095..........................................         17.3313         17.6444         18.0582         17.6864
230096..........................................         22.8410         22.7785         24.3004         23.2947
230097..........................................         21.2854         21.1254         22.5006         21.6504
230099..........................................         21.1933         21.7513         21.7402         21.5696
230100..........................................         17.1336         17.3842         18.1823         17.5576
230101..........................................         20.0932         20.5315         22.5159         20.9964
230103..........................................         22.7696         11.3429         18.5254         17.4039

[[Page 31555]]

 
230104..........................................         23.1457         24.1238         25.5606         24.3812
230105..........................................         21.5210         22.6098         23.0086         22.4180
230106..........................................         20.7997         21.6825         22.9909         21.8109
230107..........................................         16.5966         17.1386         18.9985         17.6147
230108..........................................         18.8631         20.3437         21.4592         20.2385
230110..........................................         18.9825         19.7262         20.0544         19.5843
230113..........................................         14.9411               *               *         14.9411
230115..........................................         18.4050         19.6281         21.0361         19.6522
230116..........................................         16.5419         14.5692         15.6064         15.5368
230117..........................................         25.9318         25.6797         25.4341         25.6737
230118..........................................         21.3028         20.6797         20.2770         20.7229
230119..........................................         21.1918         22.6555         23.9898         22.6112
230120..........................................         18.5264         20.3306         20.6105         19.6370
230121..........................................         20.3158         21.3342         21.0568         20.9014
230122..........................................         20.9078               *               *         20.9078
230124..........................................         20.3608         18.9981         20.9641         20.0945
230128..........................................         24.9081         24.0724         24.4952         24.4850
230130..........................................         23.5170         22.1775         23.5123         23.0660
230132..........................................         26.6386         26.1946         27.3497         26.7222
230133..........................................         17.6894         17.1058         19.0770         17.9441
230135..........................................         22.5258         20.5637         18.4193         20.8744
230137..........................................         19.1813               *               *         19.1813
230141..........................................         22.1299         22.4570         24.4560         22.9910
230142..........................................         22.2940         23.5621         24.9830         23.5261
230143..........................................         16.3043         16.7948         18.2700         17.1074
230144..........................................         22.1108         23.4237         23.3295         22.9371
230145..........................................         20.2542         19.2638         17.9811         19.0315
230146..........................................         20.5044         21.2260         22.3838         21.3821
230147..........................................         21.8496         23.2755               *         22.5377
230149..........................................         20.7691         18.8005         19.9577         19.8029
230151..........................................         22.1713         23.3967         24.1404         23.2068
230153..........................................         19.5633         18.7403         20.0098         19.4472
230154..........................................         15.4456         15.4362         16.7152         15.8739
230155..........................................         17.2076         20.5409         20.9053         19.4860
230156..........................................         24.7587         25.6228         27.2254         25.8423
230157..........................................         20.3667         17.3571               *         18.9586
230159..........................................         20.0749               *               *         20.0749
230162..........................................         21.4636         21.7148         22.7984         21.9769
230165..........................................         23.0106         23.8881         24.5193         23.7930
230167..........................................         21.5048         22.9745         24.1064         22.8649
230169..........................................         23.0652         24.3874         28.1039         25.0117
230171..........................................         13.3863         17.1282         16.1129         15.4610
230172..........................................         20.6417         21.4675         22.1709         21.4477
230174..........................................         23.0272         22.7304         23.5025         23.0851
230175..........................................         16.8909               *         14.4932         15.4643
230176..........................................         22.7772         23.8204         24.6518         23.7400
230178..........................................         16.9156         17.3030         17.3428         17.1968
230180..........................................         15.8769         18.5744         19.6062         17.9856
230184..........................................         19.0604         19.7717         20.4831         19.7582
230186..........................................         19.5337         15.7837         19.1289         18.1131
230188..........................................         15.7112         16.2975         16.8687         16.3031
230189..........................................         16.6838         17.9218         19.1990         17.9352
230190..........................................         26.8196         26.4687         24.4643         25.9234
230191..........................................         19.0013         18.4861         20.6633         19.3446
230193..........................................         19.7066         19.8287         21.5358         20.3443
230195..........................................         21.7775         22.9228         23.4647         22.7456
230197..........................................         24.0184         24.0854         25.4494         24.4929
230199..........................................         19.4451         20.6580         22.4592         20.8791
230201..........................................         17.2141         18.0787         18.2486         17.8664
230204..........................................         25.4181         23.4966         24.5127         24.4525
230205..........................................         14.3788         15.9314         18.1551         16.1081
230207..........................................         20.6375         21.2483         20.9059         20.9181
230208..........................................         16.0733         16.7454         17.4925         16.7635

[[Page 31556]]

 
230211..........................................         18.6744         21.8581         21.1245         20.4277
230212..........................................         23.3021         24.2611         24.6420         24.0563
230213..........................................         15.1908         15.5469         17.1062         15.9226
230216..........................................         20.3359         21.0710         22.2137         21.1969
230217..........................................         21.2707         22.2698         24.1455         22.5496
230219..........................................         19.1549         20.0442         18.1277         19.1400
230222..........................................         22.1785         21.9711         23.2545         22.4802
230223..........................................         21.1528         22.6887         25.2666         22.9884
230227..........................................         23.7259         22.3155         25.8826         23.9496
230230..........................................         22.2385         22.3097         22.1703         22.2333
230235..........................................         16.8684         17.7197         18.3341         17.6456
230236..........................................         24.3835         25.9676         25.2273         25.2169
230239..........................................         18.0942         17.8168         18.9790         18.2974
230241..........................................         19.1000         20.7297         20.4217         20.0924
230244..........................................         21.7413         22.2697         23.1175         22.3742
230253..........................................         20.5945         21.0433         22.7706         21.4304
230254..........................................         21.9402         22.6335         23.3714         22.6370
230257..........................................         19.6982         21.3880         23.1794         21.3083
230259..........................................         22.2393         22.3969         23.1768         22.6077
230264..........................................         17.1319         17.4864         18.4075         17.6504
230269..........................................         23.3105         24.0992         24.3772         23.9435
230270..........................................         22.6187         22.5985         24.8925         23.3219
230273..........................................         22.9199         22.8715         24.1278         23.2898
230275..........................................         17.7487         20.8985               *         18.8231
230276..........................................         21.3722         25.8709         22.3313         22.8959
230277..........................................         23.1456         23.9771         24.2319         23.8212
230278..........................................         18.2110               *               *         18.2110
230279..........................................         17.6973         17.8074         18.3256         17.9471
230280..........................................         15.6654         18.3497               *         16.7057
230283..........................................         27.9480         22.5082               *         24.9202
230287..........................................               *               *         22.5420         22.5420
240001..........................................         24.6207         25.6936         26.6372         25.6759
240002..........................................         22.7981         23.2307         24.1694         23.4122
240004..........................................         25.1908         24.4030         25.6238         25.0604
240005..........................................         17.9563         20.3193         20.2389         19.4808
240006..........................................         25.1602         23.0715         25.7288         24.6342
240007..........................................         17.7625         19.0850         20.7189         19.1593
240008..........................................         20.2158         23.3783         22.7437         21.9832
240009..........................................         16.8965         17.1187         17.4518         17.1699
240010..........................................         23.6477         25.4752         28.3796         25.8852
240011..........................................         20.5192         21.5875         22.5188         21.5240
240013..........................................         20.3282         21.7544         25.1560         22.2201
240014..........................................         23.0025         24.2610         25.2306         24.1808
240016..........................................         20.4017         22.2011         23.3772         21.9959
240017..........................................         18.3585         18.9272         19.3431         18.8677
240018..........................................         20.8501         18.4268         23.6092         20.7339
240019..........................................         22.1501         23.1477         24.0613         23.1411
240020..........................................         21.1937         20.8849         20.6378         20.8948
240021..........................................         18.7515         20.1457         19.0469         19.2586
240022..........................................         21.7889         21.3234         23.0394         22.0529
240023..........................................         21.5087         22.8224         22.3002         22.1691
240025..........................................         18.8345         20.0308         20.7672         19.8809
240027..........................................         19.1017         16.7758         18.3837         18.0732
240028..........................................         19.7918         25.1934               *         22.5025
240029..........................................         21.1329         20.0164         23.0440         21.3549
240030..........................................         18.8547         20.1653         20.9799         20.0254
240031..........................................         18.1566         19.3983         21.7620         19.6652
240036..........................................         22.2460         22.1721         22.5423         22.3294
240037..........................................         19.2345         20.1195         21.4275         20.2550
240038..........................................         25.3061         24.3957         26.3886         25.3874
240040..........................................         20.4813         23.1352         22.8191         22.1112
240041..........................................         19.2864         21.8655         21.9054         20.9373
240043..........................................         17.7335         16.9859         18.2388         17.6591

[[Page 31557]]

 
240044..........................................         18.8411         20.3339         22.5750         20.4995
240045..........................................         21.1396         24.1557         24.2936         23.2125
240047..........................................         22.6152         23.8098         25.3136         23.8879
240050..........................................         25.2983         21.6499         23.1719         22.7044
240051..........................................         19.9195         22.5855         23.2612         21.9129
240052..........................................         20.7749               *         22.3485         21.5706
240053..........................................         22.9611         23.8693         24.2783         23.7568
240056..........................................         23.4226         23.7139         24.8549         24.0398
240057..........................................         24.2159         24.8686         25.4292         24.8727
240058..........................................         14.9697         18.4009         19.0506         17.2677
240059..........................................         23.6215         23.7808         25.3847         24.2488
240061..........................................         27.2603         25.9951         27.9151         27.0571
240063..........................................         23.7866         24.4031         25.4760         24.5591
240064..........................................         23.2860         22.8578         24.6785         23.6296
240065..........................................         12.7867         14.8734         14.4623         14.0357
240066..........................................         23.0698         24.1143         25.5163         24.2946
240069..........................................         19.8282         21.7991         23.3241         21.6103
240071..........................................         20.2101         21.2463         22.5319         21.3438
240072..........................................         21.1824         20.9529         21.5455         21.2291
240073..........................................         16.0840         17.3559         17.9013         17.1144
240075..........................................         21.2654         21.3357         21.9160         21.5185
240076..........................................         21.8795         22.3280         23.6130         22.6447
240077..........................................         15.3794         20.3445         22.1509         19.1544
240078..........................................         23.9150         25.1082         25.9495         25.0087
240079..........................................         18.4338         18.8345         18.2929         18.5204
240080..........................................         24.3399         25.5619         26.0031         25.2885
240082..........................................         18.3555         18.7995         20.2018         19.1212
240083..........................................         19.7637         21.0317         22.3289         20.9906
240084..........................................         19.4739         21.7421         23.1951         21.4482
240085..........................................         22.5736         20.9778         20.7535         21.3852
240086..........................................         16.9392         18.1401         18.1497         17.7863
240087..........................................         18.8352         21.3323         21.2116         20.4135
240088..........................................         21.6858         23.1056         24.6260         23.0939
240089..........................................         20.7239         21.1989         21.3949         21.1104
240090..........................................         19.2968         19.2166         21.0856         19.8725
240093..........................................         18.7092         20.2400         20.7138         19.9194
240094..........................................         20.9446         22.0247         22.5923         21.8995
240096..........................................         20.1644         21.0417         20.2992         20.4825
240097..........................................         24.2662         27.9496         29.7597         27.1621
240098..........................................         21.3467         24.2296         23.9626         23.2314
240099..........................................         14.4649         15.4964         18.8139         15.9924
240100..........................................         20.8302         20.8325         24.1875         21.9081
240101..........................................         19.2120         19.9837         22.1329         20.4409
240102..........................................         14.6067         16.3659         15.5114         15.4871
240103..........................................         19.1540         18.7510         21.0182         19.5968
240104..........................................         23.2178         23.5351         25.2485         24.0080
240105..........................................         14.3965               *               *         14.3965
240106..........................................         23.5148         23.5005         23.9677         23.6780
240107..........................................         20.3983         20.9004         21.2163         20.8360
240108..........................................         15.3547         18.2427         17.6500         16.9347
240109..........................................         13.5537         16.3216         15.1369         14.9110
240110..........................................         19.4828         21.0277         21.7340         20.7301
240111..........................................         17.2100         17.8617         19.9712         18.3046
240112..........................................         15.8350         16.6244         17.2437         16.5628
240114..........................................         16.2505         17.3682         18.3415         17.5274
240115..........................................         23.7765         23.8675         24.6174         24.0872
240116..........................................         16.6731         18.3520         17.3460         17.3960
240117..........................................         18.0636         17.9941         18.7656         18.2986
240119..........................................         20.6126         21.8289         23.0230         21.7338
240121..........................................         23.4018         22.2266         22.4858         22.6970
240122..........................................         19.1811         21.2876         20.7795         20.4095
240123..........................................         16.5098         18.3941         18.9494         17.8731
240124..........................................         19.4400         20.4728         21.2023         20.3644

[[Page 31558]]

 
240125..........................................         12.3627         14.9708         17.3846         15.0136
240127..........................................         15.8966         17.9724         16.4294         16.7198
240128..........................................         17.2513         16.3608         17.5611         17.0478
240129..........................................         14.4212         16.5209         17.7242         16.1756
240130..........................................         14.9399         16.4271         17.7634         16.3549
240132..........................................         23.0669         23.1452         24.4301         23.5642
240133..........................................         19.2126         19.5293         20.8958         19.9049
240135..........................................         14.3069         15.7015         15.6298         15.1560
240137..........................................         20.3750         21.5073         21.6644         21.1797
240138..........................................         15.2062         16.7332         18.9731         16.7753
240139..........................................         20.8053         20.5496         21.8580         21.0743
240141..........................................         23.8066         23.1009         23.6622         23.5109
240142..........................................         25.2770         29.2238         24.0719         25.9878
240143..........................................         16.6172         20.4266         20.7307         19.0810
240144..........................................         18.2604         21.4469         23.1661         20.7059
240145..........................................         17.2778         19.0689         17.6747         18.0668
240146..........................................         16.0652         16.5412         17.3275         16.6788
240148..........................................         18.8779         19.5204         19.5372         19.2785
240150..........................................         13.8786         20.8331         23.3857         18.4647
240152..........................................         21.1678         22.4744         24.1818         22.6586
240153..........................................         16.5412         19.3336         17.7399         17.7721
240154..........................................         17.5769         21.5052         21.5859         20.1583
240155..........................................         19.8762         20.9385         23.6944         21.5112
240157..........................................         17.4168         13.7309               *         15.5390
240160..........................................         15.9492         15.9014         16.4990         16.1163
240161..........................................         15.7996         16.8809         18.0542         16.8888
240162..........................................         16.6292         19.1542         19.3296         18.3301
240163..........................................         18.8320         20.4760         22.2009         20.3835
240166..........................................         17.3233         19.4131         19.4496         18.7799
240169..........................................         16.6725         16.3958               *         16.5195
240170..........................................         18.8762         20.3779         21.5994         20.2122
240171..........................................         17.2886         18.5172         19.6732         18.5083
240172..........................................         18.2852         20.8606         20.3699         19.7027
240173..........................................         17.2655         18.5187         18.3183         18.0300
240179..........................................         17.5116         20.4004         17.7557         18.4699
240184..........................................         15.3793         16.8917         17.6979         16.5493
240187..........................................         19.9230         21.2736         23.2471         21.4869
240193..........................................         17.8226         18.4664               *         18.1403
240196..........................................         24.3472         25.3479         26.1827         25.3447
240200..........................................         14.3415         14.9076         18.7517         15.8336
240207..........................................         24.1127         25.2814         26.1748         25.2384
240210..........................................         24.2218         24.5664         25.3031         24.7274
240211..........................................         19.7399         30.6260         34.7849         25.7741
250001..........................................         18.4233         19.2756         20.2019         19.2920
250002..........................................         17.2501         18.6938         19.6081         18.5060
250003..........................................         17.6539         16.7570         18.7331         17.7215
250004..........................................         17.8868         18.3860         19.2913         18.5189
250005..........................................         12.5993         12.5834         13.7341         13.0041
250006..........................................         16.9048         17.5192         19.6894         17.9911
250007..........................................         19.2913         19.7562         20.9757         19.9959
250008..........................................         14.1760         15.8506         15.8096         15.2607
250009..........................................         18.5610         17.7283         17.1686         17.8180
250010..........................................         13.3905         14.6101         16.0233         14.5948
250012..........................................         14.1623         16.7579         17.4032         16.1420
250015..........................................         13.5274         11.7249         16.6522         13.7345
250017..........................................         17.9410         20.5976         18.8850         19.0991
250018..........................................         11.9311         13.1687         14.7291         13.0932
250019..........................................         16.7425         18.0956         19.9070         18.3382
250020..........................................         13.4476         16.2698         19.6575         16.1595
250021..........................................          9.4318         10.5844         12.7242         10.6438
250023..........................................         13.9116         12.3434         13.8210         13.3756
250024..........................................         12.7127         12.9899         14.8394         13.4135
250025..........................................         19.0390         20.3625         21.9075         20.5374

[[Page 31559]]

 
250027..........................................         14.9519         14.5445         15.1790         14.8945
250029..........................................         16.4834         16.0682         14.8216         15.7783
250030..........................................         17.3636         26.6173         25.5089         23.0726
250031..........................................         17.9715         18.3825         19.8779         19.1622
250032..........................................         17.1339         17.5957               *         17.3669
250033..........................................         17.8257         15.0941         16.9132         16.6524
250034..........................................         16.6988         17.0399         19.1875         17.6568
250035..........................................         15.2353         16.8349         18.3861         16.7093
250036..........................................         15.8445         16.1913         17.6247         16.6012
250037..........................................         15.4325         12.7156         14.3994         14.0734
250038..........................................         16.8454         17.7019         18.8434         17.7665
250039..........................................         14.1556         15.1409         16.4502         15.2329
250040..........................................         17.3430         18.3364         19.6513         18.4442
250042..........................................         16.3867         17.6531         18.3858         17.4884
250043..........................................         16.0729         16.6500         18.4025         16.9554
250044..........................................         16.1218         16.7321         19.1860         17.3262
250045..........................................         22.0839         21.8988         22.7225         22.2606
250047..........................................         13.3706         14.7461               *         13.9984
250048..........................................         16.8932         17.6649         19.4976         18.0474
250049..........................................         11.6715         12.1635         12.8275         12.2266
250050..........................................         14.3949         15.1159         16.0234         15.1991
250051..........................................          9.3464         10.4900         10.1212          9.9666
250057..........................................         15.9237         16.1838         16.3204         16.1462
250058..........................................         15.5327         15.7197         16.2623         15.8399
250059..........................................         16.2845         16.6494         17.7592         16.8861
250060..........................................         13.0301         16.1804         12.6893         13.8440
250061..........................................         11.0308         11.5108         12.0186         11.5214
250063..........................................         13.2540         13.3092         15.0894         13.8432
250065..........................................         12.8853         13.6904         15.0507         13.8065
250066..........................................         15.6760         16.1742         17.2711         16.3375
250067..........................................         16.4120         16.8522         18.3773         17.2393
250068..........................................         13.6768         13.4127         13.2644         13.4415
250069..........................................         17.8960         16.8980         18.2097         17.6479
250071..........................................         14.3781         12.3488         13.1934         13.2742
250072..........................................         18.2218         18.9487         21.0602         19.2655
250076..........................................         10.5098               *               *         10.5098
250077..........................................         12.2564         13.7404         13.9479         13.2870
250078..........................................         15.6336         15.9739         17.1972         16.2928
250079..........................................         16.2712         16.5835         16.1483         16.3337
250081..........................................         17.3325         19.0358         18.1848         18.1653
250082..........................................         16.0975         17.1427         17.3096         16.8599
250083..........................................         14.2634         16.6065         16.3054         15.6454
250084..........................................         17.0189         20.6429         21.0870         19.3827
250085..........................................         14.3797         15.4477         16.7377         15.5314
250088..........................................         17.8674         18.2736         19.3976         18.4880
250089..........................................         13.4238         14.3027         15.0238         14.2301
250093..........................................         15.2044         16.1506         16.8647         16.0778
250094..........................................         18.0852         18.5063         18.9681         18.5063
250095..........................................         17.0039         17.4217         18.4944         17.6334
250096..........................................         19.0688         19.0584         19.3630         19.1609
250097..........................................         16.9905         15.5741         16.3328         16.3172
250098..........................................         13.1341         18.3874         17.9180         16.1645
250099..........................................         14.8528         15.1265         15.9867         15.3437
250100..........................................         17.1682         17.8688         19.8795         18.3539
250101..........................................         18.4685         17.7194         17.6704         17.9924
250102..........................................         23.9329         18.9348               *         21.2970
250104..........................................         18.2502         18.7651         19.0165         18.6823
250105..........................................         14.5401         15.5133         16.1480         15.4020
250107..........................................         15.1496         15.0737         16.5635         15.5581
250109..........................................         22.1551         21.3867         24.5760         22.6981
250112..........................................         15.5610         16.3640         16.6447         16.1593
250117..........................................         16.1225         16.9787         15.9335         16.3432
250119..........................................         15.2199         16.1218         16.5700         15.9756

[[Page 31560]]

 
250120..........................................         15.3433         16.7182         18.1428         16.6322
250122..........................................         18.9417         19.2990         19.8033         19.3541
250123..........................................         18.8690         18.7863         22.1376         19.9106
250124..........................................         13.1823         13.2490         14.3551         13.5956
250125..........................................         20.8895         21.2660         21.3711         21.1778
250126..........................................         18.2355         21.9101         19.0168         19.6297
250128..........................................         14.0048         16.1418         15.9958         15.4423
250131..........................................         12.6056         12.4557         11.2470         12.0464
250134..........................................         17.0671         18.5142         21.4489         18.9054
250136..........................................         18.9689         21.3497         20.0333         20.0576
250138..........................................         18.4028         20.4550         19.3446         19.3211
250141..........................................         19.0113         19.6692         21.6835         20.2708
250145..........................................         10.2507         11.2120         11.2021         10.8489
250146..........................................         14.4924         14.7781         15.4061         14.8913
250148..........................................         18.0980         19.4233         23.1459         20.1203
250149..........................................         12.9569         15.2318         15.7537         14.6277
250150..........................................               *         21.8599               *         21.8599
260001..........................................         18.0971         20.1560         20.9602         19.7021
260002..........................................         22.1183         21.6597         23.4259         22.4118
260003..........................................         14.6553         15.4482         16.0721         15.3980
260004..........................................         13.0133         13.7035         15.2735         13.9164
260005..........................................         19.5554         23.9681         22.2119         21.8900
260006..........................................         19.7467         20.0994         22.1692         20.6408
260008..........................................         13.8495         16.8893         18.2114         15.8498
260009..........................................         18.5080         18.2863         19.0654         18.6237
260011..........................................         19.1027         19.5059         20.3279         19.6368
260012..........................................         14.3645         17.1662         17.3810         16.3363
260013..........................................         15.9884         16.1825         17.3772         16.4946
260015..........................................         16.5822         17.8817         18.0070         17.4241
260017..........................................         16.7916         16.9914         17.9796         17.2888
260018..........................................         12.0060         12.5301         13.6120         12.7676
260019..........................................         18.6113               *         18.3629         18.4928
260020..........................................         20.5142         20.2241         21.0314         20.5884
260021..........................................         22.1017         21.6237         23.3527         22.2918
260022..........................................         17.2462         17.7772         18.7707         17.9082
260023..........................................         16.4705         17.8649         18.5665         17.6119
260024..........................................         15.2356         15.7815         15.6095         15.5379
260025..........................................         15.4935         17.0965         18.2804         16.9786
260027..........................................         21.2977         22.0362         23.1505         22.1110
260029..........................................         19.7484         21.1858         20.1832         20.3332
260030..........................................         12.5118         11.9215         12.8349         12.4289
260031..........................................         19.4921         19.7249         22.5379         20.4276
260032..........................................         20.1988         19.6728         20.1817         20.0177
260034..........................................         17.4233         20.4902         20.5439         19.5050
260035..........................................         13.1065         13.0071         15.1611         13.8141
260036..........................................         16.7430         18.8104         19.9593         18.5490
260039..........................................         14.1866         14.6644         15.9689         14.9611
260040..........................................         17.3099         18.0140         18.5132         17.9641
260042..........................................         18.7567         18.7514         20.8821         19.5084
260044..........................................         15.9927         15.9206         16.7879         16.2332
260047..........................................         19.0112         19.2247         19.8178         19.3380
260048..........................................         20.0885         21.0602         22.4800         21.2299
260050..........................................         15.6908         16.8520         17.6687         16.7168
260052..........................................         18.0553         18.0914         19.1044         18.4413
260053..........................................         15.2236         16.5166         17.4110         16.3851
260054..........................................         20.0199         20.6242         23.0188         21.1083
260055..........................................         12.0118         15.4214         17.9547         14.9547
260057..........................................         17.4636         19.7144         16.5704         17.9947
260059..........................................         16.1000         17.0546         16.2074         16.4474
260061..........................................         14.7175         15.7112         17.1343         15.8685
260062..........................................         20.1477         21.3138         21.9287         21.1699
260063..........................................         18.2309         18.8973         19.7231         18.9234
260064..........................................         16.5934         17.8033         18.3749         17.5653

[[Page 31561]]

 
260065..........................................         19.4382         20.0975         20.6671         20.0563
260066..........................................         14.9640         15.3460         15.3139         15.2114
260067..........................................         14.2249         15.1837         14.5499         14.6334
260068..........................................         20.2418         19.4240         20.7947         20.1541
260070..........................................               *         13.9510         18.7384         16.1582
260073..........................................         14.2550         15.9182         16.9496         15.7508
260074..........................................         19.0350         19.8915         20.4033         19.8192
260077..........................................         18.6473         19.4482         20.5830         19.5877
260078..........................................         15.6381         14.9463         16.0586         15.5564
260079..........................................         14.2985         16.1453         16.4816         15.5347
260080..........................................         13.5384         14.6832         13.1617         13.7147
260081..........................................         21.0151         20.3053         20.2471         20.5212
260082..........................................         15.9407         15.9858         18.2853         16.7287
260085..........................................         20.4669         20.7051         21.5137         20.8993
260086..........................................         14.3164         15.2927         16.7579         15.4677
260091..........................................         19.9987         21.5464         22.0772         21.4012
260094..........................................         18.0085         18.5395         19.7308         18.8006
260095..........................................         19.6944         20.7292         21.6999         20.6994
260096..........................................         23.0282         22.5972         22.8259         22.8155
260097..........................................         16.5582         19.0632         18.6965         18.1123
260100..........................................         15.7047         16.6523         16.5439         16.3025
260102..........................................         20.1264         20.6361         21.2133         20.6454
260103..........................................         18.5957         19.7146         19.9144         19.3556
260104..........................................         21.0138         20.3176         21.6624         21.0040
260105..........................................         24.7223         24.8181         22.8005         24.0843
260107..........................................         19.8422         20.4269         22.5214         20.7581
260108..........................................         19.4609         20.0034         20.9029         20.1514
260109..........................................         13.9129         14.8181         15.9724         14.8936
260110..........................................         17.8375         18.3227         19.5633         18.5673
260113..........................................         14.6756         16.2223         16.1346         15.6436
260115..........................................         19.2259         17.4698         19.3873         18.6920
260116..........................................         16.2774         14.9812         16.0187         15.7314
260119..........................................         16.8836         17.2942         18.0725         17.4218
260120..........................................         16.3755         16.4904         17.6811         16.8504
260122..........................................         14.9697         16.0931         16.3700         15.8295
260123..........................................         14.6444         14.6822         15.2926         14.8761
260127..........................................         18.3572         18.4026         18.1342         18.2957
260128..........................................         13.0481         12.6414         13.2942         12.9961
260131..........................................         17.7686         18.4154         18.0395         18.0595
260134..........................................         16.2832         17.5127         17.1341         16.9643
260137..........................................         17.9531         19.4697         19.5976         19.0342
260138..........................................         22.6491         23.2364         23.1213         22.9952
260141..........................................         19.1580         19.1893         19.6237         19.3180
260142..........................................         17.1248         17.3084         18.2023         17.5590
260143..........................................         12.7867         13.9040         15.4688         13.9600
260147..........................................         14.0778         14.7769         15.8522         14.8908
260148..........................................         11.8674         11.3524         12.6651         11.9425
260158..........................................         12.3005         12.7699         13.9790         13.0499
260159..........................................         20.3177         19.7951         20.9636         20.3519
260160..........................................         15.8394         16.5792         18.4007         16.9325
260162..........................................         19.5655         21.4099         20.7331         20.5870
260163..........................................         16.4245         15.8593         16.8300         16.3731
260164..........................................         14.9372         15.1211         16.7279         15.6074
260166..........................................         20.1025         21.1224         22.4071         21.2079
260172..........................................         15.4163         16.0772         16.4854         15.9816
260173..........................................         12.8523         14.2090         15.5733         14.3947
260175..........................................         16.9023         17.5625         18.3632         17.6144
260176..........................................         26.8712         21.6044         23.2414         23.9990
260177..........................................         21.2578         21.9014         22.9091         22.0689
260178..........................................         19.6638         20.2796         20.8189         20.2016
260179..........................................         21.4906         22.7185         21.4470         21.8753
260180..........................................         19.5819         18.9881         19.5983         19.3863
260183..........................................         20.0712         21.3175         23.7057         21.6731

[[Page 31562]]

 
260186..........................................         19.3238         19.6026         21.0675         20.0580
260188..........................................         20.6388         22.5060         23.7475         22.1881
260189..........................................         11.3004         16.4233               *         13.8239
260190..........................................         18.5168         19.3419         21.6994         19.8001
260191..........................................         17.9812         18.1604         19.6784         18.6471
260193..........................................         21.1588         20.2577         22.2030         21.2172
260195..........................................         17.7237         19.7068               *         18.7154
260197..........................................         19.2840         20.5453               *         19.7846
260198..........................................         11.9751         19.7552         21.7926         16.7576
260200..........................................         20.5339         20.6888         21.7031         21.0210
260205..........................................         17.6210               *               *         17.6210
270002..........................................         28.9959         19.2387         19.0221         21.4738
270003..........................................         22.0995         22.5019         20.7277         21.7202
270004..........................................         19.6292         19.4834         20.1821         19.8074
270006..........................................         16.0238         17.0715         15.1006         15.9252
270007..........................................         11.3143         13.8824         15.5780         13.1858
270009..........................................         17.2292         20.8238         20.7031         19.5097
270011..........................................         20.2669         21.1653         21.8086         21.0508
270012..........................................         19.7346         19.7878         20.7913         20.0975
270014..........................................         19.0872         19.9859         20.4321         19.8518
270016..........................................         19.6717         18.6149         17.9984         18.9093
270017..........................................         21.0800         20.0152         22.1046         21.0660
270019..........................................         18.1099         15.4128         18.5111         17.2358
270021..........................................         17.1787         16.9457         18.0515         17.3782
270023..........................................         22.2639         22.7181         22.7162         22.5721
270026..........................................         17.5102         18.0568         20.1673         18.5919
270027..........................................         13.1392         17.2091         17.2005         15.5928
270028..........................................         21.1492         19.1177         19.6212         19.9204
270029..........................................         16.5666         17.3710         18.2097         17.3728
270032..........................................         17.7393         18.7811         19.3937         18.6694
270033..........................................         16.9602         18.4876         20.7060         18.6303
270035..........................................         16.8295         16.4302         17.9822         17.0833
270036..........................................         14.2537         16.8552         16.1031         15.5470
270039..........................................         15.9368         19.6796         20.3800         18.4120
270040..........................................         18.8145         20.1242         20.1887         19.6792
270041..........................................         19.0327         25.8153               *         21.5554
270044..........................................         16.7710         17.5137         19.2939         17.7721
270048..........................................         17.0154         18.0666         17.4506         17.4823
270049..........................................         22.2444         22.2540         22.0263         22.1740
270050..........................................         16.7110         19.9356         19.6317         18.7001
270051..........................................         20.2735         20.1950         20.0386         20.1652
270052..........................................         14.4773         14.7009         17.1932         15.3511
270057..........................................         21.1317         20.6714         20.1507         20.6215
270058..........................................         14.7481         16.1412         18.4780         16.2593
270059..........................................         14.7530         19.1808         16.9303         16.8245
270060..........................................         15.2727         20.4148         21.3776         18.5305
270063..........................................         12.6108         15.1049         16.4553         14.5559
270073..........................................         14.4569         16.1937         16.6083         15.6741
270079..........................................         15.6873         16.7048         19.5493         17.1331
270080..........................................         16.3171         15.0705         16.6010         15.9696
270081..........................................         15.6262         16.7389         18.0543         16.7908
270082..........................................         17.3443         23.1245         23.3209         21.2882
270083..........................................         18.4432         17.8554         16.8420         17.6939
270084..........................................         16.6243         16.2958         15.7062         16.1694
280001..........................................         17.3541         18.1831         18.7137         18.0270
280003..........................................         22.3179         23.0213         20.0498         21.6193
280005..........................................         19.2405         23.6949         20.1943         21.0207
280009..........................................         19.8145         20.9643         23.2300         21.3319
280010..........................................         17.4859         20.0462               *         18.1962
280011..........................................         15.8573         15.9614         16.2281         16.0212
280013..........................................         22.8063         22.5163         24.0852         23.1972
280014..........................................         15.9596         16.8368         16.7109         16.5080
280015..........................................         17.0281         16.6939         18.0207         17.2299

[[Page 31563]]

 
280017..........................................         14.2059         13.9939         16.9884         15.1266
280018..........................................         15.1328         15.4496         16.6439         15.7480
280020..........................................         19.9667         21.2467         21.9587         21.0976
280021..........................................         17.1048         17.6345         19.1263         17.9823
280022..........................................         16.7179         16.8184         15.3785         16.3083
280023..........................................         25.8494         22.3433         21.5761         23.0011
280024..........................................         14.2186         15.0380         15.8747         15.0019
280025..........................................         15.5850         21.4764         22.2214         19.5445
280026..........................................         16.6861         16.5851         18.7258         17.3359
280028..........................................         17.3176         18.0793         19.1080         18.1555
280029..........................................         23.1292         24.4359         17.1351         21.6012
280030..........................................         24.5366         24.7723         26.3542         25.1586
280031..........................................         13.5654          9.6321          9.6951         11.0351
280032..........................................         18.8964         19.1191         20.5246         19.5206
280033..........................................         15.7583         17.4745         17.9841         17.1215
280035..........................................         15.9170         16.6872         18.6089         16.9364
280037..........................................         16.7952         17.1064         14.8049         16.2282
280038..........................................         17.0878         18.2503         18.9305         18.0758
280039..........................................         16.0442         16.1587         17.0153         16.4148
280040..........................................         19.5333         20.9896         21.5426         20.7346
280041..........................................         16.4083         16.5503         16.6889         16.5558
280042..........................................         16.1191         16.6239         16.4684         16.3973
280043..........................................         16.6570         17.5937         16.8186         17.0314
280045..........................................         16.9048         15.7630         17.7408         16.7631
280046..........................................         17.9221         17.3214         17.9752         17.7358
280047..........................................         18.3407         17.4735         21.3143         18.9885
280048..........................................         15.8723         15.8100         17.9319         16.5389
280049..........................................         18.3605         18.4365         19.4589         18.7530
280050..........................................         16.6432         20.0379               *         18.4507
280051..........................................         15.6336         17.1942         19.6206         17.2054
280052..........................................         14.0819         14.1201         14.9903         14.4198
280054..........................................         18.7992         18.7575         19.4049         18.9732
280055..........................................         13.5667         13.8129         14.2046         13.8644
280056..........................................         12.6475         15.6135         15.6442         14.4971
280057..........................................         18.0454         20.0686         21.4754         19.8186
280058..........................................         19.6752         21.4868         22.8105         21.3952
280060..........................................         19.7527         20.7022         22.4677         20.9351
280061..........................................         17.1629         18.6370         20.2066         18.7084
280062..........................................         14.4896         15.6018         16.1708         15.4336
280064..........................................         16.2977         16.8330         18.2196         17.1053
280065..........................................         19.2932         20.7370         21.6999         20.6166
280066..........................................         11.6621         11.7207         12.2225         11.8688
280068..........................................          9.4943         10.5987         10.5103         10.1786
280070..........................................         17.7400         22.6201         18.7211         19.4766
280073..........................................         17.4244         17.7698         18.3496         17.8530
280074..........................................         16.4310         17.3143         13.6025         15.4955
280075..........................................         15.5327         13.2230         13.3154         13.8859
280076..........................................         14.8469         16.7488         16.1939         15.8857
280077..........................................         19.2068         20.0148         21.1883         20.1246
280079..........................................         10.4540         16.6117         17.1519         13.6519
280080..........................................         15.3308         16.9487         16.1902         16.1919
280081..........................................         21.0771         20.9606         23.3805         21.7809
280082..........................................         14.3399         14.6173         15.4420         14.8136
280083..........................................         18.2992         21.5336         20.8995         20.2370
280084..........................................         12.5836         13.6536         13.2158         13.1411
280085..........................................         20.4302         20.4825         20.8532         20.5742
280088..........................................         20.2961               *               *         20.2961
280089..........................................         18.1668         18.9567         19.9003         18.9565
280090..........................................         14.1362         15.1274               *         14.6858
280091..........................................         15.8436         16.1866         16.3456         16.1284
280092..........................................         14.1945         14.7912         13.3032         14.1038
280094..........................................         17.6873         16.3474         16.9180         16.9734
280097..........................................         14.1734         13.8223         14.1870         14.0603

[[Page 31564]]

 
280098..........................................         13.0029         12.5875         12.4995         12.6927
280101..........................................         13.5261         16.9973         10.5153         13.1647
280102..........................................         14.0102               *               *         14.0102
280104..........................................         13.2819         16.2167         15.5949         14.8930
280105..........................................         18.6575         21.0735         23.7103         21.1232
280106..........................................         16.1247         16.0679         16.3564         16.1791
280107..........................................         13.3311         14.4679               *         13.8480
280108..........................................         17.5625         17.1961         18.5134         17.7698
280109..........................................         12.6803         12.4408               *         12.5540
280110..........................................         12.7546         14.2136         13.0278         13.3282
280111..........................................         21.8773         19.6283         19.3508         20.2354
280114..........................................         15.7160         17.3076         17.1154         16.7114
280115..........................................         16.7041         18.1480         18.3464         17.7487
280117..........................................         17.7276         18.8279         20.3819         18.9864
280118..........................................         16.8687         18.6524         17.8891         17.8029
280123..........................................         14.0637         11.8582         23.6682         15.2035
280125..........................................         16.1332         16.3944         17.2718         16.5861
290001..........................................         22.8226         22.7450         24.1873         23.2686
290002..........................................         17.2554         16.5419         16.7948         16.8714
290003..........................................         22.8840         24.2175         24.4237         23.8452
290005..........................................         19.4888         21.9814         22.7804         21.4325
290006..........................................         21.8070         22.4063         19.9226         21.3745
290007..........................................         29.7706         30.9075         30.2824         30.3297
290008..........................................         20.6190         24.1255         26.9216         23.3785
290009..........................................         23.3620         23.9373         24.5919         23.9575
290010..........................................         15.6423         16.4476         20.8387         17.4968
290011..........................................         20.1564         21.1234         19.7410         20.3076
290012..........................................         21.8275         25.0430         25.3963         24.1843
290013..........................................         18.2713         15.7932         20.2914         17.8815
290014..........................................         18.9743         18.7829         20.2762         19.3806
290015..........................................         22.3487         19.4504         20.2336         20.6208
290016..........................................         14.3542         23.8656         21.8030         19.3661
290019..........................................         21.2509         22.2045         22.5584         22.0258
290020..........................................         20.8733         21.2380         19.5039         20.6806
290021..........................................         21.5806         22.9488         23.4950         22.6778
290022..........................................         24.5468         25.5011         24.8144         24.9547
290027..........................................         16.7786         13.3769         13.1463         14.2467
290032..........................................         22.8447         23.9504         26.8557         24.6837
290036..........................................               *         12.9074               *         12.9074
290038..........................................         20.6753         27.7030         26.0836         23.3519
290039..........................................         25.3864         25.5024         26.2466         25.7352
290041..........................................               *         25.9905         27.0613         26.6211
290042..........................................               *         18.7527         18.7669         18.7611
290043..........................................               *         27.9053               *         27.9053
300001..........................................         22.0909         23.8567         25.7142         23.9386
300003..........................................         22.9111         24.1297         25.3252         24.1024
300005..........................................         20.7545         22.2858         22.0518         21.6894
300006..........................................         23.7793         18.9745         22.2642         21.6739
300007..........................................         20.2372         20.6325         21.3633         20.7580
300008..........................................         20.7702         19.6149         20.9207         20.4237
300009..........................................         18.0602         20.0938         20.1193         19.3850
300010..........................................         19.3940         20.2130         21.0316         20.1973
300011..........................................         22.4325         23.0279         23.8390         23.0923
300012..........................................         24.5673         24.5619         25.8581         25.0347
300013..........................................         19.1247         20.1669         20.0983         19.8032
300014..........................................         20.3292         20.1774         21.6705         20.7353
300015..........................................         20.4916         19.6627         22.8966         21.0797
300016..........................................         21.8659         17.8148         15.1311         18.1853
300017..........................................         21.6563         22.7191         23.9651         22.8162
300018..........................................         21.2381         21.6385         22.9623         21.9864
300019..........................................         20.9753         19.6728         20.5801         20.4037
300020..........................................         21.9165         22.6627         23.0806         22.5724
300021..........................................         18.6211         19.3101         20.2585         19.4039

[[Page 31565]]

 
300022..........................................         18.3507         19.1875         20.1635         19.2197
300023..........................................         22.1210         22.7649         22.1896         22.3579
300024..........................................         19.9116         21.5842         22.2235         21.2127
300028..........................................         17.4075         20.0778         21.4207         19.6713
300029..........................................         22.5748         22.6013         23.8415         23.0427
300033..........................................         17.1869         17.1632         17.4836         17.2725
300034..........................................         25.5182         24.4975         25.2355         25.1020
310001..........................................         28.1329         27.4730         28.6540         28.0966
310002..........................................         28.3434         27.9728         28.5941         28.3065
310003..........................................         29.1096         27.5624         28.8314         28.5051
310005..........................................         22.1146         22.9712         22.9664         22.6779
310006..........................................         21.5957         22.0894         24.1538         22.5976
310008..........................................         23.5084         24.7618         26.4989         24.9206
310009..........................................         23.6371         21.7094         23.2420         22.8675
310010..........................................         22.5682         23.1060         24.5471         23.4312
310011..........................................         23.1977         24.2885         25.4900         24.3173
310012..........................................         26.5242         26.6772         28.0541         27.1062
310013..........................................         21.2251         22.5603         23.0073         22.2711
310014..........................................         27.4614         23.1956         31.0374         27.0132
310015..........................................         27.4331         27.9684               *         27.7058
310016..........................................         24.3838         24.5206         25.4844         24.7602
310017..........................................         25.7902         24.5976         25.1634         25.1866
310018..........................................         22.8428         22.4779         24.1496         23.1662
310019..........................................         24.0542         24.9914         28.5952         25.8565
310020..........................................         24.1848         24.4152         25.0803         24.5523
310021..........................................         23.9369         25.4393         29.9117         26.2679
310022..........................................         21.2706         20.8258         21.2563         21.1130
310024..........................................         24.2353         24.9521         27.2475         25.4630
310025..........................................         24.3513         24.1812         25.5227         24.6926
310026..........................................         23.5491         22.1997         23.2895         22.9937
310027..........................................         21.8846         22.5696         24.4437         22.9152
310028..........................................         23.4577         23.9428         26.1931         24.5392
310029..........................................         22.6629         23.6610         25.2587         23.8421
310031..........................................         26.1567         26.6831         26.7174         26.5090
310032..........................................         24.3528         24.7404         25.4768         24.8830
310034..........................................         23.2729         24.1150         27.1303         24.7884
310036..........................................         20.1905         21.7187         23.0320         21.6137
310037..........................................         27.7823         28.1289         29.0864         28.3334
310038..........................................         26.7209         28.4893         28.4732         27.9039
310039..........................................         22.1754         22.7317         23.6605         22.8221
310040..........................................         26.1492         26.3573         26.5964         26.3696
310041..........................................         24.8960         23.5559         24.9733         24.4816
310042..........................................         23.2472         24.7678         25.7747         24.5600
310043..........................................         21.9022         21.6128         24.0238         22.3478
310044..........................................         21.6677         23.1549         23.3801         22.7473
310045..........................................         28.4854         28.9274         29.5452         28.9708
310047..........................................         25.1101         26.1921         25.9777         25.7489
310048..........................................         23.6118         25.2870         23.4189         24.0965
310049..........................................         24.8299         27.0842         25.6732         25.8686
310050..........................................         25.1752         24.7988         23.7735         24.5800
310051..........................................         27.1265         27.5378         28.5946         27.7258
310052..........................................         22.9326         23.3973         27.0616         24.3173
310054..........................................         26.1726         27.7376         26.9352         26.9153
310057..........................................         21.1686         22.2572         22.2630         21.9057
310058..........................................         26.5308         26.3765         25.9389         26.3360
310060..........................................         19.1992         20.0997         21.6211         20.2716
310061..........................................         23.2646         33.9582         23.4283         26.0987
310062..........................................         22.9073               *               *         22.9073
310063..........................................         21.9045         22.1080         23.5217         22.4712
310064..........................................         24.8567         25.4822         25.3339         25.2160
310067..........................................         25.0888         23.9278         24.1943         24.4277
310069..........................................         23.7531         24.2329         25.4373         24.4865
310070..........................................         26.0903         28.2220         30.1143         28.0038

[[Page 31566]]

 
310072..........................................         21.7605         22.5611         25.0708         23.0824
310073..........................................         28.5149         26.2937         29.2805         27.9813
310074..........................................         23.8340         22.3588         24.1313         23.4934
310075..........................................         23.3266         24.4788         23.9771         23.9276
310076..........................................         30.0797         27.9918         31.4866         29.8824
310077..........................................         25.2500         26.1251         26.7227         26.0109
310078..........................................         23.8841         24.0587         24.5862         24.1519
310081..........................................         22.0762         22.4086         23.2059         22.5650
310083..........................................         23.8852         24.8204         25.0191         24.5773
310084..........................................         26.6753         24.6049         25.5110         25.5914
310086..........................................         22.1674         23.1719         23.5820         22.9629
310087..........................................         20.7243         21.1215         20.7434         20.8650
310088..........................................         22.3160         23.1722         24.2150         23.2258
310090..........................................         23.8284         24.8986         24.4746         24.3899
310091..........................................         22.7978         23.2969         24.5357         23.5110
310092..........................................         20.5165         21.6964         23.1341         21.7772
310093..........................................         22.4291         23.7251         24.0037         23.3380
310096..........................................         25.1572         24.5759         26.6982         25.4341
310105..........................................         25.5891         26.2537         25.1559         25.6770
310108..........................................         22.4756         23.8308         26.2036         24.1336
310110..........................................         21.8341         23.2146         23.1789         22.7903
310111..........................................         21.1066         22.1151         24.1731         22.4723
310112..........................................         23.6701         24.7914         24.2999         24.2528
310113..........................................         23.6841         23.1961         24.0930         23.6671
310115..........................................         21.7320         21.1645         23.4249         22.1167
310116..........................................         22.9812         23.6366               *         23.3055
310118..........................................         26.4625         26.1315         26.5619         26.3869
310119..........................................         33.6686         32.7858         29.1045         31.7976
310120..........................................         23.9681         23.3200         22.6526         23.3189
320001..........................................         19.1150         20.6225         21.0689         20.2496
320002..........................................         22.6175         23.0983         25.5144         23.6846
320003..........................................         15.9504         16.4642         16.4961         16.3037
320004..........................................         18.5824         19.6642         21.3681         19.9888
320005..........................................         21.6103         21.0411         22.4178         21.7283
320006..........................................         18.9019         20.3863         19.8672         19.6917
320009..........................................         18.2883         19.3500         20.3783         19.2661
320011..........................................         20.0601         18.5222         18.7099         19.0944
320012..........................................         16.4355         17.1764         14.3961         16.0417
320013..........................................         22.9573         24.5543         24.4795         24.0591
320014..........................................         16.3598         16.8412         21.7784         18.0981
320016..........................................         20.5398         18.8519         18.8763         19.4121
320017..........................................         18.6388         19.4498         20.4390         19.4898
320018..........................................         18.8479         19.2336         20.4375         19.5136
320019..........................................         24.4707         26.9637         24.4394         25.3985
320021..........................................         17.8705         19.1265         19.6950         18.8702
320022..........................................         16.1777         18.0606         19.9587         18.1477
320023..........................................         18.0548         17.8419               *         17.9685
320030..........................................         16.5495         18.6859         18.1556         17.7555
320031..........................................         19.6768         25.1715         18.2244         20.7137
320032..........................................         18.8097         20.6871         21.1628         20.1426
320033..........................................         25.0777         21.0621         21.9804         22.5777
320035..........................................         21.5186         15.0612         17.8058         17.7193
320037..........................................         17.0305         17.8280         17.6619         17.5121
320038..........................................         16.8117         22.2664               *         19.6948
320046..........................................         18.3190         18.9607         22.6251         20.0803
320048..........................................         19.9642         16.8769               *         18.3467
320063..........................................         18.3237         17.9089         14.4611         17.0236
320065..........................................         16.7933         18.6525         22.1138         18.8982
320067..........................................         33.8654         15.3228         16.8015         18.3132
320068..........................................         17.4785         18.5103         15.6681         17.1335
320069..........................................         13.0094         14.4212         15.7350         14.3622
320074..........................................         19.3406         20.2290         22.3403         20.2679
320079..........................................         18.2828         19.8555         19.9049         19.3010

[[Page 31567]]

 
330001..........................................         26.5533         27.3996         28.4974         27.5189
330002..........................................         26.5370         26.9341         26.6966         26.7185
330003..........................................         19.4102         18.9211         19.3972         19.2414
330004..........................................         22.5298         20.9501         22.5082         22.0002
330005..........................................         24.8338         22.1957         22.6137         22.8232
330006..........................................         25.0576         25.8006         26.2970         25.7013
330007..........................................         18.9024               *               *         18.9024
330008..........................................         19.0045         19.2341         19.6770         19.3060
330009..........................................         30.6918         31.3435         30.9087         30.9793
330010..........................................         17.4512         16.6508         17.8935         17.3146
330011..........................................         18.2986         18.6748         18.7995         18.5936
330012..........................................         32.7624               *               *         32.7624
330013..........................................         19.0856         19.6269         19.0995         19.2697
330014..........................................         32.3370         36.8669         32.4496         33.8020
330016..........................................         16.9717         16.8016         18.7194         17.4483
330019..........................................         35.9822         33.5369         31.5927         33.4812
330020..........................................         15.5527         15.1142         16.6952         15.7780
330023..........................................         24.4006         25.6512         26.6997         25.5866
330024..........................................         34.1682         37.3316         35.7485         35.6717
330025..........................................         16.2033         16.8687         17.6169         16.8903
330027..........................................         33.4738         35.5255         35.1046         34.6601
330028..........................................         28.2089         29.5294         31.7699         29.9762
330029..........................................         18.1567         17.0016         19.4377         18.2068
330030..........................................         17.4977         19.1085         18.0866         18.1511
330033..........................................         18.5353         17.4444         19.4402         18.4646
330034..........................................         31.3997         27.7738         38.2451         31.3373
330036..........................................         23.9874         25.2820         25.5888         24.9782
330037..........................................         16.1140         16.4866         18.3260         16.9831
330038..........................................         16.2549         17.3429         16.2997         16.6434
330041..........................................         24.5215         31.4871         29.5305         28.1630
330043..........................................         28.7467         27.4661         28.9622         28.3990
330044..........................................         20.0238         19.5219         19.9808         19.8437
330045..........................................         28.0758         27.9919         28.5267         28.2011
330046..........................................         32.4189         35.2703         38.1184         35.1742
330047..........................................         18.1815         18.5536         19.5561         18.7655
330048..........................................         17.8787         19.1093         19.6129         18.8634
330049..........................................         19.4993         20.5731         22.1523         20.7576
330053..........................................         17.4430         17.8082         17.8308         17.6930
330055..........................................         36.1109         32.8910         32.6387         33.8113
330056..........................................         30.4525         30.0945         29.8377         30.1337
330057..........................................         18.7478         19.3643         20.0995         19.4010
330058..........................................         17.0014         17.7672         18.1007         17.6091
330059..........................................         34.1705         34.2426         35.0121         34.4519
330061..........................................         25.7331         25.4082         26.8580         25.9786
330062..........................................         17.6067         18.1318         18.4662         18.0774
330064..........................................         33.1269         33.6447         35.1422         33.9496
330065..........................................         19.8940         19.9305         20.2835         20.0284
330066..........................................         19.5611         18.8707         19.5272         19.3115
330067..........................................         20.9443         22.1065         23.6836         22.2657
330072..........................................         30.8019         30.4171         30.3737         30.5362
330073..........................................         16.2898         16.4518         16.5166         16.4181
330074..........................................         18.0005         17.7308         18.7081         18.1472
330075..........................................         17.2298         17.6385         18.9699         17.9293
330078..........................................         16.7949         18.7884         18.0362         17.8405
330079..........................................         17.4555         18.7622         18.9398         18.3917
330080..........................................         29.2686         31.4424         28.3401         29.6840
330084..........................................         18.0435         19.3216         19.0261         18.8002
330085..........................................         20.2926         20.6203         22.8312         21.2658
330086..........................................         31.2980         23.6496         26.2979         27.1579
330088..........................................         25.6626         25.7940         26.7583         26.0739
330090..........................................         19.3954         19.2112         20.4314         19.6779
330091..........................................         19.0953         19.7776         21.6004         20.1526
330092..........................................         14.0671         13.3723         17.2083         14.8861

[[Page 31568]]

 
330094..........................................         17.5585         18.1582         18.7259         18.1488
330095..........................................         20.1073         21.1096         21.1809         20.7563
330096..........................................         17.9641         18.5149         20.0370         18.8403
330097..........................................         16.2169         16.4433         15.8232         16.1519
330100..........................................         27.0661         29.0916         28.9956         28.3021
330101..........................................         32.4105         31.5914         34.7119         32.9505
330102..........................................         17.5755         19.0058         21.0057         19.0881
330103..........................................         15.7197         16.8110         17.8864         16.8159
330104..........................................         31.6471         31.2074         31.9154         31.5867
330106..........................................         40.2686         35.3775         35.1434         36.7949
330107..........................................         28.5580         27.7797         28.9225         28.4199
330108..........................................         17.3605         18.0786         18.5194         17.9737
330111..........................................         19.5314         15.9321         13.3352         15.9787
330114..........................................         17.3522         17.0581         19.1162         17.8316
330115..........................................         17.4430         17.4684         13.0722         15.4701
330116..........................................         24.4622         14.9610         16.8567         18.1237
330118..........................................         20.6936               *               *         20.6936
330119..........................................         34.8385         33.1179         33.5653         33.8391
330121..........................................         16.1052         16.3385         17.1869         16.5359
330122..........................................         20.8204         20.2417         23.0384         21.3559
330125..........................................         19.8494         19.7638         20.3093         19.9745
330126..........................................         23.7938         23.8957         24.8787         24.2123
330127..........................................         31.9046         30.7356         33.9627         32.2469
330128..........................................         29.0222         30.8242         27.7350         29.2603
330132..........................................         15.7633         14.3673         14.8704         15.0313
330133..........................................         37.2494         35.3576         37.5192         36.5906
330135..........................................         18.7120         22.2670         23.5662         21.3289
330136..........................................         18.2422         20.1043         20.0552         19.4517
330140..........................................         19.1438         19.3615         20.2951         19.5989
330141..........................................         26.4956         26.7096         27.5960         26.9363
330144..........................................         14.0566         16.2517         17.1513         15.7880
330148..........................................         16.8151         16.2782         16.7251         16.6024
330151..........................................         16.0714         15.7594         15.2233         15.6663
330152..........................................         30.5409         30.8314         33.4288         31.5069
330153..........................................         18.9689         18.1776         19.4417         18.8671
330157..........................................         22.0792         22.3804         23.1743         22.5628
330158..........................................         25.7569         27.1228         29.3163         27.3406
330159..........................................         19.1536         19.4998         20.2601         19.6219
330160..........................................         32.7840         29.5885         30.7893         30.9997
330162..........................................         27.1166         27.6010         27.9705         27.5570
330163..........................................         18.7816         20.7456         21.4143         20.2444
330164..........................................         19.8647         20.9003         20.5006         20.4195
330166..........................................         15.0954         15.4420         17.0637         15.8309
330167..........................................         29.3634         30.2346         32.0728         30.4495
330169..........................................         37.2655         35.4794         36.3690         36.3400
330171..........................................         25.5307         24.8035         24.8515         25.0649
330175..........................................         17.3290         18.3116         18.8201         18.1260
330177..........................................         17.2907         16.3704         16.6059         16.7542
330179..........................................         13.4999         13.8953         15.8620         14.3577
330180..........................................         16.8787         17.9877         19.2670         17.9995
330181..........................................         32.5192         33.0908         34.2919         33.2777
330182..........................................         32.9371         33.6531         33.3363         33.3137
330183..........................................         19.9207         20.6164         19.6980         20.0807
330184..........................................         30.0400         31.3706         28.4726         30.0103
330185..........................................         25.6112         26.8612         27.8585         26.7622
330188..........................................         20.9587         18.8000         20.2849         20.0186
330189..........................................         15.1253         18.4498         23.5589         18.7634
330191..........................................         18.6206         19.0348         19.4168         19.0266
330193..........................................         36.5481         30.2260         32.5496         32.9872
330194..........................................         34.6785         35.2036         35.6486         35.1819
330195..........................................         33.3254         34.8966         29.8157         32.7136
330196..........................................         30.8165         30.5799         25.9671         29.2151
330197..........................................         17.6646         18.3527         19.2237         18.4045

[[Page 31569]]

 
330198..........................................         24.6038         24.8590         25.4472         24.9692
330199..........................................         28.7609         30.5409         26.0228         28.5436
330201..........................................         32.1149         28.7861         27.6320         29.6019
330202..........................................         31.4435         31.2575         31.9777         31.5574
330203..........................................         20.7575         25.0345         25.7916         23.7288
330204..........................................         29.4418         32.2005         28.4140         30.0233
330205..........................................         20.5793         22.3490         24.9040         22.5611
330208..........................................         26.1822         26.6682         27.3170         26.7219
330209..........................................         23.9924         25.1281         26.8546         25.3803
330211..........................................         19.5064         19.5405         20.0006         19.6855
330212..........................................         21.7705         24.7681         24.4902         23.6390
330213..........................................         18.7722         19.6796         20.1166         19.4878
330214..........................................         36.4447         32.4292         32.2640         33.3003
330215..........................................         19.6926         17.9863         19.0726         18.8818
330218..........................................         21.4796         21.1890         21.4747         21.3812
330219..........................................         23.9908         23.4310         25.1792         24.1748
330221..........................................         27.8485         33.3796         29.5535         30.2856
330222..........................................         18.3666         18.5571         19.3148         18.7515
330223..........................................         17.6199         17.8306         19.0773         18.1866
330224..........................................         19.6410         20.4309         20.7773         20.2793
330225..........................................         25.5823         27.0379         28.0523         26.7760
330226..........................................         16.6711         23.1859         16.9198         18.3930
330229..........................................         16.8026         17.5326         18.2554         17.5103
330230..........................................         29.7626         29.6283         30.6937         29.9984
330231..........................................         30.0923         32.7200         25.2793         29.5345
330232..........................................         17.9083         19.1787         19.6181         18.8942
330233..........................................         30.9241         44.1265         42.3510         37.9819
330234..........................................         35.1777         35.0720         35.8927         35.3813
330235..........................................         21.0842         19.5880         20.1255         20.2820
330236..........................................         29.5913         31.3463         30.9816         30.6263
330238..........................................         15.6245         17.3976         17.5807         16.8401
330239..........................................         17.4462         18.5079         18.9953         18.2764
330240..........................................         29.7082         30.7321         32.0049         30.7179
330241..........................................         24.6076         23.8638         24.7545         24.4065
330242..........................................         28.2612         27.6384         28.3561         28.0883
330245..........................................         17.6767         18.5161         20.7167         19.0400
330246..........................................         28.1090         28.1205         29.8777         28.6473
330247..........................................         28.5310         27.3937         32.5858         29.3555
330249..........................................         16.2687         17.1320         17.6846         17.0482
330250..........................................         19.5823         19.9619         20.7381         20.1092
330254..........................................         18.4057         15.9123         15.7864         16.7695
330258..........................................         29.7426         31.8910         32.6745         31.4411
330259..........................................         26.2661         25.9994         26.3620         26.2118
330261..........................................         25.7244         27.9766         30.0489         27.8583
330263..........................................         20.4149         18.7378         19.5057         19.6112
330264..........................................         22.8672         22.8099         24.6387         23.4672
330265..........................................         18.0193         17.6301         21.1215         18.8985
330267..........................................         24.5183         24.5939         27.8255         25.6678
330268..........................................         13.0595         15.9060         16.8358         15.2987
330270..........................................         34.4254         36.0824         31.3908         33.9198
330273..........................................         23.1511         26.0565         27.0454         25.3482
330275..........................................         19.0548         18.7268               *         18.9109
330276..........................................         18.2870         19.0228         19.2611         18.8572
330277..........................................         18.3169         19.1761         20.7851         19.4340
330279..........................................         19.5983         20.7107         21.7827         20.6371
330285..........................................         23.5264         24.0491         25.9154         24.4664
330286..........................................         26.7633         27.7762         28.0994         27.5677
330290..........................................         33.5056         30.4706         34.3439         32.7503
330293..........................................         16.2158         16.9238         17.2262         16.7522
330304..........................................         26.7683         27.3562         29.2207         27.7999
330306..........................................         27.3798         29.5937         25.6970         27.5466
330307..........................................         21.0673         21.7257         23.1148         21.9912
330314..........................................         24.5444         25.9937         25.5405         25.3155

[[Page 31570]]

 
330316..........................................         27.6102         27.9543         27.9277         27.8310
330327..........................................         16.4611         20.3874         20.1705         18.8688
330331..........................................         31.6216         33.1276         31.0718         31.9586
330332..........................................         27.6914         25.3689         27.6955         26.9473
330333..........................................         29.1931               *         28.8841         29.0179
330336..........................................         29.7689         29.8294         29.1415         29.5860
330338..........................................         22.4581         21.2670         23.6142         22.4472
330339..........................................         20.0111         20.1028         20.2382         20.1121
330340..........................................         28.8419         28.4129         29.4512         28.8934
330350..........................................         30.8889         30.9763         33.5493         31.7771
330353..........................................         32.1984         34.2431         34.2260         33.5106
330357..........................................         36.5928         34.1846         36.8598         35.8981
330372..........................................         28.8482         33.3771         27.8854         29.8144
330381..........................................         31.0091         31.8602               *         31.4219
330385..........................................         35.6722         33.2246         33.4159         34.1965
330386..........................................         17.6383         20.4231         21.4363         19.4104
330389..........................................         30.2505         37.3749         27.6223         31.1985
330390..........................................         31.1577         30.8744         33.4372         31.7841
330393..........................................         26.4958         27.8352         33.6061         29.1012
330394..........................................         19.2392         18.9343         19.6892         19.2847
330395..........................................         32.8749         32.7494         30.2846         32.0161
330396..........................................         34.8648         30.7961         29.1753         31.7581
330397..........................................         33.9061         32.6068         38.3281         34.7790
330398..........................................         28.7707         29.2872               *         28.9084
330399..........................................         32.9100         33.3012         32.7149         32.9707
330400..........................................               *         16.2707         16.8168         16.5566
340001..........................................         18.1814         19.7093         21.8572         19.9040
340002..........................................         20.8858         20.5253         22.2638         21.3163
340003..........................................         20.2540         19.5145         19.6545         19.8018
340004..........................................         19.0695         20.9863         23.0890         21.0811
340005..........................................         15.8205         16.7176         16.3073         16.2815
340006..........................................         16.9818         16.5709         16.1379         16.5756
340007..........................................         17.2356         18.3399         18.3760         17.9959
340008..........................................         21.2889         20.4157         22.0774         21.2828
340009..........................................         20.5023         20.9178         20.6155         20.6734
340010..........................................         18.3380         19.4302         20.6547         19.5049
340011..........................................         13.6554         14.4798         17.4534         15.1697
340012..........................................         18.8701         17.5112         19.3651         18.5479
340013..........................................         20.1747         19.4613         21.5130         20.3981
340014..........................................         20.5748         27.7888         21.9804         22.9126
340015..........................................         20.1562         19.4676         20.3493         19.9875
340016..........................................         17.5404         18.8958         19.4160         18.6049
340017..........................................         19.4192         20.2775         20.6263         20.1119
340018..........................................         14.0930         18.1751         16.4611         16.0927
340019..........................................         14.8980         15.2887         15.9037         15.3369
340020..........................................         18.6334         18.0897         19.2392         18.6598
340021..........................................         19.8020         20.5813         22.0220         20.7507
340022..........................................         17.8178         18.7714         20.6484         19.0742
340023..........................................         18.5414         19.3146         19.2617         19.0575
340024..........................................         17.3824         17.9130         19.1430         18.1515
340025..........................................         17.2648         18.4628         19.1770         18.3029
340027..........................................         18.0816         19.4548         19.4907         19.0172
340028..........................................         18.4787         19.9403         20.6496         19.7560
340030..........................................         21.1420         22.4709         24.0238         22.4825
340031..........................................         14.6951         14.6370         15.4935         14.9011
340032..........................................         20.0049         20.7444         21.7127         20.8112
340035..........................................         20.2312         18.9930         18.5883         19.2823
340036..........................................         18.2190         17.7619         18.4203         18.1226
340037..........................................         16.6576         17.5829         18.3655         17.5271
340038..........................................         17.3762         18.1493         20.3091         18.5547
340039..........................................         20.5876         21.3711         22.2939         21.4440
340040..........................................         20.4282         20.7237         21.1020         20.7582
340041..........................................         15.1419         15.5873         16.3200         15.6803

[[Page 31571]]

 
340042..........................................         16.9298         17.0034         19.1386         17.6977
340044..........................................         18.8687         18.0863         18.9562         18.6425
340045..........................................         13.0538         13.6182         20.2641         14.9554
340047..........................................         20.0602         20.0744         20.7061         20.2776
340049..........................................         19.2050         19.5127         17.2986         18.6550
340050..........................................         20.0090         19.6726         20.6831         20.1383
340051..........................................         16.5617         19.3627         19.0282         18.2702
340052..........................................         22.8173         23.2134         26.2243         23.8462
340053..........................................         20.9495         19.9915         22.6020         21.1247
340054..........................................         15.5993         15.5090         16.6208         15.8560
340055..........................................         19.6056         19.4035         20.2936         19.7761
340060..........................................         18.7137         19.3410         20.8570         19.6422
340061..........................................         21.5385         22.1175         23.7173         22.4390
340063..........................................         17.0249         16.7377         26.4132         19.5650
340064..........................................         20.7125         18.5069         17.7395         18.9394
340065..........................................         17.5414         17.3530         18.3610         17.7341
340067..........................................         19.3785         19.7187         22.4054         20.2943
340068..........................................         16.6305         17.8065         18.8758         17.7729
340069..........................................         21.0840         21.6728         22.5664         21.7942
340070..........................................         19.7796         20.6829         21.5793         20.6882
340071..........................................         17.1424         18.0767         19.3679         18.2275
340072..........................................         16.7400         17.7129         18.7920         17.7544
340073..........................................         21.9761         23.5832         23.4906         23.0367
340075..........................................         18.7090         20.0081         19.9451         19.5511
340080..........................................         22.2533         18.2061               *         20.1809
340084..........................................         17.1532         19.0103         19.6087         18.5190
340085..........................................         17.3462         18.3179         20.3684         18.6708
340087..........................................         17.3884         18.2255         20.2445         18.6743
340088..........................................         21.0226         22.2322         22.6462         21.9702
340089..........................................         13.8535         15.4760         16.1321         15.1566
340090..........................................         17.0584         18.5287         18.7701         18.1576
340091..........................................         20.5923         20.3861         21.1892         20.7475
340093..........................................         16.3276         16.8903         16.5452         16.5873
340094..........................................         19.0406               *         20.8816         19.9881
340096..........................................         17.8189         19.4696         20.9686         19.4268
340097..........................................         18.8412         18.2399         20.0302         19.0440
340098..........................................         21.4135         21.9578         23.5280         22.3354
340099..........................................         16.8305         15.3752         16.9979         16.3421
340101..........................................         13.9994         15.6509         20.7841         16.3562
340104..........................................         13.0462         11.5169         12.1845         12.2454
340105..........................................         20.2954               *               *         20.2954
340106..........................................         17.7220         18.1211         19.1147         18.3112
340107..........................................         18.0205         19.3197         20.7601         19.3267
340109..........................................         18.7746         19.0532         19.3357         19.0640
340111..........................................         16.3344         16.5976         17.2127         16.7260
340112..........................................         14.7562         15.5142         16.9592         15.7587
340113..........................................         21.2906         21.9883         24.0277         22.4262
340114..........................................         21.2166         20.7261         21.7750         21.2327
340115..........................................         19.7578         21.7586         24.7924         21.8733
340116..........................................         20.4255         20.6800         21.6616         20.9285
340119..........................................         18.8507         19.5827         20.5394         19.6919
340120..........................................         15.0410         15.8240         16.9847         15.9742
340121..........................................         16.3295         17.8771         19.0420         17.7638
340123..........................................         16.9114         18.9078         21.5041         19.1720
340124..........................................         15.5779         17.4185         17.5411         16.8707
340125..........................................         19.7164         20.2748               *         19.9923
340126..........................................         18.8100         19.3734         20.7395         19.6489
340127..........................................         19.3925         19.3842         21.4797         20.0982
340129..........................................         20.4605         20.6521         21.0773         20.7569
340130..........................................         19.7422         19.8707         20.5851         20.0891
340131..........................................         19.7908         21.3849         23.2478         21.4650
340132..........................................         17.3448         17.5711         17.7110         17.5495
340133..........................................         16.4766         17.2138         16.9829         16.8955

[[Page 31572]]

 
340137..........................................         21.0249         31.7702               *         23.8273
340138..........................................         20.7618               *               *         20.7618
340141..........................................         21.3754         21.4986         22.4525         21.7877
340142..........................................         17.1525         18.0766         18.1824         17.8038
340143..........................................         21.3604         24.4098         21.9304         22.5287
340144..........................................         20.9113         22.9183         22.8634         22.2296
340145..........................................         20.1081         19.9233         21.5958         20.6005
340146..........................................         15.9203         17.3051         19.1306         17.3989
340147..........................................         19.6827         20.5520         21.5912         20.6397
340148..........................................         18.5875         18.9912         20.6790         19.3782
340151..........................................         16.7275         18.4733         19.0779         18.0943
340153..........................................         20.6420         20.7533         21.7375         21.0743
340155..........................................         20.5792         23.1021         24.8963         22.8382
340158..........................................         18.1439         19.0843         20.0921         19.1509
340159..........................................         17.3893         19.0338         18.3028         18.2386
340160..........................................         16.1778         16.7170         17.1963         16.7262
340162..........................................         14.3472               *               *         14.3472
340164..........................................         21.2523         21.5769               *         21.4120
340166..........................................         20.0434         20.8270         22.0519         21.0278
340168..........................................         15.2919         15.6071         15.4250         15.4443
340171..........................................         21.5973         22.4779         22.7304         22.3095
340173..........................................         19.3353         21.0898         23.3690         21.3475
350001..........................................         14.9080         16.6551         15.6193         15.7235
350002..........................................         17.5259         18.3459         19.1931         18.3399
350003..........................................         18.2470         19.2840         20.0663         19.1912
350004..........................................         20.6518         23.7016         25.1976         23.1394
350005..........................................         18.3792         19.9156         20.7467         19.6757
350006..........................................         18.4107         19.0343         19.1257         18.8317
350007..........................................         13.3292         13.8824         13.9966         13.7234
350008..........................................         20.4777         22.3783         23.1361         21.9692
350009..........................................         19.1611         18.3688         19.3668         18.9603
350010..........................................         16.2808         16.6272         16.7774         16.5574
350011..........................................         18.2008         19.1944         20.6809         19.2312
350012..........................................         15.7033         18.2524         16.0990         16.7533
350013..........................................         16.4579         17.2596         17.5935         17.0893
350014..........................................         16.8403         18.0999         18.2003         17.6546
350015..........................................         16.3397         17.1071         16.5368         16.6512
350016..........................................         11.6524               *               *         11.6524
350017..........................................         17.6278         17.5124         18.0840         17.7360
350018..........................................         14.4928         16.4939         16.3210         15.7222
350019..........................................         19.3063         20.1608         20.6743         20.0169
350021..........................................         16.2898         17.7123         16.3394         16.7592
350023..........................................         17.9048         17.4983         18.3253         17.9187
350024..........................................         14.7529         15.4788         15.7510         15.3010
350025..........................................         17.1199         15.0469         14.6099         15.5234
350027..........................................         15.0835         15.5178         17.5882         15.9431
350029..........................................         13.5219         14.6173               *         14.0747
350030..........................................         17.7209         18.1131         18.7182         18.1761
350033..........................................         14.9012         16.0870         16.0903         15.6588
350034..........................................         18.7245         19.6445               *         19.1773
350035..........................................         10.4570         11.7675         12.6496         11.6111
350038..........................................         17.6666         19.6854         19.0500         18.7554
350039..........................................         17.0361         16.6278         14.8599         16.1842
350041..........................................         14.6680         19.1341         23.1150         18.5427
350042..........................................         16.7402         19.3309         19.3370         18.2440
350043..........................................         16.8876         16.7433         17.6722         17.1008
350044..........................................         10.2154         11.0601         10.9690         10.7163
350047..........................................         14.4628         18.0094         19.9749         17.4882
350049..........................................         14.8019         18.1993         16.7131         16.4253
350050..........................................         11.4921         12.2183               *         11.8525
350051..........................................         17.7279         17.0653         16.4587         17.0939
350053..........................................         14.6398         15.9160         16.5484         15.6473
350055..........................................         14.5691         15.7916         15.8572         15.3943

[[Page 31573]]

 
350056..........................................         14.8293         15.0995         15.7752         15.2147
350058..........................................         15.9378         16.7034         15.8171         16.1663
350060..........................................         10.3666         10.3076         10.5325         10.3988
350061..........................................         15.7269         18.8790         19.3748         18.0353
360001..........................................         17.0791         19.6655         18.5766         18.4186
360002..........................................         18.0139         18.2613         19.6145         18.5918
360003..........................................         22.7471         22.7521         23.2905         22.9196
360006..........................................         21.8048         22.4436         22.8554         22.3622
360007..........................................         18.0941         14.8213         15.3656         16.0665
360008..........................................         18.5439         18.7961         19.8034         19.0500
360009..........................................         18.9322         18.9935         19.6087         19.1932
360010..........................................         19.2288         19.1852         20.4671         19.6517
360011..........................................         19.3835         21.3659         19.4581         19.9957
360012..........................................         19.9881         20.0525         21.8759         20.5910
360013..........................................         20.6021         21.3690         22.3407         21.4314
360014..........................................         20.2390         20.7419         22.9930         21.3333
360016..........................................         17.8065         21.2505         21.4202         20.0256
360017..........................................         21.7543         22.2740         22.6535         22.2073
360018..........................................         23.5219         24.6686         24.6694         24.2429
360019..........................................         18.7147         20.6480         21.4708         20.1693
360020..........................................         21.7806         22.1751         21.7288         21.8938
360024..........................................         19.8508         20.1352         20.9408         20.3040
360025..........................................         20.3638         20.2531         20.9266         20.5175
360026..........................................         18.2222         17.9523         18.6739         18.2838
360027..........................................         21.0406         21.7650         22.6915         21.8330
360028..........................................         17.0177         18.7174               *         17.7935
360029..........................................         18.7622         19.2928         19.7246         19.2680
360030..........................................         17.5748         17.6058         19.0313         18.0839
360031..........................................         19.3858         21.0687         21.0481         20.5037
360032..........................................         18.6559         19.8020         19.8367         19.4058
360034..........................................         14.9534         17.9594         19.1248         17.3380
360035..........................................         20.5557         21.0674         21.0533         20.8877
360036..........................................         20.2107         20.9916         21.4665         20.8874
360037..........................................         23.5094         23.1674         23.8620         23.5454
360038..........................................         21.2467         19.9415         20.9651         20.7274
360039..........................................         18.7791         19.0013         19.1934         18.9931
360040..........................................         18.1618         18.7425         19.9750         18.9827
360041..........................................         19.5744         19.7968         21.2727         20.2776
360042..........................................         17.4306         17.1952         19.3774         17.9518
360044..........................................         17.0612         17.6882         17.8417         17.5521
360045..........................................         22.1471         22.4018         22.8112         22.4244
360046..........................................         20.4755         20.4607         21.4292         20.8030
360047..........................................         17.1871         15.2922         15.8279         16.0315
360048..........................................         22.5857         22.4890         25.6259         23.4295
360049..........................................         20.4564         20.8393               *         20.6400
360050..........................................         12.9873         15.0568         15.6847         14.5392
360051..........................................         20.8338         20.8757         21.2225         20.9792
360052..........................................         19.6233         18.7931         19.8278         19.4110
360054..........................................         17.2574         17.4911         17.5714         17.4428
360055..........................................         21.5585         21.4112         22.8755         21.9415
360056..........................................         19.0474         20.6968         23.2385         21.0356
360057..........................................         15.0146         15.8569         16.0395         15.6552
360058..........................................         18.6992         19.3306         19.0440         19.0197
360059..........................................         20.5618         19.9304         23.2129         21.1909
360062..........................................         20.7588         21.9195         24.4898         22.4391
360063..........................................         18.4512         17.5108         20.2671         18.6964
360064..........................................         20.4846         20.0615         20.9202         20.4850
360065..........................................         20.0532         19.6199         22.0853         20.5895
360066..........................................         21.6015         22.8175         23.8834         22.7933
360067..........................................         15.3157         14.2745         17.3024         15.5854
360068..........................................         21.2789         22.6227         22.2094         22.0456
360069..........................................         16.6982         14.6597         18.5382         16.4901
360070..........................................         17.3758         18.8406         19.4700         18.5552

[[Page 31574]]

 
360071..........................................         17.9756         19.0302         19.6873         18.9152
360072..........................................         18.1467         19.0166         20.8819         19.3874
360074..........................................         20.8275         18.5889         19.9876         19.7904
360075..........................................         22.4523         26.0663         27.6992         24.6791
360076..........................................         20.0700         20.3317         21.0402         20.4919
360077..........................................         21.1053         21.5517         22.2964         21.6371
360078..........................................         21.4392         22.6490         22.6075         22.2329
360079..........................................         22.1096         21.6644         23.9491         22.5122
360080..........................................         17.3892         17.6369         18.0392         17.6871
360081..........................................         21.7342         20.4614         20.7477         20.9963
360082..........................................         22.9460         20.7610         22.9390         22.1817
360084..........................................         20.4894         22.0492         22.1699         21.5674
360085..........................................         21.9051         21.5151         24.8010         22.5708
360086..........................................         19.5378         19.3701         20.5858         19.8561
360087..........................................         20.1684         20.7969         21.1621         20.7100
360088..........................................         24.0097         24.0822         20.5703         22.7567
360089..........................................         18.3881         18.1941         19.5260         18.6947
360090..........................................         21.0376         20.8971         21.2072         21.0517
360091..........................................         21.3126         21.8447         22.6510         21.9522
360092..........................................         20.4534         21.5073         20.9588         20.9684
360093..........................................         19.3292         19.0261         21.0134         19.7919
360094..........................................         18.8780         20.1227         21.1952         20.0119
360095..........................................         20.4149         19.8521         21.3505         20.5395
360096..........................................         18.2215         19.6726         20.9838         19.6144
360098..........................................         19.5314         19.8178         20.7942         20.0486
360099..........................................         18.5855         19.6241         20.8801         19.7171
360100..........................................         17.8989         18.0442         20.0683         18.5932
360101..........................................         21.3914         20.2635         24.1551         21.8064
360102..........................................         19.4345         18.5367               *         19.0252
360106..........................................         18.9752         19.1778         18.9779         19.0463
360107..........................................         19.7599         22.1359               *         20.9636
360108..........................................         17.5832         20.0681         19.0870         18.9015
360109..........................................         20.1032         19.9237         17.3564         18.9331
360112..........................................         22.5589         24.6335         25.7920         24.1917
360113..........................................         24.2654         20.8154         18.4832         21.0469
360114..........................................         17.8761         18.7509         19.4212         18.7051
360115..........................................         18.8059         20.7652         21.0104         20.2115
360116..........................................         18.8882         18.8319         20.1408         19.2675
360118..........................................         19.3732         19.9141         21.0235         20.1425
360121..........................................         22.1093         22.2175         21.9111         22.0788
360123..........................................         20.3236         20.9792         21.9985         21.1330
360125..........................................         19.0774         20.5508         21.6675         20.3325
360126..........................................         19.0036         24.5387               *         21.4419
360127..........................................         17.5882         16.5559         18.2150         17.4610
360128..........................................         16.1243         17.0515         17.5495         16.8959
360129..........................................         15.5002         16.6114         17.2309         16.4330
360130..........................................         17.2009         18.4539         19.8906         18.4639
360131..........................................         19.2241         18.4688         20.4123         19.3509
360132..........................................         19.9171         21.3493         21.0162         20.7647
360133..........................................         19.4316         20.2857         22.1957         20.5231
360134..........................................         20.6876         20.9564         21.4024         21.0100
360136..........................................         17.7827         18.2194         18.5687         18.1837
360137..........................................         20.1756         22.3648         23.1642         21.8556
360140..........................................         20.2791         21.2881         18.3463         19.9463
360141..........................................         23.0016         23.5343         23.5006         23.3475
360142..........................................         17.0059         18.3188         19.6189         18.3226
360143..........................................         20.1989         21.0336         20.9158         20.7118
360144..........................................         23.2191         20.9033         20.9386         21.6583
360145..........................................         19.6413         20.0513         21.2931         20.3252
360147..........................................         16.6616         17.6779         18.7258         17.7129
360148..........................................         19.2816         19.1393         20.3120         19.5918
360149..........................................         19.9808               *               *         19.9808
360150..........................................         21.1327         22.3620         23.1858         22.2110

[[Page 31575]]

 
360151..........................................         16.6019         19.2788         20.5594         18.6756
360152..........................................         20.8328         21.6005         20.8782         21.1044
360153..........................................         15.4132         16.7399         16.1021         16.0822
360154..........................................         14.3270         14.3593         14.8550         14.5038
360155..........................................         22.5347         22.2112         22.2805         22.3386
360156..........................................         17.8787         18.9095         19.9382         18.8811
360159..........................................         20.2841         21.5695         22.7992         21.5782
360161..........................................         19.1983         20.6160         19.9054         19.9030
360163..........................................         20.7275         21.2689         22.1012         21.3886
360165..........................................         18.2571         18.2417         19.6205         18.6959
360166..........................................         18.7321               *               *         18.7321
360170..........................................         16.4653         20.4407         19.3099         18.5975
360172..........................................         18.6720         19.8909         22.3294         20.3872
360174..........................................         19.9725         20.5399         20.5874         20.4239
360175..........................................         21.1685         21.5450         22.0274         21.5958
360176..........................................         15.9430         16.6228         17.6291         16.7269
360177..........................................         18.7898         18.9576         19.6992         19.1509
360178..........................................         18.8704         16.7962         18.0773         17.9514
360179..........................................         21.1309         20.7069         21.9617         21.2476
360180..........................................         21.3826         21.0146         18.0143         20.0375
360184..........................................         19.1224               *               *         19.1224
360185..........................................         18.7291         19.4858         20.0848         19.4376
360186..........................................         18.3246         20.7572         18.1254         19.0367
360187..........................................         18.5109         19.6535         20.8423         19.6414
360188..........................................         17.1044         18.3057         16.4329         17.3292
360189..........................................         17.8981         18.5940         19.0481         18.4968
360192..........................................         21.6365         22.7846         23.9969         22.7928
360194..........................................         17.1884         17.6140         19.3901         18.0653
360195..........................................         19.9302         20.5828         21.2083         20.5836
360197..........................................         20.0603         20.5062         21.6110         20.7240
360200..........................................         16.2306         17.9623         19.5866         17.8050
360203..........................................         16.3181         15.9609         17.9698         16.7236
360204..........................................         22.2494               *               *         22.2494
360210..........................................         20.9955         21.8629         21.5961         21.4839
360211..........................................         19.9895         20.6081         22.0011         20.8512
360212..........................................         21.1123         20.6987         21.0632         20.9556
360213..........................................         19.4765         19.0584         20.5448         19.6749
360218..........................................         18.9469         18.8204         20.7709         19.5181
360230..........................................         21.9763         20.8042         21.2417         21.3193
360231..........................................         12.9588         14.4168         12.7388         13.3090
360234..........................................         23.2588         20.6131         17.6716         20.3070
360236..........................................         17.8426         21.4628         20.5998         19.8666
360239..........................................         20.1854         19.2375         20.9440         20.0997
360241..........................................         23.5318         25.3741         23.7679         24.1749
360243..........................................         14.8694               *               *         14.8694
360245..........................................         16.4622         15.9782         16.7956         16.4127
360247..........................................         16.3092         17.0776               *         16.6743
360249..........................................               *         25.4331               *         25.4331
360251..........................................               *               *         21.3149         21.3149
360252..........................................               *               *         27.1728         27.1728
370001..........................................         22.5214         24.1929         21.8743         22.8253
370002..........................................         14.7315         15.4333         16.1853         15.4106
370004..........................................         19.3236         18.5233         22.0173         19.9087
370005..........................................         15.1654         15.3881               *         15.2760
370006..........................................         16.6484         16.4995         15.7367         16.2765
370007..........................................         15.2905         15.8312         14.4961         15.2449
370008..........................................         16.6566         17.5553         18.5253         17.5877
370011..........................................         14.9701         15.6178         16.1757         15.5584
370012..........................................         11.7265         12.4942         13.3824         12.5268
370013..........................................         19.3398         18.9584         19.3237         19.2083
370014..........................................         20.6512         20.2858         22.7976         21.2589
370015..........................................         17.0319         20.8765         18.6446         18.7763
370016..........................................         19.1191         19.1613         19.7706         19.3517

[[Page 31576]]

 
370017..........................................         12.6400         13.6531               *         13.1855
370018..........................................         18.5107         17.7054         18.7928         18.3360
370019..........................................         14.2277         14.6216         16.1367         14.9616
370020..........................................         14.3798         15.1035         15.6057         15.0288
370021..........................................         12.0474         12.9030               *         12.4760
370022..........................................         17.2344         17.3724         18.2109         17.5986
370023..........................................         17.7630         17.5148         18.1255         17.8019
370025..........................................         17.4988         18.4815         19.1013         18.3736
370026..........................................         18.3371         18.0412         18.6982         18.3516
370028..........................................         18.4445         21.1292         22.1765         20.5544
370029..........................................         16.4924         18.2580         19.3285         17.9453
370030..........................................         16.3269         16.5803         18.1779         17.0344
370032..........................................         18.2821         18.1538         18.9050         18.4517
370033..........................................         13.5216         11.3210         15.3857         13.3051
370034..........................................         15.6386         15.6288         16.2204         15.8253
370035..........................................         25.5764               *               *         25.5764
370036..........................................         12.4026         12.4070         11.7667         12.1865
370037..........................................         16.7012         18.9556         20.6493         18.6793
370038..........................................         13.3084         13.0210         15.4551         13.8393
370039..........................................         15.5206         19.4498         22.3915         18.9462
370040..........................................         14.4672         15.5109         16.8127         15.5746
370041..........................................         16.7356         16.2316         14.7346         15.7346
370042..........................................         14.9175         15.2764         15.9005         15.3820
370043..........................................         15.9534         17.0892         19.8318         17.5204
370045..........................................         10.1994         11.3560         11.6163         10.9883
370046..........................................         18.8334               *               *         18.8334
370047..........................................         16.7554         17.8769         18.4743         17.6862
370048..........................................         18.2150         15.6803         17.0785         16.9957
370049..........................................         20.7176         19.4868         20.3405         20.1537
370051..........................................         11.6736         12.5171         11.4943         11.8576
370054..........................................         16.9049         18.0787         19.2294         17.9957
370056..........................................         18.4558         18.1432         18.9395         18.5020
370057..........................................         16.7261         15.1228         16.0301         15.9579
370059..........................................         18.1386         18.3314         20.1182         18.8407
370060..........................................         16.5403         19.3051         17.5989         17.7984
370063..........................................         14.4132         16.7342               *         15.4260
370064..........................................         10.9676         11.9954         11.6347         11.5257
370065..........................................         16.6898         18.1349         18.2406         17.6615
370071..........................................         16.1439         16.4567               *         16.2906
370072..........................................         14.4742         13.6519         12.5765         13.5464
370076..........................................         13.5694         14.3555         15.4067         14.4469
370078..........................................         18.4086         19.2412         15.2513         17.4148
370079..........................................         16.6861         16.9201         17.5915         17.0209
370080..........................................         13.9239         14.7323         14.3546         14.3090
370082..........................................         13.9634         15.0669         16.9715         15.2230
370083..........................................         13.1519         13.1810         15.6824         14.0210
370084..........................................         22.0545         13.1197         15.6184         16.0638
370085..........................................         11.2842         48.1271               *         16.2341
370086..........................................         15.4404         11.1900               *         13.0199
370089..........................................         16.0966         17.2638         17.9243         17.0970
370091..........................................         19.1698         20.1822         20.8553         20.0806
370092..........................................         14.9802         15.7678         16.8432         15.8798
370093..........................................         18.4600         19.7008         22.1966         20.1375
370094..........................................         18.0002         19.5462         19.5565         19.0506
370095..........................................         12.6383         13.4202         14.5909         13.5521
370097..........................................         22.9714         23.2056         19.0437         21.4568
370099..........................................         15.4549         19.4646         18.1467         17.5179
370100..........................................         14.0168         18.8274         12.9784         15.1185
370103..........................................         19.2353         18.2685         23.1347         19.9596
370105..........................................         21.3352         20.7890         25.1252         22.1529
370106..........................................         18.5485         20.3651         21.5826         20.1129
370108..........................................         12.3279         12.7470         14.0190         13.0228
370112..........................................         14.8539         15.3039         14.3384         14.8216

[[Page 31577]]

 
370113..........................................         16.1046         17.6107         19.9767         17.8205
370114..........................................         16.5268         17.8941         17.9757         17.4836
370121..........................................         22.5611         21.3099         19.3414         20.9750
370122..........................................         15.0645         15.4375               *         15.2280
370123..........................................         18.9159         19.0313         19.7958         19.2564
370125..........................................         15.6284         13.9436         14.4664         14.6695
370126..........................................         23.9654         15.8020               *         19.5933
370131..........................................         17.5689         15.7261               *         16.5772
370133..........................................         10.9575         12.9545         16.1855         13.3276
370138..........................................         16.4005         17.5551         17.4574         17.1263
370139..........................................         14.8612         14.9964         16.0898         15.3115
370140..........................................         16.0721         17.1393         17.4950         16.9403
370141..........................................         18.4101         20.7798         19.8606         19.6250
370146..........................................         12.6402         13.0399         13.9900         13.2166
370148..........................................         20.6458         20.6612         26.6722         22.4333
370149..........................................         16.1850         17.0929         18.0699         17.1239
370153..........................................         17.8352         16.4669         16.5267         16.9839
370154..........................................         15.5127         15.6093         16.6687         15.9283
370156..........................................         13.9255         14.5696         15.4303         14.6173
370158..........................................         15.6917         15.6994         16.3637         15.9128
370159..........................................         28.0536         21.1267         25.3240         24.1146
370163..........................................         17.6361         20.4217               *         18.9027
370165..........................................         13.0910         13.0375         12.9569         13.0294
370166..........................................         17.2849         21.0797         19.4219         19.1747
370169..........................................         12.5243         12.7138         14.8384         13.3173
370176..........................................         15.9476         18.9951         19.6537         18.1230
370177..........................................         11.2536         14.6481         14.1304         13.3001
370178..........................................         10.5726         11.6200          9.8655         10.5383
370179..........................................         17.2829         21.3002         23.8404         20.1287
370183..........................................         10.2945         16.9318         16.6061         14.0419
370186..........................................         13.6192         15.4533         16.3671         15.1316
370190..........................................         14.1397         19.3570         20.6398         17.5727
370192..........................................         18.4614         19.6967         21.8343         20.0562
370198..........................................         21.3136               *               *         21.3136
370200..........................................               *         22.5299         18.3941         20.2627
370201..........................................               *               *         18.2548         18.2548
370202..........................................               *               *         16.4919         16.4919
370203..........................................               *               *         23.5454         23.5454
380001..........................................         20.3127         26.4822         25.1542         23.6052
380002..........................................         24.0241         21.9185         23.2479         22.9299
380003..........................................         21.7826         20.9007         23.8074         22.1844
380004..........................................         23.1451         23.3609         24.5418         23.6963
380005..........................................         24.0838         25.0750         24.7476         24.6467
380006..........................................         21.2731         21.3520         20.5914         21.0574
380007..........................................         25.2995         32.2678         25.9239         27.5188
380008..........................................         20.7063         22.3004         21.6133         21.5417
380009..........................................         23.8104         24.3851         25.1040         24.4366
380010..........................................         23.7488         22.7276         24.1931         23.5774
380011..........................................         21.1151         20.3357         20.6759         20.7167
380013..........................................         18.6818         19.8180         20.3705         19.6316
380014..........................................         24.6574         25.9828         26.6038         25.7705
380017..........................................         26.0578         25.3954         21.9236         24.5037
380018..........................................         22.3525         22.9822         24.8661         23.4431
380019..........................................         22.1215         20.8176         21.1743         21.3400
380020..........................................         20.1464         22.9568         23.9978         22.4898
380021..........................................         21.1590         23.8499         24.4365         23.1615
380022..........................................         22.6408         24.5974         25.6255         24.2510
380023..........................................         20.5462         21.3831         23.4328         21.9485
380025..........................................         26.3652         26.9346         26.9398         26.7561
380026..........................................         20.4706         20.6972         22.7561         21.3218
380027..........................................         20.8647         21.5490         22.2573         21.6028
380029..........................................         19.4246         20.1471         22.0371         20.5671
380031..........................................         23.3181         20.3396         23.7634         22.5126

[[Page 31578]]

 
380033..........................................         25.2454         27.1343         26.6899         26.3003
380035..........................................         22.4099         23.9719         25.6016         23.9444
380036..........................................         27.1587         27.2157               *         27.1858
380037..........................................         21.9158         22.1774         23.4798         22.5697
380038..........................................         26.0869         26.7759         28.1436         26.9990
380039..........................................         23.1746         22.8048         25.7614         23.8428
380040..........................................         26.2717         22.5477         22.6412         23.5906
380042..........................................         21.1176         24.4172         21.6793         22.3496
380047..........................................         23.0718         24.2524         25.2591         24.2189
380048..........................................         17.5885         18.3005         18.2773         18.0623
380050..........................................         20.3934         20.3205         22.1089         20.9066
380051..........................................         22.3568         22.3207         24.4081         23.0351
380052..........................................         19.4570         18.6299         20.7431         19.6320
380056..........................................         19.5185         18.4961         20.7895         19.6447
380060..........................................         24.2670         24.2059         23.0106         23.8515
380061..........................................         22.3736         22.8781         24.1121         23.0785
380062..........................................         20.7716         18.2148         25.9782         21.7912
380063..........................................         20.4077               *               *         20.4077
380064..........................................         19.9826         22.9160         27.0627         23.2721
380065..........................................         26.1404         22.9608         23.3146         24.0398
380066..........................................         22.0349         23.2794         23.1175         22.8287
380068..........................................         22.3178               *               *         22.3178
380069..........................................         19.8300         20.4882         21.2057         20.5172
380070..........................................         27.2541         27.7790         29.9706         28.3711
380071..........................................         22.6386         25.1808         25.7299         24.5669
380072..........................................         19.1553         19.4346         20.6568         19.7391
380075..........................................         22.3625         22.4139         23.1910         22.6625
380078..........................................         20.2507         21.0903         22.6996         21.3468
380081..........................................         20.9882         20.4082         22.9805         21.4341
380082..........................................         22.2275         22.9606         23.7927         23.0290
380083..........................................         21.3859         21.7431         22.4058         21.8126
380084..........................................         24.2844         27.1689         31.0111         27.0317
380087..........................................         16.5309         17.0380         21.3119         18.4448
380088..........................................         21.5225         19.5346         24.8158         21.8578
380089..........................................         19.5255         25.2908         26.1967         23.9671
380090..........................................         29.2702         24.9351         30.4223         28.0439
380091..........................................         27.5560         25.3062         28.7846         27.2892
390001..........................................         19.2989         19.6732         20.3350         19.7868
390002..........................................         21.8353         19.7833         21.0159         20.9278
390003..........................................         17.1371         18.1025         18.0436         17.7426
390004..........................................         19.2277         20.3204         20.0557         19.8647
390005..........................................         17.3506         16.9472         19.0218         17.7359
390006..........................................         20.2959         21.1786         21.8940         21.0893
390007..........................................         21.7506         21.3839               *         21.5715
390008..........................................         17.8297         18.2743         19.3496         18.4745
390009..........................................         20.6507         20.6241         22.5580         21.2847
390010..........................................         17.5127         17.3335         18.1275         17.6598
390011..........................................         18.1717         18.3257         18.2751         18.2595
390012..........................................         20.6523         21.0610         22.1912         21.3051
390013..........................................         19.2698         19.6562         20.2186         19.7244
390015..........................................         13.1337         13.7352         14.3138         13.7169
390016..........................................         16.9892         17.1133         17.3854         17.1611
390017..........................................         16.7493         18.6113         18.5869         17.9293
390018..........................................         21.3626         19.0279         20.0672         20.1854
390019..........................................         16.7848         17.7258         18.7609         17.7608
390022..........................................         21.5064         24.8468         24.7121         23.6803
390023..........................................         21.8270         22.1044         23.5236         22.6164
390024..........................................         24.9437         25.4606         27.7643         26.0343
390025..........................................         15.6155         15.5523         14.5309         15.2361
390026..........................................         22.3902         22.9718               *         22.6895
390027..........................................         26.8878         29.5940               *         28.2192
390028..........................................         22.7700         23.6571         22.7820         23.0704
390029..........................................         21.5729         21.2661         24.4753         22.2475

[[Page 31579]]

 
390030..........................................         17.9580         18.6887         18.9093         18.5094
390031..........................................         19.2755         18.8162         19.1781         19.0917
390032..........................................         17.8041         21.5105         18.7616         19.2843
390035..........................................         20.2029         22.3591         21.9021         21.4643
390036..........................................         19.9880         19.7671         20.1769         19.9773
390037..........................................         21.0616         20.4263         19.9175         20.4619
390039..........................................         17.1046         17.5300         17.6176         17.4167
390040..........................................         15.9612         16.6876         17.4451         16.6853
390041..........................................         19.8080         20.4397         19.6159         19.9368
390042..........................................         22.7693         22.5775         21.7857         22.3776
390043..........................................         17.2607         17.4764         17.9549         17.5603
390044..........................................         20.2813         20.9831         21.3382         20.8726
390045..........................................         18.5574         19.4677               *         19.0190
390046..........................................         20.7303         21.7445         21.8760         21.4470
390047..........................................         27.6661         26.9709               *         27.3457
390048..........................................         19.0920         19.7992         18.8322         19.2254
390049..........................................         21.1217         22.1586         22.7306         21.9927
390050..........................................         22.8808         22.2639         24.7169         23.2216
390051..........................................         25.7910         28.1385               *         26.8617
390052..........................................         20.9306         20.1195         21.2367         20.7439
390054..........................................         17.8852         18.4975         19.5598         18.6230
390055..........................................         24.2211         23.4017         25.7327         24.4723
390056..........................................         17.7858         19.3901         21.4121         19.5072
390057..........................................         20.2059         20.2395         21.6693         20.6975
390058..........................................         19.7379         20.3520         20.7930         20.2983
390061..........................................         21.2392         23.8722         22.8728         22.6127
390062..........................................         16.6721         17.3750         17.4710         17.1692
390063..........................................         20.0125         19.4965         20.1696         19.9019
390065..........................................         19.9361         20.0473         20.2930         20.0884
390066..........................................         19.8539         18.9296         18.9776         19.2407
390067..........................................         20.9688         20.8162         21.9905         21.2535
390068..........................................         18.3158         19.1109         21.6408         19.5148
390069..........................................         19.6466               *               *         19.6466
390070..........................................         16.1988         21.8549         22.7909         20.2250
390071..........................................         15.7165         16.0100         18.9416         16.7655
390072..........................................         16.3133         16.9232         15.1402         16.1159
390073..........................................         20.5581         21.2623         22.2009         21.3579
390074..........................................         18.4806         18.3093         19.5799         18.7617
390075..........................................         17.9840         18.7695         19.5744         18.6643
390076..........................................         20.2475         21.3290         19.7719         20.4342
390078..........................................         19.2089         19.0156         20.5750         19.5586
390079..........................................         18.3312         18.9269         19.2984         18.8525
390080..........................................         18.8028         21.4707         22.2449         20.7685
390081..........................................         24.8351         24.7461         25.6575         25.0775
390083..........................................               *               *         26.1660         26.1660
390084..........................................         16.4026         20.2529         17.0197         17.7133
390086..........................................         18.5265         18.3563               *         18.4381
390088..........................................         23.6173         23.9506               *         23.7777
390090..........................................         21.6437         21.3759         20.5444         21.2031
390091..........................................         18.1569         18.3770         18.8545         18.4554
390093..........................................         17.7171         18.4442         20.0135         18.7217
390095..........................................         16.3357         16.6930         17.9697         16.9815
390096..........................................         19.1171         22.4382         21.5922         20.9351
390097..........................................         23.5963         25.2845         24.8005         24.5139
390100..........................................         20.7859         20.9263         21.1186         20.9469
390101..........................................         17.9499         18.5039         17.0447         17.8109
390102..........................................         19.0461         21.5496         18.0199         19.5593
390103..........................................         18.4312         18.8667         20.4422         19.2092
390104..........................................         15.9008         16.3255         16.2440         16.1553
390106..........................................         16.6666         16.8439               *         16.7557
390107..........................................         19.5178         20.9841         20.6024         20.3811
390108..........................................         21.0899         21.3142         21.2602         21.2184
390109..........................................         16.4597         16.5299         17.4540         16.8127

[[Page 31580]]

 
390110..........................................         21.5282         21.6464         21.6005         21.5915
390111..........................................         27.5193         33.3971         27.0087         29.3495
390112..........................................         14.9427         15.0065         14.8634         14.9388
390113..........................................         19.1945         19.3634         19.9496         19.4908
390114..........................................         19.6295         20.9533         19.8004         20.1209
390115..........................................         23.3461         21.4287         21.9789         22.1926
390116..........................................         21.4877         21.3671         22.6783         21.8481
390117..........................................         17.9393         18.0769         18.2543         18.0888
390118..........................................         18.3440         18.9507         16.9990         18.1121
390119..........................................         18.2951         18.8815         19.3946         18.8604
390121..........................................         20.8780         19.1315         20.6253         20.2089
390122..........................................         17.1902         17.7734         15.5438         16.7430
390123..........................................         20.8344         21.3974         21.8434         21.3548
390125..........................................         16.7983         17.5446         17.0975         17.1374
390126..........................................         20.6498               *               *         20.6498
390127..........................................         21.7724         22.4555         22.8787         22.3758
390128..........................................         19.6792         19.3165         19.9764         19.6532
390130..........................................         17.7049         18.3695         18.5519         18.2059
390131..........................................         16.0986         19.2096         18.7142         17.9603
390132..........................................         21.1931         22.8414         24.1878         22.7048
390133..........................................         23.3489         24.7561         24.1814         24.0439
390135..........................................         21.5782         22.1905         21.8152         21.8560
390136..........................................         16.9737         20.6286         16.8505         18.1580
390137..........................................         17.5687         18.5397         19.1432         18.3744
390138..........................................         19.6212         20.6936         20.7726         20.3703
390139..........................................         24.4515         23.9757         23.8019         24.0822
390142..........................................         26.8086         28.8877         28.3448         28.0760
390145..........................................         20.3731         20.4228         20.4964         20.4300
390146..........................................         18.7922         18.6505         20.1788         19.1967
390147..........................................         20.9651         21.2492         21.7600         21.3199
390150..........................................         20.7294         20.3155         20.8970         20.6500
390151..........................................         21.6000         22.5206         23.6072         22.6096
390152..........................................         20.3353         19.4017         20.2581         19.9941
390153..........................................         23.7013         22.9707         23.3587         23.3403
390154..........................................         17.4036         16.7052         17.8774         17.3537
390156..........................................         21.8498         22.6398               *         22.2353
390157..........................................         19.6578         19.1783         20.2647         19.6975
390160..........................................         21.4810         19.4463         18.8676         19.8186
390161..........................................         16.4799               *               *         16.4799
390162..........................................         21.4095         21.9188         21.4600         21.5967
390163..........................................         16.8013         17.7564         18.1415         17.5746
390164..........................................         24.6765         24.9750         25.0347         24.8814
390166..........................................         19.0405         19.7978         19.8899         19.5577
390167..........................................         19.8973               *               *         19.8973
390168..........................................         18.7400         18.8863         19.6875         19.1127
390169..........................................         20.2382         22.0547         22.7920         21.7176
390170..........................................         26.5891         24.7973               *         25.6898
390173..........................................         18.5370         18.6613         18.7403         18.6472
390174..........................................         25.4189         25.3307         25.7174         25.4826
390176..........................................         17.8740         20.8368         21.7650         20.0495
390178..........................................         16.6993         17.0534         17.1142         16.9526
390179..........................................         21.6901         21.8593         21.6191         21.7220
390180..........................................         25.7074         26.5541         26.7743         26.3551
390181..........................................         19.4654         19.3832         18.8681         19.2465
390183..........................................         17.8306         17.9848         17.4535         17.7535
390184..........................................         20.8060         20.9349         21.1941         20.9693
390185..........................................         18.8798         20.3877         20.3301         19.8556
390189..........................................         20.0889         20.3338         19.0797         19.7997
390191..........................................         16.3240         17.2270         17.1919         16.8998
390192..........................................         17.4537         17.6597         17.1875         17.4275
390193..........................................         16.7874         18.1209         17.3804         17.3866
390194..........................................         20.7953         21.2689         21.0549         21.0283
390195..........................................         24.6855         24.1793         23.4250         24.1067

[[Page 31581]]

 
390197..........................................         19.2690         20.7998         22.1769         20.7816
390198..........................................         15.9721         15.8833         16.6803         16.1535
390199..........................................         17.0515         17.3865         17.7763         17.3987
390200..........................................         15.1399         15.4012         18.2456         16.2785
390201..........................................         20.6296         20.3533         21.3291         20.7767
390203..........................................         20.9432         21.4989         22.4685         21.6448
390204..........................................         20.1779         22.9616         22.1541         21.7608
390206..........................................         18.4027               *               *         18.4027
390209..........................................         17.4792         18.7059         16.8200         17.6370
390211..........................................         17.8638         18.4213         19.4552         18.6187
390213..........................................         18.8555         19.1553         19.3776         19.1155
390215..........................................         20.7084         21.2032         23.5953         21.7981
390217..........................................         19.1406         19.9837         19.9665         19.6808
390219..........................................         18.8292         19.6226         20.1311         19.5227
390220..........................................         18.7178         17.7916               *         18.2413
390222..........................................         21.5739         22.1548         22.7491         22.1668
390223..........................................         23.6482         22.1775         18.9493         21.4503
390224..........................................         15.3015         13.7518         17.2173         15.1752
390225..........................................         18.6125         18.7290         19.0364         18.7963
390226..........................................         21.8268         21.8481         22.7772         22.1197
390228..........................................         19.4083         19.8180         20.2703         19.8379
390231..........................................         22.7544         19.4798         21.3811         21.0947
390233..........................................         19.4887         20.2309         20.6673         20.1413
390235..........................................         25.0857         21.4200         19.9925         22.7713
390236..........................................         16.2397         17.8735         19.1427         17.7118
390237..........................................         19.5230         22.3011               *         20.8354
390238..........................................         17.8211         17.1055         18.1956         17.6820
390244..........................................         15.4611         15.6402         13.8845         14.9996
390245..........................................         26.0194         24.5076               *         25.2650
390246..........................................         18.9733         25.0556         22.3892         21.9107
390247..........................................         20.9526         21.2151               *         21.0479
390249..........................................         12.7920         13.1657         14.1062         13.3677
390256..........................................         23.2734         22.2773         22.3540         22.6670
390258..........................................         21.9207         22.6852         23.8318         22.8365
390260..........................................         21.9509         21.5982               *         21.7740
390262..........................................         18.2379               *         18.8942         18.5346
390263..........................................         20.6855         20.3796         20.6348         20.5647
390265..........................................         20.3580         20.4950         20.4760         20.4411
390266..........................................         17.1666         17.1966         17.5653         17.3117
390267..........................................         21.2974         19.2665         19.9578         20.2867
390268..........................................         21.3486         22.0909         22.2046         21.8827
390270..........................................         19.0925         19.2074         20.6793         19.6201
390278..........................................         18.2865         17.7176         18.5776         18.2038
390279..........................................         14.3241         14.8655         15.8080         14.9814
390283..........................................               *         22.5490               *         22.5490
390284..........................................               *         34.3904               *         34.3904
390285..........................................               *               *         29.1270         29.1270
390286..........................................               *               *         22.9746         22.9746
390287..........................................               *               *         30.3252         30.3252
390288..........................................               *               *         26.9662         26.9662
390289..........................................               *               *         22.8963         22.8963
390290..........................................               *               *         30.5037         30.5037
390291..........................................               *               *         20.0272         20.0272
390293..........................................               *               *         23.5285         23.5285
400001..........................................          9.9463         10.5757         10.7531         10.4326
400002..........................................         10.1417         13.0494         13.3684         12.2030
400003..........................................         10.8821         12.4078         11.2726         11.5031
400004..........................................          8.9864          8.5648          9.0781          8.8776
400005..........................................          9.5632          7.7432          9.7802          8.9053
400006..........................................         10.3444         10.1048         10.4988         10.3215
400007..........................................          6.4490          8.0174          8.1974          7.5138
400009..........................................          8.4207          8.8650          8.7341          8.6758
400010..........................................         10.6518         10.8011          9.1359         10.1542

[[Page 31582]]

 
400011..........................................          7.4979          8.5426          8.6252          8.2277
400012..........................................          8.2412          8.4728          8.6538          8.4546
400013..........................................          8.4579          9.2624          9.8197          9.2598
400014..........................................          9.5235          9.4798         10.2712          9.7458
400015..........................................         10.9505         14.4076         15.5827         13.3370
400016..........................................         13.2756         13.3922         13.7001         13.4570
400017..........................................          8.6421          9.2577          9.9167          9.2527
400018..........................................         10.4557         10.6208         10.5583         10.5484
400019..........................................         10.4332         10.8940         11.5139         11.0095
400021..........................................         10.6988         12.1434         12.7462         11.9145
400022..........................................         11.5861         12.2199         13.0411         12.2767
400024..........................................          7.8984          9.2409          9.0826          8.6750
400026..........................................          5.6454          5.8335          7.4280          6.2931
400027..........................................          9.5899               *               *          9.5899
400028..........................................          8.8597         19.1794          8.9567          8.9909
400031..........................................          8.2660               *               *          8.2660
400032..........................................         10.5498         10.0448         10.1898         10.2599
400044..........................................         11.9704         11.9486         12.8671         12.2011
400048..........................................          9.1701         15.1405         11.5104         11.4186
400061..........................................         12.4493         13.0988         10.3664         11.9076
400079..........................................               *          9.7203          8.7218          9.1657
400087..........................................          9.5097          9.8534          8.6480          9.3956
400094..........................................          8.9116          7.9187          8.8387          8.5180
400098..........................................          9.3308          9.7791         10.4312          9.8607
400102..........................................          9.8536          9.9903          8.5290          9.4812
400103..........................................         11.2069         11.5359         11.8454         11.4791
400104..........................................         11.0672         10.7292          7.9552         10.3151
400105..........................................          9.3049          9.0556         10.6028          9.5117
400106..........................................          9.3123          9.2187          9.8694          9.4766
400109..........................................         10.9826         11.8760               *         11.4480
400110..........................................         10.3326         10.5277         10.7228         10.5456
400111..........................................          9.5583         10.9665         12.3311         11.0412
400112..........................................         10.1755         10.8694         11.0634         10.7058
400113..........................................          9.2238          8.3168          9.3955          8.9859
400114..........................................          9.0496          7.0510          9.9477          8.5888
400115..........................................          9.8244          8.5487          7.2203          8.5322
400117..........................................         10.2295         10.8756         11.3351         10.8116
400118..........................................          9.4398         11.4051         11.4317         10.7997
400120..........................................          9.5274         10.6584         10.9315         10.3832
400121..........................................          7.8052          9.8322          8.7584          8.8340
400122..........................................          8.1911          7.6413          9.1638          8.3405
400123..........................................          7.8099         10.2367         10.3955          9.4702
400124..........................................         12.0999         12.2452         12.7323         12.3713
400125..........................................               *         10.2056         10.5997         10.3924
410001..........................................         23.2808         23.1738         22.4972         22.9875
410004..........................................         22.4801         21.0638         22.8898         22.1691
410005..........................................         23.1444         22.7170         23.8848         23.2434
410006..........................................         23.3968         23.8700         22.7636         23.3233
410007..........................................         22.1452         23.1325         22.4988         22.5921
410008..........................................         23.0662         24.9726         24.4170         24.1518
410009..........................................         24.4899         24.3895         24.3760         24.4190
410010..........................................         26.9813         28.4589         29.0876         28.1660
410011..........................................         25.2926         26.1183         27.1700         26.1594
410012..........................................         24.5811         24.1695         26.4570         25.0414
410013..........................................         24.5122         24.8800         24.8429         24.7494
420002..........................................         19.4845         20.7804         22.6182         20.9552
420004..........................................         19.7968         20.9588         16.3147         18.8438
420005..........................................         17.3510         17.9694         17.8103         17.7120
420006..........................................         18.3439         19.1760         18.7168         18.7347
420007..........................................         18.2096         18.6456         18.9047         18.5717
420009..........................................         18.5456         19.9586         21.2566         19.9500
420010..........................................         17.1184         18.0252         19.3267         18.2127
420011..........................................         16.5664         18.0970         16.7523         17.1112

[[Page 31583]]

 
420014..........................................         16.6065         18.0519         19.0455         17.8775
420015..........................................         18.8411         20.1164         20.8736         19.8858
420016..........................................         15.6241         15.5485         15.4358         15.5337
420018..........................................         19.7367         21.8775         18.7117         19.9976
420019..........................................         16.9990         17.1726         19.0199         17.6834
420020..........................................         20.9449         20.3193         20.5801         20.5993
420023..........................................         19.4855         20.4053         20.4978         20.1490
420026..........................................         20.3476         21.8749         23.3274         21.9111
420027..........................................         18.8457         19.2594         19.6743         19.2679
420030..........................................         19.1453         20.6448         22.5159         20.8443
420031..........................................         14.1855          8.2516         15.2208         11.5692
420033..........................................         21.7279         23.1303         23.7974         22.8884
420036..........................................         17.6136         21.3222         19.8080         19.4992
420037..........................................         21.7908         22.7099         23.5244         22.7289
420038..........................................         17.6726         18.6568         20.0181         18.7610
420039..........................................         15.8385         18.3017         17.7880         17.2992
420043..........................................         19.4521         19.7570         19.6834         19.6347
420048..........................................         18.4367         18.8070         20.4905         19.2520
420049..........................................         17.5854         19.4049         20.6238         19.1796
420051..........................................         19.5001         19.1555         19.8549         19.5061
420053..........................................         16.9599         18.1657         19.0780         18.0364
420054..........................................         18.2702         20.2574         20.2275         19.5600
420055..........................................         19.2048         16.8717         18.6782         18.0932
420056..........................................         14.8695         15.1835         16.5491         15.4839
420057..........................................         15.9849         20.5266         22.1312         19.6895
420059..........................................         15.8160         17.1483         18.2093         17.0936
420061..........................................         16.5555         17.3543         17.7047         17.2228
420062..........................................         17.8205         21.7469         20.9032         20.1974
420064..........................................         16.7227         16.0794         19.7067         17.5583
420065..........................................         19.6902         19.9435         19.2150         19.5969
420066..........................................         15.1804         18.0042         19.5366         17.5193
420067..........................................         18.8610         19.7824         20.7769         19.8307
420068..........................................         18.5030         18.5481         20.2580         19.1326
420069..........................................         17.0788         18.1298         18.9003         18.0124
420070..........................................         18.0057         17.3876         18.8535         18.0764
420071..........................................         19.4482         20.3902         20.1145         19.9887
420072..........................................         13.8550         15.0158         18.2531         15.7212
420073..........................................         19.1604         19.9986         20.2697         19.8499
420074..........................................         16.9292         18.0967         18.1839         17.6249
420075..........................................         14.2931         12.8158         15.0132         14.0442
420078..........................................         20.7317         21.9082         22.7156         21.7962
420079..........................................         20.8639         21.0874         21.3177         21.0994
420080..........................................         22.3443         21.9968               *         22.1649
420082..........................................         20.4653         21.7210         22.7391         21.6447
420083..........................................         20.1472         22.6376         24.0994         22.2410
420085..........................................         19.9603         21.6791         22.0071         21.2571
420086..........................................         25.7179         20.2878         23.7341         23.0645
420087..........................................         19.1403         19.8388         20.8217         19.9506
420088..........................................         17.1938         19.9919         21.8979         19.5872
420089..........................................         20.2537         20.5360         21.3954         20.7386
420091..........................................         18.8687         20.3092         21.8367         20.2654
420093..........................................         17.4689         18.3902         19.1299         18.3060
420095..........................................               *               *         33.4632         33.4632
420096..........................................               *               *         26.4863         26.4863
430004..........................................         18.5438         19.6344         19.2737         19.1454
430005..........................................         16.3059         16.4560         17.3400         16.6979
430007..........................................         14.1078         14.6331         15.1494         14.6319
430008..........................................         17.6640         18.1323         18.5234         18.0977
430010..........................................         17.1766         19.8191         16.5750         17.7180
430011..........................................         16.9848         17.4750         18.3648         17.6074
430012..........................................         17.2775         17.6997         19.2921         18.0907
430013..........................................         18.1338         18.4817         18.8978         18.5085
430014..........................................         16.8925         20.2387         20.9118         19.1361

[[Page 31584]]

 
430015..........................................         18.0019         18.2875         18.8998         18.3871
430016..........................................         19.4759         20.8850         21.2191         20.5077
430018..........................................         14.8854         16.2244         15.9424         15.6759
430022..........................................         13.4905         14.5118         14.0661         13.9980
430023..........................................         12.2331         16.2164         16.7850         14.8010
430024..........................................         15.4709         16.1801         17.4816         16.3448
430027..........................................         19.1461         20.2591         20.8666         20.0818
430028..........................................         18.2312         17.1577         18.2829         17.8947
430029..........................................         16.6500         17.6986         17.4932         17.2971
430031..........................................         13.1258         12.4660         13.2105         12.9278
430033..........................................         15.3003         17.3652         18.3978         16.9036
430034..........................................         15.4064         14.2491         13.8535         14.4964
430036..........................................         13.6967         15.6258         16.7827         15.2466
430037..........................................         16.5368         18.1293         18.7009         17.7855
430038..........................................         13.7167         18.4078               *         15.7522
430040..........................................         13.6745         14.4509         14.7860         14.2554
430041..........................................         13.1936         14.8816               *         14.0079
430043..........................................         13.6908         14.9949         17.0193         15.1103
430044..........................................         18.4970         21.0823               *         19.6187
430047..........................................         17.4956         17.9823         17.5377         17.6691
430048..........................................         18.3524         18.7602         19.0261         18.7260
430049..........................................         15.5381         15.2237         14.9025         15.2275
430051..........................................         17.0574         18.8070         18.8697         18.2650
430054..........................................         14.7251         14.8003         15.0101         14.8472
430056..........................................         11.7627         10.3697         14.1914         11.9246
430057..........................................         15.4390         17.2805         18.8777         17.1911
430060..........................................          9.0358         10.0176          9.7678          9.6151
430064..........................................         14.4367         14.2184         13.8666         14.1634
430066..........................................         14.3557         15.6660         14.5957         14.8566
430073..........................................         16.1133         15.3776         16.5112         15.9989
430076..........................................         12.7608         13.9883         15.2453         13.9494
430077..........................................         19.3012         19.8558         20.4361         19.8699
430079..........................................         13.6836         14.1815         14.4154         14.0719
430089..........................................         17.8908         17.9790         17.5100         17.7870
430090..........................................         21.5239         21.5974         23.5180         22.2918
430091..........................................         19.2146         18.1567         21.6239         20.0217
430092..........................................               *         21.3807         19.7644         20.5428
430093..........................................               *         19.5013         23.3009         21.3125
440001..........................................         14.8713         15.5897         17.2282         15.8569
440002..........................................         19.1498         20.3740         21.4299         20.3167
440003..........................................         18.3658         19.3042         20.3756         19.3464
440006..........................................         19.6021         21.4055         23.1483         21.3134
440007..........................................         12.1230         14.8959         14.0612         13.6386
440008..........................................         17.2848         18.8994         20.3303         18.7894
440009..........................................         17.8424         17.4831         18.4068         17.9080
440010..........................................         19.9829         16.3283         13.3692         16.2699
440011..........................................         17.6948         18.3375         19.3165         18.4706
440012..........................................         15.9837         19.5739         19.6437         18.4174
440014..........................................         15.9195         16.1143         15.0656         15.7064
440015..........................................         18.2632         22.0659         21.6106         20.5435
440016..........................................         15.4097         16.2964         14.6142         15.3378
440017..........................................         19.6215         20.4563         20.2241         20.0945
440018..........................................         16.4115         17.4995         18.1059         17.3355
440019..........................................         20.0416         21.5402         23.2963         21.6131
440020..........................................         18.1154         17.8879         19.0396         18.3371
440022..........................................         15.8459               *               *         15.8459
440023..........................................         15.4721         16.7837         15.6603         15.9134
440024..........................................         18.4432         18.4046         18.4276         18.4251
440025..........................................         15.8784         16.3140         17.0997         16.4428
440026..........................................         23.0550         23.2566         25.6490         23.8993
440029..........................................         19.4326         20.7050         22.2889         20.8403
440030..........................................         16.2941         16.9925         17.6297         17.0242
440031..........................................         15.5432         17.0211         17.2555         16.5726

[[Page 31585]]

 
440032..........................................         13.9775         13.8140         13.9784         13.9249
440033..........................................         14.5304         13.7328         16.4679         14.8744
440034..........................................         19.5470         20.0309         20.9470         20.1907
440035..........................................         18.9026         19.3034         20.4168         19.5344
440039..........................................         19.9439         21.6536         22.4158         21.3378
440040..........................................         16.3740         16.9275         17.6781         16.9632
440041..........................................         14.6621         14.9545         14.6684         14.7645
440046..........................................         18.1654         19.3229         20.5562         19.3415
440047..........................................         16.6646         17.8092         18.7469         17.7021
440048..........................................         19.4498         21.4993         19.6052         20.1565
440049..........................................         17.9292         18.7967         19.3000         18.6741
440050..........................................         19.1328         18.2511         19.7915         19.0510
440051..........................................         13.1901         16.0421         17.7067         15.5027
440052..........................................         16.6541         19.8075         18.1377         18.1083
440053..........................................         18.5515         19.6494         21.5253         19.8982
440054..........................................         13.8716         13.3967         15.2154         14.1791
440056..........................................         15.9821         16.2742         20.4903         17.3863
440057..........................................         12.7925         13.7257         14.4363         13.6135
440058..........................................         18.8118         19.1878         17.1548         18.4084
440059..........................................         18.5418         19.6018         20.8882         19.6895
440060..........................................         18.0586         19.7916         20.7628         19.4260
440061..........................................         14.9708         22.5525         16.9234         17.8112
440063..........................................         19.3222         19.8371         18.8061         19.2994
440064..........................................         17.7652         18.9809         18.2678         18.2991
440065..........................................         18.5825         18.8296         19.2282         18.8924
440067..........................................         16.2811         17.2397         18.2973         17.2997
440068..........................................         19.4695         19.3668         19.4392         19.4232
440070..........................................         13.7035         14.0437         18.0064         15.1918
440071..........................................         17.0186         19.7836               *         18.2110
440072..........................................         17.5995         19.1522         20.0691         18.8963
440073..........................................         19.1714         19.5554         19.6290         19.4550
440078..........................................         15.0849         16.0188         17.1645         15.9789
440081..........................................         18.3587         19.3454         20.7215         19.5016
440082..........................................         22.2857         22.6855         22.5590         22.5073
440083..........................................         14.8525         13.7423         13.7630         14.1806
440084..........................................         13.4378         13.7731         13.8085         13.6799
440091..........................................         19.6114         20.1065         20.1359         19.9669
440100..........................................         13.8437         14.7113         15.9969         14.8524
440102..........................................         14.3510         14.5500         16.0783         14.9840
440103..........................................         20.3052         18.6990               *         19.4877
440104..........................................         22.4403         22.6754         21.7135         22.2610
440105..........................................         16.7131         17.1172         18.1375         17.2950
440109..........................................         16.0446         17.7443         17.6399         17.0830
440110..........................................         21.1716         17.4816         18.4998         18.8996
440111..........................................         23.2425         23.2254         23.2111         23.2266
440114..........................................         14.4997         15.0036         18.5327         16.0830
440115..........................................         17.4514         18.5457         18.7054         18.2287
440120..........................................         17.2384         16.3115         19.8997         17.7817
440125..........................................         15.6588         19.4115         19.6848         18.2807
440130..........................................         17.8223         17.4857         19.0905         18.1589
440131..........................................         15.5048         16.1214         19.9883         17.1760
440132..........................................         16.6553         16.8871         17.9186         17.1418
440133..........................................         21.5313         23.0891         18.7556         21.1283
440135..........................................         19.2010         22.2005         22.5452         21.4251
440137..........................................         14.5632         15.0070         15.3530         14.9670
440141..........................................         13.5308         15.9429         17.6819         15.3875
440142..........................................         15.7287         16.8855         17.1483         16.5303
440143..........................................         17.7821         18.2061         18.6844         18.2206
440144..........................................         17.6415         18.3859         18.8127         18.2853
440145..........................................         17.0608         18.3948         18.3832         17.9140
440147..........................................         21.4304         26.1464         25.3766         24.0818
440148..........................................         19.2435         19.4598         19.3769         19.3574
440149..........................................         16.6923         18.4281         18.4869         17.8895

[[Page 31586]]

 
440150..........................................         20.1411         20.3006         21.2942         20.5974
440151..........................................         17.4248         18.3928         19.8977         18.5439
440152..........................................         21.0287         22.7664         26.2972         22.9356
440153..........................................         16.7769         16.5716         18.1975         17.1720
440156..........................................         29.5557         21.7577         21.9374         23.7510
440157..........................................         16.9265         18.4249         15.5316         17.0209
440159..........................................         17.7158         20.9371         21.4914         19.6375
440161..........................................         21.8013         22.8816         23.3891         22.6977
440162..........................................         14.7637         15.5534         19.8075         16.5656
440166..........................................         19.6684         19.2159         19.6632         19.5183
440168..........................................         18.6535         19.1509         21.1947         19.6498
440173..........................................         18.6402         19.1812         21.0284         19.6315
440174..........................................         17.3294         18.0865         19.3966         18.2367
440175..........................................         20.0802         18.5186         19.9065         19.4762
440176..........................................         18.0294         19.2208         19.8448         19.0126
440180..........................................         19.7773         20.2184         17.8427         19.2624
440181..........................................         16.4878         17.7709         19.0915         17.6551
440182..........................................         17.7487         19.7094         18.1953         18.4985
440183..........................................         22.7067         21.3465         22.2401         22.0840
440184..........................................         17.2037         16.8880         18.6890         17.3933
440185..........................................         19.3870         21.2188         21.1226         20.6133
440186..........................................         19.3948         19.7983         18.0450         19.1060
440187..........................................         18.9713         17.5872         16.0274         17.5444
440189..........................................               *         18.5252         22.2555         20.3772
440192..........................................         19.0839         19.1705         19.1976         19.1524
440193..........................................         19.0811         18.6999         19.9078         19.2111
440194..........................................         19.8682         22.4562         21.9609         21.4700
440197..........................................         21.9618         21.8503         22.5282         22.1263
440200..........................................         17.9575         19.8078         17.8595         18.5432
440203..........................................         18.3400         16.2861         16.9819         17.1896
440206..........................................         16.4429               *               *         16.4429
440210..........................................         11.0218         11.9815         12.3270         11.8072
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
440217..........................................               *               *         19.2834         19.2834
450002..........................................         21.3749         21.4836         21.5141         21.4583
450004..........................................         16.6723         16.7850         15.9549         16.5100
450005..........................................         18.3600         16.6396         16.6354         17.2368
450007..........................................         16.9681         19.1910         17.7721         17.9505
450008..........................................         17.0832         17.6582         19.3637         18.0034
450010..........................................         16.5001         17.6677         18.5058         17.7858
450011..........................................         17.1942         20.8102         18.9490         18.9450
450014..........................................         17.9495         17.5815         18.4937         17.9967
450015..........................................         18.9895         21.6773         23.3972         21.2507
450016..........................................         18.4463         18.3456         18.9063         18.5621
450018..........................................         21.4788         23.2293               *         22.2764
450020..........................................         17.8415         19.1153         18.4454         18.4795
450021..........................................         23.0843         23.3630         22.5937         23.0174
450023..........................................         16.0831         17.6360         19.2810         17.6838
450024..........................................         17.3518         18.5985         19.5584         18.5411
450025..........................................         17.0004               *               *         17.0004
450028..........................................         18.8764         19.1658         19.5905         19.2141
450029..........................................         17.4716         17.7425         19.7835         18.3585
450031..........................................         22.2222         29.6945         29.6772         27.1869
450032..........................................         17.3317         14.6530         20.8525         17.3455
450033..........................................         19.7437         21.0222         21.4646         20.7635
450034..........................................         19.6721         18.8823         19.4439         19.3269
450035..........................................         20.0951         20.3599         20.2269         20.2257
450037..........................................         19.5411         19.9140         19.3682         19.6099
450039..........................................         19.8143         19.7176         18.4497         19.3230

[[Page 31587]]

 
450040..........................................         16.8534         19.6370               *         18.3093
450042..........................................         19.8921         18.8357         20.2402         19.6613
450044..........................................         24.7961         21.0909         23.4476         22.9976
450046..........................................         18.6536         17.3631         18.1393         18.0789
450047..........................................         13.4486         16.9028         15.9525         15.2979
450050..........................................         14.7669         17.7209         19.1390         17.0907
450051..........................................         21.0236         21.1008         22.4159         21.4934
450052..........................................         13.8881         15.5890         16.3064         15.2550
450053..........................................         17.0467         17.2781         15.6962         16.7365
450054..........................................         22.8960         19.2431               *         21.4583
450055..........................................         15.0433         15.8526         16.4789         15.8195
450056..........................................         21.8436         21.8605         21.6890         21.7982
450058..........................................         18.0967         18.6172         20.0081         18.9393
450059..........................................         15.2168         19.8240         21.4873         18.7159
450063..........................................         14.3815         12.7211         15.1779         13.9190
450064..........................................         17.4093         19.7682         21.3929         19.5099
450065..........................................         21.4934         23.3797         23.8471         22.8509
450068..........................................         22.8998         23.3495         22.8227         23.0189
450072..........................................         19.0111         18.0307         20.0134         19.0500
450073..........................................         17.1002         16.5942         23.7700         19.3382
450078..........................................         11.7265         13.2820         13.9324         12.9289
450079..........................................         21.0518         20.6483         22.0609         21.2553
450080..........................................         17.4553         18.6212         19.7834         18.5898
450081..........................................         16.3448         17.5737         19.0276         17.6152
450082..........................................         16.1585         16.8677               *         16.5390
450083..........................................         21.5884         23.3754         20.9315         21.9323
450085..........................................         18.3602         20.0085         15.7805         17.8575
450087..........................................         22.0273         21.9320         23.4141         22.4951
450090..........................................         15.0939         15.5796         19.9180         16.7400
450092..........................................         16.8260         17.9520         15.7252         16.8197
450094..........................................         21.3158         23.2863         25.2158         23.1854
450096..........................................         17.8813         18.6802         19.3681         18.6265
450097..........................................         19.5723         19.7187         20.4932         19.9373
450098..........................................         20.5754         19.0454         19.3458         19.6276
450099..........................................         19.2258         20.4181         19.0079         19.5047
450101..........................................         17.1330         17.7928               *         17.4479
450102..........................................         18.6707         19.8793         21.4361         19.9466
450104..........................................         16.6744         17.0821         17.6834         17.1430
450107..........................................         25.1986         24.1094         20.9852         23.2733
450108..........................................         15.6324         15.2797         16.9845         15.9966
450109..........................................         13.8127         10.5973         17.7226         13.4301
450110..........................................         19.5821               *               *         19.5821
450111..........................................         19.6350         21.4908               *         20.6248
450112..........................................         16.0441         18.1026         17.3725         17.2066
450113..........................................         20.9777         20.8306         20.7782         20.8679
450118..........................................         17.9053               *               *         17.9053
450119..........................................         20.2853         20.2030         20.1335         20.2023
450121..........................................         20.4641         21.9198         22.0485         21.4762
450123..........................................         15.7618         14.1755         17.5051         15.6216
450124..........................................         22.7480         22.5208         22.6668         22.6449
450126..........................................         21.7233         21.4789         22.5290         21.9115
450128..........................................         18.2184         18.1446         18.4178         18.2629
450130..........................................         20.4156         18.9211         19.3882         19.5769
450131..........................................         19.2589         17.4168         17.7234         18.0882
450132..........................................         18.1713         21.8089         19.7672         19.9308
450133..........................................         23.6366         26.0763         24.4799         24.6993
450135..........................................         21.0306         20.4068         25.8775         22.4267
450137..........................................         22.4590         23.4346         21.3644         22.3582
450140..........................................         20.2280         17.3370         19.6205         19.0889
450143..........................................         14.5270         15.0871         16.7371         15.4651
450144..........................................         18.1121         17.4309         20.6880         18.7404
450145..........................................         15.6078         16.1895         16.4087         16.0604
450146..........................................         17.8572         15.5030         17.4391         16.8224

[[Page 31588]]

 
450147..........................................         18.9363         19.0477         20.0805         19.3489
450148..........................................         18.6758         20.4923         20.9373         20.1433
450149..........................................         19.7521         21.7219         22.6138         21.3072
450150..........................................         16.3719         17.8612         18.3079         17.5184
450151..........................................         15.2906         16.4209         16.3279         16.0117
450152..........................................         18.0061         17.7265         19.6105         18.4659
450153..........................................         19.4419         18.6514         18.8000         18.9747
450154..........................................         13.8731         13.9119         16.8748         14.8870
450155..........................................         11.5841         13.3456         20.0872         14.3751
450157..........................................         15.6371         15.3083         16.8569         15.9683
450160..........................................         16.6533         10.6852         18.7780         14.2553
450162..........................................         20.9560         21.9218         20.5032         21.1178
450163..........................................         17.5403         17.8028         19.0727         18.1175
450164..........................................         16.9741         17.7180         18.7101         17.7835
450165..........................................         13.9218         17.3283         14.9478         15.3028
450166..........................................         11.4772         11.0541         11.3813         11.3012
450169..........................................         13.1990               *               *         13.1990
450170..........................................         14.2997         14.3234         15.8525         14.8194
450176..........................................         16.9674         17.2576         18.2050         17.4802
450177..........................................         14.9241         15.2419         14.8306         14.9994
450178..........................................         17.8508         16.0280         15.8729         16.5762
450181..........................................         15.5622         18.6936         18.3600         17.5713
450184..........................................         21.1263         20.0821         20.3941         20.5023
450185..........................................         14.0714         11.5228         13.2613         12.8423
450187..........................................         16.6945         18.5053         20.6388         18.5641
450188..........................................         14.3938         15.1954         16.9407         15.5553
450191..........................................         20.1222         20.9512         20.5883         20.5559
450192..........................................         20.3795         21.2497         20.1419         20.5690
450193..........................................         23.1963         23.1639         24.9007         23.7654
450194..........................................         20.5187         20.7745         20.5396         20.6114
450196..........................................         17.1955         17.8993         20.2663         18.3910
450200..........................................         18.7387         19.2228         19.6496         19.1969
450201..........................................         16.9908         17.1463         17.7763         17.3128
450203..........................................         20.6712         19.3978         19.6050         19.8895
450209..........................................         19.0811         20.0140         21.0205         19.9890
450210..........................................         13.9758         16.3470         16.7204         15.7370
450211..........................................         17.9857         18.8114         18.7305         18.5258
450213..........................................         17.7631         19.0651         18.5334         18.4589
450214..........................................         19.0475         20.5070         21.0485         20.1729
450217..........................................         12.8457         12.7647         13.1840         12.9276
450219..........................................         15.3976         17.6884         18.3602         17.1605
450221..........................................         16.3700         15.2120         16.1398         15.8866
450222..........................................         20.3129         19.8967         23.2779         21.1824
450224..........................................         24.9046         20.1579         16.2433         19.9276
450229..........................................         16.4503         16.7853               *         16.6236
450231..........................................         19.1564         19.1746         20.7709         19.7438
450234..........................................         16.1945         16.3003         16.5793         16.3818
450235..........................................         15.2332         16.3115         17.5349         16.3996
450236..........................................         16.6703         16.4957         17.0092         16.7226
450237..........................................         20.7930         19.0325               *         19.8837
450239..........................................         17.1308         17.8401         18.8416         17.9241
450241..........................................         12.5675         16.4240         16.6046         14.9426
450243..........................................         11.9099         13.6416         11.2035         12.2464
450246..........................................         16.5478         16.7959         22.7940         18.4445
450249..........................................         12.0302         11.7658         10.6467         11.4953
450250..........................................         10.2844         13.6787               *         11.6004
450253..........................................         12.2402         13.2177         14.5492         13.3367
450258..........................................         16.0466         16.7337         17.0724         16.6100
450264..........................................         13.8929         14.5956         17.2825         15.2193
450269..........................................         12.3594         12.7717         12.9555         12.7319
450270..........................................         12.8381         14.4792         13.6733         13.6110
450271..........................................         16.6319         16.7831         17.9808         17.1692
450272..........................................         19.9331         18.4344         20.5888         19.6562

[[Page 31589]]

 
450276..........................................         13.1155         14.0745         14.0779         13.7681
450278..........................................         14.8291         15.2950         14.4871         14.8427
450280..........................................         22.2984         22.2936         20.3286         21.5973
450283..........................................         14.5664         15.1950         15.8684         15.2590
450288..........................................         16.2502         18.8935         13.5248         16.2231
450289..........................................         20.3104         20.3460         20.8745         20.5057
450292..........................................         16.9693         20.5335         17.7154         18.2921
450293..........................................         16.0132         16.2721         16.4077         16.2364
450296..........................................         21.6000         22.3430               *         21.9845
450299..........................................         21.5672               *         21.0398         21.2895
450303..........................................         12.4582         12.8996         14.3353         13.2442
450306..........................................         13.8216         14.2047         13.6333         13.8808
450307..........................................         16.4622         17.0691         17.6757         17.0817
450309..........................................         13.1480         13.3771         14.8823         13.8094
450315..........................................         22.8140         21.4684         23.8151         22.6579
450320..........................................         20.0946         20.6596         24.6129         21.4772
450321..........................................         13.1752         14.7344         14.4710         14.1070
450322..........................................         22.7667         29.1884         28.9834         26.4969
450324..........................................         17.7886         19.1692         20.9081         19.2343
450327..........................................         11.7511         13.3639         10.9732         11.8932
450330..........................................         18.9425         19.8066         20.8820         19.9093
450334..........................................         12.8051         13.8392         13.9839         13.5301
450337..........................................         17.1073         25.5708               *         20.0638
450340..........................................         17.6914               *         15.2368         16.4876
450341..........................................         18.9429               *         20.8814         19.8654
450346..........................................         17.5367         18.9475         19.2769         18.6527
450347..........................................         17.1099         19.3475         19.9109         18.7748
450348..........................................         13.9535         13.3585         15.0069         14.1063
450351..........................................         18.4116         19.3159         20.4537         19.4007
450352..........................................         18.7480         20.1871         21.2035         20.1227
450353..........................................         17.7539         16.0003         16.9105         16.8643
450355..........................................         11.9473         11.8933         12.8876         12.2285
450358..........................................         22.3235         23.0206         24.9765         23.4327
450362..........................................         15.8847         18.1983         18.1247         17.3786
450369..........................................         15.2233         15.3122         16.0667         15.5405
450370..........................................         12.6061         16.1369         18.7539         15.9177
450371..........................................         24.6339         16.0236         17.7591         19.2388
450372..........................................         20.0924         22.0746         21.4050         21.1434
450373..........................................         17.4183         17.9554         17.5600         17.6501
450374..........................................         13.6099         15.1750         15.0146         14.5995
450378..........................................         23.5789         23.4599         24.4143         23.8974
450379..........................................         22.7632         22.8756         25.1931         23.6182
450381..........................................         16.4166         16.7112         16.6476         16.5958
450388..........................................         19.2499         19.7408         20.6670         19.9390
450389..........................................         18.1797         18.8448         19.3156         18.7899
450393..........................................         20.2784         22.4992         21.1805         21.2450
450395..........................................         18.3768         18.0024         17.5236         17.9433
450399..........................................         15.7845         15.3491         16.3333         15.8319
450400..........................................         19.5379         18.6668         18.8375         18.9844
450403..........................................         20.1989         22.8430         24.7645         22.7028
450411..........................................         14.4832         15.1121         15.9178         15.1698
450417..........................................         13.4983         15.3591         15.2713         14.6933
450418..........................................         21.9161         21.9690         22.2511         22.0447
450419..........................................         20.6325         23.2551         22.4552         22.1296
450422..........................................         26.4848         28.0257         28.0395         27.5279
450423..........................................         22.7132               *               *         22.7132
450424..........................................         18.9741         18.7895               *         18.8834
450429..........................................         13.8723               *               *         13.8723
450431..........................................         19.6304         22.0361         21.7369         21.1141
450438..........................................         19.5028         15.4553         20.7791         18.3025
450446..........................................         13.0986         20.7592               *         16.2045
450447..........................................         18.0376         18.0377         19.3864         18.4641
450451..........................................         18.8948         18.2988         17.7525         18.2807

[[Page 31590]]

 
450457..........................................         24.7880         19.6569               *         21.9578
450460..........................................         15.1765         14.6523         15.8434         15.2180
450462..........................................         22.6212         22.1144         18.6080         21.0035
450464..........................................         13.2931         15.5908         15.8121         14.8193
450465..........................................         15.5650         15.4731         19.3928         16.5297
450467..........................................         10.6184         17.0004         18.9388         14.4801
450469..........................................         19.6269         22.1930         22.0389         21.2453
450473..........................................         19.9761         19.7148         18.3813         19.2637
450475..........................................         16.3404         16.9269         19.0010         17.4228
450484..........................................         16.8131         18.9825         19.2310         18.3714
450488..........................................         19.3457         19.2173         21.5440         20.0301
450489..........................................          9.9326         16.3584         17.8779         13.9861
450497..........................................         15.0886         16.2997         15.9325         15.7828
450498..........................................         13.8551         14.4713         15.9479         14.7991
450508..........................................         18.8069         19.0991         19.2176         19.0434
450514..........................................         21.3243         20.0144         20.7064         20.6957
450517..........................................         27.8815         14.3191         17.6011         18.7482
450518..........................................         19.8116         21.4873         20.7355         20.6380
450523..........................................         20.0792         21.0393         20.8469         20.6355
450530..........................................         22.8623         21.1634         22.0810         22.0042
450534..........................................         19.9376         20.1520         19.7227         19.9301
450535..........................................         19.6645         21.0513         21.5449         20.7286
450537..........................................         20.8438         20.1161         20.6100         20.5223
450539..........................................         16.4921         18.7559         19.3681         18.2066
450544..........................................         23.9283         23.6652         22.7282         23.5339
450545..........................................         19.5558         20.2823         21.0792         20.2860
450547..........................................         14.8248         18.1524         19.3002         17.4255
450551..........................................         16.9439         16.6237         16.1437         16.5621
450558..........................................         22.2574         20.7404         21.3116         21.4292
450563..........................................         19.9218         22.0708         21.8171         21.3374
450565..........................................         16.2652         17.3803         17.8058         17.1566
450570..........................................         18.9532         19.0336               *         18.9910
450571..........................................         17.5598         18.2784         19.5325         18.4467
450573..........................................         12.2502         17.3518         17.5455         15.5608
450574..........................................         14.5965         14.6128         14.8549         14.6891
450575..........................................         19.3925         22.5621         24.0386         22.1410
450578..........................................         15.4783         18.0925         17.2863         16.9084
450580..........................................         15.8321         16.7374         17.8552         16.8065
450583..........................................         15.6580         14.4411         15.1202         15.0631
450584..........................................         14.2321         14.6735         14.9237         14.6266
450586..........................................         14.3773         13.8248         15.2831         14.4737
450587..........................................         17.0230         18.0219         17.6291         17.5412
450591..........................................         17.8981         17.7795         18.6275         18.1113
450596..........................................         22.5420         21.6729         21.9445         22.0245
450597..........................................         17.0776         17.6179         19.0641         17.9259
450603..........................................         11.6442         23.5572         23.4924         18.9348
450604..........................................         16.4535         17.6582         18.6241         17.5848
450605..........................................         21.1400         19.4580         19.7400         20.0918
450609..........................................         15.9753         17.0986         14.1776         15.7466
450610..........................................         18.9924         21.5191         22.1792         21.1877
450614..........................................         17.9853         16.5754               *         17.2230
450615..........................................         14.8562         15.2956         14.9323         15.0244
450617..........................................         20.3387         20.8919         21.5004         20.9383
450620..........................................         15.8380         16.0987         16.1315         16.0378
450623..........................................         22.1950         23.1270         25.1122         23.4424
450626..........................................         18.1673         18.4349         20.5225         19.1158
450628..........................................         20.5611         18.6093         19.9760         19.7367
450630..........................................         21.6876         20.9605         23.1840         21.9334
450631..........................................         20.0417         21.6736         21.7853         21.1405
450632..........................................         11.7587         13.9147         15.1416         13.5343
450633..........................................         19.5183         19.4949               *         19.5064
450634..........................................         23.5333         22.9877         23.0470         23.1838
450638..........................................         23.1437         22.1704         23.8335         23.0423

[[Page 31591]]

 
450639..........................................         23.1936         21.6421         22.5182         22.4301
450641..........................................         16.5125         15.7578         15.1716         15.8348
450643..........................................         18.7054         16.8152         18.9088         18.1638
450644..........................................         23.6587         22.7721         24.5834         23.7084
450646..........................................         19.8274         19.1433         22.5667         20.4055
450647..........................................         24.7981         24.2763         25.0549         24.7111
450648..........................................         14.8488         15.0305         14.1565         14.6469
450649..........................................         16.4496         16.6577         16.7303         16.6187
450651..........................................         22.7664         22.7112         25.4679         23.6985
450652..........................................         13.4389         17.2445               *         14.7103
450653..........................................         18.1834         19.2349         19.5306         18.9413
450654..........................................         14.5258         14.5423         15.5858         14.8899
450656..........................................         17.6723         18.2606         18.5874         18.1828
450658..........................................         16.2657         17.2630               *         16.7212
450659..........................................         22.2550         23.0108         22.9344         22.7256
450661..........................................         19.7160         18.9071         19.5504         19.3935
450662..........................................         18.2284         19.3152         20.7973         19.5367
450665..........................................         15.2015         16.1319         14.2377         15.2093
450666..........................................         20.3248         20.2549               *         20.2912
450668..........................................         20.6965         21.0972         21.2002         20.9938
450669..........................................         21.7632         21.6746         22.5150         22.0051
450670..........................................         16.8893         20.2632         26.0785         20.9643
450672..........................................         21.8559         21.4927         23.2623         22.2025
450673..........................................         13.9620         13.7005         14.5310         14.0919
450674..........................................         22.2796         22.2426         21.9624         22.1483
450675..........................................         22.4961         21.4479         23.3954         22.4703
450677..........................................         22.6839         20.6556         21.3718         21.5395
450678..........................................         23.2617         24.1301         25.1841         24.1797
450683..........................................         20.9143         22.8699         21.9705         21.8695
450684..........................................         19.7005         21.9962         22.2380         21.3152
450686..........................................         16.5661         16.4632         17.4746         16.8354
450688..........................................         19.6250         20.1831         21.7691         20.5644
450690..........................................         21.6578         22.4707         27.2399         23.4791
450694..........................................         17.4758         18.1872         18.5520         18.0935
450696..........................................         24.9636               *               *         24.9636
450697..........................................         18.8405         19.4949         19.4424         19.2742
450698..........................................         14.6680         15.4750         16.5111         15.5420
450700..........................................         14.6421         15.9050         13.9129         14.8191
450702..........................................         20.8223         21.3739         19.3495         20.4688
450704..........................................         20.9821         20.7987         18.1835         19.7101
450705..........................................         30.0116         22.1809         18.7138         22.5666
450706..........................................         21.2072         22.0884         22.4329         21.9400
450709..........................................         20.8889         22.1490         21.9270         21.6715
450711..........................................         19.8126         19.8581         21.0779         20.2689
450712..........................................         13.6240         15.9298         11.7861         13.6660
450713..........................................         20.8065         22.6986         23.6017         22.4678
450715..........................................         22.0413         22.5988         24.8068         23.2060
450716..........................................         20.5544         20.9074         20.8913         20.7944
450717..........................................         20.7192         20.6551         22.0243         21.1286
450718..........................................         19.6886         22.1765         22.9582         21.6590
450723..........................................         19.7563         20.8213         22.1695         20.9457
450724..........................................         20.3235         20.3706         23.4039         21.3348
450727..........................................         13.5458         17.9172         24.7672         17.9685
450728..........................................         17.5284         19.8879         14.8030         17.2831
450730..........................................         22.0819         23.0054         24.5952         23.2900
450733..........................................         20.7693         20.2199         21.6162         20.8632
450735..........................................         13.8767               *               *         13.8767
450742..........................................         22.7655         21.8392         22.8135         22.4714
450743..........................................         18.8937         19.6015         20.5017         19.6892
450746..........................................         12.7904         30.2657               *         19.3854
450747..........................................         19.2585         20.3914         19.9818         19.8850
450749..........................................         16.2130         19.1678         17.2391         17.6065
450750..........................................         14.6914         13.8098               *         14.2686

[[Page 31592]]

 
450751..........................................         21.2198         19.9995         19.8170         20.4240
450754..........................................         16.0860         16.7145         16.7688         16.5644
450755..........................................         17.9904         19.8743         19.5916         19.1939
450757..........................................         13.8675         14.9434         15.5327         14.7530
450758..........................................         21.8669         19.0221         22.6196         21.1578
450760..........................................         17.4852         19.2225         20.4209         19.0477
450761..........................................         13.6152         15.7681         14.6511         14.6112
450763..........................................         18.2123         18.6092         18.9713         18.6032
450766..........................................         22.4348         23.3879         25.4057         23.7704
450769..........................................         14.5858         18.4163         17.3037         16.4629
450770..........................................         16.5458         19.0183         19.2518         18.2668
450771..........................................         22.4542         21.8268         21.4199         21.8514
450774..........................................         17.9964         16.2948               *         17.1404
450775..........................................         19.8897         21.3504         22.6526         21.2920
450776..........................................         15.7750         14.1720         13.4287         14.1843
450777..........................................         21.0682         19.0380         18.3119         19.5171
450779..........................................         21.4546         21.6642         22.1453         21.7809
450780..........................................         19.1498         19.0914         20.0824         19.4503
450785..........................................         18.4976               *               *         18.4976
450788..........................................         19.1463         19.6469         19.9597         19.6478
450794..........................................         18.2229               *               *         18.2229
450795..........................................         16.6494         22.5753         27.0250         21.6046
450796..........................................         16.5362         19.2059               *         17.7667
450797..........................................         15.9188         16.4923         20.2356         17.4420
450798..........................................          9.4634               *               *          9.4634
450801..........................................         17.5669         17.9548         17.9759         17.8371
450802..........................................         19.9168         17.1435         18.2460         18.3472
450803..........................................         18.3767         21.6653               *         20.6031
450804..........................................         19.4846         19.0893         20.5225         19.7061
450806..........................................               *               *         18.8211         18.8211
450807..........................................         11.3192         13.4306         18.4410         13.7054
450808..........................................         16.9915         17.4917         18.1728         17.5602
450809..........................................         20.0202         19.7899         21.8610         20.5411
450811..........................................         19.0961         19.9168         21.6115         20.3503
450813..........................................         15.9166         14.5392         15.3780         15.2272
450815..........................................               *         21.2741               *         21.2741
450819..........................................               *         16.5521               *         16.5521
450820..........................................               *         26.8348         24.6742         25.7177
450822..........................................               *         22.8556         24.8702         23.9136
450823..........................................               *               *         17.9756         17.9756
450824..........................................               *               *         25.7488         25.7488
450825..........................................               *               *         15.3546         15.3546
450827..........................................               *               *         20.1310         20.1310
450828..........................................               *               *         17.7667         17.7667
450829..........................................               *               *         14.7121         14.7121
460001..........................................         21.7996         22.2735         23.5485         22.5533
460003..........................................         20.0452         22.6289               *         21.2787
460004..........................................         21.3744         21.7234         23.1289         22.0969
460005..........................................         19.7069         22.5252         23.0189         21.6769
460006..........................................         20.6252         21.0700         22.1648         21.3374
460007..........................................         20.8026         21.1922         22.0409         21.4007
460008..........................................         18.8661         19.1153         22.6808         20.2069
460009..........................................         21.9016         22.5295         23.1146         22.5111
460010..........................................         21.9830         22.4948         23.8996         22.8204
460011..........................................         18.8660         19.7674         24.6789         20.7963
460013..........................................         20.7326         20.1936               *         20.4776
460014..........................................         18.3865         18.5370               *         18.4531
460015..........................................         20.6593         21.0470         22.4872         21.4209
460016..........................................         18.2408         21.9105         19.0910         19.6368
460017..........................................         17.7103         18.9929               *         18.3294
460018..........................................         17.6235         17.0063         17.0385         17.1969
460019..........................................         16.2671         17.8690         19.3442         17.7589
460020..........................................         17.3467         17.2663         18.1542         17.5580

[[Page 31593]]

 
460021..........................................         21.0470         21.5174         23.1368         21.9697
460022..........................................         20.1534         21.3614         20.7539         20.7266
460023..........................................         22.3535         22.9265         24.1825         23.1937
460025..........................................         19.4247         17.3494         17.4070         17.9267
460026..........................................         19.9241         20.2576         21.1759         20.4671
460027..........................................         21.8868         22.2955         21.4833         21.8607
460029..........................................         20.5154         20.8366         22.7658         21.3471
460030..........................................         17.6071         17.1383         18.1423         17.6207
460032..........................................         21.1006         21.4832         21.0286         21.1954
460033..........................................         19.5372         19.2664         20.2389         19.6949
460035..........................................         16.0021         16.1685         15.6979         15.9450
460036..........................................         23.5893         23.4573         24.2651         23.7927
460037..........................................         18.6850         17.7399         19.0115         18.4898
460039..........................................         24.9134         24.4808         24.5134         24.6186
460041..........................................         21.0623         20.2035         21.6676         20.9770
460042..........................................         18.8814         19.5662         20.9858         19.8725
460043..........................................         24.4779         23.2819         25.1366         24.2896
460044..........................................         21.4696         21.8485         23.6604         22.3504
460046..........................................         18.2224               *               *         18.2224
460047..........................................         23.0433         22.7524         23.4965         23.0972
460049..........................................         19.6483         20.8283         21.5241         20.8906
460051..........................................         19.4761         22.1758         21.8595         21.1765
460052..........................................               *         19.8961         20.1989         20.0325
470001..........................................         20.2299         21.3817         21.7774         21.1523
470003..........................................         23.6949         22.0563         23.4163         23.0458
470004..........................................         16.8842         18.1879         17.3576         17.4706
470005..........................................         21.9191         23.1808         22.6589         22.5826
470006..........................................         17.8699         20.2829         21.0835         19.7003
470008..........................................         19.6069         20.1969         20.3833         20.0728
470010..........................................         20.2961         21.0616         22.3913         21.2927
470011..........................................         21.7675         22.2415         24.1306         22.7075
470012..........................................         18.5339         18.9444         19.8831         19.1162
470015..........................................         19.5366         20.2125         21.8204         20.4728
470018..........................................         21.5426         21.2406         23.1159         21.9638
470020..........................................         20.6643         21.5688         21.9911         21.4308
470023..........................................         20.4511         21.7139         22.5334         21.5811
470024..........................................         20.8510         21.9807         23.2738         22.0567
490001..........................................         21.9755         20.0570         21.4952         21.1603
490002..........................................         15.2287         15.7365         16.5198         15.8281
490003..........................................         19.1040         20.3237         20.7688         20.0621
490004..........................................         19.2126         19.7074         20.7390         19.8866
490005..........................................         20.5517         21.3318         22.9490         21.6702
490006..........................................         15.9537         12.3253         19.8977         16.1242
490007..........................................         18.7740         19.8938         20.5265         19.7370
490009..........................................         23.9344         23.7659         24.7602         24.1271
490010..........................................         21.7424               *               *         21.7424
490011..........................................         18.6071         19.8042         19.8179         19.3919
490012..........................................         15.9973         15.2965         16.0994         15.7867
490013..........................................         17.3318         18.2396         18.3901         17.9911
490014..........................................         25.8315         23.5266         27.8907         25.6619
490015..........................................         19.6363         20.0667         21.4500         20.3969
490017..........................................         18.4361         19.3854               *         18.9126
490018..........................................         18.3435         18.5508         19.7456         18.8862
490019..........................................         19.6178         21.0124         21.6790         20.8153
490020..........................................         18.5691         19.3424         20.9212         19.6001
490021..........................................         19.3945         20.0496         21.2263         20.2509
490022..........................................         21.2183         22.3380         24.3008         22.6504
490023..........................................         20.6694         21.5683         22.8400         21.7338
490024..........................................         17.7221         18.4314         19.7501         18.7524
490027..........................................         16.2761         16.7556         17.5178         16.8693
490030..........................................          9.1789          8.6446               *          8.9749
490031..........................................         14.9539         16.0003         17.4262         16.1268
490032..........................................         22.4262         21.4037         22.2041         22.0055

[[Page 31594]]

 
490033..........................................         21.1723         19.2908         24.3589         21.5324
490037..........................................         16.3759         17.0113         16.7752         16.7116
490038..........................................         21.0218         17.6324         18.6012         18.9881
490040..........................................         22.7061         24.1266         24.8808         23.9273
490041..........................................         18.3589         18.7987         17.9942         18.3695
490042..........................................         16.4666         17.0972         18.1733         17.2802
490043..........................................         22.1574         22.1068         24.0198         22.7114
490044..........................................         18.3137         19.7842         18.4845         18.8757
490045..........................................         20.5468         20.5558         21.8453         21.0100
490046..........................................         18.4825         19.9102         19.7466         19.3960
490047..........................................         25.0438         18.7614         20.0837         20.6715
490048..........................................         18.4361         19.5417         20.9110         19.5970
490050..........................................         23.0729         23.3668         23.8519         23.4357
490052..........................................         16.8600         16.4787         17.6096         16.9745
490053..........................................         15.6996         16.8410         17.7363         16.7991
490054..........................................         15.4734         19.5780         22.5136         19.1813
490057..........................................         19.9210         20.3160         20.7806         20.3441
490059..........................................         20.8662         21.4801         24.1516         22.0719
490060..........................................         17.6308         18.5917         19.3525         18.5249
490063..........................................         28.6536         26.1930               *         27.3515
490066..........................................         20.6972         19.8352         21.5920         20.7067
490067..........................................         17.0195         17.8487         18.6469         17.8519
490069..........................................         17.3297         20.7582         21.5228         19.7588
490071..........................................         21.8879         23.3511         23.9246         23.0331
490073..........................................         20.7960         26.0957               *         23.1759
490075..........................................         18.6983         19.2156         20.2001         19.3654
490077..........................................         21.3670         22.6504         22.4133         22.1262
490079..........................................         17.0815         17.7016         17.5839         17.4571
490084..........................................         16.7834         18.0555         18.9679         17.9259
490085..........................................         17.4584         17.6158         19.2494         18.1150
490088..........................................         16.4362         17.9141         19.1415         17.7397
490089..........................................         17.7692         18.2290         19.6501         18.5835
490090..........................................         17.0199         17.5799         19.2094         17.9357
490091..........................................         20.8734         25.0272         23.6634         22.9282
490092..........................................         16.9533         16.4360               *         16.7160
490093..........................................         17.3711         17.8275         18.9442         18.0549
490094..........................................         18.9204         22.3033         20.2020         20.4445
490097..........................................         15.5780         16.9518         16.1076         16.1614
490098..........................................         15.1403         16.0488         18.5355         16.5130
490099..........................................         17.9665         18.3985         19.2604         18.5294
490100..........................................         22.5010               *               *         22.5010
490101..........................................         24.7616         23.5553         25.7804         24.7017
490104..........................................         25.6889         40.2529               *         29.6601
490105..........................................         18.5765         21.4428               *         19.7749
490106..........................................         17.6596         26.3821         31.8566         22.3213
490107..........................................         23.5240         22.9283         23.9962         23.5071
490108..........................................         20.2112         24.1232         24.8596         22.6562
490109..........................................         23.6620         25.9475         23.0609         24.1978
490110..........................................         16.5131         18.1561         18.8042         17.8380
490111..........................................         17.1768         17.8510         19.6489         18.2093
490112..........................................         21.4532         22.1162         23.2843         22.3013
490113..........................................         23.2235         23.9043         26.1840         24.4577
490114..........................................         17.3047         18.0359         18.8920         18.0825
490115..........................................         16.5203         16.8537         18.4499         17.2731
490116..........................................         16.6170         17.2040         18.2935         17.3997
490117..........................................         14.0104         14.7944         15.9284         14.9234
490118..........................................         21.4674         23.2022         24.2668         22.9444
490119..........................................         17.9147         18.6046         18.9640         18.4840
490120..........................................         19.3707         20.5777         20.4547         20.1460
490122..........................................         23.8801         23.8198         26.6681         24.7636
490123..........................................         17.7461         19.3056         20.0920         19.0902
490124..........................................         22.0884         21.3818         23.6526         22.4301
490126..........................................         18.6844         20.4294         19.0782         19.3248

[[Page 31595]]

 
490127..........................................         16.0516         16.5993         17.6437         16.7293
490129..........................................         22.5885         28.6868               *         23.5799
490130..........................................         16.4322         17.6943         18.6406         17.5834
490132..........................................         18.6570         18.4671         19.1742         18.7508
500001..........................................         22.1896         24.4829         25.2411         23.9385
500002..........................................         21.6332         19.8476         22.9942         21.4749
500003..........................................         24.2814         24.4333         25.1200         24.6216
500005..........................................         22.3955         24.3870         26.6971         24.3513
500007..........................................         26.0599         21.9911         24.7889         24.1708
500008..........................................         25.3064         26.1737         27.2852         26.2556
500011..........................................         24.0162         24.6554         25.7263         24.7924
500012..........................................         20.7032         24.2799         24.5450         23.0771
500014..........................................         24.3419         24.0990         25.0490         24.4936
500015..........................................         23.9297         24.9923         25.8775         24.9616
500016..........................................         24.3938         24.9439         25.1227         24.8306
500019..........................................         22.4213         23.2054         23.5730         23.0604
500021..........................................         25.9198         27.6490         25.9403         26.4613
500023..........................................         26.6535         27.1025         32.3079         28.0325
500024..........................................         23.7472         26.6452         26.2113         25.5094
500025..........................................         26.4810         24.4825         27.2601         26.0674
500026..........................................         23.8005         26.9884         26.6108         25.7916
500027..........................................         22.2158         25.1125         27.5909         24.9753
500028..........................................         19.2675         18.9556         19.0261         19.0887
500029..........................................         17.9237         18.5042         19.3130         18.5707
500030..........................................         24.9039         26.3828         28.5297         26.6182
500031..........................................         29.2707         23.6099         25.8542         26.0586
500033..........................................         22.3527         22.5462         23.8994         22.9522
500036..........................................         22.1096         23.6333         25.1255         23.5838
500037..........................................         20.7139         21.4059         22.1774         21.4194
500039..........................................         23.8918         24.0007         25.4225         24.4379
500041..........................................         23.9608         25.4376         24.7070         24.7067
500042..........................................         22.9125               *               *         22.9125
500043..........................................         20.9459         22.0466         24.1745         22.4162
500044..........................................         23.3364         24.2212         24.7816         24.1154
500045..........................................         20.8881         24.0526         24.6265         23.0766
500048..........................................         22.1906         20.3207         20.6333         21.0462
500049..........................................         24.0489         24.5997         26.5857         25.0314
500050..........................................         22.0065         22.6563         23.0804         22.6053
500051..........................................         24.8203         25.9447         26.7628         25.8820
500053..........................................         23.9397         22.8399         24.2492         23.6675
500054..........................................         22.8829         23.8089         25.7815         24.1708
500055..........................................         23.7446         23.8622         23.7988         23.8022
500057..........................................         18.2737         19.0479         20.5812         19.3310
500058..........................................         24.7882         24.1106         26.5679         25.1920
500059..........................................         23.3506         26.6270         25.3528         25.0566
500060..........................................         25.0233         28.3655         29.6030         27.5162
500061..........................................         21.7013         20.8624         24.5908         22.4271
500062..........................................         18.6329         19.0557         19.1685         18.9583
500064..........................................         25.5748         26.7000         27.5791         26.6387
500065..........................................         21.9308         23.5671         24.0966         23.2140
500068..........................................         19.6574         19.2638         20.9278         19.9560
500069..........................................         21.3592         21.4542         22.4158         21.7566
500071..........................................         19.1906         19.1428         22.3253         20.1059
500072..........................................         25.3928         25.2001         25.7734         25.4637
500073..........................................         21.2469         21.7698         22.5222         21.8777
500074..........................................         18.9679         19.5981         20.6120         19.7482
500077..........................................         22.8536         23.9410         24.5407         23.7721
500079..........................................         24.2036         23.1041         24.7946         24.0303
500080..........................................         15.6630         18.3883         18.8188         17.4053
500084..........................................         23.4032         24.4044         24.5678         24.1531
500085..........................................         21.4403         20.4517         20.7422         20.8523
500086..........................................         23.3288         22.8829         24.2556         23.4907
500088..........................................         23.2701         25.2478         25.2774         24.5589

[[Page 31596]]

 
500089..........................................         18.7080         19.7166         20.3478         19.5281
500090..........................................         16.1576         20.4429         21.7716         18.7859
500092..........................................         16.7913         19.2028         20.3058         18.6898
500094..........................................         18.5835         15.7866         17.6625         17.4874
500096..........................................         21.0151         23.3564         25.1135         23.2107
500097..........................................         19.7706         20.8774         21.4423         20.6699
500098..........................................         16.3511         15.2040         13.5203         15.0572
500101..........................................         19.7337         15.8000         19.8614         18.4197
500102..........................................         20.9389         21.8963         23.1307         22.0050
500104..........................................         22.8154         24.9389         24.7875         24.1421
500106..........................................         18.6041         19.1465         17.1066         18.3020
500107..........................................         18.1201         17.9489         17.4641         17.8401
500108..........................................         26.2939         28.6229         26.1609         27.0259
500110..........................................         21.4553         22.9775         23.5941         22.6736
500118..........................................         23.8397         24.8034         24.7875         24.4924
500119..........................................         22.4373         22.1192         23.9939         22.8469
500122..........................................         22.4268         23.5264         24.4462         23.5112
500123..........................................         20.3181         19.6646         21.7133         20.7526
500124..........................................         23.2836         23.7742         24.6591         23.9700
500125..........................................         15.1112         14.7910         15.6304         15.1911
500129..........................................         26.1575         25.4685         25.2082         25.5438
500132..........................................         15.6717         23.1822         21.9915         20.2081
500134..........................................         17.7457         17.2430         15.9791         16.9729
500139..........................................         22.2297         22.3053         23.7993         22.7606
500141..........................................         23.8838         29.9695         28.1014         27.3199
500143..........................................         18.0343         18.2570         18.7523         18.3736
500146..........................................         21.6003               *               *         21.6003
510001..........................................         19.1492         20.0429         20.2514         19.8050
510002..........................................         20.1527         17.6392         19.1517         18.9313
510005..........................................         14.2503         13.8621         13.8641         13.9934
510006..........................................         18.7313         19.9609         19.9760         19.5653
510007..........................................         21.2729         21.6761         23.0072         22.0021
510008..........................................         18.3296         19.0513         20.1039         19.1754
510012..........................................         15.8390         15.6089         15.8596         15.7743
510013..........................................         17.8527         19.5798         18.3486         18.5734
510015..........................................         14.9039         16.7311         17.1595         16.3249
510018..........................................         18.5269         18.5358         18.3023         18.4548
510020..........................................         13.1837         14.1211         15.7512         14.3266
510022..........................................         20.1763         21.5770         21.4336         21.0418
510023..........................................         16.0129         16.7777         17.6516         16.8122
510024..........................................         19.0941         18.7461         19.6521         19.1601
510026..........................................         13.6888         13.7952         14.8785         14.0865
510027..........................................         17.2900         18.5945         20.5222         18.7968
510028..........................................         20.0628         19.9208         22.4826         20.8230
510029..........................................         17.7124         18.4668         16.3204         17.4181
510030..........................................         17.4198         17.7603         19.2558         18.1712
510031..........................................         28.6673         18.6341         19.3049         21.2106
510033..........................................         18.4082         18.4718         19.6900         18.8637
510035..........................................         16.5007         18.3164         21.7818         18.6703
510036..........................................         13.4559         13.8786         15.0266         14.0903
510038..........................................         15.8132         15.5576         15.9821         15.7873
510039..........................................         16.9398         17.1461         17.4002         17.1582
510043..........................................         14.0662         13.1308         14.4202         13.8751
510046..........................................         17.3821         18.5896         18.7424         18.2568
510047..........................................         19.8963         20.8101         21.2375         20.6123
510048..........................................         21.0407         17.1647         15.2886         17.8240
510050..........................................         16.9136         18.4036         18.3964         17.9380
510053..........................................         16.1036         17.5798         18.1046         17.2603
510055..........................................         23.7248         24.2133         25.6333         24.5104
510058..........................................         18.4156         18.4501         18.6025         18.4938
510059..........................................         16.5854         16.1044         17.3844         16.6208
510060..........................................         17.5594               *               *         17.5594
510061..........................................         13.8204         14.1968         14.6774         14.2360

[[Page 31597]]

 
510062..........................................         19.3881         18.1588         19.7964         19.0922
510066..........................................         12.2943               *               *         12.2943
510067..........................................         16.7161         17.3067         17.8816         17.3091
510068..........................................         18.7938         23.0452         19.4299         20.2577
510070..........................................         18.5146         18.7091         18.6226         18.6195
510071..........................................         17.2148         18.0278         18.8766         18.0317
510072..........................................         15.6262         15.9257         16.5279         16.0216
510077..........................................         18.0668         18.2947         20.4521         18.9028
510080..........................................         17.4485         16.3453         18.5318         17.3501
510081..........................................         13.6359         11.9701         10.4972         11.9879
510082..........................................         17.4538         13.5946         16.0014         15.5120
510084..........................................         17.2395         13.5339         14.9683         15.2567
510085..........................................         17.5624         18.6227         19.0175         18.4360
510086..........................................         13.4763         14.2241         16.3413         14.6710
510088..........................................               *         14.8854         16.2850         15.6272
520002..........................................         19.7447         19.6755         19.3159         19.5604
520003..........................................         17.1248         18.7956         18.7507         18.2896
520004..........................................         19.6512         20.4591         18.8843         19.6231
520006..........................................         21.5313         21.4884         22.4099         21.7879
520007..........................................         16.2001         18.4629         18.3959         17.6275
520008..........................................         22.8024         24.9395         24.4927         24.0917
520009..........................................         18.6002         21.4638         19.8142         19.9388
520010..........................................         22.7703         22.3311         25.4845         23.5468
520011..........................................         20.7410         21.5223         21.6945         21.3155
520013..........................................         20.3965         20.5944         22.1009         21.0588
520014..........................................         17.1646         18.0841         19.2760         18.1480
520015..........................................         18.6078         19.7672         21.0428         19.8323
520016..........................................         17.3018         18.4320         19.5656         18.4077
520017..........................................         19.6008         19.4780         21.1409         20.0934
520018..........................................         21.1941         21.5279         22.1929         21.6736
520019..........................................         19.5440         20.9164         21.8870         20.7980
520021..........................................         21.3471         21.9531         22.8484         22.1016
520024..........................................         14.0175         14.4750         16.4879         15.0572
520025..........................................         18.2430         20.3838         21.9529         20.1629
520026..........................................         21.5453         20.8546         22.7429         21.7237
520027..........................................         19.9324         21.5868         22.0947         21.2079
520028..........................................         21.2852         22.5941         22.0333         21.9368
520029..........................................         19.5750         21.4197         21.6729         20.8760
520030..........................................         20.5039         21.6311         22.7239         21.6241
520031..........................................         20.4814         20.9875         21.2809         20.8937
520032..........................................         19.5697         21.1069         24.1092         21.5816
520033..........................................         19.2954         20.2520         21.0088         20.1750
520034..........................................         17.1282         20.4307         21.2944         19.6400
520035..........................................         18.9452         18.7135         19.7990         19.1719
520037..........................................         20.6686         21.6017         23.0801         21.8015
520038..........................................         19.6294         20.6130         21.2769         20.4835
520039..........................................         20.7641         23.3687         21.8688         21.9128
520040..........................................         20.4677         21.2023         23.0710         21.5679
520041..........................................         17.1959         18.4117         17.6529         17.7461
520042..........................................         18.5843         19.5466         20.6354         19.6057
520044..........................................         18.4014         19.1877         21.4913         19.6621
520045..........................................         20.5917         21.2427         21.9812         21.2870
520047..........................................         18.3048         20.3487         21.0370         19.8304
520048..........................................         20.6583         19.8926         20.3488         20.2938
520049..........................................         20.3559         20.1667         21.8271         20.7868
520051..........................................         21.6497         24.0460         23.4366         23.0036
520053..........................................         17.3945         18.0851         18.7234         18.0684
520054..........................................         15.1747         16.8363         16.6278         16.1750
520057..........................................         19.0872         19.8492         20.6959         19.9036
520058..........................................         19.7283         21.2500         23.6794         21.5351
520059..........................................         20.9913         21.5796         21.9452         21.5150
520060..........................................         17.9258         18.8232         20.3357         19.0291
520062..........................................         19.1482         19.7038         21.5525         20.1564

[[Page 31598]]

 
520063..........................................         19.6136         20.5262         21.2774         20.4843
520064..........................................         22.7423         22.0917         23.7144         22.8379
520066..........................................         22.8837         24.0087         24.1733         23.6290
520068..........................................         18.9943         19.6855         19.9595         19.5384
520069..........................................         20.2934         20.1770         21.7233         20.5221
520070..........................................         18.5938         19.4261         20.0096         19.3562
520071..........................................         18.7304         19.9866         22.0066         20.1801
520074..........................................         20.4601         20.9007         21.6636         20.9770
520075..........................................         19.8457         20.7301         22.1894         20.9388
520076..........................................         17.6088         19.5878         20.6155         19.2421
520077..........................................         17.7830         18.7119         18.1077         18.2004
520078..........................................         21.3380         21.7545         20.5734         21.2201
520082..........................................         17.7405               *               *         17.7405
520083..........................................         23.8849         23.5787         24.2131         23.8898
520084..........................................         20.8427         23.5446         21.8102         22.0208
520087..........................................         20.3624         20.7821         22.2579         21.1364
520088..........................................         20.6312         21.8931         22.3921         21.5920
520089..........................................         21.5456         22.1055         23.1221         22.2509
520090..........................................         18.9343         20.3645         20.9069         20.0854
520091..........................................         20.9927         20.9440         22.2218         21.3884
520092..........................................         17.6500         18.6248         19.7870         18.7181
520094..........................................         20.3611         20.6179         21.3082         20.7652
520095..........................................         20.3269         18.6425         21.8172         20.1804
520096..........................................         19.7757         20.6668         21.6803         20.7358
520097..........................................         20.2354         20.8016         22.2375         21.1096
520098..........................................         22.3348         23.4707         23.4273         23.0928
520100..........................................         18.3832         19.4788         20.5366         19.4712
520101..........................................         19.5186         19.9875         20.0164         19.8451
520102..........................................         20.1898         21.0138         22.1413         21.1139
520103..........................................         19.4809         20.1092         22.2765         20.6137
520107..........................................         20.3747         21.7907         23.8421         21.9354
520109..........................................         19.1303         19.7609         20.3208         19.7432
520110..........................................         20.4494         21.0055         22.3923         21.3276
520111..........................................         17.7834         17.7673         18.2744         17.9282
520112..........................................         19.1797         18.9577         17.6226         18.3876
520113..........................................         21.1485         21.8852         23.1852         22.0983
520114..........................................         16.6616         17.8476         18.5767         17.6415
520115..........................................         18.2980         19.2248         21.4279         19.6231
520116..........................................         19.8509         20.6922         22.2741         20.9026
520117..........................................         18.5414         18.3963         19.3653         18.7838
520118..........................................         14.2326         14.8626         13.9920         14.3519
520120..........................................         18.7437               *               *         18.7437
520121..........................................         19.7305         20.8492         20.9422         20.5799
520122..........................................         16.2436         16.9335         16.9905         16.7143
520123..........................................         17.3980         17.7986         19.8134         18.4575
520124..........................................         17.2619         17.9205         19.2621         18.1369
520130..........................................         15.6845         16.6873         18.8845         17.0161
520131..........................................         18.7295         20.2591         21.0400         20.0321
520132..........................................         15.6379         18.1630         18.2634         17.2681
520134..........................................         18.0953         18.8150         19.6881         18.8725
520135..........................................         15.8246         17.3476         18.1026         17.0799
520136..........................................         19.8480         20.9050         21.3966         20.7380
520138..........................................         21.2260         22.5599         22.5773         22.1218
520139..........................................         20.9988         21.4042         22.8070         21.7325
520140..........................................         21.5207         22.3671         22.5459         22.1346
520142..........................................         20.5858         21.9432         21.4120         21.2420
520144..........................................         18.5701         19.9120         20.5864         19.6719
520145..........................................         18.2654         18.7958         20.3461         19.0923
520146..........................................         17.9585         18.2370         18.6337         18.2882
520148..........................................         17.2421         19.1502         20.5075         19.0048
520149..........................................         14.1901         12.8928         13.8614         13.6192
520151..........................................         17.3267         18.7070         19.3362         18.4627
520152..........................................         19.5858         22.5980         26.2402         22.5080

[[Page 31599]]

 
520153..........................................         15.9753         17.0863         18.3447         17.1026
520154..........................................         18.5403         19.5994         21.0486         19.7479
520156..........................................         21.3377         20.9638         20.7806         21.0121
520157..........................................         17.1974         19.6008         21.6821         19.4299
520159..........................................         18.6760         17.7649         21.8783         19.4305
520160..........................................         19.4173         20.5154         21.5266         20.5092
520161..........................................         19.4905         20.1102         21.4038         20.3456
520170..........................................         21.5233         21.9857         23.0867         22.2181
520171..........................................         17.4560         18.0785         18.1844         17.8993
520173..........................................         21.3016         20.9209         23.2955         21.8315
520177..........................................         22.7221         24.0139         25.1080         23.8746
520178..........................................         18.6936         20.9010         23.1509         20.7167
520188..........................................         13.9135               *               *         13.9135
520189..........................................               *               *         21.6813         21.6813
530002..........................................         19.3273         21.0560         23.0582         21.0877
530003..........................................         16.2139         15.9523         17.1646         16.4518
530004..........................................         15.0497         13.3788         17.4672         15.2335
530005..........................................         13.3529         15.3255         18.3704         15.7393
530006..........................................         18.5894         19.1305         20.7661         19.4956
530007..........................................         18.5161         17.7897         18.5286         18.3005
530008..........................................         18.8349         19.0113         19.0016         18.9483
530009..........................................         22.5009         21.7795         23.5839         22.6178
530010..........................................         21.6092         13.9536         12.3695         15.3501
530011..........................................         18.7354         19.4606         19.9212         19.3808
530012..........................................         18.9923         21.1854         22.5084         20.9252
530014..........................................         18.0869         18.4900         20.0422         18.9065
530015..........................................         22.4568         23.4040         24.6527         23.4897
530016..........................................         18.1562         19.3205         20.3647         19.2610
530017..........................................         16.3478         17.7736         20.9408         18.2556
530018..........................................         18.3783         19.5986         20.1226         19.3605
530019..........................................         18.5430         20.1097         18.1492         18.8643
530022..........................................         18.5002         19.6136         19.7902         19.3159
530023..........................................         20.1948         20.0677         21.6352         20.6416
530025..........................................         21.2598         22.0300         22.4816         21.9309
530026..........................................         17.0118         19.8969         20.9919         19.1178
530027..........................................         18.1664         25.5067               *         20.8124
530029..........................................         16.5092         19.3361         20.3046         18.6145
530031..........................................         18.3322         20.1734         23.2766         20.4477
530032..........................................         21.0361         20.0132         20.9856        20.6817
----------------------------------------------------------------------------------------------------------------
* Denotes wage data not available for the provider for that year.
** Based on the sum of the salaries and hours computed for Federal FYs 2001, 2002, and 2003.

      
  

  

  Federal Register / Vol. 67, No. 90 / Thursday, May 9, 2002 / Proposed 
Rules  

[[Page 31599]]


      

   Table 3A.--FY 2003 and 3-Year* Average Hourly Wage for Urban Areas
  [*Based on the sum of the salaries and hours computed for Federal FYs
                          2001, 2002, and 2002]
------------------------------------------------------------------------
                                                     FY 2003     3-Year
                                                     average    average
                    Urban area                        hourly     hourly
                                                       wage       wage
------------------------------------------------------------------------
Abilene, TX.......................................    21.3116    18.2370
Aguadilla, PR.....................................    10.6548    10.3692
Akron, OH.........................................    22.2695    21.8175
Albany, GA........................................    24.9139    23.4370
Albany-Schenectady-Troy, NY.......................    19.4516    19.0017
Albuquerque, NM...................................    21.3374    20.9862
Alexandria, LA....................................    18.1736    17.9283
Allentown-Bethlehem-Easton, PA....................    22.6105    22.2137
Altoona, PA.......................................    21.3848    20.7048
Amarillo, TX......................................    20.8120    19.7427
Anchorage, AK.....................................    28.6899    28.2057
Ann Arbor, MI.....................................    25.7925    25.0051
Anniston, AL......................................    18.6862    18.3987
Appleton-Oshkosh-Neenah, WI.......................    20.8773    20.4112
Arecibo, PR.......................................    10.0744    10.0865
Asheville, NC.....................................    22.2638    21.2069
Athens, GA........................................    23.7041    22.3198
Atlanta, GA.......................................    23.2034    22.5565
Atlantic-Cape May, NJ.............................    25.4286    24.9782
Auburn-Opelika, AL................................    19.1001    18.3671
Augusta-Aiken, GA-SC..............................    23.8329    21.9394
Austin-San Marcos, TX.............................    21.9115    21.4039
Bakersfield, CA...................................    23.4741    21.9163
Baltimore, MD.....................................    22.4354    21.6104
Bangor, ME........................................    22.5137    21.5643
Barnstable-Yarmouth, MA...........................    30.1848    30.2355

[[Page 31600]]

 
Baton Rouge, LA...................................    19.2871    18.9071
Beaumont-Port Arthur, TX..........................    19.2896    19.0451
Bellingham, WA....................................    28.5297    26.6182
Benton Harbor, MI.................................    20.6766    19.7627
Bergen-Passaic, NJ................................    27.8231    26.5455
Billings, MT......................................    20.9586    20.9004
Biloxi-Gulfport-Pascagoula, MS....................    20.3045    19.0487
Binghamton, NY....................................    19.3760    19.0441
Birmingham, AL....................................    21.3884    19.7545
Bismarck, ND......................................    18.0466    17.5136
Bloomington,IN....................................    20.6895    19.8190
Bloomington-Normal, IL............................    21.1609    20.3703
Boise City, ID....................................    21.6225    20.5010
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH..    25.9941    25.2200
Boulder-Longmont, CO..............................    22.2777    21.7937
Brazoria, TX......................................    19.8139    19.0124
Bremerton, WA.....................................    25.4225    24.4379
Brownsville-Harlingen-San Benito, TX..............    20.6770    19.9443
Bryan-College Station, TX.........................    19.3399    19.2454
Buffalo-Niagara Falls, NY.........................    21.7624    21.2368
Burlington, VT....................................    23.3989    22.9310
Caguas, PR........................................    10.1529    10.1915
Canton-Massillon, OH..............................    20.7556    19.7901
Casper, WY........................................    22.5084    20.9252
Cedar Rapids, IA..................................    21.0377    19.8268
Champaign-Urbana, IL..............................    22.9565    20.9245
Charleston-North Charleston, SC...................    18.6257    19.5755
Charleston, WV....................................    20.1558    20.3125
Charlotte-Gastonia-Rock Hill, NC-SC...............    22.6242    21.3014
Charlottesville, VA...............................    24.3357    23.7751
Chattanooga, TN-GA................................    20.8534    21.0504
Cheyenne, WY......................................    20.0422    18.9065
Chicago, IL.......................................    25.4960    24.8000
Chico-Paradise, CA................................    22.6186    22.0636
Cincinnati, OH-KY-IN..............................    21.4375    21.0209
Clarksville-Hopkinsville, TN-KY...................    19.2844    18.5774
Cleveland-Lorain-Elyria, OH.......................    21.3730    21.1174
Colorado Springs, CO..............................    22.9223    21.9346
Columbia, MO......................................    20.0916    19.6531
Columbia, SC......................................    20.6722    20.8728
Columbus, GA-AL...................................    19.4319    18.9760
Columbus, OH......................................    22.3157    21.5032
Corpus Christi, TX................................    18.7495    18.7846
Corvallis, OR.....................................    26.6038    25.7705
Cumberland, MD-WV.................................    18.2292    18.3160
Dallas, TX........................................    22.6072    22.1220
Danville, VA......................................    20.2001    19.3654
Davenport-Moline-Rock Island, IA-IL...............    20.4000    19.6921
Dayton-Springfield, OH............................    21.5652    20.8876
Daytona Beach, FL.................................    21.0017    20.3557
Decatur, AL.......................................    20.8473    19.7262
Decatur, IL.......................................    18.5380    18.0259
Denver, CO........................................    23.9179    23.0032
Des Moines, IA....................................    20.3902    19.9395
Detroit, MI.......................................    24.1574    23.4668
Dothan, AL........................................    18.3729    17.7890
Dover, DE.........................................    21.7344    22.1849
Dubuque, IA.......................................    20.2381    19.4209
Duluth-Superior, MN-WI............................    24.0567    22.9550
Dutchess County, NY...............................    24.8186    23.5537
Eau Claire, WI....................................    20.7890    19.9433
El Paso, TX.......................................    21.0095    20.6428
Elkhart-Goshen, IN................................    22.6528    21.3565
Elmira, NY........................................    19.7114    19.0237
Enid, OK..........................................    19.2869    18.8881
Erie, PA..........................................    20.7316    19.9094
Eugene-Springfield, OR............................    25.4725    24.9448
Evansville, Henderson, IN-KY......................    18.9808    18.5894
Fargo-Moorhead, ND-MN.............................    22.4962    20.6192
Fayetteville, NC..................................    20.6496    19.8938
Fayetteville-Springdale-Rogers, AR................    18.8149    18.2982
Flagstaff, AZ-UT..................................    24.8141    23.9367
Flint, MI.........................................    25.8296    24.8385
Florence, AL......................................    18.2288    17.4228
Florence, SC......................................    20.3953    19.6524
Fort Collins-Loveland, CO.........................    22.8171    22.8018
Fort Lauderdale, FL...............................    23.8406    22.9502
Fort Myers-Cape Coral, FL.........................    21.7431    20.9253
Fort Pierce-Port St. Lucie, FL....................    22.5387    22.0206
Fort Smith, AR-OK.................................    17.9611    17.8193
Fort Walton Beach, FL.............................    22.1915    21.0734
Fort Wayne, IN....................................    21.8421    20.4123
Fort Worth-Arlington, TX..........................    22.1218    21.2887
Fresno, CA........................................    23.7765    22.6843
Gadsden, AL.......................................    19.7302    19.2011
Gainesville, FL...................................    22.3748    21.8054
Galveston-Texas City, TX..........................    22.0810    22.2390
Gary, IN..........................................    22.2500    21.3750
Glens Falls, NY...................................    19.1071    18.6348
Goldsboro, NC.....................................    20.6547    19.5049
Grand Forks, ND-MN................................    20.6675    19.9946
Grand Junction, CO................................    22.1097    21.1165
Grand Rapids-Muskegon-Holland, MI.................    22.1795    22.3013
Great Falls, MT...................................    20.7913    20.0975
Greeley, CO.......................................    20.6781    21.0801
Green Bay, WI.....................................    22.0738    20.9151
Greensboro-Winston-Salem-High Point, NC...........    21.3171    20.8100
Greenville, NC....................................    21.1020    20.7582
Greenville-Spartanburg-Anderson, SC...............    21.1013    20.4227
Hagerstown, MD....................................    21.5280    20.1745
Hamilton-Middletown, OH...........................    21.8081    20.7774
Harrisburg-Lebanon-Carlisle, PA...................    21.4204    21.2190
Hartford, CT......................................    26.5589    25.6600
Hattiesburg, MS...................................    17.6308    16.8808
Hickory-Morganton-Lenoir, NC......................    20.5993    20.3564
Honolulu, HI......................................    25.5733    25.7139
Houma, LA.........................................    19.4770    18.2833
Houston, TX.......................................    22.4099    21.6980
Huntington-Ashland, WV-KY-OH......................    22.4054    21.7937
Huntsville, AL....................................    20.4686    19.9112
Indianapolis, IN..................................    22.6001    21.8532
Iowa City, IA.....................................    23.0524    21.9952
Jackson, MI.......................................    22.0543    20.8972
Jackson, MS.......................................    20.0348    19.3281
Jackson, TN.......................................    21.5461    20.3227
Jacksonville, FL..................................    21.4789    20.7080
Jacksonville, NC..................................    19.1386    17.6977
Jamestown, NY.....................................    18.5184    17.7951
Janesville-Beloit, WI.............................    22.2956    21.6016
Jersey City, NJ...................................    25.7550    25.2422
Johnson City-Kingsport-Bristol, TN-VA.............    19.1020    18.7739
Johnstown, PA.....................................    19.3481    19.3567
Jonesboro, AR.....................................    18.0006    17.9165
Joplin, MO........................................    20.0064    19.0676
Kalamazoo-Battlecreek, MI.........................    24.5797    23.6868
Kankakee, IL......................................    22.0535    21.8916
Kansas City, KS-MO................................    22.5556    21.5044
Kenosha, WI.......................................    22.3994    21.6107
Killeen-Temple, TX................................    19.4230    20.6248
Knoxville, TN.....................................    20.9030    19.6266
Kokomo, IN........................................    20.5813    20.5547
La Crosse, WI-MN..................................    20.9920    20.5609
Lafayette, LA.....................................    19.6610    19.0691
Lafayette, IN.....................................    21.8803    20.4752
Lake Charles, LA..................................    18.4643    17.2545
Lakeland-Winter Haven, FL.........................    21.0679    20.4786
Lancaster, PA.....................................    21.0878    20.6617
Lansing-East Lansing, MI..........................    22.5979    21.9294
Laredo, TX........................................    19.5558    18.3090
Las Cruces, NM....................................    20.4375    19.5136
Las Vegas, NV-AZ..................................    25.3348    24.6305
\1\ Lawrence, KS..................................  .........    17.8290
Lawton, OK........................................    18.9728    19.3040
Lewiston-Auburn, ME...............................    21.2671    20.5697
Lexington, KY.....................................    19.8413    19.5837
Lima, OH..........................................    21.8791    21.1154
Lincoln, NE.......................................    20.5292    21.3398

[[Page 31601]]

 
Little Rock-North Little Rock, AR.................    20.7992    19.9953
Longview-Marshall, TX.............................    19.7471    19.4279
Los Angeles-Long Beach, CA........................    27.6569    26.7968
Louisville, KY-IN.................................    21.8834    21.1577
Lubbock, TX.......................................    17.7930    18.8697
Lynchburg, VA.....................................    21.4112    20.3454
Macon, GA.........................................    21.2905    20.2752
Madison, WI.......................................    23.4267    22.9567
Mansfield, OH.....................................    20.6712    19.6802
Mayaguez, PR......................................    11.3157    10.6879
McAllen-Edinburg-Mission, TX......................    19.3599    18.9086
Medford-Ashland, OR...............................    24.3865    23.3354
Melbourne-Titusville-Palm Bay, FL.................    24.7923    22.7180
Memphis, TN-AR-MS.................................    20.3251    19.7569
Merced, CA........................................    22.8511    21.9541
Miami, FL.........................................    22.6833    22.2549
Middlesex-Somerset-Hunterdon, NJ..................    26.3374    25.3182
Milwaukee-Waukesha, WI............................    22.7676    22.0856
Minneapolis-St. Paul, MN-WI.......................    25.2239    24.5477
Missoula, MT......................................    21.2713    20.8023
Mobile, AL........................................    18.8082    18.2018
Modesto, CA.......................................    24.3874    23.6713
Monmouth-Ocean, NJ................................    25.9158    24.8978
Monroe, LA........................................    18.8342    18.4736
Montgomery, AL....................................    17.8451    16.9642
Muncie, IN........................................    21.0399    22.2998
Myrtle Beach, SC..................................    21.0194    19.6847
Naples, FL........................................    22.5429    21.7594
Nashville, TN.....................................    21.7439    21.3869
Nassau-Suffolk, NY................................    30.9070    30.5534
New Haven-Bridgeport-Stamford-Waterbury-Danbury,      28.6474    27.5560
 CT...............................................
New London-Norwich, CT............................    27.2742    26.4332
New Orleans, LA...................................    20.8098    20.4020
New York, NY......................................    32.3513    32.1379
Newark, NJ........................................    26.4531    26.0261
Newburgh, NY-PA...................................    26.2921    24.9278
Norfolk-Virginia Beach-Newport News, VA-NC........    19.6667    19.0225
Oakland, CA.......................................    35.0027    33.9458
Ocala, FL.........................................    21.9054    21.0412
Odessa-Midland, TX................................    21.2320    21.2696
Oklahoma City, OK.................................    20.6894    19.7355
Olympia, WA.......................................    25.4588    24.6677
Omaha, NE-IA......................................    23.1988    21.8834
Orange County, CA.................................    26.6831    25.4624
Orlando, FL.......................................    21.9294    21.4758
Owensboro, KY.....................................    19.0457    18.4790
Panama City, FL...................................    20.5244    20.1345
Parkersburg-Marietta, WV-OH.......................    18.8778    18.3560
Pensacola, FL.....................................    19.9673    18.7468
Peoria-Pekin, IL..................................    20.3592    19.5705
Philadelphia, PA-NJ...............................    24.5469    24.2416
Phoenix-Mesa, AZ..................................    21.9868    21.5339
Pine Bluff, AR....................................    18.0874    17.5370
Pittsburgh, PA....................................    21.6212    21.3813
Pittsfield, MA....................................    23.4852    22.9215
Pocatello, ID.....................................    19.6333    20.1279
Ponce, PR.........................................    12.0062    11.5028
Portland, ME......................................    22.8379    21.6951
Portland-Vancouver, OR-WA.........................    24.7759    24.4428
Providence-Warwick, RI............................    24.2778    24.0071
Provo-Orem, UT....................................    23.4308    22.3948
Pueblo, CO........................................    20.3670    19.5929
Punta Gorda, FL...................................    17.3909    18.1956
Racine, WI........................................    21.6444    20.8817
Raleigh-Durham-Chapel Hill, NC....................    23.1852    22.0116
Rapid City, SD....................................    20.5485    19.8947
Reading, PA.......................................    21.4029    20.8900
Redding, CA.......................................    25.8663    25.3801
Reno, NV..........................................    24.5213    23.5887
Richland-Kennewick-Pasco, WA......................    26.6936    25.3323
Richmond-Petersburg, VA...........................    22.3862    21.6142
Riverside-San Bernardino, CA......................    25.8718    24.9920
Roanoke, VA.......................................    20.0117    19.2433
Rochester, MN.....................................    28.1983    26.1811
Rochester, NY.....................................    21.0003    20.5991
Rockford, IL......................................    21.7440    20.5098
Rocky Mount, NC...................................    21.4359    20.3593
Sacramento, CA....................................    26.7257    26.3878
Saginaw-Bay City-Midland, MI......................    22.3260    21.5138
St. Cloud, MN.....................................    22.4364    22.0902
\1\ St. Joseph, MO................................  .........    19.7467
St. Louis, MO-IL..................................    20.4806    20.0376
Salem, OR.........................................    24.0818    22.8500
Salinas, CA.......................................    33.9674    32.7871
Salt Lake City-Ogden, UT..........................    23.0757    22.1425
San Angelo, TX....................................    18.2955    18.0306
San Antonio, TX...................................    19.8888    19.2241
San Diego, CA.....................................    25.8535    25.5476
San Francisco, CA.................................    32.8557    31.7475
San Jose, CA......................................    32.5657    31.2857
San Juan-Bayamon, PR..............................    10.8224    10.5408
San Luis Obispo-Atascadero-Paso Robles, CA........    26.1821    24.6268
Santa Barbara-Santa Maria-Lompoc, CA..............    24.3466    23.8325
Santa Cruz-Watsonville, CA........................    31.3417    31.0243
Santa Fe, NM......................................    24.8842    23.5075
Santa Rosa, CA....................................    30.3046    28.9555
Sarasota-Bradenton, FL............................    21.4760    21.7771
Savannah, GA......................................    22.9060    22.0969
Scranton-Wilkes Barre-Hazleton, PA................    19.5725    19.0594
Seattle-Bellevue-Everett, WA......................    26.6067    25.2916
Sharon, PA........................................    18.2710    17.7451
Sheboygan, WI.....................................    20.1510    19.0711
Sherman-Denison, TX...............................    21.4636    20.3959
Shreveport-Bossier City, LA.......................    20.2644    19.8410
Sioux City, IA-NE.................................    21.0135    19.6404
Sioux Falls, SD...................................    20.9214    20.1349
South Bend, IN....................................    22.7694    22.2819
Spokane, WA.......................................    25.2044    23.9682
Springfield, IL...................................    19.9008    19.3840
Springfield, MO...................................    19.5680    19.0448
Springfield, MA...................................    25.4001    24.2504
State College, PA.................................    20.7690    20.2726
Steubenville-Weirton, OH-WV.......................    20.4503    19.4333
Stockton-Lodi, CA.................................    24.0178    23.7561
Sumter, SC........................................    18.8535    18.0764
Syracuse, NY......................................    21.8886    21.3766
Tacoma, WA........................................    25.4131    25.5054
Tallahassee, FL...................................    19.6007    19.0869
Tampa-St. Petersburg-Clearwater, FL...............    20.9878    20.1427
Terre Haute, IN...................................    19.9743    19.0303
Texarkana, AR-Texarkana, TX.......................    18.7416    18.5107
Toledo, OH........................................    22.6790    21.9714
Topeka, KS........................................    20.5859    20.0981
Trenton, NJ.......................................    24.6268    23.3224
Tucson, AZ........................................    20.6783    19.9418
Tulsa, OK.........................................    19.3121    19.1851
Tuscaloosa, AL....................................    18.9045    18.2544
Tyler, TX.........................................    22.1901    21.3538
Utica-Rome, NY....................................    19.6508    18.9705
Vallejo-Fairfield-Napa, CA........................    30.9785    29.7068
Ventura, CA.......................................    25.7748    24.7503
Victoria, TX......................................    20.2675    18.8655
Vineland-Millville-Bridgeton, NJ..................    23.6746    23.2888
Visalia-Tulare-Porterville, CA....................    21.6029    21.2747
Waco, TX..........................................    20.2402    18.4397
Washington, DC-MD-VA-WV...........................    24.9537    24.2243
Waterloo-Cedar Falls, IA..........................    18.7281    18.3305
Wausau, WI........................................    22.7239    21.6241
West Palm Beach-Boca Raton, FL....................    22.8320    21.9092
Wheeling, OH-WV...................................    17.8084    17.4900
Wichita, KS.......................................    22.0087    21.3928
Wichita Falls, TX.................................    18.4488    17.5804
Williamsport, PA..................................    19.8310    18.8540
Wilmington-Newark, DE-MD..........................    25.9552    24.8359
Wilmington, NC....................................    21.7789    21.1031
Yakima, WA........................................    24.5502    23.1867
Yolo, CA..........................................    21.9147    21.8929

[[Page 31602]]

 
York, PA..........................................    21.0167    20.7492
Youngstown-Warren, OH.............................    21.8109    21.2943
Yuba City, CA.....................................    23.7087    23.3825
Yuma, AZ..........................................    19.9517   20.2223
------------------------------------------------------------------------
\1\ The MSA is empty for FY 2003. 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 2003 and 3-Year* Average Hourly Wage for Rural Areas
  [*Based on the sum of the salaries and hours computed for Federal FYs
                          2001, 2002, and 2003]
------------------------------------------------------------------------
                                                     FY 2003     3-Year
                                                     average    average
                   Nonurban area                      hourly     hourly
                                                       wage       wage
------------------------------------------------------------------------
Alabama...........................................    17.9036    16.8484
Alaska............................................    28.3370    27.2338
Arizona...........................................    19.5067    19.0116
Arkansas..........................................    17.6380    16.8439
California........................................    22.8280    21.9650
Colorado..........................................    20.9354    20.0304
Connecticut.......................................    28.7896    27.0512
Delaware..........................................    20.9850    20.7345
Florida...........................................    20.4812    19.8506
Georgia...........................................    18.9804    18.5484
Hawaii............................................    23.7802    24.2085
Idaho.............................................    20.2336    19.5324
Illinois..........................................    19.0881    18.2692
Indiana...........................................    20.2273    19.4705
Iowa..............................................    19.3039    18.3140
Kansas............................................    18.3139    17.4523
Kentucky..........................................    18.5767    17.8667
Louisiana.........................................    17.5606    17.0801
Maine.............................................    20.1286    19.5633
Maryland..........................................    20.3626    19.6588
Massachusetts.....................................    25.8847    25.2714
Michigan..........................................    20.5663    20.0744
Minnesota.........................................    21.2683    20.2498
Mississippi.......................................    17.8117    16.9666
Missouri..........................................    18.6096    17.6847
Montana...........................................    19.7008    19.3096
Nebraska..........................................    19.0466    18.2894
Nevada............................................    21.8882    21.2045
New Hampshire.....................................    22.7236    21.9972
New Jersey \1\....................................  .........  .........
New Mexico........................................    19.8780    19.2303
New York..........................................    19.8523    19.1400
North Carolina....................................    20.0381    19.1521
North Dakota......................................    18.0060    17.4398
Ohio..............................................    19.9481    19.3896
Oklahoma..........................................    17.6227    16.9222
Oregon............................................    23.9321    22.8031
Pennsylvania......................................    19.6030    19.1490
Puerto Rico.......................................    10.1187    10.0248
Rhode Island \1\..................................  .........  .........
South Carolina....................................    19.7928    19.0083
South Dakota......................................    18.1545    17.3648
Tennessee.........................................    18.1050    17.6144
Texas.............................................    17.8263    17.1186
Utah..............................................    21.6749    20.5059
Vermont...........................................    21.6208    20.9793
Virginia..........................................    19.5315    18.5749
Washington........................................    23.6253    23.0484
West Virginia.....................................    18.5169    18.1434
Wisconsin.........................................    21.2222    20.2660
Wyoming...........................................    20.4416   19.7159
------------------------------------------------------------------------
\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...................................    0.9268    0.9493
  Taylor, TX
0060  Aguadilla, PR.................................    0.4634    0.5905
  Aguada, PR
  Aguadilla, PR
  Moca, PR
0080  Akron, OH.....................................    0.9685    0.9783
  Portage, OH
  Summit, OH
0120  Albany, GA....................................    1.0835    1.0565
  Dougherty, GA
  Lee, GA
0160  \2\ Albany-Schenectady-Troy, NY...............    0.8633    0.9042
  Albany, NY
  Montgomery, NY
  Rensselaer, NY
  Saratoga, NY
  Schenectady, NY
  Schoharie, NY
0200  Albuquerque, NM...............................    0.9372    0.9566
  Bernalillo, NM
  Sandoval, NM
  Valencia, NM
0220  Alexandria, LA................................    0.7929    0.8531
  Rapides, LA
0240  Allentown-Bethlehem-Easton, PA................    0.9833    0.9885
  Carbon, PA
  Lehigh, PA
  Northampton, PA
0280  Altoona, PA...................................    0.9300    0.9515
  Blair, PA
0320  Amarillo, TX -Potter, TX......................    0.9051    0.9340
  Randall, TX
0380  Anchorage, AK.................................    1.2610    1.1721
  Anchorage, AK
0440  Ann Arbor, MI.................................    1.1217    1.0818
  Lenawee, MI
  Livingston, MI
  Washtenaw, MI
0450  Anniston, AL..................................    0.8126    0.8675
  Calhoun, AL
0460  \2\ Appleton-Oshkosh-Neenah, WI...............    0.9229    0.9465
  Calumet, WI
  Outagamie, WI
  Winnebago, WI
0470  \2\ Arecibo, PR...............................    0.4400    0.5699
  Arecibo, PR
  Camuy, PR
  Hatillo, PR
0480  Asheville, NC.................................    0.9682    0.9781
  Buncombe, NC
  Madison, NC
0500  Athens, GA....................................    1.0308    1.0210
  Clarke, GA
  Madison, GA
  Oconee, GA
0520  \1\ Atlanta, GA...............................    1.0091    1.0062
  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.........................    1.1058    1.0713
  Atlantic, NJ
  Cape May, NJ
0580  Auburn-Opelika, AL............................    0.8306    0.8806
  Lee, AL
0600  Augusta-Aiken, GA-SC..........................    1.0364    1.0248
  Columbia, GA
  McDuffie, GA
  Richmond, GA
  Aiken, SC
  Edgefield, SC
0640  \1\ Austin-San Marcos, TX.....................    0.9529    0.9675
  Bastrop, TX
  Caldwell, TX
  Hays, TX
  Travis, TX
  Williamson, TX
0680  Bakersfield, CA...............................    1.0186    1.0127
  Kern, CA
0720  \1\ Baltimore, MD.............................    0.9757    0.9833
  Anne Arundel, MD
  Baltimore, MD

[[Page 31603]]

 
  Baltimore City, MD
  Carroll, MD
  Harford, MD
  Howard, MD
  Queen Anne's, MD
0733  Bangor, ME....................................    0.9791    0.9856
  Penobscot, ME
0743  Barnstable-Yarmouth, MA.......................    1.3127    1.2048
  Barnstable, MA
0760  Baton Rouge, LA...............................    0.8388    0.8866
  Ascension, LA
  East Baton Rouge, LA
  Livingston, LA
  West Baton Rouge, LA
0840  Beaumont-Port Arthur, TX......................    0.8389    0.8867
  Hardin, TX
  Jefferson, TX
  Orange, TX
0860  Bellingham, WA................................    1.2407    1.1592
  Whatcom, WA
0870  Benton Harbor, MI.............................    0.9072    0.9355
  Berrien, MI
0875  \1\ Bergen-Passaic, NJ........................    1.2100    1.1394
  Bergen, NJ
  Passaic, NJ
0880  Billings, MT..................................    0.9114    0.9384
  Yellowstone, MT
0920  Biloxi-Gulfport-Pascagoula, MS................    0.8830    0.9183
  Hancock, MS
  Harrison, MS
  Jackson, MS
0960  \2\ Binghamton, NY............................    0.8633    0.9042
  Broome, NY
  Tioga, NY
1000  Birmingham, AL................................    0.9301    0.9516
  Blount, AL
  Jefferson, AL
  St. Clair, AL
  Shelby, AL
1010  Bismarck, ND..................................    0.7881    0.8495
  Burleigh, ND
  Morton, ND
1020  Bloomington, IN...............................    0.8997    0.9302
  Monroe, IN
1040  Bloomington-Normal, IL........................    0.9202    0.9446
  McLean, IL
1080  Boise City, ID................................    0.9403    0.9587
  Ada, ID
  Canyon, ID
1123  \1\ Boston-Worcester-Lawrence-Lowell-Brockton,    1.1304    1.0876
 MA-NH..............................................
  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..........................    0.9688    0.9785
  Boulder, CO
1145  Brazoria, TX..................................    0.8617    0.9031
  Brazoria, TX
1150  Bremerton, WA.................................    1.1056    1.0712
  Kitsap, WA
1240  Brownsville-Harlingen-San Benito, TX..........    0.8992    0.9298
  Cameron, TX
1260  Bryan-College Station, TX.....................    0.8410    0.8882
  Brazos, TX
1280  \1\ Buffalo-Niagara Falls, NY.................    0.9464    0.9630
  Erie, NY
  Niagara, NY
1303  Burlington, VT................................    1.0176    1.0120
  Chittenden, VT
  Franklin, VT
  Grand Isle, VT
1310  Caguas, PR....................................    0.4453    0.5746
  Caguas, PR
  Cayey, PR
  Cidra, PR
  Gurabo, PR
  San Lorenzo, PR
1320  Canton-Massillon, OH..........................    0.9026    0.9322
  Carroll, OH
  Stark, OH
1350  Casper, WY....................................    0.9788    0.9854
  Natrona, WY
1360  Cedar Rapids, IA..............................    0.9149    0.9409
  Linn, IA
1400  Champaign-Urbana, IL..........................    0.9983    0.9988
  Champaign, IL
1440  \2\ Charleston-North Charleston, SC...........    0.8607    0.9024
  Berkeley, SC
  Charleston, SC
  Dorchester, SC
1480  Charleston, WV................................    0.8765    0.9137
  Kanawha, WV
  Putnam, WV
1520  \1\ Charlotte-Gastonia-Rock Hill, NC-SC.......    0.9839    0.9889
  Cabarrus, NC
  Gaston, NC
  Lincoln, NC
  Mecklenburg, NC
  Rowan, NC
  Stanly, NC
  Union, NC
  York, SC
1540  Charlottesville, VA...........................    1.0583    1.0396
  Albemarle, VA
  Charlottesville City, VA
  Fluvanna, VA
  Greene, VA
1560  Chattanooga, TN-GA............................    0.9069    0.9353
  Catoosa, GA
  Dade, GA
  Walker, GA
  Hamilton, TN
  Marion, TN
1580  \2\ Cheyenne, WY..............................    0.8890    0.9226
  Laramie, WY
1600  \1\ Chicago, IL...............................    1.1088    1.0733
  Cook, IL
  DeKalb, IL
  DuPage, IL
  Grundy, IL
  Kane, IL
  Kendall, IL
  Lake, IL
  McHenry, IL
  Will, IL
1620  \2\ Chico-Paradise, CA........................    0.9934    0.9955
  Butte, CA
1640  \1\ Cincinnati, OH-KY-IN......................    0.9354    0.9553
  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...............    0.8386    0.8864
  Christian, KY
  Montgomery, TN
1680  \1\ Cleveland-Lorain-Elyria, OH...............    0.9295    0.9512
  Ashtabula, OH
  Cuyahoga, OH
  Geauga, OH
  Lake, OH
  Lorain, OH
  Medina, OH
1720  Colorado Springs, CO..........................    0.9968    0.9978
  El Paso, CO
1740  Columbia, MO..................................    0.8737    0.9117
  Boone, MO
1760  Columbia, SC..................................    0.8990    0.9297
  Lexington, SC
  Richland, SC
1800  Columbus, GA-AL...............................    0.8450    0.8911
  Russell, AL
  Chattahoochee, GA
  Harris, GA
  Muscogee, GA
1840  \1\ Columbus, OH..............................    0.9705    0.9797
  Delaware, OH
  Fairfield, OH

[[Page 31604]]

 
  Franklin, OH
  Licking, OH
  Madison, OH
  Pickaway, OH
1880  Corpus Christi, TX............................    0.8154    0.8696
  Nueces, TX
  San Patricio, TX
1890  Corvallis, OR.................................    1.1569    1.1050
  Benton, OR
1900  \2\ Cumberland, MD-WV (MD Hospitals)..........    0.8855    0.9201
  Allegany, MD
  Mineral, WV
1900  \2\ Cumberland, MD-WV (WV Hospitals)..........    0.8053    0.8622
  Allegany, MD
  Mineral, WV
1920  \1\ Dallas, TX................................    0.9831    0.9884
  Collin, TX
  Dallas, TX
  Denton, TX
  Ellis, TX
  Henderson, TX
  Hunt, TX
  Kaufman, TX
  Rockwall, TX
1950  Danville, VA..................................    0.8785    0.9151
  Danville City, VA
  Pittsylvania, VA
1960  Davenport-Moline-Rock Island, IA-IL...........    0.8872    0.9213
  Scott, IA
  Henry, IL
  Rock Island, IL
2000  Dayton-Springfield, OH........................    0.9378    0.9570
  Clark, OH
  Greene, OH
  Miami, OH
  Montgomery, OH
2020  Daytona Beach, FL.............................    0.9133    0.9398
  Flagler, FL
  Volusia, FL
2030  Decatur, AL...................................    0.9066    0.9351
  Lawrence, AL
  Morgan, AL
2040  \2\ Decatur, IL...............................    0.8301    0.8803
  Macon, IL
2080  \1\ Denver, CO................................    1.0401    1.0273
  Adams, CO
  Arapahoe, CO
  Denver, CO
  Douglas, CO
  Jefferson, CO
2120  Des Moines, IA................................    0.8908    0.9239
  Dallas, IA
  Polk, IA
  Warren, IA
2160  \1\ Detroit, MI...............................    1.0506    1.0344
  Lapeer, MI
  Macomb, MI
  Monroe, MI
  Oakland, MI
  St. Clair, MI
  Wayne, MI
2180  Dothan, AL....................................    0.8028    0.8603
  Dale, AL
  Houston, AL
2190  Dover, DE.....................................    0.9452    0.9621
  Kent, DE
2200  Dubuque, IA...................................    0.8801    0.9163
  Dubuque, IA
2240  Duluth-Superior, MN-WI........................    1.0462    1.0314
  St. Louis, MN
  Douglas, WI
2281  Dutchess County, NY...........................    1.0793    1.0536
  Dutchess, NY
2290  \2\ Eau Claire, WI............................    0.9229    0.9465
  Chippewa, WI
  Eau Claire, WI
2320  El Paso, TX...................................    0.9137    0.9401
  El Paso, TX
2330  Elkhart-Goshen, IN............................    0.9851    0.9898
  Elkhart, IN
2335  \2\ Elmira, NY................................    0.8633    0.9042
  Chemung, NY
2340  Enid, OK......................................    0.8387    0.8865
  Garfield, OK
2360  Erie, PA......................................    0.9016    0.9315
  Erie, PA
2400  Eugene-Springfield, OR........................    1.1077    1.0726
  Lane, OR
2440  \2\ Evansville-Henderson, IN-KY (IN Hospitals)    0.8796    0.9159
  Posey, IN
  Vanderburgh, IN
  Warrick, IN
  Henderson, KY
2440  Evansville-Henderson, IN-KY (KY Hospitals)....    0.8254    0.8769
  Posey, IN
  Vanderburgh, IN
  Warrick, IN
  Henderson, KY
2520  Fargo-Moorhead, ND-MN.........................    0.9783    0.9851
  Clay, MN
  Cass, ND
2560  Fayetteville, NC..............................    0.9055    0.9343
  Cumberland, NC
2580  Fayetteville-Springdale-Rogers, AR............    0.8182    0.8716
  Benton, AR
  Washington, AR
2620  Flagstaff, AZ-UT..............................    1.0791    1.0535
  Coconino, AZ
  Kane, UT
2640  Flint, MI.....................................    1.1233    1.0829
  Genesee, MI
2650  Florence, AL..................................    0.7960    0.8554
  Colbert, AL
  Lauderdale, AL
2655  Florence, SC..................................    0.8869    0.9211
  Florence, SC
2670  Fort Collins-Loveland, CO.....................    0.9923    0.9947
  Larimer, CO
2680  \1\ Ft. Lauderdale, FL........................    1.0792    1.0536
  Broward, FL
2700  Fort Myers-Cape Coral, FL.....................    0.9456    0.9624
  Lee, FL
2710  Fort Pierce-Port St. Lucie, FL................    0.9959    0.9972
  Martin, FL
  St. Lucie, FL
2720  Fort Smith, AR-OK.............................    0.7811    0.8444
  Crawford, AR
  Sebastian, AR
  Sequoyah, OK
2750  Fort Walton Beach, FL.........................    0.9651    0.9760
  Okaloosa, FL
2760  Fort Wayne, IN................................    0.9499    0.9654
  Adams, IN
  Allen, IN
  De Kalb, IN
  Huntington, IN
  Wells, IN
  Whitley, IN
2800  \1\ Forth Worth-Arlington, TX.................    0.9620    0.9738
  Hood, TX
  Johnson, TX
  Parker, TX
  Tarrant, TX
2840  Fresno, CA....................................    1.0340    1.0232
  Fresno, CA
  Madera, CA
2880  Gadsden, AL...................................    0.8684    0.9079
  Etowah, AL
2900  Gainesville, FL...............................    0.9730    0.9814
  Alachua, FL
2920  Galveston-Texas City, TX......................    0.9603    0.9726
  Galveston, TX
2960  Gary, IN......................................    0.9676    0.9777
  Lake, IN
  Porter, IN
2975  \2\ Glens Falls, NY...........................    0.8633    0.9042
  Warren, NY
  Washington, NY
2980  Goldsboro, NC.................................    0.8982    0.9291
  Wayne, NC
2985  Grand Forks, ND-MN............................    0.9338    0.9542
  Polk, MN
  Grand Forks, ND
2995  Grand Junction, CO............................    0.9824    0.9879
  Mesa, CO
3000  \1\ Grand Rapids-Muskegon-Holland, MI.........    0.9664    0.9769
  Allegan, MI
  Kent, MI
  Muskegon, MI
  Ottawa, MI

[[Page 31605]]

 
3040  Great Falls, MT...............................    0.9057    0.9344
  Cascade, MT
3060  Greeley, CO...................................    0.9219    0.9458
  Weld, CO
3080  Green Bay, WI.................................    0.9599    0.9724
  Brown, WI
3120  \1\ Greensboro-Winston-Salem-High Point, NC...    0.9270    0.9494
  Alamance, NC
  Davidson, NC
  Davie, NC
  Forsyth, NC-
  Guilford, NC
  Randolph, NC
  Stokes, NC
  Yadkin, NC
3150  Greenville, NC................................    0.9257    0.9485
  Pitt, NC
3160  Greenville-Spartanburg-Anderson, SC...........    0.9177    0.9429
  Anderson, SC
  Cherokee, SC
  Greenville, SC
  Pickens, SC
  Spartanburg, SC
3180  Hagerstown, MD................................    0.9362    0.9559
  Washington, MD
3200  Hamilton-Middletown, OH.......................    0.9484    0.9644
  Butler, OH
3240  Harrisburg-Lebanon-Carlisle, PA...............    0.9315    0.9526
  Cumberland, PA
  Dauphin, PA
  Lebanon, PA
  Perry, PA
3283  \1\ \2\ Hartford, CT..........................    1.2520    1.1664
  Hartford, CT
  Litchfield, CT
  Middlesex, CT
  Tolland, CT
3285  \2\ Hattiesburg, MS...........................    0.7759    0.8405
  Forrest, MS
  Lamar, MS
3290  Hickory-Morganton-Lenoir, NC..................    0.8958    0.9274
  Alexander, NC
  Burke, NC
  Caldwell, NC
  Catawba, NC
3320  Honolulu, HI..................................    1.1121    1.0755
  Honolulu, HI
3350  Houma, LA.....................................    0.8470    0.8925
  Lafourche, LA
  Terrebonne, LA
3360  \1\ Houston, TX...............................    0.9746    0.9825
  Chambers, TX
  Fort Bend, TX
  Harris, TX
  Liberty, TX
  Montgomery, TX
  Waller, TX
3400  Huntington-Ashland, WV-KY-OH..................    0.9744    0.9824
  Boyd, KY
  Carter, KY
  Greenup, KY
  Lawrence, OH
  Cabell, WV
  Wayne, WV
3440  Huntsville, AL................................    0.8901    0.9234
  Limestone, AL
  Madison, AL
3480  \1\ Indianapolis, IN..........................    0.9828    0.9882
  Boone, IN
  Hamilton, IN
  Hancock, IN
  Hendricks, IN
  Johnson, IN
  Madison, IN
  Marion, IN
  Morgan, IN
  Shelby, IN
3500  Iowa City, IA.................................    1.0025    1.0017
  Johnson, IA
3520  Jackson, MI...................................    0.9591    0.9718
  Jackson, MI
3560  Jackson, MS...................................    0.8713    0.9100
  Hinds, MS
  Madison, MS
  Rankin, MS
3580  Jackson, TN...................................    0.9370    0.9564
  Madison, TN
  Chester, TN
3600  \1\ Jacksonville, FL..........................    0.9341    0.9544
  Clay, FL
  Duval, FL
  Nassau, FL
  St. Johns, FL
3605  \2\ Jacksonville, NC..........................    0.8714    0.9100
  Onslow, NC
3610  \2\ Jamestown, NY.............................    0.8633    0.9042
  Chautauqua, NY
3620  Janesville-Beloit, WI.........................    0.9696    0.9791
  Rock, WI
3640  Jersey City, NJ...............................    1.1200    1.0807
  Hudson, NJ
3660  Johnson City-Kingsport-Bristol, TN-VA (TN         0.8384    0.8863
 Hospitals).........................................
  Carter, TN
  Hawkins, TN
  Sullivan, TN
  Unicoi, TN
  Washington, TN
  Bristol City, VA
  Scott, VA
  Washington, VA
3660  \2\ Johnson City-Kingsport-Bristol, TN-VA (VA     0.8494    0.8942
 Hospitals).........................................
  Carter, TN
  Hawkins, TN
  Sullivan, TN
  Unicoi, TN
  Washington, TN
  Bristol City, VA
  Scott, VA
  Washington, VA
3680  \2\ Johnstown, PA.............................    0.8525    0.8965
  Cambria, PA
  Somerset, PA
3700  Jonesboro, AR.................................    0.7906    0.8514
  Craighead, AR
3710  Joplin, MO....................................    0.8700    0.9090
  Jasper, MO
  Newton, MO
3720  Kalamazoo-Battlecreek, MI.....................    1.0689    1.0467
  Calhoun, MI
  Kalamazoo, MI
  Van Buren, MI
3740  Kankakee, IL..................................    0.9591    0.9718
  Kankakee, IL
3760  \1\ Kansas City, KS-MO........................    0.9809    0.9869
  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...................................    0.9741    0.9822
  Kenosha, WI
3810  Killeen-Temple, TX............................    0.8447    0.8909
  Bell, TX
  Coryell, TX
3840  Knoxville, TN.................................    0.9090    0.9368
  Anderson, TN
  Blount, TN
  Knox, TN
  Loudon, TN
  Sevier, TN
  Union, TN
3850  Kokomo, IN....................................    0.9031    0.9326
  Howard, IN
  Tipton, IN
3870  \2\ La Crosse, WI-MN (WI Hospitals)...........    0.9229    0.9465
  Houston, MN
  La Crosse, WI
3870  \2\ La Crosse, WI-MN (MN Hospitals)...........    0.9249    0.9479
  Houston, MN
  La Crosse, WI
3880  Lafayette, LA.................................    0.8550    0.8983
  Acadia, LA
  Lafayette, LA
  St. Landry, LA
  St. Martin, LA
3920  Lafayette, IN.................................    0.9515    0.9665
  Clinton, IN
  Tippecanoe, IN
3960  Lake Charles, LA..............................    0.8030    0.8605
  Calcasieu, LA
3980  Lakeland-Winter Haven, FL.....................    0.9170    0.9424
  Polk, FL

[[Page 31606]]

 
4000  Lancaster, PA.................................    0.9171    0.9425
  Lancaster, PA
4040  Lansing-East Lansing, MI......................    0.9827    0.9881
  Clinton, MI
  Eaton, MI
  Ingham, MI
4080  Laredo, TX....................................    0.8504    0.8950
  Webb, TX
4100  Las Cruces, NM................................    0.8888    0.9224
  Dona Ana, NM
4120  \1\ Las Vegas, NV-AZ..........................    1.1018    1.0686
  Mohave, AZ
  Clark, NV
  Nye, NV
4150  Lawrence, KS..................................    0.7964    0.8556
  Douglas, KS
4200  Lawton, OK....................................    0.8251    0.8766
  Comanche, OK
4243  Lewiston-Auburn, ME...........................    0.9249    0.9479
  Androscoggin, ME
4280  Lexington, KY.................................    0.8629    0.9040
  Bourbon, KY
  Clark, KY
  Fayette, KY
  Jessamine, KY
  Madison, KY
  Scott, KY
  Woodford, KY
4320  Lima, OH......................................    0.9515    0.9665
  Allen, OH
  Auglaize, OH
4360  Lincoln, NE...................................    0.9133    0.9398
  Lancaster, NE
4400  Little Rock-North Little Rock, AR.............    0.9045    0.9336
  Faulkner, AR
  Lonoke, AR
  Pulaski, AR
  Saline, AR
4420  Longview-Marshall, TX.........................    0.8588    0.9010
  Gregg, TX
  Harrison, TX
  Upshur, TX
4480  \1\ Los Angeles-Long Beach, CA................    1.2044    1.1358
  Los Angeles, CA
4520  \1\ Louisville, KY-IN.........................    0.9517    0.9667
  Clark, IN
  Floyd, IN
  Harrison, IN
  Scott, IN
  Bullitt, KY
  Jefferson, KY
  Oldham, KY
4600  Lubbock, TX...................................    0.7809    0.8442
  Lubbock, TX
4640  Lynchburg, VA.................................    0.9311    0.9523
  Amherst, VA
  Bedford, VA
  Bedford City, VA
  Campbell, VA
  Lynchburg City, VA
4680  Macon, GA.....................................    0.9296    0.9512
  Bibb, GA
  Houston, GA
  Jones, GA
  Peach, GA
  Twiggs, GA
4720  Madison, WI...................................    1.0188    1.0128
  Dane, WI
4800  Mansfield, OH.................................    0.8989    0.9296
  Crawford, OH
  Richland, OH
4840  Mayaguez, PR..................................    0.4921    0.6153
  Anasco, PR
  Cabo Rojo, PR
  Hormigueros, PR
  Mayaguez, PR
  Sabana Grande, PR
  San German, PR
4880  McAllen-Edinburg-Mission, TX..................    0.8419    0.8888
  Hidalgo, TX
4890  Medford-Ashland, OR...........................    1.0605    1.0410
  Jackson, OR
4900  Melbourne-Titusville-Palm Bay, FL.............    1.0782    1.0529
  Brevard, Fl
4920  \1\ Memphis, TN-AR-MS.........................    0.8839    0.9190
  Crittenden, AR
  DeSoto, MS
  Fayette, TN
  Shelby, TN
  Tipton, TN
4940  Merced, CA....................................    0.9937    0.9957
  Merced, CA
5000  \1\ Miami, FL.................................    0.9878    0.9916
  Dade, FL
5015  \1\ Middlesex-Somerset-Hunterdon, NJ..........    1.1454    1.0974
  Hunterdon, NJ
  Middlesex, NJ
  Somerset, NJ
5080  \1\ Milwaukee-Waukesha, WI....................    0.9901    0.9932
  Milwaukee, WI
  Ozaukee, WI
  Washington, WI
  Waukesha, WI
5120  \1\ Minneapolis-St. Paul, MN-WI...............    1.0969    1.0654
  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..................................    0.9250    0.9480
  Missoula, MT
5160  Mobile, AL....................................    0.8181    0.8715
  Baldwin, AL
  Mobile, AL
5170  Modesto, CA...................................    1.0606    1.0411
  Stanislaus, CA
5190  \1\ Monmouth-Ocean, NJ........................    1.1290    1.0866
  Monmouth, NJ
  Ocean, NJ
5200  Monroe, LA....................................    0.8191    0.8723
  Ouachita, LA
5240  \2\ Montgomery, AL............................    0.7853    0.8475
  Autauga, AL
  Elmore, AL
  Montgomery, AL
5280  Muncie, IN....................................    0.9150    0.9410
  Delaware, IN
5330  Myrtle Beach, SC..............................    0.9141    0.9403
  Horry, SC
5345  Naples, FL....................................    0.9803    0.9865
  Collier, FL
5360  \1\ Nashville, TN.............................    0.9456    0.9624
  Cheatham, TN
  Davidson, TN
  Dickson, TN
  Robertson, TN
  Rutherford TN
  Sumner, TN
  Williamson, TN
  Wilson, TN
5380  \1\ Nassau-Suffolk, NY........................    1.3441    1.2245
  Nassau, NY
  Suffolk, NY
5483  \1\ \2\ New Haven-Bridgeport-Stamford-            1.2520    1.1664
 Waterbury-Danbury, CT..............................
  Fairfield, CT
  New Haven, CT
5523  \2\ New London-Norwich, CT....................    1.2520    1.1664
  New London, CT
5560  \1\ New Orleans, LA...........................    0.9050    0.9339
  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..............................    1.4069    1.2634
  Bronx, NY
  Kings, NY
  New York, NY
  Putnam, NY
  Queens, NY
  Richmond, NY
  Rockland, NY
  Westchester, NY

[[Page 31607]]

 
5640  \1\ Newark, NJ................................    1.1546    1.1035
  Essex, NJ
  Morris, NJ
  Sussex, NJ
  Union, NJ
  Warren, NJ
5660  Newburgh, NY-PA...............................    1.1434    1.0961
  Orange, NY
  Pike, PA
5720  \1\ Norfolk-Virginia Beach-Newport News, VA-NC    0.8553    0.8985
  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...............................    1.5324    1.3395
  Alameda, CA
  Contra Costa, CA
5790  Ocala, FL.....................................    0.9526    0.9673
  Marion, FL
5800  Odessa-Midland, TX............................    0.9233    0.9468
  Ector, TX
  Midland, TX
5880  \1\ Oklahoma City, OK.........................    0.8997    0.9302
  Canadian, OK
  Cleveland, OK
  Logan, OK
  McClain, OK
  Oklahoma, OK
  Pottawatomie, OK
5910  Olympia, WA...................................    1.1071    1.0722
  Thurston, WA
5920  Omaha, NE-IA..................................    1.0089    1.0061
  Pottawattamie, IA
  Cass, NE
  Douglas, NE
  Sarpy, NE
  Washington, NE
5945  \1\ Orange County, CA.........................    1.1726    1.1152
  Orange, CA
5960  \1\ Orlando, FL...............................    0.9537    0.9681
  Lake, FL
  Orange, FL
  Osceola, FL
  Seminole, FL
5990  Owensboro, KY.................................    0.8283    0.8790
  Daviess, KY
6015  Panama City, FL...............................    0.8926    0.9251
  Bay, FL
6020  Parkersburg-Marietta, WV-OH (WV Hospitals)....    0.8210    0.8737
  Washington, OH
  Wood, WV
6020  \2\ Parkersburg-Marietta, WV-OH (OH Hospitals)    0.8675    0.9072
  Washington, OH
  Wood, WV
6080  \2\ Pensacola, FL.............................    0.8907    0.9238
  Escambia, FL
  Santa Rosa, FL
6120  Peoria-Pekin, IL..............................    0.8854    0.9200
  Peoria, IL
  Tazewell, IL
  Woodford, IL
6160  \1\ Philadelphia, PA-NJ.......................    1.0675    1.0457
  Burlington, NJ
  Camden, NJ
  Gloucester, NJ
  Salem, NJ
  Bucks, PA
  Chester, PA
  Delaware, PA
  Montgomery, PA
  Philadelphia, PA
6200  \1\ Phoenix-Mesa, AZ..........................    0.9562    0.9698
  Maricopa, AZ
  Pinal, AZ
6240  Pine Bluff, AR................................    0.7866    0.8484
  Jefferson, AR
6280  \1\ Pittsburgh, PA............................    0.9403    0.9587
  Allegheny, PA
  Beaver, PA
  Butler, PA
  Fayette, PA
  Washington, PA
  Westmoreland, PA
6323  \2\ Pittsfield, MA............................    1.1257    1.0845
  Berkshire, MA
6340  Pocatello, ID.................................    0.9013    0.9313
  Bannock, ID
6360  Ponce, PR.....................................    0.5221    0.6408
  Guayanilla, PR
  Juana Diaz, PR
  Penuelas, PR
  Ponce, PR
  Villalba, PR
  Yauco, PR
6403  Portland, ME..................................    0.9932    0.9953
  Cumberland, ME
  Sagadahoc, ME
  York, ME
6440  \1\ Portland-Vancouver, OR-WA.................    1.0792    1.0536
  Clackamas, OR
  Columbia, OR
  Multnomah, OR
  Washington, OR
  Yamhill, OR
  Clark, WA
6483  \1\ Providence-Warwick-Pawtucket, RI..........    1.0558    1.0379
  Bristol, RI
  Kent, RI
  Newport, RI
  Providence, RI
  Washington, RI
6520  Provo-Orem, UT................................    1.0190    1.0130
  Utah, UT
6560  \2\ Pueblo, CO................................    0.9104    0.9377
  Pueblo, CO
6580  \2\ Punta Gorda, FL...........................    0.8907    0.9238
  Charlotte, FL
6600  Racine, WI....................................    0.9413    0.9594
  Racine, WI
6640  \1\ Raleigh-Durham-Chapel Hill, NC............    1.0083    1.0057
  Chatham, NC
  Durham, NC
  Franklin, NC
  Johnston, NC
  Orange, NC
  Wake, NC
6660  Rapid City, SD................................    0.8936    0.9259
  Pennington, SD
6680  Reading, PA...................................    0.9308    0.9521
  Berks, PA
6690  Redding, CA...................................    1.1249    1.0839
  Shasta, CA
6720  Reno, NV......................................    1.0664    1.0450
  Washoe, NV
6740  Richland-Kennewick-Pasco, WA..................    1.1608    1.1075
  Benton, WA
  Franklin, WA
6760  Richmond-Petersburg, VA.......................    0.9735    0.9818
  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..............    1.1251    1.0841
  Riverside, CA
  San Bernardino, CA
6800  Roanoke, VA...................................    0.8703    0.9093
  Botetourt, VA
  Roanoke, VA
  Roanoke City, VA
  Salem City, VA
6820  Rochester, MN.................................    1.2263    1.1499
  Olmsted, MN
6840  \1\ Rochester, NY.............................    0.9133    0.9398
  Genesee, NY
  Livingston, NY
  Monroe, NY

[[Page 31608]]

 
  Ontario, NY
  Orleans, NY
  Wayne, NY
6880  Rockford, IL..................................    0.9456    0.9624
  Boone, IL
  Ogle, IL
  Winnebago, IL
6895  Rocky Mount, NC...............................    0.9322    0.9531
  Edgecombe, NC
  Nash, NC
6920  \1\ Sacramento, CA............................    1.1636    1.1093
  El Dorado, CA
  Placer, CA
  Sacramento, CA
6960  Saginaw-Bay City-Midland, MI..................    0.9709    0.9800
  Bay, MI
  Midland, MI
  Saginaw, MI
6980  St. Cloud, MN.................................    0.9858    0.9903
  Benton, MN
  Stearns, MN
7000  \2\ St. Joseph, MO............................    0.8099    0.8656
  Andrew, MO
  Buchanan, MO
7040  \1\ St. Louis, MO-IL..........................    0.8907    0.9238
  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.....................................    1.0473    1.0322
  Marion, OR
  Polk, OR
7120  Salinas, CA...................................    1.4772    1.3063
  Monterey, CA
7160  \1\ Salt Lake City-Ogden, UT..................    1.0035    1.0024
  Davis, UT
  Salt Lake, UT
  Weber, UT
7200  San Angelo, TX................................    0.7956    0.8551
  Tom Green, TX
7240  \1\ San Antonio, TX...........................    0.8649    0.9054
  Bexar, TX
  Comal, TX
  Guadalupe, TX
  Wilson, TX
7320  \1\ San Diego, CA.............................    1.1247    1.0838
  San Diego, CA
7360  \1\ San Francisco, CA.........................    1.4288    1.2768
  Marin, CA
  San Francisco, CA
  San Mateo, CA
7400  \1\ San Jose, CA..............................    1.4162    1.2691
  Santa Clara, CA
7440  \1\ San Juan-Bayamon, PR......................    0.4706    0.5968
  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....    1.1386    1.0930
  San Luis Obispo, CA
7480  Santa Barbara-Santa Maria-Lompoc, CA..........    1.0588    1.0399
  Santa Barbara, CA
7485  Santa Cruz-Watsonville, CA....................    1.3630    1.2362
  Santa Cruz, CA
7490  Santa Fe, NM..................................    1.0822    1.0556
  Los Alamos, NM
  Santa Fe, NM
7500  Santa Rosa, CA................................    1.3179    1.2081
  Sonoma, CA
7510  Sarasota-Bradenton, FL........................    0.9367    0.9562
  Manatee, FL
  Sarasota, FL
7520  Savannah, GA..................................    0.9961    0.9973
  Bryan, GA
  Chatham, GA
  Effingham, GA
7560  \2\ Scranton--Wilkes-Barre--Hazleton, PA......    0.8525    0.8965
  Columbia, PA
  Lackawanna, PA
  Luzerne, PA
  Wyoming, PA
7600  \1\ Seattle-Bellevue-Everett, WA..............    1.1571    1.1051
  Island, WA
  King, WA
  Snohomish, WA
7610  \2\ Sharon, PA................................    0.8525    0.8965
  Mercer, PA
7620  \2\ Sheboygan, WI.............................    0.9229    0.9465
  Sheboygan, WI
7640  Sherman-Denison, TX...........................    0.9334    0.9539
  Grayson, TX
7680  Shreveport-Bossier City, LA...................    0.8813    0.9171
  Bossier, LA
  Caddo, LA
  Webster, LA
7720  Sioux City, IA-NE.............................    0.9138    0.9401
  Woodbury, IA
  Dakota, NE
7760  Sioux Falls, SD...............................    0.9098    0.9373
  Lincoln, SD
  Minnehaha, SD
7800  South Bend, IN................................    0.9902    0.9933
  St. Joseph, IN
7840  Spokane, WA...................................    1.0961    1.0649
  Spokane, WA
7880  Springfield, IL...............................    0.8654    0.9057
  Menard, IL
  Sangamon, IL
7920  Springfield, MO...............................    0.8510    0.8954
  Christian, MO
  Greene, MO
  Webster, MO
8003  \2\ Springfield, MA...........................    1.1257    1.0845
  Hampden, MA
  Hampshire, MA
8050  State College, PA.............................    0.9032    0.9327
  Centre, PA
8080  Steubenville-Weirton, OH-WV...................    0.8893    0.9228
  Jefferson, OH
  Brooke, WV
  Hancock, WV
8120  Stockton-Lodi, CA.............................    1.0630    1.0427
  San Joaquin, CA
8140  \2\ Sumter, SC................................    0.8607    0.9024
  Sumter, SC
8160  Syracuse, NY..................................    0.9519    0.9668
  Cayuga, NY
  Madison, NY
  Onondaga, NY
  Oswego, NY
8200  Tacoma, WA....................................    1.1052    1.0709
  Pierce, WA
8240  \2\ Tallahassee, FL...........................    0.8907    0.9238
  Gadsden, FL
  Leon, FL
8280  \1\ Tampa-St. Petersburg-Clearwater, FL.......    0.9238    0.9472
  Hernando, FL
  Hillsborough, FL
  Pasco, FL
  Pinellas, FL
8320  \2\ Terre Haute, IN...........................    0.8796    0.9159

[[Page 31609]]

 
  Clay, IN
  Vermillion, IN
  Vigo, IN
8360  Texarkana,AR-Texarkana, TX....................    0.8193    0.8724
  Miller, AR
  Bowie, TX
8400  Toledo, OH....................................    0.9863    0.9906
  Fulton, OH
  Lucas, OH
  Wood, OH
8440  Topeka, KS....................................    0.8952    0.9270
  Shawnee, KS
8480  Trenton, NJ...................................    1.0710    1.0481
  Mercer, NJ
8520  Tucson, AZ....................................    0.8993    0.9299
  Pima, AZ
8560  Tulsa, OK.....................................    0.8398    0.8873
  Creek, OK
  Osage, OK
  Rogers, OK
  Tulsa, OK
  Wagoner, OK
8600  Tuscaloosa, AL................................    0.8303    0.8804
  Tuscaloosa, AL
8640  Tyler, TX.....................................    0.9650    0.9759
  Smith, TX
8680  \2\ Utica-Rome, NY............................    0.8633    0.9042
  Herkimer, NY
  Oneida, NY
8720  Vallejo-Fairfield-Napa, CA....................    1.3544    1.2309
  Napa, CA
  Solano, CA
8735  Ventura, CA...................................    1.1209    1.0813
  Ventura, CA
8750  Victoria, TX..................................    0.8814    0.9172
  Victoria, TX
8760  Vineland-Millville-Bridgeton, NJ..............    1.0296    1.0202
  Cumberland, NJ
8780  \2\ Visalia-Tulare-Porterville, CA............    0.9934    0.9955
  Tulare, CA
8800  Waco, TX......................................    0.8802    0.9163
  McLennan, TX
8840  \1\ Washington, DC-MD-VA-WV...................    1.0852    1.0576
  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......................    0.8970    0.9283
  Black Hawk, IA
8940  Wausau, WI....................................    0.9882    0.9919
  Marathon, WI
8960  \1\ West Palm Beach-Boca Raton, FL............    0.9929    0.9951
  Palm Beach, FL
9000  \2\ Wheeling, WV-OH (WV Hospitals)............    0.8053    0.8622
  Belmont, OH
  Marshall, WV
  Ohio, WV
9000  \2\ Wheeling, WV-OH (OH Hospitals)............    0.8675    0.9072
  Belmont, OH
  Marshall, WV
  Ohio, WV
9040  Wichita, KS...................................    0.9571    0.9704
  Butler, KS
  Harvey, KS
  Sedgwick, KS
9080  Wichita Falls, TX.............................    0.8023    0.8600
  Archer, TX
  Wichita, TX
9140  Williamsport, PA..............................    0.8624    0.9036
  Lycoming, PA
9160  Wilmington-Newark, DE-MD......................    1.1287    1.0864
  New Castle, DE
  Cecil, MD
9200  Wilmington, NC................................    0.9471    0.9635
  New Hanover, NC
  Brunswick, NC
9260  Yakima, WA....................................    1.0676    1.0458
  Yakima, WA
9270  \2\ Yolo, CA..................................    0.9934    0.9955
  Yolo, CA
9280  York, PA......................................    0.9140    0.9403
  York, PA
9320  Youngstown-Warren, OH.........................    0.9485    0.9644
  Columbiana, OH
  Mahoning, OH
  Trumbull, OH
9340  Yuba City, CA.................................    1.0310    1.0211
  Sutter, CA
  Yuba, CA
9360  Yuma, AZ......................................    0.8677    0.9074
  Yuma, AZ
------------------------------------------------------------------------
\1\ Large Urban Area
\2\ Hospitals geographically located in the area are assigned the
  statewide rural wage index for FY 2003.


Table 4B.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
                               Rural Areas
------------------------------------------------------------------------
                                                        Wage
                    Nonurban area                       index      GAF
------------------------------------------------------------------------
Alabama.............................................    0.7853    0.8475
Alaska..............................................    1.2323    1.1538
Arizona.............................................    0.8483    0.8935
Arkansas............................................    0.7670    0.8339
California..........................................    0.9934    0.9988
Colorado............................................    0.9104    0.9377
Connecticut.........................................    1.2520    1.1664
Delaware............................................    0.9126    0.9393
Florida.............................................    0.8907    0.9238
Georgia.............................................    0.8254    0.8769
Hawaii..............................................    1.0342    1.0233
Idaho...............................................    0.8799    0.9161
Illinois............................................    0.8301    0.8803
Indiana.............................................    0.8796    0.9159
Iowa................................................    0.8395    0.8871
Kansas..............................................    0.7964    0.8556
Kentucky............................................    0.8079    0.8641
Louisiana...........................................    0.7719    0.8375
Maine...............................................    0.8754    0.9129
Maryland............................................    0.8855    0.9201
Massachusetts.......................................    1.1257    1.0845
Michigan............................................    0.8961    0.9276
Minnesota...........................................    0.9249    0.9479
Mississippi.........................................    0.7759    0.8405
Missouri............................................    0.8099    0.8656
Montana.............................................    0.8567    0.8995
Nebraska............................................    0.8283    0.8790
Nevada..............................................    0.9519    0.9668
New Hampshire.......................................    0.9882    0.9919
New Jersey \1\......................................  ........  ........
New Mexico..........................................    0.8645    0.9051
New York............................................    0.8633    0.9042
North Carolina......................................    0.8714    0.9100
North Dakota........................................    0.7830    0.8458
Ohio................................................    0.8675    0.9072
Oklahoma............................................    0.7664    0.8334
Oregon..............................................    1.0408    1.0278
Pennsylvania........................................    0.8525    0.8965
Puerto Rico.........................................    0.4400    0.5699
Rhode Island \1\....................................  ........  ........
South Carolina......................................    0.8607    0.9024
South Dakota........................................    0.7895    0.8506
Tennessee...........................................    0.7873    0.8489
Texas...............................................    0.7759    0.8405
Utah................................................    0.9426    0.9603
Vermont.............................................    0.9402    0.9587
Virginia............................................    0.8494    0.8942
Washington..........................................    1.0274    1.0187
West Virginia.......................................    0.8053    0.8622
Wisconsin...........................................    0.9229    0.9465
Wyoming.............................................    0.8890  0.9226 -
 
------------------------------------------------------------------------
\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.........................................    0.8534    0.8971
Akron, OH...........................................    0.9685    0.9783
Albany, GA..........................................    1.0658    1.0446
Albuquerque, NM.....................................    0.9372    0.9566
Alexandria, LA......................................    0.7929    0.8531

[[Page 31610]]

 
Allentown-Bethlehem-Easton, PA......................    0.9833    0.9885
Altoona, PA.........................................    0.9300    0.9515
Amarillo, TX........................................    0.8900    0.9233
Anchorage, AK.......................................    1.2610    1.1721
Ann Arbor, MI.......................................    1.1217    1.0818
Anniston, AL........................................    0.7983    0.8570
Asheville, NC.......................................    0.9448    0.9619
Athens, GA..........................................    1.0161    1.0110
Atlanta, GA.........................................    0.9985    0.9990
Augusta-Aiken, GA-SC................................    0.9981    0.9987
Austin-San Marcos, TX...............................    0.9529    0.9675
Barnstable-Yarmouth, MA.............................    1.2894    1.1901
Baton Rouge, LA.....................................    0.8281    0.8788
Bellingham, WA......................................    1.2139    1.1420
Benton Harbor, MI...................................    0.9072    0.9355
Bergen-Passaic, NJ..................................    1.2100    1.1394
Billings, MT........................................    0.9114    0.9384
Biloxi-Gulfport-Pascagoula, MS......................    0.8417    0.8887
Binghamton, NY......................................    0.8525    0.8965
Birmingham, AL......................................    0.9301    0.9516
Bismarck, ND........................................    0.7881    0.8495
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH....    1.1304    1.0876
Burlington, VT......................................    0.9667    0.9771
Caguas, PR..........................................    0.4453    0.5746
Casper, WY..........................................    0.9655    0.9762
Champaign-Urbana, IL................................    0.9334    0.9539
Charleston-North Charleston, SC.....................    0.8607    0.9024
Charleston, WV......................................    0.8602    0.9020
Charlotte-Gastonia-Rock Hill, NC-SC.................    0.9839    0.9889
Charlottesville, VA.................................    1.0252    1.0172
Chattanooga, TN-GA..................................    0.8878    0.9217
Chicago, IL.........................................    1.0953    1.0643
Cincinnati, OH-KY-IN................................    0.9354    0.9553
Clarksville-Hopkinsville, TN-KY.....................    0.8239    0.8758
Cleveland-Lorain-Elyria, OH.........................    0.9295    0.9512
Columbia, MO........................................    0.8737    0.9117
Columbia, SC........................................    0.8990    0.9297
Columbus, GA-AL (GA Hospitals)......................    0.8254    0.8769
Columbus, GA-AL (AL Hospitals)......................    0.8041    0.8613
Columbus, OH........................................    0.9521    0.9669
Corpus Christi, TX..................................    0.8154    0.8696
Dallas, TX..........................................    0.9831    0.9884
Danville, VA........................................    0.8530    0.8968
Davenport-Moline-Rock Island, IA-IL.................    0.8872    0.9213
Dayton-Springfield, OH..............................    0.9378    0.9570
Denver, CO..........................................    1.0401    1.0273
Des Moines, IA......................................    0.8908    0.9239
Detroit, MI.........................................    1.0506    1.0344
Dothan, AL..........................................    0.8028    0.8603
Dover, DE...........................................    0.9274    0.9497
Duluth-Superior, MN-WI..............................    1.0462    1.0314
Eau Claire, WI......................................    0.9229    0.9465
Elkhart-Goshen, IN..................................    0.9484    0.9643
Erie, PA............................................    0.8850    0.9197
Eugene-Springfield, OR..............................    1.1077    1.0726
Fargo-Moorhead, ND-MN...............................    0.9564    0.9699
Fayetteville, NC....................................    0.9055    0.9343
Flagstaff, AZ-UT....................................    1.0234    1.0160
Flint, MI...........................................    1.1041    1.0702
Florence, AL........................................    0.7960    0.8554
Florence, SC........................................    0.8869    0.9211
Fort Collins-Loveland, CO...........................    0.9923    0.9947
Ft. Lauderdale, FL..................................    1.0792    1.0536
Fort Pierce-Port St. Lucie, FL......................    0.9959    0.9972
Fort Smith, AR-OK...................................    0.7681    0.8347
Fort Walton Beach, FL...............................    0.9365    0.9561
Forth Worth-Arlington, TX...........................    0.9620    0.9738
Gadsden, AL.........................................    0.8684    0.9079
Grand Forks, ND-MN..................................    0.9338    0.9542
Grand Junction, CO..................................    0.9824    0.9879
Grand Rapids-Muskegon-Holland, MI...................    0.9664    0.9769
Great Falls, MT.....................................    0.9057    0.9344
Greeley, CO.........................................    0.9219    0.9458
Green Bay, WI.......................................    0.9347    0.9548
Greensboro-Winston-Salem-High Point, NC.............    0.9131    0.9396
Greenville, NC......................................    0.9257    0.9485
Harrisburg-Lebanon-Carlisle, PA.....................    0.9315    0.9526
Hartford, CT........................................    1.1550    1.1037
Hattiesburg, MS.....................................    0.7759    0.8405
Hickory-Morganton-Lenoir, NC........................    0.8958    0.9274
Houston, TX.........................................    0.9746    0.9825
Huntington-Ashland, WV-KY-OH........................    0.9251    0.9481
Huntsville, AL......................................    0.8901    0.9234
Indianapolis, IN....................................    0.9828    0.9882
Iowa City, IA.......................................    0.9828    0.9882
Jackson, MS.........................................    0.8587    0.9009
Jackson, TN.........................................    0.9032    0.9327
Jacksonville, FL....................................    0.9225    0.9463
Johnson City-Kingsport-Bristol, TN-VA (VA Hospitals)    0.8494    0.8942
Johnson City-Kingsport-Bristol, TN-VA (KY Hospitals)    0.8384    0.8863
Jonesboro, AR (AR Hospitals)........................    0.7906    0.8514
Jonesboro, AR (MO Hospitals)........................    0.8099    0.8656
Joplin, MO..........................................    0.8700    0.9090
Kalamazoo-Battlecreek, MI...........................    1.0490    1.0333
Kansas City, KS-MO..................................    0.9809    0.9869
Knoxville, TN.......................................    0.9090    0.9368
Kokomo, IN..........................................    0.9031    0.9326
Lafayette, LA.......................................    0.8392    0.8869
Lakeland-Winter Haven, FL...........................    0.9170    0.9424
Las Vegas, NV-AZ....................................    1.1018    1.0686
Lawton, OK..........................................    0.8073    0.8636
Lexington, KY.......................................    0.8629    0.9040
Lima, OH............................................    0.9515    0.9665
Lincoln, NE.........................................    0.9133    0.9398
Little Rock-North Little Rock, AR...................    0.8926    0.9251
Longview-Marshall, TX...............................    0.8588    0.9010
Los Angeles-Long Beach, CA..........................    1.2044    1.1358
Louisville, KY-IN...................................    0.9382    0.9573
Lubbock, TX.........................................    0.7809    0.8442
Lynchburg, VA.......................................    0.9114    0.9384
Macon, GA...........................................    0.9296    0.9512
Madison, WI.........................................    1.0188    1.0128
Mansfield, OH.......................................    0.8989    0.9296
Medford-Ashland, OR.................................    1.0408    1.0278
Memphis, TN-AR-MS...................................    0.8667    0.9067
Miami, FL...........................................    0.9878    0.9916
Milwaukee-Waukesha, WI..............................    0.9901    0.9932
Minneapolis-St. Paul, MN-WI.........................    1.0969    1.0654
Missoula, MT........................................    0.9139    0.9402
Mobile, AL..........................................    0.8181    0.8715
Modesto, CA.........................................    1.0606    1.0411
Monmouth-Ocean, NJ..................................    1.1290    1.0866
Monroe, LA..........................................    0.8191    0.8723
Montgomery, AL......................................    0.7853    0.8475
Nashville, TN.......................................    0.9283    0.9503
New Haven-Bridgeport-Stamford-Waterbury-............
 Danbury, CT........................................    1.2520    1.1664
New London-Norwich, CT..............................    1.1683    1.1124
New Orleans, LA.....................................    0.9050    0.9339
New York, NY........................................    1.3936    1.2552
Newark, NJ..........................................    1.1546    1.1035
Newburgh, NY-PA.....................................    1.0820    1.0555
Norfolk-Virginia Beach-Newport News, VA-NC..........    0.8714    0.9100
Oakland, CA.........................................    1.5324    1.3395
Ocala, FL...........................................    0.9343    0.9545
Odessa-Midland, TX..................................    0.8910    0.9240
Oklahoma City, OK...................................    0.8997    0.9302
Omaha, NE-IA........................................    1.0089    1.0061
Orange County, CA...................................    1.1726    1.1152
Orlando, FL.........................................    0.9537    0.9681
Peoria-Pekin, IL....................................    0.8854    0.9200
Philadelphia, PA-NJ.................................    1.0675    1.0457
Phoenix-Mesa, AZ....................................    0.9562    0.9698
Pine Bluff, AR......................................    0.7760    0.8406
Pittsburgh, PA......................................    0.9268    0.9493
Pittsfield, MA......................................    0.9869    0.9910
Pocatello, ID.......................................    0.9013    0.9313
Portland, ME........................................    0.9698    0.9792
Portland-Vancouver, OR-WA...........................    1.0792    1.0536
Provo-Orem, UT......................................    1.0088    1.0060
Raleigh-Durham-Chapel Hill, NC......................    0.9978    0.9985
Rapid City, SD......................................    0.8936    0.9259
Reading, PA.........................................    0.9126    0.9393
Redding, CA.........................................    1.1249    1.0839
Reno, NV............................................    1.0445    1.0303
Richland-Kennewick-Pasco, WA........................    1.1209    1.0813
Richmond-Petersburg, VA.............................    0.9735    0.9818

[[Page 31611]]

 
Roanoke, VA.........................................    0.8703    0.9093
Rochester, MN.......................................    1.2263    1.1499
Rockford, IL........................................    0.9456    0.9624
Sacramento, CA......................................    1.1636    1.1093
Saginaw-Bay City-Midland, MI........................    0.9709    0.9800
St. Cloud, MN.......................................    0.9858    0.9903
St. Joseph, MO......................................    0.8300    0.8802
St. Louis, MO-IL....................................    0.8907    0.9238
Salinas, CA.........................................    1.4772    1.3063
Salt Lake City-Ogden, UT............................    1.0035    1.0024
San Antonio, TX.....................................    0.8649    0.9054
San Diego, CA.......................................    1.1247    1.0838
Santa Fe, NM........................................    0.9927    0.9950
Santa Rosa, CA......................................    1.2891    1.1899
Sarasota-Bradenton, FL..............................    0.9367    0.9562
Savannah, GA........................................    0.9841    0.9891
Seattle-Bellevue-Everett, WA........................    1.1571    1.1051
Sherman-Denison, TX.................................    0.9090    0.9368
Shreveport-Bossier City, LA.........................    0.8813    0.9171
Sioux City, IA-NE...................................    0.8736    0.9116
Sioux Falls, SD.....................................    0.8950    0.9268
South Bend, IN......................................    0.9902    0.9933
Spokane, WA.........................................    1.0770    1.0521
Springfield, IL.....................................    0.8654    0.9057
Springfield, MO.....................................    0.8236    0.8756
Stockton-Lodi, CA...................................    1.0630    1.0427
Syracuse, NY........................................    0.9519    0.9668
Tampa-St. Petersburg-Clearwater, FL.................    0.9238    0.9472
Texarkana,AR-Texarkana, TX..........................    0.8193    0.8724
Toledo, OH..........................................    0.9863    0.9906
Topeka, KS..........................................    0.8840    0.9190
Tucson, AZ..........................................    0.8993    0.9299
Tulsa, OK...........................................    0.8398    0.8873
Tuscaloosa, AL......................................    0.8303    0.8804
Tyler, TX...........................................    0.9249    0.9479
Vallejo-Fairfield-Napa, CA..........................    1.3544    1.2309
Victoria, TX........................................    0.8668    0.9067
Waco, TX............................................    0.8671    0.9070
Washington, DC-MD-VA-WV.............................    1.0852    1.0576
Waterloo-Cedar Falls, IA............................    0.8970    0.9283
Wausau, WI..........................................    0.9710    0.9800
West Palm Beach-Boca Raton, FL......................    0.9929    0.9951
Wichita, KS.........................................    0.9235    0.9470
Wichita Falls, TX...................................    0.7918    0.8523
Wilmington-Newark, DE-MD............................    1.0973    1.0657
Wilmington, NC......................................    0.9336    0.9540
York, PA............................................    0.9140    0.9403
Youngstown-Warren, OH...............................    0.9485    0.9644
Rural Alabama.......................................    0.7853    0.8475
Rural Florida.......................................    0.8907    0.9238
Rural Illinois (IA Hospitals).......................    0.8395    0.8871
Rural Illinois (MO Hospitals).......................    0.8301    0.8803
Rural Kentucky......................................    0.8079    0.8641
Rural Louisiana.....................................    0.7719    0.8375
Rural Massachusetts.................................    1.0417    1.0284
Rural Michigan......................................    0.8961    0.9276
Rural Minnesota.....................................    0.9249    0.9479
Rural Mississippi...................................    0.7759    0.8405
Rural Missouri......................................    0.8099    0.8656
Rural Montana.......................................    0.8567    0.8995
Rural Nebraska......................................    0.8283    0.8790
Rural Nevada........................................    0.9097    0.9372
Rural Texas.........................................    0.7759    0.8405
Rural Washington....................................    1.0274    1.0187
Rural Wyoming.......................................    0.8890    0.9226
------------------------------------------------------------------------


                Table 4F.--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF)
----------------------------------------------------------------------------------------------------------------
                                                                                            Wage
                                                                                          index--       GAF--
                            Area                              Wage  index      GAF        reclass.     reclass.
                                                                                         hospitals    hospitals
----------------------------------------------------------------------------------------------------------------
Aguadilla, PR...............................................       0.9781       0.9850  ...........  ...........
\1\ Arecibo, PR.............................................       0.9289       0.9507  ...........  ...........
Caguas, PR..................................................       0.9400       0.9585       0.9400       0.9585
Mayaguez, PR................................................       1.0388       1.0264  ...........  ...........
Ponce, PR...................................................       1.1021       1.0688  ...........  ...........
San Juan-Bayamon, PR........................................       0.9935       0.9955  ...........  ...........
Rural Puerto Rico...........................................       0.9289       0.9507  ...........  ...........
----------------------------------------------------------------------------------------------------------------
\1\ Hospitals geographically located in the area are assigned the Rural Puerto Rico wage index for FY 2003.


         Table 4G.--Pre-Reclassified Wage Index for Urban Areas
------------------------------------------------------------------------
                                                                  Wage
               Urban area (constituent counties)                  index
------------------------------------------------------------------------
0040  Abilene, TX.............................................    0.9268
  Taylor, TX
0060  Aguadilla, PR...........................................    0.4634
  Aguada, PR
  Aguadilla, PR
  Moca, PR
0080  Akron, OH...............................................    0.9685
  Portage, OH
  Summit, OH
0120  Albany, GA..............................................    1.0835
  Dougherty, GA
  Lee, GA
0160  Albany-Schenectady-Troy, NY.............................    0.8633
  Albany, NY
  Montgomery, NY
  Rensselaer, NY
  Saratoga, NY
  Schenectady, NY
  Schoharie, NY
0200  Albuquerque, NM.........................................    0.9279
  Bernalillo, NM
  Sandoval, NM
  Valencia, NM
0220  Alexandria, LA..........................................    0.7903
  Rapides, LA
0240  Allentown-Bethlehem-Easton, PA..........................    0.9833
  Carbon, PA
  Lehigh, PA
  Northampton, PA
0280  Altoona, PA.............................................    0.9300
  Blair, PA
0320  Amarillo, TX............................................  0.9051 -
  Potter, TX
  Randall, TX
0380  Anchorage, AK...........................................    1.2477
  Anchorage, AK
0440  Ann Arbor, MI...........................................    1.1217
  Lenawee, MI
  Livingston, MI
  Washtenaw, MI
0450  Anniston, AL............................................    0.8126
  Calhoun, AL

[[Page 31612]]

 
0460  Appleton-Oshkosh-Neenah, WI.............................    0.9229
  Calumet, WI
  Outagamie, WI
  Winnebago, WI
0470  Arecibo, PR.............................................    0.4400
  Arecibo, PR
  Camuy, PR
  Hatillo, PR
0480  Asheville, NC...........................................    0.9682
  Buncombe, NC
  Madison, NC
0500  Athens, GA..............................................    1.0308
  Clarke, GA
  Madison, GA
  Oconee, GA
0520  Atlanta, GA.............................................    1.0091
  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...................................    1.1058
  Atlantic, NJ
  Cape May, NJ
0580  Auburn-Opelika, AL......................................    0.8306
  Lee, AL
0600  Augusta-Aiken, GA-SC....................................    1.0364
  Columbia, GA
  McDuffie, GA
  Richmond, GA
  Aiken, SC
  Edgefield, SC
0640  Austin-San Marcos, TX...................................    0.9529
  Bastrop, TX
  Caldwell, TX
  Hays, TX
  Travis, TX
  Williamson, TX
0680  Bakersfield, CA.........................................    1.0186
  Kern, CA
0720  Baltimore, MD...........................................    0.9757
  Anne Arundel, MD
  Baltimore, MD
  Baltimore City, MD
  Carroll, MD
  Harford, MD
  Howard, MD
  Queen Anne's, MD
0733  Bangor, ME..............................................    0.9791
  Penobscot, ME
0743  Barnstable-Yarmouth, MA.................................    1.3127
  Barnstable, MA
0760  Baton Rouge, LA.........................................    0.8388
  Ascension, LA
  East Baton Rouge, LA
  Livingston, LA
  West Baton Rouge, LA
0840  Beaumont-Port Arthur, TX................................    0.8389
  Hardin, TX
  Jefferson, TX
  Orange, TX
0860  Bellingham, WA..........................................    1.2407
  Whatcom, WA
0870  Benton Harbor, MI.......................................    0.8992
  Berrien, MI
0875  Bergen-Passaic, NJ......................................    1.2100
  Bergen, NJ
  Passaic, NJ
0880  Billings, MT............................................    0.9114
  Yellowstone, MT
0920  Biloxi-Gulfport-Pascagoula, MS..........................    0.8830
  Hancock, MS
  Harrison, MS
  Jackson, MS
0960  Binghamton, NY..........................................    0.8633
  Broome, NY
  Tioga, NY
1000  Birmingham, AL..........................................    0.9301
  Blount, AL
  Jefferson, AL
  St. Clair, AL
  Shelby, AL
1010  Bismarck, ND............................................    0.7848
  Burleigh, ND
  Morton, ND
1020  Bloomington, IN.........................................    0.8997
  Monroe, IN
1040  Bloomington-Normal, IL..................................    0.9202
  McLean, IL
1080  Boise City, ID..........................................    0.9403
  Ada, ID
  Canyon, ID
1123  Boston-Worcester-Lawrence-Lowell-Brockton,
  MA-NH (NH Hospitals)........................................    1.1304
  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....................................    0.9688
  Boulder, CO
1145   Brazoria, TX...........................................    0.8617
  Brazoria, TX
1150  Bremerton, WA...........................................    1.1056
  Kitsap, WA
1240  Brownsville-Harlingen-San Benito, TX....................    0.8992
  Cameron, TX
1260  Bryan-College Station, TX...............................    0.8410
  Brazos, TX
1280  Buffalo-Niagara Falls, NY...............................    0.9464
  Erie, NY
  Niagara, NY
1303  Burlington, VT..........................................    1.0176
  Chittenden, VT
  Franklin, VT
  Grand Isle, VT
1310  Caguas, PR..............................................    0.4415
  Caguas, PR
  Cayey, PR
  Cidra, PR
  Gurabo, PR
  San Lorenzo, PR
1320  Canton-Massillon, OH....................................    0.9026
  Carroll, OH
  Stark, OH
1350  Casper, WY..............................................    0.9788
  Natrona, WY
1360  Cedar Rapids, IA........................................    0.9149
  Linn, IA
1400  Champaign-Urbana, IL....................................    0.9983
  Champaign, IL
1440  Charleston-North
  Charleston, SC..............................................    0.8607
  Berkeley, SC
  Charleston, SC
  Dorchester, SC
1480  Charleston, WV..........................................    0.8765
  Kanawha, WV
  Putnam, WV
1520  Charlotte-Gastonia-Rock Hill, NC-SC.....................    0.9839
  Cabarrus, NC
  Gaston, NC
  Lincoln, NC
  Mecklenburg, NC
  Rowan, NC
  Stanly, NC
  Union, NC
  York, SC
1540  Charlottesville, VA.....................................    1.0583
  Albemarle, VA
  Charlottesville City, VA
  Fluvanna, VA
  Greene, VA
1560  Chattanooga, TN-GA......................................    0.9069
  Catoosa, GA
  Dade, GA
  Walker, GA
  Hamilton, TN
  Marion, TN
1580  Cheyenne, WY............................................    0.8890
  Laramie, WY
1600  Chicago, IL.............................................    1.1088
  Cook, IL
  DeKalb, IL
  DuPage, IL
  Grundy, IL
  Kane, IL
  Kendall, IL
  Lake, IL
  McHenry, IL
  Will, IL
1620  Chico-Paradise, CA......................................    0.9934
  Butte, CA
1640  Cincinnati, OH-KY-IN....................................    0.9323
  Dearborn, IN
  Ohio, IN
  Boone, KY
  Campbell, KY
  Gallatin, KY
  Grant, KY
  Kenton, KY
  Pendleton, KY
  Brown, OH
  Clermont, OH

[[Page 31613]]

 
  Hamilton, OH
  Warren, OH
1660  Clarksville-Hopkinsville, TN-KY.........................    0.8386
  Christian, KY
  Montgomery, TN
1680  Cleveland-Lorain-Elyria, OH.............................    0.9295
  Ashtabula, OH
  Cuyahoga, OH
  Geauga, OH
  Lake, OH
  Lorain, OH
  Medina, OH
1720  Colorado Springs, CO....................................    0.9968
  El Paso, CO
1740  Columbia, MO............................................    0.8737
  Boone, MO
1760  Columbia, SC............................................    0.8990
  Lexington, SC
  Richland, SC
1800  Columbus, GA-AL.........................................    0.8450
  Russell, AL
  Chattahoochee, GA
  Harris, GA
  Muscogee, GA
1840  Columbus, OH............................................    0.9705
  Delaware, OH
  Fairfield, OH
  Franklin, OH
  Licking, OH
  Madison, OH
  Pickaway, OH
1880  Corpus Christi, TX......................................    0.8154
  Nueces, TX
  San Patricio, TX
1890  Corvallis, OR...........................................    1.1569
  Benton, OR
1900  Cumberland, MD-WV (WV Hospital).........................    0.8053
  Allegany, MD
  Mineral, WV
1920  Dallas, TX..............................................    0.9831
  Collin, TX
  Dallas, TX
  Denton, TX
  Ellis, TX
  Henderson, TX
  Hunt, TX
  Kaufman, TX
  Rockwall, TX
1950  Danville, VA............................................    0.8785
  Danville City, VA
  Pittsylvania, VA
1960  Davenport-Moline-Rock
  Island, IA-IL...............................................    0.8872
  Scott, IA
  Henry, IL
  Rock Island, IL
2000  Dayton-Springfield, OH..................................    0.9378
  Clark, OH
  Greene, OH
  Miami, OH
  Montgomery, OH
2020  Daytona Beach, FL.......................................    0.9133
  Flagler, FL
  Volusia, FL
2030  Decatur, AL.............................................    0.9066
  Lawrence, AL
  Morgan, AL
2040  Decatur, IL.............................................    0.8301
  Macon, IL
2080  Denver, CO..............................................    1.0401
  Adams, CO
  Arapahoe, CO
  Denver, CO
  Douglas, CO
  Jefferson, CO
2120  Des Moines, IA..........................................    0.8867
  Dallas, IA
  Polk, IA
  Warren, IA
2160  Detroit, MI.............................................    1.0506
  Lapeer, MI
  Macomb, MI
  Monroe, MI
  Oakland, MI
  St. Clair, MI
  Wayne, MI
2180  Dothan, AL..............................................    0.7990
  Dale, AL
  Houston, AL
2190  Dover, DE...............................................    0.9452
  Kent, DE
2200  Dubuque, IA.............................................    0.8801
  Dubuque, IA
2240  Duluth-Superior, MN-WI..................................    1.0462
  St. Louis, MN
  Douglas, WI
2281  Dutchess County, NY.....................................    1.0793
  Dutchess, NY
2290  Eau Claire, WI..........................................    0.9229
  Chippewa, WI
  Eau Claire, WI
2320  El Paso, TX.............................................    0.9137
  El Paso, TX
2330  Elkhart-Goshen, IN......................................    0.9851
  Elkhart, IN
2335  Elmira, NY..............................................    0.8633
  Chemung, NY
2340  Enid, OK................................................    0.8387
  Garfield, OK
2360  Erie, PA................................................    0.9016
  Erie, PA
2400  Eugene-Springfield, OR..................................    1.1077
  Lane, OR
2440  Evansville-Henderson,
  IN-KY (IN Hospitals)........................................    0.8796
  Posey, IN
  Vanderburgh, IN
  Warrick, IN
  Henderson, KY
2520  Fargo-Moorhead, ND-MN...................................    0.9783
  Clay, MN
  Cass, ND
2560  Fayetteville, NC........................................    0.8980
  Cumberland, NC
2580  Fayetteville-Springdale-Rogers, AR......................    0.8182
  Benton, AR
  Washington, AR
2620  Flagstaff, AZ-UT........................................    1.0791
  Coconino, AZ
  Kane, UT
2640  Flint, MI...............................................    1.1233
  Genesee, MI
2650  Florence, AL............................................    0.7927
  Colbert, AL
  Lauderdale, AL
2655  Florence, SC............................................    0.8869
  Florence, SC
2670  Fort Collins-Loveland, CO...............................    0.9923
  Larimer, CO
2680  Ft. Lauderdale, FL......................................    1.0368
  Broward, FL
2700  Fort Myers-Cape Coral, FL...............................    0.9456
  Lee, FL
2710  Fort Pierce-Port St. Lucie, FL..........................    0.9802
  Martin, FL
  St. Lucie, FL
2720  Fort Smith, AR-OK.......................................    0.7811
  Crawford, AR
  Sebastian, AR
  Sequoyah, OK
2750  Fort Walton Beach, FL...................................    0.9651
  Okaloosa, FL
2760  Fort Wayne, IN..........................................    0.9499
  Adams, IN
  Allen, IN
  De Kalb, IN
  Huntington, IN
  Wells, IN
  Whitley, IN
2800  Forth Worth-Arlington, TX...............................    0.9620
  Hood, TX
  Johnson, TX
  Parker, TX
  Tarrant, TX
2840  Fresno, CA..............................................    1.0340
  Fresno, CA
  Madera, CA
2880  Gadsden, AL.............................................    0.8580
  Etowah, AL
2900  Gainesville, FL.........................................    0.9730
  Alachua, FL
2920  Galveston-Texas City, TX................................    0.9603
  Galveston, TX
2960  Gary, IN................................................    0.9676
  Lake, IN
  Porter, IN
2975  Glens Falls, NY.........................................    0.8633
  Warren, NY
  Washington, NY
2980  Goldsboro, NC...........................................    0.8982
  Wayne, NC
2985  Grand Forks, ND-MN......................................    0.8988
  Polk, MN
  Grand Forks, ND
2995  Grand Junction, CO......................................    0.9615
  Mesa, CO
3000  Grand Rapids-
  Muskegon-Holland, MI........................................    0.9645
  Allegan, MI
  Kent, MI
  Muskegon, MI
  Ottawa, MI
3040  Great Falls, MT.........................................    0.9042
  Cascade, MT
3060  Greeley, CO.............................................    0.9104
  Weld, CO
3080  Green Bay, WI...........................................    0.9599
  Brown, WI
3120  Greensboro-Winston-Salem-High Point, NC.................    0.9270
  Alamance, NC
  Davidson, NC
  Davie, NC
  Forsyth, NC
  Guilford, NC
  Randolph, NC

[[Page 31614]]

 
  Stokes, NC
  Yadkin, NC
3150  Greenville, NC..........................................    0.9177
  Pitt, NC
3160  Greenville-Spartanburg-Anderson, SC.....................    0.9177
  Anderson, SC
  Cherokee, SC
  Greenville, SC
  Pickens, SC
  Spartanburg, SC
3180  Hagerstown, MD..........................................    0.9362
  Washington, MD
3200  Hamilton-Middletown, OH.................................    0.9484
  Butler, OH
3240  Harrisburg-Lebanon-Carlisle, PA.........................    0.9315
  Cumberland, PA
  Dauphin, PA
  Lebanon, PA
  Perry, PA
3283  Hartford, CT............................................    1.2520
  Hartford, CT
  Litchfield, CT
  Middlesex, CT
  Tolland, CT
3285  \2\ Hattiesburg, MS.....................................    0.7746
  Forrest, MS
  Lamar, MS
3290  Hickory-Morganton-Lenoir, NC............................    0.8958
  Alexander, NC
  Burke, NC
  Caldwell, NC
  Catawba, NC
3320  Honolulu, HI............................................    1.1121
  Honolulu, HI
3350 Houma, LA................................................    0.8470
  Lafourche, LA
  Terrebonne, LA
3360  Houston, TX.............................................    0.9746
  Chambers, TX
  Fort Bend, TX
  Harris, TX
  Liberty, TX
  Montgomery, TX
  Waller, TX
3400  Huntington-Ashland,
  WV-KY-OH....................................................    0.9744
  Boyd, KY
  Carter, KY
  Greenup, KY
  Lawrence, OH
  Cabell, WV
  Wayne, WV
3440  Huntsville, AL..........................................    0.8901
  Limestone, AL
  Madison, AL
3480  Indianapolis, IN........................................    0.9828
  Boone, IN
  Hamilton, IN
  Hancock, IN
  Hendricks, IN
  Johnson, IN
  Madison, IN
  Marion, IN
  Morgan, IN
  Shelby, IN
3500  Iowa City, IA...........................................    1.0025
  Johnson, IA
3520  Jackson, MI.............................................    0.9591
  Jackson, MI
3560  Jackson, MS.............................................    0.8713
  Hinds, MS
  Madison, MS
  Rankin, MS
3580  Jackson, TN.............................................    0.9370
  Madison, TN
  Chester, TN
3600  Jacksonville, FL........................................    0.9341
  Clay, FL
  Duval, FL
  Nassau, FL
  St. Johns, FL
3605  Jacksonville, NC........................................    0.8714
  Onslow, NC
3610  Jamestown, NY...........................................    0.8633
  Chautauqua, NY
3620  Janesville-Beloit, WI...................................    0.9696
  Rock, WI
3640  Jersey City, NJ.........................................    1.1200
  Hudson, NJ
3660  Johnson City-
  Kingsport-Bristol, TN-VA....................................    0.8307
  Carter, TN
  Hawkins, TN
  Sullivan, TN
  Unicoi, TN
  Washington, TN
  Bristol City, VA
  Scott, VA
  Washington, VA
3680  Johnstown, PA...........................................    0.8525
  Cambria, PA
  Somerset, PA
3700  Jonesboro, AR...........................................    0.7828
  Craighead, AR
3710  Joplin, MO..............................................    0.8700
  Jasper, MO
  Newton, MO
3720  Kalamazoo-Battlecreek, MI...............................    1.0689
  Calhoun, MI
  Kalamazoo, MI
  Van Buren, MI
3740  Kankakee, IL............................................    0.9591
  Kankakee, IL
3760  Kansas City, KS-MO......................................    0.9809
  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.............................................    0.9741
  Kenosha, WI
3810  Killeen-Temple, TX......................................    0.8447
  Bell, TX
  Coryell, TX
3840  Knoxville, TN...........................................    0.9090
  Anderson, TN
  Blount, TN
  Knox, TN
  Loudon, TN
  Sevier, TN
  Union, TN
3850  Kokomo, IN..............................................    0.8950
  Howard, IN
  Tipton, IN
3870  La Crosse, WI-MN........................................    0.9229
  Houston, MN
  La Crosse, WI
3880  Lafayette, LA...........................................    0.8550
  Acadia, LA
  Lafayette, LA
  St. Landry, LA
  St. Martin, LA
3920  Lafayette, IN...........................................    0.9515
  Clinton, IN
  Tippecanoe, IN
3960  Lake Charles, LA........................................    0.8030
  Calcasieu, LA
3980  Lakeland-Winter Haven, FL...............................    0.9162
  Polk, FL
4000  Lancaster, PA...........................................    0.9171
  Lancaster, PA
4040  Lansing-East Lansing, MI................................    0.9827
  Clinton, MI
  Eaton, MI
  Ingham, MI
4080  Laredo, TX..............................................    0.8504
  Webb, TX
4100  Las Cruces, NM..........................................    0.8888
  Dona Ana, NM
4120  Las Vegas, NV-AZ........................................    1.1018
  Mohave, AZ
  Clark, NV
  Nye, NV
4150  Lawrence, KS............................................    0.7964
  Douglas, KS
4200  Lawton, OK..............................................    0.8251
  Comanche, OK
4243  Lewiston-Auburn, ME.....................................    0.9249
  Androscoggin, ME
4280  Lexington, KY...........................................    0.8629
  Bourbon, KY
  Clark, KY
  Fayette, KY
  Jessamine, KY
  Madison, KY
  Scott, KY
  Woodford, KY
4320  Lima, OH................................................    0.9515
  Allen, OH
  Auglaize, OH
4360  Lincoln, NE.............................................    0.8928
  Lancaster, NE
4400  Little Rock-North
  Little Rock, AR.............................................    0.9045
  Faulkner, AR
  Lonoke, AR
  Pulaski, AR
  Saline, AR
4420  Longview-Marshall, TX...................................    0.8588
  Gregg, TX
  Harrison, TX
  Upshur, TX
4480  Los Angeles-Long Beach, CA..............................    1.2027
  Los Angeles, CA
4520  \1\ Louisville, KY-IN...................................    0.9517
  Clark, IN
  Floyd, IN
  Harrison, IN
  Scott, IN
  Bullitt, KY

[[Page 31615]]

 
  Jefferson, KY
  Oldham, KY
4600  Lubbock, TX.............................................    0.7752
  Lubbock, TX
4640  Lynchburg, VA...........................................    0.9311
  Amherst, VA
  Bedford, VA
  Bedford City, VA
  Campbell, VA
  Lynchburg City, VA
4680  Macon, GA...............................................    0.9259
  Bibb, GA
  Houston, GA
  Jones, GA
  Peach, GA
  Twiggs, GA
4720  Madison, WI.............................................    1.0188
  Dane, WI
4800  Mansfield, OH...........................................    0.8989
  Crawford, OH
  Richland, OH
4840  Mayaguez, PR............................................    0.4921
  Anasco, PR
  Cabo Rojo, PR
  Hormigueros, PR
  Mayaguez, PR
  Sabana Grande, PR
  San German, PR
4880  McAllen-Edinburg-Mission, TX............................    0.8419
  Hidalgo, TX
4890   Medford-Ashland, OR....................................    1.0605
  Jackson, OR
4900  Melbourne-Titusville-Palm Bay, FL.......................    1.0782
  Brevard, Fl
4920  Memphis, TN-AR-MS.......................................    0.8839
  Crittenden, AR
  DeSoto, MS
  Fayette, TN
  Shelby, TN
  Tipton, TN
4940  Merced, CA..............................................    0.9937
  Merced, CA
5000  Miami, FL...............................................    0.9864
  Dade, FL
5015  Middlesex-Somerset-Hunterdon, NJ........................    1.1454
  Hunterdon, NJ
  Middlesex, NJ
  Somerset, NJ
5080  Milwaukee-Waukesha, WI..................................    0.9901
  Milwaukee, WI
  Ozaukee, WI
  Washington, WI
  Waukesha, WI
5120  Minneapolis-St. Paul, MN-WI.............................    1.0969
  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............................................    0.9250
  Missoula, MT
5160  Mobile, AL..............................................    0.8179
  Baldwin, AL
  Mobile, AL
5170  Modesto, CA.............................................    1.0606
  Stanislaus, CA
5190  Monmouth-Ocean, NJ......................................    1.1270
  Monmouth, NJ
  Ocean, NJ
5200  Monroe, LA..............................................    0.8191
  Ouachita, LA
5240  Montgomery, AL..........................................    0.7786
  Autauga, AL
  Elmore, AL
  Montgomery, AL
5280  Muncie, IN..............................................    0.9150
  Delaware, IN
5330  Myrtle Beach, SC........................................    0.9141
  Horry, SC
5345  Naples, FL..............................................    0.9803
  Collier, FL
5360  Nashville, TN...........................................    0.9456
  Cheatham, TN
  Davidson, TN
  Dickson, TN
  Robertson, TN
  Rutherford TN
  Sumner, TN
  Williamson, TN
  Wilson, TN
5380  Nassau-Suffolk, NY......................................    1.3441
  Nassau, NY
  Suffolk, NY
5483  New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT.....    1.2520
  Fairfield, CT
  New Haven, CT
5523  New London-Norwich, CT..................................    1.2520
  New London, CT
5560  New Orleans, LA.........................................    0.9050
  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............................................    1.4069
  Bronx, NY
  Kings, NY
  New York, NY
  Putnam, NY
  Queens, NY
  Richmond, NY
  Rockland, NY
  Westchester, NY
5640  Newark, NJ..............................................    1.1504
  Essex, NJ
  Morris, NJ
  Sussex, NJ
  Union, NJ
  Warren, NJ
5660  Newburgh, NY-PA.........................................    1.1434
  Orange, NY
  Pike, PA
5720  Norfolk-Virginia Beach-Newport News, VA-NC..............    0.8553
  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.............................................    1.5222
  Alameda, CA
  Contra Costa, CA
5790  Ocala, FL...............................................    0.9526
  Marion, FL
5800  Odessa-Midland, TX......................................    0.9233
  Ector, TX
  Midland, TX
5880  Oklahoma City, OK.......................................    0.8997
  Canadian, OK
  Cleveland, OK
  Logan, OK
  McClain, OK
  Oklahoma, OK
  Pottawatomie, OK
5910   Olympia, WA............................................    1.1071
  Thurston, WA
5920  Omaha, NE-IA............................................    1.0089
  Pottawattamie, IA
  Cass, NE
  Douglas, NE
  Sarpy, NE
  Washington, NE
5945  Orange County, CA.......................................    1.1604
  Orange, CA
5960  Orlando, FL.............................................    0.9537
  Lake, FL
  Orange, FL
  Osceola, FL
  Seminole, FL
5990  Owensboro, KY...........................................    0.8283
  Daviess, KY
6015   Panama City, FL........................................    0.8926
  Bay, FL
6020  Parkersburg-Marietta, WV-OH.............................    0.8210
  Washington, OH
  Wood, WV
6080  Pensacola, FL...........................................    0.8907
  Escambia, FL
  Santa Rosa, FL
6120  Peoria-Pekin, IL........................................    0.8854
  Peoria, IL
  Tazewell, IL
  Woodford, IL
6160  Philadelphia, PA-NJ.....................................    1.0675
  Burlington, NJ
  Camden, NJ
  Gloucester, NJ
  Salem, NJ
  Bucks, PA
  Chester, PA
  Delaware, PA

[[Page 31616]]

 
  Montgomery, PA
  Philadelphia, PA
6200  Phoenix-Mesa, AZ........................................    0.9562
  Maricopa, AZ
  Pinal, AZ
6240  Pine Bluff, AR..........................................    0.7866
  Jefferson, AR
6280  Pittsburgh, PA..........................................    0.9403
  Allegheny, PA
  Beaver, PA
  Butler, PA
  Fayette, PA
  Washington, PA
  Westmoreland, PA
6323  Pittsfield, MA..........................................    1.1257
  Berkshire, MA
6340  Pocatello, ID...........................................    0.8799
  Bannock, ID
6360  Ponce, PR...............................................    0.5221
  Guayanilla, PR
  Juana Diaz, PR
  Penuelas, PR
  Ponce, PR
  Villalba, PR
  Yauco, PR
6403  Portland, ME............................................    0.9932
  Cumberland, ME
  Sagadahoc, ME
  York, ME
6440  Portland-Vancouver,
  OR-WA.......................................................    1.0774
  Clackamas, OR
  Columbia, OR
  Multnomah, OR
  Washington, OR
  Yamhill, OR
  Clark, WA
6483  Providence-Warwick-Pawtucket, RI........................    1.0558
  Bristol, RI
  Kent, RI
  Newport, RI
  Providence, RI
  Washington, RI
6520  Provo-Orem, UT..........................................    1.0190
  Utah, UT
6560  Pueblo, CO..............................................    0.9104
  Pueblo, CO
6580  Punta Gorda, FL.........................................    0.8907
  Charlotte, FL
6600  Racine, WI..............................................    0.9413
  Racine, WI
6640  Raleigh-Durham-Chapel Hill, NC..........................    1.0083
  Chatham, NC
  Durham, NC
  Franklin, NC
  Johnston, NC
  Orange, NC
  Wake, NC
6660  Rapid City, SD..........................................    0.8936
  Pennington, SD
6680  Reading, PA.............................................    0.9308
  Berks, PA
6690  Redding, CA.............................................    1.1249
  Shasta, CA
6720  Reno, NV................................................    1.0664
  Washoe, NV
6740  Richland-Kennewick-Pasco, WA............................    1.1608
  Benton, WA
  Franklin, WA
6760  Richmond-Petersburg, VA.................................    0.9735
  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..............................................    1.1251
  Riverside, CA
  San Bernardino, CA
6800  Roanoke, VA.............................................    0.8703
  Botetourt, VA
  Roanoke, VA
  Roanoke City, VA
  Salem City, VA
6820  Rochester, MN...........................................    1.2263
  Olmsted, MN
6840  Rochester, NY...........................................    0.9133
  Genesee, NY
  Livingston, NY
  Monroe, NY
  Ontario, NY
  Orleans, NY
  Wayne, NY
6880  Rockford, IL............................................    0.9456
  Boone, IL
  Ogle, IL
  Winnebago, IL
6895  Rocky Mount, NC.........................................    0.9322
  Edgecombe, NC
  Nash, NC
6920  Sacramento, CA..........................................    1.1622
  El Dorado, CA
  Placer, CA
  Sacramento, CA
6960  Saginaw-Bay
  City-Midland, MI............................................    0.9709
  Bay, MI
  Midland, MI
  Saginaw, MI
6980  St. Cloud, MN...........................................    0.9757
  Benton, MN
  Stearns, MN
7000  St. Joseph, MO..........................................    0.8093
  Andrew, MO
  Buchanan, MO
7040  St. Louis, MO-IL........................................    0.8907
  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...............................................    1.0473
  Marion, OR
  Polk, OR
7120  Salinas, CA.............................................    1.4772
  Monterey, CA
7160  Salt Lake City-Ogden, UT................................    1.0035
  Davis, UT
  Salt Lake, UT
  Weber, UT
7200  San Angelo, TX..........................................    0.7956
  Tom Green, TX
7240  San Antonio, TX.........................................    0.8649
  Bexar, TX
  Comal, TX
  Guadalupe, TX
  Wilson, TX
7320  San Diego, CA...........................................    1.1243
  San Diego, CA
7360  San Francisco, CA.......................................    1.4288
  Marin, CA
  San Francisco, CA
  San Mateo, CA
7400  San Jose, CA............................................    1.4162
  Santa Clara, CA
7440  San Juan-Bayamon, PR....................................    0.4706
  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..................................    1.1386
  San Luis Obispo, CA
7480  Santa Barbara-Santa Maria-Lompoc, CA....................    1.0588
  Santa Barbara, CA
7485  Santa Cruz-Watsonville, CA..............................    1.3630
  Santa Cruz, CA
7490  Santa Fe, NM............................................    1.0822
  Los Alamos, NM
  Santa Fe, NM
7500   Santa Rosa, CA.........................................    1.3179
  Sonoma, CA
7510  Sarasota-Bradenton, FL..................................    0.9339
  Manatee, FL
  Sarasota, FL

[[Page 31617]]

 
7520  Savannah, GA............................................    0.9961
  Bryan, GA
  Chatham, GA
  Effingham, GA
7560  Scranton--Wilkes-Barre--Hazleton, PA....................    0.8525
  Columbia, PA
  Lackawanna, PA
  Luzerne, PA
  Wyoming, PA
7600  Seattle-Bellevue-Everett, WA............................    1.1571
  Island, WA
  King, WA
  Snohomish, WA
7610  Sharon, PA..............................................    0.8525
  Mercer, PA
7620  Sheboygan, WI...........................................    0.9229
  Sheboygan, WI
7640  Sherman-Denison, TX.....................................    0.9334
  Grayson, TX
7680   Shreveport-Bossier City, LA............................    0.8813
  Bossier, LA
  Caddo, LA
  Webster, LA
7720  Sioux City, IA-NE.......................................    0.9138
  Woodbury, IA
  Dakota, NE
7760  Sioux Falls, SD.........................................    0.9098
  Lincoln, SD
  Minnehaha, SD
7800  South Bend, IN..........................................    0.9902
  St. Joseph, IN
7840  Spokane, WA.............................................    1.0961
  Spokane, WA
7880  Springfield, IL.........................................    0.8654
  Menard, IL
  Sangamon, IL
7920  Springfield, MO.........................................    0.8510
  Christian, MO
  Greene, MO
  Webster, MO
8003  Springfield, MA.........................................    1.1257
  Hampden, MA
  Hampshire, MA
8050  State College, PA.......................................    0.9032
  Centre, PA
8080  Steubenville-Weirton, OH-WV (WV Hospitals)..............    0.8893
  Jefferson, OH
  Brooke, WV
  Hancock, WV
8120  Stockton-Lodi, CA.......................................    1.0445
  San Joaquin, CA
8140  Sumter, SC..............................................    0.8607
  Sumter, SC
8160  Syracuse, NY............................................    0.9519
  Cayuga, NY
  Madison, NY
  Onondaga, NY
  Oswego, NY
8200  Tacoma, WA..............................................    1.1052
  Pierce, WA
8240  Tallahassee, FL.........................................    0.8907
  Gadsden, FL
  Leon, FL
8280  Tampa-St. Petersburg-Clearwater, FL.....................    0.9127
  Hernando, FL
  Hillsborough, FL
  Pasco, FL
  Pinellas, FL
8320  Terre Haute, IN.........................................    0.8796
  Clay, IN
  Vermillion, IN
  Vigo, IN
8360  Texarkana,AR-Texarkana, TX..............................    0.8150
  Miller, AR
  Bowie, TX
8400  Toledo, OH..............................................    0.9863
  Fulton, OH
  Lucas, OH
  Wood, OH
8440  Topeka, KS..............................................    0.8952
  Shawnee, KS
8480   Trenton, NJ............................................    1.0710
  Mercer, NJ
8520  Tucson, AZ..............................................    0.8993
  Pima, AZ
8560  Tulsa, OK...............................................    0.8398
  Creek, OK
  Osage, OK
  Rogers, OK
  Tulsa, OK
  Wagoner, OK
8600  Tuscaloosa, AL..........................................    0.8221
  Tuscaloosa, AL
8640  Tyler, TX...............................................    0.9650
  Smith, TX
8680  Utica-Rome, NY..........................................    0.8633
  Herkimer, NY
  Oneida, NY
8720  Vallejo-Fairfield-Napa, CA..............................    1.3472
  Napa, CA
  Solano, CA
8735  Ventura, CA.............................................    1.1209
  Ventura, CA
8750  Victoria, TX............................................    0.8814
  Victoria, TX
8760  Vineland-Millville-Bridgeton, NJ........................    1.0296
  Cumberland, NJ
8780  Visalia-Tulare-Porterville, CA..........................    0.9934
  Tulare, CA
8800  Waco, TX................................................    0.8802
  McLennan, TX
8840  Washington, DC-MD-
  VA-WV.......................................................    1.0852
  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................................    0.8395
  Black Hawk, IA
8940  Wausau, WI..............................................    0.9882
  Marathon, WI
8960  West Palm Beach-
  Boca Raton, FL..............................................    0.9929
  Palm Beach, FL
9000  Wheeling, WV-OH.........................................    0.8053
  Belmont, OH
  Marshall, WV
  Ohio, WV
9040  Wichita, KS.............................................    0.9571
  Butler, KS
  Harvey, KS
  Sedgwick, KS
9080  Wichita Falls, TX.......................................    0.8023
  Archer, TX
  Wichita, TX
9140  Williamsport, PA........................................    0.8624
  Lycoming, PA
9160  Wilmington-Newark, DE-MD................................    1.1287
  New Castle, DE
  Cecil, MD
9200  Wilmington, NC..........................................    0.9471
  New Hanover, NC
  Brunswick, NC
9260  Yakima, WA..............................................    1.0676
  Yakima, WA
9270  Yolo, CA................................................    0.9934
  Yolo, CA
9280  York, PA................................................    0.9140
  York, PA
9320  Youngstown-Warren, OH...................................    0.9485
  Columbiana, OH
  Mahoning, OH
  Trumbull, OH
9340  Yuba City, CA...........................................    1.0310
  Sutter, CA
  Yuba, CA
9360  Yuma, AZ................................................    0.8677
  Yuma, AZ
------------------------------------------------------------------------


         Table 4H.--Pre-Reclassified Wage Index for Rural Areas
------------------------------------------------------------------------
                                                                  Wage
                         Nonurban area                            index
------------------------------------------------------------------------
Alabama.......................................................    0.7786
Alaska........................................................    1.2323
Arizona.......................................................    0.8483
Arkansas......................................................    0.7670
California....................................................    0.9934
Colorado......................................................    0.9104
Connecticut...................................................    1.2520
Delaware......................................................    0.9126
Florida.......................................................    0.8907
Georgia.......................................................    0.8254
Hawaii........................................................    1.0342
Idaho.........................................................    0.8799
Illinois......................................................    0.8301
Indiana.......................................................    0.8796
Iowa..........................................................    0.8395
Kansas........................................................    0.7964

[[Page 31618]]

 
Kentucky......................................................    0.8079
Louisiana.....................................................    0.7637
Maine.........................................................    0.8754
Maryland......................................................    0.8855
Massachusetts.................................................    1.1257
Michigan......................................................    0.8944
Minnesota.....................................................    0.9249
Mississippi...................................................    0.7746
Missouri......................................................    0.8093
Montana.......................................................    0.8567
Nebraska......................................................    0.8283
Nevada........................................................    0.9519
New Hampshire.................................................    0.9882
New Jersey \1\................................................  ........
New Mexico....................................................    0.8645
New York......................................................    0.8633
North Carolina................................................    0.8714
North Dakota..................................................    0.7830
Ohio..........................................................    0.8675
Oklahoma......................................................    0.7664
Oregon........................................................    1.0408
Pennsylvania..................................................    0.8525
Puerto Rico...................................................    0.4400
Rhode Island \1\..............................................  ........
South Carolina................................................    0.8607
South Dakota..................................................    0.7895
Tennessee.....................................................    0.7873
Texas.........................................................    0.7752
Utah..........................................................    0.9426
Vermont.......................................................    0.9402
Virginia......................................................    0.8494
Washington....................................................    1.0274
West Virginia.................................................    0.8053
Wisconsin.....................................................    0.9229
Wyoming.......................................................    0.8890
------------------------------------------------------------------------
\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.

GEOMETRIC MEAN IS USED ONLY TO DETERMINE PAYMENT FOR TRANSFER CASES.

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 31618]]



  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 W CC....      3.7174         8.1        11.2
2...............       01  SURG                  CRANIOTOMY AGE >17 W/O CC..      1.9613         4.0         5.2
3...............       01  SURG                  * CRANIOTOMY AGE 0-17......      1.9441        12.7        12.7
4...............       01  SURG                  SPINAL PROCEDURES..........      2.2960         4.5         7.2
5...............       01  SURG                  EXTRACRANIAL VASCULAR            1.3846         2.1         3.1
                                                  PROCEDURES.
6...............       01  SURG                  CARPAL TUNNEL RELEASE......       .8237         2.1         2.9
7...............       01  SURG                  PERIPH & CRANIAL NERVE &         2.5718         6.5         9.8
                                                  OTHER NERV SYST PROC W CC.
8...............       01  SURG                  PERIPH & CRANIAL NERVE &         1.4925         1.9         2.8
                                                  OTHER NERV SYST PROC W/O
                                                  CC.
9...............       01  MED                   SPINAL DISORDERS & INJURIES      1.3592         4.6         6.6
10..............       01  MED                   NERVOUS SYSTEM NEOPLASMS W       1.2507         4.9         6.6
                                                  CC.
11..............       01  MED                   NERVOUS SYSTEM NEOPLASMS W/       .8629         3.0         4.0
                                                  O CC.
12..............       01  MED                   DEGENERATIVE NERVOUS SYSTEM       .8881         4.4         5.9
                                                  DISORDERS.
13..............       01  MED                   MULTIPLE SCLEROSIS &              .7928         4.1         5.0
                                                  CEREBELLAR ATAXIA.
14..............       01  MED                   INTRACRANIAL HEMORRHAGE &        1.2742         4.8         6.2
                                                  STROKE W INFARCT.
15..............       01  MED                   NONSPECIFIC CVA &                 .9844         4.0         5.0
                                                  PRECEREBRAL OCCLUSION W/O
                                                  INFARCT.
16..............       01  MED                   NONSPECIFIC CEREBROVASCULAR      1.2389         4.7         6.2
                                                  DISORDERS W CC.
17..............       01  MED                   NONSPECIFIC CEREBROVASCULAR       .6651         2.5         3.1
                                                  DISORDERS W/O CC.
18..............       01  MED                   CRANIAL & PERIPHERAL NERVE        .9712         4.2         5.4
                                                  DISORDERS W CC.
19..............       01  MED                   CRANIAL & PERIPHERAL NERVE        .6939         2.8         3.5
                                                  DISORDERS W/O CC.
20..............       01  MED                   NERVOUS SYSTEM INFECTION         2.7921         8.0        10.8
                                                  EXCEPT VIRAL MENINGITIS.
21..............       01  MED                   VIRAL MENINGITIS...........      1.5323         5.0         6.6
22..............       01  MED                   HYPERTENSIVE ENCEPHALOPATHY      1.0334         3.9         5.0
23..............       01  MED                   NONTRAUMATIC STUPOR & COMA.       .8214         3.1         4.3
24..............       01  MED                   SEIZURE & HEADACHE AGE >17        .9953         3.6         4.9
                                                  W CC.
25..............       01  MED                   SEIZURE & HEADACHE AGE >17        .6061         2.5         3.2
                                                  W/O CC.
26..............       01  MED                   SEIZURE & HEADACHE AGE 0-17       .7854         2.5         4.7
27..............       01  MED                   TRAUMATIC STUPOR & COMA,         1.3045         3.2         5.0
                                                  COMA >1 HR.
28..............       01  MED                   TRAUMATIC STUPOR & COMA,         1.3318         4.5         6.3
                                                  COMA 1 HR AGE >17 W CC.
29..............       01  MED                   TRAUMATIC STUPOR & COMA,          .7069         2.7         3.6
                                                  COMA 1 HR AGE >17 W/O CC.
30..............       01  MED                   * TRAUMATIC STUPOR & COMA,        .3288         2.0         2.0
                                                  COMA 1 HR AGE 0-17.
31..............       01  MED                   CONCUSSION AGE >17 W CC....       .8787         3.0         4.1
32..............       01  MED                   CONCUSSION AGE >17 W/O CC..       .5318         1.9         2.4
33..............       01  MED                   * CONCUSSION AGE 0-17......       .2066         1.6         1.6
34..............       01  MED                   OTHER DISORDERS OF NERVOUS        .9962         3.7         5.1
                                                  SYSTEM W CC.
35..............       01  MED                   OTHER DISORDERS OF NERVOUS        .6353         2.5         3.2
                                                  SYSTEM W/O CC.
36..............       02  SURG                  RETINAL PROCEDURES.........       .6814         1.2         1.5
37..............       02  SURG                  ORBITAL PROCEDURES.........      1.0534         2.6         3.8
38..............       02  SURG                  PRIMARY IRIS PROCEDURES....       .5412         1.9         2.5
39..............       02  SURG                  LENS PROCEDURES WITH OR           .5924         1.5         1.9
                                                  WITHOUT VITRECTOMY.
40..............       02  SURG                  EXTRAOCULAR PROCEDURES            .8647         2.5         3.6
                                                  EXCEPT ORBIT AGE >17.
41..............       02  SURG                  * EXTRAOCULAR PROCEDURES          .3348         1.6         1.6
                                                  EXCEPT ORBIT AGE 0-17.
42..............       02  SURG                  INTRAOCULAR PROCEDURES            .6552         1.7         2.4
                                                  EXCEPT RETINA, IRIS & LENS.
43..............       02  MED                   HYPHEMA....................       .4951         2.4         3.0
44..............       02  MED                   ACUTE MAJOR EYE INFECTIONS.       .6374         4.1         5.1
45..............       02  MED                   NEUROLOGICAL EYE DISORDERS.       .7064         2.6         3.2

[[Page 31619]]

 
46..............       02  MED                   OTHER DISORDERS OF THE EYE        .7810         3.4         4.6
                                                  AGE >17 W CC.
47..............       02  MED                   OTHER DISORDERS OF THE EYE        .5193         2.5         3.2
                                                  AGE >17 W/O CC.
48..............       02  MED                   * OTHER DISORDERS OF THE          .2949         2.9         2.9
                                                  EYE AGE 0-17.
49..............       03  SURG                  MAJOR HEAD & NECK                1.7706         3.3         4.6
                                                  PROCEDURES.
50..............       03  SURG                  SIALOADENECTOMY............       .8318         1.5         1.8
51..............       03  SURG                  SALIVARY GLAND PROCEDURES         .9325         1.9         3.1
                                                  EXCEPT SIALOADENECTOMY.
52..............       03  SURG                  CLEFT LIP & PALATE REPAIR..       .8003         1.5         1.9
53..............       03  SURG                  SINUS & MASTOID PROCEDURES       1.1968         2.1         3.4
                                                  AGE >17.
54..............       03  SURG                  * SINUS & MASTOID                 .4779         3.2         3.2
                                                  PROCEDURES AGE 0-17.
55..............       03  SURG                  MISCELLANEOUS EAR, NOSE,          .9492         1.9         3.0
                                                  MOUTH & THROAT PROCEDURES.
56..............       03  SURG                  RHINOPLASTY................       .9678         2.0         3.0
57..............       03  SURG                  T&A PROC, EXCEPT                  .9849         2.4         3.7
                                                  TONSILLECTOMY &/OR
                                                  ADENOIDECTOMY ONLY, AGE
                                                  >17.
58..............       03  SURG                  * T&A PROC, EXCEPT                .2714         1.5         1.5
                                                  TONSILLECTOMY &/OR
                                                  ADENOIDECTOMY ONLY, AGE 0-
                                                  17.
59..............       03  SURG                  TONSILLECTOMY &/OR                .7530         1.8         2.6
                                                  ADENOIDECTOMY ONLY, AGE
                                                  >17.
60..............       03  SURG                  * TONSILLECTOMY &/OR              .2067         1.5         1.5
                                                  ADENOIDECTOMY ONLY, AGE 0-
                                                  17.
61..............       03  SURG                  MYRINGOTOMY W TUBE               1.3030         2.9         4.8
                                                  INSERTION AGE >17.
62..............       03  SURG                  * MYRINGOTOMY W TUBE              .2927         1.3         1.3
                                                  INSERTION AGE 0-17.
63..............       03  SURG                  OTHER EAR, NOSE, MOUTH &         1.4279         3.0         4.5
                                                  THROAT O.R. PROCEDURES.
64..............       03  MED                   EAR, NOSE, MOUTH & THROAT        1.3100         4.4         6.6
                                                  MALIGNANCY.
65..............       03  MED                   DYSEQUILIBRIUM.............       .5487         2.3         2.8
66..............       03  MED                   EPISTAXIS..................       .5626         2.4         3.1
67..............       03  MED                   EPIGLOTTITIS...............       .7763         2.8         3.6
68..............       03  MED                   OTITIS MEDIA & URI AGE >17        .6690         3.1         3.8
                                                  W CC.
69..............       03  MED                   OTITIS MEDIA & URI AGE >17        .5033         2.4         3.0
                                                  W/O CC.
70..............       03  MED                   OTITIS MEDIA & URI AGE 0-17       .4570         2.8         3.5
71..............       03  MED                   LARYNGOTRACHEITIS..........       .6933         2.8         3.4
72..............       03  MED                   NASAL TRAUMA & DEFORMITY...       .7159         2.6         3.6
73..............       03  MED                   OTHER EAR, NOSE, MOUTH &          .7961         3.2         4.4
                                                  THROAT DIAGNOSES AGE >17.
74..............       03  MED                   * OTHER EAR, NOSE, MOUTH &        .3326         2.1         2.1
                                                  THROAT DIAGNOSES AGE 0-17.
75..............       04  SURG                  MAJOR CHEST PROCEDURES.....      3.0978         7.7        10.1
76..............       04  SURG                  OTHER RESP SYSTEM O.R.           2.8553         8.5        11.4
                                                  PROCEDURES W CC.
77..............       04  SURG                  OTHER RESP SYSTEM O.R.           1.2070         3.5         4.9
                                                  PROCEDURES W/O CC.
78..............       04  MED                   PULMONARY EMBOLISM.........      1.2980         5.7         6.7
79..............       04  MED                   RESPIRATORY INFECTIONS &         1.6199         6.7         8.5
                                                  INFLAMMATIONS AGE >17 W CC.
80..............       04  MED                   RESPIRATORY INFECTIONS &          .8747         4.4         5.5
                                                  INFLAMMATIONS AGE >17 W/O
                                                  CC.
81..............       04  MED                   * RESPIRATORY INFECTIONS &       1.5059         6.1         6.1
                                                  INFLAMMATIONS AGE 0-17.
82..............       04  MED                   RESPIRATORY NEOPLASMS......      1.3926         5.2         7.0
83..............       04  MED                   MAJOR CHEST TRAUMA W CC....       .9653         4.3         5.5
84..............       04  MED                   MAJOR CHEST TRAUMA W/O CC..       .5109         2.6         3.2
85..............       04  MED                   PLEURAL EFFUSION W CC......      1.2119         4.8         6.4
86..............       04  MED                   PLEURAL EFFUSION W/O CC....       .6963         2.9         3.8
87..............       04  MED                   PULMONARY EDEMA &                1.3625         4.8         6.3
                                                  RESPIRATORY FAILURE.
88..............       04  MED                   CHRONIC OBSTRUCTIVE               .9039         4.1         5.1
                                                  PULMONARY DISEASE.
89..............       04  MED                   SIMPLE PNEUMONIA & PLEURISY      1.0431         4.8         5.9
                                                  AGE >17 W CC.
90..............       04  MED                   SIMPLE PNEUMONIA & PLEURISY       .6270         3.4         4.0
                                                  AGE >17 W/O CC.
91..............       04  MED                   SIMPLE PNEUMONIA & PLEURISY       .6854         3.2         4.0
                                                  AGE 0-17.
92..............       04  MED                   INTERSTITIAL LUNG DISEASE W      1.2255         5.0         6.4
                                                  CC.
93..............       04  MED                   INTERSTITIAL LUNG DISEASE W/      .7331         3.3         4.1
                                                  O CC.
94..............       04  MED                   PNEUMOTHORAX W CC..........      1.1575         4.7         6.4
95..............       04  MED                   PNEUMOTHORAX W/O CC........       .5895         2.9         3.7
96..............       04  MED                   BRONCHITIS & ASTHMA AGE >17       .7541         3.7         4.6
                                                  W CC.
97..............       04  MED                   BRONCHITIS & ASTHMA AGE >17       .5602         2.9         3.5
                                                  W/O CC.
98..............       04  MED                   BRONCHITIS & ASTHMA AGE 0-        .9319         3.7         5.1
                                                  17.
99..............       04  MED                   RESPIRATORY SIGNS &               .7022         2.4         3.2
                                                  SYMPTOMS W CC.
100.............       04  MED                   RESPIRATORY SIGNS &               .5347         1.7         2.1
                                                  SYMPTOMS W/O CC.
101.............       04  MED                   OTHER RESPIRATORY SYSTEM          .8567         3.3         4.4
                                                  DIAGNOSES W CC.
102.............       04  MED                   OTHER RESPIRATORY SYSTEM          .5447         2.0         2.6
                                                  DIAGNOSES W/O CC.
103.............      PRE  SURG                  HEART TRANSPLANT...........     19.5361        29.7        49.4
104.............       05  SURG                  CARDIAC VALVE & OTH MAJOR        7.9615        12.3        14.4
                                                  CARDIOTHORACIC PROC W CARD
                                                  CATH.
105.............       05  SURG                  CARDIAC VALVE & OTH MAJOR        5.7856         8.3        10.0
                                                  CARDIOTHORACIC PROC W/O
                                                  CARD CATH.
106.............       05  SURG                  CORONARY BYPASS W PTCA.....      7.4493         9.6        11.4
107.............       05  SURG                  CORONARY BYPASS W CARDIAC        5.3894         9.2        10.5
                                                  CATH.

[[Page 31620]]

 
108.............       05  SURG                  OTHER CARDIOTHORACIC             5.4585         7.8        10.3
                                                  PROCEDURES.
109.............       05  SURG                  CORONARY BYPASS W/O PTCA OR      3.9756         6.8         7.7
                                                  CARDIAC CATH.
110.............       05  SURG                  MAJOR CARDIOVASCULAR             4.0985         6.5         9.1
                                                  PROCEDURES W CC.
111.............       05  SURG                  MAJOR CARDIOVASCULAR             2.4445         3.5         4.4
                                                  PROCEDURES W/O CC.
112.............       05  SURG                  NO LONGER VALID............       .0000          .0          .0
113.............       05  SURG                  AMPUTATION FOR CIRC SYSTEM       2.9028        10.4        13.4
                                                  DISORDERS EXCEPT UPPER
                                                  LIMB & TOE.
114.............       05  SURG                  UPPER LIMB & TOE AMPUTATION      1.6530         6.2         8.5
                                                  FOR CIRC SYSTEM DISORDERS.
115.............       05  SURG                  PRM CARD PACEM IMPL W            3.4452         5.9         8.3
                                                  AMI,HRT FAIL OR SHK,OR
                                                  AICD LEAD OR GN.
116.............       05  SURG                  OTHER PERMANENT CARDIAC          2.3075         3.2         4.5
                                                  PACEMAKER IMPLANT.
117.............       05  SURG                  CARDIAC PACEMAKER REVISION       1.3312         2.6         4.2
                                                  EXCEPT DEVICE REPLACEMENT.
118.............       05  SURG                  CARDIAC PACEMAKER DEVICE         1.5696         1.9         2.9
                                                  REPLACEMENT.
119.............       05  SURG                  VEIN LIGATION & STRIPPING..      1.3027         3.0         5.1
120.............       05  SURG                  OTHER CIRCULATORY SYSTEM         2.2337         5.3         8.8
                                                  O.R. PROCEDURES.
121.............       05  MED                   CIRCULATORY DISORDERS W AMI      1.5813         5.3         6.6
                                                  & MAJOR COMP, DISCHARGED
                                                  ALIVE.
122.............       05  MED                   CIRCULATORY DISORDERS W AMI      1.0393         3.0         3.8
                                                  W/O MAJOR COMP, DISCHARGED
                                                  ALIVE.
123.............       05  MED                   CIRCULATORY DISORDERS W          1.5526         2.8         4.7
                                                  AMI, EXPIRED.
124.............       05  MED                   CIRCULATORY DISORDERS            1.4301         3.3         4.4
                                                  EXCEPT AMI, W CARD CATH &
                                                  COMPLEX DIAG.
125.............       05  MED                   CIRCULATORY DISORDERS            1.0846         2.1         2.7
                                                  EXCEPT AMI, W CARD CATH W/
                                                  O COMPLEX DIAG.
126.............       05  MED                   ACUTE & SUBACUTE                 2.6971         9.5        12.2
                                                  ENDOCARDITIS.
127.............       05  MED                   HEART FAILURE & SHOCK......      1.0027         4.1         5.3
128.............       05  MED                   DEEP VEIN THROMBOPHLEBITIS.       .7241         4.7         5.5
129.............       05  MED                   CARDIAC ARREST, UNEXPLAINED      1.0803         1.8         2.8
130.............       05  MED                   PERIPHERAL VASCULAR               .9384         4.5         5.7
                                                  DISORDERS W CC.
131.............       05  MED                   PERIPHERAL VASCULAR               .5683         3.3         4.1
                                                  DISORDERS W/O CC.
132.............       05  MED                   ATHEROSCLEROSIS W CC.......       .6540         2.3         3.0
133.............       05  MED                   ATHEROSCLEROSIS W/O CC.....       .5359         1.8         2.3
134.............       05  MED                   HYPERTENSION...............       .5884         2.5         3.2
135.............       05  MED                   CARDIAC CONGENITAL &              .8961         3.3         4.5
                                                  VALVULAR DISORDERS AGE >17
                                                  W CC.
136.............       05  MED                   CARDIAC CONGENITAL &              .5709         2.1         2.6
                                                  VALVULAR DISORDERS AGE >17
                                                  W/O CC.
137.............       05  MED                   * CARDIAC CONGENITAL &            .8113         3.3         3.3
                                                  VALVULAR DISORDERS AGE 0-
                                                  17.
138.............       05  MED                   CARDIAC ARRHYTHMIA &              .8249         3.1         4.0
                                                  CONDUCTION DISORDERS W CC.
139.............       05  MED                   CARDIAC ARRHYTHMIA &              .5128         2.0         2.5
                                                  CONDUCTION DISORDERS W/O
                                                  CC.
140.............       05  MED                   ANGINA PECTORIS............       .5384         2.1         2.6
141.............       05  MED                   SYNCOPE & COLLAPSE W CC....       .7284         2.8         3.6
142.............       05  MED                   SYNCOPE & COLLAPSE W/O CC..       .5605         2.1         2.6
143.............       05  MED                   CHEST PAIN.................       .5394         1.7         2.1
144.............       05  MED                   OTHER CIRCULATORY SYSTEM         1.1931         3.8         5.5
                                                  DIAGNOSES W CC.
145.............       05  MED                   OTHER CIRCULATORY SYSTEM          .5881         2.1         2.7
                                                  DIAGNOSES W/O CC.
146.............       06  SURG                  RECTAL RESECTION W CC......      2.7193         8.8        10.2
147.............       06  SURG                  RECTAL RESECTION W/O CC....      1.5566         5.8         6.4
148.............       06  SURG                  MAJOR SMALL & LARGE BOWEL        3.4444        10.2        12.3
                                                  PROCEDURES W CC.
149.............       06  SURG                  MAJOR SMALL & LARGE BOWEL        1.5247         5.9         6.5
                                                  PROCEDURES W/O CC.
150.............       06  SURG                  PERITONEAL ADHESIOLYSIS W        2.8477         9.1        11.2
                                                  CC.
151.............       06  SURG                  PERITONEAL ADHESIOLYSIS W/O      1.3334         4.5         5.7
                                                  CC.
152.............       06  SURG                  MINOR SMALL & LARGE BOWEL        1.9467         6.9         8.3
                                                  PROCEDURES W CC.
153.............       06  SURG                  MINOR SMALL & LARGE BOWEL        1.1736         4.8         5.4
                                                  PROCEDURES W/O CC.
154.............       06  SURG                  STOMACH, ESOPHAGEAL &            4.1397         9.8        13.2
                                                  DUODENAL PROCEDURES AGE
                                                  >17 W CC.
155.............       06  SURG                  STOMACH, ESOPHAGEAL &            1.3054         3.0         4.0
                                                  DUODENAL PROCEDURES AGE
                                                  >17 W/O CC.
156.............       06  SURG                  * STOMACH, ESOPHAGEAL &           .8355         6.0         6.0
                                                  DUODENAL PROCEDURES AGE 0-
                                                  17.
157.............       06  SURG                  ANAL & STOMAL PROCEDURES W       1.2618         3.9         5.6
                                                  CC.
158.............       06  SURG                  ANAL & STOMAL PROCEDURES W/       .6504         2.0         2.5
                                                  O CC.
159.............       06  SURG                  HERNIA PROCEDURES EXCEPT         1.3593         3.7         5.1
                                                  INGUINAL & FEMORAL AGE >17
                                                  W CC.
160.............       06  SURG                  HERNIA PROCEDURES EXCEPT          .8070         2.2         2.7
                                                  INGUINAL & FEMORAL AGE >17
                                                  W/O CC.
161.............       06  SURG                  INGUINAL & FEMORAL HERNIA        1.1278         2.8         4.2
                                                  PROCEDURES AGE >17 W CC.
162.............       06  SURG                  INGUINAL & FEMORAL HERNIA         .6337         1.6         1.9
                                                  PROCEDURES AGE >17 W/O CC.

[[Page 31621]]

 
163.............       06  SURG                  * HERNIA PROCEDURES AGE 0-        .6855         2.1         2.1
                                                  17.
164.............       06  SURG                  APPENDECTOMY W COMPLICATED       2.2964         7.0         8.3
                                                  PRINCIPAL DIAG W CC.
165.............       06  SURG                  APPENDECTOMY W COMPLICATED       1.2622         4.0         4.7
                                                  PRINCIPAL DIAG W/O CC.
166.............       06  SURG                  APPENDECTOMY W/O                 1.4680         3.7         4.9
                                                  COMPLICATED PRINCIPAL DIAG
                                                  W CC.
167.............       06  SURG                  APPENDECTOMY W/O                  .9104         2.1         2.5
                                                  COMPLICATED PRINCIPAL DIAG
                                                  W/O CC.
168.............       03  SURG                  MOUTH PROCEDURES W CC......      1.2974         3.3         4.9
169.............       03  SURG                  MOUTH PROCEDURES W/O CC....       .7397         1.8         2.3
170.............       06  SURG                  OTHER DIGESTIVE SYSTEM O.R.      2.8017         7.4        11.0
                                                  PROCEDURES W CC.
171.............       06  SURG                  OTHER DIGESTIVE SYSTEM O.R.      1.1651         3.1         4.3
                                                  PROCEDURES W/O CC.
172.............       06  MED                   DIGESTIVE MALIGNANCY W CC..      1.3567         5.1         7.0
173.............       06  MED                   DIGESTIVE MALIGNANCY W/O CC       .7531         2.7         3.8
174.............       06  MED                   G.I. HEMORRHAGE W CC.......       .9937         3.9         4.8
175.............       06  MED                   G.I. HEMORRHAGE W/O CC.....       .5553         2.5         2.9
176.............       06  MED                   COMPLICATED PEPTIC ULCER...      1.0832         4.1         5.3
177.............       06  MED                   UNCOMPLICATED PEPTIC ULCER        .9193         3.7         4.5
                                                  W CC.
178.............       06  MED                   UNCOMPLICATED PEPTIC ULCER        .6843         2.6         3.1
                                                  W/O CC.
179.............       06  MED                   INFLAMMATORY BOWEL DISEASE.      1.0778         4.6         6.0
180.............       06  MED                   G.I. OBSTRUCTION W CC......       .9429         4.2         5.4
181.............       06  MED                   G.I. OBSTRUCTION W/O CC....       .5322         2.8         3.4
182.............       06  MED                   ESOPHAGITIS, GASTROENT &          .7982         3.3         4.4
                                                  MISC DIGEST DISORDERS AGE
                                                  >17 W CC.
183.............       06  MED                   ESOPHAGITIS, GASTROENT &          .5722         2.3         2.9
                                                  MISC DIGEST DISORDERS AGE
                                                  >17 W/O CC.
184.............       06  MED                   ESOPHAGITIS, GASTROENT &          .4806         2.3         2.8
                                                  MISC DIGEST DISORDERS AGE
                                                  0-17.
185.............       03  MED                   DENTAL & ORAL DIS EXCEPT          .8998         3.3         4.7
                                                  EXTRACTIONS &
                                                  RESTORATIONS, AGE >17.
186.............       03  MED                   * DENTAL & ORAL DIS EXCEPT        .3185         2.9         2.9
                                                  EXTRACTIONS &
                                                  RESTORATIONS, AGE 0-17.
187.............       03  MED                   DENTAL EXTRACTIONS &              .8564         3.0         4.1
                                                  RESTORATIONS.
188.............       06  MED                   OTHER DIGESTIVE SYSTEM           1.0955         4.1         5.6
                                                  DIAGNOSES AGE >17 W CC.
189.............       06  MED                   OTHER DIGESTIVE SYSTEM            .5821         2.4         3.1
                                                  DIAGNOSES AGE >17 W/O CC.
190.............       06  MED                   OTHER DIGESTIVE SYSTEM            .6986         3.3         4.8
                                                  DIAGNOSES AGE 0-17.
191.............       07  SURG                  PANCREAS, LIVER & SHUNT          4.2962         9.8        13.8
                                                  PROCEDURES W CC.
192.............       07  SURG                  PANCREAS, LIVER & SHUNT          1.6932         4.7         6.1
                                                  PROCEDURES W/O CC.
193.............       07  SURG                  BILIARY TRACT PROC EXCEPT        3.4015        10.4        12.8
                                                  ONLY CHOLECYST W OR W/O
                                                  C.D.E. W CC.
194.............       07  SURG                  BILIARY TRACT PROC EXCEPT        1.6023         5.5         6.9
                                                  ONLY CHOLECYST W OR W/O
                                                  C.D.E. W/O CC.
195.............       07  SURG                  CHOLECYSTECTOMY W C.D.E. W       3.0046         8.6        10.4
                                                  CC.
196.............       07  SURG                  CHOLECYSTECTOMY W C.D.E. W/      1.6036         4.6         5.4
                                                  O CC.
197.............       07  SURG                  CHOLECYSTECTOMY EXCEPT BY        2.4858         7.3         9.0
                                                  LAPAROSCOPE W/O C.D.E. W
                                                  CC.
198.............       07  SURG                  CHOLECYSTECTOMY EXCEPT BY        1.2276         3.8         4.4
                                                  LAPAROSCOPE W/O C.D.E. W/O
                                                  CC.
199.............       07  SURG                  HEPATOBILIARY DIAGNOSTIC         2.4260         7.0         9.9
                                                  PROCEDURE FOR MALIGNANCY.
200.............       07  SURG                  HEPATOBILIARY DIAGNOSTIC         2.9570         6.5        10.5
                                                  PROCEDURE FOR NON-
                                                  MALIGNANCY.
201.............       07  SURG                  OTHER HEPATOBILIARY OR           3.7421        10.3        14.5
                                                  PANCREAS O.R. PROCEDURES.
202.............       07  MED                   CIRRHOSIS & ALCOHOLIC            1.2879         4.8         6.4
                                                  HEPATITIS.
203.............       07  MED                   MALIGNANCY OF HEPATOBILIARY      1.3499         5.0         6.8
                                                  SYSTEM OR PANCREAS.
204.............       07  MED                   DISORDERS OF PANCREAS            1.1826         4.4         5.8
                                                  EXCEPT MALIGNANCY.
205.............       07  MED                   DISORDERS OF LIVER EXCEPT        1.1933         4.6         6.2
                                                  MALIG,CIRR,ALC HEPA W CC.
206.............       07  MED                   DISORDERS OF LIVER EXCEPT         .7038         3.0         3.9
                                                  MALIG,CIRR,ALC HEPA W/O CC.
207.............       07  MED                   DISORDERS OF THE BILIARY         1.1338         4.0         5.3
                                                  TRACT W CC.
208.............       07  MED                   DISORDERS OF THE BILIARY          .6526         2.3         2.9
                                                  TRACT W/O CC.
209.............       08  SURG                  MAJOR JOINT & LIMB               2.0531         4.5         5.0
                                                  REATTACHMENT PROCEDURES OF
                                                  LOWER EXTREMITY.
210.............       08  SURG                  HIP & FEMUR PROCEDURES           1.8289         6.1         7.0
                                                  EXCEPT MAJOR JOINT AGE >17
                                                  W CC.
211.............       08  SURG                  HIP & FEMUR PROCEDURES           1.2715         4.6         5.0
                                                  EXCEPT MAJOR JOINT AGE >17
                                                  W/O CC.
212.............       08  SURG                  * HIP & FEMUR PROCEDURES          .8391        11.1        11.1
                                                  EXCEPT MAJOR JOINT AGE 0-
                                                  17.
213.............       08  SURG                  AMPUTATION FOR                   1.8664         6.6         9.2
                                                  MUSCULOSKELETAL SYSTEM &
                                                  CONN TISSUE DISORDERS.
214.............       08  SURG                  NO LONGER VALID............       .0000          .0          .0
215.............       08  SURG                  NO LONGER VALID............       .0000          .0          .0

[[Page 31622]]

 
216.............       08  SURG                  BIOPSIES OF MUSCULOSKELETAL      2.2151         6.6         9.6
                                                  SYSTEM & CONNECTIVE TISSUE.
217.............       08  SURG                  WND DEBRID & SKN GRFT            3.0062         9.1        13.4
                                                  EXCEPT HAND,FOR MUSCSKELET
                                                  & CONN TISS DIS.
218.............       08  SURG                  LOWER EXTREM & HUMER PROC        1.5404         4.3         5.4
                                                  EXCEPT HIP,FOOT,FEMUR AGE
                                                  >17 W CC.
219.............       08  SURG                  LOWER EXTREM & HUMER PROC        1.0244         2.7         3.2
                                                  EXCEPT HIP,FOOT,FEMUR AGE
                                                  >17 W/O CC.
220.............       08  SURG                  * LOWER EXTREM & HUMER PROC       .5789         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,       1.0248         2.1         2.9
                                                  OR OTHER UPPER EXTREMITY
                                                  PROC W CC.
224.............       08  SURG                  SHOULDER,ELBOW OR FOREARM         .7868         1.6         1.9
                                                  PROC,EXC MAJOR JOINT PROC,
                                                  W/O CC.
225.............       08  SURG                  FOOT PROCEDURES............      1.1460         3.4         5.0
226.............       08  SURG                  SOFT TISSUE PROCEDURES W CC      1.5663         4.6         6.7
227.............       08  SURG                  SOFT TISSUE PROCEDURES W/O        .8129         2.1         2.7
                                                  CC.
228.............       08  SURG                  MAJOR THUMB OR JOINT             1.1339         2.6         4.1
                                                  PROC,OR OTH HAND OR WRIST
                                                  PROC W CC.
229.............       08  SURG                  HAND OR WRIST PROC, EXCEPT        .6984         1.7         2.2
                                                  MAJOR JOINT PROC, W/O CC.
230.............       08  SURG                  LOCAL EXCISION & REMOVAL OF      1.2657         3.3         5.1
                                                  INT FIX DEVICES OF HIP &
                                                  FEMUR.
231.............       08  SURG                  LOCAL EXCISION & REMOVAL OF      1.3977         3.1         4.9
                                                  INT FIX DEVICES EXCEPT HIP
                                                  & FEMUR.
232.............       08  SURG                  ARTHROSCOPY................      1.0021         1.8         2.7
233.............       08  SURG                  OTHER MUSCULOSKELET SYS &        1.9862         4.8         7.2
                                                  CONN TISS O.R. PROC W CC.
234.............       08  SURG                  OTHER MUSCULOSKELET SYS &        1.2329         2.3         3.2
                                                  CONN TISS O.R. PROC W/O CC.
235.............       08  MED                   FRACTURES OF FEMUR.........       .7648         3.8         5.1
236.............       08  MED                   FRACTURES OF HIP & PELVIS..       .7233         4.0         4.9
237.............       08  MED                   SPRAINS, STRAINS, &               .5797         2.9         3.6
                                                  DISLOCATIONS OF HIP,
                                                  PELVIS & THIGH.
238.............       08  MED                   OSTEOMYELITIS..............      1.3934         6.6         8.9
239.............       08  MED                   PATHOLOGICAL FRACTURES &         1.0031         4.9         6.3
                                                  MUSCULOSKELETAL & CONN
                                                  TISS MALIGNANCY.
240.............       08  MED                   CONNECTIVE TISSUE DISORDERS      1.3301         5.0         6.7
                                                  W CC.
241.............       08  MED                   CONNECTIVE TISSUE DISORDERS       .6493         3.1         3.9
                                                  W/O CC.
242.............       08  MED                   SEPTIC ARTHRITIS...........      1.1093         5.1         6.7
243.............       08  MED                   MEDICAL BACK PROBLEMS......       .7407         3.7         4.7
244.............       08  MED                   BONE DISEASES & SPECIFIC          .7056         3.7         4.7
                                                  ARTHROPATHIES W CC.
245.............       08  MED                   BONE DISEASES & SPECIFIC          .4686         2.7         3.4
                                                  ARTHROPATHIES W/O CC.
246.............       08  MED                   NON-SPECIFIC ARTHROPATHIES.       .5658         2.9         3.8
247.............       08  MED                   SIGNS & SYMPTOMS OF               .5725         2.6         3.4
                                                  MUSCULOSKELETAL SYSTEM &
                                                  CONN TISSUE.
248.............       08  MED                   TENDONITIS, MYOSITIS &            .8317         3.8         4.9
                                                  BURSITIS.
249.............       08  MED                   AFTERCARE, MUSCULOSKELETAL        .6895         2.5         3.7
                                                  SYSTEM & CONNECTIVE TISSUE.
250.............       08  MED                   FX, SPRN, STRN & DISL OF          .6886         3.3         4.2
                                                  FOREARM, HAND, FOOT AGE
                                                  >17 W CC.
251.............       08  MED                   FX, SPRN, STRN & DISL OF          .4624         2.2         2.8
                                                  FOREARM, HAND, FOOT AGE
                                                  >17 W/O CC.
252.............       08  MED                   * FX, SPRN, STRN & DISL OF        .2513         1.8         1.8
                                                  FOREARM, HAND, FOOT AGE 0-
                                                  17.
253.............       08  MED                   FX, SPRN, STRN & DISL OF          .7384         3.7         4.7
                                                  UPARM,LOWLEG EX FOOT AGE
                                                  >17 W CC.
254.............       08  MED                   FX, SPRN, STRN & DISL OF          .4433         2.6         3.1
                                                  UPARM,LOWLEG EX FOOT AGE
                                                  >17 W/O CC.
255.............       08  MED                   * FX, SPRN, STRN & DISL OF        .2928         2.9         2.9
                                                  UPARM,LOWLEG EX FOOT AGE 0-
                                                  17.
256.............       08  MED                   OTHER MUSCULOSKELETAL             .8038         3.8         5.1
                                                  SYSTEM & CONNECTIVE TISSUE
                                                  DIAGNOSES.
257.............       09  SURG                  TOTAL MASTECTOMY FOR              .8995         2.1         2.7
                                                  MALIGNANCY W CC.
258.............       09  SURG                  TOTAL MASTECTOMY FOR              .7107         1.6         1.8
                                                  MALIGNANCY W/O CC.
259.............       09  SURG                  SUBTOTAL MASTECTOMY FOR           .9130         1.7         2.7
                                                  MALIGNANCY W CC.
260.............       09  SURG                  SUBTOTAL MASTECTOMY FOR           .6821         1.2         1.4
                                                  MALIGNANCY W/O CC.
261.............       09  SURG                  BREAST PROC FOR NON-              .9773         1.6         2.2
                                                  MALIGNANCY EXCEPT BIOPSY &
                                                  LOCAL EXCISION.
262.............       09  SURG                  BREAST BIOPSY & LOCAL             .9324         2.9         4.3
                                                  EXCISION FOR NON-
                                                  MALIGNANCY.

[[Page 31623]]

 
263.............       09  SURG                  SKIN GRAFT &/OR DEBRID FOR       2.2113         9.3        12.5
                                                  SKN ULCER OR CELLULITIS W
                                                  CC.
264.............       09  SURG                  SKIN GRAFT &/OR DEBRID FOR       1.1350         5.5         7.1
                                                  SKN ULCER OR CELLULITIS W/
                                                  O CC.
265.............       09  SURG                  SKIN GRAFT &/OR DEBRID           1.5906         4.2         6.7
                                                  EXCEPT FOR SKIN ULCER OR
                                                  CELLULITIS W CC.
266.............       09  SURG                  SKIN GRAFT &/OR DEBRID            .8540         2.2         3.1
                                                  EXCEPT FOR SKIN ULCER OR
                                                  CELLULITIS W/O CC.
267.............       09  SURG                  PERIANAL & PILONIDAL              .9343         2.5         4.3
                                                  PROCEDURES.
268.............       09  SURG                  SKIN, SUBCUTANEOUS TISSUE &      1.1068         2.4         3.6
                                                  BREAST PLASTIC PROCEDURES.
269.............       09  SURG                  OTHER SKIN, SUBCUT TISS &        1.6798         5.7         8.2
                                                  BREAST PROC W CC.
270.............       09  SURG                  OTHER SKIN, SUBCUT TISS &         .7495         2.3         3.3
                                                  BREAST PROC W/O CC.
271.............       09  MED                   SKIN ULCERS................      1.0266         5.6         7.3
272.............       09  MED                   MAJOR SKIN DISORDERS W CC..      1.0013         4.6         6.1
273.............       09  MED                   MAJOR SKIN DISORDERS W/O CC       .5578         3.0         3.9
274.............       09  MED                   MALIGNANT BREAST DISORDERS       1.1936         4.8         6.8
                                                  W CC.
275.............       09  MED                   MALIGNANT BREAST DISORDERS        .5469         2.2         3.0
                                                  W/O CC.
276.............       09  MED                   NON-MALIGANT BREAST               .6781         3.5         4.5
                                                  DISORDERS.
277.............       09  MED                   CELLULITIS AGE >17 W CC....       .8580         4.7         5.8
278.............       09  MED                   CELLULITIS AGE >17 W/O CC..       .5497         3.6         4.3
279.............       09  MED                   * CELLULITIS AGE 0-17......       .6580         4.2         4.2
280.............       09  MED                   TRAUMA TO THE SKIN, SUBCUT        .6972         3.2         4.2
                                                  TISS & BREAST AGE >17 W CC.
281.............       09  MED                   TRAUMA TO THE SKIN, SUBCUT        .4634         2.3         2.9
                                                  TISS & BREAST AGE >17 W/O
                                                  CC.
282.............       09  MED                   * TRAUMA TO THE SKIN,             .2545         2.2         2.2
                                                  SUBCUT TISS & BREAST AGE 0-
                                                  17.
283.............       09  MED                   MINOR SKIN DISORDERS W CC..       .7211         3.5         4.7
284.............       09  MED                   MINOR SKIN DISORDERS W/O CC       .4300         2.4         3.1
285.............       10  SURG                  AMPUTAT OF LOWER LIMB FOR        2.0391         8.0        10.6
                                                  ENDOCRINE,NUTRIT,& METABOL
                                                  DISORDERS.
286.............       10  SURG                  ADRENAL & PITUITARY              2.0831         4.5         5.9
                                                  PROCEDURES.
287.............       10  SURG                  SKIN GRAFTS & WOUND DEBRID       1.8701         7.7        10.6
                                                  FOR ENDOC, NUTRIT & METAB
                                                  DISORDERS.
288.............       10  SURG                  O.R. PROCEDURES FOR OBESITY      2.2124         4.3         5.4
289.............       10  SURG                  PARATHYROID PROCEDURES.....       .9697         1.8         2.8
290.............       10  SURG                  THYROID PROCEDURES.........       .8955         1.7         2.2
291.............       10  SURG                  THYROGLOSSAL PROCEDURES....       .6333         1.4         1.6
292.............       10  SURG                  OTHER ENDOCRINE, NUTRIT &        2.4623         6.8        10.0
                                                  METAB O.R. PROC W CC.
293.............       10  SURG                  OTHER ENDOCRINE, NUTRIT &        1.2998         3.3         4.9
                                                  METAB O.R. PROC W/O CC.
294.............       10  MED                   DIABETES AGE >35...........       .7573         3.4         4.5
295.............       10  MED                   DIABETES AGE 0-35..........       .7854         3.0         4.0
296.............       10  MED                   NUTRITIONAL & MISC                .8469         3.9         5.1
                                                  METABOLIC DISORDERS AGE
                                                  >17 W CC.
297.............       10  MED                   NUTRITIONAL & MISC                .5046         2.7         3.4
                                                  METABOLIC DISORDERS AGE
                                                  >17 W/O CC.
298.............       10  MED                   NUTRITIONAL & MISC                .5879         2.9         4.4
                                                  METABOLIC DISORDERS AGE 0-
                                                  17.
299.............       10  MED                   INBORN ERRORS OF METABOLISM       .9367         3.8         5.4
300.............       10  MED                   ENDOCRINE DISORDERS W CC...      1.0930         4.7         6.2
301.............       10  MED                   ENDOCRINE DISORDERS W/O CC.       .6308         2.8         3.7
302.............       11  SURG                  KIDNEY TRANSPLANT..........      3.2671         7.4         8.7
303.............       11  SURG                  KIDNEY,URETER & MAJOR            2.4195         6.7         8.3
                                                  BLADDER PROCEDURES FOR
                                                  NEOPLASM.
304.............       11  SURG                  KIDNEY,URETER & MAJOR            2.3243         6.2         8.7
                                                  BLADDER PROC FOR NON-NEOPL
                                                  W CC.
305.............       11  SURG                  KIDNEY,URETER & MAJOR            1.1946         2.9         3.6
                                                  BLADDER PROC FOR NON-NEOPL
                                                  W/O CC.
306.............       11  SURG                  PROSTATECTOMY W CC.........      1.2725         3.6         5.5
307.............       11  SURG                  PROSTATECTOMY W/O CC.......       .6329         1.8         2.2
308.............       11  SURG                  MINOR BLADDER PROCEDURES W       1.6399         4.0         6.3
                                                  CC.
309.............       11  SURG                  MINOR BLADDER PROCEDURES W/       .8980         1.7         2.2
                                                  O CC.
310.............       11  SURG                  TRANSURETHRAL PROCEDURES W       1.1281         2.9         4.3
                                                  CC.
311.............       11  SURG                  TRANSURETHRAL PROCEDURES W/       .6270         1.5         1.8
                                                  O CC.
312.............       11  SURG                  URETHRAL PROCEDURES, AGE         1.0583         3.0         4.5
                                                  >17 W CC.
313.............       11  SURG                  URETHRAL PROCEDURES, AGE          .6693         1.7         2.1
                                                  >17 W/O CC.
314.............       11  SURG                  * URETHRAL PROCEDURES, AGE        .4905         2.3         2.3
                                                  0-17.
315.............       11  SURG                  OTHER KIDNEY & URINARY           2.0954         3.8         7.2
                                                  TRACT O.R. PROCEDURES.
316.............       11  MED                   RENAL FAILURE..............      1.3241         4.9         6.6
317.............       11  MED                   ADMIT FOR RENAL DIALYSIS...       .6603         2.0         3.1
318.............       11  MED                   KIDNEY & URINARY TRACT           1.1819         4.4         6.1
                                                  NEOPLASMS W CC.
319.............       11  MED                   KIDNEY & URINARY TRACT            .6051         2.1         2.9
                                                  NEOPLASMS W/O CC.
320.............       11  MED                   KIDNEY & URINARY TRACT            .8555         4.3         5.3
                                                  INFECTIONS AGE >17 W CC.

[[Page 31624]]

 
321.............       11  MED                   KIDNEY & URINARY TRACT            .5645         3.1         3.8
                                                  INFECTIONS AGE >17 W/O CC.
322.............       11  MED                   KIDNEY & URINARY TRACT            .4769         3.1         3.7
                                                  INFECTIONS AGE 0-17.
323.............       11  MED                   URINARY STONES W CC, &/OR         .8049         2.4         3.1
                                                  ESW LITHOTRIPSY.
324.............       11  MED                   URINARY STONES W/O CC......       .4643         1.5         1.8
325.............       11  MED                   KIDNEY & URINARY TRACT            .6508         2.9         3.8
                                                  SIGNS & SYMPTOMS AGE >17 W
                                                  CC.
326.............       11  MED                   KIDNEY & URINARY TRACT            .4441         2.2         2.7
                                                  SIGNS & SYMPTOMS AGE >17 W/
                                                  O CC.
327.............       11  MED                   * KIDNEY & URINARY TRACT          .3668         3.1         3.1
                                                  SIGNS & SYMPTOMS AGE 0-17.
328.............       11  MED                   URETHRAL STRICTURE AGE >17        .7339         2.8         3.8
                                                  W CC.
329.............       11  MED                   URETHRAL STRICTURE AGE >17        .4891         1.7         2.2
                                                  W/O CC.
330.............       11  MED                   * URETHRAL STRICTURE AGE 0-       .3160         1.6         1.6
                                                  17.
331.............       11  MED                   OTHER KIDNEY & URINARY           1.0553         4.2         5.6
                                                  TRACT DIAGNOSES AGE >17 W
                                                  CC.
332.............       11  MED                   OTHER KIDNEY & URINARY            .5998         2.4         3.2
                                                  TRACT DIAGNOSES AGE >17 W/
                                                  O CC.
333.............       11  MED                   OTHER KIDNEY & URINARY            .7662         3.3         4.7
                                                  TRACT DIAGNOSES AGE 0-17.
334.............       12  SURG                  MAJOR MALE PELVIC                1.5217         4.0         4.8
                                                  PROCEDURES W CC.
335.............       12  SURG                  MAJOR MALE PELVIC                1.1249         2.9         3.2
                                                  PROCEDURES W/O CC.
336.............       12  SURG                  TRANSURETHRAL PROSTATECTOMY       .8721         2.6         3.4
                                                  W CC.
337.............       12  SURG                  TRANSURETHRAL PROSTATECTOMY       .6046         1.8         2.1
                                                  W/O CC.
338.............       12  SURG                  TESTES PROCEDURES, FOR           1.2297         3.5         5.6
                                                  MALIGNANCY.
339.............       12  SURG                  TESTES PROCEDURES, NON-          1.1006         2.9         4.6
                                                  MALIGNANCY AGE >17.
340.............       12  SURG                  * TESTES PROCEDURES, NON-         .2808         2.4         2.4
                                                  MALIGNANCY AGE 0-17.
341.............       12  SURG                  PENIS PROCEDURES...........      1.2148         1.9         3.1
342.............       12  SURG                  CIRCUMCISION AGE >17.......       .7897         2.3         3.1
343.............       12  SURG                  * CIRCUMCISION AGE 0-17....       .1526         1.7         1.7
344.............       12  SURG                  OTHER MALE REPRODUCTIVE          1.2631         1.6         2.4
                                                  SYSTEM O.R. PROCEDURES FOR
                                                  MALIGNANCY.
345.............       12  SURG                  OTHER MALE REPRODUCTIVE          1.1839         2.9         4.8
                                                  SYSTEM O.R. PROC EXCEPT
                                                  FOR MALIGNANCY.
346.............       12  MED                   MALIGNANCY, MALE                 1.0453         4.5         6.0
                                                  REPRODUCTIVE SYSTEM, W CC.
347.............       12  MED                   MALIGNANCY, MALE                  .5654         2.0         2.7
                                                  REPRODUCTIVE SYSTEM, W/O
                                                  CC.
348.............       12  MED                   BENIGN PROSTATIC                  .7111         3.2         4.2
                                                  HYPERTROPHY W CC.
349.............       12  MED                   BENIGN PROSTATIC                  .3943         1.9         2.5
                                                  HYPERTROPHY W/O CC.
350.............       12  MED                   INFLAMMATION OF THE MALE          .7192         3.6         4.5
                                                  REPRODUCTIVE SYSTEM.
351.............       12  MED                   * STERILIZATION, MALE......       .2342         1.3         1.3
352.............       12  MED                   OTHER MALE REPRODUCTIVE           .7227         2.8         4.0
                                                  SYSTEM DIAGNOSES.
353.............       13  SURG                  PELVIC EVISCERATION,             1.8746         5.0         6.5
                                                  RADICAL HYSTERECTOMY &
                                                  RADICAL VULVECTOMY.
354.............       13  SURG                  UTERINE, ADNEXA PROC FOR         1.5439         4.8         5.8
                                                  NON-OVARIAN/ADNEXAL MALIG
                                                  W CC.
355.............       13  SURG                  UTERINE, ADNEXA PROC FOR          .9119         3.0         3.2
                                                  NON-OVARIAN/ADNEXAL MALIG
                                                  W/O CC.
356.............       13  SURG                  FEMALE REPRODUCTIVE SYSTEM        .7675         1.9         2.2
                                                  RECONSTRUCTIVE PROCEDURES.
357.............       13  SURG                  UTERINE & ADNEXA PROC FOR        2.3212         6.7         8.4
                                                  OVARIAN OR ADNEXAL
                                                  MALIGNANCY.
358.............       13  SURG                  UTERINE & ADNEXA PROC FOR        1.2295         3.5         4.3
                                                  NON-MALIGNANCY W CC.
359.............       13  SURG                  UTERINE & ADNEXA PROC FOR         .8356         2.4         2.6
                                                  NON-MALIGNANCY W/O CC.
360.............       13  SURG                  VAGINA, CERVIX & VULVA            .8857         2.3         2.8
                                                  PROCEDURES.
361.............       13  SURG                  LAPAROSCOPY & INCISIONAL         1.1215         2.3         3.7
                                                  TUBAL INTERRUPTION.
362.............       13  SURG                  * ENDOSCOPIC TUBAL                .2993         1.4         1.4
                                                  INTERRUPTION.
363.............       13  SURG                  D&C, CONIZATION & RADIO-          .8801         2.6         3.6
                                                  IMPLANT, FOR MALIGNANCY.
364.............       13  SURG                  D&C, CONIZATION EXCEPT FOR        .8399         2.7         3.9
                                                  MALIGNANCY.
365.............       13  SURG                  OTHER FEMALE REPRODUCTIVE        1.9401         5.2         7.7
                                                  SYSTEM O.R. PROCEDURES.
366.............       13  MED                   MALIGNANCY, FEMALE               1.2804         4.9         6.9
                                                  REPRODUCTIVE SYSTEM W CC.
367.............       13  MED                   MALIGNANCY, FEMALE                .5388         2.3         3.0
                                                  REPRODUCTIVE SYSTEM W/O CC.
368.............       13  MED                   INFECTIONS, FEMALE               1.2019         5.2         6.7
                                                  REPRODUCTIVE SYSTEM.
369.............       13  MED                   MENSTRUAL & OTHER FEMALE          .5941         2.4         3.2
                                                  REPRODUCTIVE SYSTEM
                                                  DISORDERS.
370.............       14  SURG                  CESAREAN SECTION W CC......       .9721         4.4         5.7
371.............       14  SURG                  CESAREAN SECTION W/O CC....       .6742         3.3         3.6
372.............       14  MED                   VAGINAL DELIVERY W                .6053         2.6         3.7
                                                  COMPLICATING DIAGNOSES.
373.............       14  MED                   VAGINAL DELIVERY W/O              .3931         2.0         2.3
                                                  COMPLICATING DIAGNOSES.
374.............       14  SURG                  VAGINAL DELIVERY W                .7855         2.5         2.9
                                                  STERILIZATION &/OR D&C.
375.............       14  SURG                  * VAGINAL DELIVERY W O.R.         .5714         4.4         4.4
                                                  PROC EXCEPT STERIL &/OR
                                                  D&C.
376.............       14  MED                   POSTPARTUM & POST ABORTION        .4827         2.6         3.5
                                                  DIAGNOSES W/O O.R.
                                                  PROCEDURE.

[[Page 31625]]

 
377.............       14  SURG                  POSTPARTUM & POST ABORTION       1.4673         3.2         4.4
                                                  DIAGNOSES W O.R. PROCEDURE.
378.............       14  MED                   ECTOPIC PREGNANCY..........       .8385         2.0         2.5
379.............       14  MED                   THREATENED ABORTION........       .3944         2.1         3.0
380.............       14  MED                   ABORTION W/O D&C...........       .3662         1.6         2.0
381.............       14  SURG                  ABORTION W D&C, ASPIRATION        .5859         1.6         2.1
                                                  CURETTAGE OR HYSTEROTOMY.
382.............       14  MED                   FALSE LABOR................       .1588         1.2         1.4
383.............       14  MED                   OTHER ANTEPARTUM DIAGNOSES        .5475         2.7         4.0
                                                  W MEDICAL COMPLICATIONS.
384.............       14  MED                   OTHER ANTEPARTUM DIAGNOSES        .4188         1.8         2.7
                                                  W/O MEDICAL COMPLICATIONS.
385.............       15  MED                   * NEONATES, DIED OR              1.3636         1.8         1.8
                                                  TRANSFERRED TO ANOTHER
                                                  ACUTE CARE FACILITY.
386.............       15  MED                   * EXTREME IMMATURITY.......      4.4966        17.9        17.9
387.............       15  MED                   * PREMATURITY W MAJOR            3.0711        13.3        13.3
                                                  PROBLEMS.
388.............       15  MED                   * PREMATURITY W/O MAJOR          1.8531         8.6         8.6
                                                  PROBLEMS.
389.............       15  MED                   * FULL TERM NEONATE W MAJOR      3.1546         4.7         4.7
                                                  PROBLEMS.
390.............       15  MED                   * NEONATE W OTHER                1.1165         3.4         3.4
                                                  SIGNIFICANT PROBLEMS.
391.............       15  MED                   * NORMAL NEWBORN...........       .1512         3.1         3.1
392.............       16  SURG                  SPLENECTOMY AGE >17........      3.1530         6.9         9.5
393.............       16  SURG                  * SPLENECTOMY AGE 0-17.....      1.3357         9.1         9.1
394.............       16  SURG                  OTHER O.R. PROCEDURES OF         1.7961         4.3         7.0
                                                  THE BLOOD AND BLOOD
                                                  FORMING ORGANS.
395.............       16  MED                   RED BLOOD CELL DISORDERS          .8141         3.2         4.4
                                                  AGE >17.
396.............       16  MED                   RED BLOOD CELL DISORDERS          .6515         2.4         3.8
                                                  AGE 0-17.
397.............       16  MED                   COAGULATION DISORDERS......      1.2348         3.7         5.2
398.............       16  MED                   RETICULOENDOTHELIAL &            1.2646         4.6         5.9
                                                  IMMUNITY DISORDERS W CC.
399.............       16  MED                   RETICULOENDOTHELIAL &             .6883         2.8         3.6
                                                  IMMUNITY DISORDERS W/O CC.
400.............       17  SURG                  LYMPHOMA & LEUKEMIA W MAJOR      2.6627         5.5         9.0
                                                  O.R. PROCEDURE.
401.............       17  SURG                  LYMPHOMA & NON-ACUTE             2.7815         8.0        11.3
                                                  LEUKEMIA W OTHER O.R. PROC
                                                  W CC.
402.............       17  SURG                  LYMPHOMA & NON-ACUTE             1.1184         2.7         3.9
                                                  LEUKEMIA W OTHER O.R. PROC
                                                  W/O CC.
403.............       17  MED                   LYMPHOMA & NON-ACUTE             1.7630         5.7         8.0
                                                  LEUKEMIA W CC.
404.............       17  MED                   LYMPHOMA & NON-ACUTE              .8543         3.0         4.2
                                                  LEUKEMIA W/O CC.
405.............       17  MED                   * ACUTE LEUKEMIA W/O MAJOR       1.8937         4.9         4.9
                                                  O.R. PROCEDURE AGE 0-17.
406.............       17  SURG                  MYELOPROLIF DISORD OR            2.7896         6.9         9.7
                                                  POORLY DIFF NEOPL W MAJ
                                                  O.R.PROC W CC.
407.............       17  SURG                  MYELOPROLIF DISORD OR            1.2754         3.3         4.1
                                                  POORLY DIFF NEOPL W MAJ
                                                  O.R.PROC W/O CC.
408.............       17  SURG                  MYELOPROLIF DISORD OR            2.0472         4.7         7.9
                                                  POORLY DIFF NEOPL W OTHER
                                                  O.R.PROC.
409.............       17  MED                   RADIOTHERAPY...............      1.2026         4.5         6.1
410.............       17  MED                   CHEMOTHERAPY W/O ACUTE           1.0423         3.1         4.0
                                                  LEUKEMIA AS SECONDARY
                                                  DIAGNOSIS.
411.............       17  MED                   HISTORY OF MALIGNANCY W/O         .3885         2.2         2.9
                                                  ENDOSCOPY.
412.............       17  MED                   HISTORY OF MALIGNANCY W           .2791         1.6         2.0
                                                  ENDOSCOPY.
413.............       17  MED                   OTHER MYELOPROLIF DIS OR         1.3594         5.3         7.3
                                                  POORLY DIFF NEOPL DIAG W
                                                  CC.
414.............       17  MED                   OTHER MYELOPROLIF DIS OR          .6897         3.0         4.0
                                                  POORLY DIFF NEOPL DIAG W/O
                                                  CC.
415.............       18  SURG                  O.R. PROCEDURE FOR               3.6521        10.4        14.5
                                                  INFECTIOUS & PARASITIC
                                                  DISEASES.
416.............       18  MED                   SEPTICEMIA AGE >17.........      1.5936         5.6         7.5
417.............       18  MED                   SEPTICEMIA AGE 0-17........      1.1657         4.5         6.1
418.............       18  MED                   POSTOPERATIVE & POST-            1.0377         4.8         6.2
                                                  TRAUMATIC INFECTIONS.
419.............       18  MED                   FEVER OF UNKNOWN ORIGIN AGE       .8636         3.6         4.7
                                                  >17 W CC.
420.............       18  MED                   FEVER OF UNKNOWN ORIGIN AGE       .5907         2.8         3.4
                                                  >17 W/O CC.
421.............       18  MED                   VIRAL ILLNESS AGE >17......       .7028         2.9         3.8
422.............       18  MED                   VIRAL ILLNESS & FEVER OF          .4351         2.3         2.9
                                                  UNKNOWN ORIGIN AGE 0-17.
423.............       18  MED                   OTHER INFECTIOUS &               1.7883         5.9         8.3
                                                  PARASITIC DISEASES
                                                  DIAGNOSES.
424.............       19  SURG                  O.R. PROCEDURE W PRINCIPAL       2.2964         8.1        13.0
                                                  DIAGNOSES OF MENTAL
                                                  ILLNESS.
425.............       19  MED                   ACUTE ADJUSTMENT REACTION &       .6796         2.9         3.9
                                                  PSYCHOSOCIAL DYSFUNCTION.
426.............       19  MED                   DEPRESSIVE NEUROSES........       .5177         3.2         4.5
427.............       19  MED                   NEUROSES EXCEPT DEPRESSIVE.       .5199         3.1         4.4
428.............       19  MED                   DISORDERS OF PERSONALITY &        .7376         4.4         7.4
                                                  IMPULSE CONTROL.
429.............       19  MED                   ORGANIC DISTURBANCES &            .8268         4.7         6.3
                                                  MENTAL RETARDATION.
430.............       19  MED                   PSYCHOSES..................       .7128         5.7         8.0
431.............       19  MED                   CHILDHOOD MENTAL DISORDERS.       .5925         4.2         5.9
432.............       19  MED                   OTHER MENTAL DISORDER             .6333         2.9         4.6
                                                  DIAGNOSES.

[[Page 31626]]

 
433.............       20  MED                   ALCOHOL/DRUG ABUSE OR             .2752         2.2         3.0
                                                  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...      1.6840         5.4         8.5
440.............       21  SURG                  WOUND DEBRIDEMENTS FOR           1.9031         5.7         9.0
                                                  INJURIES.
441.............       21  SURG                  HAND PROCEDURES FOR               .9231         2.1         3.1
                                                  INJURIES.
442.............       21  SURG                  OTHER O.R. PROCEDURES FOR        2.4078         5.6         8.6
                                                  INJURIES W CC.
443.............       21  SURG                  OTHER O.R. PROCEDURES FOR        1.0670         2.6         3.5
                                                  INJURIES W/O CC.
444.............       21  MED                   TRAUMATIC INJURY AGE >17 W        .7577         3.2         4.3
                                                  CC.
445.............       21  MED                   TRAUMATIC INJURY AGE >17 W/       .4857         2.3         2.9
                                                  O CC.
446.............       21  MED                   * TRAUMATIC INJURY AGE 0-17       .2936         2.4         2.4
447.............       21  MED                   ALLERGIC REACTIONS AGE >17.       .5000         1.8         2.4
448.............       21  MED                   * ALLERGIC REACTIONS AGE 0-       .0965         2.9         2.9
                                                  17.
449.............       21  MED                   POISONING & TOXIC EFFECTS         .8233         2.6         3.7
                                                  OF DRUGS AGE >17 W CC.
450.............       21  MED                   POISONING & TOXIC EFFECTS         .4272         1.6         2.0
                                                  OF DRUGS AGE >17 W/O CC.
451.............       21  MED                   * POISONING & TOXIC EFFECTS       .2607         2.1         2.1
                                                  OF DRUGS AGE 0-17.
452.............       21  MED                   COMPLICATIONS OF TREATMENT       1.0378         3.5         5.0
                                                  W CC.
453.............       21  MED                   COMPLICATIONS OF TREATMENT        .5133         2.1         2.8
                                                  W/O CC.
454.............       21  MED                   OTHER INJURY, POISONING &         .8272         3.0         4.4
                                                  TOXIC EFFECT DIAG W CC.
455.............       21  MED                   OTHER INJURY, POISONING &         .4542         1.8         2.4
                                                  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         1.1927         2.2         4.1
                                                  OTHER CONTACT W HEALTH
                                                  SERVICES.
462.............       23  MED                   REHABILITATION.............      1.1251         9.3        11.5
463.............       23  MED                   SIGNS & SYMPTOMS W CC......       .6930         3.2         4.2
464.............       23  MED                   SIGNS & SYMPTOMS W/O CC....       .4957         2.4         3.0
465.............       23  MED                   AFTERCARE W HISTORY OF            .6785         1.8         2.9
                                                  MALIGNANCY AS SECONDARY
                                                  DIAGNOSIS.
466.............       23  MED                   AFTERCARE W/O HISTORY OF          .7305         2.1         3.9
                                                  MALIGNANCY AS SECONDARY
                                                  DIAGNOSIS.
467.............       23  MED                   OTHER FACTORS INFLUENCING         .6095         2.1         8.4
                                                  HEALTH STATUS.
468.............  .......  ....................  EXTENSIVE O.R. PROCEDURE         3.6658         9.2        13.0
                                                  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      3.0990         4.8         5.5
                                                  JOINT PROCS OF LOWER
                                                  EXTREMITY.
472.............       22  SURG                  NO LONGER VALID............       .0000          .0          .0
473.............       17  SURG                  ACUTE LEUKEMIA W/O MAJOR         3.5075         7.3        12.6
                                                  O.R. PROCEDURE AGE >17.
474.............       04  SURG                  NO LONGER VALID............       .0000          .0          .0
475.............       04  MED                   RESPIRATORY SYSTEM               3.6408         8.0        11.3
                                                  DIAGNOSIS WITH VENTILATOR
                                                  SUPPORT.
476.............  .......  SURG                  PROSTATIC O.R. PROCEDURE         2.2587         8.0        11.3
                                                  UNRELATED TO PRINCIPAL
                                                  DIAGNOSIS.
477.............  .......  SURG                  NON-EXTENSIVE O.R.               1.8605         5.3         8.2
                                                  PROCEDURE UNRELATED TO
                                                  PRINCIPAL DIAGNOSIS.
478.............       05  SURG                  OTHER VASCULAR PROCEDURES W      2.3660         4.9         7.4
                                                  CC.
479.............       05  SURG                  OTHER VASCULAR PROCEDURES W/     1.4314         2.5         3.3
                                                  O CC.
480.............      PRE  SURG                  LIVER TRANSPLANT...........     10.1911        15.7        21.5
481.............      PRE  SURG                  BONE MARROW TRANSPLANT.....      6.9570        19.3        22.0
482.............      PRE  SURG                  TRACHEOSTOMY FOR FACE,MOUTH      3.4938         9.7        12.5
                                                  & NECK DIAGNOSES.
483.............      PRE  SURG                  TRACHEOSTOMY/MECH VENT          16.2670        34.6        42.0
                                                  96+HRS EXCEPT FACE,MOUTH &
                                                  NECK DIAGNOSES.
484.............       24  SURG                  CRANIOTOMY FOR MULTIPLE          5.5512         8.9        13.2
                                                  SIGNIFICANT TRAUMA.
485.............       24  SURG                  LIMB REATTACHMENT, HIP AND       2.9897         7.6         9.5
                                                  FEMUR PROC FOR MULTIPLE
                                                  SIGNIFICANT TRA.
486.............       24  SURG                  OTHER O.R. PROCEDURES FOR        4.8066         8.4        12.4
                                                  MULTIPLE SIGNIFICANT
                                                  TRAUMA.
487.............       24  MED                   OTHER MULTIPLE SIGNIFICANT       1.9538         5.5         7.8
                                                  TRAUMA.
488.............       25  SURG                  HIV W EXTENSIVE O.R.             4.6394        11.5        16.9
                                                  PROCEDURE.
489.............       25  MED                   HIV W MAJOR RELATED              1.7885         6.0         8.6
                                                  CONDITION.

[[Page 31627]]

 
490.............       25  MED                   HIV W OR W/O OTHER RELATED       1.0200         3.7         5.3
                                                  CONDITION.
491.............       08  SURG                  MAJOR JOINT & LIMB               1.7021         2.9         3.5
                                                  REATTACHMENT PROCEDURES OF
                                                  UPPER EXTREMITY.
492.............       17  MED                   CHEMOTHERAPY W ACUTE             3.9117         9.2        15.0
                                                  LEUKEMIA AS SECONDARY
                                                  DIAGNOSIS.
493.............       07  SURG                  LAPAROSCOPIC                     1.8188         4.3         5.9
                                                  CHOLECYSTECTOMY W/O C.D.E.
                                                  W CC.
494.............       07  SURG                  LAPAROSCOPIC                     1.0128         1.9         2.5
                                                  CHOLECYSTECTOMY W/O C.D.E.
                                                  W/O CC.
495.............      PRE  SURG                  LUNG TRANSPLANT............      8.9713        14.3        17.2
496.............       08  SURG                  COMBINED ANTERIOR/POSTERIOR      5.7699         7.1         9.5
                                                  SPINAL FUSION.
497.............       08  SURG                  SPINAL FUSION EXCEPT             3.3834         5.4         6.5
                                                  CERVICAL W CC.
498.............       08  SURG                  SPINAL FUSION EXCEPT             2.4714         3.7         4.1
                                                  CERVICAL W/O CC.
499.............       08  SURG                  BACK & NECK PROCEDURES           1.4381         3.4         4.6
                                                  EXCEPT SPINAL FUSION W CC.
500.............       08  SURG                  BACK & NECK PROCEDURES            .9487         2.0         2.5
                                                  EXCEPT SPINAL FUSION W/O
                                                  CC.
501.............       08  SURG                  KNEE PROCEDURES W PDX OF         2.5940         8.4        10.7
                                                  INFECTION W CC.
502.............       08  SURG                  KNEE PROCEDURES W PDX OF         1.5391         5.3         6.4
                                                  INFECTION W/O CC.
503.............       08  SURG                  KNEE PROCEDURES W/O PDX OF       1.2111         2.9         3.9
                                                  INFECTION.
504.............       22  SURG                  EXTENSIVE 3RD DEGREE BURNS      14.4707        26.9        35.1
                                                  W SKIN GRAFT.
505.............       22  MED                   EXTENSIVE 3RD DEGREE BURNS       1.9872         2.2         3.7
                                                  W/O SKIN GRAFT.
506.............       22  SURG                  FULL THICKNESS BURN W SKIN       4.6264        12.7        17.3
                                                  GRAFT OR INHAL INJ W CC OR
                                                  SIG TRAUMA.
507.............       22  SURG                  FULL THICKNESS BURN W SKIN       1.7118         6.5         9.0
                                                  GRFT OR INHAL INJ W/O CC
                                                  OR SIG TRAUMA.
508.............       22  MED                   FULL THICKNESS BURN W/O          1.4160         5.8         8.4
                                                  SKIN GRFT OR INHAL INJ W
                                                  CC OR SIG TRAUMA.
509.............       22  MED                   FULL THICKNESS BURN W/O           .9410         4.1         5.5
                                                  SKIN GRFT OR INH INJ W/O
                                                  CC OR SIG TRAUMA.
510.............       22  MED                   NON-EXTENSIVE BURNS W CC OR      1.2161         4.6         6.7
                                                  SIGNIFICANT TRAUMA.
511.............       22  MED                   NON-EXTENSIVE BURNS W/O CC        .6968         3.0         4.4
                                                  OR SIGNIFICANT TRAUMA.
512.............      PRE  SURG                  SIMULTANEOUS PANCREAS/           5.7000        11.7        14.2
                                                  KIDNEY TRANSPLANT.
513.............      PRE  SURG                  PANCREAS TRANSPLANT........      6.1951         9.4        10.7
514.............       05  SURG                  CARDIAC DEFIBRILLATOR            6.3288         5.0         7.3
                                                  IMPLANT W CARDIAC CATH.
515.............       05  SURG                  CARDIAC DEFIBRILLATOR            5.0380         3.3         5.5
                                                  IMPLANT W/O CARDIAC CATH.
516.............       05  SURG                  PERCUTANEOUS CARDIOVASC          2.7295         3.7         4.7
                                                  PROC W AMI.
517.............       05  SURG                  PERC CARDIO PROC W CORONARY      2.1793         1.9         2.6
                                                  ARTERY STENT W/O AMI.
518.............       05  SURG                  PERC CARDIO PROC W/O             1.7267         2.3         3.4
                                                  CORONARY ARTERY STENT OR
                                                  AMI.
519.............       08  SURG                  CERVICAL SPINAL FUSION W CC      2.3467         3.2         5.2
520.............       08  SURG                  CERVICAL SPINAL FUSION W/O       1.5390         1.7         2.1
                                                  CC.
521.............       20  MED                   ALCOHOL/DRUG ABUSE OR             .7267         4.3         5.8
                                                  DEPENDENCE W CC.
522.............       20  MED                   ALC/DRUG ABUSE OR DEPEND W        .5829         7.5         9.5
                                                  REHABILITATION THERAPY W/O
                                                  CC.
523.............       20  MED                   ALC/DRUG ABUSE OR DEPEND W/       .4007         3.3         4.1
                                                  O REHABILITATION THERAPY W/
                                                  O CC.
524.............       01  MED                   TRANSIENT ISCHEMIA.........       .7236         2.7         3.4
525.............       05  SURG                  HEART ASSIST SYSTEM IMPLANT     11.3787         9.3       16.2
----------------------------------------------------------------------------------------------------------------
* 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.
GEOMETRIC MEAN IS USED ONLY TO DETERMINE PAYMENT FOR TRANSFER CASES.
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. 67, No. 90 / Thursday, May 9, 2002 / Proposed 
Rules  

[[Page 31627]]


      

                                         Table 6A.--New Diagnosis Codes
----------------------------------------------------------------------------------------------------------------
 Diagnosis
    code              Description                    CC               MDC                     DRG
----------------------------------------------------------------------------------------------------------------
     040.82  Toxic shock syndrome.........  Y                             18  423
      066.4  West Nile fever..............  N                             18  421, 422
     277.02  Cystic fibrosis with           Y                              4  79, 80, 81
              pulmonary manifestations.
     277.03  Cystic fibrosis with           Y                              6  188, 189, 190
              gastrointestinal
              manifestations.
     277.09  Cystic fibrosis with other     Y                             10  296, 297, 298
              manifestations.
     357.81  Chronic inflammatory           N                              1  18, 19
              demyelinating polyneuritis.
     357.82  Critical illness               N                              1  18, 19
              polyneuropathy.
     357.89  Other inflammatory and toxic   N                              1  18, 19
              neuropathy.
     359.81  Critical illness myopathy....  N                              1  34, 35
     359.89  Other myopathies.............  N                              1  34, 35
     365.83  Aqueous misdirection.........  N                              2  46, 47, 48
     414.06  Coronary atherosclerosis of    N                              5  132, 133
              coronary artery of
              transplanted heart.

[[Page 31628]]

 
     414.12  Dissection of coronary artery  N                              5  121, 144, 145
     428.20  Unspecified systolic heart     Y                              5  115, 121, 124, 127
              failure.
     428.21  Acute systolic heart failure.  Y                              5  115, 121, 124, 127
     428.22  Chronic systolic heart         Y                              5  115, 121, 124, 127
              failure.
     428.23  Acute on chronic systolic      Y                              5  115, 121, 124, 127
              heart failure.
     428.30  Unspecified diastolic heart    Y                              5  115, 121, 124, 127
              failure.
     428.31  Acute diastolic heart failure  Y                              5  115, 121, 124, 127
     428.32  Chronic diastolic heart        Y                              5  115, 121, 124, 127
              failure.
     428.33  Acute on chronic diastolic     Y                              5  115, 121, 124, 127
              heart failure.
     428.40  Unspecified combined systolic  Y                              5  115, 121, 124, 127
              and diastolic heart failure.
     428.41  Acute combined systolic and    Y                              5  115, 121, 124, 127
              diastolic heart failure.
     428.42  Chronic combined systolic and  Y                              5  115, 121, 124, 127
              diastolic heart failure.
     428.43  Acute on chronic combined      Y                              5  115, 121, 124, 127
              systolic and diastolic heart
              failure.
      438.6  Alterations of sensations....  N                              1  12
      438.7  Disturbances of vision.......  N                              1  12
     438.83  Facial weakness..............  N                              1  12
     438.84  Ataxia.......................  N                              1  12
     438.85  Vertigo......................  N                              1  12
     443.21  Dissection of carotid artery.  N                              5  130, 131
     443.22  Dissection of iliac artery...  N                              5  130, 131
     443.23  Dissection of renal artery...  N                             11  331, 332, 333
     443.24  Dissection of vertebral        N                              5  130, 131
              artery.
     443.29  Dissection of other artery...  N                              5  130, 131
     445.01  Atheroembolism, upper          Y                              5  130, 131
              extremity.
     445.02  Atheroembolism, lower          Y                              5  130, 131
              extremity.
     445.81  Atheroembolism, kidney.......  Y                             11  331, 332, 333
     445.89  Atheroembolism, other site...  Y                              5  130, 131
      454.8  Varicose veins of the lower    N                              5  130, 131
              extremities, with other
              complications.
     459.10  Postphlebetic syndrome         N                              5  130, 131
              without complications.
     459.11  Postphlebetic syndrome with    N                              5  130, 131
              ulcer.
     459.12  Postphlebetic syndrome with    N                              5  130, 131
              inflammation.
     459.13  Postphlebetic syndrome with    N                              5  130, 131
              ulcer and inflammation.
     459.19  Postphlebetic syndrome with    N                              5  130, 131
              other complication.
     459.30  Chronic venous hypertension    N                              5  130, 131
              without complications.
     459.31  Chronic venous hypertension    N                              5  130, 131
              with ulcer.
     459.32  Chronic venous hypertension    N                              5  130, 131
              with inflammation.
     459.33  Chronic venous hypertension    N                              5  130, 131
              with ulcer and inflammation.
     459.39  Chronic venous hypertension    N                              5  130, 131
              with other complication.
     537.84  Dieulafoy lesion               Y                              6  174, 175
              (hemorrhagic) of stomach and
              duodenum.
     569.86  Dieulafoy lesion               Y                              6  188, 189, 190
              (hemorrhagic) of intestine.
     633.00  Abdominal pregnancy without    N                             14  378
              intrauterine pregnancy.
     633.01  Abdominal pregnancy with       N                             14  378
              intrauterine pregnancy.
     633.10  Tubal pregnancy without        N                             14  378
              intrauterine pregnancy.
     633.11  Tubal pregnancy with           N                             14  378
              intrauterine pregnancy.
     633.20  Ovarian pregnancy without      N                             14  378
              intrauterine pregnancy.
     633.21  Ovarian pregnancy with         N                             14  378
              intrauterine pregnancy.
     633.80  Other ectopic pregnancy        N                             14  378
              without intrauterine
              pregnancy.
     633.81  Other ectopic pregnancy with   N                             14  378
              intrauterine pregnancy.
     633.90  Unspecified ectopic pregnancy  N                             14  378
              without intrauterine
              pregnancy.
     633.91  Unspecified ectopic pregnancy  N                             14  378
              with intrauterine pregnancy.
     747.83  Persistent fetal circulation.  N                             15  387, 389
     765.20  Unspecified weeks of           N                             15  391
              gestation.
     765.21  Less than 24 completed weeks   N                             15  386
              of gestation.
     765.22  24 completed weeks of          N                             15  386
              gestation.
     765.23  25-26 completed weeks of       N                             15  386
              gestation.
     765.24  27-28 completed weeks of       N                             15  387, 388
              gestation.
     765.25  29-30 completed weeks of       N                             15  387, 388
              gestation.
     765.26  31-32 completed weeks of       N                             15  387, 388
              gestation.
     765.27  33-34 completed weeks of       N                             15  387, 388
              gestation.
     765.28  35-36 completed weeks of       N                             15  387, 388
              gestation.
     765.29  37 or more completed weeks of  N                             15  391
              gestation.
     770.81  Primary apnea of newborn.....  N                             15  390
     770.82  Other apnea of newborn.......  N                             15  390
     770.83  Cyanotic attacks of newborn..  N                             15  390
     770.84  Respiratory failure of         Y                             15  387, 389
              newborn.
     770.89  Other respiratory problems     N                             15  390
              after birth.
     771.81  Septicemia [sepsis] of         Y                             15  387, 389
              newborn.
     771.82  Urinary tract infection of     N                             15  387, 389
              newborn.
     771.83  Bacteremia of newborn........  Y                             15  387, 389
     771.89  Other infections specific to   N                             15  387, 389
              the perinatal period.
     779.81  Neonatal bradycardia.........  N                             15  390

[[Page 31629]]

 
     779.82  Neonatal tachycardia.........  N                             15  390
     779.89  Other specified conditions     N                             15  390
              originating in the perinatal
              period.
     780.91  Fussy infant (baby)..........  N                             23  463,464
     780.92  Excessive crying of infant     N                             23  463,464
              (baby).
     780.99  Other general symptoms.......  N                             23  463,464
     781.93  Ocular torticollis...........  N                              8  243
     795.00  Nonspecific abnormal           N                             13  358, 359, 369
              Papanicolaou smear of
              cervix, unspecified.
     795.01  Atypical squamous cell
              changes of undetermined
              significance favor benign
               (ASCUS favor benign).......  N                             13  358, 359, 369
     795.02  Atypical squamous cell
              changes of undetermined
              significance favor dysplasia
 
               (ASCUS favor dysplasia)....  N                             13  358, 359, 369
     795.09  Other nonspecific abnormal     N                             13  358, 359, 369
              Papanicolaou smear of cervix.
     795.31  Nonspecific positive findings  N                             18  423
              for anthrax.
     795.39  Other nonspecific positive     N                             18  423
              culture findings.
     813.45  Torus fracture of radius.....  N                              8  250, 251, 252
                                                                          24  487
     823.40  Torus fracture, tibia alone..  N                              8  253, 254, 255
                                                                          24  487
     823.41  Torus fracture, fibula alone.  N                              8  253, 254, 255
                                                                          24  487
     823.42  Torus fracture, fibula with    N                              8  253, 254, 255
              tibia.                                                      24  487
     995.90  Systemic inflammatory          Y                             18  416, 417
              response syndrome,
              unspecified.
     995.91  Systemic inflammatory
              response syndrome due to
              infectious process without
               organ dysfunction..........  Y                             18  416, 417
     995.92  Systemic inflammatory
              response syndrome due to
              infectious process with
               organ dysfunction..........  Y                             18  416, 417
     995.93  Systemic inflammatory
              response syndrome due to non-
              infectious process
               without organ dysfunction..  Y                             18  416, 417
     995.94  Systemic inflammatory
              response syndrome due to non-
              infectious process with
               organ dysfunction..........  Y                             18  416, 417
     998.31  Disruption of internal         Y                             21  452, 453
              operation wound.
     998.32  Disruption of external         Y                             21  452, 453
              operation wound.
     V01.81  Contact with or exposure to    N                             15  391 \1\
              communicable diseases,                                      23  467
              anthrax.
     V01.89  Contact with or exposure to
              communicable diseases, other
              communicable
               diseases...................  N                             15  391 \1\
                                                                          23  467
     V13.21  Personal history of pre-term   N                             23  467
              labor.
     V13.29  Personal history of other      N                             23  467
              genital system and obstetric
              disorders.
     V23.41  Pregnancy with history of pre- N                             14  469
              term labor.
     V23.49  Pregnancy with other poor      N                             14  469
              obstetric history.
      V46.2  Other dependence on machines,  N                             23  467
              supplemental oxygen.
     V54.10  Aftercare for healing          N                              8  249
              traumatic fracture of arm,
              unspecified.
     V54.11  Aftercare for healing          N                              8  249
              traumatic fracture of upper
              arm.
     V54.12  Aftercare for healing          N                              8  249
              traumatic fracture of lower
              arm.
     V54.13  Aftercare for healing          N                              8  249
              traumatic fracture of hip.
     V54.14  Aftercare for healing          N                              8  249
              traumatic fracture of leg,
              unspecified.
     V54.15  Aftercare for healing          N                              8  249
              traumatic fracture of upper
              leg.
     V54.16  Aftercare for healing          N                              8  249
              traumatic fracture of lower
              leg.
     V54.17  Aftercare for healing          N                              8  249
              traumatic fracture of
              vertebrae.
     V54.19  Aftercare for healing          N                              8  249
              traumatic fracture of other
              bone.
     V54.20  Aftercare for healing          N                              8  249
              pathologic fracture of arm,
              unspecified.
     V54.21  Aftercare for healing          N                              8  249
              pathologic fracture of upper
              arm.
     V54.22  Aftercare for healing          N                              8  249
              pathologic fracture of lower
              arm.
     V54.23  Aftercare for healing          N                              8  249
              pathologic fracture of hip.
     V54.24  Aftercare for healing          N                              8  249
              pathologic fracture of leg,
              unspecified.
     V54.25  Aftercare for healing          N                              8  249
              pathologic fracture of upper
              leg.
     V54.26  Aftercare for healing          N                              8  249
              pathologic fracture of lower
              leg.
     V54.27  Aftercare for healing          N                              8  249
              pathologic fracture of
              vertebrae.
     V54.29  Aftercare for healing          N                              8  249
              pathologic fracture of other
              bone.
     V54.81  Aftercare following joint      N                              8  249
              replacement.
     V54.89  Other orthopedic aftercare...  N                              8  249
     V58.42  Aftercare following surgery    N                             23  465,466
              for neoplasm.
     V58.43  Aftercare following surgery    N                             23  465,466
              for injury and trauma.
     V58.71  Aftercare following surgery    N                             23  465,466
              of the sense organs, NEC.
     V58.72  Aftercare following surgery    N                             23  465,466
              of the nervous system, NEC.
     V58.73  Aftercare following surgery    N                             23  465,466
              of the circulatory system,
              NEC.
     V58.74  Aftercare following surgery    N                             23  465,466
              of the respiratory system,
              NEC.
     V58.75  Aftercare following surgery    N                             23  465,466
              of the teeth, oral cavity
              and digestive system, NEC.

[[Page 31630]]

 
     V58.76  Aftercare following surgery    N                             23  465,466
              of the genitourinary system,
              NEC.
     V58.77  Aftercare following surgery    N                             23  465,466
              of the skin and subcutaneous
              tissue, NEC.
     V58.78  Aftercare following surgery    N                             23  465,466
              of the musculoskeletal
              system, NEC.
     V71.82  Observation and evaluation     N                             23  467
              for suspected exposure to
              anthrax.
     V71.83  Observation and evaluation     N                             23  467
              for suspected exposure to
              other biological agent.
     V83.81  Cystic fibrosis gene carrier.  N                             23  467
     V83.89  Other genetic carrier status.  N                             23  467
----------------------------------------------------------------------------------------------------------------
\1\ Classified as an ``only secondary diagnosis'' in this DRG.


                                         Table 6B.--New Procedure Codes
----------------------------------------------------------------------------------------------------------------
 Procedure
    code              Description                    OR               MDC                     DRG
----------------------------------------------------------------------------------------------------------------
      00.01  Therapeutic ultrasound of      N
              vessels of head and neck.
      00.02  Therapeutic ultrasound of      N
              heart.
      00.03  Therapeutic ultrasound of      N
              peripheral vascular vessels.
      00.09  Other therapeutic ultrasound.  N
      00.10  Implantation of                N
              chemotherapeutic agent.
      00.11  Infusion of drotrecogin alfa   N
              (activated).
      00.12  Administration of inhaled      N
              nitric oxide.
      00.13  Injection or infusion of       N
              nesiritide.
      00.14  Injection or infusion of       N
              oxazolidinone class of
              antibiotics.
      00.50  Implantation of cardiac
              resynchronization pacemaker
              without mention of
               defibrillation, total        Y                              5  115 \1\, 116 \1\
              system [CRT-P].
      00.51  Implantation of cardiac        Y                              5  514 \1\, 515 \1\
              resynchronization
              defibrillator, total system
              [CRT-D].
      00.52  Implantation or replacement
              of transvenous lead
              (electrode) into left
              ventricular
               coronary venous system.....  Y                              5  115 \2\, 116 \3\, 514 \4\, 515 \4\
      00.53  Implantation or replacement
              of cardiac resynchronization
              pacemaker pulse
               generator only [CRT-P].....  Y                              5  115 \2\, 116 \3\, 118
      00.54  Implantation or replacement
              of cardiac resynchronization
              defibrillator pulse
               generator only [CRT-D].....  Y                              5  115 \1\, 514 \4\, 515 \4\
      00.55  Insertion of drug-eluting      N
              noncoronary artery stent(s).
      36.07  Insertion of drug-eluting      N*                             5  517
              coronary artery stents(s).
      39.72  Endovascular repair or         Y                              1  1,2,3
              occlusion of head and neck                                   5  110, 111
              vessels.                                                    11  315
                                                                          21  442, 443
                                                                          24  486
      49.75  Implantation or revision of    Y                              6  157, 158
              artificial anal sphincter.                                   9  267
                                                                          21  442, 443
                                                                          24  486
      49.76  Removal of artificial anal     Y                              6  157, 158
              sphincter.                                                   9  267
                                                                          21  442, 443
                                                                          24  486
      81.61  360 degree spinal fusion,      Y                              1  4
              single incision approach.                                    8  496
                                                                          21  442, 443
                                                                          24  486
      84.51  Insertion of interbody spinal  N
              fusion device.
      84.52  Insertion of recombinant bone  N
              morphogenetic protein.
      88.96  Other intraoperative magnetic  N
              resonance imaging.
      99.76  Extracorporeal                 N
              immunoadsorption.
      99.77  Application or administration  N
              of an adhesion barrier
              substance.
----------------------------------------------------------------------------------------------------------------
*Non-operating room procedure, but affects DRG.
\1\ Classified under ``operating room procedures''.
\2\ Classified under ``operating room procedure'' and under ``as any of the following procedure combinations''
  as 00.52 and 00.53.
\3\ Classified under ``any of the following procedure combinations'' as 00.52 and 00.53.
\4\ Classified under ``any of the following procedure combinations'' as 00.52 and 00.54.


                                       Table 6C.--Invalid Diagnosis Codes
----------------------------------------------------------------------------------------------------------------
 Diagnosis
    code              Description                    CC               MDC                     DRG
----------------------------------------------------------------------------------------------------------------
      357.8  Other inflammatory and toxic   N                              1  18, 19
              neuropathy.
      359.8  Other myopathies.............  N                              1  34, 35

[[Page 31631]]

 
      459.1  Postphlebetic syndrome.......  N                              5  130, 131
      633.0  Abdominal pregnancy..........  N                             14  378
      633.1  Tubal pregnancy..............  N                             14  378
      633.2  Ovarian pregnancy............  N                             14  378
      633.8  Other ectopic pregnancy......  N                             14  378
      633.9  Unspecified ectopic pregnancy  N                             14  378
      770.8  Other respiratory problems     N                             15  387, 389
              after birth.
      771.8  Other infections specific to   Y                             15  387, 389
              the perinatal period.
      779.8  Other specified conditions     N                             15  390
              originating in the perinatal
              period.
      780.9  Other general symptoms.......  N                             23  463, 464
      795.0  Nonspecific abnormal           N                             13  358, 359, 369
              Papanicolaou smear of cervix.
      795.3  Nonspecific positive culture   N                             18  423
              findings.
      998.3  Disruption of operation wound  Y                             21  452, 453
      V01.8  Other communicable diseases..  N                             23  467
      V13.2  Other genital system and       N                             23  467
              obstetric disorders.
      V23.4  Pregnancy with other poor      N                             14  469
              obstetric history.
      V54.8  Other orthopedic aftercare...  N                              8  249
----------------------------------------------------------------------------------------------------------------


                   Table 6D.--Invalid Procedure Codes
------------------------------------------------------------------------
 
-------------------------------------------------------------------------
         Note: There are no invalid procedure codes for FY 2003.
------------------------------------------------------------------------


                                    Table 6E.--Revised Diagnosis Code Titles
----------------------------------------------------------------------------------------------------------------
 Diagnosis
    code              Description                    CC               MDC                     DRG
----------------------------------------------------------------------------------------------------------------
     402.00  Hypertensive heart disease,    Y                              5  134
              malignant, without heart
              failure.
     402.01  Hypertensive heart disease,    Y                              5  115, 121, 124, 127
              malignant, with heart
              failure.
     402.10  Hypertensive heart disease,    N                              5  134
              benign, without heart
              failure.
     402.11  Hypertensive heart disease,    Y                              5  115, 121, 124, 127
              benign, with heart failure.
     402.90  Hypertensive heart disease,    N                              5  134
              unspecified, without heart
              failure.
     402.91  Hypertensive heart disease,    Y                              5  115, 121, 124, 127
              unspecified, with heart
              failure.
     404.00  Hypertensive heart and renal
              disease, malignant, without
              mention of heart
               failure or renal failure...  Y                              5  134
     404.01  Hypertensive heart and renal   Y                              5  115, 121, 124, 127
              disease, malignant, with
              heart failure.
     404.03  Hypertensive heart and renal
              disease, malignant, with
              heart failure and renal
               failure....................  Y                              5  115, 121, 124, 127
     404.10  Hypertensive heart and renal
              disease, benign, without
              mention of heart failure
               or renal failure...........  N                              5  134
     404.11  Hypertensive heart and renal   Y                              5  115, 121, 124, 127
              disease, benign, with heart
              failure.
     404.13  Hypertensive heart and renal
              disease, benign, with heart
              failure and renal
               failure....................  Y                              5  115, 121, 124, 127
     404.90  Hypertensive heart and renal
              disease, unspecified,
              without mention of heart
               failure or renal failure...  N                              5  134
     404.91  Hypertensive heart and renal   Y                              5  115, 121, 124, 127
              disease, unspecified, with
              heart failure.
     404.93  Hypertensive heart and renal
              disease, unspecified, with
              heart failure and renal
               failure....................  Y                              5  115, 121, 124, 127
     414.10  Aneurysm of heart............  N                              5  121, 144, 145
     414.11  Aneurysm of coronary vessels.  N                              5  121, 144, 145
     414.19  Other aneurysm of heart......  N                              5  121, 144, 145
      428.0  Congestive heart failure,      Y                              5  115, 121, 124, 127
              unspecified.
      454.9  Asymptomatic varicose veins..  N                              5  130, 131
      627.2  Symptomatic menopausal or      N                             13  358, 359, 369
              female climacteric states.
      627.4  Symptomatic states associated  N                             13  358, 359, 369
              with artificial menopause.
     V49.81  Asymptomatic postmenopausal    N                             23  467
              status (age-related)
              (natural).
----------------------------------------------------------------------------------------------------------------


                                    Table 6F.--Revised Procedure Code Titles
----------------------------------------------------------------------------------------------------------------
        Procedure  code               Description             OR            MDC                  DRG
----------------------------------------------------------------------------------------------------------------
36.06.........................  Insertion of nondrug-   N*                       5  517
                                 eluting coronary
                                 artery stents(s).
39.79.........................  Other endovascular      Y                        1  1, 2, 3
                                 repair of aneurysm of                           5  110, 111
                                 other vessels.                                 11  315
                                                                                21  442, 443

[[Page 31632]]

 
39.90.........................  Insertion of nondrug-   N                       24  486
                                 eluting, noncoronary
                                 artery stent(s).
----------------------------------------------------------------------------------------------------------------
*Nonoperating room procedure, but affects DRG.


[[Page 31633]]


             Table 6G.--Additions to the CC Exclusions List
   [CCs that are added to the list are in Table 6G-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.]
------------------------------------------------------------------------
 
------------------------------------------------------------------------
*0031       99591     6829     99591    99593    44501    42821    4280
  99590     99592     99590    99592    99594    44502    42822    4281
  99591     99593     99591    99593  *04186     44581    42823    42820
  99592     99594     99592    99594    99590    44589    42830    42821
  99593   *03843      99593  *0412      99591  *25090     42831    42822
  99594     99590     99594    99590    99592    44501    42832    42823
*0202       99591   *04089     99591    99593    44502    42833    42830
  99590     99592     99590    99592    99594    44581    42840    42831
  99591     99593     99591    99593  *04189     44589    42841    42832
  99592     99594     99592    99594    99590  *25091     42842    42833
  99593   *03844      99593  *0413      99591    44501    42843    42840
  99594     99590     99594    99590    99592    44502  *40211     42841
*0362       99591   *04100     99591    99593    44581    42820    42842
  99590     99592     99590    99592    99594    44589    42821    42843
  99591     99593     99591    99593  *0419    *25092     42822    4289
  99592     99594     99592    99594    99590    44501    42823    5184
  99593   *03849      99593  *0414      99591    44502    42830  *42821
  99594     99590     99594    99590    99592    44581    42831    39891
*0380       99591   *04101     99591    99593    44589    42832    40201
  99590     99592     99590    99592    99594  *25093     42833    40211
  99591     99593     99591    99593  *0545      44501    42840    40291
  99592     99594     99592    99594    99590    44502    42841    4280
  99593   *0388       99593  *0415      99591    44581    42842    4281
  99594     99590     99594    99590    99592    44589    42843    42820
*03810      99591   *04102     99591    99593  *2515    *40291     42821
  99590     99592     99590    99592    99594    53784    42820    42822
  99591     99593     99591    99593  *1398      56986    42821    42823
  99592     99594     99592    99594    99590  *27700     42822    42830
  99593   *0389       99593  *0416      99591    27702    42823    42831
  99594     99590     99594    99590    99592    27703    42830    42832
*03811      99591   *04103     99591    99593    27709    42831    42833
  99590     99592     99590    99592    99594  *27701     42832    42840
  99591     99593     99591    99593  *25070     27702    42833    42841
  99592     99594     99592    99594    44501    27703    42840    42842
  99593   *04082      99593  *0417      44502    27709    42841    42843
  99594     0380      99594    99590    44581  *27702     42842    4289
*03819      03810   *04104     99591    44589    27700    42843    5184
  99590     03811     99590    99592  *25071     27701  *4280    *42822
  99591     03819     99591    99593    44501    27702    42820    39891
  99592     0382      99592    99594    44502    27703    42821    40201
  99593     0383      99593  *04181     44581    27709    42822    40211
  99594     03840     99594    99590    44589  *27703     42823    40291
*0382       03841   *04105     99591  *25072     27700    42830    4280
  99590     03842     99590    99592    44501    27701    42831    4281
  99591     03843     99591    99593    44502    27702    42832    42820
  99592     03844     99592    99594    44581    27703    42833    42821
  99593     03849     99593  *04182     44589    27709    42840    42822
  99594     0388      99594    99590  *25073   *27709     42841    42823
*0383       0389    *04109     99591    44501    27700    42842    42830
  99590     04082     99590    99592    44502    27701    42843    42831
  99591     6800      99591    99593    44581    27702  *4281      42832
  99592     6801      99592    99594    44589    27703    42820    42833
  99593     6802      99593  *04183   *25080     27709    42821    42840
  99594     6803      99594    99590    44501  *39891     42822    42841
*03840      6804    *04110     99591    44502    42820    42823    42842
  99590     6805      99590    99592    44581    42821    42830    42843
  99591     6806      99591    99593    44589    42822    42831    4289
  99592     6807      99592    99594  *25081     42823    42832    5184
  99593     6808      99593  *04184     44501    42830    42833  *42823
  99594     6809      99594    99590    44502    42831    42840    39891
*03841      6820    *04111     99591    44581    42832    42841    40201
  99590     6821      99590    99592    44589    42833    42842    40211
  99591     6822      99591    99593  *25082     42840    42843    40291
  99592     6823      99592    99594    44501    42841  *42820     4280
  99593     6825      99593  *04185     44502    42842    39891    4281
  99594     6826      99594    99590    44581    42843    40201    42820
*03842      6827    *04119     99591    44589  *40201     40211    42821
  99590     6828      99590    99592  *25083     42820    40291    42822
------------------------------------------------------------------------


[[Page 31634]]


        Table 6G.--Additions to the CC Exclusions List--Continued
   [CCs that are added to the list are in Table 6G-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.]
------------------------------------------------------------------------
 
------------------------------------------------------------------------
  42823     5184      42822    42831    56986  *53270     53784  *56202
  42830   *42833      42823    42832  *53140     53784    56986    53784
  42831     39891     42830    42833    53784    56986  *53411     56986
  42832     40201     42831    42840    56986  *53271     53784  *56203
  42833     40211     42832    42841  *53141     53784    56986    53784
  42840     40291     42833    42842    53784    56986  *53420     56986
  42841     4280      42840    42843    56986  *53290     53784  *56212
  42842     4281      42841    44501  *53150     53784    56986    53784
  42843     42820     42842    44502    53784    56986  *53421     56986
  4289      42821     42843    44581    56986  *53291     53784  *56213
  5184      42822     4289     44589  *53151     53784    56986    53784
*42830      42823     5184   *4599      53784    56986  *53430     56986
  39891     42830   *42843     42820    56986  *53300     53784  *5693
  40201     42831     39891    42821  *53160     53784    56986    53784
  40211     42832     40201    42822    53784    56986  *53431     56986
  40291     42833     40211    42823    56986  *53301     53784  *56985
  4280      42840     40291    42830  *53161     53784    56986    53784
  4281      42841     4280     42831    53784    56986  *53440     56986
  42820     42842     4281     42832    56986  *53310     53784  *56986
  42821     42843     42820    42833  *53170     53784    56986    56986
  42822     4289      42821    42840    53784    56986  *53441   *5780
  42823     5184      42822    42841    56986  *53311     53784    53784
  42830   *42840      42823    42842  *53171     53784    56986    56986
  42831     39891     42830    42843    53784    56986  *53450   *5781
  42832     40201     42831    44501    56986  *53320     53784    53784
  42833     40211     42832    44502  *53190     53784    56986    56986
  42840     40291     42833    44581    53784    56986  *53451   *5789
  42841     4280      42840    44589    56986  *53321     53784    53784
  42842     4281      42841  *5184    *53191     53784    56986    56986
  42843     42820     42842    42820    53784    56986  *53460   *74783
  4289      42821     42843    42821    56986  *53330     53784    42971
  5184      42822     4289     42822  *53200     53784    56986    42979
*42831      42823     5184     42823    53784    56986  *53461     7450
  39891     42830   *4289      42830    56986  *53331     53784    74510
  40201     42831     42820    42831  *53201     53784    56986    74511
  40211     42832     42821    42832    53784    56986  *53470     74512
  40291     42833     42822    42833    56986  *53340     53784    74519
  4280      42840     42823    42840  *53210     53784    56986    7452
  4281      42841     42830    42841    53784    56986  *53471     7453
  42820     42842     42831    42842    56986  *53341     53784    7454
  42821     42843     42832    42843  *53211     53784    56986    74560
  42822     4289      42833  *5302      53784    56986  *53490     74569
  42823     5184      42840    53784    56986  *53350     53784    7457
  42830   *42841      42841    56986  *53220     53784    56986    74601
  42831     39891     42842  *5307      53784    56986  *53491     74602
  42832     40201     42843    53784    56986  *53351     53784    7461
  42833     40211   *44489     56986  *53221     53784    56986    7462
  42840     40291     44501  *53082     53784    56986  *53501     7463
  42841     4280      44502    53784    56986  *53360     53784    7464
  42842     4281      44581    56986  *53230     53784    56986    7465
  42843     42820     44589  *53100     53784    56986  *53511     7466
  4289      42821   *4449      53784    56986  *53361     53784    7467
  5184      42822     44501    56986  *53231     53784    56986    74681
*42832      42823     44502  *53101     53784    56986  *53521     74682
  39891     42830     44581    53784    56986  *53370     53784    74683
  40201     42831     44589    56986  *53240     53784    56986    74684
  40211     42832   *44501   *53110     53784    56986  *53531     74686
  40291     42833     44501    53784    56986  *53371     53784    74711
  4280      42840   *44502     56986  *53241     53784    56986    74722
  4281      42841     44502  *53111     53784    56986  *53541   *76520
  42820     42842   *44581     53784    56986  *53390     53784    76501
  42821     42843     44581    56986  *53250     53784    56986    76502
  42822     4289    *44589   *53120     53784    56986  *53551     76503
  42823     5184      44589    53784    56986  *53391     53784    76504
  42830   *42842    *4560      56986  *53251     53784    56986    76505
  42831     39891     53784  *53121     53784    56986  *53561     76506
  42832     40201     56986    53784    56986  *53400     53784    76507
  42833     40211   *45989     56986  *53260     53784    56986    76508
  42840     40291     42820  *53130     53784    56986  *53783   *76521
  42841     4280      42821    53784    56986  *53401     53784    76501
  42842     4281      42822    56986  *53261     53784    56986    76502
  42843     42820     42823  *53131     53784    56986  *53784     76503
  4289      42821     42830    53784    56986  *53410     53784    76504
------------------------------------------------------------------------


[[Page 31635]]


        Table 6G.--Additions to the CC Exclusions List--Continued
   [CCs that are added to the list are in Table 6G-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.]
------------------------------------------------------------------------
 
------------------------------------------------------------------------
  76505     76506     769      76508    7703     7713     78039    03811
  76506     76507     7700     7670     7704     77181    7817     03819
  76507     76508     7701     7685     7705     77183    7854     0382
  76508   *7685       7702     769      7707     77210    78550    0383
*76522      77084     7703     7700     77084    77211    78551    03840
  76501   *7686       7704     7701     7710     77212    78559    03841
  76502     77084     7705     7702     7711     77213    7863     03842
  76503   *7689       7707     7703     7713     77214    78820    03843
  76504     77084     77084    7704     77181    7722     78829    03844
  76505   *769      *7709      7705     77183    7724     7895     03849
  76506     77084     77084    7707     77210    7725     7907     0388
  76507   *7700     *7714      77084    77211    7730     7911     0389
  76508     77084     77181    7710     77212    7731     7913     0545
*76523    *7701       77183    7711     77213    7732     7991     99590
  76501     77084   *7715      7713     77214    7733     7994     99591
  76502   *7702       77181    77181    7722     7734   *78099     99592
  76503     77084     77183    77183    7724     7740     04082    99593
  76504   *7703     *7716      77210    7725     7741     44024    99594
  76505     77084     77181    77211    7730     7742     78001  *99592
  76506   *7704       77183    77212    7731     77430    78003    0362
  76507     77084   *7717      77213    7732     77431    7801     0380
  76508   *7705       77181    77214    7733     77439    78031    03810
*76524      77084     77183    7722     7734     7744     78039    03811
  76501   *7706     *77181     7724     7740     7745     7817     03819
  76502     77084     77181    7725     7741     7747     7854     0382
  76503   *7707       77183    7730     7742     7751     78550    0383
  76504     77084   *77182     7731     77430    7752     78551    03840
  76505   *77081      77181    7732     77431    7753     78559    03841
  76506     7685      77183    7733     77439    7754     7863     03842
  76507     769     *77183     7734     7744     7755     78820    03843
  76508     7700      77181    7740     7745     7756     78829    03844
*76525      7701      77183    7741     7747     7757     7895     03849
  76501     7702    *77189     7742     7751     7760     7907     0388
  76502     7703      77181    77430    7752     7761     7911     0389
  76503     7704      77183    77431    7753     7762     7913     0545
  76504     7705    *7760      77439    7754     7763     7991     99590
  76505     7707      77181    7744     7755     7771     7994     99591
  76506     77084     77183    7745     7756     7772   *78550     99592
  76507   *77082    *7761      7747     7757     7775     04082    99593
  76508     7685      77181    7751     7760     7776   *78551     99594
*76526      769       77183    7752     7761     7780     04082  *99593
  76501     7700    *7762      7753     7762     7790   *78559     0362
  76502     7701      77181    7754     7763     7791     04082    0380
  76503     7702      77183    7755     7771     7797   *7859      03810
  76504     7703    *7763      7756     7772   *78091     04082    03811
  76505     7704      77181    7757     7775     04082  *7998      03819
  76506     7705      77183    7760     7776     44024    04082    0382
  76507     7707    *7764      7761     7780     78001  *99590     0383
  76508     77084     77181    7762     7790     78003    0362     03840
*76527    *77083      77183    7763     7791     7801     0380     03841
  76501     7685    *7765      7771     7797     78031    03810    03842
  76502     769       77181    7772   *77989     78039    03811    03843
  76503     7700      77183    7775     76501    7817     03819    03844
  76504     7701    *7766      7776     76502    7854     0382     03849
  76505     7702      77181    7780     76503    78550    0383     0388
  76506     7703      77183    7790     76504    78551    03840    0389
  76507     7704    *7767      7791     76505    78559    03841    0545
  76508     7705      77181    7797     76506    7863     03842    99590
*76528      7707      77183  *77982     76507    78820    03843    99591
  76501     77084   *7768      76501    76508    78829    03844    99592
  76502   *77084      77181    76502    7670     7895     03849    99593
  76503     7685      77183    76503    7685     7907     0388     99594
  76504     769     *7769      76504    769      7911     0389   *99594
  76505     7700      77181    76505    7700     7913     0545     0362
  76506     7701      77183    76506    7701     7991     99590    0380
  76507     7702    *77981     76507    7702     7994     99591    03810
  76508     7703      76501    76508    7703   *78092     99592    03811
*76529      7704      76502    7670     7704     04082    99593    03819
  76501     7705      76503    7685     7705     44024    99594    0382
  76502     7707      76504    769      7707     78001  *99591     0383
  76503     77084     76505    7700     77084    78003    0362     03840
  76504   *77089      76506    7701     7710     7801     0380     03841
  76505     7685      76507    7702     7711     78031    03810    03842
------------------------------------------------------------------------


[[Page 31636]]


        Table 6G.--Additions to the CC Exclusions List--Continued
   [CCs that are added to the list are in Table 6G-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.]
------------------------------------------------------------------------
 
------------------------------------------------------------------------
  03843     99591
  03844     99592
  03849     99593
  0388      99594
  0389    *V096
  0545      99590
  99590     99591
  99591     99592
  99592     99593
  99593     99594
  99594   *V0970
*99791      99590
  99831     99591
  99832     99592
*99799      99593
  99831     99594
  99832   *V0971
*99831      99590
  99831     99591
  99832     99592
*99832      99593
  99831     99594
  99832   *V0980
*99881      99590
  99831     99591
  99832     99592
*99883      99593
  99831     99594
  99832   *V0981
*99889      99590
  99831     99591
  99832     99592
*9989       99593
  99831     99594
  99832   *V0990
*V090       99590
  99590     99591
  99591     99592
  99592     99593
  99593     99594
  99594   *V0991
*V091       99590
  99590     99591
  99591     99592
  99592     99593
  99593     99594
  99594   *V2341
*V092       V237
  99590     V2381
  99591     V2382
  99592     V2383
  99593     V2384
  99594     V2389
*V093       V239
  99590   *V2349
  99591     V237
  99592     V2381
  99593     V2382
  99594     V2383
*V094       V2384
  99590     V2389
  99591     V239
  99592   *V462
  99593     V461
  99594
*V0950
  99590
  99591
  99592
  99593
  99594
*V0951
  99590
------------------------------------------------------------------------


[[Page 31637]]


             Table 6H.--Deletions to the CC Exclusions List
 [CCs that are deleted from the list are in Table 6H-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.]
------------------------------------------------------------------------
 
------------------------------------------------------------------------
*7708       7722      9983
  7685      7724    *9989
  769       7725      9983
  7700      7730    *V234
  7701      7731      V237
  7702      7732      V2381
  7703      7733      V2382
  7704      7734      V2383
  7705      7740      V2384
  7707      7741      V2389
*7714       7742      V239
  7718      77430
*7715       77431
  7718      77439
*7716       7744
  7718      7745
*7717       7747
  7718      7751
*7718       7752
  7718      7753
*7760       7754
  7718      7755
*7761       7756
  7718      7757
*7762       7760
  7718      7761
*7763       7762
  7718      7763
*7764       7771
  7718      7772
*7765       7775
  7718      7776
*7766       7780
  7718      7790
*7767       7791
  7718      7797
*7768     *7809
  7718      44024
*7769       78001
  7718      78003
*7798       7801
  76501     78031
  76502     78039
  76503     7817
  76504      7854
  76505     78550
  76506     78551
  76507     78559
  76508     7863
  7670      78820
  7685      78829
  769       7895
  7700      7907
  7701      7911
  7702      7913
  7703      7991
  7704      7994
  7705    *99791
  7707      9983
  7710    *99799
  7711      9983
  7713    *9983
  7718      9983
  77210   *99881
  77211     9983
  77212   *99883
  77213     9983
  77214   *99889
------------------------------------------------------------------------


[[Page 31638]]


                                   Table 7A.--Medicare Prospective Payment System Selected Percentile Lengths of Stay
                                                       [FY 2001 MEDPAR Update 12/01 Grouper V19.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                              Number        Arithmetic         10th            25th            50th            75th             90th
                   DRG                      discharges       mean LOS       percentile      percentile      percentile      percentile      percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1.......................................           34667          8.9765               2               3               6              12              19
2.......................................            7122          9.9083               3               5               8              13              20
3.......................................               7          7.4286               1               1               3               4              10
4.......................................            6414          7.1743               1               2               5               9              16
5.......................................           93169          3.0674               1               1               2               3               7
6.......................................             398          2.9196               1               1               2               4               6
7.......................................           14187          9.7565               1               4               7              12              20
8.......................................            4350          2.7572               1               1               1               3               6
9.......................................            1738          6.4689               1               3               5               8              13
10......................................           18019          6.5224               2               3               5               8              13
11......................................            3400          4.0044               1               2               3               5               8
12......................................           49655          5.8699               2               3               4               7              11
13......................................            6646          5.0141               2               3               4               6               9
14......................................          320358          5.8150               2               3               5               7              11
15......................................          152285          3.4737               1               2               3               4               6
16......................................           11455          6.0111               2               3               5               7              12
17......................................            3729          3.2773               1               2               3               4               6
18......................................           28016          5.4234               2               3               4               7              10
19......................................            8679          3.5369               1               2               3               5               7
20......................................            5618         10.4676               3               5               8              13              20
21......................................            1429          6.5850               2               3               5               8              13
22......................................            2723          5.0165               2               2               4               6              10
23......................................           11192          4.2429               1               2               3               5               8
24......................................           55364          4.8878               1               2               4               6              10
25......................................           27208          3.2250               1               2               3               4               6
26......................................              34          4.6765               1               1               2               4               6
27......................................            3839          5.0253               1               1               3               6              11
28......................................           12344          6.2286               1               3               5               8              13
29......................................            4930          3.5613               1               2               3               5               7
31......................................            3815          4.0765               1               2               3               5               8
32......................................            1893          2.4464               1               1               2               3               5
34......................................           21788          5.0453               1               2               4               6               9
35......................................            6839          3.2388               1               1               3               4               6
36......................................            2493          1.4705               1               1               1               1               2
37......................................            1419          3.8182               1               1               2               4               9
38......................................              93          2.4946               1               1               1               3               6
39......................................             667          1.9340               1               1               1               2               4
40......................................            1524          3.6037               1               1               2               5               8
42......................................            1938          2.3710               1               1               1               3               5
43......................................             110          3.0455               1               1               2               4               6
44......................................            1295          5.0347               2               3               4               6               9
45......................................            2600          3.2423               1               2               3               4               6
46......................................            3374          4.5871               1               2               4               6               9
47......................................            1350          3.1719               1               1               3               4               6
48......................................               1          2.0000               2               2               2               2               2
49......................................            2335          4.6188               1               2               3               5               9
50......................................            2483          1.8212               1               1               1               2               3
51......................................             251          3.1195               1               1               1               3               7
52......................................             239          1.9205               1               1               1               2               3
53......................................            2516          3.3792               1               1               2               4               8
54......................................               1          4.0000               4               4               4               4               4
55......................................            1566          3.0556               1               1               1               3               6
56......................................             528          2.9848               1               1               2               3               6
57......................................             692          3.6893               1               1               2               4               8
59......................................             128          2.6641               1               1               1               3               6
60......................................               6          3.3333               1               1               2               5               5
61......................................             243          4.8354               1               1               3               7              10
62......................................               3          1.6667               1               1               1               3               3
63......................................            2887          4.4891               1               1               3               6               9
64......................................            3132          6.6028               1               2               4               8              14
65......................................           39024          2.7977               1               1               2               3               5
66......................................            7671          3.1068               1               1               2               4               6
67......................................             440          3.5955               1               2               3               4               6
68......................................            8648          3.8274               1               2               3               5               7
69......................................            2973          3.0054               1               2               2               4               6
70......................................              25          3.4800               1               2               3               4               8
71......................................              87          3.4368               1               2               3               4               6
72......................................             926          3.5659               1               1               3               4               7
73......................................            7073          4.3867               1               2               3               6               9
75......................................           39878         10.0489               3               5               7              12              20

[[Page 31639]]

 
76......................................           41691         11.4166               3               5               9              14              22
77......................................            2445          4.8634               1               2               4               7              10
78......................................           35316          6.6636               3               4               6               8              11
79......................................          166404          8.5040               3               4               7              11              16
80......................................            8320          5.4954               2               3               5               7              10
81......................................               2          8.0000               3               3              13              13              13
82......................................           63426          6.9938               2               3               6               9              14
83......................................            6394          5.4759               2               3               4               7              10
84......................................            1559          3.2290               1               2               3               4               6
85......................................           21268          6.3168               2               3               5               8              12
86......................................            2180          3.8138               1               2               3               5               8
87......................................           59482          6.3070               1               3               5               8              12
88......................................          396842          5.1059               2               3               4               6               9
89......................................          502709          5.8920               2               3               5               7              11
90......................................           46817          4.0322               2               2               3               5               7
91......................................              57          4.0000               2               2               3               5               8
92......................................           14816          6.3579               2               3               5               8              12
93......................................            1710          4.1076               1               2               3               5               8
94......................................           12574          6.3304               2               3               5               8              13
95......................................            1679          3.7123               1               2               3               5               7
96......................................           53729          4.5526               2               2               4               6               8
97......................................           28601          3.5208               1               2               3               4               6
98......................................              15          5.0000               1               2               3               4              13
99......................................           21279          3.1677               1               1               2               4               6
100.....................................            8950          2.1349               1               1               2               3               4
101.....................................           21127          4.3832               1               2               3               6               9
102.....................................            5559          2.5690               1               1               2               3               5
103.....................................             428         49.2103               9              14              26              61             116
104.....................................           19836         14.4245               6               8              12              17              25
105.....................................           27462          9.9935               5               6               8              11              18
106.....................................            3308         11.3987               5               7              10              14              20
107.....................................           85791         10.4560               5               7               9              12              17
108.....................................            6205         10.2743               3               5               8              13              20
109.....................................           59572          7.7288               4               5               6               9              13
110.....................................           53172          9.0340               2               4               7              11              18
111.....................................            9394          4.4159               1               2               4               6               8
113.....................................           41424         12.4557               4               6               9              15              24
114.....................................            8852          8.5204               2               4               7              11              17
115.....................................           15271          8.2839               1               4               7              11              16
116.....................................          109277          4.4721               1               2               3               6               9
117.....................................            4177          4.1611               1               1               2               5               9
118.....................................            8112          2.8930               1               1               1               3               7
119.....................................            1316          5.1117               1               1               3               6              12
120.....................................           37220          8.7981               1               2               6              12              20
121.....................................          167308          6.3297               2               3               5               8              12
122.....................................           81710          3.6163               1               2               3               5               7
123.....................................           41163          4.7016               1               1               3               6              11
124.....................................          137232          4.3524               1               2               3               5               8
125.....................................           91133          2.7831               1               1               2               4               5
126.....................................            5016         11.8909               4               6               9              15              22
127.....................................          682134          5.2700               2               3               4               7              10
128.....................................            8254          5.4723               2               3               5               7               9
129.....................................            4105          2.8378               1               1               1               3               6
130.....................................           88700          5.6615               2               3               5               7              10
131.....................................           27798          4.0539               1               2               4               5               7
132.....................................          152312          2.9301               1               1               2               4               5
133.....................................            8929          2.2655               1               1               2               3               4
134.....................................           39623          3.1770               1               2               2               4               6
135.....................................            7554          4.4298               1               2               3               5               8
136.....................................            1237          2.5594               1               1               2               3               5
138.....................................          203378          3.9834               1               2               3               5               8
139.....................................           90000          2.4829               1               1               2               3               5
140.....................................           66435          2.5585               1               1               2               3               5
141.....................................          102391          3.5917               1               2               3               4               7
142.....................................           51719          2.5539               1               1               2               3               5
143.....................................          250133          2.0827               1               1               2               3               4
144.....................................           88510          5.4530               1               2               4               7              11
145.....................................            7598          2.6481               1               1               2               3               5
146.....................................           10799         10.2146               5               7               8              12              17
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148.....................................          129350         12.2861               5               7              10              15              22
149.....................................           19313          6.4669               4               5               6               8              10
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151.....................................            4963          5.6756               1               3               5               8              10
152.....................................            4425          8.3250               3               5               7              10              14
153.....................................            2014          5.3803               3               4               5               7               8
154.....................................           29001         13.2057               3               7              10              16              26
155.....................................            7262          3.9898               1               2               3               6               8
156.....................................               3         15.0000              11              11              13              21              21
157.....................................            8154          5.5581               1               2               4               7              11
158.....................................            4562          2.5184               1               1               2               3               5
159.....................................           17114          5.0598               1               2               4               6              10
160.....................................           12169          2.6492               1               1               2               3               5
161.....................................           11152          4.1588               1               1               3               5               9
162.....................................            7288          1.9175               1               1               1               2               4
163.....................................               3          3.0000               1               1               3               5               5
164.....................................            5118          8.2651               3               5               7              10              14
165.....................................            2185          4.6499               2               3               4               6               8
166.....................................            3903          4.8737               1               2               4               6               9
167.....................................            3800          2.5132               1               1               2               3               4
168.....................................            1279          5.0023               1               2               3               6              11
169.....................................             827          2.2866               1               1               2               3               5
170.....................................           12108         10.9853               2               4               8              14              22
171.....................................            1355          4.3107               1               2               3               6               9
172.....................................           30622          6.9624               2               3               5               9              14
173.....................................            2711          3.7444               1               1               3               5               8
174.....................................          247222          4.8059               2               3               4               6               9
175.....................................           35165          2.9201               1               2               3               4               5
176.....................................           15219          5.2481               2               3               4               6              10
177.....................................            9429          4.5038               2               2               4               6               8
178.....................................            3758          3.0780               1               2               3               4               6
179.....................................           12541          5.9632               2               3               5               7              11
180.....................................           88300          5.3709               2               3               4               7              10
181.....................................           27097          3.3767               1               2               3               4               6
182.....................................          248889          4.4042               1               2               3               5               8
183.....................................           87342          2.8973               1               1               2               4               5
184.....................................              90          2.9000               1               1               2               4               6
185.....................................            5021          4.7104               1               2               3               6               9
186.....................................               3          4.6667               2               2               3               9               9
187.....................................             446          4.3565               1               2               3               6               8
188.....................................           79403          5.5558               1               2               4               7              11
189.....................................           13113          3.0563               1               1               2               4               6
190.....................................              74          4.7838               1               2               3               5               9
191.....................................            9222         13.7304               3               6              10              17              28
192.....................................            1257          6.0963               1               3               5               8              11
193.....................................            4865         12.7394               5               7              10              16              23
194.....................................             733          6.8759               2               4               6               8              12
195.....................................            4157         10.3560               4               6               9              12              18
196.....................................            1051          5.4186               2               3               5               7               9
197.....................................           18569          8.9827               3               5               7              11              16
198.....................................            5672          4.4381               2               3               4               6               8
199.....................................            1644          9.9179               2               4               7              13              21
200.....................................            1042         10.4539               1               3               7              14              22
201.....................................            1466         14.4734               3               6              11              18              29
202.....................................           26156          6.3731               2               3               5               8              13
203.....................................           29310          6.7403               2               3               5               9              13
204.....................................           61544          5.8119               2               3               4               7              11
205.....................................           24459          6.1537               2               3               5               8              12
206.....................................            2049          3.9204               1               2               3               5               8
207.....................................           32107          5.1834               1               2               4               7              10
208.....................................           10745          2.8598               1               1               2               4               5
209.....................................          371105          4.9903               3               3               4               6               8
210.....................................          121541          6.8894               3               4               6               8              11
211.....................................           32567          4.9284               3               4               5               6               7
212.....................................               7          3.2857               1               2               2               2               4
213.....................................            9878          9.1432               2               4               7              11              18
216.....................................            6916          9.5448               2               4               7              12              19
217.....................................           17029         13.4060               3               5               9              16              28
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[[Page 31641]]

 
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225.....................................            6124          5.0144               1               2               3               7              11
226.....................................            5702          6.6733               1               3               5               8              14
227.....................................            4923          2.6669               1               1               2               3               5
228.....................................            2481          4.0806               1               1               2               5               9
229.....................................            1176          2.2168               1               1               2               3               4
230.....................................            2407          5.0586               1               2               3               6              11
231.....................................           13540          4.8875               1               1               3               6              10
232.....................................             882          2.7426               1               1               1               3               7
233.....................................            7199          7.2148               1               3               5               9              15
234.....................................            4623          3.1573               1               1               2               4               7
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236.....................................           39785          4.7450               1               3               4               6               9
237.....................................            1744          3.5740               1               2               3               4               7
238.....................................            8625          8.8420               3               4               7              11              17
239.....................................           48235          6.2846               2               3               5               8              12
240.....................................           11808          6.7199               2               3               5               8              13
241.....................................            3223          3.8849               1               2               3               5               7
242.....................................            2516          6.5568               2               3               5               8              13
243.....................................           93807          4.6804               1               2               4               6               9
244.....................................           13584          4.7331               1               2               4               6               9
245.....................................            5733          3.3630               1               2               3               4               6
246.....................................            1347          3.7647               1               2               3               5               7
247.....................................           19620          3.3687               1               1               3               4               6
248.....................................           12067          4.8652               1               2               4               6               9
249.....................................           12912          3.6678               1               1               2               4               8
250.....................................            3795          4.1686               1               2               3               5               7
251.....................................            2489          2.7814               1               1               2               4               5
253.....................................           20861          4.6779               1               3               4               6               9
254.....................................           10809          3.1314               1               2               3               4               6
255.....................................               1          2.0000               2               2               2               2               2
256.....................................            6422          5.1110               1               2               4               6              10
257.....................................           16706          2.6651               1               1               2               3               5
258.....................................           16972          1.8186               1               1               2               2               3
259.....................................            3813          2.6693               1               1               1               2               6
260.....................................            5087          1.3666               1               1               1               1               2
261.....................................            1889          2.1615               1               1               1               2               4
262.....................................             683          4.2958               1               1               3               5              10
263.....................................           24569         11.8050               3               5               8              14              23
264.....................................            3982          6.9006               2               3               5               8              14
265.....................................            4052          6.7347               1               2               4               8              14
266.....................................            2676          3.1371               1               1               2               4               6
267.....................................             267          4.2584               1               1               2               4               8
268.....................................             899          3.6274               1               1               2               4               8
269.....................................            9064          8.2177               2               3               6              10              17
270.....................................            2746          3.2618               1               1               2               4               7
271.....................................           19612          7.2767               2               4               6               9              13
272.....................................            5471          6.1349               2               3               5               7              12
273.....................................            1387          3.9250               1               2               3               5               7
274.....................................            2344          6.7675               1               3               5               8              14
275.....................................             247          3.0202               1               1               2               4               6
276.....................................            1315          4.5384               1               2               4               6               8
277.....................................           93957          5.7577               2               3               5               7              10
278.....................................           31764          4.2755               2               3               4               5               7
279.....................................               3          7.0000               3               3               8              10              10
280.....................................           17047          4.1686               1               2               3               5               8
281.....................................            7834          2.9183               1               1               2               4               5
283.....................................            5638          4.6568               1               2               4               6               9
284.....................................            1950          3.0569               1               1               2               4               6
285.....................................            6574         10.6492               3               5               8              13              20
286.....................................            2183          5.9464               2               3               4               7              11
287.....................................            6460         10.5718               3               5               8              12              20
288.....................................            3675          5.3897               2               3               4               6               8
289.....................................            6423          2.8026               1               1               1               3               6
290.....................................            9500          2.2281               1               1               1               2               4
291.....................................              78          1.6026               1               1               1               2               3
292.....................................            5423          9.9458               2               4               8              13              20
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[[Page 31642]]

 
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297.....................................           47743          3.3559               1               2               3               4               6
298.....................................             103          4.3495               1               2               3               5               8
299.....................................            1218          5.3760               1               2               4               6              10
300.....................................           17546          6.1581               2               3               5               8              12
301.....................................            3644          3.6509               1               2               3               5               7
302.....................................            7896          8.6990               4               5               7              10              15
303.....................................           20694          8.2722               3               4               6               9              15
304.....................................           11944          8.6761               2               4               6              11              18
305.....................................            2972          3.5697               1               2               3               4               6
306.....................................            7213          5.4883               1               2               3               7              13
307.....................................            2168          2.2002               1               1               2               3               4
308.....................................            7359          6.3367               1               2               4               8              14
309.....................................            4375          2.1913               1               1               2               3               4
310.....................................           24597          4.3470               1               1               3               5               9
311.....................................            8323          1.8264               1               1               1               2               3
312.....................................            1547          4.4945               1               1               3               6              10
313.....................................             644          2.1289               1               1               1               2               4
314.....................................               1          5.0000               5               5               5               5               5
315.....................................           31230          6.8866               1               1               4               9              16
316.....................................          116645          6.6308               2               3               5               8              13
317.....................................            1890          3.0899               1               1               2               3               7
318.....................................            5739          6.0294               1               3               4               8              12
319.....................................             494          2.8543               1               1               2               4               6
320.....................................          193283          5.3020               2               3               4               7              10
321.....................................           30745          3.7500               1               2               3               5               7
322.....................................              64          3.6563               1               2               3               4               7
323.....................................           18622          3.1423               1               1               2               4               6
324.....................................            7455          1.8437               1               1               1               2               3
325.....................................            8938          3.7880               1               2               3               5               7
326.....................................            2803          2.6718               1               1               2               3               5
327.....................................               2          2.5000               1               1               4               4               4
328.....................................             685          3.7883               1               1               3               5               7
329.....................................             105          2.2000               1               1               1               2               5
331.....................................           49140          5.5819               1               3               4               7              11
332.....................................            5119          3.1686               1               1               2               4               6
333.....................................             311          4.6849               1               2               3               6              10
334.....................................           10271          4.7684               2               3               4               5               8
335.....................................           12383          3.1779               2               2               3               4               5
336.....................................           36334          3.4249               1               2               2               4               7
337.....................................           29524          2.0688               1               1               2               2               3
338.....................................            1055          5.5526               1               2               3               8              13
339.....................................            1505          4.6186               1               1               3               6              10
340.....................................               1          1.0000               1               1               1               1               1
341.....................................            3670          3.0695               1               1               2               3               6
342.....................................             723          3.1355               1               1               2               4               6
343.....................................               1          5.0000               5               5               5               5               5
344.....................................            3810          2.2850               1               1               1               2               4
345.....................................            1180          3.8542               1               1               2               4               8
346.....................................            4562          6.0342               1               3               5               8              12
347.....................................             373          2.6971               1               1               2               3               6
348.....................................            3281          4.1591               1               2               3               5               8
349.....................................             597          2.4623               1               1               2               3               5
350.....................................            6497          4.5045               2               2               4               6               8
351.....................................               1          1.0000               1               1               1               1               1
352.....................................             768          3.9557               1               2               3               5               8
353.....................................            2659          6.4772               2               3               5               7              12
354.....................................            7491          5.8265               3               3               4               7              10
355.....................................            5680          3.2347               2               2               3               4               5
356.....................................           25943          2.1725               1               1               2               3               4
357.....................................            5715          8.4126               3               4               6              10              16
358.....................................           20616          4.3038               2               3               3               5               7
359.....................................           31095          2.6372               1               2               3               3               4
360.....................................           15579          2.8185               1               2               2               3               5
361.....................................             369          3.6694               1               1               2               4               8
362.....................................               2          1.0000               1               1               1               1               1
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[[Page 31643]]

 
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368.....................................            3288          6.7318               2               3               5               8              13
369.....................................            3280          3.1976               1               1               2               4               6
370.....................................            1244          5.6937               3               3               4               5               9
371.....................................            1416          3.6031               2               3               3               4               5
372.....................................             919          3.6529               1               2               2               3               5
373.....................................            3878          2.2935               1               2               2               3               3
374.....................................             116          2.8793               1               2               2               3               5
375.....................................               8          5.2500               1               3               5               5               9
376.....................................             263          3.5095               1               2               2               4               6
377.....................................              29          4.3793               1               2               3               4               7
378.....................................             169          2.4615               1               1               2               3               4
379.....................................             408          3.0000               1               1               2               3               6
380.....................................              76          1.9605               1               1               1               2               4
381.....................................             181          2.0829               1               1               1               2               4
382.....................................              25          1.3600               1               1               1               1               3
383.....................................            1841          3.9620               1               1               3               4               8
384.....................................             149          2.7315               1               1               1               3               6
389.....................................               5          3.4000               1               1               2               4               8
390.....................................               8          2.7500               1               1               1               4               5
392.....................................            2247          9.5167               2               4               7              12              19
393.....................................               1          2.0000               2               2               2               2               2
394.....................................            1959          6.2950               1               2               4               8              14
395.....................................          100668          4.3478               1               2               3               5               9
396.....................................              11          3.8182               1               1               2               4               6
397.....................................           17952          5.1683               1               2               4               7              10
398.....................................           17121          5.8897               2               3               5               7              11
399.....................................            1788          3.5520               1               2               3               5               7
400.....................................            6488          8.9578               1               3               6              11              20
401.....................................            5837         11.2479               2               5               9              15              23
402.....................................            1598          3.8899               1               1               3               5               8
403.....................................           32013          8.0033               2               3               6              10              17
404.....................................            4593          4.1916               1               2               3               5               9
406.....................................            2495          9.6970               2               4               7              12              20
407.....................................             702          4.1140               1               2               3               5               8
408.....................................            2122          7.8591               1               2               5              10              18
409.....................................            2517          6.1339               2               3               4               6              13
410.....................................           30770          4.0138               1               2               4               5               6
411.....................................              14          2.9286               1               1               2               4               6
412.....................................              18          2.0000               1               1               1               2               4
413.....................................            5767          7.2917               2               3               6               9              14
414.....................................             763          4.0170               1               2               3               5               8
415.....................................           39920         14.4391               4               6              11              18              29
416.....................................          181162          7.4625               2               4               6               9              14
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418.....................................           23410          6.1742               2               3               5               8              12
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420.....................................            2958          3.4324               1               2               3               4               6
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422.....................................              69          2.9130               1               1               2               3               6
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425.....................................           16309          3.8956               1               2               3               5               8
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428.....................................             745          7.3732               1               2               4               8              15
429.....................................           27035          6.1425               2               3               4               7              12
430.....................................           63072          7.9697               2               3               6              10              16
431.....................................             321          5.9470               1               2               4               7              13
432.....................................             411          4.5645               1               1               3               5               9
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439.....................................            1457          8.5003               1               3               6              10              17
440.....................................            5440          9.0241               2               3               6              11              20
441.....................................             612          3.0735               1               1               2               4               7
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450.....................................            7369          1.9900               1               1               1               2               4
451.....................................               5          1.6000               1               1               2               2               2
452.....................................           25229          5.0164               1               2               3               6              10
453.....................................            5648          2.7665               1               1               2               3               5
454.....................................            4624          4.3575               1               2               3               5               9
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462.....................................           11994         11.3643               4               6              10              14              21
463.....................................           25215          4.1639               1               2               3               5               8
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467.....................................            1043          8.3931               1               1               2               3               6
468.....................................           57090         12.8803               3               6              10              16              25
471.....................................           12468          5.4931               3               3               4               6               9
473.....................................            8236         12.3409               1               3               7              17              32
475.....................................          104072         11.1941               2               5               9              15              22
476.....................................            3803         11.2611               2               5              10              15              21
477.....................................           25564          8.1456               1               3               6              11              17
478.....................................          108638          7.3817               1               3               5               9              16
479.....................................           24179          3.3012               1               1               3               4               7
480.....................................             622         21.5354               7               9              14              28              49
481.....................................             726         21.9353              13              17              20              25              33
482.....................................            5562         13.2251               4               7              10              16              25
483.....................................           43028         39.7169              15              22              33              49              71
484.....................................             317         13.0820               2               5              10              18              27
485.....................................            3029          9.4262               4               5               7              11              18
486.....................................            1867         12.3214               1               5              10              16              25
487.....................................            3536          7.6683               1               3               6              10              16
488.....................................             776         16.9162               3               6              13              22              35
489.....................................           13557          8.5376               2               3               6              10              18
490.....................................            5252          5.2582               1               2               4               6              10
491.....................................           13607          3.4664               1               2               3               4               6
492.....................................            2875         15.0104               2               5               7              25              34
493.....................................           58106          5.8777               1               3               5               7              11
494.....................................           30972          2.4751               1               1               2               3               5
495.....................................             211         17.1659               8              10              13              20              31
496.....................................            1842          9.4870               3               4               7              11              19
497.....................................           18414          6.5560               3               4               5               7              11
498.....................................           13584          4.1477               2               3               4               5               6
499.....................................           33300          4.6629               1               2               3               6               9
500.....................................           49827          2.4760               1               1               2               3               5
501.....................................            2356         10.6341               4               5               8              13              20
502.....................................             637          6.4066               2               4               5               8              11
503.....................................            5894          3.8884               1               2               3               5               7
504.....................................             123         34.9756               9              15              27              44              66
505.....................................             147          3.6667               1               1               1               5               9
506.....................................             937         17.2604               4               8              14              22              36
507.....................................             288          8.9549               2               4               7              12              18
508.....................................             667          8.2219               2               3               6              10              17
509.....................................             177          5.4350               1               2               4               7              10
510.....................................            1671          6.6092               1               3               5               8              13
511.....................................             616          4.3766               1               1               3               5               9
512.....................................             450         14.2244               6               8              11              15              24
513.....................................             142         10.7042               5               7               9              11              20
514.....................................           19261          7.2615               1               3               6               9              15
515.....................................            4570          5.4897               1               1               3               7              13
516.....................................           76256          4.7308               2               2               4               6               9
517.....................................          191586          2.6138               1               1               2               3               6
518.....................................           51638          3.3905               1               1               2               4               7
519.....................................            7316          5.1875               1               2               3               6              12
520.....................................           11118          2.1205               1               1               2               2               4
521.....................................           28568          5.7752               2               3               4               7              12
522.....................................            6141          9.4402               3               4               8              12              20
523.....................................           14812          4.0927               1               2               3               5               7
                                         ----------------
                                                11403341
--------------------------------------------------------------------------------------------------------------------------------------------------------


[[Page 31645]]


                                   Table 7B.--Medicare Prospective Payment System Selected Percentile Lengths of Stay
                                                       [FY 2001 MEDPAR Update 12/01 Grouper V20.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                              Number        Arithmetic         10th            25th            50th            75th             90th
                   DRG                      discharges       mean LOS       percentile      percentile      percentile      percentile      percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1.......................................           27708         11.1212               3               5               8              14              22
2.......................................           14081          5.2277               1               3               4               7              10
3.......................................               7          7.4286               1               1               3               4              10
4.......................................            6426          7.1748               1               2               5               9              16
5.......................................           93169          3.0674               1               1               2               3               7
6.......................................             398          2.9196               1               1               2               4               6
7.......................................           14187          9.7565               1               4               7              12              20
8.......................................            4350          2.7572               1               1               1               3               6
9.......................................            1737          6.4669               1               3               5               8              13
10......................................           18019          6.5224               2               3               5               8              13
11......................................            3400          4.0044               1               2               3               5               8
12......................................           49655          5.8699               2               3               4               7              11
13......................................            6646          5.0141               2               3               4               6               9
14......................................          236067          6.0768               2               3               5               7              12
15......................................          101726          4.9503               2               3               4               6               9
16......................................            9257          6.1391               2               3               5               8              12
17......................................            2871          3.1379               1               1               2               4               6
18......................................           28016          5.4234               2               3               4               7              10
19......................................            8679          3.5369               1               2               3               5               7
20......................................            5618         10.4676               3               5               8              13              20
21......................................            1429          6.5850               2               3               5               8              13
22......................................            2723          5.0165               2               2               4               6              10
23......................................           11192          4.2429               1               2               3               5               8
24......................................           55364          4.8878               1               2               4               6              10
25......................................           27208          3.2250               1               2               3               4               6
26......................................              34          4.6765               1               1               2               4               6
27......................................            3839          5.0253               1               1               3               6              11
28......................................           12344          6.2286               1               3               5               8              13
29......................................            4930          3.5613               1               2               3               5               7
31......................................            3815          4.0765               1               2               3               5               8
32......................................            1893          2.4464               1               1               2               3               5
34......................................           22342          5.0412               1               2               4               6               9
35......................................            7331          3.2195               1               1               3               4               6
36......................................            2493          1.4705               1               1               1               1               2
37......................................            1419          3.8182               1               1               2               4               9
38......................................              93          2.4946               1               1               1               3               6
39......................................             667          1.9340               1               1               1               2               4
40......................................            1524          3.6037               1               1               2               5               8
42......................................            1938          2.3710               1               1               1               3               5
43......................................             110          3.0455               1               1               2               4               6
44......................................            1295          5.0347               2               3               4               6               9
45......................................            2600          3.2423               1               2               3               4               6
46......................................            3374          4.5871               1               2               4               6               9
47......................................            1350          3.1719               1               1               3               4               6
48......................................               1          2.0000               2               2               2               2               2
49......................................            2337          4.6166               1               2               3               5               9
50......................................            2483          1.8212               1               1               1               2               3
51......................................             251          3.1195               1               1               1               3               7
52......................................             239          1.9205               1               1               1               2               3
53......................................            2518          3.3777               1               1               2               4               8
54......................................               1          4.0000               4               4               4               4               4
55......................................            1566          3.0556               1               1               1               3               6
56......................................             528          2.9848               1               1               2               3               6
57......................................             692          3.6893               1               1               2               4               8
59......................................             128          2.6641               1               1               1               3               6
60......................................               6          3.3333               1               1               2               5               5
61......................................             243          4.8354               1               1               3               7              10
62......................................               3          1.6667               1               1               1               3               3
63......................................            2900          4.4831               1               1               3               6               9
64......................................            3132          6.6028               1               2               4               8              14
65......................................           39024          2.7977               1               1               2               3               5
66......................................            7671          3.1068               1               1               2               4               6
67......................................             440          3.5955               1               2               3               4               6
68......................................            8754          3.8284               1               2               3               5               7
69......................................            3035          2.9997               1               2               2               4               5
70......................................              25          3.4800               1               2               3               4               8
71......................................              87          3.4368               1               2               3               4               6
72......................................             926          3.5659               1               1               3               4               7
73......................................            7073          4.3867               1               2               3               6               9
75......................................           39878         10.0489               3               5               7              12              20

[[Page 31646]]

 
76......................................           41691         11.4166               3               5               9              14              22
77......................................            2445          4.8634               1               2               4               7              10
78......................................           35316          6.6636               3               4               6               8              11
79......................................          166404          8.5040               3               4               7              11              16
80......................................            8320          5.4954               2               3               5               7              10
81......................................               2          8.0000               3               3              13              13              13
82......................................           63426          6.9938               2               3               6               9              14
83......................................            6394          5.4759               2               3               4               7              10
84......................................            1559          3.2290               1               2               3               4               6
85......................................           21268          6.3168               2               3               5               8              12
86......................................            2180          3.8138               1               2               3               5               8
87......................................           59482          6.3070               1               3               5               8              12
88......................................          396842          5.1059               2               3               4               6               9
89......................................          502709          5.8920               2               3               5               7              11
90......................................           46817          4.0322               2               2               3               5               7
91......................................              57          4.0000               2               2               3               5               8
92......................................           14816          6.3579               2               3               5               8              12
93......................................            1710          4.1076               1               2               3               5               8
94......................................           12574          6.3304               2               3               5               8              13
95......................................            1679          3.7123               1               2               3               5               7
96......................................           53729          4.5526               2               2               4               6               8
97......................................           28601          3.5208               1               2               3               4               6
98......................................              15          5.0000               1               2               3               4              13
99......................................           21279          3.1677               1               1               2               4               6
100.....................................            8950          2.1349               1               1               2               3               4
101.....................................           21127          4.3832               1               2               3               6               9
102.....................................            5559          2.5690               1               1               2               3               5
103.....................................             428         49.2103               9              14              26              61             116
104.....................................           19517         14.4041               6               8              12              17              25
105.....................................           27289          9.9529               5               6               8              11              18
106.....................................            3308         11.3987               5               7              10              14              20
107.....................................           85791         10.4560               5               7               9              12              17
108.....................................            6205         10.2743               3               5               8              13              20
109.....................................           59572          7.7288               4               5               6               9              13
110.....................................           53172          9.0340               2               4               7              11              18
111.....................................            9394          4.4159               1               2               4               6               8
113.....................................           41424         12.4557               4               6               9              15              24
114.....................................            8852          8.5204               2               4               7              11              17
115.....................................           15271          8.2839               1               4               7              11              16
116.....................................          109277          4.4721               1               2               3               6               9
117.....................................            4177          4.1611               1               1               2               5               9
118.....................................            8112          2.8930               1               1               1               3               7
119.....................................            1316          5.1117               1               1               3               6              12
120.....................................           37308          8.7872               1               2               6              12              20
121.....................................          167308          6.3297               2               3               5               8              12
122.....................................           81710          3.6163               1               2               3               5               7
123.....................................           41163          4.7016               1               1               3               6              11
124.....................................          138287          4.3673               1               2               3               6               8
125.....................................           90077          2.7417               1               1               2               4               5
126.....................................            5016         11.8909               4               6               9              15              22
127.....................................          682134          5.2700               2               3               4               7              10
128.....................................            8254          5.4723               2               3               5               7               9
129.....................................            4105          2.8378               1               1               1               3               6
130.....................................           88700          5.6615               2               3               5               7              10
131.....................................           27798          4.0539               1               2               4               5               7
132.....................................          152311          2.9301               1               1               2               4               5
133.....................................            8929          2.2655               1               1               2               3               4
134.....................................           39623          3.1770               1               2               2               4               6
135.....................................            7554          4.4298               1               2               3               5               8
136.....................................            1237          2.5594               1               1               2               3               5
138.....................................          203378          3.9834               1               2               3               5               8
139.....................................           90000          2.4829               1               1               2               3               5
140.....................................           66435          2.5585               1               1               2               3               5
141.....................................          102391          3.5917               1               2               3               4               7
142.....................................           51719          2.5539               1               1               2               3               5
143.....................................          250133          2.0827               1               1               2               3               4
144.....................................           88510          5.4530               1               2               4               7              11
145.....................................            7598          2.6481               1               1               2               3               5
146.....................................           10800         10.2147               5               7               8              12              17
147.....................................            2799          6.4012               3               5               6               8              10

[[Page 31647]]

 
148.....................................          129450         12.2855               5               7              10              15              22
149.....................................           19342          6.4670               4               5               6               8              10
150.....................................           20334         11.2329               4               7              10              14              20
151.....................................            4963          5.6756               1               3               5               8              10
152.....................................            4425          8.3250               3               5               7              10              14
153.....................................            2015          5.3782               3               4               5               7               8
154.....................................           29004         13.2062               3               7              10              16              26
155.....................................            7262          3.9898               1               2               3               6               8
156.....................................               3         15.0000              11              11              13              21              21
157.....................................            8155          5.5579               1               2               4               7              11
158.....................................            4564          2.5184               1               1               2               3               5
159.....................................           17115          5.0602               1               2               4               6              10
160.....................................           12172          2.6489               1               1               2               3               5
161.....................................           11155          4.1600               1               1               3               5               9
162.....................................            7290          1.9177               1               1               1               2               4
163.....................................               3          3.0000               1               1               3               5               5
164.....................................            5118          8.2651               3               5               7              10              14
165.....................................            2185          4.6499               2               3               4               6               8
166.....................................            3903          4.8737               1               2               4               6               9
167.....................................            3800          2.5132               1               1               2               3               4
168.....................................            1382          4.8705               1               2               3               6              10
169.....................................             869          2.2842               1               1               2               3               5
170.....................................           12156         10.9845               2               4               8              14              22
171.....................................            1359          4.3061               1               2               3               6               9
172.....................................           30622          6.9624               2               3               5               9              14
173.....................................            2711          3.7444               1               1               3               5               8
174.....................................          247222          4.8059               2               3               4               6               9
175.....................................           35165          2.9201               1               2               3               4               5
176.....................................           15219          5.2481               2               3               4               6              10
177.....................................            9429          4.5038               2               2               4               6               8
178.....................................            3758          3.0780               1               2               3               4               6
179.....................................           12541          5.9632               2               3               5               7              11
180.....................................           88300          5.3709               2               3               4               7              10
181.....................................           27097          3.3767               1               2               3               4               6
182.....................................          260686          4.3600               1               2               3               5               8
183.....................................           91243          2.8817               1               1               2               4               5
184.....................................              93          2.8387               1               1               2               4               6
185.....................................            5070          4.6984               1               2               3               6               9
186.....................................               3          4.6667               2               2               3               9               9
187.....................................             668          4.1153               1               2               3               6               8
188.....................................           79403          5.5558               1               2               4               7              11
189.....................................           13113          3.0563               1               1               2               4               6
190.....................................              74          4.7838               1               2               3               5               9
191.....................................            9222         13.7304               3               6              10              17              28
192.....................................            1257          6.0963               1               3               5               8              11
193.....................................            4865         12.7394               5               7              10              16              23
194.....................................             733          6.8759               2               4               6               8              12
195.....................................            4157         10.3560               4               6               9              12              18
196.....................................            1051          5.4186               2               3               5               7               9
197.....................................           18569          8.9827               3               5               7              11              16
198.....................................            5672          4.4381               2               3               4               6               8
199.....................................            1644          9.9179               2               4               7              13              21
200.....................................            1042         10.4539               1               3               7              14              22
201.....................................            2013         14.4287               4               6              11              18              28
202.....................................           26156          6.3731               2               3               5               8              13
203.....................................           29310          6.7403               2               3               5               9              13
204.....................................           61544          5.8119               2               3               4               7              11
205.....................................           24459          6.1537               2               3               5               8              12
206.....................................            2049          3.9204               1               2               3               5               8
207.....................................           32107          5.1834               1               2               4               7              10
208.....................................           10745          2.8598               1               1               2               4               5
209.....................................          371105          4.9903               3               3               4               6               8
210.....................................          121541          6.8894               3               4               6               8              11
211.....................................           32567          4.9284               3               4               5               6               7
212.....................................               7          3.2857               1               2               2               2               4
213.....................................            9878          9.1432               2               4               7              11              18
216.....................................            6916          9.5448               2               4               7              12              19
217.....................................           17029         13.4060               3               5               9              16              28
218.....................................           22744          5.4422               2               3               4               7              10
219.....................................           20866          3.2085               1               2               3               4               5

[[Page 31648]]

 
220.....................................               1          2.0000               2               2               2               2               2
223.....................................           13666          2.8724               1               1               2               3               6
224.....................................           12467          1.8627               1               1               1               2               3
225.....................................            6124          5.0144               1               2               3               7              11
226.....................................            5699          6.6699               1               3               5               8              14
227.....................................            4921          2.6651               1               1               2               3               5
228.....................................            2481          4.0806               1               1               2               5               9
229.....................................            1175          2.2179               1               1               2               3               4
230.....................................            2406          5.0590               1               2               3               6              11
231.....................................           12533          4.8810               1               1               3               6              11
232.....................................             882          2.7426               1               1               1               3               7
233.....................................            7179          7.2117               1               3               5               9              15
234.....................................            4607          3.1532               1               1               2               4               7
235.....................................            5091          5.0304               1               2               4               6               9
236.....................................           39785          4.7450               1               3               4               6               9
237.....................................            1744          3.5740               1               2               3               4               7
238.....................................            8625          8.8420               3               4               7              11              17
239.....................................           48230          6.2846               2               3               5               8              12
240.....................................           11807          6.7199               2               3               5               8              13
241.....................................            3223          3.8849               1               2               3               5               7
242.....................................            2516          6.5568               2               3               5               8              13
243.....................................           93654          4.6808               1               2               4               6               9
244.....................................           13584          4.7331               1               2               4               6               9
245.....................................            5732          3.3627               1               2               3               4               6
246.....................................            1346          3.7645               1               2               3               5               7
247.....................................           19620          3.3687               1               1               3               4               6
248.....................................           12067          4.8652               1               2               4               6               9
249.....................................           12651          3.6505               1               1               2               4               7
250.....................................            3795          4.1686               1               2               3               5               7
251.....................................            2489          2.7814               1               1               2               4               5
253.....................................           20861          4.6779               1               3               4               6               9
254.....................................           10809          3.1314               1               2               3               4               6
255.....................................               1          2.0000               2               2               2               2               2
256.....................................            6404          5.1084               1               2               4               6              10
257.....................................           16706          2.6651               1               1               2               3               5
258.....................................           16974          1.8185               1               1               2               2               3
259.....................................            3813          2.6693               1               1               1               2               6
260.....................................            5087          1.3666               1               1               1               1               2
261.....................................            1893          2.1590               1               1               1               2               4
262.....................................             686          4.2886               1               1               3               5              10
263.....................................           24569         11.8050               3               5               8              14              23
264.....................................            3982          6.9006               2               3               5               8              14
265.....................................            4052          6.7347               1               2               4               8              14
266.....................................            2676          3.1371               1               1               2               4               6
267.....................................             267          4.2584               1               1               2               4               8
268.....................................             899          3.6274               1               1               2               4               8
269.....................................            9064          8.2177               2               3               6              10              17
270.....................................            2746          3.2618               1               1               2               4               7
271.....................................           19612          7.2767               2               4               6               9              13
272.....................................            5471          6.1349               2               3               5               7              12
273.....................................            1387          3.9250               1               2               3               5               7
274.....................................            2344          6.7675               1               3               5               8              14
275.....................................             247          3.0202               1               1               2               4               6
276.....................................            1326          4.5181               1               2               4               6               8
277.....................................           93957          5.7577               2               3               5               7              10
278.....................................           31764          4.2755               2               3               4               5               7
279.....................................               3          7.0000               3               3               8              10              10
280.....................................           17047          4.1686               1               2               3               5               8
281.....................................            7834          2.9183               1               1               2               4               5
283.....................................            5638          4.6568               1               2               4               6               9
284.....................................            1950          3.0569               1               1               2               4               6
285.....................................            6574         10.6492               3               5               8              13              20
286.....................................            2183          5.9464               2               3               4               7              11
287.....................................            6460         10.5718               3               5               8              12              20
288.....................................            3675          5.3897               2               3               4               6               8
289.....................................            6423          2.8026               1               1               1               3               6
290.....................................            9500          2.2281               1               1               1               2               4
291.....................................              78          1.6026               1               1               1               2               3
292.....................................            5423          9.9458               2               4               8              13              20
293.....................................             345          4.9246               1               2               3               7              10

[[Page 31649]]

 
294.....................................           95391          4.5356               1               2               3               6               9
295.....................................            3359          3.9690               1               2               3               5               7
296.....................................          250941          5.1144               1               2               4               6              10
297.....................................           47743          3.3559               1               2               3               4               6
298.....................................             103          4.3495               1               2               3               5               8
299.....................................            1218          5.3760               1               2               4               6              10
300.....................................           17546          6.1581               2               3               5               8              12
301.....................................            3643          3.6508               1               2               3               5               7
302.....................................            7896          8.6990               4               5               7              10              15
303.....................................           20709          8.2736               3               4               6               9              15
304.....................................           12044          8.6857               2               4               6              11              18
305.....................................            3008          3.6051               1               2               3               5               6
306.....................................            7213          5.4883               1               2               3               7              13
307.....................................            2168          2.2002               1               1               2               3               4
308.....................................            7245          6.2803               1               2               4               8              14
309.....................................            4338          2.1547               1               1               2               3               4
310.....................................           24597          4.3470               1               1               3               5               9
311.....................................            8323          1.8264               1               1               1               2               3
312.....................................            1547          4.4945               1               1               3               6              10
313.....................................             644          2.1289               1               1               1               2               4
314.....................................               1          5.0000               5               5               5               5               5
315.....................................           33711          7.1835               1               1               4               9              17
316.....................................          115329          6.5892               2               3               5               8              13
317.....................................            1890          3.0899               1               1               2               3               7
318.....................................            5739          6.0294               1               3               4               8              12
319.....................................             494          2.8543               1               1               2               4               6
320.....................................          193283          5.3020               2               3               4               7              10
321.....................................           30745          3.7500               1               2               3               5               7
322.....................................              64          3.6563               1               2               3               4               7
323.....................................           18622          3.1423               1               1               2               4               6
324.....................................            7455          1.8437               1               1               1               2               3
325.....................................            8938          3.7880               1               2               3               5               7
326.....................................            2803          2.6718               1               1               2               3               5
327.....................................               2          2.5000               1               1               4               4               4
328.....................................             685          3.7883               1               1               3               5               7
329.....................................             105          2.2000               1               1               1               2               5
331.....................................           49140          5.5819               1               3               4               7              11
332.....................................            5119          3.1686               1               1               2               4               6
333.....................................             311          4.6849               1               2               3               6              10
334.....................................           10271          4.7684               2               3               4               5               8
335.....................................           12383          3.1779               2               2               3               4               5
336.....................................           36334          3.4249               1               2               2               4               7
337.....................................           29524          2.0688               1               1               2               2               3
338.....................................            1055          5.5526               1               2               3               8              13
339.....................................            1505          4.6186               1               1               3               6              10
340.....................................               1          1.0000               1               1               1               1               1
341.....................................            3670          3.0695               1               1               2               3               6
342.....................................             723          3.1355               1               1               2               4               6
343.....................................               1          5.0000               5               5               5               5               5
344.....................................            3840          2.3802               1               1               1               2               5
345.....................................            1336          4.7859               1               1               3               6              10
346.....................................            4562          6.0342               1               3               5               8              12
347.....................................             373          2.6971               1               1               2               3               6
348.....................................            3281          4.1591               1               2               3               5               8
349.....................................             597          2.4623               1               1               2               3               5
350.....................................            6497          4.5045               2               2               4               6               8
351.....................................               1          1.0000               1               1               1               1               1
352.....................................             768          3.9557               1               2               3               5               8
353.....................................            2659          6.4772               2               3               5               7              12
354.....................................            7491          5.8265               3               3               4               7              10
355.....................................            5680          3.2347               2               2               3               4               5
356.....................................           25943          2.1725               1               1               2               3               4
357.....................................            5715          8.4126               3               4               6              10              16
358.....................................           20617          4.3038               2               3               3               5               7
359.....................................           31095          2.6372               1               2               3               3               4
360.....................................           15583          2.8183               1               2               2               3               5
361.....................................             369          3.6694               1               1               2               4               8
362.....................................               2          1.0000               1               1               1               1               1
363.....................................            2683          3.6254               1               2               2               4               7
364.....................................            1631          3.8780               1               1               3               5               8

[[Page 31650]]

 
365.....................................            1834          7.6930               2               3               5              10              17
366.....................................            4436          6.8537               2               3               5               9              14
367.....................................             521          3.0115               1               1               2               4               6
368.....................................            3288          6.7318               2               3               5               8              13
369.....................................            3281          3.1987               1               1               2               4               6
370.....................................            1244          5.6937               3               3               4               5               9
371.....................................            1416          3.6031               2               3               3               4               5
372.....................................             919          3.6529               1               2               2               3               5
373.....................................            3878          2.2935               1               2               2               3               3
374.....................................             116          2.8793               1               2               2               3               5
375.....................................               8          5.2500               1               3               5               5               9
376.....................................             263          3.5095               1               2               2               4               6
377.....................................              29          4.3793               1               2               3               4               7
378.....................................             169          2.4615               1               1               2               3               4
379.....................................             408          3.0000               1               1               2               3               6
380.....................................              76          1.9605               1               1               1               2               4
381.....................................             181          2.0829               1               1               1               2               4
382.....................................              25          1.3600               1               1               1               1               3
383.....................................            1841          3.9620               1               1               3               4               8
384.....................................             149          2.7315               1               1               1               3               6
389.....................................               5          3.4000               1               1               2               4               8
390.....................................               1          4.0000               4               4               4               4               4
392.....................................            2247          9.5167               2               4               7              12              19
393.....................................               1          2.0000               2               2               2               2               2
394.....................................            2329          7.0575               1               2               5               9              15
395.....................................          100668          4.3478               1               2               3               5               9
396.....................................              11          3.8182               1               1               2               4               6
397.....................................           17952          5.1683               1               2               4               7              10
398.....................................           17121          5.8897               2               3               5               7              11
399.....................................            1788          3.5520               1               2               3               5               7
400.....................................            6488          8.9578               1               3               6              11              20
401.....................................            5837         11.2479               2               5               9              15              23
402.....................................            1599          3.8899               1               1               3               5               8
403.....................................           32013          8.0033               2               3               6              10              17
404.....................................            4592          4.1916               1               2               3               5               9
406.....................................            2495          9.6970               2               4               7              12              20
407.....................................             702          4.1140               1               2               3               5               8
408.....................................            2122          7.8591               1               2               5              10              18
409.....................................            2517          6.1339               2               3               4               6              13
410.....................................           30770          4.0138               1               2               4               5               6
411.....................................              14          2.9286               1               1               2               4               6
412.....................................              18          2.0000               1               1               1               2               4
413.....................................            5767          7.2917               2               3               6               9              14
414.....................................             763          4.0170               1               2               3               5               8
415.....................................           39922         14.4392               4               6              11              18              29
416.....................................          181162          7.4625               2               4               6               9              14
417.....................................              37          6.1351               2               2               4               8              13
418.....................................           23408          6.1732               2               3               5               8              12
419.....................................           15730          4.6490               1               2               4               6               9
420.....................................            2958          3.4324               1               2               3               4               6
421.....................................            9274          3.7804               1               2               3               4               7
422.....................................              69          2.9130               1               1               2               3               6
423.....................................            7273          8.2391               2               3               6              10              17
424.....................................            1292         12.9690               2               5               9              16              26
425.....................................           16309          3.8956               1               2               3               5               8
426.....................................            4483          4.4716               1               2               3               5               9
427.....................................            1576          4.4143               1               2               3               5               9
428.....................................             745          7.3732               1               2               4               8              15
429.....................................           27035          6.1425               2               3               4               7              12
430.....................................           63072          7.9697               2               3               6              10              16
431.....................................             321          5.9470               1               2               4               7              13
432.....................................             411          4.5645               1               1               3               5               9
433.....................................            5523          2.9714               1               1               2               3               6
439.....................................            1457          8.5003               1               3               6              10              17
440.....................................            5440          9.0241               2               3               6              11              20
441.....................................             612          3.0735               1               1               2               4               7
442.....................................           16700          8.5598               1               3               6              10              18
443.....................................            3808          3.5355               1               1               3               4               7
444.....................................            5676          4.3175               1               2               3               5               8
445.....................................            2726          2.8995               1               1               2               4               5

[[Page 31651]]

 
447.....................................            6278          2.4462               1               1               2               3               5
448.....................................               1          1.0000               1               1               1               1               1
449.....................................           30478          3.6796               1               1               3               4               8
450.....................................            7369          1.9900               1               1               1               2               4
451.....................................               5          1.6000               1               1               2               2               2
452.....................................           25229          5.0164               1               2               3               6              10
453.....................................            5646          2.7669               1               1               2               3               5
454.....................................            4624          4.3575               1               2               3               5               9
455.....................................            1098          2.3752               1               1               2               3               5
461.....................................            4563          4.0690               1               1               2               4              10
462.....................................           11994         11.3643               4               6              10              14              21
463.....................................           25215          4.1639               1               2               3               5               8
464.....................................            7115          3.0145               1               1               2               4               6
465.....................................             224          2.8973               1               1               1               3               5
466.....................................            1797          3.9321               1               1               2               4               7
467.....................................            1043          8.3931               1               1               2               3               6
468.....................................           54726         12.9153               3               6              10              16              25
471.....................................           12468          5.4931               3               3               4               6               9
473.....................................            8236         12.3409               1               3               7              17              32
475.....................................          104072         11.1941               2               5               9              15              22
476.....................................            3814         11.2651               2               5              10              15              21
477.....................................           25602          8.1413               1               3               6              11              17
478.....................................          108638          7.3817               1               3               5               9              16
479.....................................           24179          3.3012               1               1               3               4               7
480.....................................             622         21.5354               7               9              14              28              49
481.....................................             726         21.9353              13              17              20              25              33
482.....................................            5300         12.4930               4               7               9              15              23
483.....................................           43301         39.6393              14              22              33              49              71
484.....................................             317         13.0820               2               5              10              18              27
485.....................................            3029          9.4262               4               5               7              11              18
486.....................................            1867         12.3214               1               5              10              16              25
487.....................................            3536          7.6683               1               3               6              10              16
488.....................................             776         16.9162               3               6              13              22              35
489.....................................           13557          8.5376               2               3               6              10              18
490.....................................            5252          5.2582               1               2               4               6              10
491.....................................           13607          3.4664               1               2               3               4               6
492.....................................            2875         15.0104               2               5               7              25              34
493.....................................           58106          5.8777               1               3               5               7              11
494.....................................           30972          2.4751               1               1               2               3               5
495.....................................             211         17.1659               8              10              13              20              31
496.....................................            1842          9.4870               3               4               7              11              19
497.....................................           19927          6.5368               3               4               5               7              11
498.....................................           14665          4.1305               2               3               4               5               6
499.....................................           32668          4.6299               1               2               3               6               9
500.....................................           49512          2.4657               1               1               2               3               5
501.....................................            2356         10.6341               4               5               8              13              20
502.....................................             637          6.4066               2               4               5               8              11
503.....................................            5894          3.8884               1               2               3               5               7
504.....................................             123         34.9756               9              15              27              44              66
505.....................................             147          3.6667               1               1               1               5               9
506.....................................             937         17.2604               4               8              14              22              36
507.....................................             288          8.9549               2               4               7              12              18
508.....................................             667          8.2219               2               3               6              10              17
509.....................................             177          5.4350               1               2               4               7              10
510.....................................            1671          6.6092               1               3               5               8              13
511.....................................             616          4.3766               1               1               3               5               9
512.....................................             450         14.2244               6               8              11              15              24
513.....................................             142         10.7042               5               7               9              11              20
514.....................................           19261          7.2615               1               3               6               9              15
515.....................................            4570          5.4897               1               1               3               7              13
516.....................................           76256          4.7308               2               2               4               6               9
517.....................................          191586          2.6138               1               1               2               3               6
518.....................................           51638          3.3905               1               1               2               4               7
519.....................................            7220          5.1497               1               2               3               6              12
520.....................................           11073          2.1137               1               1               2               2               4
521.....................................           28568          5.7752               2               3               4               7              12
522.....................................            6141          9.4402               3               4               8              12              20
523.....................................           14812          4.0927               1               2               3               5               7
524.....................................          136857          3.3964               1               2               3               4               6

[[Page 31652]]

 
525.....................................             492         15.9309               2               5               9              18              35
                                         ----------------
                                                11420001
--------------------------------------------------------------------------------------------------------------------------------------------------------


 Table 8A.--Statewide Average Operating Cost-To-Charge Ratios for Urban
             and Rural Hospitals (Case Weighted) March 2002
------------------------------------------------------------------------
                        State                           Urban     Rural
------------------------------------------------------------------------
ALABAMA.............................................     0.337     0.394
ALASKA..............................................     0.407     0.675
ARIZONA.............................................     0.349     0.478
ARKANSAS............................................     0.456     0.438
CALIFORNIA..........................................     0.335     0.419
COLORADO............................................     0.463     0.538
CONNECTICUT.........................................     0.494     0.509
DELAWARE............................................     0.516     0.484
DISTRICT OF COLUMBIA................................     0.413  ........
FLORIDA.............................................     0.349     0.365
GEORGIA.............................................     0.446     0.456
HAWAII..............................................     0.403     0.519
IDAHO...............................................     0.558     0.599
ILLINOIS............................................     0.398     0.492
INDIANA.............................................     0.522     0.529
IOWA................................................     0.484     0.594
KANSAS..............................................     0.380     0.591
KENTUCKY............................................     0.478     0.490
LOUISIANA...........................................     0.390     0.482
MAINE...............................................     0.585     0.523
MARYLAND............................................     0.759     0.821
MASSACHUSETTS.......................................     0.550     0.568
MICHIGAN............................................     0.460     0.562
MINNESOTA...........................................     0.470     0.581
MISSISSIPPI.........................................     0.444     0.434
MISSOURI............................................     0.399     0.473
MONTANA.............................................     0.504     0.544
NEBRASKA............................................     0.428     0.550
NEVADA..............................................     0.284     0.473
NEW HAMPSHIRE.......................................     0.524     0.579
NEW JERSEY..........................................     0.393  ........
NEW MEXICO..........................................     0.471     0.516
NEW YORK............................................     0.500     0.595
NORTH CAROLINA......................................     0.511     0.465
NORTH DAKOTA........................................     0.611     0.611
OHIO................................................     0.492     0.568
OKLAHOMA............................................     0.405     0.485
OREGON..............................................     0.545     0.579
PENNSYLVANIA........................................     0.376     0.500
PUERTO RICO.........................................     0.467     0.561
RHODE ISLAND........................................     0.486  ........
SOUTH CAROLINA......................................     0.438     0.455
SOUTH DAKOTA........................................     0.498     0.546
TENNESSEE...........................................     0.432     0.457
TEXAS...............................................     0.380     0.484
UTAH................................................     0.495     0.570
VERMONT.............................................     0.572     0.595
VIRGINIA............................................     0.452     0.546
WASHINGTON..........................................     0.580     0.598
WEST VIRGINIA.......................................     0.563     0.534
WISCONSIN...........................................     0.524     0.599
WYOMING.............................................     0.524     0.707
------------------------------------------------------------------------


    Table 8B.--Statewide Average Capital Cost-To-Charge Ratios (Case
                          Weighted) March 2002
------------------------------------------------------------------------
                             State                                Ratio
------------------------------------------------------------------------
ALABAMA.......................................................     0.041
ALASKA........................................................     0.053
ARIZONA.......................................................     0.038
ARKANSAS......................................................     0.049
CALIFORNIA....................................................     0.033
COLORADO......................................................     0.045
CONNECTICUT...................................................     0.036
DELAWARE......................................................     0.048
DISTRICT OF COLUMBIA..........................................     0.032
FLORIDA.......................................................     0.043
GEORGIA.......................................................     0.049
HAWAII........................................................     0.038
IDAHO.........................................................     0.048
ILLINOIS......................................................     0.039
INDIANA.......................................................     0.056
IOWA..........................................................     0.049
KANSAS........................................................     0.047
KENTUCKY......................................................     0.046
LOUISIANA.....................................................     0.046
MAINE.........................................................     0.038
MARYLAND......................................................     0.013
MASSACHUSETTS.................................................     0.050
MICHIGAN......................................................     0.044
MINNESOTA.....................................................     0.043
MISSISSIPPI...................................................     0.043
MISSOURI......................................................     0.043
MONTANA.......................................................     0.051
NEBRASKA......................................................     0.047
NEVADA........................................................     0.032
NEW HAMPSHIRE.................................................     0.058
NEW JERSEY....................................................     0.035
NEW MEXICO....................................................     0.045
NEW YORK......................................................     0.049
NORTH CAROLINA................................................     0.047
NORTH DAKOTA..................................................     0.073
OHIO..........................................................     0.047
OKLAHOMA......................................................     0.045
OREGON........................................................     0.042
PENNSYLVANIA..................................................     0.037
PUERTO RICO...................................................     0.041
RHODE ISLAND..................................................     0.031
SOUTH CAROLINA................................................     0.046
SOUTH DAKOTA..................................................     0.050
TENNESSEE.....................................................     0.049
TEXAS.........................................................     0.043
UTAH..........................................................     0.045
VERMONT.......................................................     0.049
VIRGINIA......................................................     0.057
WASHINGTON....................................................     0.068
WEST VIRGINIA.................................................     0.044
WISCONSIN.....................................................     0.050
WYOMING.......................................................     0.062
------------------------------------------------------------------------


            Table 9.--Hospital Reclassifications and Redesignations by Individual Hospital--FY--2003
----------------------------------------------------------------------------------------------------------------
                                                                                                  Standardized
                      Provider number                         Actual MSA or    Wage index MSA      amount MSA
                                                               rural area     reclassification  reclassification
----------------------------------------------------------------------------------------------------------------
010005....................................................                01              3440              3440
010008....................................................                01              5240  ................
010010....................................................                01              3440              3440
010012....................................................                01              2880  ................
010022....................................................                01              2880  ................
010029....................................................              0580              1800  ................
010035....................................................                01              1000  ................
010036....................................................                01              2750  ................
010043....................................................                01              1000              1000
010044....................................................                01                25  ................
010072....................................................                01              0450              0450
010101....................................................                01              0450              0450

[[Page 31653]]

 
010118....................................................                01              5240  ................
010120....................................................                01              5160  ................
010121....................................................                01              5240  ................
010126....................................................                01              2180  ................
010150....................................................                01              5240  ................
010158....................................................                01              2650  ................
020008....................................................                02              0380  ................
030007....................................................                03              2620  ................
030012....................................................                03              6200  ................
030033....................................................                03              2620  ................
030043....................................................                03              8520  ................
040014....................................................                04              4400  ................
040017....................................................                04              7920  ................
040019....................................................                04              4920  ................
040020....................................................              3700              4920  ................
040026....................................................                04              4400  ................
040027....................................................                04              7920  ................
040041....................................................                04              4400  ................
040045....................................................                04                26  ................
040066....................................................                04              4400  ................
040069....................................................                04              4920  ................
040076....................................................                04              4400  ................
040078....................................................                04              4400  ................
040080....................................................                04              3700  ................
040088....................................................                04              7680  ................
040091....................................................                04              8360  ................
040107....................................................                04              8360  ................
040119....................................................                04              4400  ................
050042....................................................                05              6690  ................
050045....................................................                05  ................              7320
050069....................................................              5945              4480  ................
050071....................................................              7400              5775  ................
050073....................................................              8720              5775  ................
050076....................................................              7360              5775  ................
050101....................................................              8720              5775  ................
050150....................................................                05              6920  ................
050174....................................................              7500              8720  ................
050192....................................................              2840                05  ................
050228....................................................              7360              5775  ................
050230....................................................              5945              4480  ................
050236....................................................              8735              4480  ................
050286....................................................              8780                05  ................
050296....................................................                05              7120  ................
050301....................................................                05              7500  ................
050325....................................................                05              5170  ................
050335....................................................                05              5170  ................
050419....................................................                05              6690  ................
050446....................................................              0680                05  ................
050457....................................................              7360              5775  ................
050464....................................................              5170              8120  ................
050469....................................................              6780                05  ................
050494....................................................                05              6920  ................
050510....................................................              7360              5775  ................
050528....................................................              4940                05  ................
050541....................................................              7360              5775  ................
050549....................................................              8735              4480  ................
050569....................................................                05              7500  ................
050594....................................................              5945              4480  ................
050609....................................................              5945              4480  ................
050686....................................................              6780              5945  ................
050701....................................................              6780              7320  ................
060003....................................................              1125              2080              2080
060013....................................................                06              0200  ................
060018....................................................                06              2995  ................
060023....................................................              2995              6520  ................
060027....................................................              1125              2080              2080
060044....................................................                06              2080  ................
060049....................................................                06              2670  ................
060075....................................................                06              2995  ................
060076....................................................                06              3060  ................

[[Page 31654]]

 
060096....................................................                06              2080  ................
060103....................................................              1125              2080              2080
070006....................................................              5483              5600  ................
070018....................................................              5483              5600  ................
070033....................................................              5483              5600  ................
070034....................................................              5483              5600  ................
070036....................................................              3283              5483  ................
080002....................................................                08  ................              0720
080004....................................................              2190              9160  ................
080006....................................................                08              2190  ................
080007....................................................                08              2190  ................
100022....................................................              5000              2680  ................
100023....................................................                10              5960  ................
100024....................................................                10              5000  ................
100045....................................................              2020              5960  ................
100048....................................................              6080                10  ................
100049....................................................                10              3980  ................
100098....................................................                10              8960              8960
100103....................................................                10              3600              3600
100105....................................................                10              2710  ................
100109....................................................                10              5960  ................
100118....................................................              2020                10  ................
100150....................................................                10              5000  ................
100157....................................................              3980              8280  ................
100176....................................................              8960              2710  ................
100211....................................................              8280              3980  ................
100217....................................................                10              2710  ................
100232....................................................                10              5790              2900
100239....................................................              8280              7510  ................
100249....................................................                10              8280  ................
100268....................................................              8960              2680  ................
110001....................................................                11              0520  ................
110002....................................................                11              0520  ................
110003....................................................                11              3600  ................
110016....................................................                11              1800  ................
110023....................................................                11              0520  ................
110025....................................................                11              3600  ................
110029....................................................                11              0520  ................
110038....................................................                11                10  ................
110040....................................................                11              0500              0500
110050....................................................                11              0520  ................
110054....................................................                11              0520  ................
110075....................................................                11              7520  ................
110100....................................................                11              0600  ................
110118....................................................                11              0120  ................
110122....................................................                11                10  ................
110150....................................................                11              4680  ................
110168....................................................                11              0520  ................
110187....................................................                11              0520  ................
110188....................................................                11              0520  ................
110189....................................................                11              0520  ................
110190....................................................                11              4680  ................
110205....................................................                11              0520  ................
120015....................................................                12              3320  ................
130002....................................................                13                29  ................
130003....................................................                13                50  ................
130011....................................................                13                50  ................
130018....................................................                13              6340  ................
130049....................................................                13              7840  ................
130060....................................................                13              1080  ................
140012....................................................                14              1600  ................
140015....................................................                14              7040  ................
140031....................................................                14              1400  ................
140032....................................................                14              7040  ................
140034....................................................                14              7040  ................
140040....................................................                14              6120  ................
140043....................................................                14              6880  ................
140046....................................................                14              7040  ................
140058....................................................                14              7880  ................
140064....................................................                14              6120  ................

[[Page 31655]]

 
140086....................................................                14  ................              7040
140093....................................................                14              1400  ................
140102....................................................                14              7880              7880
140110....................................................                14              6120  ................
140141....................................................                14              7040              7040
140143....................................................                14              6120  ................
140155....................................................              3740  ................              1600
140160....................................................                14              6880  ................
140161....................................................                14              1600  ................
140164....................................................                14              7040  ................
140189....................................................                14              1400  ................
140199....................................................                14              7040  ................
140230....................................................                14  ................              1400
140234....................................................                14              6120  ................
140245....................................................                14  ................              7040
140271....................................................                14              7800              7800
150002....................................................              2960              1600  ................
150004....................................................              2960              1600  ................
150006....................................................                15              7800  ................
150008....................................................              2960              1600  ................
150011....................................................                15              3480              3480
150015....................................................                15              1600  ................
150027....................................................                15  ................              3480
150030....................................................                15              3480              3480
150034....................................................              2960              1600  ................
150036....................................................                15              3850  ................
150048....................................................                15              2000  ................
150051....................................................              1020  ................              3480
150062....................................................                15              3480              3480
150065....................................................                15              3480  ................
150067....................................................                15  ................              3480
150069....................................................                15              1640              1640
150076....................................................                15              7800  ................
150090....................................................              2960              1600  ................
150096....................................................                15              2330  ................
150105....................................................                15              3480              3480
150112....................................................                15              3480              3480
150122....................................................                15              3480  ................
150125....................................................              2960              1600              1600
150126....................................................              2960              1600              1600
150132....................................................              2960              1600  ................
150133....................................................                15              2330  ................
150146....................................................                15              2330  ................
160001....................................................                16              2120  ................
160016....................................................                16              2120  ................
160026....................................................                16              2120  ................
160030....................................................                16              2120  ................
160037....................................................                16                24  ................
160057....................................................                16              3500  ................
160064....................................................                16              8920  ................
160080....................................................                16              1960  ................
160089....................................................                16              2120  ................
160094....................................................                16              8920  ................
160122....................................................                16                14  ................
160147....................................................                16              2120  ................
170001....................................................                17              9040  ................
170006....................................................                17              3710  ................
170010....................................................                17              8560  ................
170012....................................................                17              9040  ................
170013....................................................                17              9040  ................
170014....................................................                17              3760  ................
170020....................................................                17              9040  ................
170022....................................................                17              7000  ................
170023....................................................                17              9040  ................
170025....................................................                17              9040  ................
170033....................................................                17              9040  ................
170058....................................................                17                26  ................
170060....................................................                17                28  ................
170094....................................................                17              8440  ................
170120....................................................                17              3710  ................

[[Page 31656]]

 
170131....................................................                17  ................              8440
170137....................................................              4150                17  ................
170142....................................................                17              8440  ................
170145....................................................                17              8560  ................
170166....................................................                17              0320  ................
170175....................................................                17              9040  ................
180005....................................................                18              3400  ................
180011....................................................                18              4280  ................
180012....................................................                18              4520  ................
180013....................................................                18              5360  ................
180016....................................................                18              4520  ................
180018....................................................                18              4280  ................
180027....................................................                18              1660  ................
180028....................................................                18              3400  ................
180029....................................................                18              3660  ................
180044....................................................                18              3400  ................
180048....................................................                18              4280  ................
180054....................................................                18              1660  ................
180065....................................................                18              1640  ................
180066....................................................                18              5360  ................
180069....................................................                18              3400  ................
180078....................................................                18              3400  ................
180102....................................................                18              1660  ................
180104....................................................                18              1660  ................
180116....................................................                18              1660  ................
180124....................................................                18              5360  ................
180127....................................................                18              4520  ................
180132....................................................                18              4280  ................
180139....................................................                18              4280  ................
190001....................................................                19              5560              5560
190003....................................................                19              3880  ................
190010....................................................                19              5560              5560
190014....................................................                19              3880  ................
190015....................................................                19              5560  ................
190018....................................................                19              3880  ................
190025....................................................                19              3880  ................
190048....................................................              3350                19  ................
190054....................................................                19              3880  ................
190083....................................................                19              5200  ................
190086....................................................                19              5200  ................
190099....................................................                19              3880  ................
190106....................................................                19              3880  ................
190110....................................................              3880                19  ................
190131....................................................                19              5560  ................
190218....................................................                19              0220  ................
200020....................................................              6403              1123              1123
200024....................................................              4243              6403  ................
200034....................................................              4243              6403  ................
200039....................................................                20              6403  ................
200040....................................................              6403  ................              1123
200063....................................................                20              6403  ................
220060....................................................              1123              0743  ................
220077....................................................              8003              3283  ................
230015....................................................                23              3720  ................
230022....................................................                23              3720  ................
230027....................................................                23              3000              3000
230030....................................................                23              6960  ................
230036....................................................                23              6960  ................
230037....................................................                23              0440  ................
230040....................................................                23              3720              3720
230054....................................................                23              3080  ................
230078....................................................              0870                23  ................
230080....................................................                23              6960  ................
230093....................................................                23              3000  ................
230096....................................................                23              3720  ................
230097....................................................                23              3000  ................
230105....................................................                23              6960  ................
230106....................................................                23              3000  ................
230121....................................................                23              2640              2640
230188....................................................                23              6960              6960

[[Page 31657]]

 
230199....................................................                23              0870              0870
230235....................................................                23              6960              6960
230253....................................................                23              2160  ................
240008....................................................                24              6820  ................
240011....................................................                24              5120  ................
240014....................................................                24              5120  ................
240016....................................................                24              2520  ................
240018....................................................                24  ................              5120
240023....................................................                24              5120  ................
240045....................................................                24              2240  ................
240064....................................................                24              2240  ................
240075....................................................                24              6980  ................
240088....................................................                24              6980  ................
240089....................................................                24              5120  ................
240100....................................................                24              2985  ................
240121....................................................                24              2240  ................
240139....................................................                24              5120  ................
240142....................................................                24              6980  ................
240152....................................................                24              5120  ................
250004....................................................                25              4920  ................
250009....................................................                25              3580  ................
250012....................................................                25              4920  ................
250025....................................................                25                 1  ................
250030....................................................                25              3560  ................
250031....................................................                25              3560  ................
250034....................................................                25              4920  ................
250042....................................................                25              4920  ................
250058....................................................                25              3285  ................
250069....................................................                25              3560  ................
250078....................................................              3285              0920  ................
250079....................................................                25              3560  ................
250081....................................................                25              3560  ................
250082....................................................                25              6240  ................
250084....................................................                25                19  ................
250088....................................................                25              0760  ................
250094....................................................              3285              0920  ................
250097....................................................                25              0760  ................
250100....................................................                25              8600  ................
250101....................................................                25              3560  ................
250104....................................................                25              3560  ................
250122....................................................                25                19  ................
250126....................................................                25              4920  ................
260006....................................................              7000                26  ................
260009....................................................                26              3760  ................
260011....................................................                26              1740  ................
260015....................................................                26              3700  ................
260017....................................................                26              7040  ................
260022....................................................                26              1740  ................
260025....................................................                26                14  ................
260034....................................................                26              3760  ................
260047....................................................                26              1740  ................
260050....................................................                26              7000  ................
260064....................................................                26              1740  ................
260074....................................................                26              1740  ................
260078....................................................                26              7920  ................
260094....................................................                26              7920  ................
260110....................................................                26              7040              7040
260113....................................................                26                14  ................
260116....................................................                26              7040  ................
260119....................................................                26              3700  ................
260120....................................................                26              3700  ................
260127....................................................                26              7040  ................
260131....................................................                26              1740  ................
260183....................................................                26              7040  ................
260186....................................................                26              1740  ................
270002....................................................                27              0880  ................
270003....................................................                27              3040  ................
270011....................................................                27              3040  ................
270016....................................................                27              0880  ................
270017....................................................                27              5140  ................

[[Page 31658]]

 
270051....................................................                27              5140  ................
270057....................................................                27              0880  ................
270083....................................................                27              5140  ................
280009....................................................                28              4360  ................
280023....................................................                28              4360  ................
280032....................................................                28              4360  ................
280054....................................................                28              4360  ................
280061....................................................                28                53  ................
280065....................................................                28              3060  ................
280077....................................................                28              5920  ................
280111....................................................                28              5920  ................
280125....................................................                28              7720  ................
290006....................................................                29              6720  ................
290019....................................................                29              6720  ................
300003....................................................                30              1123  ................
300005....................................................                30              1123              1123
300009....................................................              1123                30  ................
300019....................................................                30                22  ................
300024....................................................                30  ................              1123
310001....................................................              0875              5600  ................
310002....................................................              5640              5600  ................
310003....................................................              3640              5600  ................
310015....................................................              5640              0875  ................
310021....................................................              8480              5190  ................
310031....................................................              6160              5190  ................
310038....................................................              5015              5600  ................
310039....................................................              5015              5190  ................
310045....................................................              0875              5600  ................
310048....................................................              5015              5640  ................
310049....................................................              3640  ................              5640
310070....................................................              5015              5640  ................
310076....................................................              5640              5600  ................
310087....................................................              8760              6160  ................
310108....................................................              5015              5190  ................
310118....................................................              3640  ................              0875
310119....................................................              5640              5600  ................
320005....................................................                32              0200  ................
320006....................................................                32              7490  ................
320011....................................................                32              7490  ................
320013....................................................                32              7490  ................
320063....................................................                32              5800  ................
320065....................................................                32              5800  ................
330001....................................................              5660              5600  ................
330004....................................................                33              5660  ................
330023....................................................              2281              5660  ................
330027....................................................              5380              5600  ................
330084....................................................                33              1303  ................
330085....................................................                33              8160  ................
330103....................................................                33  ................              1280
330106....................................................              5380              5600  ................
330126....................................................              5660              5600  ................
330135....................................................              5660              5600  ................
330136....................................................                33              8160  ................
330157....................................................                33              8160  ................
330181....................................................              5380              5600  ................
330182....................................................              5380              5600  ................
330205....................................................              5660              5600  ................
330209....................................................              5660              5600  ................
330224....................................................                33              3283  ................
330235....................................................              8160  ................              6840
330239....................................................              3610              2360  ................
330250....................................................                33              1303  ................
330264....................................................              5660              5600  ................
330307....................................................                33              8160  ................
330386....................................................                33              5660  ................
340003....................................................                34              3120  ................
340008....................................................                34              2560  ................
340013....................................................                34              1520  ................
340017....................................................                34              0480  ................
340021....................................................                34              1520  ................

[[Page 31659]]

 
340023....................................................                34              0480  ................
340027....................................................                34              3150  ................
340039....................................................                34              1520              1520
340050....................................................                34              2560  ................
340051....................................................                34              3290  ................
340052....................................................              3120              1520  ................
340064....................................................                34              3120  ................
340068....................................................                34              9200  ................
340071....................................................                34              6640              6640
340084....................................................                34              1520  ................
340088....................................................                34              0480  ................
340097....................................................                34              3120  ................
340109....................................................                34              5720              5720
340115....................................................                34              6640  ................
340124....................................................                34              6640              6640
340126....................................................                34              6640              6640
340129....................................................                34              1520  ................
340131....................................................                34              3150  ................
340143....................................................              3290              1520  ................
340144....................................................                34              1520  ................
340147....................................................              6895              6640  ................
350005....................................................                35              2985  ................
350006....................................................                35              1010  ................
350009....................................................                35              2520  ................
350017....................................................                35                27  ................
350043....................................................                35              1010  ................
360002....................................................                36  ................              1680
360008....................................................                36              3400  ................
360010....................................................                36              0080  ................
360011....................................................                36              1840  ................
360013....................................................                36              2000  ................
360014....................................................                36              1840  ................
360024....................................................                36              1680              1680
360025....................................................                36              1680              1680
360036....................................................                36              0080  ................
360037....................................................              1680              0080  ................
360039....................................................                36              1840  ................
360046....................................................              3200              1640              1640
360056....................................................              3200              1640              1640
360063....................................................                36              1680              1680
360065....................................................                36              1680              1680
360071....................................................                36              4320              4320
360076....................................................              3200              1640              1640
360078....................................................              0080  ................              1680
360084....................................................              1320              0080  ................
360088....................................................                36              1840  ................
360089....................................................                36              8400  ................
360090....................................................              8400  ................              2160
360092....................................................                36              1840              1840
360095....................................................                36              8400  ................
360101....................................................              1680              0080  ................
360107....................................................                36              8400  ................
360108....................................................                36              4800  ................
360109....................................................                36              1840  ................
360112....................................................              8400              0440  ................
360121....................................................                36              0440  ................
360132....................................................              3200              1640              1640
360142....................................................                36  ................              1640
360144....................................................              1680              0080  ................
360159....................................................                36              1840  ................
360175....................................................                36              1840              1640
360197....................................................                36              1840              1840
360211....................................................              8080  ................              6280
370004....................................................                37              3710  ................
370006....................................................                37              8560  ................
370014....................................................                37              7640  ................
370015....................................................                37              8560  ................
370018....................................................                37              8560  ................
370022....................................................                37              4200  ................
370023....................................................                37              4200  ................

[[Page 31660]]

 
370025....................................................                37              8560  ................
370034....................................................                37              2720  ................
370047....................................................                37              7640  ................
370048....................................................                37              8360  ................
370049....................................................                37              5880  ................
370054....................................................                37              5880  ................
370084....................................................                37              2720  ................
370103....................................................                37                45  ................
370153....................................................                37              4200  ................
370200....................................................                37              5880  ................
380001....................................................                38              6440  ................
380002....................................................                38              4890  ................
380003....................................................                38              2400  ................
380006....................................................                38  ................              6440
380027....................................................                38              2400  ................
380040....................................................                38              2400  ................
380047....................................................                38              2400  ................
380050....................................................                38              4890  ................
380051....................................................              7080  ................              6440
380065....................................................                38              2400  ................
380070....................................................                38              6440  ................
380084....................................................              7080                38  ................
380090....................................................                38              2400  ................
390006....................................................                39              3240  ................
390008....................................................                39              6280              6280
390013....................................................                39              3240  ................
390016....................................................                39              6280              6280
390017....................................................                39              6280              6280
390030....................................................                39              0240              6680
390031....................................................                39              0240              6680
390048....................................................                39              3240  ................
390052....................................................                39              0280  ................
390065....................................................                39              8840              9280
390079....................................................                39              0960  ................
390091....................................................                39              6280  ................
390093....................................................                39              6280  ................
390110....................................................              3680              6280  ................
390113....................................................                39              9320  ................
390133....................................................              0240              6160  ................
390138....................................................                39              8840  ................
390150....................................................                39              6280  ................
390151....................................................                39              8840  ................
390181....................................................                39              6680              6680
390183....................................................                39              6680              6680
390189....................................................                39              3240  ................
390197....................................................              0240              6160  ................
390201....................................................                39              5660              5640
390263....................................................              0240              6160  ................
400018....................................................                40              1310  ................
410010....................................................              6483              1123  ................
410013....................................................              6483              5523  ................
420020....................................................                42              1440  ................
420036....................................................                42              1520  ................
420059....................................................                42              2655  ................
420062....................................................                42              1520  ................
420068....................................................                42              0600  ................
420070....................................................              8140              1760  ................
420071....................................................                42              0600  ................
420080....................................................                42              7520  ................
420085....................................................              5330              9200  ................
430008....................................................                43                24  ................
430012....................................................                43              7760  ................
430013....................................................                43              7760  ................
430014....................................................                43              2520  ................
430015....................................................                43              6660  ................
430047....................................................                43                28  ................
430048....................................................                43                53  ................
430089....................................................                43              7720  ................
440020....................................................                44              3440  ................
440024....................................................                44              1560  ................

[[Page 31661]]

 
440050....................................................                44              0480  ................
440058....................................................                44              1560  ................
440059....................................................                44              5360  ................
440067....................................................                44              3840  ................
440068....................................................                44              1560  ................
440073....................................................                44              5360  ................
440083....................................................                44              3840  ................
440143....................................................                44              5360  ................
440148....................................................                44              5360  ................
440175....................................................                44              3440  ................
440180....................................................                44              3840  ................
440182....................................................                44              3580  ................
440185....................................................                44              1560  ................
440186....................................................                44              5360  ................
440187....................................................                44                18  ................
440192....................................................                44              5360  ................
440200....................................................                44              5360  ................
440203....................................................                44              1560  ................
450007....................................................                45              7240  ................
450014....................................................                45              8750  ................
450053....................................................                45              8750  ................
450072....................................................              1145              3360  ................
450080....................................................                45              4420  ................
450085....................................................                45              9080  ................
450098....................................................                45              4420  ................
450099....................................................                45              0320  ................
450113....................................................                45              1920  ................
450140....................................................                45              5800  ................
450144....................................................                45              5800  ................
450146....................................................                45              0320  ................
450155....................................................                45              0320  ................
450163....................................................                45              1880  ................
450178....................................................                45              5800  ................
450187....................................................                45              3360  ................
450192....................................................                45              1920  ................
450194....................................................                45              1920  ................
450196....................................................                45  ................              1920
450211....................................................                45              3360  ................
450214....................................................                45              3360  ................
450224....................................................                45              8640  ................
450246....................................................                45              8750  ................
450347....................................................                45              3360  ................
450351....................................................                45              2800  ................
450353....................................................                45              1880  ................
450373....................................................                45              4420  ................
450395....................................................                45              3360  ................
450400....................................................                45              8800  ................
450438....................................................                45              0640  ................
450447....................................................                45              1920  ................
450451....................................................                45              2800  ................
450484....................................................                45              3360  ................
450508....................................................                45              8640  ................
450534....................................................                45              0320  ................
450587....................................................                45                40  ................
450591....................................................              1145              3360  ................
450623....................................................                45              1920  ................
450626....................................................                45              8750  ................
450653....................................................                45              5800  ................
450656....................................................                45              8640  ................
450694....................................................                45              3360  ................
450747....................................................                45              1920  ................
450755....................................................                45              4600  ................
450763....................................................                45               320  ................
460007....................................................                46              2620  ................
460011....................................................                46              6520  ................
460021....................................................                46              4120  ................
460027....................................................                46              6520  ................
460032....................................................                46              6520  ................
460036....................................................                46              6520  ................
460039....................................................                46              7160  ................

[[Page 31662]]

 
470001....................................................                47              1303  ................
470003....................................................              1303              1123  ................
470011....................................................                47              1123              1123
470012....................................................                47              6323  ................
470018....................................................                47              1123  ................
490001....................................................                49              3660  ................
490004....................................................                49              1540  ................
490005....................................................                49              8840  ................
490013....................................................                49              1950  ................
490018....................................................                49              4640  ................
490038....................................................                49              3660  ................
490047....................................................                49              8840  ................
490060....................................................                49              3660  ................
490066....................................................              5720              6760  ................
490079....................................................                49              3120  ................
490126....................................................                49              6800  ................
500002....................................................                50              6740  ................
500003....................................................                50              7600  ................
500007....................................................                50              0860  ................
500016....................................................                50              7600  ................
500041....................................................                50              6440  ................
500059....................................................                50              7600  ................
500072....................................................                50              7600  ................
500079....................................................              8200  ................              7600
510001....................................................                51              6280  ................
510002....................................................                51              6800  ................
510006....................................................                51              6280  ................
510024....................................................                51              6280              6280
510028....................................................                51              1480  ................
510046....................................................                51              1480  ................
510047....................................................                51              6280  ................
510048....................................................                51              3400  ................
510062....................................................                51              1480  ................
510070....................................................                51              1480  ................
510071....................................................                51              1480  ................
520002....................................................                52              8940  ................
520006....................................................                52              8940  ................
520011....................................................                52              2290  ................
520021....................................................              3800              1600              1600
520028....................................................                52              4720  ................
520037....................................................                52              8940  ................
520059....................................................              6600              5080              5080
520066....................................................              3620              4720  ................
520071....................................................                52              5080              5080
520076....................................................                52              5080  ................
520084....................................................                52              4720  ................
520088....................................................                52              5080  ................
520091....................................................                52                23  ................
520094....................................................              6600              5080              5080
520096....................................................              6600              5080              5080
520102....................................................                52              5080              5080
520107....................................................                52              3080  ................
520113....................................................                52              3080  ................
520116....................................................                52              5080              5080
520152....................................................                52              3080  ................
520173....................................................                52              2240  ................
520189....................................................              3800              1600              1600
530008....................................................                53              1350  ................
530009....................................................                53              1350  ................
530015....................................................                53              6340  ................
530025....................................................                53              2670  ................
530032....................................................                53              7160  ................
----------------------------------------------------------------------------------------------------------------


[[Page 31663]]


  Table 10.--Means and Standard Deviations, by Diagnosis Related Groups
                               (DRGs) \1\
------------------------------------------------------------------------
                                                               Mean + 1
                      DRG                          Cases       standard
                                                              deviation
------------------------------------------------------------------------
1.............................................       27,704      $66,748
2.............................................       14,078      $34,337
3.............................................            7      $55,030
4.............................................        6,426      $41,870
5.............................................       93,104      $23,280
6.............................................          398      $14,095
7.............................................       14,187      $46,968
8.............................................        4,349      $28,253
9.............................................        1,737      $24,223
10............................................       18,015      $22,246
11............................................        3,398      $15,519
12............................................       49,619      $15,429
13............................................        6,637      $13,922
14............................................      235,975      $21,928
15............................................      101,681      $16,969
16............................................        9,257      $21,632
17............................................        2,870      $11,541
18............................................       28,000      $17,036
19............................................        8,672      $12,308
20............................................        5,616      $51,920
21............................................        1,429      $27,335
22............................................        2,722      $18,422
23............................................       11,189      $14,276
24............................................       55,342      $17,340
25............................................       27,205      $10,640
26............................................           34      $13,463
27............................................        3,839      $23,063
28............................................       12,339      $23,674
29............................................        4,928      $12,505
31............................................        3,814      $15,329
32............................................        1,891       $9,174
34............................................       22,336      $17,368
35............................................        7,323      $11,138
36............................................        2,481      $10,985
37............................................        1,418      $18,071
38............................................           93       $9,775
39............................................          666      $10,551
40............................................        1,524      $14,863
42............................................        1,936      $11,289
43............................................          110       $8,855
44............................................        1,295      $11,245
45............................................        2,598      $12,352
46............................................        3,373      $13,685
47............................................        1,350       $9,302
49............................................        2,337      $31,134
50............................................        2,477      $13,972
51............................................          251      $16,197
52............................................          238      $13,055
53............................................        2,517      $20,530
55............................................        1,564      $16,073
56............................................          526      $16,460
57............................................          692      $17,299
59............................................          127      $13,165
60............................................            6      $10,986
61............................................          243      $21,950
62............................................            3       $6,623
63............................................        2,900      $25,070
64............................................        3,131      $23,886
65............................................       39,014       $9,512
66............................................        7,668       $9,851
67............................................          439      $13,316
68............................................        8,752      $11,567
69............................................        3,034       $8,666
70............................................           25       $8,029
71............................................           87      $12,279
72............................................          926      $12,429
73............................................        7,070      $13,912
75............................................       39,852      $53,451
76............................................       41,676      $50,324
77............................................        2,444      $21,281
78............................................       35,270      $22,207
79............................................      166,273      $29,036
80............................................        8,304      $15,356
81............................................            2      $17,479
82............................................       63,407      $25,645
83............................................        6,390      $16,990
84............................................        1,558       $8,753
85............................................       21,262      $21,607
86............................................        2,179      $12,312
87............................................       59,447      $24,541
88............................................      396,490      $15,658
89............................................      502,217      $18,132
90............................................       46,781      $10,653
91............................................           57      $12,409
92............................................       14,806      $21,600
93............................................        1,710      $13,018
94............................................       12,571      $20,639
95............................................        1,679      $10,242
96............................................       53,684      $13,018
97............................................       28,583       $9,626
98............................................           15      $16,431
99............................................       21,274      $12,269
100...........................................        8,941       $9,245
101...........................................       21,119      $14,939
102...........................................        5,557       $9,489
103...........................................          428     $349,756
104...........................................       19,511     $130,539
105...........................................       27,278      $94,418
106...........................................        3,307     $121,657
107...........................................       85,660      $86,239
108...........................................        6,200      $95,309
109...........................................       59,511      $64,065
110...........................................       53,164      $71,438
111...........................................        9,392      $42,529
113...........................................       41,401      $49,111
114...........................................        8,849      $29,028
115...........................................       15,270      $58,727
116...........................................      109,194      $38,515
117...........................................        4,176      $23,091
118...........................................        8,104      $27,103
119...........................................        1,316      $22,646
120...........................................       37,306      $39,416
121...........................................      167,277      $27,051
122...........................................       81,670      $17,860
123...........................................       41,145      $28,071
124...........................................      138,236      $23,982
125...........................................       89,996      $18,048
126...........................................        5,015      $48,094
127...........................................      681,606      $17,412
128...........................................        8,240      $12,365
129...........................................        4,100      $19,186
130...........................................       88,663      $16,401
131...........................................       27,776       $9,821
132...........................................      152,256      $11,138
133...........................................        8,915       $9,314
134...........................................       39,612      $10,344
135...........................................        7,552      $15,416
136...........................................        1,237      $10,011
138...........................................      203,304      $14,336
139...........................................       89,960       $8,832
140...........................................       66,409       $9,140
141...........................................      102,377      $12,604
142...........................................       51,706       $9,672
143...........................................      250,001       $9,216
144...........................................       88,480      $21,330
145...........................................        7,594      $10,378
146...........................................       10,796      $45,993
147...........................................        2,797      $25,903
148...........................................      129,351      $59,354
149...........................................       19,315      $24,710
150...........................................       20,330      $49,351
151...........................................        4,962      $22,681
152...........................................        4,424      $33,239
153...........................................        2,013      $19,418
154...........................................       28,996      $73,715
155...........................................        7,260      $21,846
156...........................................            3      $32,596
157...........................................        8,151      $22,041
158...........................................        4,560      $10,941
159...........................................       17,109      $23,315
160...........................................       12,156      $13,554
161...........................................       11,153      $19,125
162...........................................        7,270      $10,677
163...........................................            3       $7,876
164...........................................        5,116      $39,084
165...........................................        2,184      $20,580
166...........................................        3,902      $24,579
167...........................................        3,799      $14,801
168...........................................        1,381      $22,419
169...........................................          869      $12,657
170...........................................       12,155      $49,736
171...........................................        1,359      $19,892
172...........................................       30,603      $24,475
173...........................................        2,709      $13,824
174...........................................      247,084      $17,229
175...........................................       35,141       $9,564
176...........................................       15,215      $18,581
177...........................................        9,422      $15,760
178...........................................        3,756      $11,718
179...........................................       12,540      $18,881
180...........................................       88,253      $16,534
181...........................................       27,085       $9,241
182...........................................      260,632      $13,956
183...........................................       91,215       $9,962
184...........................................           93       $8,646
185...........................................        5,069      $15,675
186...........................................            3      $17,560
187...........................................          666      $14,847
188...........................................       79,377      $19,332
189...........................................       13,104      $10,335
190...........................................           74      $12,681
191...........................................        9,220      $77,337
192...........................................        1,257      $30,601
193...........................................        4,862      $59,463
194...........................................          733      $27,612
195...........................................        4,151      $50,509
196...........................................        1,050      $26,194
197...........................................       18,557      $42,811
198...........................................        5,667      $20,952
199...........................................        1,644      $42,977
200...........................................        1,042      $53,497
201...........................................        2,013      $67,182
202...........................................       26,142      $23,012
203...........................................       29,301      $24,716
204...........................................       61,516      $20,412
205...........................................       24,447      $21,124
206...........................................        2,048      $12,455
207...........................................       32,101      $19,874
208...........................................       10,740      $11,426
209...........................................      370,349      $31,852
210...........................................      121,438      $29,326
211...........................................       32,517      $19,885
212...........................................            7      $11,988
213...........................................        9,875      $32,709

[[Page 31664]]

 
216...........................................        6,916      $38,905
217...........................................       17,022      $53,503
218...........................................       22,732      $25,771
219...........................................       20,855      $16,751
223...........................................       13,650      $17,145
224...........................................       12,431      $12,855
225...........................................        6,124      $19,539
226...........................................        5,698      $26,964
227...........................................        4,915      $13,522
228...........................................        2,481      $19,438
229...........................................        1,175      $11,756
230...........................................        2,406      $21,932
231...........................................       12,530      $24,031
232...........................................          880      $16,464
233...........................................        7,178      $34,665
234...........................................        4,607      $21,908
235...........................................        5,089      $13,039
236...........................................       39,744      $12,220
237...........................................        1,743       $9,880
238...........................................        8,617      $24,817
239...........................................       48,197      $17,565
240...........................................       11,800      $23,191
241...........................................        3,218      $11,428
242...........................................        2,515      $19,784
243...........................................       93,611      $12,959
244...........................................       13,570      $12,429
245...........................................        5,726       $8,349
246...........................................        1,346       $9,926
247...........................................       19,616      $10,001
248...........................................       12,060      $14,559
249...........................................       12,649      $11,805
250...........................................        3,793      $11,824
251...........................................        2,489       $8,063
253...........................................       20,842      $12,750
254...........................................       10,802       $7,656
256...........................................        6,400      $14,186
257...........................................       16,692      $14,784
258...........................................       16,950      $11,403
259...........................................        3,812      $15,230
260...........................................        5,072      $11,046
261...........................................        1,888      $16,770
262...........................................          686      $15,951
263...........................................       24,560      $37,753
264...........................................        3,982      $19,495
265...........................................        4,052      $27,077
266...........................................        2,676      $14,584
267...........................................          267      $15,879
268...........................................          899      $19,361
269...........................................        9,060      $29,801
270...........................................        2,746      $12,961
271...........................................       19,594      $18,154
272...........................................        5,470      $17,426
273...........................................        1,387      $10,047
274...........................................        2,343      $22,054
275...........................................          247      $10,261
276...........................................        1,326      $11,997
277...........................................       93,843      $14,927
278...........................................       31,720       $9,470
279...........................................            3      $19,964
280...........................................       17,038      $12,041
281...........................................        7,827       $8,003
283...........................................        5,635      $12,585
284...........................................        1,950       $7,589
285...........................................        6,568      $35,890
286...........................................        2,183      $35,565
287...........................................        6,457      $32,850
288...........................................        3,675      $36,854
289...........................................        6,414      $16,097
290...........................................        9,482      $14,860
291...........................................           78      $10,570
292...........................................        5,422      $44,164
293...........................................          345      $24,530
294...........................................       95,355      $13,252
295...........................................        3,358      $13,707
296...........................................      250,808      $14,775
297...........................................       47,716       $8,713
298...........................................          103      $10,114
299...........................................        1,218      $16,149
300...........................................       17,532      $19,436
301...........................................        3,639      $11,261
302...........................................        7,896      $54,753
303...........................................       20,698      $41,205
304...........................................       12,041      $40,662
305...........................................        3,006      $20,536
306...........................................        7,210      $21,938
307...........................................        2,164      $10,268
308...........................................        7,244      $28,300
309...........................................        4,331      $15,304
310...........................................       24,587      $19,325
311...........................................        8,309      $10,483
312...........................................        1,547      $18,439
313...........................................          644      $11,749
315...........................................       33,708      $36,795
316...........................................      115,275      $23,727
317...........................................        1,889      $12,419
318...........................................        5,736      $21,305
319...........................................          494      $11,322
320...........................................      193,134      $14,735
321...........................................       30,723       $9,566
322...........................................           64       $8,657
323...........................................       18,621      $14,311
324...........................................        7,451       $8,122
325...........................................        8,937      $11,466
326...........................................        2,802       $7,872
327...........................................            2      $10,679
328...........................................          685      $13,051
329...........................................          105       $8,650
331...........................................       49,123      $18,734
332...........................................        5,117      $10,727
333...........................................          311      $13,719
334...........................................       10,262      $24,961
335...........................................       12,370      $18,084
336...........................................       36,313      $14,365
337...........................................       29,498       $9,686
338...........................................        1,055      $21,430
339...........................................        1,505      $18,435
341...........................................        3,670      $21,442
342...........................................          723      $13,001
344...........................................        3,838      $22,438
345...........................................        1,335      $19,558
346...........................................        4,559      $18,995
347...........................................          373      $10,844
348...........................................        3,280      $12,862
349...........................................          597       $7,194
350...........................................        6,493      $12,462
352...........................................          768      $12,805
353...........................................        2,655      $31,864
354...........................................        7,485      $25,534
355...........................................        5,670      $14,447
356...........................................       25,920      $12,488
357...........................................        5,710      $39,602
358...........................................       20,605      $20,138
359...........................................       31,042      $13,346
360...........................................       15,575      $14,638
361...........................................          369      $18,778
362...........................................            2       $9,180
363...........................................        2,683      $15,573
364...........................................        1,629      $14,738
365...........................................        1,834      $34,245
366...........................................        4,432      $23,297
367...........................................          520      $10,108
368...........................................        3,285      $21,162
369...........................................        3,279      $10,693
370...........................................        1,242      $16,029
371...........................................        1,413      $10,589
372...........................................          919       $9,639
373...........................................        3,876       $6,330
374...........................................          116      $12,936
375...........................................            8      $21,289
376...........................................          262       $8,664
377...........................................           29      $24,590
378...........................................          169      $15,095
379...........................................          408       $6,916
380...........................................           76       $6,684
381...........................................          181      $10,112
382...........................................           25       $2,798
383...........................................        1,841       $9,336
384...........................................          149       $7,372
389...........................................            5      $11,692
392...........................................        2,246      $55,515
394...........................................        2,326      $31,257
395...........................................      100,607      $14,330
396...........................................           11      $12,749
397...........................................       17,906      $21,719
398...........................................       17,113      $22,322
399...........................................        1,788      $12,303
400...........................................        6,486      $47,400
401...........................................        5,836      $50,173
402...........................................        1,599      $19,649
403...........................................       31,999      $32,078
404...........................................        4,588      $15,824
406...........................................        2,494      $48,934
407...........................................          701      $21,576
408...........................................        2,122      $36,343
409...........................................        2,515      $21,666
410...........................................       30,760      $18,311
411...........................................           14       $7,688
412...........................................           18       $4,980
413...........................................        5,766      $24,842
414...........................................          763      $12,866
415...........................................       39,905      $66,206
416...........................................      181,072      $28,177
417...........................................           37      $21,802
418...........................................       23,398      $18,311
419...........................................       15,719      $15,131
420...........................................        2,957      $10,195
421...........................................        9,270      $11,869
422...........................................           69       $7,590
423...........................................        7,269      $31,897
424...........................................        1,292      $41,189
425...........................................       16,304      $11,890
426...........................................        4,481       $9,206
427...........................................        1,576       $9,291
428...........................................          744      $12,949
429...........................................       27,018      $14,174
430...........................................       63,051      $12,703
431...........................................          320      $10,737
432...........................................          411      $11,105
433...........................................        5,520       $4,883
439...........................................        1,457      $29,345
440...........................................        5,435      $32,696
441...........................................          612      $15,577
442...........................................       16,693      $42,597
443...........................................        3,807      $17,673

[[Page 31665]]

 
444...........................................        5,675      $13,003
445...........................................        2,724       $8,465
447...........................................        6,278       $8,499
449...........................................       30,470      $14,241
450...........................................        7,366       $7,229
451...........................................            5       $4,039
452...........................................       25,215      $18,340
453...........................................        5,643       $9,105
454...........................................        4,623      $14,423
455...........................................        1,096       $8,019
461...........................................        4,563      $21,124
462...........................................       11,981      $19,956
463...........................................       25,204      $12,097
464...........................................        7,101       $8,636
465...........................................          224      $10,305
466...........................................        1,795      $11,397
467...........................................        1,043       $9,854
468...........................................       54,705      $66,153
470...........................................           49     $302,446
471...........................................       12,391      $47,581
473...........................................        8,235      $63,556
475...........................................      104,025      $67,384
476...........................................        3,812      $40,882
477...........................................       25,600      $32,847
478...........................................      108,611      $42,010
479...........................................       24,176      $24,354
480...........................................          622     $176,423
481...........................................          726     $123,849
482...........................................        5,299      $61,539
483...........................................       43,282     $288,420
484...........................................          317     $100,224
485...........................................        3,028      $50,619
486...........................................        1,867      $85,814
487...........................................        3,533      $35,194
488...........................................          776      $88,052
489...........................................       13,548      $32,178
490...........................................        5,247      $18,195
491...........................................       13,575      $26,985
492...........................................        2,874      $74,770
493...........................................       58,081      $30,868
494...........................................       30,883      $16,784
495...........................................          211     $155,662
496...........................................        1,841      $98,777
497...........................................       19,917      $57,641
498...........................................       14,635      $41,713
499...........................................       32,659      $24,252
500...........................................       49,444      $15,562
501...........................................        2,352      $44,432
502...........................................          636      $25,677
503...........................................        5,888      $20,546
504...........................................          123     $281,048
505...........................................          147      $31,985
506...........................................          937      $84,055
507...........................................          288      $30,296
508...........................................          667      $24,629
509...........................................          177      $16,475
510...........................................        1,671      $20,337
511...........................................          616      $11,613
512...........................................          450      $95,226
513...........................................          142      $99,439
514...........................................       19,241     $104,112
515...........................................        4,568      $87,754
516...........................................       76,169      $45,006
517...........................................      190,940      $36,508
518...........................................       51,620      $30,281
519...........................................        7,216      $39,899
520...........................................       11,045      $25,111
521...........................................       28,562      $12,663
522...........................................        6,139      $10,035
523...........................................       14,802       $6,921
524...........................................      136,805      $12,350
525...........................................          492    $209,675
------------------------------------------------------------------------
\1\ Cases are taken from the FY 2001 MedPAR file; DRGs are from GROUPER
  V20.0.


[[Page 31666]]

Appendix A--Regulatory Impact Analysis

I. Introduction

    We have examined the impacts of this rule as required by Executive 
Order 12866 (September 1993, Regulatory Planning and Review) and the 
Regulatory Flexibility Act (RFA) (September 19, 1980, Public Law 96-
354), section 1102(b) of the Social Security Act, the Unfunded Mandate 
Reform Act of 1995 (Public Law 104-4), and Executive Order 13132.
    Executive Order 12866 directs agencies to assess all costs and 
benefits of available regulatory alternatives and, if regulation is 
necessary, to select regulatory approaches that maximize net benefits 
(including potential economic, environmental, public health and safety 
effects, distributive impacts, and equity). A regulatory impact 
analysis (RIA) must be prepared for major rules with economically 
significant effects ($100 million or more in any 1 year). We have 
determined that this proposed rule is a major rule as defined in 5 
U.S.C. 804(2). We estimate that the total impact of these changes for 
FY 2003 payments compared to FY 2002 payments to be approximately a 
$0.3 billion increase.
    The RFA requires agencies to analyze options for regulatory relief 
of small businesses. For purposes of the RFA, small entities include 
small businesses, nonprofit organizations, and government agencies. 
Most hospitals and most other providers and suppliers are small 
entities, either by nonprofit status or by having revenues of $5 
million to $25 million in any 1 year. For purposes of the RFA, all 
hospitals and other providers and suppliers are considered to be small 
entities. Individuals and States are not included in the definition of 
a small entity.
    In addition, section 1102(b) of the Act requires us to prepare a 
regulatory impact analysis for any proposed rule that may have a 
significant impact on the operations of a substantial number of small 
rural hospitals. This analysis must conform to the provisions of 
section 603 of the RFA. With the exception of hospitals located in 
certain New England counties, 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 proposed 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 
proposed rule, constitutes a combined regulatory impact analysis and 
regulatory flexibility analysis.
    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 proposed rule (or a final rule that has 
been preceded by a proposed 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 proposed rule would not 
mandate any requirements for State, local, or tribal governments.
    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule (and subsequent 
final rule) that imposes substantial direct requirement costs on State 
and local governments, preempts State law, or otherwise has Federalism 
implications. We have reviewed this proposed rule in light of Executive 
Order 13132 and have determined that it will not have any negative 
impact on the rights, roles, and responsibilities of State, local, or 
tribal governments.
    In accordance with the provisions of Executive Order 12866, this 
proposed rule was reviewed by the Office of Management and Budget.

II. Objectives

    The primary objective of the acute care hospital inpatient 
prospective payment system is to create incentives for hospitals to 
operate efficiently and minimize unnecessary costs while at the same 
time ensuring that payments are sufficient to adequately compensate 
hospitals for their legitimate costs. In addition, we share national 
goals of preserving the Medicare Trust Fund.
    We believe the proposed changes would further each of these goals 
while maintaining the financial viability of the hospital industry and 
ensuring access to high quality health care for Medicare beneficiaries. 
We expect that these proposed changes would ensure that the outcomes of 
this payment system are reasonable and equitable while avoiding or 
minimizing unintended adverse consequences.

III. Limitations of Our Analysis

    The following quantitative analysis presents the projected effects 
of our proposed policy changes, as well as statutory changes effective 
for FY 2003, 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. As we have done 
in previous proposed rules, we are soliciting comments and information 
about the anticipated effects of these changes on hospitals and our 
methodology for estimating them.

IV. Hospitals Included In and Excluded From the Acute Care Hospital 
Inpatient 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 44 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. Among other short-term, 
acute care hospitals, only the 67 such hospitals in Maryland remain 
excluded from the hospital inpatient prospective payment system under 
the waiver at section 1814(b)(3) of the Act.
    There are approximately 515 critical access hospitals (CAHs). These 
small, limited service hospitals are paid on the basis of reasonable 
costs rather than under the acute care hospital inpatient prospective 
payment system. The remaining 20 percent are specialty hospitals that 
are excluded from the acute-care, short-term prospective payment 
system. These hospitals include psychiatric hospitals and units, 
rehabilitation hospitals and units, long-term care hospitals, 
children's hospitals, and cancer hospitals. The impacts of our final 
policy changes on these hospitals are discussed below.
    Thus, as of February 2002, we have included 4,301 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.

V. Impact on Excluded Hospitals and Hospital Units

    As of February 2002, there were 1,065 specialty hospitals excluded 
from the

[[Page 31667]]

acute care hospital inpatient 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 493 
psychiatric, 216 rehabilitation, 270 long-term care, 75 children's, and 
11 cancer hospitals. In addition, there were 1,436 psychiatric units 
and 936 rehabilitation units in hospitals otherwise subject to the 
acute care hospital inpatient prospective payment system. Under 
Sec. 413.40(a)(2)(i)(A), the rate-of-increase ceiling is not applicable 
to the 67 specialty hospitals and units in Maryland that are paid in 
accordance with the waiver at section 1814(b)(3) of the Act.
    In the past, hospitals and units excluded from the acute care 
hospital inpatient prospective payment system have been paid based on 
their reasonable costs subject to limits as established by the Tax 
Equity and Fiscal Responsibility Act of 1982 (TEFRA). Hospitals that 
continue to be paid based on their reasonable costs are subject to 
TEFRA limits for FY 2003. For these hospitals, the proposed update is 
the percentage increase in the excluded hospital market basket 
(currently estimated at 3.4 percent).
    Inpatient rehabilitation facilities (IRFs) are paid under the IRF 
prospective payment system for cost reporting periods beginning on or 
after January 1, 2002. For cost reporting periods beginning during FY 
2003, the IRF prospective payment is based on 100 percent of the 
adjusted Federal IRF prospective payment amount, updated annually (see 
the August 7, 2001 final rule (66 FR 41316 through 41430)). Therefore, 
these hospitals are not impacted by this proposed rule.
    Effective for cost reporting periods beginning during FY 2003, we 
have proposed that long-term care hospitals would be paid under a long-
term care hospital prospective payment system, where long-term care 
hospitals receive payment based on a 5-year transition period (see the 
March 22, 2002 proposed rule (67 FR 13416 through 13494)). However, 
under this proposed payment system, a long-term care hospital may also 
elect to be paid at 100 percent of the Federal prospective rate at the 
beginning of any of its cost reporting periods during the 5-year 
transition period. For purposes of the update factor, the portion of 
the proposed prospective payment system transition blend payment based 
on reasonable costs for inpatient operating services would be 
determined by updating the long-term care hospital's TEFRA limit by the 
proposed estimate of the excluded hospital market basket (or 3.4 
percent).
    The impact on excluded hospitals and hospital 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 rate-of-increase limits since their 
base period, the major effect will be on the level of incentive 
payments these hospitals and hospital units receive. Conversely, for 
excluded hospitals and hospital 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 hospital 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 hospital units to restrain the growth in their spending 
for patient services.

VI. Quantitative Impact Analysis of the Proposed Policy Changes 
Under the Hospital Inpatient Prospective Payment System for 
Operating Costs

A. Basis and Methodology of Estimates

    In this proposed rule, we are announcing policy changes and payment 
rate updates for the hospital inpatient prospective payment systems for 
operating and capital-related costs. We estimate the total impact of 
these changes for FY 2003 payments compared to FY 2002 payments to be 
approximately a $0.3 billion increase. We have prepared separate impact 
analyses of the proposed 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 FY 2001 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 proposed policy 
changes. Second, due to the interdependent nature of the hospital 
inpatient prospective payment system, it is very difficult to precisely 
quantify the impact associated with each proposed 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 source 
overall. For individual hospitals, however, some miscategorizations are 
possible.
    Using cases in the FY 2001 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 short-term acute-care hospital inpatient prospective payment 
systems (Indian Health Service hospitals and hospitals in Maryland) are 
excluded from the simulations. The impact of payments under the capital 
prospective payment system, or the impact of payments for costs other 
than inpatient operating costs, are not analyzed in this section. 
Estimated payment impacts of proposed FY 2003 changes to the capital 
prospective payment system are discussed in section IX. of this 
Appendix.
    The proposed changes discussed separately below are the following:
     The effects of the proposed change to the labor portion of 
the standardized amounts from 71.1 percent to 72.5 percent.
     The effects of the proposed changes in hospitals' wage 
index values reflecting wage data from hospitals' cost reporting 
periods beginning during FY 1999, compared to the FY 1998 wage data, 
and the effects of removing from the wage data the costs and hours 
associated with graduate medical education (GME) and certified 
registered nurse anesthetists (CRNAs).
     The effects of the proposed 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 geographic reclassifications by the 
Medicare Geographic Classification Review Board (MGCRB) that will be 
effective in FY 2003.

[[Page 31668]]

     The total change in payments based on FY 2003 policies 
relative to payments based on FY 2002 policies.
    To illustrate the impacts of the FY 2003 proposed changes, our 
analysis begins with a FY 2003 baseline simulation model using: the FY 
2002 DRG GROUPER (version 19.0); the FY 2002 wage index; and no MGCRB 
reclassifications. Outlier payments are set at 5.1 percent of total DRG 
plus outlier payments.
    Each proposed and statutory policy change is then added 
incrementally to this baseline model, finally arriving at an FY 2003 
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 2002 to FY 2003. Six 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 are proposing to update the large 
urban and the other areas average standardized amounts for FY 2003 
using the most recently forecasted hospital market basket increase for 
FY 2003 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 
Medicare-dependent small rural hospitals (MDHs) is also 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 2002 to FY 2003 is the change in MGCRB status 
from one year to the next. That is, hospitals reclassified in FY 2002 
that are no longer reclassified in FY 2003 may have a negative payment 
impact going from FY 2002 to FY 2003; conversely, hospitals not 
reclassified in FY 2002 that are reclassified in FY 2003 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 is 
alleviated, however, 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 2002 will be 6.7 percent of total DRG 
payments. When the FY 2002 final rule was published, we projected FY 
2002 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 2002 (as 
discussed in the Addendum to this proposed rule) are reflected in the 
analyses below comparing our current estimates of FY 2002 payments per 
case to estimated FY 2003 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. This option was to be 
phased in over 4 years. For FY 2003, the proportion of payments based 
on affected SCHs' FY 1996 hospital-specific amount increases from 50 
percent to 75 percent.
    Fifth, under section 1886(d)(5)(B)(ii) of the Act, the formula for 
indirect medical education (IME) is reduced beginning in FY 2003. The 
reduction is from approximately a 6.5 percent increase for every 10 
percent increase in the resident-to-bed ratio during FY 2002 to 
approximately a 5.5 percent increase.
    Sixth, the disproportionate share hospital (DSH) adjustment 
increases in FY 2003 compared with FY 2002. In accordance with section 
1886(d)(5)(F)(ix) of the Act, during FY 2002, DSH payments that the 
hospital would otherwise receive were reduced by 3 percent. This 
reduction is no longer applicable beginning with FY 2003.
    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 4,301 hospitals included in the analysis. This number is 494 
fewer hospitals than were included in the impact analysis in the FY 
2002 final rule (66 FR 40087). Of this number, 437 are now CAHs and are 
excluded from our analysis.
    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 2,613 
hospitals located in urban areas (MSAs or NECMAs) included in our 
analysis. Among these, there are 1,511 hospitals located in large urban 
areas (populations over 1 million), and 1,102 hospitals in other urban 
areas (populations of 1 million or fewer). In addition, there are 1,688 
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 2003 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 2,645, 1,570, 1,075, 
and 1,656, respectively.
    The next three groupings examine the impacts of the proposed 
changes on hospitals grouped by whether or not they have GME residency 
programs (teaching hospitals that receive an IME adjustment) or receive 
DSH payments, or some combination of these two adjustments. There are 
3,195 nonteaching hospitals in our analysis, 872 teaching hospitals 
with fewer than 100 residents, and 234 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.)
    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 proposed 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 (159), SCHs (540), MDHs (216), and 
hospitals that are both SCH and RRC (75) shown here were not 
reclassified for purposes of the standardized amount. There are 4 RRCs 
and 1 SCH and RRC that will be reclassified as urban for the 
standardized amount in FY 2003 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 were unavailable for 213 
hospitals. Similarly, the data needed to determine

[[Page 31669]]

Medicare utilization were unavailable for 109 hospitals.
    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 2003. 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 2003 Operating Prospective Payment System
                                                         [Percent changes in payments per case]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                        Remove
                                        Number of  New labor      DRG       New wage    GME &    Remove GME   DRG & WI          MCGRB           All FY
                                        hosps.\1\  share \2\  changes.\3\   data \4\   CRNA 80/  & CRNA 100    changes     reclassification      2003
                                            (0)        (1)         (2)        (3)       20 \5\     percent    \7\  (6)         \8\  (7)         changes
                                                                                         (4)      \6\  (5)                                     \9\  (8)
--------------------------------------------------------------------------------------------------------------------------------------------------------
By Geographic Location:
    All hospitals.....................      4,301        0.0        -0.2         0.0        0.0         0.0         0.0             0.0              0.4
    Urban hospitals...................      2,613        0.0        -0.2        -0.1        0.0         0.0         0.0            -0.5              0.1
    Large urban areas (populations          1,511        0.1        -0.2        -0.2        0.0         0.0        -0.2            -0.5             -0.3
     over 1 million)..................
    Other urban areas (populations of       1,102       -0.1        -0.1         0.1        0.0         0.0         0.3            -0.4              0.8
     1 million of fewer)..............
    Rural hospitals...................      1,688       -0.2        -0.4         0.5        0.1         0.1         0.3             2.5              2.1
    Bed Size (Urban):
        0-99 beds.....................        647        0.0        -0.2         0.0        0.1         0.1         0.3            -0.6              1.5
        100-199 beds..................        904        0.0        -0.3        -0.1        0.0         0.1         0.0            -0.5              1.0
        200-299 beds..................        528        0.0        -0.3         0.0        0.0         0.1         0.1            -0.4              0.5
        300-499 beds..................        387        0.0        -0.1        -0.2        0.0         0.0         0.0            -0.4              0.1
        500 or more beds..............        147        0.1        -0.2        -0.1        0.0         0.0        -0.1            -0.5             -1.1
    Bed Size (Rural):
        0-49 beds.....................        819       -0.2        -0.6         0.6        0.1         0.1         0.2             0.5              2.6
        50-99 beds....................        507       -0.2        -0.5         0.4        0.1         0.1         0.2             1.0              2.4
        100-149 beds..................        216       -0.2        -0.4         0.6        0.1         0.1         0.5             2.9              2.0
        150-199 beds..................         78       -0.2        -0.4         0.5        0.1         0.1         0.5             4.8              1.9
        200 or more beds..............         68       -0.2        -0.3         0.4        0.1         0.1         0.4             4.1              1.4
    Urban by Region:
        New England...................        134        0.2        -0.3         0.1        0.0         0.1         0.9            -0.2              0.0
        Middle Atlantic...............        402        0.2        -0.1        -0.8        0.0         0.0        -0.8            -0.1             -1.8
        South Atlantic................        380       -0.1        -0.2         0.1        0.1         0.1         0.2            -0.5              0.9
        East North Central............        431        0.0        -0.2         0.1        0.0         0.0         0.2            -0.5              0.4
        East South Central............        158       -0.2        -0.2         0.2        0.0         0.0         0.1            -0.7              0.9
        West North Central............        180       -0.1        -0.3         0.5        0.1         0.1         0.6            -0.7              0.9
        West South Central............        334       -0.2        -0.2        -0.2        0.1         0.1        -0.1            -0.7              0.4
        Mountain......................        132        0.0         0.0        -0.3        0.1         0.1         0.0            -0.6              0.6
        Pacific.......................        416        0.2        -0.4         0.0        0.1         0.1         0.1            -0.5              0.7
        Puerto Rico...................         46       -0.7        -0.4        -0.8        0.0         0.0        -0.7            -0.8              0.0
    Rural by Region:
        New England...................         40        0.0        -0.4         0.2        0.0         0.0         0.0             2.8              1.0
        Middle Atlantic...............         68       -0.1        -0.4        -0.1        0.0         0.0        -0.3             2.5              1.6
        South Atlantic................        239       -0.2        -0.5         0.4        0.1         0.1         0.2             3.0              1.9
        East North Central............        225       -0.1        -0.3         0.4        0.1         0.1         0.4             2.1              2.5
        East South Central............        243       -0.3        -0.6         1.0        0.1         0.1         0.8             2.4              2.0
        West North Central............        311       -0.2        -0.4         0.8        0.0         0.0         0.7             1.5              2.4
        West South Central............        294       -0.3        -0.6         0.3        0.1         0.1         0.0             3.4              1.8
        Mountain......................        151       -0.1        -0.4         0.2        0.0         0.0         0.1             1.6              2.0
        Pacific.......................        112        0.0        -0.4         0.8        0.1         0.1         0.6             2.3              2.7
        Puerto Rico...................          5       -0.7        -0.5        -4.9        0.1         0.1        -5.0            -0.5             -2.8
By Payment Classification:
    Urban hospitals...................      2,645        0.0        -0.2        -0.1        0.0         0.0         0.0            -0.4              0.2
    Large urban areas (populations          1,570        0.1        -0.2        -0.2        0.0         0.0        -0.2            -0.4             -0.2
     over 1 million)..................
    Other urban areas (populations of       1,075       -0.1        -0.1         0.1        0.0         0.0         0.3            -0.4              0.8
     1 million of fewer)..............
    Rural areas.......................      1,656       -0.2        -0.5         0.5        0.1         0.1         0.3             2.4              2.1
    Teaching Status:
        Non-teaching..................      3,195       -0.1        -0.4         0.2        0.1         0.1         0.2             0.3              1.5
        Fewer than 100 Residents......        872        0.0        -0.1        -0.1        0.0         0.0         0.0            -0.3              0.5
        100 or more Residents.........        234        0.1        -0.2        -0.3        0.0         0.0        -0.3            -0.3             -1.7
    Urban DSH:
        Non-DSH.......................      1,565        0.0        -0.1         0.0        0.0         0.0         0.2             0.1              0.7
        100 or more beds..............      1,354        0.0        -0.2        -0.2        0.0         0.0        -0.1            -0.5              0.0
        Less than 100 beds............        295        0.0        -0.4         0.1        0.1         0.1         0.1            -0.3              1.5

[[Page 31670]]

 
    Rural DSH:
        Sole Community (SCH)..........        470       -0.1        -0.7         0.4        0.0         0.0        -0.1             0.1              2.3
        Referral Center (RRC).........        156       -0.2        -0.4         0.5        0.1         0.1         0.5             5.1              1.6
        Other Rural:
          100 or more beds............         78       -0.3        -0.5         0.6        0.1         0.1         0.6             1.2              2.0
          Less than 100 beds..........        383       -0.3        -0.6         0.7        0.1         0.1         0.5             0.8              2.5
    Urban teaching and DSH:
        Both teaching and DSH.........        758        0.0        -0.2        -0.3        0.0         0.0        -0.2            -0.5             -0.6
        Teaching and no DSH...........        278        0.0         0.0         0.0        0.0         0.0         0.2            -0.1             -0.1
        No teaching and DSH...........        891        0.0        -0.4         0.1        0.1         0.1         0.2            -0.4              1.4
        No teaching and no DSH........        718        0.0        -0.2         0.0        0.0         0.1         0.2            -0.4              1.0
    Rural Hospital Types:
        Non special status hospitals..        666       -0.3        -0.5         0.7        0.1         0.1         0.6             1.2              2.3
        RRC...........................        159       -0.3        -0.3         0.6        0.1         0.1         0.6             6.0              1.2
        SCH...........................        540       -0.1        -0.6         0.2        0.0         0.0        -0.2             0.3              2.3
        Medicare-dependent hospitals          216       -0.2        -0.6         0.7        0.1         0.1         0.3             0.5              2.7
         (MDH)........................
        SCH and RRC...................         75       -0.1        -0.3         0.3        0.0         0.0         0.1             1.8              2.5
    Type of Ownership:
        Voluntary.....................      2,473        0.0        -0.2        -0.1        0.0         0.0         0.0            -0.1              0.4
        Proprietary...................        705        0.0        -0.2        -0.2        0.1         0.1        -0.1            -0.1              0.3
        Government....................        910       -0.1        -0.5         0.3        0.1         0.1         0.2             0.2              0.8
        Unknown.......................        213       -0.1        -0.3         0.2        0.1         0.1         0.2            -0.4              0.6
    Medicare Utilization as a Percent
     of Inpatient Days:
        0-25..........................        319        0.1        -0.4        -0.3        0.1         0.1        -0.4            -0.3             -0.7
        25-50.........................      1,650        0.0        -0.2        -0.1        0.0         0.0         0.0            -0.3              0.0
        50-65.........................      1,706       -0.1        -0.2         0.1        0.0         0.0         0.2             0.3              1.1
        Over 65.......................        517       -0.1        -0.4        -0.1        0.0         0.0        -0.1             0.5              0.6
        Unknown.......................        109        0.2         0.1        -1.1        0.0         0.0        -0.8            -0.7             -0.4
Hospitals Reclassified by the Medicare
 Geographic Classification Review
 Board: FY 2003 Reclassifications:
    All Reclassified Hospitals........        620       -0.1        -0.3         0.3        0.0         0.1         0.4             4.4              1.0
        Standardized Amount Only......         29        0.0        -0.4         0.6        0.1         0.1         0.6             0.3              1.6
        Wage Index Only...............        527       -0.1        -0.3         0.3        0.0         0.1         0.3             4.5              0.8
        Both..........................         41       -0.2        -0.2         0.4        0.1         0.1         0.6             5.1              1.1
    Nonreclassified Hospitals.........      3,666        0.0        -0.2        -0.1        0.0         0.0         0.0            -0.7              0.3
    All Reclassified Urban Hospitals..        108        0.1        -0.1         0.1        0.0         0.0         0.4             4.0             -0.4
        Standardized Amount Only......          1        0.0        -0.1         0.4       -0.1        -0.1         0.4            -0.9              1.6
        Wage Index Only...............         95        0.1        -0.1         0.1        0.0         0.0         0.4             4.1              0.6
        Both..........................         12       -0.1        -0.2         0.6        0.1         0.1         0.9             2.9              4.1
        Urban Nonreclassified               2,471        0.0        -0.2        -0.1        0.0         0.0         0.0            -0.7              0.2
         Hospitals....................
    All Reclassified Rural Hospitals..        512       -0.2        -0.4         0.4        0.1         0.1         0.4             4.6              1.8
        Standardized Amount Only......          1       -0.4         0.1         0.1        0.1         0.1         0.6             0.9              3.7
        Wage Index Only...............        502       -0.2        -0.4         0.5        0.1         0.1         0.4             4.6              1.8
        Both..........................          9       -0.2        -0.2         0.2        0.1         0.1         0.2             4.7              0.7
    Rural Nonreclassified Hospitals...      1,175       -0.2        -0.6         0.5        0.1         0.1         0.3            -0.4              2.4
    Other Reclassified Hospitals               35       -0.1        -0.6        -0.1        0.0         0.0        -0.5            -1.4             2.8
     (Section 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 2001, and hospital cost report data are from reporting periods beginning in FY 1999 and FY 1998.
\2\ This column displays impact of the proposed change to the labor share from 71.1 percent to 72.5 percent.
\3\ This column displays the payment impact of the recalibration of the DRG weights based on FY 2001 MedPAR data and the DRG reclassification changes,
  in accordance with section 1886(d)(4)(C) of the Act.
\4\ This column displays the impact of updating the wage index with wage data from hospitals' FY 1999 cost reports.

[[Page 31671]]

 
\5\ This column displays the impact of an 80/20 percent blend of removing the labor costs and hours associated with graduate medical education and for
  the Part A costs of certified registered nurse anesthetists.
\6\ This column displays the impact of completely removing the labor costs and hours associated with graduate medical education (GME) and for the Part A
  costs of certified registered nurse anesthetists (CRNAs).
\7\ 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 phase-out of GME and CRNA costs and hours, and the budget neutrality adjustment factor for DRG and wage index 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 2, 3, 4 and 5, and
  the FY 2003 budget neutrality factor of 1.001026.
\8\ Shown here are the effects of geographic reclassifications by the Medicare Geographic Classification Review Board (MGCRB). The effects demonstrate
  the FY 2003 payment impact of going from no reclassifications to the reclassifications scheduled to be in effect for FY 2003. Reclassification for
  prior years has no bearing on the payment impacts shown here.
\9\ This column shows changes in payments from FY 2002 to FY 2003. It incorporates all of the changes displayed in columns 1, 6 and 7 (the changes
  displayed in columns 2, 3, 4, and 5 are included in column 6). It also displays the impact of the FY 2003 update, changes in hospitals'
  reclassification status in FY 2003 compared to FY 2002, and the difference in outlier payments from FY 2002 to FY 2003. It also reflects the gradual
  phase-in for some SCHs of the full 1996 hospital-specific rate. Finally, the impacts of the reduction in IME adjustment payments, and the increase in
  the DSH adjustment are shown in this column. The sum of these impacts may be different from the percentage changes shown here due to rounding and
  interactive effect.

B. Impact of the Proposed Changes to the Labor Share (Column 1)

    In Column 1 of Table 1, we present the effects of our proposal to 
update the labor share from 71.10 percent to 72.49 percent. We estimate 
the impact of this change by calculating payments using payment rates 
updated to FY 2003, but using the FY 2002 DRG GROUPER and wage index. 
The change in this column represents the impact upon various hospital 
categories of the proposed change to the labor share. This proposed 
change negatively impacts hospitals with wage indexes less than 1.0, 
and positively affects those with wage indexes greater than 1.0.
    This proposed change has no impact on overall hospital payments. 
However, there are redistributive impacts generally in the range of 
plus or minus 0.1 percent or 0.2 percent. The net redistributive impact 
from those positively and negatively affected is approximately $65 
million. Hospitals in large urban areas would experience an increase of 
0.1 percent. Hospitals in both ``other'' urban and rural areas would 
experience -0.1 and -0.2 percent decreases, respectively.
    Under the urban by region category, New England, Middle Atlantic 
and Pacific regions would experience a 0.2 percent increase. The urban 
East South Central and West South Central regions would experience -0.2 
percent decreases. Puerto Rico has a projected decrease of -0.7 
percent, due to the low wage indexes in the Puerto Rico MSAs.
    All rural regions would experience a negative percent decrease 
except New England and Pacific regions (at 0.0 percent change). The 
South Atlantic and West North Central regions would experience a 
decrease of -0.2 percent. The East South Central and West South Central 
regions each would experience a -0.3 percent decrease, while Puerto 
Rico would experience a -0.7 percent decrease. Rural nonspecial status 
hospitals and RRCs would decline by -0.3. SCH and MDHs also would 
experience decreases of -0.1 and -0.2 percent, respectively. The 
relatively smaller negative impact for these hospitals is due to the 
fact that the hospital-specific rate is not adjusted by the wage index. 
Therefore, this proposed change would have no effect on hospitals paid 
on that basis (other than SCHs receiving a blended of their FY 1996 
hospital-specific rate and the Federal rate).

C. Impact of the Proposed Changes to the DRG Reclassifications and 
Recalibration of Relative Weights (Column 3)

    In column 3 of Table I, we present the combined effects of the DRG 
reclassifications and recalibration, as discussed in section II. of the 
preamble to this proposed 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 2002 DRG relative 
weights (GROUPER version 19.0) to aggregate payments using the proposed 
FY 2003 DRG relative weights (GROUPER version 20.0). Overall payments 
decrease -0.2 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 changes (combined with the wage 
index changes) is budget neutral. This budget neutrality factor of 
1.001026 is applied to payments in Column 6. Because this is a combined 
DRG reclassification and recalibration and wage index budget neutrality 
factor, it is not applied to payments in this column.
    The DRG changes we are proposing would result in 0.2 percent lower 
payments to hospitals overall. This is the reason the budget neutrality 
factor is greater than 1.0. This change is largely related to the 
proposed changes we are making to DRGs 14 (proposed to be retitled, 
Intracranial Hemorrhage and Stroke with Infarction) and 15 (proposed to 
be retitled, Nonspecific Cerebrovascular and Precerebral Occlusion 
without Infarction), and new DRG 524 (Transient Ischemia). With the new 
configuration of these DRGs, over 80,000 cases that previously would 
have been assigned to DRG 14 (with a FY 2003 proposed relative weight 
of 1.2742) would now be assigned to DRG 15 (with a FY 2003 proposed 
relative weight of 0.9844).
    This change is evident most dramatically in small and rural 
hospitals. Rural hospitals with fewer than 50 beds would experience a 
0.6 percent decrease, and rural hospitals with between 50 and 99 beds 
would experience a 0.5 percent decrease. Among rural hospitals 
categorized by region, the East South Central and West South Central 
would experience a 0.6 percent decrease in payments. Among special 
rural hospital categories, SCHs and MDHs both would experience 0.6 
percent decreases.

D. Impact of Wage Index Changes (Columns 3, 4, and 5)

    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 proposed wage index for 
FY 2003 is based on data submitted for hospital cost reporting periods 
beginning on or after October 1, 1998 and before October 1, 1999. As 
with column 2, the impact of the new data on hospital payments is 
isolated in columns 3, 4 and 5 by holding the other payment parameters 
constant in the three simulations. That is, columns 3, 4, and 5 show 
the percentage changes in payments when going from a model using the FY 
2002 wage index (based on FY 1997 wage data before geographic 
reclassifications to a model using the FY 2003 pre-

[[Page 31672]]

reclassification wage index based on FY 1998 wage data).
    The wage data collected on the FY 1999 cost reports are similar to 
the data used in the calculation of the FY 2002 wage index. Also, as 
described in section III.B of this preamble, the proposed FY 2003 wage 
index is calculated by removing 100 percent of hospitals' GME and CRNA 
costs (and hours). The FY 2002 wage index was calculated by blending 60 
percent of hospitals' average hourly wages, excluding GME and CRNA 
data, with 40 percent of average hourly wages including these data.
    Column 3 shows the impacts of updating the wage data using FY 1999 
cost reports. This column maintains the same 60/40 phase-out of GME and 
CRNA costs as the FY 2002 wage index, which is the baseline for 
comparison. Among regions, the largest impact of updating the wage data 
is seen in rural Puerto Rico (a 4.9 percent decrease). Rural hospitals 
in the East South Central region experience the next largest impact, a 
1.0 percent increase. This is primarily due to a 6 percent increase in 
the rural Alabama wage index, and a little under a 3 percent increase 
in the rural Mississippi wage index. Among urban hospitals, the Middle 
Atlantic region would experience a 0.8 percent decrease, largely due to 
a 2.4 percent decrease in the New York City wage index and a 2.3 
percent decrease in the Philadelphia wage index.
    The next two columns show the impacts of removing the GME and CRNA 
data from the wage index calculation. Under the 5-year phaseout of 
these data, FY 2003 would be the fourth year of the phaseout. This 
means that, under the phaseout, the FY 2003 wage index would be 
calculated with 20 percent of the GME and CRNA data included and 80 
percent with these data removed, and FY 2004 would begin the 
calculation with 100 percent of these data removed. However, we are 
proposing to remove 100 percent of GME and CRNA costs from the FY 2003 
wage index. To demonstrate the impacts of this proposal, we first show 
the impacts of moving to a wage index with 80 percent of these data 
removed (Column 4), then show a wage index with 100 percent of these 
data removed (Column 5). As expected, the impacts in the two columns 
are similar, with some differences due to rounding. Generally, no group 
of hospitals is impacted by more than 0.1 percent by this change. Even 
among the hospital group most likely to be negatively impacted by this 
change, teaching hospitals with 100 or more residents, the net effect 
of removing 100 percent of GME and CRNA data is 0.0 percent change in 
payments.
    We note that the wage data used for the proposed wage index are 
based upon the data available as of February 22, 2001 and, therefore, 
do not reflect revision requests received and processed by the fiscal 
intermediaries after that date. To the extent these requests are 
granted by hospitals' fiscal intermediaries, these revisions will be 
reflected in the final rule. In addition, we continue to verify the 
accuracy of the data for hospitals with extraordinary changes in their 
data from the prior year.
    The following chart compares the shifts in wage index values for 
labor market areas for FY 2002 relative to FY 2003. This chart 
demonstrates the impact of the proposed changes for the FY 2003 wage 
index, including updating to FY 1999 wage data and removing 100 percent 
of GME and CRNA data. The majority of labor market areas (324) 
experience less than a 5 percent change. A total of 19 labor market 
areas experience an increase of more than 5 percent and less than 10 
percent. One area experiences an increase greater than 10 percent. A 
total of 26 areas experience decreases of more than 5 percent and less 
than 10 percent. Finally, 2 areas experience declines of 10 percent or 
more.

------------------------------------------------------------------------
                                                 Number of labor market
                                                          areas
  Percentage change in area wage index values  -------------------------
                                                  FY 2002      FY 2003
------------------------------------------------------------------------
Increase more than 10 percent.................            2            1
Increase more than 5 percent and less than 10            26           19
 percent......................................
Increase or decrease less than 5 percent......          335          320
Decrease more than 5 percent and less than 10            10           26
 percent......................................
Decrease more than 10 percent.................            1            2
------------------------------------------------------------------------

    Among urban hospitals, 24 would experience an increase of between 5 
and 10 percent and 2 more than 10 percent. A total of 53 rural 
hospitals have increases greater than 5 percent, but none greater than 
10 percent. On the negative side, 75 urban hospitals have decreases in 
their wage index values of at least 5 percent but less than 10 percent. 
Six urban hospitals have decreases in their wage index values greater 
than 10 percent. There are 19 rural hospitals with decreases in their 
wage index values greater than 5 percent or with increases of more than 
10 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.................            2            0
Increase more than 5 percent and less than 10            24           53
 percent......................................
Increase or decrease less than 5 percent......         2506         1616
Decrease more than 5 percent and less than 10            75           19
 percent......................................
Decrease more than 10 percent.................            6            0
------------------------------------------------------------------------


[[Page 31673]]

E. Combined Impact of DRG and Wage Index Changes--Including Budget 
Neutrality Adjustment (Column 6)

    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 proposed rule, we compared 
simulated aggregate payments using the FY 2002 DRG relative weights and 
wage index to simulated aggregate payments using the proposed FY 2003 
DRG relative weights and blended wage index. Based on this comparison, 
we computed a wage and recalibration budget neutrality factor of 
1.001026. 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 6. 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 2, 3, 4, and 5, plus approximately 0.1 percent 
attributable to the budget neutrality factor. In addition, 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. This 
provision is required to be budget neutral. The impact of this 
provision, which is to increase overall payments by 0.1 percent, is not 
shown in columns 2, 3, 4, and 5. It is included in the impacts shown in 
column 6. There also may be some variation of plus or minus 0.1 percent 
due to rounding.

F. Impact of MGCRB Reclassifications (Column 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 6 reflect the per case 
payment impact of moving from this baseline to a simulation 
incorporating the MGCRB decisions for FY 2003. These decisions affect 
hospitals' standardized amount and wage index area assignments.
    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 another area's 
standardized amount, wage index value, or both.
    The proposed FY 2003 wage index values incorporate all of the 
MGCRB's reclassification decisions for FY 2003. The wage index values 
also reflect any decisions made by the CMS Administrator through the 
appeals and review process for MGCRB decisions as of February 28, 2002. 
Additional changes that result from the Administrator's review of MGCRB 
decisions or a request by a hospital to withdraw its application will 
be reflected in the final rule for FY 2003.
    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 0.990536 to ensure that the effects of 
reclassification are budget neutral. (See section II.A.4.b. of the 
Addendum to this proposed rule.)
    As a group, rural hospitals benefit from geographic 
reclassification. Their payments rise 2.5 percent in column 6. Payments 
to urban hospitals decline 0.5 percent. Hospitals in other urban areas 
see a decrease in payments of 0.5 percent, while large urban hospitals 
lose 0.5 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 smallest increases among the rural census divisions are 1.5 
and 1.6 percent for West North Central and Mountain regions, 
respectively. The largest increases are in rural South Atlantic and 
West South Central regions. These regions receive increases of 3.0 and 
3.4 percent, respectively.
    Among all the hospitals that were reclassified for FY 2003 
(including hospitals that received wage index reclassification in a FY 
2001 or FY 2002 that extend for 3-years), the MGCRB changes are 
estimated to provide a 4.4 percent increase in payments. Urban 
hospitals reclassified for FY 2003 are expected to receive an increase 
of 4.0 percent, while rural reclassified hospitals are expected to 
benefit from the MGCRB changes with a 4.6 percent increase in payments. 
Overall, among hospitals that were reclassified for purposes of the 
standardized amount only, a payment increase of 0.3 percent is 
expected, while those reclassified for purposes of the wage index only 
show a 4.5 percent increase in payments. Payments to urban and rural 
hospitals that did not reclassify are expected to decrease slightly due 
to the MGCRB changes, decreasing by 0.7 for urban hospitals and 0.4 for 
rural hospitals. Those hospitals located in rural counties but deemed 
to be urban under section 1886(d)(8)(B) of the Act are expected to 
receive a decrease in payments of 1.4 percent.
    The foregoing analysis was based on MGCRB and CMS Administrator 
decisions made by February 28, 2002. As previously noted, there may be 
changes to some MGCRB decisions through the appeals, review, and 
applicant withdrawal process. The outcome of these cases will be 
reflected in the analysis presented in the final rule.

G. All Changes (Column 8)

    Column 8 compares our estimate of payments per case, incorporating 
all changes reflected in this proposed rule for FY 2003 (including 
statutory changes), to our estimate of payments per case in FY 2002. 
This column includes all of the policy changes to date, including the 
proposed new labor share shown in column 1, and the combined DRG and 
wage index changes from column 6. Because the reclassifications shown 
in column 7 do not reflect FY 2002 reclassifications, the impacts of FY 
2003 reclassifications only affect the impacts from FY 2002 to FY 2003 
if the reclassification impacts for any group of hospitals are 
different in FY 2003 compared to FY 2002.
    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 1.7 percentage point difference between the 
projected outlier payments in FY 2002 (5.1 percent of total DRG 
payments) and the current estimate of the percentage of actual outlier 
payments in FY 2002 (6.8 percent), as described in the introduction to 
this Appendix and the Addendum to this proposed rule.
    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 2003, eligible SCHs 
that rebase receive a hospital-specific rate comprised of 25 percent of 
the higher of their FY 1982 or FY 1987 hospital-specific rate or their 
Federal rate, and 75 percent of their 1996 hospital-specific rate. The 
impact of this provision is modeled in column 8 as well.

[[Page 31674]]

    Under section 1886(d)(5)(B)(ii) of the Act, the formula for IME is 
reduced beginning in FY 2003. The reduction is from approximately a 6.5 
percent increase for every 10 percent increase in the resident-to-bed 
ratio during FY 2002 to approximately a 5.5 percent increase. We 
estimate the impact of this change to be a 0.9 percent reduction in 
hospitals' overall FY 2003 payments. The impact upon teaching hospitals 
would be larger.
    Finally, the DSH adjustment increases in FY 2003 compared with FY 
2002. In accordance with section 1886(d)(5)(F)(ix) of the Act, during 
FY 2002, DSH payments that the hospital would otherwise receive were 
reduced by 3 percent. This reduction is no longer applicable beginning 
with FY 2003. The estimated impact of this change is to increase 
overall hospital payments by 0.2 percent.
    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 6 and 7, plus the other impacts that we are able to 
identify.
    The overall change in payments per case for hospitals in FY 2003 
increases by 0.4 percent. This reflects the update of 2.75 percent, the 
1.7 percent higher outlier payments in FY 2002 than projected for FY 
2003, a 0.9 percent reduction in payments for IME, and a 0.2 percent 
increase in payments due to higher DSH payments in FY 2003. Hospitals 
in urban areas experience a 0.1 percent increase in payments per case 
compared to FY 2002, although hospitals in large urban areas experience 
a 0.3 percent decline in payments, largely due to reduction in IME 
payments. The impact of the reduction in IME payments is most evident 
among teaching hospitals with 100 or more residents, who would 
experience a decrease in payments per case of 1.7 percent. Hospitals in 
rural areas, meanwhile, experience a 2.1 percent payment increase.
    Among urban census divisions, the largest payment increase was 0.9 
percent in South Atlantic, East South Central, and West North Central. 
Hospitals in urban Middle Atlantic would experience an overall decrease 
of 1.8 percent. This is primarily due to the combination of the 
negative impact on these hospitals of reducing IME and the lower 
outlier payments during FY 2003. The rural census division experiencing 
the smallest increase in payments were New England and the Middle 
Atlantic regions (1.0 and 1.6 percent, respectively). The only 
decreases by rural hospitals are in Puerto Rico, where payments appear 
to decrease by 2.8 percent, largely due to the updated wage data. In 
the Pacific, payments appear to increase by 2.7 percent. Rural East and 
West North Central regions also benefited, with 2.5 and 2.4 percent 
increases, 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 2.3 percent, 2.7 percent, 
and 2.5 percent, respectively. This outcome is primarily related to the 
fact that, for hospitals receiving payments under the hospital-specific 
methodology, there are no outlier payments. Therefore, these hospitals 
do not experience negative payment impacts from the decline in outlier 
payments from FY 2002 to FY 2003 (from 6.8 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 2003, hospitals 
overall are estimated to receive a 1.0 percent increase in payments. 
Urban hospitals reclassified for FY 2003 are anticipated to receive a 
decrease of -0.4 percent, while rural reclassified hospitals are 
expected to benefit from reclassification with a 1.8 percent increase 
in payments. Overall, among hospitals reclassified for purposes of the 
standardized amount, a payment increase of 1.6 percent is expected, 
while those hospitals reclassified for purposes of the wage index only 
show an expected 0.8 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 2.8 percent.

             Table II.--Impact Analysis of Changes for FY 2003 Operating Prospective Payment System
                                               [Payments per Case]
----------------------------------------------------------------------------------------------------------------
                                                                         Average FY    Average FY
                                                            Number of   2002 payment  2003 payment   All FY 2003
                                                           hosps.  (1)  per case \1\  per case \1\  changes  (4)
                                                                             (2)           (3)
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
    All hospitals.......................................         4,301         7,194         7,224           0.4
    Urban hospitals.....................................         2,613         7,707         7,718           0.1
    Large urban areas (populations over 1 million)......         1,511         8,269         8,245          -0.3
    Other urban areas (populations of 1 million of               1,102         6,977         7,034           0.8
     fewer).............................................
    Rural hospitals.....................................         1,688         5,108         5,213           2.1
    Bed Size (Urban):
        0-99 beds.......................................           647         5,299         5,380           1.5
        100-199 beds....................................           904         6,436         6,498           1.0
        200-299 beds....................................           528         7,391         7,425           0.5
        300-499 beds....................................           387         8,276         8,280           0.1
        500 or more beds................................           147        10,046         9,932          -1.1
    Bed Size (Rural):
        0-49 beds.......................................           819         4,204         4,313           2.6
        50-99 beds......................................           507         4,754         4,866           2.4
        100-149 beds....................................           216         5,052         5,154           2.0
        150-199 beds....................................            78         5,494         5,600           1.9
        200 or more beds................................            68         6,651         6,742           1.4
    Urban by Region:
        New England.....................................           134         8,228         8,225           0.0
        Middle Atlantic.................................           402         8,832         8,675          -1.8
        South Atlantic..................................           380         7,287         7,353           0.9
        East North Central..............................           431         7,269         7,296           0.4

[[Page 31675]]

 
        East South Central..............................           158         6,919         6,984           0.9
        West North Central..............................           180         7,330         7,399           0.9
        West South Central..............................           334         7,089         7,121           0.4
        Mountain........................................           132         7,505         7,553           0.6
        Pacific.........................................           416         9,319         9,383           0.7
        Puerto Rico.....................................            46         3,310         3,311           0.0
    Rural by Region:
        New England.....................................            40         6,227         6,290           1.0
        Middle Atlantic.................................            68         5,345         5,430           1.6
        South Atlantic..................................           239         5,221         5,319           1.9
        East North Central..............................           225         5,059         5,185           2.5
        East South Central..............................           243         4,723         4,819           2.0
        West North Central..............................           311         5,093         5,214           2.4
        West South Central..............................           294         4,547         4,627           1.8
        Mountain........................................           151         5,424         5,531           2.0
        Pacific.........................................           112         6,592         6,772           2.7
        Puerto Rico.....................................             5         2,754         2,677          -2.8
By Payment Classification:
    Urban hospitals.....................................         2,645         7,691         7,703           0.2
    Large urban areas (populations over 1 million)......         1,570         8,194         8,175          -0.2
    Other urban areas (populations of 1 million of               1,075         7,003         7,057           0.8
     fewer).............................................
    Rural areas.........................................         1,656         5,094         5,199           2.1
    Teaching Status:
        Non-teaching....................................         3,195         5,866         5,952           1.5
        Fewer than 100 Residents........................           872         7,479         7,515           0.5
        100 or more Residents...........................           234        11,431        11,239          -1.7
    Urban DSH:
        Non-DSH.........................................         1,565         6,538         6,581           0.7
        100 or more beds................................         1,354         8,299         8,299           0.0
        Less than 100 beds..............................           295         5,235         5,312           1.5
    Rural DSH:                                                     470         4,938         5,053           2.3
        Sole Community (SCH)............................
        Referral Center (RRC)...........................           156         5,906         6,001           1.6
        Other Rural:
            100 or more beds............................            78         4,509         4,598           2.0
            Less than 100 beds..........................           383         4,076         4,179           2.5
    Urban teaching and DSH:
        Both teaching and DSH...........................           758         9,185         9,134          -0.6
        Teaching and no DSH.............................           278         7,724         7,717          -0.1
        No teaching and DSH.............................           891         6,510         6,600           1.4
        No teaching and no DSH..........................           718         6,066         6,124           1.0
    Rural Hospital Types:
        Non special status hospitals....................           666         4,247         4,345           2.3
        RRC.............................................           159         5,667         5,737           1.2
        SCH.............................................           540         5,223         5,344           2.3
        Medicare-dependent hospitals (MDH)..............           216         4,032         4,142           2.7
        SCH and RRC.....................................            75         6,429         6,589           2.5
    Type of Ownership:
        Voluntary.......................................         2,473         7,322         7,349           0.4
        Proprietary.....................................           705         6,907         6,929           0.3
        Government......................................           910         6,764         6,815           0.8
        Unknown.........................................           213         7,281         7,326           0.6
    Medicare Utilization as a Percent of Inpatient Days:
        0-25............................................           319         9,820         9,755          -0.7
        25-50...........................................         1,650         8,252         8,252           0.0
        50-65...........................................         1,706         6,225         6,293           1.1
        Over 65.........................................           517         5,645         5,679           0.6
        Unknown.........................................           109         8,871         8,832          -0.4
    Hospitals Reclassified by the Medicare Geographic
     Classification Review Board:
    FY 2002 Reclassifications:
    All Reclassified Hospitals..........................           620         6,513         6,579           1.0
        Standardized Amount Only........................            29         5,918         6,016           1.6
        Wage Index Only.................................           527         6,678         6,728           0.8
        Both............................................            41         5,874         5,936           1.1
    All Nonreclassified Hospitals.......................         3,666         7,310         7,335           0.3
    All Urban Reclassified Hospitals....................           108         8,752         8,720          -0.4

[[Page 31676]]

 
    Urban Nonreclassified Hospitals.....................             1         5,484         5,569           1.6
        Standardized Amount Only........................            95         9,003         8,951          -0.6
        Wage Index Only.................................            12         5,680         5,911           4.1
        Both............................................         2,471         7,672         7,685           0.2
    All Reclassified Rural Hospitals....................           512         5,666         5,768           1.8
        Standardized Amount Only........................             1         5,408         5,605           3.7
        Wage Index Only.................................           502         5,650         5,754           1.8
        Both............................................             9         6,370         6,415           0.7
Rural Nonreclassified Hospitals.........................         1,175         4,478         4,585           2.4
Other Reclassified Hospitals (Section 1886(D)(8)(B))....            35         4,892         5,031           2.8
----------------------------------------------------------------------------------------------------------------
\1\ These payment amounts per case do not reflect any estimates of annual case-mix increase.

    Table II presents the projected impact of the proposed changes for 
FY 2003 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 2002 with the average estimated per case payments for FY 
2003, 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.

VII. Impact of Specific Proposed Policy Changes

A. Impact of Proposed Policy Changes Relating to Hospital Bed Counts

    As discussed in section V.E.3. of the preamble of this proposed 
rule, we are proposing that if a hospital's reported bed count results 
in an occupancy rate below 35 percent, the applicable bed count for 
that hospital would be the number of beds that would result in an 
occupancy rate of 35 percent.
    We have calculated an estimated impact on the Medicare program for 
FY 2003 as a result of this policy. We first identified urban hospitals 
receiving DSH with bed counts above 100, but with occupancy rates below 
35 percent. Then, we determined the amount of DSH payments made to 
these hospitals in FY 1999. Next, we simulated what these hospitals' 
DSH payments would have been had their bed counts been less than 100. 
We compared the difference between actual DSH payments using 100 or 
more beds to simulated DSH payments using fewer than 100 beds, and 
determined that the reductions in DSH payments to these hospitals, 
inflated to FY 2003 using the update to the average standardized 
amount, would be approximately $38.9 million.

B. Impact of Proposed Changes Relating to EMTALA Provisions

    In section V.J. of the preamble to this proposed rule, we discuss 
our proposed changes to our policies relating to the responsibilities 
of Medicare-participating hospitals under the patient antidumping 
statute (EMTALA) to medically screen all patients seeking emergency 
services and provide stabilizing medical treatment as necessary to 
patients whose conditions warrant it. In summary, to help promote 
consistent application of our regulations concerning EMTALA, we are 
proposing to clarify certain policies in areas where issues have arisen 
and at the same time address concerns about EMTALA raised by the 
Secretary's Regulatory Reform Task Force, including the following:
     We are proposing to change the requirements relating to 
emergency patients presenting at those off-campus outpatient clinics 
that do not routinely provide emergency services. We believe these 
changes would enhance the quality and promptness of emergency care by 
permitting individuals to be referred to appropriately equipped 
emergency facilities close to such clinics.
     We are proposing to clarify when EMTALA applies to both 
inpatients and outpatients. We believe these clarifications would 
enhance overall patient access to emergency services by helping to 
relieve administrative burdens on frequently overcrowded emergency 
departments.
     We are proposing to clarify the circumstances in which 
physicians, particularly specialty physicians, must serve on hospital 
medical staff ``on-call'' lists. We expect these clarifications would 
help improve access to physician services for all hospital patients by 
permitting hospitals local flexibility to determine how best to 
maximize their available physician resources. We are currently aware of 
reports of physicians, particularly specialty physicians, severing 
their relationships with hospitals, especially when those physicians 
belong to more than one hospital medical staff. Physician attrition 
from these medical staffs could result in hospitals having no specialty 
physician service coverage for their patients. Our proposed 
clarification of the on-call list requirement would permit hospitals to 
continue to attract physicians to serve on their medical staffs and 
thereby continue to provide services to emergency room patients.
     We are proposing to clarify the responsibilities of 
hospital-owned ambulances so that these ambulances can be more fully 
integrated with citywide and local community EMS procedures for 
responding to medical emergencies and thus use these resources more 
efficiently for the benefit of these communities.
    We believe it would be difficult to quantify the impact of these 
changes and are soliciting comments on these issues.

C. Impact of Proposed Policy Changes Relating to Provider-Based Entity

    In section V.K. of the preamble of this proposed rule, we discuss 
our proposed Medicare payment policy changes relating to determinations 
of provider-based status for entities of main providers. These changes 
are intended to focus mainly on issues raised by the hospital industry 
surrounding the provider-based regulations and to allow for a orderly 
and uniform implementation strategy once the

[[Page 31677]]

grandfathering provision for these entities expires on September 30, 
2002.
    We believe it would be difficult to quantify the impact of these 
changes and are soliciting comments on these issues.

VIII. Impact of Proposed Policies Affecting Rural Hospitals

A. Raising the Threshold To Qualify for the CRNA Pass-Through Payments

    In section V. of the preamble of this proposed rule, we are 
proposing to raise the maximum number of surgical procedures (including 
inpatient and outpatient procedures) requiring anesthesia services that 
a rural hospital may perform to qualify for pass-through payments for 
the costs of CRNAs to 800 from 500. Currently, we have identified 622 
hospitals that qualify under this provision.
    To measure the impact of this provision, we determined that 
approximately half of the hospitals that would appear to be eligible 
based on the current number of procedures appear to receive this 
adjustment. In order to be eligible, hospitals must employ the CRNA and 
the CRNA must agree not to bill for services under Part B. We estimate 
approximately 90 rural hospitals would qualify under the increased 
maximum volume threshold. If one-half of these hospitals then met the 
other criteria, 45 additional hospitals would be eligible for these 
pass-through payments under this proposed change.

B. Removal of Requirement for CAHs To Use State Resident Assessment 
Instrument

    In section VII. of the preamble of this proposed rule, we are 
proposing to eliminate the requirement that CAHs use the State resident 
assessment instrument (RAI) to conduct patient assessments. There are 
approximately 600 CAHs. The overwhelming majority of CAHs, 95 percent, 
provide SNF level care. The elimination of the requirement to use the 
State RAI would greatly reduce the burden on CAHs because facilities 
would no longer be required to complete an RAI document for each SNF 
patient (which would involve approximately 12,000 admissions based on 
the most recent claims data). Facilities would have the flexibility to 
document the assessment data in the medical record in a manner 
appropriate for their facility. The elimination of the requirement for 
use of the State RAI would reduce the amount of time required to 
perform patient assessments and allow more time for direct patient 
care.

IX. Impact of Proposed Changes in the Capital Prospective Payment 
System

A. General Considerations

    Fiscal year 2001 was the last year of the 10-year transition period 
established to phase in the prospective payment system for hospital 
capital-related costs. During the transition period, hospitals were 
paid under one of two payment methodologies: fully prospective or hold 
harmless. Under the fully prospective methodology, hospitals were paid 
a blend of the Federal rate and their hospital-specific rate (see 
Sec. 412.340). Under the hold-harmless methodology, unless a hospital 
elected payment based on 100 percent of the Federal rate, hospitals 
were paid 85 percent of reasonable costs for old capital costs (100 
percent for SCHs) plus an amount for new capital costs based on a 
proportion of the Federal rate (see Sec. 412.344). As we state in 
section VI.A. of the preamble of this proposed rule, the end of the 10-
year transition period ending with hospital cost reporting periods 
beginning on or after October 1, 2001 (FY 2002), capital prospective 
payment system payments for most hospitals are based solely on the 
Federal rate in FY 2003. Therefore, we no longer include information on 
obligated capital costs or projections of old capital costs and new 
capital costs, which were factors needed to calculate payments during 
the transition period, for our impact analysis.
    In accordance with section Sec. 412.312, the basic methodology for 
determining a capital prospective payment system payment is:

(Standard Federal Rate)  x  (DRG weight)  x  (Geographic Adjustment 
Factor(GAF))  x  (Large Urban Add-on, if applicable)  x  (COLA 
adjustment for hospitals located in Alaska and Hawaii)  x  (1 + 
Disproportionate Share (DSH) Adjustment Factor + Indirect Medical 
Education (IME) Adjustment Factor, if applicable).

    In addition, hospitals may also receive outlier payments for those 
cases that qualify under the proposed threshold established for each 
fiscal year.
    The data used in developing the impact analysis presented below are 
taken from the December 2001 update of the FY 2001 MedPAR file and the 
December 2001 update of the Provider Specific File that is used for 
payment purposes. Although the analyses of the changes to the capital 
prospective payment system do not incorporate cost data, we used the 
December 2001 update of the most recently available hospital cost 
report data (FY 1999) to categorize hospitals. Our analysis has several 
qualifications. First, we do not make adjustments for behavioral 
changes that hospitals may adopt in response to policy changes. Second, 
due to the interdependent nature of the prospective payment system, it 
is very difficult to precisely quantify the impact associated with each 
proposed change. Third, we draw upon various sources for the data used 
to categorize hospitals in the tables. In some cases (for instance, 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. However, for individual hospitals, 
some miscategorizations are possible.
    Using cases from the December 2001 update of the FY 2001 MedPAR 
file, we simulated payments under the capital prospective payment 
system for FY 2002 and FY 2003 for a comparison of total payments per 
case. Any short-term, acute care hospitals not paid under the general 
hospital inpatient prospective payment systems (Indian Health Service 
Hospitals and hospitals in Maryland) are excluded from the simulations.
    As we explain in section III.A.4. of the Addendum of this proposed 
rule, payments will no longer be made under the regular exceptions 
provision under Secs. 412.348(b) through (e). Therefore, we are no 
longer using the actuarial capital cost model (described in Appendix B 
of August 1, 2001 final rule (66 FR 40099)). We modeled payments for 
each hospital by multiplying the Federal rate by the GAF and the 
hospital's case-mix. We then added estimated payments for indirect 
medical education, disproportionate share, large urban add-on, and 
outliers, if applicable. For purposes of this impact analysis, the 
model includes the following assumptions:
     We estimate that the Medicare case-mix index will increase 
by 0.99800 percent in FY 2002 and will increase by 1.01505 percent in 
FY 2003.
     We estimate that the Medicare discharges will be 
13,398,000 in FY 2002 and 13,658,000 in FY 2003 for a 1.9 percent 
increase from FY 2002 to FY 2003.
     The Federal capital rate was 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 proposed FY 2003 update is 1.1 
percent (see section III.A.1.a. of the Addendum to this proposed rule).

[[Page 31678]]

     In addition to the proposed FY 2003 update factor, the 
proposed FY 2003 Federal rate was calculated based on a proposed GAF/
DRG budget neutrality factor of 1.0224, a proposed outlier adjustment 
factor of 0.9460, a proposed exceptions adjustment factor of 0.9960, 
and a proposed special adjustment for FY 2003 of 1.0255 (see section 
III.A. of the Addendum of this proposed rule).
2. Results
    In the past, in this impact section we presented the redistributive 
effects that were expected to occur between ``hold-harmless'' hospitals 
and ``fully prospective'' hospitals and a cross-sectional summary of 
hospital groupings by the capital prospective payment system transition 
period payment methodology. We are no longer including this information 
since all hospitals (except new hospitals under Sec. 412.324(b) and 
under proposed Sec. 412.32(c)(2)) are paid 100 percent of the Federal 
rate in FY 2003.
    We used the actuarial model described above to estimate the 
potential impact of our proposed changes for FY 2003 on total capital 
payments per case, using a universe of 4,300 hospitals. As described 
above, the individual hospital payment parameters are taken from the 
best available data, including the December 2001 update of the MedPAR 
file, the December 2001 update to the Provider-Specific File, and the 
most recent cost report data. In Table III, we present a comparison of 
total payments per case for FY 2002 compared to FY 2003 based on 
proposed FY 2003 payment policies. Column 3 shows estimates of payments 
per case under our model for FY 2002. Column 4 shows estimates of 
payments per case under our model for FY 2003. Column 5 shows the total 
percentage change in payments from FY 2002 to FY 2003. The change 
represented in Column 5 includes the 1.1 percent increase in the 
Federal rate, a 1.01505 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, as well as changes in special exception 
payments. The comparisons are provided by: (1) Geographic location; (2) 
region; and (3) payment classification.
    The simulation results show that, on average, capital payments per 
case can be expected to increase 3.7 percent in FY 2003. 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 (3.5 percent and 5.1 percent, respectively). 
This difference is due to a projection that urban hospitals will 
experience a larger decrease in outlier payments from FY 2002 to FY 
2003 compared to rural hospitals.
    All regions are estimated to receive an increase in total capital 
payments per case, partly due to the elimination of the 2.1 percent 
reduction to the Federal rate for FY 2003 (see section VI.D. of the 
preamble of this proposed rule). Changes by region vary from a minimum 
increase of 2.1 percent (Middle Atlantic urban region) to a maximum 
increase of 5.7 percent (West North Central rural region). Hospitals 
located in Puerto Rico are expected to experience an increase in total 
capital payments per case of 4.3 percent.
    By type of ownership, government hospitals are projected to have 
the largest rate of increase of total payment changes (4.4 percent). 
Similarly, payments to voluntary hospitals will increase 3.9 percent, 
while payments to proprietary hospitals will increase 2.0 percent.
    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. 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 
2003 compared to the effects of reclassification for FY 2002, we show 
the average payment percentage increase for hospitals reclassified in 
each fiscal year and in total. For FY 2003 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 2003 as a whole are projected to 
experience a 4.2 percent increase in payments. Payments to 
nonreclassified hospitals will increase slightly less (3.6 percent) 
than reclassified hospitals, overall. Hospitals reclassified during 
both FY 2002 and FY 2003 are projected to receive an increase in 
payments of 3.9 percent. Hospitals reclassified during FY 2003 only are 
projected to receive an increase in payments of 9.0 percent. This 
increase is primarily due to changes in the GAF (wage index).

                                Table III.--Comparison of Total Payments Per Case
                                 [FY 2002 Payments Compared To FY 2003 Payments]
----------------------------------------------------------------------------------------------------------------
                                                                            Average FY  Average  FY
                                                               Number of       2002         2003
                                                               hospitals    payments/    payments/      Change
                                                                               case         case
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
    All hospitals...........................................        4,300          667          692          3.7
    Large urban areas (populations over 1 million)..........        1,511          773          798          3.1
    Other urban areas (populations of 1 million of fewer)...        1,102          652          678          4.0
    Rural areas.............................................        1,687          448          471          5.1
    Urban hospitals.........................................        2,613          721          746          3.5
        0-99 beds...........................................          647          511          533          4.3
        100-199 beds........................................          904          611          634          3.7
        200-299 beds........................................          528          692          717          3.6
        300-499 beds........................................          387          762          790          3.7
        500 or more beds....................................          147          935          961          2.8
    Rural hospitals.........................................        1,687          448          471          5.1
        0-49 beds...........................................          818          370          393          6.0

[[Page 31679]]

 
        50-99 beds..........................................          507          412          435          5.6
        100-149 beds........................................          216          454          477          5.1
        150-199 beds........................................           78          493          517          4.9
        200 or more beds....................................           68          566          589          4.1
By Region:
    Urban by Region.........................................        2,613          721          746          3.5
        New England.........................................          134          771          804          4.3
        Middle Atlantic.....................................          402          817          834          2.1
        South Atlantic......................................          380          690          716          3.7
        East North Central..................................          431          687          718          4.5
        East South Central..................................          158          649          675          4.0
        West North Central..................................          180          703          735          4.6
        West South Central..................................          334          666          685          2.9
        Mountain............................................          132          695          724          4.2
        Pacific.............................................          416          841          866          2.9
        Puerto Rico.........................................           46          305          319          4.3
    Rural by Region.........................................        1,687          448          471          5.1
        New England.........................................           40          549          575          4.6
        Middle Atlantic.....................................           68          472          497          5.4
        South Atlantic......................................          239          467          489          4.8
        East North Central..................................          225          456          481          5.5
        East South Central..................................          243          414          435          5.0
        West North Central..................................          311          440          465          5.7
        West South Central..................................          294          403          423          5.0
        Mountain............................................          150          460          483          5.0
        Pacific.............................................          112          528          557          5.5
By Payment Classification:
    All hospitals...........................................        4,300          667          692          3.7
    Large urban areas (populations over 1 million)..........        1,570          767          791          3.2
    Other urban areas (populations of 1 million of fewer)...        1,075          654          680          4.0
    Rural areas.............................................        1,655          447          469          5.1
    Teaching Status:
        Non-teaching........................................        3,194          545          568          4.2
        Fewer than 100 Residents............................          872          699          726          3.8
        100 or more Residents...............................          234        1,041        1,069          2.7
        Urban DSH:
            100 or more beds................................        1,354          759          784          3.3
            Less than 100 beds..............................          295          492          512          4.2
        Rural DSH:
            Sole Community (SCH/EACH).......................          469          392          414          5.6
            Referral Center (RRC/EACH)......................          156          518          540          4.3
            Other Rural:
                100 or more beds............................           78          418          439          5.0
                Less than 100 beds..........................          383          378          400          5.8
    Urban teaching and DSH:
        Both teaching and DSH...............................          758          838          864          3.1
        Teaching and no DSH.................................          278          746          776          4.0
        No teaching and DSH.................................          891          600          623          3.8
        No teaching and no DSH..............................          718          600          623          3.8
    Rural Hospital Types:
        Non special status hospitals........................          666          398          420          5.5
        RRC/EACH............................................          159          526          548          4.2
        SCH/EACH............................................          539          415          438          5.5
        Medicare-dependent hospitals (MDH)..................          216          368          391          6.3
        SCH, RRC and EACH...................................           75          503          530          5.3
Hospitals Reclassified by the Medicare Geographic
 Classification Review Board:
    Reclassification Status During FY2002 and FY2003:
        Reclassified During Both FY2002 and FY2003..........          567          588          611          3.9
            Reclassified During FY2003 Only.................           53          516          563          9.0
            Reclassified During FY2002 Only.................           77          623          651          4.4
        FY2003 Reclassifications:
            All Reclassified Hospitals......................          620          583          607          4.2
            All Nonreclassified Hospitals...................        3,645          683          708          3.6
            All Urban Reclassified Hospitals................          108          799          826          3.4
            Urban Nonreclassified Hospitals.................        2,471          718          743          3.5
            All Reclassified Rural Hospitals................          512          500          524          4.7
            Rural Nonreclassified Hospitals.................        1,174          389          411          5.7
        Other Reclassified Hospitals (Section 1886(D)(8)(B))           35          454          484          6.4

[[Page 31680]]

 
    Type of Ownership:
        Voluntary...........................................        2,473          680          707          3.9
        Proprietary.........................................          705          658          671          2.0
        Government..........................................          909          600          627          4.4
    Medicare Utilization as a Percent of Inpatient Days:
        0-25................................................          318          859          885          3.0
        25-50...............................................        1,650          767          792          3.3
        50-65...............................................        1,706          582          606          4.2
        Over 65.............................................          517          525          547          4.3
----------------------------------------------------------------------------------------------------------------

BILLING CODE 4120-01-P

Appendix B--Report to Congress

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BILLING CODE 4120-01-C

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

I. Background

    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 inpatient hospital 
services 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. 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, this 
Appendix provides the recommendations of appropriate update factors and 
the analysis underlying our recommendations. We also respond to 
MedPAC's recommendations concerning the update factors.
    Section 1886(b)(3)(B)(i)(XVIII) of the Act, as amended by Section 
301 Public Law 106-554, sets the FY 2003 percentage increase in the 
operating cost standardized amounts equal to the rate of increase in 
the hospital market basket minus 0.55 percent for prospective payment 
hospitals in all areas. Section 1886(b)(3)(B)(iv) of the Act sets the 
FY 2003 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 acute care hospital inpatient 
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 2003 percentage increase in the rate-of-increase limits 
for hospitals and hospital units excluded from the acute care hospital 
inpatient prospective payment system is the market basket percentage 
increase.
    In accordance with section 1886(d)(3)(A) of the Act, we are 
proposing to update the standardized amounts, the hospital-specific 
rates, and the rate-of-increase limits for hospitals and hospital units 
excluded from the prospective payment system as provided in section 
1886(b)(3)(B) of the Act. Based on the proposed revised and rebased 
first quarter 2002 forecast of the FY 2003 market basket increase of 
3.3 percent for hospitals subject to the acute care hospital inpatient 
prospective payment system, the proposed update to the standardized 
amounts is 2.75 percent (that is, the market basket rate of increase 
minus 0.55 percent percentage points) for hospitals in both large urban 
and other areas. The proposed update to the hospital-specific rate 
applicable to SCHs and MDHs is also 2.75 percent.

[[Page 31686]]

    Consistent with section 1886(e)(3) of the Act, we are proposing a 
recommendation for updating payments for hospitals and distinct-part 
hospital units that are excluded from the hospital inpatient 
prospective payment system. Facilities excluded from the hospital 
inpatient prospective payment system include psychiatric hospitals and 
units, rehabilitation hospitals and units, long-term care hospitals, 
cancer hospitals, and children's hospitals.
    In the past, hospitals and hospital units excluded from the 
hospital inpatient prospective payment system have been paid based on 
their reasonable costs subject to limits as established by the Tax 
Equity and Fiscal Responsibility Act of 1982 (TEFRA). Hospitals that 
continue to be paid based on their reasonable costs are subject to 
TEFRA limits for FY 2003. For these hospitals, the proposed update is 
the percentage increase in the excluded hospital market basket 
(currently estimated at 3.4 percent).
    Inpatient rehabilitation facilities (IRFs) are paid under the IRF 
prospective payment system for cost reporting periods beginning on or 
after January 1, 2002. For cost reporting periods beginning during FY 
2003, the Federal prospective payment for IRFs is based on 100 percent 
of the adjusted Federal IRF prospective payment amount, updated 
annually (see the August 7, 2001 final rule (66 FR 41316)).
    Effective for cost reporting periods beginning during FY 2003, we 
are proposing that long-term care hospitals would be paid under a 
prospective payment system under which long-term care hospitals receive 
payment based on a 5-year transition period (see the March 22, 2002 
proposed rule (67 FR 13416)). We are also proposing that long-term care 
hospitals may elect to be paid on 100 percent of the Federal 
prospective rate at the beginning of any of its cost reporting periods 
during the 5-year transition period. For purposes of the update factor, 
the portion of the proposed prospective payment system transition blend 
payment based on reasonable costs for inpatient operating services 
would be determined by updating the long-term care hospital's TEFRA 
limit by the current estimate of the excluded hospital market basket 
(or 3.4 percent).
    In its March 1, 2002 Report to the Congress, MedPAC recommended 
that the base payment rates for Medicare covered services under the 
hospital inpatient prospective payment system be increased by the 
market basket percentage increase minus 0.55 percent for hospitals 
located in large urban areas, and by the full market basket percentage 
increase for hospitals located in all other areas (page 66). MedPAC did 
not make a separate recommendation for the hospital-specific rate 
applicable to SCHs and MDHs. MedPAC also presented a new approach for 
updating the hospital inpatient prospective system payment rates, which 
assesses the adequacy of current payments and accounts for the increase 
in efficient providers' costs in the upcoming year. While this approach 
is not fundamentally different from what MedPAC has done in the past, 
it no longer produces a detailed update framework for direct comparison 
with the Secretary's framework. We discuss MedPAC's recommendations 
concerning the update factors and our responses to these 
recommendations in section III. of this Appendix C. Below we describe 
the basis of our FY 2003 update recommendation (as shown in Table 1).

II. Secretary's Recommendations

    Under section 1886(e)(4) of the Act, we are recommending that an 
appropriate update factor for the standardized amounts is the market 
basket percentage increase minus 0.55 percentage points for hospitals 
located in large urban and other areas. We are also recommending an 
update factor of the market basket percentage increase minus 0.55 
percentage points for the hospital-specific rate for SCHs and MDHs. We 
believe these recommended update factors for FY 2003 would ensure that 
Medicare acts as a prudent purchaser and provide incentives to 
hospitals for increased efficiency, thereby contributing to the 
solvency of the Medicare Part A Trust Fund.
    Rehabilitation hospitals and units are now paid under the IRF 
prospective payment system. For cost reporting periods beginning on or 
after October 1, 2002, the IRF prospective payment is based on 100 
percent of the adjusted Federal IRF prospective payment system amount 
updated annually.
    Effective for cost reporting periods beginning during FY 2003, we 
have proposed that long-term care hospitals be paid under a prospective 
payment system (67 FR 13416). For purposes of the update factor, the 
portion of the proposed prospective payment system transition blend 
payment based on reasonable costs for inpatient operating services for 
FY 2003 would be determined by updating the TEFRA target amount for 
long-term care hospitals by the most recent available estimate of the 
increase in the excluded hospital operating market basket (or 3.4 
percent).
    We recommend that the remaining excluded hospitals and units (which 
are excluded from the acute care hospital inpatient prospective payment 
system and will continue to be paid on a reasonable cost basis in FY 
2003) receive an update of 3.4 percent. The update for excluded 
hospitals and hospital units is equal to the most recent available 
estimate of the increase in the excluded hospital operating market 
basket. Based on the proposed revised and rebased first quarter 2002 
forecast for FY 2003, the proposed market basket rate of increase for 
excluded hospitals and hospital units is 3.4 percent.
    As required by section 1886(e)(4) of the Act, we have taken into 
consideration the recommendations of MedPAC in setting these 
recommended update factors. Our responses to the MedPAC recommendations 
concerning the update factors are discussed below. Consistent with 
current law, we are proposing an update recommendation of the market 
basket percentage increase minus 0.55 percentage points for the 
hospital inpatient prospective payment system operating cost 
standardized amounts for FY 2003. This proposed update recommendation 
is supported by the following analyses that measure changes in hospital 
productivity, scientific and technological advances, practice pattern 
changes, changes in case-mix, the effect of reclassification on 
recalibration, and forecast error correction.

A. Productivity

    Service level labor productivity is defined as the ratio of total 
service output to full-time equivalent employees (FTEs). While we 
recognize that productivity is a function of many variables (for 
example, labor, nonlabor material, and capital inputs), we use the 
portion of productivity attributed to direct labor since this update 
framework applies to operating payment. To recognize that we are 
apportioning the short-run output changes to the labor input and not 
considering the nonlabor inputs, we weight our productivity measure by 
the share of direct labor services in the market basket to determine 
the expected effect on cost per case.
    Our recommendation for the service productivity component is based 
on historical trends in productivity and total output for both the 
hospital industry and the general economy, and projected levels of 
future hospital service output. MedPAC's predecessor, the Prospective 
Payment Assessment Commission (ProPAC), estimated cumulative service 
productivity growth to be 4.9 percent from 1985 through

[[Page 31687]]

1989 or 1.2 percent annually. At the same time, ProPAC estimated total 
output growth at 3.4 percent annually, implying a ratio of service 
productivity growth to output growth of 0.35.
    Absent a productivity measure specific to Medicare patients, we 
examined productivity (output per hour) and output (gross domestic 
product) for the economy. Depending on the exact time period, annual 
changes in productivity range from 0.3 to 0.35 percent of the change in 
output (that is, a 1.0 percent increase in output would be correlated 
with a 0.3 to 0.35 percent change in output per hour).
    Under our framework, the recommended update is based in part on 
expected productivity--that is, projected service output during the 
year, multiplied by the historical ratio of service productivity to 
total service output, multiplied by the share of direct labor in total 
operating inputs, as calculated in the hospital market basket. This 
method estimates an expected productivity improvement in the same 
proportion to expected total service growth that has occurred in the 
past and assumes that, at a minimum, growth in FTEs changes 
proportionally to the growth in total service output. Thus, the 
recommendation allows for unit productivity to be smaller than the 
historical averages in years that output growth is relatively low and 
larger in years that output growth is higher than the historical 
averages. Based on the above estimates from both the hospital industry 
and the economy, we have chosen to employ the range of ratios of 
productivity change to output change of 0.30 to 0.35.
    The expected change in total hospital service output is the product 
of projected growth in total admissions (adjusted for outpatient 
usage), projected real case-mix growth, expected quality-enhancing 
intensity growth, and net of expected decline in intensity due to 
reduction of cost-ineffective practice. Case-mix growth and intensity 
numbers for Medicare are used as proxies for those of the total 
hospital, since case-mix increases (used in the intensity measure as 
well) are unavailable for non-Medicare patients. Thus, expected FY 2003 
hospital output growth is simply the sum of the expected change in 
intensity (1.0 percent), projected admissions change (1.9 percent), and 
projected real case-mix growth (1.0 percent), or 3.9 percent. The share 
of direct labor services in the market basket (consisting of wages, 
salaries, and employee benefits) is 61.7 percent (based on the proposed 
revised and rebased hospital market basket discussed in section IV. of 
the preamble of this proposed rule).
    Multiplying the expected change in total hospital service output 
(3.9 percent) by the ratio of historical service productivity change to 
total service growth of 0.30 to 0.35 and by the direct labor share 
percentage 61.6, provides our productivity standard of 0.9 to 0.7 
percent. Because productivity gains hold down the rate of increase in 
hospitals' costs, this factor is applied as a negative offset to the 
market basket increase.

B. Intensity

    We base our intensity standard on the combined effect of three 
separate factors: changes in the use of quality enhancing services, 
changes in the use of services due to shifts in within-DRG severity, 
and changes in the use of services due to reductions of cost-
ineffective practices. For FY 2003, we recommend an adjustment of 1.0 
percent. The basis of this recommendation is discussed below.
    Following methods developed by CMS' Office of the Actuary for 
deriving hospital output estimates from total hospital charges, we have 
developed Medicare-specific intensity measures based on a 5-year 
average using FYs 1997 through 2001 MedPAR billing data. Case-mix 
constant intensity is calculated as the change in total Medicare 
charges per discharge adjusted for changes in the average charge per 
unit of service as measured by the Consumer Price Index (CPI) for 
hospital and related services and changes in real case-mix.\1\ The 5-
year average percentage change in charge per discharge was 6.3 percent, 
the 5-year average annual change in the CPI for hospital and related 
services was 4.5 percent, and the 5-year average annual change in case-
mix was -0.3 percent. Dividing the change in charge per discharge by 
the product of the real case-mix index change and the CPI for hospital 
and related services yields a 5-year average annual change in intensity 
of 2.0 percent. To account for the proportions of the overall annual 
intensity increases due to ineffective practice patterns and to the 
combination of quality-enhancing new technologies and within-DRG 
complexity, we assume that one-half of the annual increase is due to 
each of these factors. Our recommended adjustment excludes the 
estimated amount of the overall intensity increase due to ineffective 
practice patterns. Thus, we are recommending an intensity adjustment 
for FY 2003 of 1.0 percent.
---------------------------------------------------------------------------

    \1\ In the past, we have considered the upper bound of real case 
mix to be from 1.0 to 1.4 percent annually, with any increase beyond 
this bound assumed to be due to changes in coding practices. Because 
none of the annual changes in observed case mix change during the 5-
year period from FY 1997 through FY 2001 exceeded 1.0 percent, it is 
all assumed to be real case mix change.
---------------------------------------------------------------------------

C. Change in Case-Mix

    Our analysis takes into account projected changes in case-mix, 
adjusted for changes attributable to improved coding practices. For our 
FY 2003 update recommendation, we are projecting a 1.0 percent increase 
in the case-mix index. 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 greater resource requirements. 
We do not believe changes in coding behavior will impact the overall 
case-mix in FY 2003. As such, for FY 2003, we estimate that real case-
mix is equal to projected change in case-mix. Thus, we are recommending 
a 0.0 percent adjustment for case-mix.

D. Effect of FY 2001 DRG Reclassification and Recalibration

    We estimate that DRG reclassification and recalibration for FY 2001 
resulted in a 0.3 percent change in the case-mix index when compared 
with the case-mix index that would have resulted if we had not made the 
reclassification and recalibration changes to the GROUPER. Therefore, 
we are recommending a -0.3 percent adjustment for the effect of FY 2001 
DRG reclassification and recalibration.

E. Forecast Error Correction

    We make a forecast error correction if the actual market basket 
changes differ from the forecasted market basket by 0.25 percentage 
points or more. There is a 2-year lag between the forecast and the 
measurement of forecast error. The estimated market basket percentage 
increase used to update the FY 2001 payment rates was 3.4 percent. Our 
most recent data indicates the actual FY 2001 increase was 4.1 percent. 
The resulting forecast error in the FY 2001 market basket rate of 
increase is 0.7 percentage points. This forecast error is a result of 
prices for wages, benefits, and utilities increasing more rapidly than 
expected. The effects of a labor shortage within the health services 
industry caused hospitals to increase wages greater than initially 
projected. Increases in actual benefits were faster than projected due 
to a greater than expected increase in health insurance premiums. 
Finally, market conditions for natural gas and electricity caused

[[Page 31688]]

prices for those products to increase more rapidly than expected.
    The following is a summary of the update range supported by our 
analyses:

                   HHS's FY 2003 Update Recommendation
------------------------------------------------------------------------
            Market basket                             MB
------------------------------------------------------------------------
Policy Adjustment Factors:
    Productivity....................  -0.9 to -0.7
    Intensity.......................  1.0
        Subtotal....................  0.1 to 0.3
Case-Mix Adjustment Factors:
    Projected Case-Mix Change.......  1.0
    Real Across DRG Change..........  -1.0
        Subtotal....................  0.0
Effect of FY 2001 DRG                 -0.3
 Reclassification and Recalibration.
Forecast Error Correction...........  0.7
Total Recommendation Update.........  MB + 0.5 to MB + 0.7
------------------------------------------------------------------------

    While the above analysis would suggest an update between market 
basket plus 0.5 percentage points and the market basket plus 0.7 
percentage points, the Secretary is recommending, consistent with 
current law, an update of the market basket percentage increase minus 
0.55 percentage points (or 2.75 percent) for hospitals in all areas.
    We believe that a 2.75 percent update factor for FY 2003 will 
appropriately reflect current trends in health care delivery, including 
the recent decreases in the use of hospital inpatient services and the 
corresponding increase in the use of hospital outpatient and postacute 
care services. Also, consistent with current law, we are recommending 
that the hospital-specific rates applicable to SCHs and MDHs be 
increased by the same update, 2.75 percentage points.
    Since the inception of the acute care hospital inpatient 
prospective payment system, hospitals have received a full market 
basket update only once, in FY 2001. The stabilization of overall 
hospital margins in recent years suggests that the restrictions on 
market basket increases have not resulted in inadequate hospital 
payments. Modest limits below full market basket updates could be 
linked to continued careful review of Medicare hospital margin data to 
ensure that margins do not worsen among certain hospital types with 
negative and declining Medicare margins.

III. MedPAC Recommendations for Assessing Payment Adequacy and 
Updating Payments in Traditional Medicare

    In its FY 2002 Report to Congress, MedPAC developed a new approach 
for updating fee-for-service payments that breaks the process into two 
basic parts: assessing the adequacy of current payments; and accounting 
for the increase in efficient providers' costs in the coming year. 
MedPAC points out this new approach ``is not fundamentally different 
from what the Commission has done in the past, but we expect 
formalizing the two parts of our process will lead to greater emphasis 
on the broad question of whether the amount of money in the system 
currently is right and less emphasis on the role of specific cost-
influencing factors'' (page 39).
    In assessing payment adequacy, MedPAC reviews the relationship 
between costs and payments (conventionally expressed as a margin). On 
the payment side, MedPAC applied the annual payment updates specified 
in law through FY 2002 and then modeled the effects of other policy 
changes that have affected the level of payments. On the cost side, 
MedPAC estimated the increases in costs per unit of output over the 
same period using the change in cost per adjusted admission in the 
American Hospital Association's annual survey of hospitals for FY 2000, 
and the CMS projected increase in the FYs 2001 and 2002 market baskets 
(page 58). MedPAC estimated that the inpatient Medicare margin would be 
10.8 percent in FY 2002 (with FY 2003 payment rules). This amount is 
down slightly from MedPAC's estimate of 11.9 percent in FY 1999. In 
addition to the inpatient Medicare margin, MedPAC measured the overall 
Medicare margin, incorporating almost all Medicare-related payments and 
costs to hospitals. This overall Medicare margin was estimated to be 
3.8 percent. The report notes that ``the Commission does not plan to 
specify a 'standard margin,' although we will take the need for a small 
positive margin into account as we assess the adequacy of various fee-
for-service payments'' (page 43).
    In addition to considering the relationship between estimated 
payments and costs, MedPAC also considered the following three factors 
to assess whether current payments are adequate (page 43):
     Changes in access to or quality of care;
     Changes in the volume of services or number of providers; 
and
     Changes in providers access to capital.
    MedPAC found no evidence that the hospital cost base is 
inappropriate and concluded that Medicare payment is adequate and no 
payment adequacy adjustment is needed for FY 2003.
    MedPAC recommends gradually eliminating the differential in the 
standardized amounts for hospitals in large urban and other areas. 
MedPAC's data on margins and its analysis of costs suggest that a 
different standardized amount (the large urban standardized amount is 
1.6 percent higher than the amount for other areas) is unwarranted. 
MedPAC estimates the FY 2002 Medicare inpatient margins will range from 
5 percent for rural hospitals to 14 percent for hospitals in large 
urban areas. Because much of this difference is due to the greater 
proportion of IME and DSH payments going to hospitals in large urban 
areas, MedPAC removed DSH payments and the portion of the IME payment 
above the measured cost relationship between IME and hospitals' costs, 
and found that hospitals in large urban areas still have Medicare 
margins that are about 4 percentage points higher than other urban and 
rural hospitals (page 64).
    MedPAC believes that ``(e)liminating the differential would improve 
payment equity across geographic areas and also help to simplify the 
payment system'' (page 63). For example, eliminating the standardized 
amount differential would also eliminate the need for hospitals to 
reclassify for a higher standardized amount through the MGCRB. 
Therefore, MedPAC recommends holding the update for hospitals in large 
urban areas to the legislated level of the market

[[Page 31689]]

basket percentage increase minus 0.55 percent for FY 2003, while 
updating the other areas standardized amount by the full market basket 
percentage increase.
    MedPAC accounts for providers' cost changes in the coming payment 
year primarily through a forecast of input price inflation, which 
estimates how much providers' costs would rise in the coming year if 
the quality and mix of inputs they use to furnish care and the types of 
patients they treat remain constant. MedPAC relies on CMS' market 
basket estimate to forecast input price inflation, but considers other 
factors that may affect providers' costs. These other factors are 
scientific and technological advances, changes in DRG case-mix 
complexity, site-of-service substitution, and other one-time factors.
    In the past, MedPAC recommended specific adjustments to its update 
recommendation for each of these factors. In its March 2002 Report to 
Congress, MedPAC did not provide specific estimates for these factors, 
but stated ``(a)fter considering all factors that might potentially 
affect the rate of growth in efficient providers' costs, we conclude 
that the appropriate adjustment for cost growth in fiscal year 2003 is 
the forecasted increase in the market basket, or 2.9 percent'' (page 
66). This market basket forecast was based on the December 2001 market 
basket estimated by CMS' Office of the Actuary, and does not reflect 
the proposed revisions and rebasing discussed in section IV. of the 
preamble of this proposed rule.
    MedPAC's second recommendation related to updating payments under 
the hospital inpatient prospective payment system is that the Congress 
should increase the base rate for inpatient services covered by 
Medicare's prospective payment system in FY 2003 by the market basket 
percentage increase minus 0.55 percent for hospitals in large urban 
areas and by the market basket percentage increase for hospitals in all 
other areas. MedPAC focused on the operating update only because it 
applies to 92 percent of hospitals' Medicare costs. The report noted 
that, in its March 2000 report to Congress, MedPAC recommended 
combining the operating and capital payment systems into a single 
prospective payment system.
    Response: As described above, we continue to use our detailed 
update framework to develop our recommended update for FY 2003. 
However, we believe MedPAC's new approach will be useful to focusing 
the policy discussion more directly on the overall adequacy of hospital 
payments. We look forward to continuing to work with MedPAC to refine 
and utilize both methodologies in an effort to produce analyses that 
provide the most helpful information for setting the annual updates.
    We agree with MedPAC's recommendation that the current law update 
for FY 2003 of the market basket percentage increase minus 0.55 
percentage points is appropriate for the operating system update. 
However, we are not recommending differential updates to gradually 
eliminate the higher standardized amount for hospitals in large urban 
areas, as recommended by MedPAC. We believe the stabilization of 
overall hospital margins in recent years suggests that modest limits 
below full market basket updates provide adequate payments. We agree, 
however, that certain hospital types that show clear evidence of 
negative and declining Medicare margins should be monitored closely.
    Because the operating and capital prospective payment systems 
remain separate, CMS continues to use separate updates for operating 
and capital payments. The proposed update to the capital payment rate 
is discussed in section III. of the Addendum of this proposed rule.

[FR Doc. 02-11290 Filed 5-8-02; 8:45 am]
BILLING CODE 4120-01-P