[Federal Register Volume 67, Number 148 (Thursday, August 1, 2002)]
[Rules and Regulations]
[Pages 49982-50289]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 02-19292]



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Part II





Department of Health and Human Services





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Centers for Medicare and Medicaid Services



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42 CFR Part 405, et al.



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

  Federal Register / Vol. 67, No. 148 / Thursday, August 1, 2002 / 
Rules and Regulations  

[[Page 49982]]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 405, 412, 413, and 485

[CMS-1203-F]
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: Final rule.

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SUMMARY: We are revising 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 final rule, we describe 
the 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 are applicable to discharges occurring on 
or after October 1, 2002. We also are setting forth rate-of-increase 
limits as well as policy changes for hospitals and hospital units 
excluded from the acute care hospital inpatient prospective payment 
systems.
    In addition, we are setting forth 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); and requirements and responsibilities 
related to provider-based entities.

DATES: The provisions of this final rule are effective on October 1, 
2002. This rule is a major rule as defined in 5 U.S.C. 804(2). Pursuant 
to 5 U.S.C. 801(a)(1)(A), we are submitting a report to Congress on 
this rule on August 1, 2002.

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).
Stephen Heffler, (410) 786-1211, Hospital Market Basket Rebasing.
Jeannie Miller, (410) 786-3164, Clinical Standards for CAHs.

SUPPLEMENTARY INFORMATION:

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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) 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 an average 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.
    Additional payments may be made for cases that involve new 
technologies that have been approved for special add-on payments. To 
qualify, the technologies must be shown to be a substantial clinical 
improvement over technologies otherwise available and that they would 
be inadequately paid otherwise (absent the add-on payments) under the 
regular DRG payment.
    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

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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 (Pub. L. 
105-33), the Medicare, Medicaid, and SCHIP [State Children's Health 
Insurance Program] Balanced Budget Refinement Act of 1999 (Pub. L. 106-
113), and the Medicare, Medicaid, and SCHIP Benefits Improvement and 
Protection Act of 2000 (Pub. L. 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, for cost reporting 
periods beginning in FY 2003, inpatient rehabilitation facilities that 
are subject to the blend methodology 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, 
during the transition, long-term care hospitals subject to the blend 
methodology would also be permitted to elect to be paid based on full 
Federal prospective rates. The final regulations governing payments 
under the long-term care hospital prospective payment system are under 
development and will 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 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. Summary of the Provisions of the May 9, 2002 Proposed Rule

    On May 9, 2002, we published a proposed rule in the Federal 
Register (67 FR 31404) that set forth proposed changes to the Medicare 
hospital inpatient prospective payment systems for operating costs and 
for capital-related costs in FY 2003. We also set forth proposed 
changes relating to payments for GME costs; payments to excluded 
hospitals and units; policies implementing the Emergency Medical 
Treatment and Active Labor Act (EMTALA); clinical requirements for 
swing beds in CAHs; and other hospital payment policy changes. These 
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 proposed 
and the issues we addressed in the May 9, 2002 proposed rule:
1. Changes to the DRG Reclassifications and Recalibrations of Relative 
Weights
    As required by section 1886(d)(4)(C) of the Act, we proposed annual 
adjustments to the DRG classifications and relative weights. Based on 
analyses of Medicare claims data, we proposed to establish a number of 
new DRGs and to make changes to the designation of diagnosis and 
procedure codes under other existing DRGs.
    Among the proposed changes discussed were:
     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 major diagnostic category (MDC) 24.
     Reconfiguration and retitling of existing DRG 14 (Specific 
Cerebrovascular Disorders Except Transient Ischemic Attack) and DRG 15

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(Transient Ischemic Attack and Precerebral Occlusions) and creation of 
a new DRG 524 (Transient Ischemia).
     Creation of a new DRG 525 (Heart Assist System Implant) 
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.
     Redesignation of a code for insertion of totally 
implantable vascular access device (VAD) as an operating room 
procedure.
     Changes in the DRG assignment for the bladder 
reconstruction procedure code.
     Changes in DRG and MDC assignments for numerous newborn 
and neonate diagnosis codes. (We note that, based on public comments 
received on the proposed rule, we are not making these changes in this 
final rule, as discussed in section II.B.6. of this preamble.)
     Changes in DRG assignment for cases of tracheostomy and 
continuous mechanical ventilation greater than 96 hours.
     We also discussed other DRG classification issues for 
which we did not propose changes. One of those was the new drug-eluting 
stent technology. We received many public comments suggesting higher 
payments would be needed in order to adequately compensate hospitals 
for the higher costs of this technology. Therefore, in this final rule, 
we are creating new DRG 525 (Percutaneous Cardiovascular Procedure 
with, Drug-Eluting Stent with AMI) and new DRG 527 (Percutaneous 
Cardioascular Procedure with Drug-Eluting Stent without AMI).
    We also presented our analysis of applicants for add-on payments 
for high-cost new medical technologies. We have approved one new 
technology, the drug drotrecogin alfa (activated), trade name 
XigrisTM, as a new technology eligible for add-on payments. 
XigrisTM is used to treat patients with severe sepsis.
2. Changes to the Hospital Wage Index
    We proposed revisions to the wage index and the annual update of 
the wage data. Specific issues addressed in this section included 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
    We proposed rebasing and revising the hospital market basket to be 
used in developing the 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 
revised market basket relative weights and choice of price proxies.
    In the proposed rule, we also reestimated the labor-related share 
of the average standardized amount that is adjusted by the wage index. 
In response to public comments received recommending further evaluation 
of the methodology used to estimate the labor-related share, we are not 
proceeding with that reestimation in this final rule.
4. Other Decisions and Changes to the Prospective Payment System for 
Inpatient Operating and Graduate Medical Education Costs
    We discussed several provisions of the regulations in 42 CFR Parts 
412 and 413 and set forth certain proposed changes concerning the 
following:
     Options for expanding the postacute care transfer policy. 
Based on public comments received, we are not expanding the policy at 
this time.
     Clarification of the application of the statutory 
provisions on the calculation of hospital-specific rates for SCHs.
     Exclusion of certain limited-service specialty hospitals 
from the like hospital definition for purposes of granting SCH status. 
We proposed to set the threshold for determining a specialty hospital 
is not a like hospital at 3 percent service overlap between the SCH and 
the specialty hospital. In this final rule, in response to public 
comments, we are establishing that threshold at 8 percent.
     Technical change regarding additional payments for outlier 
cases.
     Proposed case-mix index values for FY 2003 for rural 
referral centers.
     Changes relating to the IME adjustment, including 
resident-to-bed ratio caps and counting beds. (We note that because of 
the need for a future comprehensive analysis on bed and patient day 
counting policies, and our limited timeframe for preparing the FY 2003 
final rule for the acute care hospital inpatient prospective payment 
systems for publication by the statutory deadline of August 1, 2002, we 
have decided to postpone finalizing the proposed changes and will 
address the comments in a separate document.)
     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 
reclassification decisions made by the MGCRB.
     Changes relating to payment for the direct costs of GME.
     Changes relating to emergency medical conditions in 
hospital emergency departments under the EMTALA provisions. (We note 
that because of the number and nature of the public comments we 
received on these proposed changes and our limited timeframe for 
preparing the FY 2003 final rule for the acute care hospital inpatient 
prospective payment systems for publication by the statutory deadline 
of August 1, we have decided to postpone finalizing the proposed 
changes and will address the comments in a separate document.)
     Criteria for, and responsibilities related to, payments 
for provider-based entities.
     CMS-directed reopening of intermediary determinations and 
hearing decisions on provider reimbursements.
    We proposed to revise our methodology used to determine the fixed-
loss cost threshold for outlier cases based on a 3-year average of the 
rates of change in hospitals' costs. We received many public comments 
opposing this change. In this proposed rule, we are using a 2-year 
average of the rate of change in charges to establish the threshold.
5. Prospective Payment System for Capital-Related Costs
    We proposed payment requirements for capital-related costs 
effective October 1, 2002, which included:
     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.

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     Clarification of the special exceptions payment policy.
6. Changes for Hospitals and Hospital Units Excluded From the 
Prospective Payment Systems
    We discussed the following proposals concerning excluded hospitals 
and hospital units and CAHs:
     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.
     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 the May 9, 2002 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 proposed threshold amounts for outlier cases. In 
addition, we proposed update factors for determining the rate-of-
increase limits for cost reporting periods beginning in FY 2003 for 
hospitals and hospital units excluded from the acute care hospital 
inpatient prospective payment system.
8. Impact Analysis
    In Appendix A of the proposed rule, we set forth an analysis of the 
impact that the proposed changes 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
    In Appendix B of the proposed rule, as required by section 
1886(e)(3) of the Act, we set forth our report to Congress on our 
initial estimate of a recommended update factor for FY 2003 for 
payments to hospitals included in the acute care hospital inpatient 
prospective payment system, and hospitals excluded from this 
prospective payment system.
10. Recommendation of Update Factor for Hospital Inpatient Operating 
Costs
    In Appendix C of the proposed rule, as required by sections 
1886(e)(4) and (e)(5) of the Act, we included 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 the proposed rule, 
we discussed the MedPAC recommendations concerning hospital inpatient 
payment policies and presented our response to those recommendations. 
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 Web site at: www.medpac.gov.

C. Public Comments Received in Response to the May 9, 2002 Proposed 
Rule

    We received approximately 1,196 timely items of correspondence 
containing multiple comments on the May 9, 2002 proposed rule. 
Summaries of the public comments and our responses to those comments 
are set forth below under the appropriate heading.

II. 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. Changes to the DRG 
classification system and the 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 2003, cases are assigned to one of 510 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 2003, 
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

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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 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.
    We proposed numerous changes to the DRG classification system for 
FY 2003. The proposed changes, the public comments we received 
concerning them, and the final DRG changes and the methodology used to 
recalibrate the DRG weights are set forth below. Unless otherwise 
noted, the changes we are implementing will be effective in the revised 
GROUPER software (Version 20.0) to be implemented for discharges on or 
after October 1, 2002. Also, unless otherwise noted, we are relying on 
the DRG data analysis in the proposed rule for the changes discussed 
below.
2. MDC 1 (Diseases and Disorders of the Nervous System)
a. 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 1 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 of   Average
              Cases in  DRGs 1 and 2                 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 proposed 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).
    Comment: Nine commenters addressed this proposal. Three of the 
commenters supported the proposal. One commenter was concerned about 
the significant redefinition of DRGs to the extent that longitudinal 
DRG data analysis would be seriously comprised. This commenter 
recommended that we consider creating new DRGs when significant changes 
to the structure of existing DRGs are necessary in order to preserve 
the core definition of the existing DRGs for data analysis purposes. 
The commenter believed that this proposed revision would significantly 
alter the definition of these DRGs.
    Response: We appreciate the support of the commenters for our 
position on this issue. In response to the commenter's concern that 
this revision would significantly alter the definition of these DRGs, 
thus affecting longitudinal DRG data analysis, our practice in the past 
has been to alter current DRGs to account for better clinical coherence 
as well as similar patterns of resource intensity. For example, last 
year we removed defibrillator cases from DRGs 104 and 105 to make these 
DRGs and the new DRGs 514 and 515 that were created for defibrillators, 
more homogenous in terms of patient characteristics and resource 
consumption.
    Currently, the DRGs are generally ordered by MDC, which gives the 
DRGs a logical structure. Adding new DRGs sequentially at the end of 
the existing DRGs disturbs that order. However, because there is not a 
perfect solution to this problem, we will take the commenter's concerns 
into consideration as we proceed with future DRG revisions.
    Longitudinal data analysis can be performed by mapping prior year's 
data with the current Medicare GROUPER. A conversion table is available 
for this purpose through the National Center for Health Statistics' 
website: http://www.cdc.gov/nchs/icd9.htm or may be purchased from the 
American Hospital Association (1-800-261-6246).
    Comment: A commenter from a manufacturer of an implantable 
intracranial neurostimulator device used in the treatment of 
Parkinson's disease and essential tremor recommended that we revise the 
proposed revisions to DRGs 1 and 2 so that all deep brain stimulation 
procedures, such as intracranial neurostimulators for Parkinson's 
disease, are paid under proposed DRG 1. The commenter stated that, 
based on its review of FY 2000 MedPAR data,

[[Page 49987]]

approximately 75 percent of these cases would be assigned to proposed 
DRG 2 (and subject to an approximate 40-percent payment reduction under 
the proposed rule).
    Response: Our proposed modification was based on FY 2001 MedPAR 
data. DRGs 1 and 2 included many different procedures with a range of 
costs associated with these procedures. Our analysis indicated a 
substantial cost differential between patients with CCs and patients 
without CCs, and the current DRGs 1 and 2 do not reflect this 
difference. We believe that the revision we proposed will improve the 
payment accuracy for cases in these DRGs. The prospective payment 
system is an average-based payment methodology under which losses that 
may be incurred for specific procedures or classes of patients are 
offset by payment gains from other procedures or classes of patients.
    In our analysis, we found 847 cases in which an implantation of 
intracranial neurostimulator procedures was reported. The majority of 
these cases were being assigned to DRG 2 with average standardized 
charges of approximately $37,546. These charges are higher than the 
overall average standardized charges for all cases within DRG 2. 
However, this group of cases represents a small subset of all of the 
cases that are assigned to DRG 2. As noted above, we believe our 
proposed changes represent an overall improvement in payment accuracy 
for the over 40,000 cases assigned to these two DRGs.
    Comment: Three commenters expressed concern with the proposed 
restructuring of DRGs 1 and 2 as it pertains to the open or 
endovascular treatment of ruptured or nonruptured aneurysms and 
arteriovenous malformation.
    One commenter submitted data showing the average charges for 
ruptured aneurysm cases at $34,794 (and in some cases, $52,568), which 
are more than the average charges for DRG 1, and lengths of stay that 
are significantly higher than those for the proposed DRG 1. Another 
commenter assumed that treatment for ruptured aneurysms will remain in 
the revised DRG 1, and stated that our proposal to reduce the cost 
variance of these DRGs is a good beginning. However, according to the 
commenter, this proposed change does not go far enough because it will 
continue to underpay these extremely resource intensive cases. The 
commenter recommended that these cases be assigned to a different DRG 
(DRG 484 (Craniotomy for Multiple Significant Trauma) was suggested) or 
that a new DRG be created for these cases.
    With respect to the treatment of nonruptured aneurysms, the 
commenters noted that we did not specify whether these cases would be 
assigned to DRG 1 or 2 and urged that these cases be assigned to DRG 1. 
The commenter noted that nonruptured interventional aneurysm cases are 
complex, and patients spend an average of 4.2 days in intensive care.
    Response: In these cases, the patients' principal diagnosis would 
probably be the aneurysm. It is the secondary diagnosis or secondary 
condition that may be classified as a CC. Under the proposed changes, 
cases would be assigned to DRG 1 on the basis of a complication that 
occurred during the hospital stay or a comorbidity that existed at the 
time of admission or developed during the course of hospitalization. We 
found in our analysis that the majority of ruptured aneurysm cases and 
over half of craniotomy procedures in nonruptured aneurysm cases were 
being assigned to DRG 1, where charges for these cases were similar to 
the average for all cases in this DRG. The remaining nonruptured 
aneurysm cases were assigned to DRG 2 ($33,144 compared to $52,254). 
Our analysis did show the average standardized charges for the ruptured 
aneurysm to be $109,698, which is higher than the overall average 
charges of all cases within DRG 1. However, we point out, as noted by 
the commenter, these cases actually do receive higher payments under 
the changes we proposed.
    Currently, DRG 484 includes complex, multiple significant trauma 
cases; that is, patients with a principal diagnosis of trauma and at 
least two significant trauma diagnosis codes (either as principal or 
secondaries) from different body site categories. While the intensity 
of treatment for aneurysms and arteriovenous malformations is 
significant, we do not believe aneurysm and arteriovenous malformation 
cases are clinically similar to other cases currently assigned to DRG 
484.
    Comment: One commenter stated that procedures involving 
implantation of a chemotherapeutic agent into the brain will be 
underpaid, causing hospitals to further limit use of this technology. 
The commenter provided data based on 24 patients being treated with 
this procedure and concluded that the hospital claims data did not 
reflect the true hospital cost for this product. The commenter stated 
that the average cost for this procedure is approximately $26,113. The 
commenter believed that these cases would be assigned to DRG 2 with an 
estimated payment of approximately $13,225.
    Response: Procedure code 00.10 (Implantation of a chemotherapeutic 
agent) will be effective October 1, 2002, that will enable specific 
identification of these procedures. At this point, there are limited 
data available to assess the payment implications of our proposed 
change on this procedure. As noted above, cases that remain in DRG 1 
would receive higher payments as a result of this change. Further, we 
would expect hospitals to generally be able to offset payment losses 
associated with a procedure that is used only rarely with payment gains 
associated with the higher payments for higher volume cases in DRG 1. 
Also, a low markup associated with one device or procedure is often 
offset by relatively higher markups associated with another device or 
procedure, leading to higher relative weights, and thus higher 
payments, for the latter device or procedure.
    We believe that our proposal is appropriate according to currently 
available data. Therefore, we are adopting as final our proposal 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. Revisions of DRGs 14 and 15
    To assess the appropriate classification of patients with stroke 
symptoms, we evaluated the assignment of cases to DRG 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. We proposed to 
continue to group patients with intracranial hemorrhage and infarction 
together. These types of cases are different from patients with, for 
example, an occlusive

[[Page 49988]]

carotid artery without infarction. In this latter 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 a non-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 proposed to remove code 436 
from DRG 14 and reassign it to DRG 15. We also proposed to create a 
third new DRG that would help further differentiate cases currently 
assigned to DRGs 14 and 15. The proposed revised and new DRG titles 
were as follows: DRG 14 (Intracranial Hemorrhage and Stroke with 
Infarction); DRG 15 (Nonspecific Cerebrovascular Accident and 
Precerebral Occlusion without Infarction) (a corrected title from the 
one in the proposed rule); and DRG 524 (Transient Ischemia).
    The following table represents a reconfiguration of DRGs 14 and 15 
and the creation of a new DRG 524 reflecting these three 
categorizations (based on more recent data than that used in the 
proposed rule):

----------------------------------------------------------------------------------------------------------------
                                                                               Average length
                       DRG and Title                         Number of cases   of stay (days)    Average charge
----------------------------------------------------------------------------------------------------------------
Revised DRG 14 (Intracranial Hemorrhage and Stroke with              236,067               6.1           $15,643
 Infarction)..............................................
Revised DRG 15 (Nonspecific Cerebrovascular Accident and             101,726               4.9            11,595
 Precerebral Occlusion without Infarction)................
New DRG 524 (Transient Ischemia)..........................           136,857               3.4             8,633
----------------------------------------------------------------------------------------------------------------

    The reconfiguration of DRGs 14 and 15 results in the following 
codes being designated as principal diagnosis codes in 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.
    We proposed 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.
    We proposed redefining DRG 15 so that it contains 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.
    We proposed 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 proposed 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 represented a modification to improve clinical coherence and 
seems to be a logical change for the construction of the proposed new 
DRG 524.
    Comment: Several commenters opposed the movement of code 436 from 
DRG 14 into DRG 15. One commenter stated that the change is not 
supported in either the ICD-9-CM coding manual or the Coding Clinic for 
ICD-9-CM. The commenter noted that an inclusion note under code 436 
identified this code as a diagnosis code for a stroke patient with 
cerebral infarctions. In addition, the commenter cited the Coding 
Clinic, Fourth Quarter, 1993 (pages 38 and 39), as including the term 
``cerebral infarction'' following the term ``stroke'', which indicated 
to the commenter that these terms are synonymous. The commenter 
recommended that, prior to making any changes, CMS work with the ICD-9-
CM Coordination and Maintenance Committee to revise the ICD-9-CM 
tabular section to correct this inconsistency.
    Response: We agree with the commenter that the ICD-9-CM code 436 
does, in fact, describe a stroke. However, the code is nonspecific as 
to the nature of a stroke. In addition, data on cases containing code 
436 that were reported in our MedPAR file indicated that these types of 
cases have a shorter length of stay and lower hospital charges 
associated with them. Our revised title of DRG 15 reflects our 
recognition of code 436 as describing a stroke; that is, we are 
changing the title of DRG 15 to ``Nonspecific Cerebrovascular Accident 
and Precerebral Occlusion without Infarction.'' With regard to the 
revision

[[Page 49989]]

of the ICD-9-CM diagnosis tabular section describing code 436, we 
understand that the National Center for Health Statistics (NCHS) plans 
to address this issue at the December 4th and 5th, 2003 meeting of the 
ICD-9-CM Coordination and Maintenance Committee. While we agree with 
NCHS' plan to examine this issue, we are not delaying these DRG changes 
while waiting for modifications to this section of the coding manual.
    Comment: Two commenters opposed any changes in DRGs 14 and 15 until 
better data become available. One of these commenters noted that moving 
approximately 80,000 cases from a higher paying DRG to a lower paying 
DRG will significantly impact many hospital's financial status.
    Both commenters opposed moving code 436 from DRG 14 into DRG 15, 
noting that code 436 is a common code for stroke or cerebrovascular 
accident when the physician does not specify whether the stroke is an 
intracranial hemorrhage or cerebral infarction. The commenters noted 
that performance of diagnostic imaging may add specificity to determine 
which artery was involved, thus allowing more specific coding to occur. 
However, it may not change the course of treatment for the stroke. In 
addition, the commenters stated that, in some cases, it is ill-advised 
to subject the patient to further testing to make this determination. 
Further, in some cases, the tests may be inconclusive but in most cases 
the course of treatment would not be changed.
    One commenter indicated that there is probably inconsistency among 
coders in the use of the more specific 5-digit codes for ``with 
cerebral infarction'' for categories 433 (Occlusion and stenosis of 
precerebral arteries) and 434 (Occlusion of cerebral arteries) due to 
variable interpretations of coding instructions. The commenter noted 
that there are currently efforts to provide clarification regarding the 
proper use of these 5-digit codes.
    Response: We recognize that some of the diagnostic codes in section 
430 through 437 of ICD-9-CM may be more specific than the diagnostic 
documentation in the medical record, which may make it difficult to 
precisely code cerebrovascular disease. We also recognize that code 436 
may be a catchall code when more specific information on the patient's 
condition is not available in the record. Further, it is possible that 
other less severe cases are being labeled ``stroke,'' absent more 
thorough testing or workup. However, our proposed changes to DRGs 14 
and 15 were based on actual MedPAR data from FY 2001. As demonstrated 
above, there is a clear demarcation between average charges and lengths 
of stay across the two revised DRGs and one new DRG. Further, payment 
for many cases is higher after these changes than it was previously. 
For FY 2003, the DRG relative weights for DRGs 14 and 15 were 1.1655 
and 0.7349, respectively. The proposed FY 2003 relative weights for 
DRGs 14, 15 and 524 were 1.2742, 0.9844, and 0.7236. Therefore, cases 
remaining in DRG 14 would receive higher payments as a result of moving 
less expensive cases into DRG 15 or 524. Similarly, cases remaining in 
DRG 15 would receive much higher payments than they had previously.
    We believe these changes improve the clinical and resource 
cohesiveness of the DRGs for these cases. We acknowledge the concerns 
expressed by the commenters that code 436 may frequently be used in 
lieu of more specific codes that require further tests even though the 
cases are as severely ill as those with more specific diagnosis 
indicated on the bill. However, this is not borne out by the data.
    To the prospect of more available data in the future, we note that 
changes to codes in the related section of the ICD-9-CM coding book 
have been in place since 1993. We believe that 9 years is sufficient 
time to clarify the coding issues and to adequately train both the 
coding and medical staffs regarding documentation of cerebrovascular 
disease.
    Comment: One commenter opposed the movement of code 437.1 to new 
DRG 524, noting that conditions classified to this code are generally 
chronic or long term in nature, not transient.
    Response: The titles of DRGs are not intended to uniquely identify 
each case within the DRG, but to logically group cases that globally 
have similar characteristics in terms of clinical requirements and 
resources utilized. We proposed the movement of code 437.1 from DRGs 16 
and 17 in order to improve the clinical coherence of DRGs 16 and 17, 
and the new DRG 524; we believe this change accomplishes that. 
Therefore, we are adopting the proposed change as final.
    Comment: One commenter supported the movement of codes 437.3 and 
784.3 from DRG 14 to DRGs 34 and 35.
    Response: We appreciate the commenter's support. Accordingly, we 
are adopting the proposed change to move codes 437.3 and 784.3 to DRGs 
34 and 35, as final.
    We are adopting as final the proposed changes to DRGs 14 and 15 and 
the creation of new DRG 524 without modifications. We will continue to 
monitor these DRGs for shifts in resource consumption and validity of 
DRG assignment and will specifically monitor code 436 for appropriate 
placement in DRG 15. We support the concept of clarification of the 
coding guidelines in this section of ICD-9-CM and will also monitor 
these DRGs when the guidelines are updated.
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

[[Page 49990]]

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 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 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 DRG average charges to any great 
degree.
    Therefore, we proposed to create a new DRG 525 (Heart Assist System 
Implant), which would contain these cases. The FY 2003 relative weight 
for the new DRG 525 is 11.6479.
    As discussed below, the comments we received supported this change. 
Therefore, we are creating new DRG 525, which consists 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 will 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.
    Comment: Several commenters supported the proposed creation of a 
new DRG 525 for patients receiving implanted heart assist systems. One 
commenter stated that the creation of a new DRG 525 would be more 
sensitive to the patient population, more accurate in statistical 
analysis and data reports, and more responsive to changes in LVAD 
charges and utilization patterns.
    Other commenters suggested that the payment amount still 
understates the reasonable cost of LVAD implantation. One commenter 
provided analysis that purported to show that the net payment effect of 
this change is insignificant due to the increase in the outlier 
threshold as discussed in the proposed rule (and in the Addendum to 
this final rule). Another commenter stated that this new DRG results in 
payment that does not even compensate for the costs to the hospital of 
the device itself. The commenter noted that current payment levels for 
LVADs do not take into account the equipment required for discharge, 
that is, both disposable and durable medical equipment.
    Some of the commenters recommended that we consider allowing LVADs 
to qualify for a new technology add-on payment in addition to 
establishing a new DRG specific to this technology.
    Response: Regarding the commenter's analysis of the net payment 
effect of the proposed new DRG 525, the increase in the outlier 
threshold is not related to the creation of the new DRG 525. As 
discussed in detail in the Addendum, the FY 2002 outlier threshold was 
set at a point that resulted in excessive outlier payments. The 
commenter's analysis compared payments if these cases remained in DRGs 
104 and 105 and received outlier payments in accordance with the lower 
FY 2002 outlier threshold to payments under the new DRG 525 using the 
proposed outlier threshold. Therefore, the commenter's analysis does 
not accurately represent payments under the DRGs. The correct analysis 
is to compare payments under DRGs 104 and 105 with payments under the 
new DRG 525, absent outlier payments, which results in an increase in 
payments of over 40 percent per case. Since cases qualify for outlier 
payments on the basis of a constant fixed-dollar loss threshold and 
receive payments equal to 80 percent of costs above the threshold, the 
40-percent differential in payments is not affected by outlier 
payments.
    With regard to the commenters' indication that the payment under 
the new DRG 525 is insufficient, we note that the DRG relative weights 
are based on charge data for actual LVAD cases in the Medicare 
discharge database, using the most recent information available (the FY 
2001 MedPAR file). (Section II.C. of this final rule contains a 
complete discussion of this methodology.)
    With regard to the commenter's suggestion that LVADs be eligible 
for add-on payments for new technology, we point out that our criteria 
require that the mean charges of the cases involving a new technology 
exceed a threshold of one standard deviation beyond the mean charge for 
all cases in the DRG. Since DRG 525 is specific to heart assist 
systems, the mean charge of the cases involving the new technology is 
the same as the mean charge for all cases in the DRG. Also, this 
technology does not meet our criteria to be considered new (see 
discussion at section II.D. below).
    Finally, with regard to the concept that the DRG payment for LVAD 
should take into account disposable and

[[Page 49991]]

durable medical equipment after discharge, we point out that the 
Medicare Part A inpatient hospital payment is distinct from the 
Medicare Part B outpatient payments.
    Comment: One commenter stated if LVAD implantation is approved for 
patients who are not heart transplant patients, the payment is likely 
to still be too low, as it is anticipated that these patients comprise 
a generally sicker population. The commenter suggested that we direct 
hospitals to bill uniformly for LVAD devices via the designated ICD-9-
CM procedure codes that will classify into DRG 525.
    Response: As we noted in the proposed rule, we understand that 
studies are currently underway to evaluate LVADs as permanent support 
for end-stage heart failure patients. However, at this time, these 
applications are only on a trial basis. Further, in the absence of 
specific data demonstrating additional costs associated with expanded 
uses of LVADs beyond bridge-to-transplant patients, we do not take 
anticipated higher costs into account in the DRG relative weight 
calculation. However, we will continue to monitor new DRG 525 as new 
developments occur in the approved uses of LVAD technology to ensure 
appropriate classification and payment of these cases.
    With respect to the comment that we should provide further guidance 
on the correct ICD-9-CM coding procedures for LVADs, as explained above 
and in the proposed rule, cases with any principal diagnosis in MDC 5 
reporting code 37.62, 37.63, 37.65, or 37.66 will be assigned to DRG 
525 (in the absence of a transplant). Further information regarding the 
use of these codes may be obtained by referring to a relevant article 
from the Coding Clinic, Fourth Quarter, 1995 (pages 68 and 69).
    Comment: One commenter, while approving the movement of codes 
37.63, 37.65, and 37.66 to DRG 525, did not believe that cases with 
code 37.62 belong in this DRG. The commenter stated that code 37.62 
includes centrifugal pumps, heart assist systems that are not specified 
as pulsatile, and the insertion of not otherwise specified heart assist 
systems, and urged CMS to reconsider inclusion of this code in the new 
DRG. The commenter stated that centrifugal pumps are more similar to 
cardiac bypass procedures than to ventricular assist systems, and 
inclusion of this code would likely reduce the relative weight of DRG 
525 due to the lower cost of this type of technology. The commenter 
recommended that code 37.62 remain in DRG 104 and 105. The commenter 
was also concerned that the change would create a potential incentive 
for these technologies to be used for purposes not yet approved by the 
FDA.
    Response: Our analysis indicates that these four codes represent 
the most expensive cases in MDC 5, aside from heart transplantation in 
DRG 103, which is the reason we moved them out of DRGs 104 and 105. 
However, we will continue to evaluate the appropriate assignment of 
cases into this new DRG, particularly if new uses for heart assist 
systems are approved by the FDA, and will take the commenter's 
recommendation into account when we conduct our annual MedPAR review 
next year.
    Comment: One commenter suggested that we develop a new heart 
transplant DRG entitled ``Heart Transplant with LVAD,'' because the 
costs of the LVADs have not been incorporated into the heart transplant 
DRG. The commenter stated that, since a great number of LVAD cases 
remain inpatients until heart transplant occurs, there is a disparity 
in costs between heart transplant patients who receive LVADs during the 
stay, and those who do not remain inpatients.
    Response: As we pointed out above, cases in which a subsequent 
heart transplant occurs during the hospitalization episodes are 
currently assigned to DRG 103 (Heart Transplant) because cases 
involving procedure codes 33.6 (Combined heart/lung transplant) and 
37.5 (Heart transplant) are assigned to DRG 103, regardless of other 
codes included on the bill. We believe these cases are appropriately 
compensated in these DRGs, but we will continue to monitor this issue 
in the future.
    Comment: One commenter requested that we review our data to 
determine if there is an incorrect mix of devices being included in the 
calculation of the DRG weight. The commenter suggested that perhaps 
that there is some inappropriate mixing of data, and that there are 
temporary assist devices used in the intensive care unit (ICU) that are 
quite distinct from those used for longer term bridge-to-transplant. 
This commenter noted that these ICU devices are much less expensive.
    Response: As noted in the proposed rule, average length of stay and 
charge data were calculated for all cases including codes 37.62, 37.63, 
37.65, and 37.66. These codes describe the implantation of heart assist 
systems, which is the construct of the new DRG 525. Therefore, we 
believe we have appropriately accounted for these cases in our 
analysis.
    Comment: One commenter expressed concern that we did not separate 
payment for LVADs used in the acute care setting from LVADs used as 
chronic care devices, and pointed out that the short-term indication 
uses only a fraction of the resources required for a chronic or long-
term LVAD. The commenter asked us to consider two DRGs, one for acute 
care devices and one for long-term care devices, that better reflect 
the resource consumption of each indication.
    Response: The LVAD is currently being studied as a device that 
would support end-stage heart failure patients in the absence of a 
heart transplant. This use is not out of the clinical trial phase and, 
more importantly, has not been recognized as a Medicare covered 
service. It would be premature to establish a DRG based on the 
possibility that the LVAD may some day be approved for this indication 
is premature.
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 has 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

[[Page 49992]]

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 that 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 proposed 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.
    Several commenters representing hospitals and medical coders 
supported our proposal to classify code 398.91 as a complex diagnosis 
within DRG 124, which moves these cases from DRG 125. Accordingly, we 
are adopting as final the proposed change.
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 an MDC 
principal diagnosis and code 92.27 do not meet the criteria for 
assignment to DRG 517 because there is no indication of a percutaneous 
cardiovascular procedure, they are currently assigned to DRG 468 
(Extensive O.R. Procedure Unrelated to Principal Diagnosis). Because 
DRG 468 is reserved for cases in which the O.R. procedure is unrelated 
to the principal diagnosis, we proposed to assign cases with code 92.27 
that do not meet the criteria for assignment to DRG 517, but that would 
otherwise be assigned to MDC 5, to DRG 120 (Other Circulatory System 
O.R. Procedures).
    Comment: One commenter supported the proposal. Another commenter 
was unclear why code 92.27 is designated as an operating room procedure 
and would be assigned to DRG 120 (Other Circulatory System O.R. 
Procedures) if reported as a stand-alone procedure. This commenter 
stated that it is not aware of instances when it is appropriate to 
report this code without a concomitant cardiovascular procedure, and 
believed that another procedure, such as angioplasty, is needed in 
order to insert the radioactive implants. The commenter believed that 
cases in which code 92.27 was reported by itself for treatment of a 
cardiovascular disorder may represent incorrect coding.
    Response: We proposed this modification to MDC 5 (Diseases and 
Disorders of the Circulatory System), concerning the assignment of code 
92.27 (when reported as the only procedure) to DRG 120 in part, as a 
result of a telephone call from a member of the general public. The 
inquirer questioned the assignment of code 92.27 without angioplasty 
and with a principal diagnosis in MDC 5 to DRG 468 (Extensive O.R. 
Procedure Unrelated to Principal Diagnosis). When we created DRG 517 in 
the FY 2002 final rule, we also did not consider that a radioactive 
implant would be inserted without angioplasty as a delivery technique. 
We were advised by our medical advisors that it could occur, but it was 
unlikely. Code 92.27 has not yet been reported in our MedPAR data in 
MDC 5 as a stand-alone procedure. However, to address the possibility 
that it might be reported alone, we are taking this opportunity to 
assign code 92.27 to DRG 120 in MDC 5, consistent with the principal 
diagnosis, instead of a (higher-weighted) DRG in which the principal 
diagnosis and the procedure do not match (DRG 468).
    With regard to the commenter's question about the designation of 
code 92.27 as an operating room procedure, we note that code 92.27 has 
always been considered by the Medicare GROUPER to be a procedure code 
affecting DRG assignment. It can be found in 12 MDCs and 20 DRGs in 
GROUPER version 19.0.
    Comment: One commenter commended us for responding to its 
previously submitted comments concerning inadequate DRG payment for GP 
IIb-IIIa platelet inhibitors, but noted that its request from last year 
was not mentioned in our proposed rule in our review of several 
cardiovascular DRGs for both interventional and medical cases that 
receive GP IIb-IIIa inhibitors. The commenter stated that without a 
review of the presence of code 99.20 (Injection or infusion of platelet 
inhibitor) in DRGs 124 (Circulatory Disorders Except AMI, with Cardiac 
Catheterization and Complex Diagnosis) and 140 (Angina Pectoris), CMS 
cannot be certain that a significant number of cases are not 
significantly underpaid.
    Response: We regret this omission in the proposed rule. We did, in 
fact review both DRGs 124 and 140 for the presence of code 99.20. In 
DRG 124, there were a total of 95,452 cases without code 99.20. These 
cases had an average length of stay of 4.4 days and average charges of 
$17,594. There were 1,120 cases in DRG 124 with code 99.20.
    These cases had an average length of stay of 3.5 days, and average 
charges of $17,256. In DRG 140, there were a total of 45,886 cases 
without code 99.20, with an average length of stay of 2.5 days and 
average charges of $6,204. There were 126 cases in DRG 140 with code 
99.20, with an average length of stay of 2.3 days, and average charges 
of $8,675.
    The data do not demonstrate a level of disparity in days and 
charges that would warrant an adjustment to these DRGs based on the 
presence of code 99.20. Therefore, we are not making any changes 
concerning the status of code 99.20 in these DRGs for FY 2003.
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 cases involving code 
277.00 as a principal diagnosis in DRGs 296, 297, and 298. Our analysis 
of the average charges for these cases indicates that resource 
utilization for these cases is quite different from resource 
utilization for other cases in these three DRGs. We believe that this 
difference in resource utilization is due to the fact it

[[Page 49993]]

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 Age >17          271    $34,111
 with CC).........................................
DRG 297 (Nutritional & Metabolic Disease Age >17          133     21,998
 without CC)......................................
DRG 298 (Nutritional & Metabolic Disease Age 0-17)          0  .........
------------------------------------------------------------------------


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

    Based on the results of our analysis, we proposed 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 proposed to use the following three new principal diagnosis 
codes to further inform DRG assignment of these patients:
     277.02 (Cystic fibrosis with pulmonary manifestations)
     277.03 (Cystic fibrosis with gastrointestinal 
manifestations)
     277.09 (Cystic fibrosis with other manifestations)
    We proposed 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 the new code 277.02 would identify those patients with 
cystic fibrosis who have pulmonary manifestations, we proposed to 
assign cases in which this is the principal diagnosis 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 proposed that the 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 the new code 277.09 could involve a number of manifestations 
(excluding pulmonary and gastrointestinal), we proposed to assign this 
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:

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

    Several commenters representing hospitals, medical coders, and 
specialty groups supported the proposed DRG assignments relating to 
cystic fibrosis discussed above. Therefore, we are adopting the 
proposed DRG assignments as final, effective for discharges occurring 
on or after October 1, 2002.
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. In other words, the 
Medicare GROUPER software program does not recognize code 86.07 as a 
procedure code when reported with any principal diagnosis in this MDC. 
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 venous (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.
    In the FY 2002 final rule (66 FR 39844-39845), we pointed out that 
cases where the VAD was inserted as an inpatient procedure often 
involved complications, leading to higher average charges and longer 
lengths of stay for those cases. Therefore, we indicated that we would 
not assign 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 divided based on 
the presence or absence 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

[[Page 49994]]

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 proposed to designate code 86.07 as an O.R. procedure under MDC 11.
    Specifically, code 86.07 will 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
    We received two comments in support of this proposal. Therefore, we 
are adopting as final the proposed redesignation of code 87.06 as an 
O.R. procedure under MDC 11 and its assignment to DRG 315 when combined 
with the principal diagnosis codes from DRG 316 listed above.
    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:

------------------------------------------------------------------------
                                                                Without
                                                    With 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 Procedures       14,116    $30,691
 for Neoplasm)....................................
304 (Kidney, Ureter and Major Bladder Procedures        8,060     30,577
 for Nonneoplasm with CC).........................
305 (Kidney, Ureter and Major Bladder Procedures        2,029     15,492
 for Nonneoplasm without CC)......................
------------------------------------------------------------------------

    Based on the results of our analysis and the advice of our medical 
consultants discussed above, we proposed to classify code 57.87 as a 
major bladder procedure and to assign it to DRGs 303, 304, and 305.
    We received several comments from associations representing 
hospitals and medical coders in support of the proposed 
reclassification of bladder reconstruction surgery from a minor bladder 
to a major bladder procedure. Accordingly, we are adopting as final the 
proposed reclassification, effective for discharges occurring on or 
after October 1, 2002.
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 overall look at the DRGs within MDC 15.
    Because of our limited data and experience with newborn cases under 
Medicare, 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

[[Page 49995]]

diagnosis codes to be adopted, effective October 1, 2002, to assist 
with refinements to the existing DRG category definitions.
    In the May 9, 2002 proposed rule, we proposed to make extensive 
changes to multiple DRG categories in MDC 15. A complete description of 
these proposed changes appears in the May 9, 2002 Federal Register at 
67 FR 31412 through 31414. In summary, the proposed changes involved 
removing a number of congenital anomalies from MDC 15 and assigning 
them to other MDCs. NACHRI advised us that these congenital anomalies 
would be better classified in the MDC for the body system affected. We 
also proposed revising DRG 386 (Extreme Immaturity or Respiratory 
Distress Syndrome, Neonate), to refine the assignment of newborn cases 
diagnosed with extreme immaturity. We proposed major revisions for DRG 
387 (Prematurity With Major Problems) to redefine the codes for 
prematurity and the codes that define a ``major problem''. We proposed 
modifications of DRG 388 (Prematurity Without Problems), which involved 
changes in the classification of prematurity for newborns. We proposed 
revising the definition of a ``major problem'' for DRG 389 (Full Term 
Neonate With Major Problem) as well. By changing the definition of 
``major problem'' in the other DRGs, our proposal would have increased 
the number of cases being assigned to DRG 390. Finally, we proposed to 
expand the number of minor problem newborn diagnoses included in DRG 
391 (Normal Newborn). All of these extensive changes would have greatly 
shifted the DRG assignments for newborns, involving hundreds of ICD-9-
CM codes.
    Comment: One commenter, a national hospital association, opposed at 
this time the reassignment of a large number of diagnosis codes from 
the ``major problems'' list in DRGs 387 and 389 to DRG 391. The 
commenter agreed that refinements to MDC 15 would be beneficial to 
allow more accurate grouping of neonatal admissions but recommended 
that, prior to making extensive changes, CMS work with NACHRI, the 
commenter, and other interested parties to develop a separate DRG that 
would group neonates with minor problems that are not otherwise 
recognized currently or under the proposed changes.
    Other commenters, representing hospitals, medical groups, and 
medical coders, offered a similar comment. One commenter stated that 
since NACHRI represents specialty hospitals, NACHRI's data may not 
fully represent the entire newborn population. Other commenters 
recommended that the proposed revisions to DRGs 387 through 391 not be 
implemented until input is obtained from representatives of general 
community hospitals that treat newborns. The commenters stated that 
newborn DRG data from general community hospitals may vary 
significantly from NACHRI's data and should be taken into consideration 
prior to implementing the proposed revisions to DRGs 387 through 391.
    One commenter also stated that, while it supported the proposed 
removal of the listed codes for congenital anomalies, periventricular 
leukomalacia, and nonspecific abnormal findings on chromosomal analysis 
from MDC 15, the commenter was confused as to the rationale for the 
proposed DRG assignments for the codes for congenital anomalies. (We 
proposed that code 759.4, Conjoined twins, be classified to DRGs 188, 
189, and 190.) In addition, several commenters stated that these DRGs 
are for digestive system diagnoses and conjoined twins may or may not 
have medical conditions involving the digestive system. The commenters 
stated that the rationale for the selection of these DRGs was not 
described in the proposed rule.
    One commenter stated that additional study of newborn DRG 
classifications was needed. This commenter recommended that when 
cardiac surgery procedures are performed on neonates born in the 
hospital, the case be assigned to the applicable cardiac surgery DRG 
instead of one of the neonatal DRGs. The commenter pointed out that 
when a baby is born in a hospital and surgery is performed on a 
congenital heart condition during the same stay, the newborn is 
assigned to DRG 389 where the relative weight is approximately one-half 
the weight of the applicable cardiac surgery DRG. When the newborn is 
delivered at another facility and then transferred for surgery, the 
newborn is assigned to the appropriate cardiac surgery DRG. The 
commenter recommended that this issue be considered when MDC 15 is 
revised.
    Response: The commenters raised a number of important issues. We 
solicited the assistance of NACHRI to develop refinements to MDC 15 
because, while MDC 15 is part of the Medicare DRG system, the types of 
patients in classified to DRGs in MDC 15 are not a significant part of 
the Medicare program. It was our goal to develop refinements that could 
be useful for non-Medicare purposes. Given the extensive nature of the 
proposed revisions, we concur that additional study is necessary. 
Therefore, we are not implementing as final any of the proposed 
revisions to MDC 15. We are maintaining the existing structure of DRGs 
385 through 390 within MDC 15 (Version 19.0) for FY 2003. Nonetheless 
we believe that changes in this area may be worthwhile, and we would be 
interested in considering a set of appropriate changes that might be 
broadly acceptable to the affected community. If we receive such 
suggested changes by December 1, 2002, we would consider it as part of 
our annual review and updates to the DRG system for FY 2004. Any 
proposals could be included in the notice of proposed rulemaking for FY 
2004, which is scheduled to be published in early Spring 2003. In the 
meantime, as stated earlier, we are not making any of the proposed 
changes to MDC 15 for FY 2003.
    Comment: One commenter supported the creation of the new ICD-9-CM 
codes that differentiate between extreme immaturity or gestational age, 
or both.
    Response: As explained in the proposed rule, we are adding the new 
ICD-9-CM codes for newborns that were approved in 2002 for use by acute 
care hospitals in FY 2003. These codes are listed in Table 6A of this 
final rule. The codes are assigned to the existing DRGs as indicated in 
Table 6A under the column ``DRG'' (codes 747.83 through 779.89). Tables 
6A through 6F in this final rule also reflect the assignment of these 
new codes.
    Comment: One commenter pointed out several typographical errors and 
omissions in the proposed changes for MDC 15 in the proposed rule.
    Response: The commenter is correct that there were typographical 
errors in the proposed rule. However, since we are not finalizing the 
proposed changes, we are not addressing the errors specifically in this 
final rule. We will provide clarifications of these errors to those 
interested parties who participating in future efforts to refine MDC 
15.
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 that suggested that we should have also

[[Page 49996]]

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.
    We received several comments in support of this change. 
Accordingly, in this final rule we are adding code V10.53 to the list 
of secondary diagnosis in DRG 465, effective for discharges occurring 
on or after October 1, 2002.
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 proposed 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 
continuous mechanical ventilation for 96 consecutive hours or more 
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 proposed 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) would be assigned to DRG 483. We would 
continue to assign to DRG 483 those patients who have a principal 
diagnosis unrelated to disease of the face, mouth, or neck and a 
tracheostomy. We proposed to retitle DRG 483 ``Tracheostomy/Mechanical 
Ventilation 96+ Hours Except Face, Mouth, and Neck Diagnosis.''
    In the proposed rule, we indicated that we would give future 
consideration to modifying DRGs 482 and DRG 483 based on the presence 
of code 96.72, and specifically invited comments on this area.
    Comment: Several commenters representing hospital associations and 
medical groups supported the proposed modification to DRG 483. Some 
commenters strongly supported using code 96.72 as a determining factor 
for assigning ventilator patients to DRG 483. Another commenter 
indicated that the proposal was a more accurate means of identifying 
high-cost ventilator patients.
    One commenter representing medical coders opposed the proposed 
modification. The commenter expressed concern that there were no 
supporting data to justify the revision. The commenter pointed out that 
it was not clear to which DRG tracheostomy patients with mechanical 
ventilation of less than 96 hours and with out a face, neck, or mouth 
diagnosis would be classified, since no modification to DRG 482 was 
proposed. The commenter did note that CMS was encouraging the reporting 
of code 96.72, but believed that this might be a problem when a number 
of other significant operative procedures are performed, given the 
limited spaces available on the claim form to report ICD-9-CM procedure 
codes.
    Response: The proposed change was a first attempt to refine DRGs 
482 and 483 so that those patients who receive long-term (> 96 hours) 
mechanical ventilation are separated from those patients who receive 
mechanical ventilation of less than 96 hours. The proposed change to 
DRG 483 was partially in response to concern that hospitals could omit 
diagnosis codes indicating face, mouth, or neck diagnosis in order to 
have cases assigned to DRG 483 rather than the much lower paying DRG 
482. It also was an attempt to improve the classification of patients 
on mechanical ventilation by identifying those who receive long-term 
use of a ventilator. By making the GROUPER recognize long-term 
mechanical ventilation and assigning those patients to the higher 
weighted DRG 483, we hoped that hospitals would be more aware of the 
importance of reporting code 96.72 when, in fact, patients had been on 
the ventilator for greater than 96 hours. Therefore, hospitals would 
appropriately increase the reporting of this code. This reporting would 
allow us to continue to refine DRGs 482 and 483 to better reflect the 
resource utilization of these cases.
    We agree with the commenter that hospitals frequently are faced 
with cases where more than six procedures are performed during the 
inpatient stay and that there are limited spaces available on the 
claims form for reporting procedure codes. The proposed change 
encourages hospitals to begin to report code 96.72, since it will 
effect DRG assignment.
    The commenter was correct; we were not completely clear in the 
proposed rule about the effect that the addition of code 96.72 would 
have on DRG 482. The change will have an impact on DRG 482. All cases 
involving a tracheostomy and a diagnosis of face, mouth, and neck 
diagnosis that also have been on continuous mechanical ventilation for 
greater than 96 hours (code 96.72) will be moved out of DRG 482 and 
into DRG 483. The effect is that the expensive, long-term mechanical 
ventilation cases will be moved out of DRG 482 and into the higher-
weighted DRG 483. As mentioned earlier, we did not propose any DRG 
modification involving patients who receive a tracheostomy, have 
mechanical ventilation of less than 96 hours, and do not have a face, 
neck, or mouth diagnosis. These cases will continue to be assigned to 
DRG 483.

[[Page 49997]]

Should future data indicate a need for further refinement of DRGs 482 
and 483, we would propose these changes at that time. The public would 
be given an opportunity to comment on these proposals through the 
normal notice-and-comment rulemaking process.
    In this final rule, we are adopting as final the proposed change in 
the definition of DRG 483 and the proposed change to add code 96.72 to 
DRG 483. To further clarify this change, we are changing the title of 
DRG 483 to ``Tracheostomy with Mechanical Ventilation 96 + Hours or 
Principal Diagnosis Except Face, Mouth, and Neck.''
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.
    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 or have not been 
utilized 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 proposed 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 final rule under the discussion of 
MDC 5 changes with regard to the remodeling of DRGs 14 and 15.
    We received two comments in support of this proposal. However, one 
of the commenters noted that code 436 is not just limited to use in 
smaller hospitals, as we stated in the proposed rule. We acknowledge 
the commenters remarks that code 436 is widely used in hospitals of all 
sizes and is not exclusively used in smaller hospitals. However, our 
rationale for removing code 436 from the MCE because it is frequently 
used, still holds. Accordingly, we are adopting as final the proposed 
removal of code 436 from the MCE ``nonspecific principal diagnisis'' 
edit, effective with discharges occurring on or after October 1, 2002.
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.
    In the May 9, 2002, we proposed 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 proposed to reorder DRG 495 (Lung 
Transplant) above DRG 512 (Simultaneous Pancreas/Kidney Transplant).
     In MDC 5, we proposed 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).
    In the proposed rule, we were unable to test the effects of the 
proposed revisions to the surgical hierarchy and to reflect these 
changes in the proposed relative weights because the revised GROUPER 
software was unavailable at the time the proposed rule was completed. 
Rather, we simulated most major classification changes to

[[Page 49998]]

approximate the placement of cases under the proposed reclassification, 
and then determined the average charge for each DRG. These average 
charges served as our best estimate of relative resources used for each 
surgical class. We have now tested the proposed surgical hierarchy 
changes after the revised GROUPER was received and are reflecting the 
final changes in the DRG relative weights in this final rule. Further, 
as discussed in section II.C. of this preamble, the final recalibrated 
weights are somewhat different from the proposed weights because they 
were based on more complete data.
    Based on a test of the proposed revisions using the April 2002 
update of the FY 2001 MedPAR file and the revised GROUPER software, we 
have found that the revisions are still supported by the data, and no 
additional changes are indicated except those discussed below 
pertaining to the implementation of two new cardiac drug-eluting stent 
DRGs. (For a complete description of this change, see the discussion 
under ``Other Issues'' in section II.B.14. of this preamble.) Due to 
the implementation of two new DRGs pertaining to cardiac drug-eluting 
stents, DRGs 526 (Percutaneous Cardiovascular Procedure with Drug-
Eluting Stent with AMI) and 527 (Percutaneous Cardiovascular Procedure 
with Drug-Eluting Stent without AMI), we also are reordering the 
following DRGs in MDC 5: DRGs 115 (Permanent Cardiac Pacemaker Implant 
with AMI, Heart Failure or Stroke, or AICD Lead or and Generator 
Procedure) and 116 (Other Permanent Cardiac Pacemaker Implant) above 
DRG 526; DRG 526 above DRG 516 (Percutaneous Cardiovascular Procedures 
with Acute Myocardial Infarction (AMI)); DRG 516 above DRG 527; DRG 527 
above DRG 517 (Percutaneous Cardiovascular Procedure without AMI, with 
Coronary Artery Stent Implant); DRG 517 above DRG 518 (Percutaneous 
Cardiovascular Procedures without AMI, without Coronary Artery Stent 
Implant); and DRG 518 above DRGs 478 (Other Vascular Procedures with 
CC) and 479 (Other Vascular Procedures without CC).
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. In the May 9, 2002 proposed rule, we did not 
propose 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 
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.
    In this final rule, we are making limited revisions of the CC 
Exclusions List to take into account the changes that will be made in 
the ICD-9-CM diagnosis coding system effective October 1, 2002. (See 
section II.B.13. of this preamble for a discussion of ICD-9-CM 
changes.) These changes are being made in accordance with the 
principles established when we created the CC Exclusions List in 1987.
    Tables 6G and 6H in the Addendum to this final rule contain the 
revisions to the CC Exclusions List that will be effective for 
discharges occurring on or after October 1, 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 will not be recognized by the GROUPER as valid 
CCs for the asterisked principal diagnosis.
    CCs that are deleted from the list are in Table 6H--Deletions from 
the CC Exclusions List. Beginning with discharges on or after October 
1, 2002, the indented diagnoses will be recognized by the GROUPER as 
valid CCs for the asterisked principal diagnosis.
    Copies of the original CC Exclusions List applicable to FY 1988 can 
be obtained from the National Technical

[[Page 49999]]

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 
22161; or by calling (800) 553-6847.
    Users should be aware of the fact that all revisions to the CC 
Exclusions List (FYs 1989, 1990, 1991, 1992, 1993, 1994, 1995, 1996, 
1997, 1998, 1999, 2000, and 2002) and those in Tables 6F and 6G of this 
FY 2003 final rule 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.
    We received no comments on our proposed changes to the CC list, and 
we are adopting the changes as final.
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 
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 identify 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 did not propose 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 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            170  Other Digestive
                    cava.                             System O.R.
                                                      Procedures with
                                                      CC.
387..............  Interruption vena            171  Other Digestive
                    cava.                             System O.R.
                                                      Procedures without
                                                      CC.
3950.............  Angioplasty or               170  Other Digestive
                    atherectomy of                    System O.R.
                    noncoronary vessel.               Procedures with
                                                      CC.
3950.............  Angioplasty or               171  Other Digestive
                    atherectomy of                    System O.R.
                    noncoronary vessel.               Procedures without
                                                      CC.
------------------------------------------------------------------------
 MDC 7--Diseases and Disorders of the Hepatobiliary System and Pancreas
------------------------------------------------------------------------
387..............  Interruption vena            201  Other Hepatobiliary
                    cava.                             & Pancreas
                                                      Procedures.

[[Page 50000]]

 
3949.............  Other revision of            201  Other Hepatobiliary
                    vascular procedure.               & Pancreas
                                                      Procedures.
3950.............  Angioplasty or               201  Other Hepatobiliary
                    atherectomy of                    & Pancreas
                    noncoronary vessel.               Procedures.
------------------------------------------------------------------------
     MDC 8--Diseases and Disorders of the Musculoskeletal System and
                            Connective Tissue
------------------------------------------------------------------------
387..............  Interruption vena            233  Other
                    cava.                             Musculoskeletal
                                                      System &
                                                      Connective Tissue
                                                      O.R. Procedures
                                                      with CC.
387..............  Interruption vena            234  Other
                    cava.                             Musculoskeletal
                                                      System &
                                                      Connective Tissue
                                                      O.R. Procedures
                                                      without CC.
3950.............  Angioplasty or               233  Other
                    atherectomy of                    Musculoskeletal
                    noncoronary vessel.               System &
                                                      Connective Tissue
                                                      O.R. Procedures
                                                      with CC.
3950.............  Angioplasty or               234  Other
                    atherectomy of                    Musculoskeletal
                    noncoronary vessel.               System &
                                                      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             269  Other Skin,
                    graft.                            Subcutaneous
                                                      Tissue & Breast
                                                      Procedures with
                                                      CC.
8382.............  Muscle or fascia             270  Other Skin,
                    graft.                            Subcutaneous
                                                      Tissue & Breast
                                                      Procedures without
                                                      CC.
------------------------------------------------------------------------
   MDC 10--Endocrine, Nutritional and Metabolic Diseases and Disorders
------------------------------------------------------------------------
387..............  Interruption vena            292  Other Endocrine,
                    cava.                             Nutritional, &
                                                      Metabolic O.R.
                                                      Procedures with
                                                      CC.
387..............  Interruption vena            293  Other Endocrine,
                    cava.                             Nutritional, &
                                                      Metabolic O.R.
                                                      Procedures without
                                                      CC.
5459.............  Other Lysis of               292  Other Endocrine,
                    Peritoneal                        Nutritional, &
                    adhesions.                        Metabolic O.R.
                                                      Procedures with
                                                      CC.
5459.............  Other Lysis of               293  Other Endocrine,
                    Peritoneal                        Nutritional, &
                    adhesions.                        Metabolic O.R.
                                                      Procedures without
                                                      CC.
------------------------------------------------------------------------
     MDC 11--Diseases and Disorders of the Kidney and Urinary Tract
------------------------------------------------------------------------
0492.............  Implantation or              315  Other Kidney &
                    replacement of                    Urinary Tract O.R.
                    peripheral neuro-                 Procedures.
                    stimulator.
3821.............  Blood vessel biopsy          315  Other Kidney &
                                                      Urinary Tract O.R.
                                                      Procedures.
387..............  Interruption vena            315  Other Kidney &
                    cava.                             Urinary Tract O.R.
                                                      Procedures.
3949.............  Other revision of            315  Other Kidney &
                    vascular procedure.               Urinary Tract O.R.
                                                      Procedures.
------------------------------------------------------------------------
         MDC 12--Diseases and Disorders Male Reproductive System
------------------------------------------------------------------------
387..............  Interruption vena            344  Other Male
                    cava.                             Reproductive
                                                      System O.R.
                                                      Procedures for
                                                      Malignancy.
387..............  Interruption vena            345  Other Male
                    cava.                             Reproductive
                                                      System O.R.
                                                      Procedures Except
                                                      for Malignancy.
8622.............  Excisional                   344  Other Male
                    debridement of                    Reproductive
                    wound, infection,                 System O.R.
                    or burn.                          Procedures for
                                                      Malignancy.
8622.............  Excisional                   345  Other Male
                    debridement of                    Reproductive
                    wound, infection,                 System O.R.
                    or burn.                          Procedures Except
                                                      for Malignancy.
------------------------------------------------------------------------
    MDC 13--Diseases and Disorders of the Female Reproductive System
------------------------------------------------------------------------
387..............  Interruption vena            365  Other Female
                    cava.                             Reproductive
                                                      System O.R.
                                                      Procedures.
------------------------------------------------------------------------
   MDC 16--Diseases and Disorders of the Blood, Blood Forming Organs,
                         Immunological Disorders
------------------------------------------------------------------------
387..............  Interruption vena            394  Other O.R.
                    cava.                             Procedures of the
                                                      Blood & Blood
                                                      Forming Organs.
------------------------------------------------------------------------


[[Page 50001]]

    We did not receive any comments on the proposed movement of 
procedures codes from DRG 468. Accordingly, we are adopting, as final, 
the movement of the codes as outlined above.
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 move 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 moving 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 adding 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 ICD-9-CM Manual contains the list of valid diagnosis and 
procedure codes. (The ICD-9-CM Manual is available from the Government 
Printing Office on CD-ROM for $22.00 by calling (202) 512-1800.) 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 of the Manual.
    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.
    We described our plans to expedite the implementation of coding 
changes in the September 7, 2001 Federal Register, including moving the 
dates of the ICD-9-CM Coordination and Maintenance Committee to 
December and April of each year. We also established the possibility of 
implementing procedure codes discussed in the April meeting as part of 
the October update in the same year. This reduces the time for 
activating a new code from a minimum of 11 months to a minimum of 6 
months.
    Because the changes would not be included in the proposed rule 
published in the spring, the public would be given less opportunity to 
consider the merits of the proposals. Decisions from the spring meeting 
must be finalized by early June in order to be included in changes in 
the GROUPER software and be effective October 1. The addenda must also 
be published on the homepage and distributed to publishers so that both 
paper versions of the ICD-9-CM code book and software applications can 
be ready in time for use by health care providers. Only those issues 
from the April meeting that could be quickly resolved and that received 
support from the public would be able to be included in the October 
addendum. Those that could not be quickly resolved would continue to be 
addressed as part of the addendum for October 1 of the next year.
    The ICD-9-CM Coordination and Maintenance Committee met on April 18 
and 19, 2002. Two code title issues discussed during that meeting were 
approved in time to be included in the Addendum of this final rule, to 
be effective October 1, 2002. These codes are new code 89.60 
(Continuous intra-arterial blood gas monitoring) which is shown in 
Table 6B in the Addendum of this final rule, and revised code title 
02.41 (Irrigation and exploration of ventricular shunt) which is shown 
in Table 6F in the Addendum of this final rule.
    For a report of procedure topics discussed at the April 2002 
meeting, see the Summary Report at: http://www.cms.hhs.gov/medicare/icd9cm.asp. This site also includes the Final Addendum for ICD-9-CM 
Procedures, which will be effective October 1, 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.asp. 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-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

[[Page 50002]]

Addendum to this final rule. As we stated above, the code numbers and 
their titles were presented for public comment at the ICD-9-CM 
Coordination and Maintenance Committee meetings. Both oral and written 
comments were considered before the codes were approved. In the 
proposed rule, we only solicited comments on the proposed DRG 
classification of these new codes.
    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) in the Addendum of this final rule. New procedure 
codes are shown in Table 6B. 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. 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).
    Comment: One commenter expressed concern about making procedure 
code changes discussed at the April ICD-9-CM Coordination and 
Maintenance Committee effective the following October. The commenter 
had concerns with the fact that these coding changes would not be 
discussed in the proposed rule, but would appear in the final rule. The 
commenter indicated that hospitals need time to comment on all proposed 
changes to the DRGS and to analyze changes for budgeting, train staff 
on coding changes, and implement software changes. The commenter also 
endorsed movements toward replacing ICD-9-CM with ICD-10-PCS and 
believed this would improve coded data. In addition, the commenter 
suggested that consideration be given to using Alpha-numeric HCPCS 
codes to report the use of drugs, supplies, and devices used for 
inpatients, instead of trying to make ICD-9-CM serve this purpose.
    Response: We discussed the issue of consideration of coding changes 
at the April meeting of the Committee in the final rule on Payment for 
New Medical Services and New Technologies Under the Acute Care Hospital 
Inpatient Prospective Payment System published in the Federal Register 
on September 7, 2001 (66 FR 46902). We were responding to section 533 
of Public Law 106-554, which provided for expediting the incorporation 
of new services into the coding system. While we recognize the 
commenter's concern, we also are responding to repeated requests to 
expedite our process of updating codes. We will carefully evaluate 
requests for new codes that are discussed at the April ICD-9-CM 
Coordination and Maintenance Committee to determine which codes can and 
should be included in the addendum on ICD-9-CM effective October of 
each year. We encourage the commenter to continue to participate in the 
process by attending these public meetings and offering its opinions.
    On the issue of the movement to ICD-10-PCS and the possibility of 
using HCPCS codes for inpatient reporting, we note this issue is 
currently under review by the National Committee on Vital and Health 
Statistics (NCVHS). This committee advises the Secretary on coding 
standards issues under the Health Insurance Portability and 
Accountability Act of 1996 (HIPAA). The committee is currently 
conducting public meetings on the issues raised by this commenter. We 
will defer issues involving changes to the HIPAA standards to the 
NCVHS. For more information on this committee, please see its web site 
at: http://www.ncvhs.hhs.gov/.
14. Other Issues
    In addition to the specific topics discussed in section II.B.1. 
through 13. of this final rule, we addressed a number of other DRG-
related issues in the May 9, 2002 proposed rule. In the proposed rule, 
we did not propose any changes to the DRGs relating to the issues. 
Below is a summary of the issues that were addressed, any public 
comments we received, and our responses to those comments.
a. Intestinal Transplantation
    We examined our data to determine whether it is appropriate to add 
a new intestinal transplant DRG. Our data revealed that nine intestinal 
transplantation cases were reported by two facilities. Of the nine 
cases, two cases involved a liver transplant during the same admission 
and, therefore, would be assigned to DRG 480 (Liver Transplant). As we 
stated in the proposed rule, we do not believe that the remaining seven 
cases provide a sufficient number to warrant the creation of a new 
intestinal transplant DRG.
    Comment: Commenters supported the proposal not to create a separate 
new DRG for intestinal transplants and pointed out that this procedure 
is not being widely performed.
    Response: We will continue to monitor intestinal transplantation 
cases to determine whether it may be appropriate in the future to 
establish a new DRG for the intestinal transplant procedure.
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 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.
    Comment: Commenters supported the creation of a new diagnosis code 
so that Myasthenia Gravis in crisis patients can be uniquely identified 
and the mild and severe forms of the disease is distinguished.
    Response: This topic was addressed at the April 18, 2002 ICM-9-CM 
Coordination and Maintenance Committee meeting. NCHS proposed two new 
codes to capture Myasthenia Gravis not in crisis and Myasthenia Gravis 
in crisis. If the Committee approves these two codes, they would not 
become effective until October 1, 2003. At that point, we would be able 
to assess the charges associated with Myasthenia Gravis in crisis 
patients receiving plasmapheresis.
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

[[Page 50003]]

Coronary Artery Stent or AMI) in MDC 5. For the proposed rule, 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.
    We received one comment in support of our proposal not to make DRG 
changes to the cardiac mapping and ablation codes. Accordingly, in this 
final rule, we will not make any changes relating to the DRG assignment 
of codes 37.20, 37.26, and 37.34
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 did not propose to assign cases without CCs 
from DRG 111 to DRG 110. We reiterate that hospitals are responsible 
for coding their records completely and for recording and submitting 
all relevant diagnosis and procedure codes that have a bearing on the 
current admission (in particular, any secondary or additional diagnosis 
codes that may be recognized by the GROUPER software as codes 
describing complications or comorbidities associated with a case).
    Comment: One commenter recommended a new DRG due to the significant 
costs associated with the device.
    Response: The commenter submitted no data that would cause us to 
question our findings described above. Therefore, in this final rule, 
we are not changing the current DRG assignment of procedure code 39.71. 
e. Platelet Inhibitors.
    In the August 1, 2001 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.
    For the May 9, 2002 proposed rule, 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 we did not propose any changes to the assignment of 
the procedure code 99.20.
    We received one comment in support of maintaining the current DRG 
assignments of code 99.20. Therefore, in this final rule, we are not 
making any changes to the DRG assignments of code 99.20.
f. Drug-Eluting Stents
    The drug-eluting stent technology has been developed to combat the 
problem of restenosis of blood vessels previously treated for stenosis. 
The drug is coated on a stent with a special polymer, and after the 
stent is placed in the vessel, the drug is slowly released into the 
vessel wall tissue over a period of 30 to 45 days. The drug coating on 
the stent is intended to prevent the build-up of scar tissue that can 
narrow the reopened artery.
    In Table 6B of the Addendum to this final 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 
adding code 00.55 (Insertion of drug-eluting noncoronary artery stent).
    A manufacturer of this technology 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). The manufacturer requested that code 36.07 be 
assigned to DRG 516 (Percutaneous Cardiovascular Procedure with Acute 
Myocardial Infarction (AMI)) even without the presence of AMI.
    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 Multivessel Disease,'' Serruys, P.W., Unger, 
F., et al., The New England Journal of Medicine, April 12, 2001, 
Vol. 344, No. 15, p. 1117.
---------------------------------------------------------------------------

    The FDA has not yet approved this technology for use. In the May 9, 
2002 proposed rule, we specifically solicited comments on our proposal 
to treat the new codes cited above consistent with the current DRG 
assignment for coronary artery stents. We also stated that 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.
    Comment: Several commenters supported the development of new ICD-9-
CM codes 36.07 and 00.55 for drug-eluting stents, citing the need for 
identification of this new technology. Several commenters supported the 
creation of new ICD-9-CM codes in order to ensure this technology would 
receive payment under Medicare.
    Response: We created two new ICD-9-CM codes for use with cases

[[Page 50004]]

involving discharges occurring on or after October 1, 2002. These codes 
can be found in Table 6B. ``New Procedure Codes'' in the Addendum of 
this final rule. However, we emphasize that it is not necessary to 
assign new technologies a new ICD-9-CM code in order for Medicare 
payment to commence. In the absence of a new code, technologies are 
assigned to the nearest similar existing code and, consequently, to the 
relevant DRG for payment.
    Comment: Numerous comments opposed our proposed DRG assignment of 
code 36.07 to DRG 517. One commenter noted that, while this technology 
is not yet approved, it has shown promise to significantly advance the 
treatment of coronary artery disease, and encouraged CMS to consider 
the available data to determine the most appropriate paying DRG. This 
commenter supported the reassignment of code 36.07 to another DRG or, 
if necessary, the modification of all affected DRGs, once verifiable 
data on the costs associated with drug-eluting stents become available.
    Many of the commenters who supported higher payment for this 
technology were clinical practitioners and hospitals who expressed 
great anticipation for the potential benefits of this technology. In 
addition, commenters referred to the likelihood that, once these new 
drug-eluting stents are approved, patients would demand to have them 
inserted. This demand would put tremendous financial strain on 
hospitals.
    Commenters also argued there should be long-term cost savings to 
the Medicare program and the health system generally from this 
technology after approval by the FDA. Specifically, if dramatically 
fewer patients require restenting, savings will result from fewer 
repeat angioplasty procedures. Also, to the extent bypass surgeries are 
also reduced (as suggested by the article footnoted above), savings 
will result from that outcome as well.
    Response: We note that, at this point, the FDA has not approved 
this technology for general use. However, we also note that public 
presentation of the results from recent clinical trials have found 
virtually no in-stent restenosis in patients treated with the drug-
eluting stent. Therefore, we recognize the potentially significant 
impact this technology may conceivably have on the treatment of 
coronary artery blockages.
    As we have previously stated, new technology is generally assigned 
to the same DRG as the predecessor technologies. In this way, hospitals 
can receive payment immediately for the new technology. As use of the 
new technology diffuses among hospitals, we have gradually and largely 
automatically recalibrated DRG payment rates based on hospital claims 
data to reflect increasing or decreasing costs of cases assigned to the 
DRG. Generally, it takes 2 years for claims data to be reflected in the 
DRG weights.
    Section 533 of Public Law 106-554 added sections 1886(d)(5)(K) and 
(d)(5)(L) to the Act (as implemented by Secs. 412.87 and 412.88) to 
reduce the time needed for the DRG system to recognize the higher costs 
of new technologies that meet certain criteria (see section II.D. of 
this final rule). However, drug-eluting stents did not meet the cost 
threshold criterion. Therefore, we proposed to assign cases involving 
code 36.07 to DRG 517. Although this DRG assignment would be consistent 
with our prior practice of assigning new technology to the same DRGs to 
which its predecessor technologies were assigned, further consideration 
of this issue persuades us that a different approach is needed, given 
the extraordinary circumstances in this particular instance.
    We are concerned that, if the FDA does approve this technology and 
the predictions of its rapid, widespread use are accurate, this action 
will result in a significant strain on hospital financial resources. In 
particular, we are concerned that the higher costs of this technology 
would create undue financial hardships for hospitals due to the high 
volume of stent cases and the fact that a large proportion of these 
cases could involve the new technology soon after FDA approval. 
Therefore, in this final rule we are creating two new DRGs that 
parallel existing DRGs 516 and 517, to reflect cases involving the 
insertion of a drug-eluting coronary artery stent as signified by the 
presence of code 36.07: DRG 526 (Percutaneous Cardiovascular Procedure 
with Drug-Eluting Stent with AMI); and DRG 527 (Percutaneous 
Cardiovascular Procedure with Drug-Eluting Stent without AMI). We 
understand the earliest date that a decision from the FDA is 
anticipated is late 2002. To further ensure that payments for the new 
DRGs 526 and 527 will not be made prior to FDA approval, we will 
activate these DRGs effective for discharges occurring on or after 
April 1, 2003. If the FDA approves the use of drug-eluting stents prior 
to April 1, 2003, cases coded with procedure code 36.07 will be paid 
using the DRG relative weights for DRG 517. New DRGs 526 and 527 will 
be temporary DRGs. By creating separate new DRGs, we are able to ensure 
that higher payments will only be made after a positive decision by the 
FDA. We expect that when claims data are available that reflect the use 
of these stents, we will combine drug-eluting stent cases with other 
cases in DRGs 516 and 517.
    Although one manufacturer of this technology submitted data to us 
that included charges, hospital provider numbers, and admission and 
discharge dates on the Medicare patients for whom hospital bills were 
collected under the trial in order to demonstrate the higher average 
charges of cases included in the trial, much of the data submitted to 
us included only estimated charges for the new technology. Therefore, 
it was necessary to undertake several calculations to establish the DRG 
relative weights for these two new DRGs. First, based on prices in 
countries where drug-eluting stents are currently being used, and the 
average price of currently available stents, we calculated a price 
differential of approximately $1,200. Assuming average hospital charge 
markups for this technology (based on weighted average cost-to-charge 
ratios), the anticipated charge differential between old and new stents 
would be approximately $2,664 per stent. However, we recognize that 
some cases involve more than one stent. Using an average of 1.5 stents 
per procedure, the net estimated incremental charge for cases that 
would receive a drug-eluting stents is $3,996.
    In order to accurately determine the DRG relative weights for these 
two new DRGs relative to all other DRGs, we must also estimate the 
volume of cases likely to occur in them among discharges occurring on 
or after April 1, 2003 and by September 30, 2003. To approximate the 
number of cases that would likely receive the drug-eluting stent 
between April 1, 2003 and September 30, 2003 (and thus would be 
assigned to new DRGs 526 and 527), we first identified cases in DRGs 
516 and 517 with procedure code 36.06 (Insertion of non-drug-eluting 
coronary artery stent). Of these cases, we estimated what percentage 
would be likely to receive the drug-eluting stent after April 1, 2003. 
The manufacturer estimated that as many as 43 percent of current stent 
patients will receive drug-eluting stents during FY 2003. However, this 
estimate assumes 9 months of sales of the new stents during FY 2003, 
from January to September. Because these two new DRGs will only be 
valid for 6 months during FY 2003, from April through September, we 
estimated that 21.5 percent of all stent cases will be assigned to new 
DRGs 526 and 527 (43 percent of stent cases for 6 months instead of 9 
months).

[[Page 50005]]

    In determining the DRG relative weights, we assumed that 21.5 
percent of coronary stent cases (those with code 36.06) from DRGs 516 
and 517 would be reassigned to new DRGs 526 and 527 (with code 36.07), 
and the charges of these cases would be increased $3,996 per case, to 
approximate the higher charges associated with the drug-eluting stents 
in DRGs 526 and 527. The relative weights for DRGs 516 and 517 are 
calculated based on the charges of the cases estimated to remain in 
these two DRGs.
    We note that this unprecedented approach is in response to the 
unique circumstances surrounding the potential breakthrough nature of 
this technology. We anticipate that the vast majority of new 
technologies in the future will continue to be routinely incorporated 
into the existing DRGs.
    New DRG 526 (Percutaneous Cardiovascular Procedure With Drug-
Eluting Stent With AMI) will have the following principal diagnoses:
     410.01, Acute myocardial infarction, anterolateral wall, 
initial episode of care.
     410.11, Acute myocardial infarction, other anterior wall, 
initial episode of care.
     410.21, Acute myocardial infarction, inferolateral wall, 
initial episode of care.
     410.31, Acute myocardial infarction, inferoposterior wall, 
initial episode of care.
     410.41, Acute myocardial infarction, inferior wall, 
initial episode of care.
     410.51, Acute myocardial infarction, other lateral wall, 
initial episode of care.
     410.61, True posterior wall infarction, initial episode of 
care.
     410.71, Subendocardial infarction, initial episode of 
care.
     410.81, Acute myocardial infarction of other specified 
sites, initial episode of care.
     410.91, Acute myocardial infarction, unspecified site, 
initial episode of care.
    And operating room procedures:
     35.96, Percutaneous valvuloplasty.
     36.01, Single vessel percutaneous transluminal coronary 
angioplasty [PTCA] or coronary atherectomy without mention of 
thrombolytic agent.
     36.02, Single vessel percutaneous transluminal coronary 
angioplasty [PTCA] or coronary atherectomy with mention of thrombolytic 
agent.
     36.05, Multiple vessel percutaneous transluminal coronary 
angioplasty [PTCA] or coronary atherectomy performed during the same 
operation, with or without mention of thrombolytic agent.
     36.09, Other removal of coronary artery obstruction.
     37.34, Catheter ablation of lesion or tissues of heart.
    Or nonoperating room procedures:
     37.26, Cardiac electrophysiologic stimulation and 
recording studies.
     37.27, Cardiac mapping.
    And nonoperating room procedure:
     36.07, Insertion of drug-eluting coronary artery stent(s).
    The principal diagnosis will consist of any principal diagnosis in 
MDC 5 except AMI:
     410.01, Acute myocardial infarction, anterolateral wall, 
initial episode of care.
     410.11, Acute myocardial infarction, other anterior wall, 
initial episode of care.
     410.21, Acute myocardial infarction, inferolateral wall, 
initial episode of care.
     410.31, Acute myocardial infarction, inferoposterior wall, 
initial episode of care.
     410.41, Acute myocardial infarction, inferior wall, 
initial episode of care.
     410.51, Acute myocardial infarction, other lateral wall, 
initial episode of care.
     410.61, True posterior wall infarction, initial episode of 
care.
     410.71, Subendocardial infarction, initial episode of 
care.
     410.81, Acute myocardial infarction of other specified 
sites, initial episode of care.
     410.91, Acute myocardial infarction, unspecified site, 
initial episode of care.
     And operating room procedures:
     35.96, Percutaneous valvuloplasty.
     36.01, Single vessel percutaneous transluminal coronary 
angioplasty [PTCA] or coronary atherectomy without mention of 
thrombolytic agent.
     36.02, Single vessel percutaneous transluminal coronary 
angioplasty [PTCA] or coronary atherectomy with mention of thrombolytic 
agent
     36.05, Multiple vessel percutaneous transluminal coronary 
angioplasty [PTCA] or coronary atherectomy performed during the same 
operation, with or without mention of thrombolytic agent
     36.09, Other removal of coronary artery obstruction
     37.34, Catheter ablation of lesion or tissues of heart
    Or nonoperating room procedures:
     37.26, Cardiac electrophysiologic stimulation and 
recording studies
     37.27, Cardiac mapping
    And nonoperating room procedure:
     36.07, Insertion of drug-eluting coronary artery stent(s).
    Comment: One commenter expressed concern that this technology will 
be used to treat lesions that are not clinically indicated. This 
commenter suggested that there should be clear language stating that 
drug-eluting stents should only be used in patients who are symptomatic 
from coronary artery disease as documented by noninvasive stress tests 
and imaging to locate the ischemia.
    Response: We appreciate the commenter's concern that this new 
technology be used only where it is clinically indicated. We note that 
our treatment of this technology should in no way be construed to 
circumvent the ongoing FDA review. We expect that the technology, if 
approved, would be used in accordance with any labeling guidelines 
issued by the FDA, and we reserve the right to evaluate the need for 
Medicare coverage limitations or restrictions in the future.
    Comment: One commenter applauded our recognition of the potential 
advance in peripheral vascular care by creating a code for noncoronary 
artery stents, code 00.55 (Insertion of drug-eluting noncoronary artery 
stent(s)). However, the commenter indicated it could not discern from 
Table 6B (67 FR 31630) the DRG to which code 00.55 was assigned.
    Response: Our usual practice is to assign a new code to the DRG to 
which the predecessor code had been assigned. For example, in 1995, 
when we added additional fourth digits to 60.2 (Transurethral 
prostatectomy) and created 60.21 (Transurethral (ultrasound) guided 
laser induced prostatectomy (TULIP)) and 60.29 (Other Transurethral 
prostatectomy), we assigned the two new codes to the DRGs in which 60.2 
had been located. (In version 12.0 of the GROUPER, those DRGs were 306 
and 307 and DRG 336 and 337; the two newer codes continue to be 
assigned to the same DRGs today.) We have followed this precedent with 
code 00.55, which is patterned after code 39.90 (Insertion of non-
coronary artery stent or stents). Code 39.90 is not a code recognized 
by the GROUPER software as a procedure code that causes DRG assignment, 
and therefore it is not assigned to a DRG or DRGs by itself. The 
GROUPER will recognize the main procedure in which a stent is inserted 
in order to make the DRG assignment for that case. We recognize that 
insertion of stents in noncoronary vessels has the potential to occur 
in many MDCs and DRGs. We will monitor the new stent code in 
noncoronary vessels in our MedPAR data to determine if the DRG 
placement in which it is reported is appropriate.

[[Page 50006]]

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.
    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). 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. 
The manufacturer 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 also 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 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.
    We proposed to assign code 00.51 to DRG 514 or 515 and to assign 
code 00.50 to DRG 115 and 116. However, we solicited comments on these 
proposed DRG assignments and indicated that we would carefully consider 
any relevant evidence about the clinical efficacy and costs of this 
technology.
    Comment: Numerous commenters responded to our statement that we 
would further consider evidence on the costs and clinical efficacy of 
the cardiac resynchronization technology. Commenters noted that, on 
average, patients with moderate to severe heart failure (New York Heart 
Class III/IV), for whom the CRT is indicated, are more physically 
compromised and need the support of additional personnel such as 
physical assistants and clinical heart failure coordinators. Data were 
submitted showing that heart failure cases have significantly longer 
average lengths of stay than average stays for other cases. These cases 
also have higher average charges (approximately $11,000 to $13,000 
higher, according to one commenter). The commenters acknowledged that 
DRG 115 does specifically account for heart failure cases, but noted 
that DRGs 514 and 515 do not.
    Commenters also argued there are additional costs associated with 
the additional surgical supplies required to perform these procedures 
(as well as the price differential of the new technology itself). 
Examples of supplies include a special left ventricular coronary sinus 
lead, a special pulse generator device, and a special electrical lead. 
One manufacturer estimated the incremental difference in the charges of 
the device and the additional surgical supplies to be $23,500.
    Commenters further noted the additional surgical procedure time 
associated with CRTs. They noted that the implant procedure itself is 
much more complex than a conventional pacemaker or implanted 
cardioverter defibrillator, and generally requires additional staff, 
anesthesia, and other specialized services and supplies. The insertion 
of the left ventricular lead is estimated to require an additional 2 
hours beyond a conventional procedure. Commenters pointed out that 
typically a venogram is required to navigate the coronary venous 
system. The additional time and resources were estimated to increase 
costs to the hospitals by $7,500.
    Finally, commenters also cited data and anecdotal evidence to 
demonstrate the clinical benefits of this technology. The commenters 
noted that FDA approved CRT-D on May 2, 2002, which provides further 
evidence of the clinical efficacy of this technology. One commenter 
provided information to show that CRT-D improves peak oxygen uptake, 
translating to an increased ability to perform activities of daily 
living. Another commenter noted that pacing therapy offers the 
potential to increase blood pressure and heart rate.
    On the basis of these higher costs and clinical improvements, these 
commenters generally recommended that CRT-Ds should be assigned to DRG 
104. This DRG has a higher relative payment weight than either DRGs 514 
or 515 (7.9615, compared to 6.3288 and 5.0380, respectively, based on 
the FY 2003 proposed DRG weights). One commenter suggested that if CRT-
D cases are not assigned to DRG 104, they should only be assigned to 
DRG 514, not DRG 515. Several commenters suggested that CRT-Ps be 
assigned only to DRG 115, and not to DRG 116, since DRG 115 is the 
higher paying DRG. Other commenters suggested that all DRT-Ps be 
assigned to DRG 515 since DRG 515 pays more.
    One commenter suggested that CRT-Ds are more clinically coherent to 
cases now assigned to DRG 104 based on: (1) The similarity of the 
diagnosis (for example, congestive heart failure); and (2) the 
similarities in clinical procedures used to implant a left ventricular 
lead and other cardiac catheterizations included in DRG 104. The 
commenter also suggested that the operating room preparation and 
procedure time for CRT-D cases was similar to that for other major 
cardiovascular procedures included in DRG 104, which supports the 
commenter's contention that CRT-Ds are more clinically consistent with 
DRG 104 than DRG 514 and 515.
    Several commenters, including a national and a State hospital 
association, supported the assignment of new code 00.51 to DRG 514 or 
515. Some commenters also supported the assignment of new code 00.50 to 
DRG 115 and DRG 116. The commenters added that cardiac 
resynchronization therapy is a new technology that recently received 
FDA approval and is still not widely used in hospitals in the United 
States. The commenters indicated that even though there is limited 
information at this time with regard to the clinical efficacy and costs 
of these devices, the technology seems to be similar to pacemakers and 
defibrillators, so the proposed DRG grouping is logical.
    Response: We have carefully evaluated the information provided to 
us by the commenters. With respect to the cost data provided, we note 
that it is our previously stated preference to review actual data 
reflecting the total costs per case from patients treated with a 
particular new technology. Because the DRG payment is intended to cover 
all of the care provided during the course of an inpatient 
hospitalization, it is necessary to evaluate the impact a new 
technology may have on other aspects of patients' hospitalization. For 
example, many new technologies allow patients to be discharged sooner, 
actually reducing the total costs of the stay. While there is no 
indication that

[[Page 50007]]

this is the case with the CRT-D technology, we are unable to make an 
assessment based on the segregated data that were provided.
    With respect to the suggestion that CRT-D cases should be assigned 
to DRG 104, we note that the DRG system groups cases that are similar 
clinically and in terms of costs. DRG 104 includes procedures performed 
on cardiac valves such as valve replacement and repair. Our clinical 
advisors disagree with the suggestion that the implantation of a CRT 
with or without defibrillation is clinically related or similar to 
procedures such as valve repair or replacement, which are assigned to 
DRG 104. We believe that, based on the nature and function of the 
devices, they are more appropriately classified as either pacemakers 
for the CRT-P or implantable cardioverter-defibrillators (ICDs) for the 
CRT-D devices. The additional lead is not, in our view, sufficient 
justification for classifying the CRT-Ds differently from all other 
debibrillators.
    Furthermore, although chronic heart failure, for which these CRTs 
are used, is a common diagnosis, the etiology of the heart failure may 
vary significantly. Heart failure due to a faulty valve may be treated 
with valvuloplasty or valve replacement, and would be classified to DRG 
104. On the other hand, heart failure due to ischemic events, such as a 
myocardial infarction, usually requires a completely different 
therapeutic approach involving other DRG assignments. Therefore, we do 
not believe it would be appropriate to classify cases receiving CRT-Ds 
to DRG 104.
    With respect to the fall-back recommendation of the commenter that, 
if CRT-D cases are not assigned to DRG 104, they should all be assigned 
to DRG 514, we considered and rejected this suggestion. We note that a 
fundamental assumption underlying the DRGs is that the hospital has the 
responsibility for deciding what technology and process to employ in 
treating a particular type of patient. As hospitals in the aggregate 
make treatment decisions, these decisions are reflected in the DRG 
payment weights. This allows the payment rates to evolve in response to 
changing practice patterns.
    The decision to treat CRT-D technology similarly to existing 
defibrillator technology is affected by our opinion that substantial 
improvement in health outcome benefits of adding the cardioverter-
defibrillator component have not been fully established through 
clinical research. There are no published articles that have shown an 
improvement in survival from CRT. Although we appreciate the 
information provided by the commenters in this regard, we note there is 
not a significant body of evidence that CRT-D technology will supplant 
existing treatments for large numbers of patients. Because the DRG 
payment system is an average-based system wherein hospitals are 
expected to offset the higher costs of some cases with below-average 
costs in others, we anticipate that hospitals will be able to 
adequately finance this new technology as it is utilized. To the extent 
hospitals move to adopt this technology more widely over time, 
appropriate adjustments will be reflected in the DRG weights.
    With respect to the recommendation that all CRT-P cases be assigned 
to DRG 115, CRT-Ps are inserted into patients with congestive heart 
failure. Therefore, when the code for CRT-P is reported in a patient 
with congestive heart failure, the case will be assigned to DRG 115. 
Only if the CRT-P were inserted in a patient who does not have 
congestive heart failure would the case be assigned to DRG 116. Since 
all the commenters agree that only patients with congestive heart 
failure would be candidates for the CRT-P, the end result will be that 
all of these cases would be assigned to DRG 115 as the commenters 
recommended. With respect to the recommendation that all CRT-Ps be 
assigned to DRG 515, our response is the same as for rejecting the 
assignment of DRT-Ds to DRG 515. Assignment of CRT-Ps to DRG 515 is not 
clinically appropriate.
    Accordingly, we are adopting as final our proposed classification 
of code 00.50 to DRGs 115 and 116, and code 00.51 to DRGs 514 and 515. 
These changes will be effective for discharges occurring on or after 
October 1, 2002.
    Comment: Many commenters mentioned that when the CRT-Ds are 
inserted, a coronary sinus venogram is often performed. The commenters 
stated that a venogram is a procedure that is similar to an 
arteriogram, which is classified as a non-O.R. procedure that affects 
the DRG assignment in some cases. The commenters stated that the 
additional time and resources of the venogram for a CRT-D should be 
accounted for by assignment of these cases to DRG 104.
    Response: Coronary arteriograms and angiocardiograms do effect the 
DRG assignment in some cases. Arteriograms and angiograms of other 
sites that are not of the heart do not affect the DRG assignment. 
Venograms are not currently on the list of non-O.R. procedures that 
affect the DRG assignment. While the commenters are not suggesting that 
we add venograms to the list of non-O.R. procedures that affect the DRG 
assignment, they are recommending that the comparison of venograms to 
angiocardiograms be used as a justification for assigning CRT-Ds to DRG 
104. Our medical consultants advise us that venograms are not as 
difficult to perform as are the coronary arterigrams and 
angiocardiograms. Venograms also have fewer associated risks than 
coronary arterigrams and angiocardiograms. Therefore, we would not 
reclassify venograms and make them affect the DRG assignment. In short, 
we do not believe that the performance of a venogram is justification 
for moving CRT-Ds to DRG 104.
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.
    Comment: Two commenters addressed this issue. One commenter stated 
that additional data review was needed to determine the variation in 
charges and length of stay to determine if this recommendation should 
be pursued. Another commenter stated that using charge data is 
incorrect. Hospitals are under increased pressure and scrutiny to keep 
their charges low and would not increase the charges of the revision 
prosthetic because it does not influence the amount of payment 
received. The commenter suggested that revisions of the hip and knee 
procedures should have their own DRG.
    Response: Hospital charges have been the basis for recalibration of 
the DRG weights since FY 1986. Therefore, it is in the hospitals' best 
interest to submit accurate billing data. We utilize charge data in our 
analysis of the DRGs to ensure that each DRG contains patients with a 
similar pattern of resource intensity. To the extent that the markup of 
charges over cost varies from one particular device or procedure to 
another, the relative weights will be impacted. However, due to the 
relativity of the DRG weights, a low markup associated with one device 
or procedure will be offset by relatively higher markups associated 
with another device or procedure, leading to higher relative weights, 
and thus higher payments, for the latter device or procedure.

[[Page 50008]]

i. Multiple Level Spinal Fusions
    We received correspondence suggesting that we create new spinal 
fusion DRGs that differentiate by the number of discs that are fused in 
a spinal fusion. The correspondents 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 explored the possibility of 
creating codes to differentiate cases by the number of discs fused 
during a spinal fusion procedure at the April 18 and 19, 2002 meetings 
of the ICD-9-CM Coordination and Maintenance Committee. Because the 
topic proved to be quite challenging and will require additional 
discussion, the Committee will consider it further at its scheduled 
December 5 and 6, 2002 meeting.
    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 did not propose DRG 
changes for multiple level spinal fusions in the May 9, 2002 proposed 
rule.
    Comment: Commenters representing national and state hospital 
associations supported the proposal to not make DRG changes for 
multiple level spinal fusions at this time. The commenters agreed that 
ICD-9-CM historically has not been used to differentiate among cases by 
the number of repairs or manipulations performed during a single 
procedure. Also, the commenters wrote that developing a coding 
methodology for multiple level spinal fusions will require careful 
consideration because it will be introducing a new concept into ICD-9-
CM coding. The commenters offered to work with CMS to examine whether 
such a methodology could be developed in the future.
    One commenter urged CMS to carefully examine the issue of providing 
separate codes and payment for multiple level spinal procedures. The 
commenter stated that increased costs were incurred in this type of 
surgery and may warrant recognition within the DRGs.
    Response: We appreciate the comments on what has evolved as a 
challenging coding issue. We look forward to working with the commenter 
and other groups as we attempt to develop an efficient way to capture 
multilevel spinal fusions. The topic will be discussed at the next 
meeting of the ICD-9-CM Coordination and Maintenance Committee, which 
will be held on December 5 and 6, 2002. The agenda for this meeting 
will be posted in November 2002 at: www.cms.hhs.gov/medicare/icd9cm.asp. Once new codes are developed, we will evaluate the DRG 
assignments.
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 >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.
    We received comments in support on our proposed decision that the 
current DRG assignments for code 882.0 are appropriate. Accordingly, in 
this final rule we are not making any modifications of the DRG 
assignments for cases with code 882.0 at this time.
k. Cavernous Nerve Stimulation
    As discussed in the August 1, 2001 final rule (66 FR 39845), we 
reviewed data in MDC 12 (Diseases and Disorders of the Male 
Reproductive System) to look 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 assigned. Therefore, we did not 
propose any DRG assignment changes to procedures code 89.58 or any 
changes to DRGs 334 and 335.
    We received one comment in support of our proposal not to change 
the DRG assignment of code 89.58 or DRGs 334 and 335. Accordingly, in 
the final rule we are making no changes to DRGs 334 and 335 with regard 
to procedure code 88.58. We anticipate that procedure code 89.58 will 
be performed in conjunction with radical prostastectomy, which is an 
operative code(s) describing the major surgical procedure.
1. Additional Issues Raised by Comments
    We received a number of comments on additional specific DRG 
assignment issues that were not raised in the proposed rule. We are not 
responding to them individually here because they were not raised in 
the proposed rule. We will be considering each issue raised for 
consideration in the FY 2004 DRG reclassifications. We also note that 
we previously described a process for submission of non-MedPAR data for 
consideration in evaluating the DRG assignment issue (64 FR 41499).

C. Recalibration of DRG Weights

    We are using 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 recalibrate the weights based on charge data for 
Medicare discharges. For the proposed rule, we used 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.
    The final recalibrated DRG relative weights are constructed from 
the FY 2001 MedPAR data, which include discharges occurring between 
October 1, 2000 and September 30, 2001, based on bills received by CMS 
through March 31, 2002, from all hospitals subject to the acute care 
hospital inpatient prospective payment system and short-term acute care 
hospitals in waiver

[[Page 50009]]

States. The FY 2001 MedPAR file includes data for approximately 
11,483,663 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.
    The 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.
     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. 
(See section II.B.14.f. of this preamble for a discussion of the 
special adjustment used in calculating the FY 2003 DRG relative weights 
for DRGs 526 and 527.)
     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 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 new weights are normalized by an adjustment factor (1.43889) 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.
    We did not receive any comments on DRG recalibration.
    Section 1886(d)(4)(C)(iii) of the Act requires that, beginning with 
FY 1991, reclassification and recalibration changes be made in a manner 
that assures that the aggregate payments are neither greater than nor 
less than the aggregate payments that would have been made without the 
changes. Although normalization is intended to achieve this effect, 
equating the average case weight after recalibration to the average 
case weight before recalibration does not necessarily achieve budget 
neutrality with respect to aggregate payments to hospitals because 
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 final rule, we make a budget 
neutrality adjustment to ensure that the requirement of section 
1886(d)(4)(C)(iii) of the Act is met.

D. 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, 2001 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 of this final rule lists the qualifying 
criteria by DRG based on the discharge data that we are using to 
calculate the FY 2003 DRG weights. These thresholds 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 requiring 
applicants for FY 2004 to submit a significant sample of the data no 
later than early October 2002. The complete request also must include a 
full

[[Page 50010]]

description of the clinical applications of the technology and the 
results of any clinical evaluations demonstrating that the new 
technology represents a substantial clinical improvement. Subsequently, 
we are requiring that a complete database be submitted no later than 
mid-December 2002.
    Applications for consideration under this provision for FY 2004 
should be sent to the following address: Centers for Medicare & 
Medicaid Services, c/o Inpatient New Technology Applications, Mail Stop 
C4-08-06, 7500 Security Boulevard, Baltimore, MD 21244.
    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 FY 
2003 DRG weights in this final 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 Food and Drug Administration (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.
    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 actual 
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. Rept. 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 the new technology provision 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 
and the hospital-specific amounts.
    Because any additional payments directed toward new technology 
under this provision must be offset to ensure budget neutrality, it is 
important to consider carefully 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 balance appropriately 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 the target limit is exceeded, we would reduce the level of 
payments for approved technologies across the board, 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 would be reduced, this would be offset by large overall 
payments to hospitals for new technologies under this provision.
    Comment: Numerous commenters expressed concern that the method by 
which payments are made--in a budget neutral manner--reduces the amount 
of DRG payments for other cases. The commenters noted that shifting 
money around within the prospective payment system leaves hospitals 
without the additional money they need to ensure beneficiaries have 
access to the newest medical tests and treatments. Many of the 
commenters believed that reducing payments for other services in order 
to increase payments for new technology is inappropriate, as the costs 
associated with all other inpatient procedures are not declining. The 
commenters noted that they will continue to urge Congress to adopt an 
appropriate adjustment to hospital payments without redistributing 
payments from elsewhere in the system.
    Some commenters also wrote that the new technologies listed in the 
proposed rule are worthy of additional funding, but, since budget 
neutrality would reduce payments for all other inpatient procedures, 
even though costs for these procedures are not declining, the 
applications should not be approved. However, if the applications are 
approved, the commenters stressed the need to maintain the requirement 
that no more than 1 percent of total acute inpatient prospective 
payments may be used for new technology payments. Furthermore, if 
actual total add-on payments were less than estimated in calculating 
the budget neutrality adjustment, the commenters argued that unspent 
funds should be restored to the standardized amount.
    Response: As stated above, the Congressional Report language 
accompanying section 533 of Public Law 106-554 clearly indicated 
Congress' intent that this provision is to be implemented in a budget 
neutral manner. Therefore, the commenters are correct that Congress is 
the appropriate body to consider concerns about the budget neutrality 
of this provision. We

[[Page 50011]]

also agree with the commenters about the need to limit the total 
payments made under this provision. In the September 7, 2001 final 
rule, we established a target limit of 1 percent of total acute 
inpatient prospective payment system payments for new technology. This 
target is intended to limit the redistributional impact of these higher 
payments for new technology relative to payments for other services.
    Although our estimates are influenced by past experience, it has 
been our longstanding practice not to adjust our budget neutrality 
calculations retroactively on the basis of actual payments. We note 
that hospitals may either benefit or lose in any given year, depending 
on whether we underestimate or overestimate the budget neutrality 
factor. We would note that, in years when hospitals benefited from an 
underestimate of the budget neutrality factor, we did not recoup any 
payments resulting from the underestimate.
    Comment: Some commenters criticized our implementation of the add-
on payment provision for new technology. They claimed that the criteria 
we set make it impossible for technologies to qualify for add-on 
payments and suggest that many companies did not apply for new 
technology add-on payments because the threshold and other criteria 
were set so high. As proof, the commenters pointed to the small number 
of applications we received for new technology add-on payments for FY 
2003, and to the apparent denial of all applicants. The commenters 
argued that our criteria operate to nullify the effect of the provision 
and, therefore, go against Congress' intent.
    Response: Unlike the commenters, we believe the limited number of 
applications lends support to the appropriateness of the criteria. It 
was our intention to implement this provision without fundamentally 
disrupting the prospective payment system. A substantial number of 
cases receiving extra cost-based payments, (or substantial 
disaggregation of the DRGs into smaller units of payment) would 
undermine the efficiency incentives of the DRG payment system. This 
system, is founded on the theory that, by paying for patients with 
similar clinical characteristics based on the average resources needed 
to treat those patients, the system creates an incentive for physicians 
and hospitals to evaluate the most appropriate treatment approach for 
an individual patient, knowing that the payment to the hospital will, 
on average, reflect the average resources utilized across all patients 
in the DRG. Add-on payments for specific new technologies influence the 
financial incentives faced by the physician and the hospital, and, 
because these payments are implemented in a budget neutral manner, they 
impact the average payments for all DRGs.
    While we recognize Congress' intent that Medicare beneficiaries 
have faster access to new technologies that may be introduced more 
slowly otherwise due to payment concerns, we believe Congress also did 
not intend to fundamentally disrupt the incentives of the prospective 
payment system. We will continue to carefully evaluate whether our 
criteria appropriately balance these two objectives.
    Comment: Many commenters repeated objections to policies proposed 
in the May 4, 2001 proposed rule (66 FR 22646). These comments are 
listed here.
    Several commenters argued that the one standard deviation threshold 
was too high for most new technologies to qualify. Commenters also 
wrote that the substantial clinical improvement criterion should be 
removed, and that the 50-percent pass-through payment does not 
adequately reimburse hospitals for the cost of new technologies. Many 
commenters suggested that we use the 80-percent standard that we use 
for outlier thresholds.
    One commenter objected to our requirement of a ``significant 
sample'' of ``verifiable'' external data. This commenter wrote that any 
economic data required should be reasonably derived from the clinical 
trials conducted in conjunction with submissions to the FDA. In 
addition, our data requirements should not be overly burdensome and 
should recognize the difficulties faced by hospitals, such as 
compliance with patient confidentiality regulations.
    Some commenters suggested that we incorporate new technologies 
directly into the DRG system and adjust the weights to reflect the 
increased costs of the item(s) as data become available. They argued 
that this method would be more consistent with the fundamental 
structure of the acute care hospital inpatient prospective payment 
system and would avoid the complexity of coding and billing for new 
technology cases.
    Some commenters suggested that the ICD-9-CM Coding System cannot 
continue to be expanded to create new codes to identify new 
technologies in the long term, and the ICD-10-Procedure Coding System 
(ICD-10-PCS) would be an appropriate long-term solution. One commenter, 
a national hospital association, referred to ICD-10-PCS as ``the system 
of choice with appropriate attention given to implementation, education 
and system related issues.'' This commenter recommended that the 
approval process be revised to include a requirement that the applicant 
must barcode each item for ease of hospital reporting and billing, 
based on Universal Product Numbers.
    Response: We discussed our positions on each of these issues in 
detail in the September 7, 2001 final rule (66 FR 46905). We appreciate 
the interest of the many stakeholders in ensuring that Medicare 
beneficiaries have full access to improvements in medical technology. 
Our rationales for these policies have not changed since we discussed 
them in that final rule, and we did not propose changes to these 
policies in the May 9, 2002 proposed rule. Therefore, readers are 
referred to the September 7, 2001 final rule for our responses to these 
comments. However, we will continue to assess each of these policies as 
we gain more experience with this provision, and would appreciate the 
commenters' continued input.
    Comment: MedPAC agreed with the approach that we have taken in 
implementing this provision. MedPAC stated that our approach is ``a 
reasonable compromise between the need to provide quick access to 
important new technologies for Medicare beneficiaries and not spending 
more than necessary.''
    Response: We appreciate the supportive comments submitted by 
MedPAC.
    Comment: In conjunction with concern regarding overall payment 
decreases as a result of the requirement that add-on payments for new 
technology be budget neutral, several other commenters indicated that 
they agreed with our proposed denial of all of the new technology 
applications.
    Response: We want to clarify the misunderstanding expressed by some 
new technology applicants that we proposed to deny all of the 
applications. In the May 9, 2002 proposed rule, we stated that, for two 
of the applicants, XigrisTM and the InFUSE TM 
Bone Graft/LT-CAGE TM Lumbar Tapered Fusion Device, we were 
withholding a final determination on whether these technologies 
represented a substantial clinical improvement or met the cost 
threshold until the final rule. We did propose to deny the other two 
applicants, ZyvoxTM and RenewTM Radio Frequency 
Spinal Cord Stimulation Therapy.
    Comment: One commenter believed that the cost threshold for a new 
technology to qualify for add-on payments is too high, but also 
expressed

[[Page 50012]]

concern that recent proposed legislation, which would establish that 
the cost of new technology must exceed the lesser of the current 
threshold or 50 percent above the standardized amount (about $2,100), 
was too low. This commenter urged us to amend our regulations to 
continue to allow the threshold to vary by DRG (currently, the 
threshold is based on the DRG's geometric mean charge plus the DRG's 
standard deviation of charges), but at a lower level than at present.
    However, another commenter argued in favor of the alternative lower 
threshold. This commenter wrote that the current cost threshold was the 
primary reason that many technology manufacturers determined that 
submission of an application for an add-on payment would be fruitless.
    Response: We agree with the commenter that the alternative 
threshold proposed in the legislation is too low. Reducing the 
threshold to such an extent would lead to many more technologies 
qualifying for add-on payments, which would be contrary to the bundling 
theory of the DRG system and would be inflationary. Under these lower 
thresholds, technology sponsors would have a strong incentive to 
establish prices for otherwise low-cost technologies at marginally 
higher levels that would meet this minimal threshold. In contrast, 
market forces prevent otherwise low-cost technologies being priced at a 
level sufficient to meet our present, higher threshold. Even though the 
add-on payments are budget neutral, this price inflation would 
eventually be reflected in the market basket. On the other hand, the 
current thresholds greatly limit inflationary pressures by targeting 
technologies that have extraordinarily high costs. However, we will 
continue to assess the adequacy of our current criteria as we continue 
to gain experience implementing the provision for add-on payments for 
new technologies.
    Comment: One commenter argued that the evaluation of an application 
for the substantial clinical improvement criteria should focus on the 
potential for the new technology to result in a substantial improvement 
over currently covered therapies. The commenter noted that very few 
medical devices are approved by the FDA on the basis of clinical trials 
that directly compare the new technology to other Medicare-covered 
alternatives. Data demonstrating a clear advantage in clinical outcomes 
are often not available until several years after FDA approval.
    The commenter believed this approach would be beneficial to CMS, 
noting that the current process suggests a coverage-type analysis, 
potentially limiting CMS' ability to undertake any later coverage 
review after a substantial improvement determination is made. The 
commenter added that denying a request on the basis that a technology 
does not represent a substantial improvement could lead local Medicare 
contractors to restrict coverage based upon such a denial.
    Response: We disagree that data needed to evaluate whether new 
devices are a substantial improvement over current therapies are 
unavailable until years after the technology is introduced. Our 
experience evaluating the applications discussed below, as well as 
under the outpatient prospective payment system pass-through policy, 
demonstrates that the sponsors of new technologies generally do collect 
data that can be used to assess whether a new technology is a 
substantial improvement over previously available technologies. 
Further, we believe it would be difficult, if not infeasible, to assess 
objectively the validity of an unsupported claim about potential 
outcomes. Rather, we believe it is appropriate and reasonable to expect 
applicants to present verifiable data demonstrating a substantial 
improvement of any applicant new technology relative to available 
alternatives.
    We also do not believe that denial of an application on the grounds 
that the new technology is not a substantial improvement over existing 
technologies would lead to Medicare's contractors denying coverage. The 
criteria for substantial improvement determinations are quite different 
from coverage determinations, and we do not believe our contractors are 
likely to confuse the two.
    Comment: One commenter wrote that it would be inappropriate to 
apply the budget neutrality adjustment to the hospital-specific 
payments to sole community hospitals (SCHs) and Medicare-dependent 
hospitals (MDHs). The commenter's argument appears to be based on the 
presumption that the add-on payments would not be available to 
hospitals paid using the hospital-specific rates.
    Response: The commenter has correctly pointed out that we did not 
address whether add-on payments would be made to SCHs or MDHs paid on 
the basis of their hospital-specific amount in accordance with 
Sec. 412.92(d) and Sec. 412.108(c), respectively. We believe these 
additional payments for new technologies should be available to SCHs 
and MDHs paid on the basis of their hospital-specific amounts. These 
hospitals' payments under the hospital-specific amount methodology are 
adjusted by the DRG weight for each discharge. Because the costs of new 
technology would not be reflected in the base years used to calculate 
the applicable hospital-specific amounts, it is appropriate to provide 
for these hospitals to receive the add-on payments under this 
provision. Therefore, we are amending Sec. 412.88(a)(1) to reflect this 
oversight.
    Because SCHs and MDHs will be eligible to receive add-on payments 
in addition to their hospital-specific amounts, it is also appropriate 
to apply the applicable budget neutrality adjustments to the hospital-
specific amounts.
    Comment: Some commenters requested a payment calculation, showing 
that the add-on payment is made before the outlier adjustment. The 
commenters also were confused about the add-on payments in transfer 
situations. They wanted clarification on whether the transferring 
hospital would get the full add-on payment or if it would receive a 
prorated payment, and requested an example.
    In addition, one commenter asked whether payments for indirect 
medical education (IME) or the disproportionate share hospital (DSH) 
adjustment are included in the ``DRG payment amount'' that is compared 
against costs to determine whether an individual case qualifies for the 
add-on payment. The commenter argued that if the add-on payment amount 
is calculated before outlier payments, it would logically follow that 
they would also be calculated before IME and DSH payments.
    Response: The commenters are correct that the add-on payment is 
made prior to calculating whether the case qualifies for outlier 
payments (see Sec. 412.80(a)(3)). In response to the request for a 
payment example, consider a new technology estimated to cost $3,000, in 
a DRG that pays $20,000. A hospital submits three claims for cases 
involving this new technology. After applying the hospital's cost-to-
charge ratio, it is determined that the costs of these three cases are 
$19,000, $22,000, and $25,000. Under the proposed approach, Medicare 
would pay $20,000 (the DRG payment, including any IME or DSH payments) 
for the first claim. For the second claim, Medicare would pay one half 
of the amount by which the costs of the case exceed the DRG payment, up 
to the estimated cost of the new technology, or $21,000 ($20,000 plus 
one half of the amount by which costs of the case exceed the standard 
DRG payment). For the third claim, Medicare would pay $21,500 ($20,000 
plus one half of the

[[Page 50013]]

total estimated costs of the new technology). In the event the hospital 
had a fourth case with extraordinarily high costs, the fixed-loss 
outlier threshold would be applied to the total DRG payment plus the 
add-on payment for new technology ($21,500), for comparison with the 
actual costs to determine whether the case would qualify for outlier 
payments.
    With respect to the comment requesting clarification regarding the 
amount of the add-on payment made to a transferring hospital where the 
new technology eligible for add-on payments is provided prior to the 
transfer, the amount of the new technology add-on payment is not 
adjusted, but is paid up to 50 percent of the full cost of the new 
technology. This is appropriate because the hospital is likely to incur 
the full cost of the new technology when it is used. We are amending 
Sec. 412.88(a)(1) to reflect this clarification.
    With respect to whether IME and DSH payments are excluded from the 
comparison between the full DRG payment for the case and the costs for 
purposes of computing the add-on payment, Sec. 412.88(a)(1) states that 
the full DRG payment ``includes indirect medical education and 
disproportionate share.'' This amount is then compared to the costs of 
the discharge to compute the amount of the add-on payment 
Sec. 412.88(a).
    Comment: One commenter, representing a national hospital 
association, recommended against approving new technologies with very 
limited utilization because these technologies should already be 
receiving additional funds as outlier cases, and the added 
administrative burden of including these items negates any benefit. 
This commenter also suggested that we limit the number of applications 
that can be approved by setting a minimum of $30 million in projected 
payments for each new technology.
    This commenter argued that this limitation would reflect the added 
burden and administrative expense for hospitals associated with each 
additional new technology item that is approved. The commenter stated 
that training and operational and behavioral changes in response to 
specific coding requirements were examples of such additional costs.
    Response: We believe the incremental costs to hospitals associated 
with this provision should be minimal. Specifically, the additional 
payments are triggered by the presence of an ICD-9-CM code on the bill, 
information already required to process the claim for normal DRG 
payment. Accordingly, there should be little need for training or other 
operational changes in response to the approval of a new technology for 
add-on payments.
    Comment: Commenters requested further guidance for future 
applications.
    Response: We are developing more detailed instructions for 
applicants, based on our experience in processing the FY 2003 
applications. In the meantime, individuals interested in obtaining more 
information about the application process should call the Division of 
Acute Care at (410) 786-4548.
2. Applicants for FY 2003
    We received five applications for new technologies to be designated 
eligible for inpatient add-on payments for new technology. One of these 
applications was subsequently withdrawn. In the proposed rule, we 
proposed that two of the applicants, ZyvoxTM and 
RenewTM Radio Frequency Spinal Cord Stimulation Therapy, did 
not meet our criteria. We withheld a final determination on two other 
applicants, XigrisTM and the InFUSETM Bone Graft/
LT-CAGETM Lumbar Tapered Fusion Device, pending further 
review to determine whether they met the substantial clinical 
improvement criteria.
    Comment: A few commenters noted that, according to the final rule 
last year (66 FR 46914), we indicated we would propose our 
determination regarding new technology applications in the proposed 
rule. The public would then have the opportunity to comment on the 
proposed determinations. Because the FY 2003 proposed rule did not 
include specific proposed determinations for two technologies, the 
commenters argued that we did not give the public and the provider 
community an appropriate notice and comment period before the decisions 
take effect on October 1, 2002. These commenters urged us to allow for 
additional public comments on our final decisions announced in this 
final rule.
    Response: We presented the results of our analysis of the available 
data in the May 9, 2002 proposed rule, including the budget neutrality 
implications, to provide an opportunity for those interested to submit 
specific comments on the applications. In fact, we did receive comments 
on specific aspects of the applications, as noted below. In addition, 
we clearly indicated in the proposed rule we were continuing to 
evaluate XigrisTM and the InFUSETM Bone Graft/LT-
CAGETM Lumbar Tapered Fusion Device for possible approval in 
the final rule (67 FR 31428 and 31429). Therefore, we believe 
interested parties had sufficient information to evaluate our proposed 
decisions and to provide informed comments. For these reasons, we are 
not extending the period for providing public comment on the decisions 
on applicants announced below.
    We also noted in the May 9 proposed rule that, due to the very 
limited timeframe between enactment of this provision, its 
implementation through the final rule, and the deadlines to submit 
applications for consideration for FY 2003, it was necessary to be more 
flexible this first year in working with the applicants to ensure that 
they were given every opportunity to demonstrate that their new 
technology qualified for add-on payments. Insofar as possible, we 
intend in the future to announce our proposed determinations in the 
annual proposed rule updating the acute care hospital inpatient 
prospective payment system.
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

[[Page 50014]]

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).
    XigrisTM was approved by the FDA in November 2001. In 
its approval letter, the FDA wrote that this biologic ``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 (for example, as determined by APACHE II [acute physiology and 
chronic health evaluation]).'' In the May 9, 2002, proposed rule, 
however, we indicated that we were 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. Specifically, because the 
reduction in mortality in the published data was the result of a 
treatment effect in a relatively small number of patients and mortality 
was examined for only 28 days after treatment, we indicated that we 
planned to review unpublished data on all-cause mortality at the time 
of hospital discharge for all patients enrolled in the study.
    Subsequent to the publication of the proposed rule, Lilly submitted 
additional data in response to our request. The major endpoint of the 
PROWESS study was a reported reduction in 28-day all-cause mortality of 
6.1 percent. At the time the study ended, many of the participants were 
still hospitalized and whether they would ultimately recover was 
unknown. We requested data about those hospitalized patients to 
determine if the reported advantage in mortality from 
XigrisTM use persisted for all study participants. These 
data are now available and show an overall decrease in mortality for 
all patients, including patients over 65 years of age.
    Therefore, we have concluded that, when used in accordance with the 
following FDA-listed indications and contraindications, 
XigrisTM meets the substantial improvement criteria for 
additional payment for new medical services and technologies under 
Sec. 412.87(b)(1):
     Active internal bleeding;
     Recent (within 3 months) hemorrhagic stroke;
     Recent (within 2 months) intracranial or intraspinal 
surgery or severe head trauma;
     Trauma with an increased risk of like-threatening 
bleeding;
     Presence of an epidural catheter;
     Intracranial neoplasm or mass lesion or evidence of 
cerebral herniation.
    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. 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.\2\ Of course, 
the data submitted do not represent a random sample of all cases in 
these DRGs across all hospitals.
---------------------------------------------------------------------------

    \2\ The formula is n = 4\2\/B\2\, where  is 
the standard deviation of the population, and B 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.
    We noted in the May 9, 2002 proposed rule (67 FR 31429) that, due 
to the passage of Public Law 106-554 in December 2000, and the 
publication of the final rule in September 2001, it was understandable 
that the data requirements that were included in the final rule in 
order to ensure that we would receive the information necessary to 
analyze applicants for new technology add-on payments were not 
accommodated in the design of the PROWESS trial. Therefore, in this 
case, it was necessary for CMS to work with Lilly to verify 
independently the data in order to determine whether 
XigrisTM represents a substantial clinical improvement.
    After publication of the proposed rule, we analyzed our MedPAR data 
to develop a cohort group of patients in order to assess the validity 
of the charges reported for the patients in the PROWESS trial. Using 
the same methodology as Lilly, we were able to identify a cohort group 
of cases in the MedPAR data with similar criteria as the patients who 
were screened for the PROWESS trial and were discharged from the 
hospitals included in the trial. We calculated that the average total 
charges for these cases closely approximated the total charges that 
Lilly sent with its analysis. Based on this analysis, we have 
determined that the average standardized charges of $86,184 described 
above exceeds the cost threshold criteria of $82,882 for the DRGs 
involved. Therefore, we are approving XigrisTM for add-on 
payments under Sec. 412.88, to be effective for FY 2003 and FY 2004.
    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

[[Page 50015]]

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 
(24g/kg/hr for 96 hours for a 70kg person).'' Therefore, cases 
involving the administration of XigrisTM as identified by 
the presence of code 00.11 are eligible for additional payments of up 
to $3,400 (50 percent of the average cost of the drug).
    For purposes of budget neutrality, we have estimated the additional 
payments that would be made under this provision during FY 2003. Lilly 
had estimated that, initially, 25,000 Medicare patients would receive 
XigrisTM. However, Lilly's estimate does not fully reflect 
severe sepsis patients who may not have multiple organ failure, but for 
whom XigrisTM is indicated nonetheless due to APACHE II 
scores in the third and fourth quartiles. Therefore, for purposes of 
our budget neutrality estimates, we are projecting 50,000 Medicare 
patients will receive XigrisTM during FY 2003. We believe 
this projection reflects modest growth in FY 2003 from $35 million in 
sales reported by Lilly through February 2002 (since the drug was 
approved in November 2001). (At $6,800 per patient, $35 million in 
sales equates to just over 5,000 cases for the first 4 months since FDA 
approval.) We note that some analysts project sales of 
XigrisTM as high as approximately 100,000 cases annually. We 
believe our estimate reflects the potential for growth beyond the 
current usage since FDA approval in November 2001, and for the use of 
XigrisTM in treating patients without multiple organ failure 
for whom the drug is indicated but who were not included in Lilly's 
estimate.
    If the maximum $3,400 add-on payment is made for all 50,000 of 
these patients, the total amount that would be paid for these cases 
would be an additional $170 million. However, comparing the total 
standardized charges for the 274 patients age 65 or older, we 
calculated that 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 
XigrisTM would be $74.8 million (44 percent of $170 
million).
    Comment: Numerous commenters recommended that we approve 
XigrisTM. Many of the commenters described 
XigrisTM as a major advance in the treatment of patients 
with severe sepsis. However, some commenters indicated that its use has 
substantially increased the costs of caring for these patients. One 
commenter reported rationing of this drug at some institutions due to 
cost considerations. Another commenter submitted an article from a 
pharmaceutical newsletter recommending the ``best method for patient 
selection is to use the criteria for enrollment in the PROWESS trial.''
    Response: We are pleased to approve XigrisTM for add-on 
payments under this provision. As described above, we believe this drug 
represents a substantial improvement over currently available therapies 
for the treatment of severe sepsis in patients who have a high risk of 
death. We note that our finding that XigrisTM represents a 
substantial clinical improvement is limited to the indications and 
contraindications listed in the approved FDA labeling guidelines.
    Comment: Some commenters, including the applicant, objected to CMS' 
request for additional data and endpoints beyond those requested by the 
FDA for its approval of XigrisTM. The commenters argued that 
the FDA has the regulatory responsibility to monitor safety and 
efficacy of drugs and medical devices and provides rigorous review and 
oversight to the approval of drugs. They further contended that the 
placement of drugs under FDA ``priority review'' process for approval 
should be given weight when determining whether a drug meets the CMS 
``substantial improvement'' criteria.
    According to the commenters, by asking manufacturers for additional 
data to determine if an applicant meets our substantial clinical 
improvement criteria, CMS has inappropriately substituted its judgment 
for that of the FDA. The commenters suggested that we implement 
policies to ensure that these ``improprieties'' will not be repeated. 
One commenter argued that, if we plan to ask for unpublished data from 
future sponsors, we should amend our rulemaking to specify the 
conditions under which unpublished data may be required.
    Response: Although we are affiliated with the FDA and we do not 
question the FDA's regulatory responsibility for decisions to approve 
drugs, we are not using FDA guidelines to determine what drugs, 
devices, or technologies qualify for new technology add-on payments 
under Medicare. Our criteria do not depend on the standard of safety 
and efficacy that the FDA sets for general use, but on a demonstration 
of substantial clinical improvement in the Medicare population 
(particularly patients over age 65).
    To clarify this distinction, we offer the following example. The 
FDA approves a drug for general use to control the effects of seasonal 
allergies. This drug works well and has minimal side effects, but it 
makes some people feel nauseous if they take it without food. Two years 
later, another company creates a new allergy medicine that does not 
cause nausea. This drug also gets approval from the FDA. This does not 
necessarily mean that the new drug represents a substantial clinical 
improvement over the existing drug. The new drug may be better for some 
patients to take, but it is only an equivalent treatment, or another 
option, to the first drug. Therefore, the new drug would not meet the 
CMS substantial clinical improvement criteria.
    We also disagree with the suggestion that the FDA priority review 
process should be the standard by which CMS should approve new 
technologies for add-on pass-through payments. We do not want to accept 
a priority review determination by the FDA as a de facto substantial 
improvement determination by us because: (1) The FDA decision is made 
prior to reviewing all the clinical data about the product (the 
decision to review the marketing application as a priority review is 
made at the beginning of the review process); (2) if the FDA changes 
its criteria for priority review, it would change the criteria for 
substantial improvement; (3) the current criteria used by the FDA for 
priority review are not the same across product types; (4) the criteria 
for priority review are not exactly the same as CMS substantial 
improvement in all instances; and (5) it would mean that the FDA would 
be making a de facto reasonable and necessary determination, since a 
product that offers a substantial improvement is certainly reasonable 
and necessary.
    With respect to the comments regarding the request for submission 
of unpublished data, we note that the September 7, 2001 final rule 
indicated that we would require applicants to submit evidence that the 
technology does provide a substantial clinical improvement over 
existing technologies (66 FR 46914). Therefore, we disagree with the 
commenter that it is necessary to amend our regulatory process in this 
regard.
    Comment: The applicant commenter made several additional points in 
addition to the previous comment. The

[[Page 50016]]

applicant objected to the suggestion in the proposed rule that payment 
would likely be limited to patients meeting the FDA labeling 
guidelines. The applicant also objected to the statement in the 
proposed rule that the charge data submitted did not represent a random 
sample. The applicant reiterated its estimate that 25,000 Medicare 
beneficiaries would receive XigrisTM in FY 2003.
    Response: We are approving XigrisTM for add-on payments 
on the basis that it represents a substantial clinical improvement over 
other treatments for patients consistent with the FDA-listed 
indications. We do not have an administrable mechanism to identify 
patients who may receive this drug without having the FDA-listed 
indications. We will review potential options to enable us to more 
precisely make such distinctions in the future. We reserve the right to 
reexamine the issue of limiting the types of patients for which add-on 
payments are made for FY 2004.
    In determining whether a new technology is eligible for add-on 
payments, we compare the average standardized charges of cases 
involving the applicant technology to the weighted threshold of the 
relevant DRGs, which reflects the charges of all cases in those DRGs 
that are discharged from all hospitals (weighted by the number of cases 
in each DRG). Thus, our statement that the data submitted did not 
represent a random sample was made in the context of measuring whether 
the average standardized charge of the PROWESS trial data was 
statistically significantly higher than the threshold. In order for 
such a significance test to be truly valid, the trial cases would have 
to have been drawn randomly from all cases and all hospitals with cases 
in the relevant DRGs. Clearly, the PROWESS trial was not designed in 
this manner, nor would we expect it to be. Thus, we were attempting to 
approximate a standard using a methodology that requires certain 
assumptions that were not met by the data at hand, and we were merely 
acknowledging it was only an approximation.
    As stated above, we believe the applicant's estimate of 25,000 
Medicare patients receiving XigrisTM during FY 2003 does not 
reflect cases without multiple organ failures but with APACHE II scores 
in the third and fourth quartiles.
    Comment: Some commenters noted that ICD-9-CM codes do not 
distinguish between dosage amounts for drugs. They recommended (at 
least until ICD-10-PCS becomes available) relying on ICD-9-CM for 
identifying new procedures such as a new pancreas implant or a 
minimally invasive hip replacement; and incorporating the HCPCS Level 
II codes. (HCPCS stands for Health Care Financing Administration 
[recently renamed the Centers for Medicare & Medicaid Services] Common 
Procedure Coding System) for new drugs or supplies.
    One commenter indicated that ICD-9-CM codes appear to be sufficient 
at this time, but, as new technologies proliferate, they will become 
overwhelming. However, the commenter did request guidance from us about 
using ``nontraditional'' ICD-9-CM codes, as well as information about 
reporting these codes in instances where more than six procedure codes 
(the maximum spaces provided on the bill) are involved.
    Response: We appreciate the insight provided by this commenter 
regarding future coding options and will take it into consideration as 
we look to future refinements to this policy. However, for the reasons 
addressed at length in the September 7, 2001 final rule, we are using 
the ICD-9-CM codes at this time to identify cases eligible for the new 
technology add-on (66 FR 46909-10). However, because of limited space 
available for new ICD-9-CM codes, we are unable at this time to 
differentiate the volume of drugs that are administered. Therefore, as 
described above, we will pay on the basis of an average dose per 
patient.
    As stated above, add-on payments for XigrisTM will be 
calculated for cases identified by use of the ICD-9-CM code 00.11 (when 
other conditions are met). In relation to guidance on the use of this 
code, we believe the documentation requirements are straightforward: 
consistent with the definition of the code, the medical record must 
indicate infusion of drotrecogin alfa (activated). With respect to 
situations where more than six procedure codes may be involved, 
hospitals should follow normal coding guidelines for selecting which 
codes to include.
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.

[[Page 50017]]

    Cost data were submitted for 88 patients participating in the 
follow-up study described above. This trial was a single-level, 
anterior lumbar interbody fusion clinical study. Of the 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.
    At the time of the proposed rule, this technology was not approved 
for general use by the FDA. Therefore, we indicated that if the FDA 
approved the product for general use prior to our issuance of the final 
rule, we would issue a determination whether this technology represents 
a substantial clinical improvement under the criteria outlined in the 
September 7, 2001 final rule.
    On July 2, 2002, the FDA approved this technology. The approval was 
for spinal fusion procedures in skeletally mature patients with 
degenerative disc disease at one level from L4-S1. Therefore, based on 
the FDA's approval, multilevel usages of this technology would be off-
label. As noted above, this technology would meet the cost threshold 
only if the added costs of multilevel fusions are taken into account. 
Because the FDA has not approved this technology for multilevel 
fusions, and the applicant has not submitted data to demonstrate this 
technology is a substantial clinical improvement for multilevel fusions 
(as described above, the clinical trial upon which the application was 
based was a single-level fusion trial), we cannot issue a substantial 
clinical improvement determination for multilevel fusions. Therefore, 
because the average charges for this new technology, when used for 
single-level spinal fusions, does not exceed the threshold of $37,815 
noted above, we are denying this application for add-on payments during 
FY 2003. Because the new technology did not qualify on the basis of 
charges above the thresholds, we did not make a substantial improvement 
determination.
    Comment: A few commenters were very supportive of approving 
Medtronic Sofamor Danek's InFUSETM Bone Graft technology. 
These commenters note that this rhBMP-2 technology is a substantial 
clinical improvement as it obviates the need for a second surgical 
procedure to harvest autogenous iliac crest bone. The commenters noted 
that this substantial improvement focuses mostly on relief of pain in 
patients because many patients who undergo bone harvesting have pain at 
the donor site up to 10 years after the surgery.
    Several other commenters, however, recommend that we not approve 
this application for add-on payments. These commenters stated that 
``the clinical trial results solidly counter the claim of significant 
improvement.'' Commenters also objected to the data that the 
manufacturer provided, stating that in order for the threshold to be 
met, the manufacturer provided estimates for procedures that would 
involve multilevel fusions. At the time of the proposed rule, the FDA 
had not approved the treatment, and commenters noted that the FDA could 
not approve the treatment for multilevel surgeries because it had been 
given no clinical evidence for these procedures. The commenters pointed 
out that FDA's approval (which came on July 2, 2002) could (and does) 
only indicate approval for use of the product for single-level fusions. 
Therefore, the commenters strongly opposed the approval of the BMP 
applicant because it does not meet our financial threshold. The 
commenters also were concerned that, if approved for new technology 
payments, the technology may be used inappropriately off label and for 
indications that have not been approved by the FDA.
    Response: We stated in the September 7, 2001 final rule that we 
believe the technologies approved for add-on payments should be limited 
to those new technologies that have been demonstrated to represent a 
substantial improvement in caring for Medicare beneficiaries, such that 
there is a clear advantage to creating a payment incentive for 
physicians and hospitals to utilize the new technology (66 FR 46913). 
Further, we stated that we believe it is in the best interest of 
Medicare beneficiaries to proceed very carefully with respect to the 
incentives created to quickly adopt new technology.
    As noted above, we are denying this application for add-on payments 
during FY 2003 because it does not meet our cost threshold when used 
for single-level spinal fusions, and there is no available evidence 
upon which to determine whether it represents a substantial improvement 
for multilevel uses.
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

[[Page 50018]]

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, in the May 9, 2002 proposed rule, we did 
not propose any changes to the DRG assignment of these cases. We 
indicated that 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.
    Comment: Several commenters, including the applicant, strongly 
objected to our denial of ZyvoxTM for new technology 
payments. They criticized our decision not to approve it on the grounds 
that payments for this expensive drug are already incorporated into the 
DRG recalibration for FY 2003. The commenters argued that, based on the 
recent assignment of an ICD-9-CM code, the drug still qualifies for 
add-on payments under the Congressional intent of the law.
    The commenters referenced the language of section 
1886(d)(5)(K)(ii)(II) of the Act in support of their claim that this 
technology qualifies as new. They believed the 2-year to 3-year period 
``beginning on the date on which an inpatient hospital code is issued 
with respect to the service or technology'' applicable to 
ZyvoxTM should begin October 1, 2002, when new code 00.14 
becomes effective. They argued that this new code will allow data to be 
accumulated to track the costs of these cases.
    Response: Again, we do not believe it would be appropriate to 
consider technologies that have been on the market for 2 or 3 years for 
approval under this provision on the basis that a new, more precise, 
procedure code is subsequently issued. Allowing technologies that have 
already been in use to attain higher payments as a result of the 
assignment of a new, more specific ICD-9-CM code would open the door 
for the sponsors of any medical device or technology to consider 
whether they might qualify their product for add-on payments by 
requesting and receiving a new code from the ICD-9-CM Coordination and 
Maintenance Committee. We do not believe it was Congress' intent that 
this provision should be interpreted that way.
    Therefore, it is necessary to establish a point after which 
previously existing technologies are not eligible to qualify for add-on 
payments under this new provision. We believe it is reasonable to 
establish the cutoff point such that those technologies with data 
available in the FY 2001 MedPAR to be included in the calculation of 
the FY 2003 DRG weights will not be eligible for new technology 
payments. We note that this process of incorporating new technologies 
into existing DRGs, where they eventually affect the weights depending 
on their utilization, was how all new technologies have been introduced 
since 1984. While we recognize Congress' intent to revise this process 
to expedite the introduction of new technologies, there was no 
indication in the legislation that the new policy was to apply to 
technologies whose costs were already reflected in the DRG weights.
    Comment: The applicant criticized CMS for delaying the 
implementation of the provision. The commenter noted that the provision 
was to be implemented, ``[n]ot later than October 1, 2001'' and stated 
that CMS failed to implement the law by October 1, 2001. They argued 
that, by delaying the implementation, CMS effectively prevented 
ZyvoxTM from ever meeting the ``new'' criteria, even though 
the drug got approval only 8 months before the provision was passed.
    Response: We disagree that we delayed implementation of this 
provision. In the September 7, 2001 final rule, we stated that, 
although we did not approve any new technologies for add-on payments 
effective October 1, 2001, we did carefully evaluate all technologies 
that were brought to our attention, either as a result of our internal 
analysis or by the public, including those submitted for consideration 
during the public comment period on the May 4, 2001 proposed rule. 
ZyvoxTM was not among the technologies submitted for 
consideration at that time.
    Comment: Commenters argued that, although ZyvoxTM was 
available and used during FY 2001, and therefore would be reflected in 
hospitals' charges used to set the FY 2003 DRG relative weights, due to 
the high cost of the drug, it is far from clear that hospitals 
prescribed the product for the majority of Medicare patients for whom 
it would be most appropriate. Therefore, the impact of the costs of the 
drug on the DRG weights is understated.
    Response: We cannot assess whether the utilization of 
ZyvoxTM was hampered by Medicare payments during FY 2001. 
However, we would note that ZyvoxTM was treated in the same 
manner as other new technologies have been over the years. Further, we 
will continue to evaluate the appropriateness of payment for these 
patients as we do all other technologies and patient categories.
    Comment: One commenter objected to the reference to 
ZyvoxTM sales figures as evidence of expanding general 
access to the drug. The commenter stated that we provided no evidence 
to indicate this sale growth is the result of expanding use in the 
treatment of Medicare beneficiaries. The commenter went on to argue 
that ``sales reports and other company financial data must be 
considered outside the scope of the review process.''
    Response: We disagree that we should ignore sales reports related 
to a product seeking additional payments to promote its expansion into 
the medical market. This market analysis was certainly not the basis 
for our decision not to approve this applicant, as described above. The 
sales reports were simply a portion of data we considered in our 
evaluation of the effects of our decision. We also note

[[Page 50019]]

that we received no evidence during the comment period to document that 
the sales growth referenced above did not pertain to Medicare 
beneficiaries.
    Comment: The applicant expressed concern that, during discussions 
and meetings with CMS, no mention was made that there might be an issue 
related to the application meeting the ``new'' criterion.
    Response: The criteria to qualify for add-on payments were 
specified clearly in the September 7, 2001 final rule. Clearly, the 
applicant believed it met the criteria, as evidenced by the fact that 
it applied and its subsequent comments on our proposed decision. The 
facts regarding the point at which ZyvoxTM was approved by 
the FDA and when it became available for use are agreed upon. The 
difference of opinion centers on the criteria for ``new''. The 
commenter has described its interpretation, with which we disagree, as 
discussed above. The public comment process is part of the review and 
approval process. We believe the public comment process is the most 
appropriate avenue to consider the interpretation of legislative and 
regulatory criterion. As discussed above, we do not believe that it 
would be appropriate to allow technologies that have already been in 
use to attain higher payments as a result of the assignment of a new, 
more specific, ICD-9-CM code.
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 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)....................................   $2,750.00
  One Extension (8 Electrode)...............................      695.00
  Receiver (8 Channel)......................................    4,995.00
  Transmitter (8 Channel)...................................    4,995.00
    Total System............................................   13,435.00
16 Channel/Electrode System:
  Two Leads (16 electrode)..................................    5,550.00
  Two Extensions (16 electrode).............................    1,390.00
  Receiver (16 Channel).....................................    7,295.00
  Transmitter (16 Channel)..................................    7,295.00
    Total System............................................   21,480.00
------------------------------------------------------------------------

    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 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 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.
    Comment: Several commenters objected to our proposed decision to 
not approve this application because the technology does not meet our 
criterion for ``new'' designation.

[[Page 50020]]

    Response: We continue to believe that this technology does not meet 
the criterion for the reasons given in the proposed rule, as elaborated 
on in our response to comments discussed above in relation to 
ZyvoxTM.

III. Changes to the Hospital Wage Index

A. Background

    Section 1886(d)(3)(E) of the Act requires that, as part of the 
methodology for determining prospective payments to hospitals, the 
Secretary must adjust the standardized amounts ``for area differences 
in hospital wage levels by a factor (established by the Secretary) 
reflecting the relative hospital wage level in the geographic area of 
the hospital compared to the national average hospital wage level.'' In 
accordance with the broad discretion conferred under the Act, we 
currently define hospital labor market areas based on the definitions 
of Metropolitan Statistical Areas (MSAs), Primary MSAs (PMSAs), and New 
England County Metropolitan Areas (NECMAs) issued by the Office of 
Management and Budget (OMB). 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 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.
    Comment: Commenters strongly encouraged us to take the time needed 
to develop the most appropriate survey instrument for collecting 
occupational mix data and to provide adequate time for hospitals to 
have available the required information. One commenter wrote that 
neither CMS nor the hospital industry is ready to implement an 
occupational mix adjustment. The commenter believed that, when the law 
was passed requiring occupational mix data to be collected by the end 
of September 2003, Congress did not understand the burden and 
complexity of collecting and using the information. The commenter noted 
that, over 10 years, CMS encountered many problems when it first tried 
to collect occupational mix data and believed that, today, hospitals 
are in no better position to provide the necessary information.
    A commenter also requested that we publish a rule for comment that 
delineates our proposed occupational mix methodology and illustrates 
how the index mix would be calculated and used to adjust the overall 
wage index. The commenter expressed interest in continuing to work with 
us on this effort.
    MedPAC has recommended that CMS collect the occupational mix data 
as part of the Medicare cost report, just as the wage data are 
currently collected. MedPAC notes that a separate survey usually has a 
lower initial response rate, and incorporating the survey as part of 
the cost report should minimize reporting burden on hospitals, enhance 
data accuracy, and help to achieve a 100-percent response rate. MedPAC 
recommended that we modify the cost report form and instructions as 
soon as possible to enable the collection of this data during the 
second round of data collection. MedPAC also recommended that we 
provide detailed information as soon as possible to hospitals regarding 
the specific occupational mix data they will be required to report in 
order to allow hospitals time to modify their information systems to 
collect the necessary wage and hours data. Although, MedPAC 
acknowledges it may not be possible to collect accurate data for FY 
2002, it believes that it still may be feasible to collect the data for 
FY 2003 and meet the Congressional mandate to implement an occupational

[[Page 50021]]

mix adjustment for the FY 2005 wage index.
    A few commenters expressed concern that an occupational mix 
adjustment would only recognize geographical differences in the price 
hospitals pay for a particular employee category and would not reflect 
that a hospital, such as a teaching hospital, may have higher labor 
costs because its patient population requires a larger number of highly 
skilled, highly priced employees. The commenters noted that a previous 
MedPAC study showed that an occupational mix adjustment would lower the 
wage index values for many areas where teaching hospitals are located. 
The commenters also expressed concern that Medicare's current DRG 
payment system does not adequately recognize patient severity and the 
higher resource costs that are associated with treating complex 
patients. The commenters believed that the current wage index 
methodology more appropriately reflects a higher employee skill mix, as 
reflected in higher wage indices where teaching hospitals are located, 
allowing teaching hospitals to recoup some of the losses they incur 
under the current DRG system. The commenters suggested that, if we 
include an occupational mix adjustment in the wage index, we should 
also refine the DRG system to ensure that more complex cases are 
adequately reimbursed.
    Response: We appreciate all the comments we received and the 
continued support and assistance of hospitals in developing the 
occupational mix adjustment. Before implementing the adjustment, we 
will publish the details of the occupational mix methodology in the 
Federal Register and provide for public comment.

B. FY 2003 Wage Index Update

    The FY 2003 wage index values in section V. of the Addendum to this 
final 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 final 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 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

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, in the May 
9, 2002 proposed rule, we proposed to remove 100 percent of GME and 
CRNA costs from the FY 2003 wage index.
    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 
used the final wage index file. We found that the majority of labor 
market areas, both rural and urban, would benefit by the removal of all 
of these costs (304 out of 373). Only one rural labor market area would 
be negatively impacted by this change (New Hampshire by -0.09 percent). 
We note that, as part of its Report to the Congress on Medicare in 
Rural America (June 2001), 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 decreases range from .01 to 1.0 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 proposed to remove 100 percent of GME and CRNA 
costs beginning with FY 2003 wage index.
    Comment: Several commenters stated that, although the early 
elimination of GME and CRNA costs from the wage index calculation is 
not as significant as some other payment reductions, the proposed 
policy represents a net reduction in payments for some hospitals 
compared to payments using a wage index with 80 percent of GME and CRNA 
costs removed. Based on CMS' analysis presented in the proposed rule, 
the commenters noted that excluding 100 percent of these costs from the 
FY 2003 wage index would negatively affect hospitals in more than 20 
percent of the labor market areas. Commenters also noted that the 
affected areas are primarily urban, where large teaching hospitals are 
more likely to be located. In addition, the commenters noted that urban 
hospitals have to absorb increased indigent care costs.
    The commenters believed that our current 5-year phaseout policy was 
the result of a good-faith agreement negotiated with a hospital 
industry workgroup. They further believed that adoption of the proposed 
accelerated phaseout for the FY 2003 wage index would establish an 
unfortunate

[[Page 50022]]

precedent that questions the rationale for hospital associations to 
enter into any future negotiations with CMS. The commenters request us 
to adhere to our original 5-year phaseout schedule.
    One commenter supported our proposal to remove 100 percent of GME 
and CRNA costs from the FY 2003 wage index.
    Response: We implemented changes to the FY 1995 cost report (used 
to calculate the FY 1999 wage index) in order to separately identify 
the wage data associated with GME and CRNAs. However, due to data 
reporting problems, we were unable to remove these costs until the FY 
2000 wage index. In the meantime, the hospital industry established a 
workgroup that developed a compromise agreement on the removal of these 
data from the wage index, including a 5-year phaseout to alleviate the 
negative impact this change would have on some areas. The 
recommendations of the workgroup were presented to CMS, and most (but 
not all) of them were accepted (see the July 30, 1999 final rule, 64 FR 
41505). However, we note that CMS was not a party to the industry 
workgroup that developed the compromise agreement.
    As noted above, Medicare pays hospitals for GME and CRNA costs 
separately from the acute care hospital inpatient prospective payment 
system. CMS is responsible for ensuring the accuracy and fairness of 
the wage index and it is our assessment at this time that, due to the 
small impact as described above, of removing GME and CRNA costs from 
the wage index, and because hospitals that are negatively impacted by 
this change are in areas that have benefited from the inclusion of 
these costs over the years, it is in the interest of improving the 
overall fairness of the wage index to accelerate the phaseout. 
Therefore, we are proceeding with removing 100 percent of GME and CRNA 
costs beginning with the FY 2003 wage index.
    Comment: One commenter representing CRNAs requested that we 
continue to include in the wage index the costs of contract CRNAs who 
are used by hospitals to address staffing shortages. The commenters 
noted that our proposal recognizes the fact that hospitals are 
increasingly reliant upon contract labor for providing direct and 
indirect patient care. The commenter believed that hospitals should not 
be penalized for having to use contract CRNAs to meet staffing needs.
    Response: As explained above, we believe the wage index should, to 
the extent possible, reflect those costs for which hospitals receive 
payment under the acute care hospital inpatient prospective payment 
system. Because hospitals are not paid under this system for CRNAs' 
services, we continue to believe that CRNA costs are appropriately 
excluded from the 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 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 the May 9, 2002 proposed rule, we proposed 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 proposed 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).
    Comment: Several commenters supported our continuing efforts to 
examine contract labor costs for inclusion in the wage index and to 
ensure that the wage index is not manipulated to distort an area's wage 
level. MedPAC commented that ``excluding contract labor costs may 
affect the accuracy of the wage index and introduces undesirable 
incentives that may affect hospital employment decisions.'' However, 
some commenters cautioned that it will be challenging for hospitals to 
provide the required detailed data and documentation for the 
appropriate costs and hours and to exclude nonlabor expenses, such as 
equipment and supplies, from total contract expenses. The commenters 
believed that, for most housekeeping and dietary services contracts,

[[Page 50023]]

meaningful data regarding hours are nonexistent. For management 
contracts, some commenters believed that the collection of cost and 
hours data may be more feasible. However, the contract itself may not 
provide enough detail to be a sufficient source of documentation. One 
commenter disagreed with the inclusion of contract labor costs in the 
administrative and general cost center because the commenter believed 
that the types of costs reported in that center vary too widely across 
hospitals to be comparable.
    The commenters advised that it is important for us to ensure 
consistency among fiscal intermediaries in their auditing of supporting 
documentation for contract labor. Further, some commenters supported a 
delay in including the additional contract labor costs until we develop 
clear definitions and acceptable methods for tracking the costs and 
hours. A delay would also allow hospitals more time to assure the 
appropriate and accurate collection of the required data. One commenter 
also requested that CMS make the new data regarding contract labor 
costs available for review, analysis, and comment prior to including 
these costs in the wage index.
    Response: Due to, among other things, the general support we 
received for our proposal to include costs for contract indirect 
patient care services in the wage index, we are proceeding as proposed. 
We will revise the cost report form and instructions, as early as it is 
feasible to do so. We also will monitor the hospital industry for 
information regarding hospitals' ability to provide the data. Further, 
we will work with hospitals and intermediaries to develop acceptable 
methods for tracking the costs and hours. Finally, before including 
these additional costs in the wage index, we will provide a detailed 
analysis of the impact of including these additional costs in the wage 
index values in the Federal Register and provide for public comment. 
Our final decision on whether to include contract indirect patient care 
labor costs in our calculation of the wage index will depend on the 
outcome of our analyses and public comments.
    Comment: One commenter believed that, in order to be a true measure 
of labor market differences, the wage index should reflect only those 
jobs and employment practices that are the same in every geographic 
area. In addressing the disparity in the current wage index policy that 
excludes the costs for contracted low paying jobs from the wage index, 
while the costs for the same services under direct hire are included, 
the commenter suggested that we consider excluding from the wage index 
all labor costs that are obtained under different methods across 
hospitals.
    Response: The use of contract labor is widespread among hospitals, 
and the practice of hiring under contract exists to some degree in 
virtually every service a hospital provides. Under the commenter's 
proposal, the resulting wage index would reflect too few categories of 
services to be representative of hospitals' labor force. Therefore, we 
believe it would not be feasible to exclude from the wage index all 
services that are obtained by hospitals using different employment 
methods.

D. Verification of Wage Data From the Medicare Cost Report

    The data for the 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 July 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. The unresolved data 
elements that were included in the calculation of the proposed FY 2003 
wage index have been resolved and are reflected in calculation of the 
final FY 2003 wage index.
    The final rule we removed data for 36 hospitals that failed edits. 
For 14 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, 
or are in bankruptcy status, and supporting documentation is no longer 
available. We identified 22 hospitals with incomplete or inaccurate 
data resulting in zero or negative, or otherwise aberrant, average 
hourly wages. Therefore, the hospitals were removed from the 
calculation. As a result, the final FY 2003 wage index is calculated 
based on FY 1999 wage data for 4,797 hospitals.
    Comment: One commenter requested that we remove the data from the 
FY 2003 wage index calculation for a specific hospital that closed in 
2001. According to the commenter, the hospital had a major accounting 
and recordkeeping problem dating back several years.
    Response: We have always maintained, subject to limited 
expectations, that any hospital that is in operation during the data 
collection period used to calculate the wage index should be included 
in the database, since the hospital's data reflect conditions occurring 
in that labor market area during the period surveyed (59 FR 45353). 
While we also believe it is appropriate to eliminate data for 
terminated hospitals when there is reason to believe that the data are 
incorrect, and the data cannot be verified due to the hospital's 
closure, if the wage data for a terminated hospital does not fail any 
of our edits for reasonableness, the hospital's data are included in 
the calculation of the area's wage index.
    During FY 1999, the period used to calculate the FY 2003 wage 
index, the hospital in question was the second largest hospital in its 
MSA. We find the hospital's FY 1999 Worksheet S-3 wage data to be 
consistent with hospitals of similar size in the MSA. Therefore, we 
will retain the wage data for the closed hospital in the FY 2003 wage 
index. We also note that removing the hospital's data from the wage 
index calculation would actually lower the MSA's wage index value.
    Comment: One commenter representing a national hospital association 
requested that CMS add a fatal edit to the cost reporting systems to 
eliminate obvious errors that are difficult or impossible to correct 4 
years later when we use the data for the wage index. Examples of such 
errors are negative average hourly wages or a line item that includes 
salaries but no associated hours. Currently, we delete the problematic 
data elements, but the commenter believed that this does not 
necessarily make the reported data better, nor does it make the data 
consistent with data reported by other hospitals. The commenter 
recommended that we include a fatal edit that will not allow the cost 
report to be filed by the hospital until all required wage data have 
been entered.
    Response: We agree with the commenter that these obvious errors 
should be corrected by the hospital before the cost report is filed. 
The cost reporting system currently has an edit that prevents the 
reporting of negative adjusted salaries. Therefore, no line item should 
have a negative average hourly wage. However, due to the complexities 
of the cost report software, a hospital is unable to simply adjust 
Worksheet S-3, Part II salaries to zero, if hours are missing or 
inaccurate, without also triggering a necessary adjustment to the trial 
balance (Worksheet A), as most salary items reported on Worksheet S-3, 
Part II are directly transferred from Worksheet A. Because Worksheet S-
3, Part II wage

[[Page 50024]]

data are only used for wage index purposes, we believe it is preferable 
for both CMS and hospitals not to have the entire cost report rejected, 
and risk an untimely submission of the cost report, because the hours 
on Worksheet S-3, Part II are problematic.
    We are working on revising the intermediaries' software to improve 
their edits and give them more flexibility to make adjustments directly 
to Worksheet S-3, Part II when the adjustments are necessary for wage 
index purposes only. We acknowledge that this revision would not help 
hospitals to detect obvious errors as early as possible, that is, 
before they file their cost reports with their intermediaries. However, 
improved intermediary edits would allow the errors to be identified and 
corrected before the data are submitted to us to be used in developing 
the wage index.

E. Computation of the FY 2003 Wage Index

    The method used to compute the final FY 2003 wage index follows.
    Step 1--As noted above, we based the 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 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
------------------------------------------------------------------------
         After                   Before             Adjustment 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                 01/15/00                 1.00710
        01/14/00                 02/15/00                 1.00358
        02/14/00                 03/15/00                 1.00000
        03/14/00                 04/15/00                 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

[[Page 50025]]

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.
    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 $23.2295.
    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 
$11.0086 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 180 hospitals in 39 MSAs. The MSAs affected by this 
provision are identified by a footnote in Table 4A in the Addendum of 
this final rule.
    Comment: Two commenters opposed our use of 3-year-old data for 
developing the wage index. The commenters believed that the FY 2003 
wage index does not reflect current market conditions for nurses. For 
example, one commenter stated that, due to the current nursing 
shortage, her facility's average hourly wage has increased 10 percent 
over the past 18 months. However, the wage index does not adequately 
reflect the increased wage costs. The commenter noted that rural 
hospitals have been severely impacted by the nursing shortage. Since 
rural hospitals are reliant upon Medicare reimbursement, the commenter 
suggested that we revise the wage index methodology to allow the wage 
index to reflect labor cost increases sooner.
    Response: The wage index is a relative measure, which compares area 
average hourly wages to the national average hourly wage. The nursing 
shortage and increased nursing wages are a national phenomenon. We 
believe the wage index is minimally impacted by inflationary effects of 
increased nursing costs. Increases in hospital wages overall would be 
reflected in the market basket.
    In computing the wage index, we use data from cost reports 
beginning during the most recent Federal fiscal year for which we have 
a complete year's worth of data. For the FY 2003 wage index, that is 
cost reports that began during FY 1999. Because hospitals' cost reports 
may end as late as August or even September of the following year, it 
would not be feasible for us to use cost reports that began during FY 
2000 (many of which would not close until the latter part of 2001). Due 
to the time period allowed for: (1) Hospitals to complete and submit 
their cost reports to their intermediaries; (2) intermediaries to 
perform a separate, detailed review of all hospitals' wage data and 
submit the results to CMS; and (3) CMS to compile a complete set of all 
hospitals' wage data from a given Federal fiscal year, it would not be 
possible to use FY 2000 cost report data to calculate the FY 2003 wage 
index. As described in the proposed rule (67 FR 31434) and section 
III.E. of this final rule, we adjust the wage index to a common period 
that reflects the latest cost reporting period for the filing year. For 
the FY 2003 wage index, this period is September 1, 1999 to August 31, 
2000.
    Comment: One commenter recommended that, to reflect the labor 
markets in which rural hospitals compete more accurately, the wage 
index value for a rural area should be the average of the three lowest 
MSA rates in the geographic area.
    Response: We note that the statute requires that we apply wage 
indexes that reflect ``the relative hospital wage level in the 
geographic area of the hospital'' (section 1886(d)(3)(E) of the Act). 
Furthermore, in some States, there are some MSAs for which the 
calculated wage index value is actually lower than the rural area of 
the state. As we discussed in the proposed rule (67 FR 31435) and in 
section III.E. of this final rule, for those urban areas, we assign the 
statewide rural wage index value. We are uncertain as to whether the 
commenter considered this policy in its recommendation. While the 
commenter did not provide details of its rationale for the recommended 
change, we appreciate the commenter's suggestion and welcome a more 
detailed discussion and analysis.
    Comment: One commenter wrote that CMS' instructions for developing 
wage-related costs using Generally Accepted Accounting Principles 
(GAAP) are inconsistently communicated by CMS staff and inconsistently 
applied by the fiscal intermediaries. The commenter urged us to ensure 
the credibility of the wage index by requiring that our staff and 
contractors understand and consistently apply our wage index policies 
to eliminate variations in interpretation and application of the wage 
data.
    Response: In an effort to clarify our instructions and to promote 
consistency in hospitals' reporting and CMS' and the intermediary's 
handling of wage-related costs that are developed using GAAP, we have 
revised the cost report instructions (in Transmittals 8 and, soon to be 
released, 9) and the intermediary's desk review program. Because of the 
wide variation in GAAP methodologies, we continue to emphasize that it 
is the responsibility of the hospitals to be able to provide adequate 
support for the GAAP methodologies they apply. In addition, if a 
hospital believes that an intermediary may be incorrectly handling a 
particular issue, the hospital is encouraged to bring it to our 
attention. We will continue our efforts to ensure uniform reporting of 
the wage data.
    Comment: One commenter, representing the District of Columbia,

[[Page 50026]]

indicated that the Washington, DC-MD-VA-WV MSA includes 16 Virginia 
hospitals, 13 Maryland hospitals, 12 District of Columbia hospitals, 
and 2 West Virginia hospitals. The commenter was concerned about the 
negative impact of the West Virginia and Maryland hospitals on the 
Washington, DC-MD-VA-WV MSA wage index (although the commenter did not 
specify a particular issue with the West Virginia hospitals). Unlike 
hospitals in all other States and the District of Columbia, Maryland 
hospitals, which are under a waiver from the acute inpatient 
prospective payment system, do not rely on the wage index adjustment 
factor to adjust their inpatient Medicare payments. Therefore, the 
commenter wrote, Maryland hospitals have no incentive to accurately 
report their wage costs on the Medicare cost report or to review and 
request corrections to CMS' wage index public use files. The commenter 
requested us to carefully review the impact of Maryland's all-payor 
system on hospitals within the same MSA.
    Response: As the commenter notes, Maryland hospitals are paid under 
a program waiver (section 1814(b)(3) of the Act), in which the State 
establishes hospital inpatient and outpatient payment rates for 
Medicare, Medicaid, and private payors. The Medicare wage index is not 
a factor in the State's ratesetting methodology. However, in recent 
years the wage index has been applied to the Medicare payment rates for 
other providers that are not under the State's waiver, such as SNFs, 
hospices, and home health agencies. Many Maryland hospitals own, or are 
members of systems that own, facilities or entities that are now 
directly impacted by the quality of the hospitals' reported data.
    As with all hospitals in the wage index, we edited the FY 1999 wage 
data for the Maryland and West Virginia hospitals. We found no 
significant problems in their wage data. We believe that the Maryland 
hospitals' wage data are reasonable for the State and the MSA. The 
lower average hourly wages for the West Virginia hospitals are 
comparable to other hospitals in that State. Furthermore, under OMB's 
definition of the Washington, DC-MD-VA-WV MSA, these Maryland and West 
Virginia hospitals are part of that MSA. Therefore, the wage data for 
these hospitals will continued to be used in the calculation of the 
area wage index for the Washington DC-MD-VA-WV MSA.

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. In accordance with section 
1886(d)(8)(B)(ii)(II) of the Act, in the May 9, 2002 proposed rule, we 
proposed 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.

[[Page 50027]]

     The wage index value for a redesignated urban or rural 
hospital cannot be reduced below the wage index value for the rural 
areas of the State in which the hospital is located.
     Rural areas whose wage index values would be reduced by 
excluding the wage data for hospitals that have been redesignated to 
another area continue to have their wage index values calculated as if 
no redesignation had occurred.
     Rural areas whose wage index values increase as a result 
of excluding the wage data for the hospitals that have been 
redesignated to another area have their wage index values calculated 
exclusive of the wage data of the redesignated hospitals.
     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 wage index values for FY 2003 are shown in Tables 4A, 4B, 4C, 
and 4F in the Addendum to this final rule. Hospitals that are 
redesignated should use the wage index values shown in Table 4C. Areas 
in Table 4C may have more than one wage index value because the wage 
index value for a redesignated urban or rural hospital cannot be 
reduced below the wage index value for the rural areas of the State in 
which the hospital is located.
    Tables 3A and 3B in the Addendum of this final rule list the 3-year 
average hourly wage for each labor market area before the redesignation 
of hospitals, based on FYs 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 final 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) 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.
    We indicated in the proposed rule that, at the time the proposed 
wage index was constructed, that the MGCRB had completed its review of 
FY 2003 reclassification requests. Table 9 of this final rule 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. This table also includes hospitals reclassified for 
purposes of the standardized amount and hospitals located in urban 
areas that have been designated rural in accordance with section 
1886(d)(8)(E) of the Act. There are 54 hospitals reclassified for the 
wage index beginning during FY 2003. In addition, 367 hospitals are 
reclassified for FY 2003 based on their 3-year reclassification that 
became effective during FY 2001, and 181 hospitals are reclassified for 
FY 2003 based on their 3-year reclassification that became effective 
during FY 2002. There are 24 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 34 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 59 
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 FY 2003 wage 
index values incorporate all of these hospitals. Since publication of 
the May 9 proposed rule, the number of reclassifications has changed 
because some MGCRB decisions were still under review by the 
Administrator and because some hospitals decided to withdraw their 
requests for reclassification.
    Applications for FY 2004 reclassifications are due to the MGCRB by 
September 3, 2002. We note this is also the deadline for canceling a 
previous wage index reclassification withdrawal or termination under 
Sec. 412.273(d) (as added by this final rule). At the time of 
publication the May 9, 2002 proposed rule, the internet site for 
reclassification (http://www.hcfa.gov/regs/mgcinfo.htm) was not 
operational. To obtain an application for MGCRB reclassification, call 
the MGCRB at (410) 786-1174. The mailing address of the MGCRB is: 2520 
Lord Baltimore Drive, Suite L, Baltimore, MD 21244-2670.
    Changes to the wage index that resulted from withdrawals of 
requests for reclassification, wage index corrections, appeals, and the 
Administrator's review process have been incorporated into the wage 
index values published in this final rule. The changes may affect not 
only the wage index value for specific geographic areas, but also the 
wage index value redesignated hospitals receive; that is, whether they 
receive the wage index value for the area to which they are 
redesignated, or a wage index value that includes the data for both the 
hospitals already in the area and the redesignated hospitals. Further, 
the wage index value for the area from which the hospitals are 
redesignated may be affected.
    In the May 9, 2002 proposed rule, we proposed 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, including any comments 
received and our responses to those comments.
    We receive several comments pertaining to the FY 2003 or FY 2004 
MGCRB reclassification process. These are addressed below.
    Comment: One commenter expressed concern that the methodology used 
for wage index reclassification for FY 2003 reclassification 
applications does not include a process by which corrections to 1996 
and 1997 cost reporting data may be submitted. The commenter suggested 
that we allow for the correction of inaccurate data from prior years as 
part of a hospital's bid for geographic reclassification, and that not 
to allow corrections to the data results in inequities in the 
calculation in the average hourly wage for purposes of 
reclassification.
    Response: Effective with reclassifications for FY 2003, section 
1886(d)(10)(D)(vi)(II) of the Act provides that the MGCRB must use the 
average of the 3 most recent years of hourly wage data for the hospital 
when evaluating a hospital's request for reclassification. To evaluate 
applications for wage index reclassifications for FY 2003, the MGCRB 
used the 3-year average hourly wages published in Table 2 of the August 
1, 2001 Federal Register. These average hourly wages are taken from 
data used to calculate the wage indexes for FY 2000, FY 2001, and FY 
2002, based on cost reporting periods beginning during FY 1996, FY 
1997, and FY 1998, respectively.
    In the August 1, 2001 Federal Register, we revised the Medicare 
regulations at Sec. 412.230(e)(2)(ii)(A) to specify that hospitals 
seeking reclassification must provide a 3-year average hourly wage 
using data from the hospital wage survey used to construct the wage 
index in effect for prospective payment purposes (66 FR 39934).

[[Page 50028]]

Hospitals have ample opportunity to verify the accuracy of the wage 
data used to calculate their wage index and to request revisions, but 
must do so within the prescribed timelines. We consistently instruct 
hospitals that they are responsible for reviewing their data and 
availing themselves to the opportunity to correct their wage data 
within the prescribed timeframes. Once the data are finalized and the 
wage indexes published in the final rule, they may not be revised, 
except through the mid-year correction process set forth in the 
regulations at Sec. 412.63(x)(2). Accordingly, it has been our 
consistent policy that if a hospital does not request corrections 
within the prescribed timeframes for the development of the wage index, 
the hospital may not later seek to revise its data in an attempt to 
qualify for MGCRB reclassification.
    Allowing hospitals the opportunity to revise their data beyond the 
timelines required to finalize the data used to calculate the wage 
index each year would lessen the importance of complying with those 
deadlines. The likely result would be that the data used to compute the 
wage index would not be as carefully scrutinized because hospitals 
would know they may change it later, leading to inaccuracy in the data 
and less stability in the wage indexes from year to year.
    Comment: Several commenters requested that we clarify whether we 
intend to utilize OMB's new MSA standards and, if so, how we intend to 
incorporate the changes into the Medicare program. Relatedly, one 
commenter requested that we specify in the text of the final rule 
whether or not a hospital that was treated as a rural referral center 
(RRC) as of October 1, 2000, will continue to qualify for the RRC 
exception if their physical location becomes urban as a result of 
subsequent updates to metropolitan areas issued by the OMB. The 
commenter is concerned that the absence of a clear statement in the 
regulations text indicating that the grandfathered status of RRCs will 
continue into subsequent years could possibly result in a loss of their 
special status. The commenter referenced the instance when many RRCs 
located in areas that were redesignated as urban by OMB lost their RRC 
status. (See the August 29, 1997 final rule (62 FR 45999) for a more 
detailed explanation.)
    Response: At this time, it is our understanding that OMB is not 
expected to announce changes to the new MSA standards until after we 
have published the proposed rule for FY 2004. Even if the new standards 
are announced in advance of the publication of our FY 2004 proposed 
rule, we would need time to assess their implications for payment 
purposes (for example, how will the new Micropolitan Areas designated 
by OMB, which will encompass counties currently considered rural, 
interact with other statutory and regulatory requirements for special 
hospital designation, such as an RRC).
    Therefore, we intend at this time to continue to use the current 
MSA standards for FY 2004 acute inpatient prospective payment system 
payments. Hospitals applying for MGCRB reclassification for FY 2004 
must apply based on the existing MSA definitions. With respect to the 
commenter's concern regarding the implications of the revised MSA 
definitions on RRCs, we are not prepared at this time to address this 
issue. We intend to evaluate this and other issues related to the new 
MSA definitions when they become available next year.
    Comment: One commenter requested clarification as to whether Table 
9, Hospital Reclassifications and Redesignations by Individual 
Hospital, is an official list and whether the wage index calculation is 
affected by errors in omission. The commenter indicated that the list 
in the proposed rule includes hospitals that have withdrawn their FY 
2002 reclassifications and subsequently cancelled the withdrawal for FY 
2003 and FY 2004, as well as omits hospitals that have received 
approval letters from the MGCRB reinstating the remaining years of the 
3-year appeal.
    Response: We indicated in the proposed rule that, while Table 9 
shows hospitals that have been reclassified under either section 
1886(d)(8)(B) or section 1886(d)(10)(D) of the Act, it may not reflect 
all withdrawals from reclassifications approved by the MGCRB or 
decisions of the CMS Administrator if those withdrawals were made 
subsequent to the preparation of the proposed rule. Similar to the 
other provisions and tables included in the proposed rule, publication 
of Table 9 in the proposed rule provided an opportunity for affected 
hospitals to review and verify the accuracy of the data. In situations 
such as those described by the commenter, we encourage affected 
providers to furnish us with specific feedback regarding the 
information contained in the proposed rule. Any changes that result 
from withdrawals of requests for reclassification, wage index 
corrections, appeals, and the Administrator's review process are 
incorporated into the wage index values and Table 9 published in the 
final rule.
    Comment: Several commenters requested that the wage data for urban 
hospitals redesignated as rural under section 1886(d)(8)(E) of the Act, 
be included both in the MSA where the hospital is physically located 
and the rural area to which they are redesignated for purposes of the 
wage index. Commenters cited section 1886(d)(8) of the Act and section 
152(b) of the Balanced Budget Refinement Act of 1999 (Pub. L. 106-113) 
in support of their request. The commenters asserted that section 
1886(d)(8) of the Act protects nonreclassified hospitals from being 
negatively impacted by reclassifications. They also pointed out that in 
implementing the statutory reclassifications required by section 152(b) 
of Public Law 106-113, CMS calculated the wage index values of the MSAs 
that contain the counties specified in section 152(b) by ``including 
the wages of hospitals that were reclassified out of the MSA by section 
152(b).'' The commenters stated that the exclusion of hospitals 
redesignated under section 1886(d)(8)(E) of the Act in calculating the 
wage index is contrary to the expectations of the hospitals prior to 
the enactment of this provision (by section 401 of Public Law 106-113).
    Response: Section 1886(d)(8)(E) of the Act permits 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. A 
hospital granted redesignation under section 1886(d)(8)(E) of the Act 
is therefore treated as a rural hospital for all purposes of payment 
under the Medicare acute inpatient prospective payment system, 
including standardized amount, wage index, and disproportionate share 
calculations, as of the effective date of the redesignation. Therefore, 
for purposes of calculating the wage index as a result of the 
redesignation to a rural area, the wage index data of the redesignated 
hospital is treated as though the hospital were located in the rural 
area of the State. That is, its data are excluded from the wage index 
calculation for the urban area where the hospital is geographically 
located and included in the wage index calculation for the rural area 
to which the hospital is designated. This is consistent with the 
statutory language requiring that a hospital be treated as though it is 
located in a rural area.
    In the case of section 1886(d)(8) of the Act, Congress specifically 
acted to provide special protection for rural hospitals negatively 
impacted by reclassifications. Section 1886(d)(8)(C) of the Act 
provides that rural areas are held harmless for decisions resulting 
from the application of section

[[Page 50029]]

1886(d)(8)(B) of the Act, or of decisions of the MGCRB or the 
Secretary. Redesignations under section 1886(d)(8)(E) of the Act are 
not covered under this provision.
    In the case of section 152(b) of Public Law 106-113, Congress 
specifically directed the Secretary to treat these statutorily mandated 
reclassifications as decisions by the MGCRB. Section 1886(d)(8)(E) of 
the Act directs the Secretary to treat the redesignated hospitals as 
being located in the rural area of the State in which the hospital is 
located. We did not exclude the wages of the hospitals reclassified 
under section 152(b) in calculating the FY 2001 wage index for the 
affected areas because we believed that this approach appropriately 
reflected the expectations of the hospitals that had applied to 
reclassify into the areas affected by this provision prior to enactment 
of this provision. Because section 1886(d)(8)(E) of the Act has been in 
place for well over a year, hospitals applying for reclassification for 
FY 2003 could not reasonably have expected, in light of the language of 
that section, that they would benefit from the inclusion of the wage 
data of the redesignated hospitals in two different areas.
    We note that the commenters' suggestion would not uniformly benefit 
hospitals remaining in or reclassified into the urban area from which 
the now rural hospital was reclassified. Our analysis indicates several 
such areas would be negatively impacted. The greatest positive impact 
would occur in the area of concern to the commenter.
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. 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:

--------------------------------------------------------------------------------------------------------------------------------------------------------
           Rural county                         1980 MSA designation                                       1990 MSA designation
--------------------------------------------------------------------------------------------------------------------------------------------------------
Ionia, MI........................  Lansing-East Lansing, MI.....................  Grand Rapids-Muskegon-Holland, 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 amended section 1886(d)(8)(B) of 
the Act by adding clause (ii). This clause 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 for redesignation under the January 3, 1980 
standards elected to use those older standards so they would not 
receive the urban designation accorded to them under section 402 
because they would lose their special rural designation (that is, an 
RRC, a sole community hospital (SCH), or a Medicare-dependent hospital 
(MDH)). Under section 1886(d)(8)(B)(ii) of the Act, the option to make 
such an election was available only for FY 2001 and FY 2002. Effective 
for FY 2003, as we proposed, we are providing that hospitals located in 
counties qualifying for redesignation under section 1886(d)(8)(B) of 
the Act based on the 1990 standards will 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 under section 1886(d)(8)(B) of the Act 
unless the counties again qualify when the standards based on the 2000 
census data are available.
    Comment: One commenter expressed concern that the reclassification 
based on 1990 standards disadvantages hospitals classified as RRCs, 
SCHs, or MDHs by taking away their special status classification 
because they are no longer considered rural. The commenter was 
concerned that the provision is not in keeping with Congressional 
intent. As an alternative, the commenter suggested that an affected 
hospital should be allowed to request reclassification as a rural 
hospital under Sec. 412.103(a)(3), which allows hospitals to be treated 
as rural if they qualify as either a rural referral center or a SCH.
    Response: Because the law does not provide for an election on the 
part of the hospital for FY 2003, while specifying such an election for 
FYs 2001 and 2002, hospitals in affected counties are reclassified as 
urban. Therefore, consistent with our longstanding policy that 
hospitals reclassified as urban for purposes of the standardized amount 
are considered urban and lose their eligibility for special rural 
hospital status, the commenter is correct that a hospital becoming 
urban under section 1886(d)(8)(B)(ii)(II) of the Act would lose its 
special status as a result. With respect to the commenter's request 
that, in the event an affected hospital is not permitted the option to 
decline reclassification to an urban area that it may apply to be 
redesignated rural under Sec. 412.103, we agree with the commenter that 
a reclassified hospital may seek rural redesignation under 
Sec. 412.103. We will then determine whether the hospital meets the 
criteria for reclassification under this regulation. However, any such 
reclassification would be subject to the limitations on 
reclassification at Sec. 412.230(a)(5)(iv), which prohibit a hospital 
that has been granted redesignation as a rural hospital under 
Sec. 412.103 from receiving an additional reclassification by the 
MGCRB.
    We also note that it has been brought to our attention that the 
reclassifications applicable under section 1886(d)(8)(B)(ii) of the Act 
are applicable for cost reporting periods beginning in the relevant 
Federal fiscal year. Therefore, in applying such reclassifications for 
FY 2003, they are effective as of the beginning of the hospital's cost 
reporting period beginning during FY 2003. This effective date has no 
impact on hospitals that are reclassified to the same MSA under this 
provision as they were reclassified into for FY 2002. Such

[[Page 50030]]

hospitals will be paid in accordance with the FY 2003 wage index value 
of the area to which they are reclassified effective with discharges on 
or after October 1, 2002. However, hospitals whose reclassification 
changes as a result of applying the 1990 standards for FY 2003 will be 
paid in accordance with the wage index applicable to the area to which 
they would otherwise have been classified were it not for section 
1886(d)(8)(B)(ii) of the Act at the start of FY 2003. Then, for 
discharges occurring on or after the date of the start of their cost 
reporting period beginning during FY 2003, they will be paid in 
accordance with the wage index applicable to the area they are 
reclassified into under section 1886(d)(8)(B)(ii).

G. Requests for Wage Data Corrections

    In the May 9, 2002 proposed rule, we stated that, to allow 
hospitals time to construct the proposed FY 2003 hospital wage index, 
in May 2002 we would make available a final public data file containing 
the FY 1999 hospital wage data.
    The final wage data file was released on May 10, 2002. As noted 
above in section III.D. of this preamble, this file included hospitals' 
cost report data obtained from Worksheet S-3, Parts II and III of their 
FHY 1999 Medicare cost reports. In addition, Table 2 in the Addendum to 
this final rule contains each hospital's adjusted average hourly wage 
used to construct the wage index values for the past 3 years, including 
the FY 1999 data used to construct the final FY 2003 wage index.
    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 were discussed in section IX.A. of 
the preamble of the May 9, 2002 proposed rule, ``Requests for Data from 
the Public.''
    In addition, Table 2 in the Addendum to the proposed rule contained 
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. We noted that 
the hospital average hourly wages shown in Table 2 only reflected 
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, were reflected in the final 
public use wage data file made available on May 10, 2002.
    We believe hospitals had 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 were 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 provided an opportunity to submit corrections along 
with complete, detailed supporting documentation to its intermediary by 
February 8, 2002.
    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 notified 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 noted that the April 5, 2002 deadline also applied to 
these requested changes. During this review, we did 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 were necessary to allow sufficient time to review 
and process the data so that the final wage index calculation could be 
completed for development of the final FY 2003 prospective payment 
rates published in this final rule.
    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 did not 
meet the procedural deadlines set forth above were not afforded a later 
opportunity to submit wage data corrections or to dispute the 
intermediary's decision with respect to requested changes. 
Specifically, our policy is that hospitals that do not meet the 
procedural deadlines set forth above are not permitted to challenge 
later, 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)).
    As stated above, the final wage data public use file was released 
on May 10, 2002. Hospitals had an opportunity to examine both Table 2 
of the proposed rule and the May 2002 final public use wage data file 
(which reflected revisions to the data used to calculate the values in 
Table 2) to verify the data CMS used to calculate the wage index.
    As with the file made available in January 2002, CMS made 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 
was 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 were encouraged to 
review their hospital wage data promptly after the release of the May 
2002 file. Data presented at that time could not be used by hospitals 
to initiate new wage data correction requests.
    If, after reviewing the May 2002 final file, a hospital believed 
that its wage data were incorrect due to a fiscal intermediary or CMS 
error in the entry or tabulation of the final wage data, it was 
provided an opportunity to send a letter to both its fiscal 
intermediary and CMS, outlining why the hospital believed an error 
existed and providing all supporting information, including relevant 
dates (for example, when it first became aware of the error). These 
requests had to be received by CMS and the fiscal intermediaries no 
later than June 7, 2002.
    Changes to the hospital wage data were only 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, at this stage of the process, neither the 
intermediary nor CMS accepted the following types of requests:
     Requests for wage data corrections that were submitted too 
late to be

[[Page 50031]]

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) are incorporated into the final wage index in this final 
rule, to be 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 had access to the final wage data by early May 2002, they 
have had 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 in this final rule, and the 
implementation of the FY 2003 wage index on October 1, 2002. If 
hospitals availed themselves of this opportunity, the wage index 
implemented on October 1 should be accurate. Nevertheless, in the event 
that errors are identified after publication in the final rule, 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 had the opportunity to verify its data, and the fiscal 
intermediary notified 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 will be 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 
in the May 9, 2002 proposed rule we proposed 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 in the May 9, 2002 proposed rule we proposed 
to delete it as well.
    Finally, we proposed 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.
    Comment: One commenter disagreed with the proposed revision to 
clarify Sec. 412.63(x)(2). The commenter stated that the clarification 
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 is illogical. The commenter 
believed that we should allow all potentially affected hospitals to 
report what they believe to be errors that they failed to correct 
before the beginning of the Federal fiscal year.
    Response: We frequently instruct hospitals that they are 
responsible for reviewing their data and notifying the intermediary if 
there is an error or omission.
    The proposed revision is consistent with the current rules in that 
it reinforces for hospitals the responsibility they have for assuring 
the accuracy of the wage data they submit.
    The wage index is recalculated each year based on wage data from 
acute care hospitals nationwide. Since this calculation must be carried 
out on a nationwide basis, it is critical that we have the necessary 
data from all hospitals in a timely fashion so that the wage index 
values can be calculated prior to the beginning of the upcoming fiscal 
year. Accordingly, we set out well in advance a detailed timetable for 
reviewing and revising the data that hospitals, fiscal intermediaries, 
and CMS must follow. In this way, all hospitals are given an equal 
opportunity to review and correct their data within the established 
process. To further assist in the wage data review process, we require 
that fiscal intermediaries notify state hospital associations when a 
hospital fails to respond to issues raised during the wage data review 
process. The purpose of the notification is to inform the hospital 
association that its member hospital's failure to respond to matters 
raised by the fiscal intermediary can result in data being disallowed, 
thereby possibly lowering an area's wage index value. Consistent with 
out efforts to finalize the data used to construct the wage index prior 
to publication of the final rule, we make mid-year data revisions in 
only very limited circumstances, so that the disruptive effects of such 
changes can be avoided to the greatest extent possible. In turn, 
consistent with that principle, we think it is appropriate to limit 
such mid-year revisions to those pertaining only to the data of the 
requesting hospital. We do not believe this revision will unduly 
restrict the ability of hospitals to bring to our attention the need 
for revisions in a neighboring hospital's data; under our wage data 
revision process, hospitals have an ample opportunity to do this prior 
to the publication of the rule. Therefore, we disagree with the 
commenter that it is necessary or advisable to allow other hospitals an 
opportunity to request changes to a hospital's wage data after the 
final rule is published, and we are adopting our proposed changes as 
final.
    Comment: One commenter representing Medicare fiscal intermediaries 
recommended that we revise the wage index development process to 
provide an incentive for hospitals to submit accurate wage data with 
their as-filed cost reports. The

[[Page 50032]]

commenter noted that, in the August 1, 2001 Federal Register (66 FR 
39871), we implemented procedural changes that allow the intermediaries 
additional time to review hospital's wage data. In that rule, we 
indicated that wage data were revised between the publication of the 
proposed and final rules for 30 percent of the hospitals. To reduce 
this percentage, and the number of ``second'' desk reviews that 
intermediaries must perform when hospitals revise their wage data, the 
commenter recommended the following changes:
     CMS should publish an initial wage index public use file 
in September based on provider as-filed wage data.
     Hospitals should be allowed 4 weeks to review and submit 
to their intermediaries requests for corrections to the initial wage 
index public use file.
     After the hospitals 4-week review and correction request 
period, intermediaries should perform a single desk review of each 
hospital s wage data and make the appropriate requested corrections.
     After CMS publishes the reviewed final wage index file, 
hospitals should submit only corrections due to CMS' or the fiscal 
intermediary's mishandling of the wage data.
    Response: We appreciate the commenter's recommendation, and we 
agree that revisions to the current wage index process should be 
considered to reduce duplicative review efforts. We will carefully 
explore options and their associated risks before making further 
refinements to the wage index development process.

IV. 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. 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 which we discussed the 
previous rebasing of the hospital input price index. For FY 2003, 
payment rates will be updated by the projected increase in the hospital 
market basket minus 0.55 percentage points.
    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 that 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 for use in providing inpatient care, 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 in the market basket. 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, 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 combined.
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, 
the base year cost structure for the prospective payment system 
hospital index shifts from FY 1992 to FY 1997). Revising means changing 
data sources, cost categories, or price proxies used in the input price 
index.
    We used a rebased and revised hospital market basket in developing 
the FY 2003 update factor for the prospective payment rates. The 
rebased and revised market basket reflects FY 1997, rather than FY 
1992, cost data. 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

[[Page 50033]]

Commerce publications: the Bureau of the Census' Business Expenditure 
Survey (BES) and the Bureau of Economic Analysis' Annual Input-Output 
Tables. In addition, analysis of FYs 1998 and 1999 Medicare cost report 
data showed little difference in comparable cost shares from FY 1997 
data.
    In developing the rebased and revised market baskets set forth in 
the May 9, 2002 proposed rule (67 FR 31438) and adopted in this final 
rule, we used hospital operating expenditure data in determining the 
market basket cost weights. We relied primarily on Medicare hospital 
cost report data for the 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. We are providing the 
following detailed discussion of the process for calculating cost share 
weights.
    Cost category weights for the FY 1997-based market baskets were 
developed in several stages. First, base weights for several of the 
operating cost categories (Wages and Salaries, Employee Benefits, 
Contract Labor, Pharmaceuticals, and Blood and Blood Products) were 
derived from the FY 1997 Medicare cost reports. 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 of the hospitals' cost centers are utilized for 
both inpatient and outpatient care. Health Economics Research (HER), 
under contract with CMS, just recently completed a feasibility study on 
the construction of a separate outpatient market basket for our 
outpatient hospital prospective payment system. While this research 
provided some insight about ways to separate inpatient and outpatient 
costs, HER also found that substantially more data would need to be 
collected from hospitals in order to accomplish this. Furthermore, 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 payor. 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 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 operating expenses to obtain a portion for all other 
expenses.
    Finally, 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 are unable to incorporate these data in this final rule.
    Comment: Several commenters mentioned the need for an improved 
market basket, where the composition of the market basket is a more 
contemporary reflection of the cost pressures hospitals are facing. 
They suggest that we rebase more frequently than the current interval 
of approximately every 5 years.
    Response: As explained in the May 9, 2002 proposed rule (67 FR 
31439), FY 1997 was selected as the base year for the revised and 
rebased hospital market basket because it is the most recent year for 
which relatively complete data are available.
    It is important to realize that the Medicare cost reports were used 
as the primary source of data because these data were supplied directly 
from hospitals. The independent secondary sources such as the BES and 
the input-output table fill in where cost report data were not 
available or appeared to be incomplete. While the major cost categories 
are available for a more recent year from the cost reports, the 
additional detail derived from the input-output tables and the BES was 
not, as the Bureau of the Census only publishes these data for 5-year 
intervals. In addition, the major cost category weights determined 
using the FY 1997 Medicare cost reports were compared to weights 
calculated using FY 1998 and FY 1999 Medicare cost reports. These 
results were then compared to the weights calculated from the 1997 
Medicare cost reports. The results were very similar to those 
calculated using FY 1997 Medicare cost report data. Thus, 1997 data are 
the most recent, complete, and consistent data readily available for 
our rebasing work this year, and using more recent data woud not 
produce dissimilar results.
    Below, we further describe the sources of the six main category 
weights and their subcategories in the FY 1997-based market basket 
while noting 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 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 we used the 1992 Current Population Survey to break out various 
occupational subcategories. These subcategories were not broken out for 
the 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

[[Page 50034]]

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 FY 1997-based 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 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 the national level. The 1997 proportion as 
calculated by ANASYS was compared to limited data for FYs 1998 and 1999 
contained in the Medicare Cost Reports System. 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.
    Comment: A few commenters indicated that the explanation provided 
for the derivation of the professional liability insurance weight does 
not convey a full understanding of the methodology and data used; they 
would like additional information. They also questioned the 
appropriateness of assuming a constant level of malpractice coverage at 
a national level across time when updating this weight.
    Response: We believe the method for calculating the weight for 
professional liability insurance in the hospital market basket is 
reasonable given the alternatives we examined. The weight for 
professional liability insurance was derived from a survey conducted by 
ANASYS for CMS called the National Hospital Malpractice Insurance 
Survey (NHMIS). This survey was designed to collect hospital 
malpractice insurance costs of primary and excess coverage as well as 
deductible and other costs for 1996 and 1997. The survey collected 
malpractice information directly from a representative sample of 
hospitals derived from a universe defined as all non-Federal short-term 
acute care prospective payment system hospitals. The hospitals were 
sent a questionnaire derived from a 1986 General Accounting Office 
Survey. Follow-up phone calls were made where necessary resulting in a 
total response rate to the survey was 67 percent. After the data were 
collected, several edits were run to test the validity and 
reasonableness of the data. The total malpractice cost was derived by 
adding the adjusted primary and excess premiums, deductible costs, and 
other costs. The survey hospitals were then matched to the 
corresponding Medicare cost reports to derive a total hospital cost 
using the malpractice insurance policy year and hospital fiscal year as 
matching variables. The total professional liability insurance cost for 
each hospital calculated from the survey was then divided by the total 
hospital costs calculated from the Medicare cost reports to arrive at a 
weight for professional liability insurance for the hospital. The mean 
cost weight of all of the hospital weights was then used as the 
professional liability insurance weight.
    Other methods, such as using the Medicare cost reports or trending 
1992 data forward, presented significant data limitations. We were 
unable to use the Medicare cost report data in the development of a 
weight because 1997 data were incomplete, with very few hospitals 
submitting information on professional liability insurance. We compared 
weights derived from 1998 and 1999 cost report data, which were much 
more complete than 1997 data, and found that they produced results very 
similar to the weight calculated in the ANASYS report. We were also 
unable to use the prior method of calculating a professional liability 
insurance weight by trending 1992 data forward. This method would only 
capture the effect of price changes over time and would not reflect 
increases or decreases in the quantities of professional liability 
insurance purchased that should be reflected in the cost category 
weight. In the development of the 1992-based market basket, the method 
used was the only available option. Therefore, given the data available 
from ANASYS and the limitations of other methods we considered, we 
believe that the method of calculating a weight chosen was reasonable.
    To address the commenters' second point, we feel that it is 
appropriate to assume a constant level of malpractice coverage at a 
national level. By doing so, we are able to capture only the `pure' 
price change in professional liability premiums and not the additional 
effect of increasing or decreasing liability coverage. This method is 
consistent with the methods used by Bureau of Labor Statistics (BLS) in 
constructing its Producer Price Indexes (PPIs).
    Comment: Several commenters believe that we should explicitly 
account for other insurance categories such as property and general 
liability insurance in the market basket and not just professional 
liability insurance because of large premium increases in those 
categories. In addition, the commenters believe that we should adjust 
the weight given to insurance, blood products, and other items that 
experience extraordinary price increases.
    Response: The market basket implicitly accounts for increases in 
other insurance categories under the All Other-Labor Intensive Services 
category. We are unable to separate out other detailed insurance 
categories in the market basket due to data limitations. A publicly 
available data source that meets our criteria for developing weights 
for these other insurance categories does not exist at this time. In 
addition, data for price proxies such as the BLS PPI for property and 
casualty insurance show similar price movements to those of the All 
Other-Labor Intensive category in the market basket.
    In addition, we cannot inflate the weights of some categories and 
not others. This would violate the general principles of price index 
construction. We have compiled data for all of the cost categories in 
addition to total costs for a common base year and developed a set of 
weights that are consistent with respect to the principles of price 
index construction. Attempting to reflect more

[[Page 50035]]

recent trends in some categories and not in others would not accurately 
capture the entire cost structure that hospitals face at a given time. 
In addition, while expenditures for a category may be increasing, this 
may not necessarily lead to a greater weight for that category in the 
market basket. For example, property insurance expenditures could be 
increasing, but other categories could be increasing faster, so that 
the weight for property insurance in the market basket would be 
declining. Thus, it is necessary that all of the weights are reflective 
of a consistent base year.
     Utilities: For the FY 1997-based market baskets, the cost 
weight for utilities is 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. Even though the Business Expenditure Survey 
replaced the Asset and Expenditure Survey, the categories and results 
are still 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, photographic 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.
    The shares for pharmaceuticals and blood and blood products are 
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 are 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) (Pub. L. 106-554) required that we 
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, we have 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. We studied four alternative data sources 
to possibly determine a weight for blood in the market basket. If none 
of these data sources were deemed acceptable, we could conclude that a 
component for blood should not be reintroduced in the hospital market 
basket. In its December 2001 report 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, we have 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

[[Page 50036]]

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 FY 1997 cost reports 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. 
In this final rule, we use the Medicare cost reports to determine a 
weight for blood and blood products in the hospital market basket given 
the consistency with these other sources, the representativeness of our 
estimate, and the stability of the cost share.
    Overall, our work resulted in the identification of 23 separate 
cost categories in the 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 categories). The differences 
between the weights of the major categories determined from the 
Medicare cost reports for the FY 1997-based index and the previous FY 
1992-based index are summarized in Table 1.

  Table 1.--FY 1992-Based and FY 1997-Based Prospective Payment System
 Hospital Operating Major Cost Categories and Weights as Determined from
                        the Medicare Cost Reports
------------------------------------------------------------------------
                                     Rebased FY 1997-    FY 1992-Based
        Expense categories            based 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  .................
All Other.........................             32.053             34.448
                                   -------------------------------------
    Total.........................            100.000            100.000
------------------------------------------------------------------------

    Table 2 sets forth all of the 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 FY 1997-Based Prospective Payment Hospital
                  Operating Cost Categories and Weights
------------------------------------------------------------------------
                                     Rebased FY 1997-
                                      based hospital     FY 1992-based
        Expense categories            market basket     hospital market
                                         weights         basket 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                       0.840              1.189
 Insurance........................
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                    0.875  .................
         Products.................
        (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                     1.040              0.207
         Equipment................
        (12.) Miscellaneous                     0.956              2.236
         Products.................
    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                   5.438              7.277
         Intensive................
        (4.) All Other: Non-Labor               4.519              0.796
         Intensive................
                                   -------------------------------------
    Total.........................            100.000           100.000
------------------------------------------------------------------------
Note: Due to rounding, weights may not sum to total.


[[Page 50037]]

3. Selection of Price Proxies
    After computing the FY 1997 cost weights for the rebased and 
revised hospital market basket, it was necessary to select appropriate 
wage and price proxies for each expenditure category. Most of the 
indicators are based on 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 changes at the 
final stage of production.
     Consumer Price Indexes--Consumer Price Indexes (CPIs) 
measure price changes 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 wholesale purchasers. For example, the 
CPI for food purchased away from home was 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 
skill mix.
    Table 3 sets forth the complete hospital market basket including 
cost categories, weights, and price proxies. For comparison purposes, 
we also list the respective FY 1992-based market basket price proxies. 
A summary outlining the choice of the various proxies follows the 
table.

 Table 3.--FY 1997-Based Prospective Payment System Hospital Operating Cost Categories and Weights, and FY 1992-
                                      Based and FY 1997-Based Price Proxies
----------------------------------------------------------------------------------------------------------------
                                      Rebased FY 1997
         Expense categories           hospital market     Rebased FY 1997 hospital     FY 1992 hospital market
                                       basket weights    market basket price proxy        basket price proxy
----------------------------------------------------------------------------------------------------------------
1. Compensation....................             61.656
Wages and Salaries.................             50.686  ECI-Wages and Salaries,      CMS Occupational Wage Proxy
                                                         Civilian Hospital Workers.
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 Commercial Natural Gas.  PPI Commercial Natural Gas
    B. Electricity.................              0.833  PPI Commercial Electric      PPI Commercial Electric
                                                         Power.                       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.......................             30.749
    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 & Feeds  PPI Processed Foods & 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                     0.875  PPI Blood and Blood          N/A
         Products.                                       Derivatives, Human Use.
        (6.) Medical Instruments...              2.192  PPI Medical Instruments &    PPI Medical Instruments &
                                                         Equipment.                   Equipment
        (7.) Photographic Supplies.              0.204  PPI Photographic Supplies..  PPI Photographic Supplies
        (8.) Rubber and Plastics...              1.668  PPI Rubber & Plastic         PPI Rubber & Plastic
                                                         Products.                    Products
        (9.) Paper Products........              1.355  PPI Converted Paper &        PPI Converted Paper &
                                                         Paperboard Products.         Paperboard Products
        (10.) Apparel..............              0.583  PPI Apparel................  PPI Apparel
        (11.) Machinery and                      1.040  PPI Machinery & Equipment..  PPI Machinery & Equipment
         Equipment.
        (12.) Miscellaneous                      0.956  PPI Finished Goods less      PPI Finished Goods
         Products.                                       Food 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                    5.438  ECI-Compensation for         ECI-Compensation for
         Intensive.                                      Private Service              Private Service
                                                         Occupations.                 Occupations
        (4.) All Other: Non-Labor                4.519  CPI-U All Items............  CPI-U All Items
         Intensive.
                                    -------------------
    Total..........................           100.000
----------------------------------------------------------------------------------------------------------------
Note: Totals may not sum to 100 due to rounding.


[[Page 50038]]

a. Wages and Salaries
    For measuring the price growth of wages in the FY 1997-based market 
basket, we 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 was 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. During 
the period from 1995 through 2000, this trend reversed; each year the 
ECI grew slower than the blended occupational wage proxy. 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 
and salaries for hospital workers has again grown 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 through 
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 few 
years, there has been a move back towards less restrictive plans, and a 
subsequent increase in the utilization of hospital services. This 
recent surge appears to reflect the true underlying effect of rising 
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, our analysis has indicated that the hospital labor market is 
more competitive than before 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. For FY 2003, the hospital 
market basket is forecast to increase 0.2 percentage points faster (3.5 
versus 3.3) than it would have if the occupational blend had been used. 
Based on this, we use the ECI for wages and salaries for hospitals as 
the proxy in the hospital market basket for wages. 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 quarterly.
b. Employee Benefits
    The 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 an analysis similar to that 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) is 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) is 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) is 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 is 
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. In addition, we continue to monitor a BLS 
PPI for medical malpractice premiums that in the future could be used 
as a proxy for this cost category.

[[Page 50039]]

    Comment: Several commenters indicated that hospital malpractice 
costs are increasing much faster than the professional liability 
portion of the market basket and we should consider other alternatives.
    Response: We believe that our price proxy for professional 
liability insurance adequately measures the increases in professional 
liability insurance costs facing hospitals. While anecdotal evidence 
suggests that malpractice costs are increasing at double-digit rates, 
actual data as measured by the CMS hospital professional liability 
insurance survey as well as data on insurance from the BLS Producer 
Price Index through 2001 do not reflect this. Since the FY 2003 market 
basket increase is based on a forecast from DRI-WEFA, the expected 
trends in hospital professional liability insurance premiums are indeed 
reflected. As is the case with all of our indexes, we regularly review 
all of the proxies in the index to verify that they are representative 
of current industry trends. In addition, as mentioned in the May 9, 
2002 proposed rule (67 FR 31444), we are currently exploring 
alternatives to our price proxy for hospital professional liability 
insurance including possibly using the BLS Producer Price Index for 
medical malpractice. We are also working with our contractor to explore 
possible methods of improving our hospital professional liability 
proxy, though this research is not yet complete.
h. Pharmaceuticals
    The percentage change in the price of prescription drugs as 
measured by the PPI (Commodity Code #PPI283D#RX) is 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 as measured 
by the PPI (Commodity Code #02) is 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) 
is 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) is applied to this 
component. While the chemicals hospitals use include industrial as well 
as other types 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) is 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 use the PPI for blood and blood derivatives as the price proxy 
for the blood and blood products cost category. 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 are not widely available. The PPI for blood and 
blood derivatives was the only index we found that met all of our 
criteria.
    Comment: Several commenters supported the separate expense category 
for blood and blood products in the market basket and the use of the 
PPI for blood and blood derivatives for human use as the price proxy 
for monitoring the rate of change in blood costs. However, the 
commenters indicated that it is important to ensure that the PPI for 
blood and blood derivatives is appropriately and timely updated by the 
BLS so that it adequately tracks changing blood technologies and safety 
initiatives. The commenters added that ensuring the safety of the 
nation's blood supply requires constant attention to developing disease 
states and testing technologies and creates changing costs that must be 
captured by the blood PPI to ensure adequate reflection in the 
prospective payment system market basket.
    Response: We agree that the PPI for blood and blood derivatives 
should appropriately reflect the price of blood and blood products. We 
will continue to monitor the PPI to ensure that this is the case. We 
are supportive of efforts by the BLS to collect the necessary 
information on the price of blood and blood products so they are 
accurately reflected in the PPI for blood and blood derivatives. 
Organizations that represent blood providers are also encouraged to 
work with BLS to accomplish this goal.
    Comment: One commenter suggested that we use data from the Red 
Cross, America's Blood Centers or Zeman and Company in developing a 
price proxy that reflects recent cost increases for blood products.
    Response: We require that all price indexes used in our market 
baskets to be relevant, reliable, available, and timely. The BLS PPI 
for blood and blood derivatives is an independent estimate of prices 
for these products that are published on a regular schedule (monthly). 
It is based on sound statistical methods and meets our criteria listed 
above. The possible sources of data mentioned by the commenter are not 
available frequently enough and on a regular basis and, therefore, do 
not meet the criterion of timeliness. Also, it has not been determined 
if indexes based on these data would be relevant or reliable enough for 
use in the CMS market baskets. Furthermore, because of their method of 
construction, the BLS indexes that we use as price proxies in the 
market baskets reflect only the effect of price changes and not the 
effects of quantity or quality changes. Our market baskets are designed 
to measure only the price change effects on increases in costs and not 
the quantity or quality effects. It has not been demonstrated whether 
indexes from these other data sources would capture only price effects 
or whether they mix price and quantity/quality effects.
m. Surgical and Medical Equipment
    The percentage change in the price of medical and surgical 
instruments as measured by the PPI (Commodity Code #1562) is 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) is 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) is applied to this 
component. The same

[[Page 50040]]

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) is 
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) is 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) is 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) is 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) is 
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) is 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 is 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) is 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 FY 1997-based and the FY 1992-based market baskets.

 Table 4.--FY 1992-Based and FY 1997-Based Prospective Payment Hospital
                Operating Index Percent Change, 1995-2004
------------------------------------------------------------------------
                                                  Rebased
                                                 1997-based    FY 1992-
               Fiscal year (FY)                   hospital      based
                                                   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.......................................          4.3          4.1
Average FYs 1995-2001.........................          2.8          3.0
Forecast:
FY 2002.......................................          3.9          3.0
FY 2003.......................................          3.5          3.2
FY 2004.......................................          3.1          3.2
Average FYs 2002-2004.........................          3.5         3.1
------------------------------------------------------------------------
Source: Global Insights, Inc, DRI-WEFA, 2nd Qtr. 2002; @USMACRO/MODTREND
  @CISSIM/TL0502.SIM

As indicated by Table 5, switching the proxy for wages and benefits to 
the ECI for Civilian Hospitals has a minimal effect over time. While 
the FY 2003 update is 0.2 percentage points higher than using the 
previous blended occupational wage proxy, 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.--1997-Based Prospective Payment System Hospital Operating Index
   Percent Change, Using Different Wage and Benefit Proxies, 1995-2004
------------------------------------------------------------------------
                                                 Rebased
                                                   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:

[[Page 50041]]

 
FY 1995......................................          2.8           3.0
FY 1996......................................          2.3           2.5
FY 1997......................................          1.6           2.2
FY 1998......................................          2.7           3.2
FY 1999......................................          2.7           3.0
FY 2000......................................          3.3           3.4
FY 2001......................................          4.3           4.1
Average FYs 1995-2001........................          2.8           3.1
Forecast:
FY 2002......................................          3.9           3.3
FY 2003......................................          3.5           3.3
FY 2004......................................          3.1           3.3
Average FYs 2002-2004........................          3.5          3.3
------------------------------------------------------------------------
 Source: Global Insights, Inc, DRI-WEFA, 2nd Qtr. 2002; @USMACRO/
  MODTREND @CISSIM/TL0502.SIM

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 * * *.'' 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.
    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 methodology, 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.
    Our proposed methodology was 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. However, we noted that, while we did not propose to 
change the methodology for calculating the labor-related share in the 
proposed rule, we have begun the research necessary to reevaluate the 
current assumptions used in determining this share. This reevaluation 
is consistent with MedPAC's recommendation in their June 2001 report. 
Our research involves analyzing the compensation share separately for 
urban and rural hospitals, using regression analysis to determine 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.
    We also noted our concern that the result of our methodology 
(increasing the labor-related share from 71.066 percent to 72.495 
percent) could have negative impacts that would fall predominantly on 
rural hospitals. In addition, we noted that we planned to conduct 
further research and would make the appropriate changes in the final 
rule if another methodology was found to be superior to our current 
methodology.
    Comment: Commenters generally supported our expressed willingness 
to review this methodology, and emphasized the need for a full and 
careful study of any changes before adopting major changes. Comments on 
behalf of some national and State hospital associations recommended 
that we not make any change to the labor-related share calculation, 
while proceeding with market basket rebasing, until completing a more 
thorough examination of the proportion of labor costs influenced by the 
local labor market, noting that we included in our methodology costs 
related to, influenced by, or that vary with the local labor market, 
even if these services may be purchased at the national level.
    MedPAC commented that it believes that certain expenditures 
identified in our methodology as locally purchased are in fact 
purchased, in whole or in part, in national markets. The Commission 
gave examples such as computing, legal, and accounting services. The 
Commission noted it has worked with us in the past to discuss these 
issues, and commented that continued use of our proposed approach is 
appropriate in the absence of a superior method. Several commenters 
referred to the difference between MedPAC's and CMS's methodologies and 
suggested that we should adopt MedPAC's methodology.

[[Page 50042]]

    Other commenters argued the labor-related share must be decreased, 
noting that increasing the percentage will only exacerbate current 
flaws in the payment system. Some commenters referred to the fact that 
the outpatient prospective payment system labor-related share is only 
60 percent. Another commenter suggested the labor-related share should 
be changed to a State-specific share.
    Still other commenters, some of whom represent national and State 
hospital associations, supported the proposed methodology, and 
expressed their belief that any revised methodology from the one 
discussed in the proposed rule would need to be separately proposed 
with an opportunity for specific public comment. It was also noted that 
it has been our standard practice to empirically estimate the labor 
share in accordance with changes in the market basket, and it was 
recommended that we continue to follow our empirical estimate. Another 
commenter stated that our proposed methodology is consistent with both 
our past practice and statutory mandate.
    Response: We have decided not to proceed with reestimating the 
labor-related share at this time. We will conduct further analysis to 
determine the most appropriate methodology before proceeding. 
Therefore, for FY 2003, the labor-related share applicable to the 
standardized amounts will remain at 71.066 percent. Any future 
revisions to the labor-related share or the methodology will be 
proposed and subject to public comment.
    We appreciate the input from commenters on this issue, and look 
forward to continuing to work with MedPAC and the hospital industry on 
future refinements to the labor-related share methodology.
    Comment: One commenter offered several specific refinements to the 
proposed methodology. The commenter agreed with our proposal to remove 
postage costs from the methodology and recommended that insurance costs 
and certain other wage-related costs also be removed.
    Another commenter noted that we are adjusting the labor portion of 
the standardized amount using data that is not measured through the 
existing hospital wage index. The commenter reports estimating a labor 
share of 61.656 percent by excluding contract labor costs not included 
in the wage index.
    Response: As noted above, we are not revising our estimate of the 
labor-related share at this time. We will take these comments into 
consideration in our future analysis.
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 HCFA (now 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 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 used for freestanding psychiatric 
hospitals. This is 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 6 compares major weights in the rebased FY 1997 market basket 
for excluded hospitals with weights in the 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 weight for the excluded hospital market basket was 
derived using the same data sources and methods as for the acute care 
prospective payment market basket which were outlined previously. 
Differences in weights between the 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 50043]]



Table 6.--FY 1997-Based Excluded Hospital and Prospective Payment System
       Hospital Market Baskets, Comparison of Significant Weights
------------------------------------------------------------------------
                                                        Rebased FY 1997-
                                     Rebased FY 1997-  based prospective
             Category                 based excluded     payment system
                                     hospital market    hospital market
                                          basket             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 7 lists the cost categories, weights, and proxies for the FY 
1997-based excluded hospital market basket. For comparison, the FY 
1992-based cost category weights are included. The proxies are the same 
as those used in the FY 1997-based acute care hospital inpatient 
prospective payment system market basket.

Table 7.--FY 1992-Based and FY 1997-Based Excluded Hospital Operating Cost Categories, Weights and Price Proxies
----------------------------------------------------------------------------------------------------------------
                                      Rebased FY 1997-
                                       based excluded     FY 1992-based
         Expense categories           hospital market   excluded hospital        FY 1997-based price proxy
                                       basket weights     market weights
----------------------------------------------------------------------------------------------------------------
1. Compensation....................             63.251             63.721  .....................................
    A. Wages and Salaries..........             51.998             52.152  ECI-Wages and Salaries, Civilian
                                                                            Hospital Workers
    B. Employee Benefits...........             11.253             11.569  ECI-Benefits, Civilian Hospital
                                                                            Workers
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 & 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 and 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                     0.821                N/A  PPI Blood and Blood Derivatives,
         Products.                                                          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                      0.936              0.212  PPI Machinery & Equipment
         Equipment.
        (12.) Miscellaneous                      0.860              2.232  PPI Finished Goods less Food and
         Products.                                                          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                    4.892              5.439  ECI-Compensation for Private Service
         Intensive.                                                         Occupations
        (4.) All Other: Non-Labor                4.065              0.833  CPI-U All Items
         Intensive.
    Total..........................            100.000            100.000  .....................................
                                    --------------------------------------
----------------------------------------------------------------------------------------------------------------
Note: Due to rounding, weights may not sum to total.

    Table 8 shows the historical and forecasted updates under both the 
FY 1997-based and the FY 1992-based excluded hospital market baskets.

[[Page 50044]]



  Table 8.--FY 1992-Based and FY 1997-Based Excluded Hospital Operating
                     Index Percent Change, 1995-2004
------------------------------------------------------------------------
                                                 Rebased FY    FY 1992-
                                                 1997-based     based
                                                  excluded     excluded
               Fiscal year (FY)                   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.......................................          4.0          3.0
FY 2003.......................................          3.5          3.2
FY 2004.......................................          3.1          3.2
Average FYs 2002-2004.........................          3.5         3.1
------------------------------------------------------------------------
Source: Global Insights, Inc, DRI-WEFA, 2nd Qtr. 2002; @USMACRO/MODTREND
  @CISSIM/TLO502.SIM.

    A comparison of the FY 1997-based index incorporating the new wage 
and benefits proxies (ECIs) and updated occupational wage proxies is 
included in Table 9. Like the FY 1997-based prospective payment 
hospital index showed, there is little difference in the index over 
time when different compensation proxies are used.

    Table 9.--FY 1997-Based Excluded Hospital Operating Index Percent
       Change, Using Different Wage and Benefit Proxies, 1995-2004
------------------------------------------------------------------------
                                                  Rebased FY 1997-based
                                                excluded hospital market
                                                         basket
                                              --------------------------
               Fiscal year (FY)                 Using ECIs      Using
                                                   for      occupational
                                                 hospital     wages and
                                                 wage and     Benefits
                                                 benefit       proxies
------------------------------------------------------------------------
Historical Data:
FY 1995......................................          2.7           2.9
FY 1996......................................          2.4           2.5
FY 1997......................................          1.7           2.2
FY 1998......................................          3.0           3.5
FY 1999......................................          2.9           3.0
FY 2000......................................          3.3           3.5
FY 2001......................................          4.3           4.1
Average FYs 1995-2001........................          2.9           3.1
Forecast:
FY 2002......................................          4.0           3.4
FY 2003......................................          3.5           3.3
FY 2004......................................          3.1           3.3
Average FYs 2002-2004........................          3.5          3.3
------------------------------------------------------------------------
Source: Global Insights, Inc, DRI-WEFA, 2nd Qtr. 2002; @USMACRO/MODTREND
  @CISSIM/TL0502.SIM

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 revising and rebasing the CIPI to a FY 1997 base year to 
reflect a 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 weights in order to 
calculate the FY 1997-based CIPI. The first set of weights identifies 
the proportion of hospital capital expenditures attributable to each 
capital expenditure category, while the second 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

[[Page 50045]]

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 using 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 90 percent of 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 10 presents a comparison of the rebased FY 1997 capital cost 
weights and the FY 1992 capital cost weights.

   Table 10.--Comparison of FY 1992 and Rebased FY 1997 Cost Category
                                 Weights
------------------------------------------------------------------------
                                          Rebased
      Expense categories        FY 1992   FY 1997       Price proxy
                                weights   weights
------------------------------------------------------------------------
Total........................    1.0000    1.0000  .....................
    Total depreciation.......    0.6484    0.7135  .....................
        Building and Fixed       0.3009    0.3422  Boeckh Institutional
         Equipment                                  Construction Index--
         Depreciation.                              vintage weighted (23
                                                    years)
        Movable Equipment        0.3475    0.3713  PPI for machinery and
         Depreciation.                              equipment--vintage
                                                    weighted (11 years)
    Total interest...........    0.3184    0.2346  .....................
        Government/Nonprofit     0.2706    0.1994  Average yield on
         Interest.                                  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 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 base year 
is FY 1997.
    In order to estimate capital purchases from AHA data for 
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

[[Page 50046]]

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 FY 1997 CIPI 
are presented in Table 11.

             Table 11.--1992-Based and 1997-Based Vintage Weights for Capital-Related Price Proxies
----------------------------------------------------------------------------------------------------------------
                                       Building and fixed         Movable equipment             Interest
                                            equipment        ---------------------------------------------------
    Year (From farthest to most    --------------------------
              recent)               FY 1992  22  FY 1997  23  FY 1992  10  FY 1997  11  FY 1992  22  FY 1997  23
                                       years        years        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

[[Page 50047]]

 
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 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 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. A more detailed explanation 
of our rationale for selecting the price proxies is in the August 30, 
1996 final rule (61 FR 46196). The proxies are presented in Table 10.
    Global Insights, Inc., DRIWEFA forecasts a 0.7 percent increase in 
the rebased FY 1997 CIPI for FY 2003, as shown in Table 12.

 Table 12.--FY 1992 and FY 1997-Based Capital Input Price Index, Percent
                            Change, 1995-2004
------------------------------------------------------------------------
                                                     CIPI, FY   CIPI, FY
                Federal fiscal year                   1992-      1997-
                                                      based      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..............................................        0.6        0.9
Average: FYs 1995-2001............................        0.9        1.1
Forecast:
2002..............................................        0.6        0.8
2003..............................................        0.5        0.7
2004..............................................        0.6        0.8
Average: FYs 2002-2004............................        0.6       0.8
------------------------------------------------------------------------
Source: Global Insights, Inc, DRI-WEFA, 2nd\t\ Qtr. 2002; @USMACRO/
  MODTREND @CISSIM/TL0502.SIM.

    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 3.0 percent increase in other 
capital expense prices, partially offset by a 2.3 percent decrease in 
vintage-weighted interest rates in FY 2003, as indicated in Table 13.

     Table 13.--CMS Capital Input Price Index Percent Changes, Total and Components, Fiscal Years 1995-2005
----------------------------------------------------------------------------------------------------------------
                                                       Depreciation,
                                           Total       building and    Depreciation,
         Fiscal Year           Total   depreciation        fixed          movable       Interest        Other
                                                         equipment       equipment
----------------------------------------------------------------------------------------------------------------
Weights 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           4.3
2003........................   0.7            1.3             2.7            -0.1          -2.3           3.0
2004........................   0.8            1.3             2.6            -0.1          -2.0           2.8
2005........................   0.7            1.3             2.4            -0.1          -2.1           2.8
----------------------------------------------------------------------------------------------------------------
Source: Global Insights, Inc, DRI-WEFA, 2nd Qtr. 2002; @USMACRO/MODTREND @CISSIM/TL0502.SIM.

    Rebasing the CIPI from FY 1992 to FY 1997 increased the percentage 
change in the FY 2003 forecast by 0.2 percentage points, from 0.5 to 
0.7 as shown in Table 12. 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

[[Page 50048]]

vintage weights have only a minor impact on the overall percent change 
in the index. We did not receive any public comments on the rebasing 
and revising of the capital input price index.

V. Other Decisions and 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 a 
discharge to postacute home health services to constitute a transfer 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 care 
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 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 care 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 care transfer situations. For these 3 DRGs, hospitals receive 
50 percent of the full DRG payment plus the per diem 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 current 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

[[Page 50049]]

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 potential expansion 
of 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
     Eliminate disparities between hospitals that happen to be 
disproportionately treating the current 10 DRGs and hospitals with an 
aggressive, short-stay, postacute care transfer policy for other DRGs.
    The complete HER report may be obtained at: http://www.cms.hhs.gov/medicare/ippsmain.asp.
    In the May 9, 2002 proposed rule, we stated that, consistent with 
HER's findings, we believed expanding the postacute care transfer 
policy to all DRGs might be the most equitable approach, since a policy 
that is limited to certain DRGs may result in disparate payment 
treatment across hospitals, depending on the types of cases treated. 
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 could 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 hospitals than for rural hospitals (34 percent compared with 25 
percent through 1999), presumably due to earlier discharges to 
postacute care settings. Although the MedPAC report 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 care 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 Medicare Trust Fund expenditures for patients who are 
transferred to a postacute care setting after a very short acute care 
hospital stay would improve the program's overall financial stability.
    As noted in the proposed rule, we believe that the current policy 
may create payment inequities among patients and among hospitals. By 
expanding the postacute care transfer policy, we would expect to reduce 
or eliminate these possible inequities. Therefore, in the May 9, 2002 
proposed rule, we announced two options that we might use to expand the 
postacute care transfer provision and solicited comments and additional 
methodologies from commenters. The first method we proposed was to 
expand the postacute care transfer provision to all DRGs. The second 
proposal was to expand the provision to an additional 13 DRGs (We 
selected 10 DRGs using the same methodology we used in the July 31, 
1998 final rule. Three of these 10 additional DRGs were paired, making 
the total 13.). However, expanding the postacute care transfer policy 
in this limited manner would retain many of the potential inequities of 
the current system.
    As discussed further in the specific comments and responses that 
follow, we are not expanding the discharge to postacute care provision 
to additional DRGs for FY 2003. We believe the commenters have raised 
many issues regarding the impact of expanding this policy that we need 
to consider carefully before proceeding. In particular, due to the 
limited time between the close of the comment period and the required 
publication date of August 1, we were unable to completely analyze and 
respond to all of the points that were raised. However, we will 
continue to conduct research to assess whether further expansion of 
this policy may be warranted for FY 2004 or subsequent years and, if 
so, how to design any such refinements.
    Comment: Many commenters argued that, in a system based on 
averages, expansion of the postacute care transfer policy negatively 
influences, and in fact penalizes, hospitals for efficient care. They 
claimed that this policy indiscriminately penalizes hospitals for 
efficient treatment and for ensuring that patients receive the right 
care at the right time in the right place. They believed that the 
postacute care transfer provision creates a perverse incentive for 
hospitals to keep patients longer.
    Commenters also stated their concern that the expansion of the 
transfer provision violates the fundamental principle of the Medicare 
DRG payment system. The system is based on payments that will, on 
average, be adequate. These commenters argued that expansion of the 
transfer policy would give the system a per-diem focus and would mean 
that hospitals would be paid less for shorter than average lengths of 
stay, although they would not be paid more for the cases that are 
longer than average (except for outlier cases). One commenter suggested 
that if we expand the transfer rule, we should adopt a policy to pay 
more for long-stay cases.
    Response: The Conference Agreement accompanying Public Law 105-33 
states 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 
[prospective payment system] payments in a manner that accounts for 
reduced hospital lengths of stay because of a discharge to another 
setting.'' The current postacute care transfer policy adjusts payments 
to hospitals to reflect the reduced length of stay arising from the 
shift of patient care from the acute care setting to the postacute care 
setting. In addition, because Medicare also often pays for the 
postacute care portion of beneficiaries' care, the transfer policy 
appropriately adjusts hospitals' payments to avoid duplicate payments 
for the care provided during a patient's episode of care.
    However, we are not expanding the postacute care transfer policy in 
this final rule because we are not able to completely respond to all of 
the points raised by commenters prior to publication of the final rule. 
Specifically, we intend to undertake a more comprehensive analysis of 
the impact on the averaging aspects of the prospective payment system 
if this policy were to be expanded. We agree with the commenters that 
the transfer policy should not hamper the provision of effective 
patient care, and any future expansion will consider both the need to 
reduce payments to reflect cost-shifting due to reductions in length of 
stay attributable to early postacute care transfers and the need to 
ensure that payments, on average, remain adequate to ensure effective 
patient care.

[[Page 50050]]

    Comment: Commenters believed that the proposal to expand the 
postacute care transfer policy would place an additional administrative 
burden on hospitals and would expand the liability of hospitals for 
decisions that are not in their control, particularly after the patient 
has gone home. In cases where an acute care hospital is unaware that a 
patient has been sent to a postacute care facility or is receiving home 
health care, the commenters argued that it should not be the burden of 
the hospital to obtain that information.
    Response: As stated previously, we are not expanding the postacute 
care transfer policy at this time. In response to the point raised by 
the commenter, with respect to our current policy, in those cases where 
the hospital discharges a beneficiary to home and the beneficiary 
subsequently receives postacute care, without the hospital's knowledge, 
the incorrect discharge code will not be considered fraudulent. 
However, if the hospital has knowledge of the beneficiary receiving 
postacute care after discharge, the hospital is responsible for 
submitting the claim as a transfer or submitting an adjustment bill.
    Comment: Some commenters noted that, although the statute clearly 
states that the Secretary is authorized to expand the postacute care 
transfer policy to additional DRGs, the Secretary is not required to do 
so. These commenters pointed to the policy decisions made in FY 2001 
and FY 2002 not to expand the policy and encouraged CMS to make the 
same policy decision for this and all subsequent years, calling the 
proposed expansion unjustified and unreasonable.
    Several commenters argued that, although the Secretary does have 
authority to expand the postacute care transfer provision, the 
Secretary was not given the authority to expand the provision to all 
DRGs. Section 1886(d)(5)(J)(iv) of the Act provides that the Secretary 
may extend the policy to additional DRGs with high volumes of 
discharges to postacute care settings. Commenters noted that not all 
DRGs meet this criteria.
    Response: We agree that we are not required by section 
1886(d)(5)(J)(iv) of the Act to expand the transfer provision beyond 
the 10 DRGs currently covered under the policy. However, the statute 
clearly indicates that the policy may be expanded further, as 
appropriate. Whether the policy should be expanded to all DRGs or a few 
will be considered in future analysis.
    Comment: Several commenters believed that the impact of the 
expansion of the postacute care transfer needs to be considered more 
thoroughly and noted that the impact of such an expansion was not 
included in the proposed rule impact tables. These commenters were 
concerned that the overall effect of implementing either of the two 
proposed expansions would result in an overall decrease in per case 
payments in FY 2003. Commenters believed this expansion would 
disproportionately harm teaching hospitals that treat the most costly 
and complex cases within each DRG. They further charged that this 
policy would interfere with good clinical decisionmaking.
    Response: We did not analyze the postacute care transfer policy in 
the impact tables in the proposed rule because we did not propose a 
specific policy expansion. We did include overall savings estimates 
attributable to the provision in the preamble discussion. The full 
impact of any proposed expansion of this policy, including the impacts 
on specific categories of hospitals, would be considered fully before 
proceeding to expand the policy in the future.
    Comment: Many commenters strongly opposed the proposal to expand 
the postacute care transfer policy to all DRGs. Several commenters 
suggested that we repeal the original 10 DRG postacute care transfer 
policy provision, on the grounds that, through experience, hospitals 
have learned to operate more efficiently and seek best practices in 
patient care management. Therefore, the prospective payment system has 
met its objectives and lengths of stay have been reduced. In addition, 
the commenters noted that the lower length of stay achieved is better 
for patients due to lower risk of acquiring a nosocomial infection and 
better recovery rates at home. Therefore, the commenters argued, 
hospitals that have shortened the length of stay across all DRGs should 
not be punished by a reduction in payment amounts to per diem rates. As 
such, the commenters argued that premature discharges should be 
identified through the Quality Improvement Organization review process 
and not by the prospective payment system.
    Response: We agree that shorter lengths of stay are better for 
patients in general and that more efficient hospitals should not be 
penalized for greater than average efficiency. In the July 31, 1998 
final rule implementing the policy for the current 10 DRGs, we included 
analysis showing that, across virtually all lengths of stay for each of 
the 10 DRGs, Medicare paid in excess of costs even after the 
implementation of this provision. We also note that we do not believe 
the intent of this policy was to require a change in physician clinical 
decisionmaking, nor in the manner in which physicians and hospitals 
practice medicine. Rather, it simply addresses the appropriate level of 
payments once those decisions have been made, so the intent of the 
policy was to avoid overpayments. We agree with the commenter that an 
appropriate mechanism to identify premature discharges is the quality 
review process. As we have noted above, we will consider fully all of 
the financial implications on hospitals before proceeding to expand the 
policy in the future.
    Comment: Some commenters stated that there is no longer any 
justification to expand the postacute care policy, particularly to all 
DRGs. Commenters argued that expansion is unjustified because at the 
time the original policy was implemented, data showed that lengths of 
stay were dropping and that use of postacute care was increasing. The 
commenters indicated that, since that time, inpatient length of stay 
has stabilized and Medicare spending on postacute care has slowed. In 
addition, any incentive hospitals may have had to discharge patients 
early to a postacute care facility has been removed now that Medicare 
also pays these facilities under prospective payment systems.
    In addition, commenters stated that neither CMS nor its contractor, 
HER, has provided data to support the assumption that hospitals are 
benefiting financially from short-stay postacute care transfer cases. 
In fact, commenters noted that the HER report included one table that 
suggests the opposite is true. As described by the commenters, Table 4-
8 in the HER report shows the average cost of short-stay cases in the 
10 DRGs currently subject to the payment reduction. As shown by this 
table, short-stay postacute transfer cases are 7.4 percent more costly 
than short-stay nonpostacute care transfer cases. As a result, the 
commenters asserted that postacute care transfer cases are 
significantly less profitable than the non-postacute care transfer 
cases.
    Response: While it is true that postacute care providers such as 
skilled nursing facilities, home health agencies, and rehabilitation 
hospitals are now paid under prospective payment systems rather than 
cost-based payment systems, the acute hospital still has an incentive 
to discharge patients as soon as possible. The impact of expanding 
prospective payments to other settings is that it changes the 
incentives for those providers in terms of their willingness to 
continue to accept patients needing a more acute level of

[[Page 50051]]

care, because sicker patients are more likely to have above average 
costs. There is no impact on the incentives of acute care hospitals.
    We point out that the analysis prepared by HER was undertaken as an 
evaluation of the original policy, conducted in 2000 based on partial 
FY 1999 data. With respect to HER's finding that patients transferred 
for postacute care are more expensive than cases discharged home, one 
would expect cases receiving followup care to be sicker and require 
more resources. In fact, the postacute care transfer policy was 
implemented out of concern that these patients were being transferred 
out of the acute care setting much earlier in the course of their 
treatment than had previously been the case, and that some of the acute 
care portion of the patients' hospitalization was being provided by the 
postacute care facility. Because the acute care hospital was receiving 
the full DRG payment and the postacute care facility was receiving 
higher cost-based reimbursement, the Medicare program was paying, in 
essence, two facilities for the acute care of the patient.
    Comment: Commenters noted that in the proposed rule CMS quoted five 
points from the HER report that supported an expansion of the 
provision, but did not include the section of the HER report that lists 
the arguments against expansion. The commenters included this list of 
HER's arguments against expansion:
     Expansion to all DRGs would require multiple per-diem 
payment policies. The current ten DRGs require two distinct payment 
methodologies to ensure equitable reimbursement. A policy covering all 
DRGs might require many more methodologies.
     The policy would be irrelevant for many DRGs. Many DRGs 
have few or no cases that are discharged to postacute care.
     Expansion to all DRGs would have relatively high costs 
compared to the benefits. There is little benefit to extending the 
policy to the many DRGs with low postacute care volume. The cost of 
requiring that fiscal intermediaries implement and audit compliance 
with the policy for these DRGs would dilute the overall benefit to the 
program.
     It would be difficult to identify unrelated postacute care 
cases prior to admission. If a patient is under postacute care before 
admission and then returns to that care after an unrelated admission, 
the transfer policy does not apply. With many more DRGs, CMS and 
hospitals would have more work sorting out the unrelated admissions.
     Many DRGs are ``inhomogeneous.'' HER cautioned that 
payment under the postacute care transfer policy would be inequitable 
for ``inhomogeneous DRGs'' that contain two or more distinct types of 
cases with disparate lengths of stay.
    Response: The negative points raised above were included in our 
report of HER's analysis in the August 1, 2000 final rule (65 FR 
47081). We note that in the final rule we also referred readers to 
where they could obtain a copy of the complete report.
    Comment: Commenters analyzed the 13 DRGs identified in the proposed 
rule for possible partial expansion of the postacute care transfer 
policy using information derived from the FY 2000 MedPAR data. The 
commenters reported that many of the DRGs are inhomogeneous, including 
a wide variety of cases, some of which may be susceptible to early 
transfer and some of which may not.
    Response: We are not adopting either of the methodologies for 
expanding the postacute care transfer policy at this time. However, if 
in the future we should consider expanding the policy, we will consider 
the effect of inhomogeneity in any DRGs we select.
    Comment: Some commenters believed that the current system is 
inequitable. However, they argued that targeting 13 additional DRGs 
would only worsen the problem, and extending the policy to all DRGs is 
not an acceptable response. Commenters urged us to work to have the 
policy repealed altogether or at least to revise the policy to make it 
more equitable. For example, commenters noted that DRG 483 
(Tracheostomy except for face, mouth and neck diagnoses), which is 
included under the current policy, has an average length of stay of 35 
days. Commenters noted that the variation around the average is quite 
high, and that patients requiring this procedure and level of care 
almost always require postacute care. Therefore, commenters contended, 
because the variation around the average is so large, and the per diem 
cost for this DRG is well above average, the postacute care transfer 
policy has a very significant impact on payment that is unrelated to 
the use of postacute care services. These commenters urged us to 
reconsider the current policy because they believed that the logic of 
applying the standard per diem methodology to this DRG is flawed. They 
urged us either toreplace this DRG with another one on its high-volume 
postacute care transfer list or change the payment method to one that 
addressed the length of stay volatility.
    Response: We believe the current policy remains an appropriate 
response to reductions in length of stay resulting from shifting care 
out of the acute hospital setting. However, as noted above, we do have 
concerns about limiting it to 10 specific DRGs. We will continue to 
closely monitor the data to assess whether future expansions or 
refinements are needed. With respect to the inclusion of DRG 483 in the 
current 10 DRGs covered by the postacute care transfer policy, in the 
July 31, 1998 final rule we responded to a similar comment (63 FR 
40981). Our analysis showed this DRG was appropriate to include under 
the policy. Over 45 percent of discharges from this DRG were to 
postacute care, and it was ranked ninth in terms of volume of cases 
receiving postacute care. These factors qualify it for inclusion in the 
postacute care transfer policy under section 1886(d)(5)(J) of the Act.
    Comment: One commenter contended that expanding the postacute care 
transfer provision would distort the meaning of a transfer case. 
According to the commenter, a transfer is a case that has been admitted 
to one hospital and is stabilized there, but which is then sent to 
another acute care hospital for treatment that the first hospital was 
not equipped to provide. The commenter further explained that patients 
discharged to postacute care, in contrast, have completed the acute 
care phase of their treatment and need postacute care either to assist 
their convalescence or to manage a chronic illness. The commenter 
contended that these are very different concepts.
    Response: Under the acute inpatient prospective payment system, 
payments to the transferring hospital are reduced to reflect the fact 
that the patient is transferred prior to receiving the full course of 
treatment from the acute hospital. When Congress established the 
postacute care transfer policy, it did so in recognition of the fact 
that hospitals were transferring patients who still had acute symptoms 
into the postacute care setting for the remainder of their care. 
Therefore, the principle that the transferring hospital did not provide 
the full course of treatment is consistent under both the preexisting 
policy and the postacute care transfer policy.
    Comment: One commenter claimed that the special payment formula for 
a transfer from DRG 209, 210 and 211 often results in less payment than 
the flat per diem method. The commenters provided an example assuming 
that a DRG with a payment of $10,000 and an average length of stay of 5 
days received a per diem rate of $2,000. For a transfer case with a 
stay of 4 days under the

[[Page 50052]]

standard per diem transfer payment, the payment rate would be $10,000 
($4,000 for the first day and $2,000 for each of the next 3 days). The 
commenter argued that, under the special transfer payment policy, the 
payment rate would be only $8,000 ($5,000 for the first day and $1,000 
for each of the next 3 days). The commenter recommended that we 
increase the percentage of the per diem paid on days after the first 
day to 75 percent of the per diem under the special payment method.
    Response: Under Sec. 412.4(f)(2), payment for a postacute care 
transfer case from DRGs 209, 210, or 211 is equal to 50 percent of the 
appropriate prospective payment rate for the first day of the stay, and 
50 percent of the amount the hospital would receive under the standard 
transfer payment methodology. Thus, the example provided by the 
commenter is not correct. The payment would be the full $10,000 if the 
patient was transferred on the fourth day. Rather than receiving $5,000 
for the first day, the hospital in the example would receive $7,000 (50 
percent of the full DRG payment equals $5,000, plus 50 percent of the 
standard transfer payment equals $2,000, because the standard transfer 
payment is double the per diem for the first day of a transfer stay). 
The hospital would receive $1,000 for each of the next 3 days, 
resulting in total payments under this special transfer payment rule 
equal to $10,000 on day 4.
    This example also demonstrates that, if the patient stay is one day 
shorter than average, the hospital receives the full DRG rate. Using 
both postacute care transfer payment methodologies, the hospital would 
receive the full DRG amount if the patient stay is one day shorter than 
the national average.
    Comment: One commenter suggested that we determine if the 
administrative resources we are using to recalculate a hospital's 
payment under this policy are actually saving the Medicare program 
money or if a greater amount of administrative resources are spent to 
recover the payment differential for the transferred beneficiary. The 
commenter stated that we should not expand a ``cost-savings'' policy 
that fails to result in true savings.
    Response: Currently, the transfer payment calculation is made at 
the time a claim is processed based on the discharge status code 
assigned by the hospital to the patient at the time of discharge. 
Therefore, there is no recalculation, and thus the administrative costs 
associated with this policy are marginal, as long as hospitals 
appropriately code the patient's discharge status.
    Comment: Another commenter recommended that the postacute care 
transfer issue be addressed from a total system perspective, centered 
on meeting the patients' needs and include referral dynamics from the 
new postacute care prospective payment systems. The commenter also 
suggested that there should be an analysis of the medical versus 
payment dynamics of the 3-day prior hospitalization requirement for 
postacute care coverage.
    One commenter suggested that we expand the postacute care transfer 
policy to include swing beds. The commenter pointed to the ease with 
which hospitals may move these swing beds from one care setting to 
another, suggesting that it would be easy for hospitals with swing beds 
to get around the existing transfer policy.
    Response: We will take these suggestions into consideration as we 
continue to monitor the transfer policy. With respect to expanding the 
policy to include transfers to swing beds, we indicated in the July 31, 
1998 final rule that we elected not to include swing beds under this 
policy because of the potential adverse impact on small rural 
hospitals. At this time, we are not changing this policy, although we 
will continue to evaluate whether it is appropriate to exclude 
transfers to swing beds from the postacute care transfer policy.
    Comment: One commenter recommended waiting at least 3 years before 
expanding the transfer policy to provide for sufficient time for the 
entire continuum of care to reach equilibrium. In addition, the 
commenter indicated that when independent groups analyzed internal data 
on the 10 DRGs initially identified in the existing postacute care 
transfer policy, they found only 3 where there were significant numbers 
of transfers to postacute care. The commenter recommended reanalyzing 
the current policy to determine whether volume and disposition of the 
DRGs still require the policy. Some commenters stated that the 
perceived ``gaming'' hypothesis does not exist, meaning that hospitals 
are not cutting short patient care in order to make more money. Another 
commenter suggested that we monitor the recalibration of DRG weights, 
noting that if patients are being discharged too soon, these premature 
discharges would be reflected in frequent readmissions to the hospital, 
would increase the acuity of postacute care providers, and would lower 
the charges for acute stays. Earlier discharges will ultimately result 
in lower weights for associated DRGs. The commenter indicated that we 
could then easily monitor readmissions and acuity of postacute care 
treatment to target problem providers.
    Response: We will examine these and other issues in future analysis 
of this issue. With respect to the treatment of transfers in DRG 
recalibration, we note that a transfer case is counted as only a 
fraction of a case toward DRG recalibration based on the ratio of its 
transfer payment to the full DRG payment for nontransfer cases. This 
ensures the DRG weight calculation is consistent with the payment 
policy for these 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 excluded 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)) in the types of cases paid under the general rule 
for transfer cases. In the May 9, 2002 proposed rule, we proposed 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 proposed to correct 
this error by revising Sec. 412.4(f)(1) to provide that only the 
circumstances described in paragraphs (b)(1) and (c) of Sec. 412.4 are 
paid as transfers under the general transfer rule.
    We did not receive any public comments on this proposal. Therefore, 
we are adopting the proposed revisions of the regulations text as 
final. This correction reflects 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

[[Page 50053]]

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 regarding 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 payment options will yield the highest 
rate of payment for an SCH.
    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.
    We did not receive any comments on this clarification.
2. SCH Like Hospitals
    Section 1886(d)(5)(D)(iii) of the Act provides that, to qualify as 
an SCH, a hospital must be more than 35 road miles from another 
hospital. In addition, there are several other conditions under which a 
hospital may qualify as an 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 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 an 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, 
an 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

[[Page 50054]]

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, in the May 
9, 2002 proposed rule, we proposed 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 SCH. We believe the percentage of overlapping services 
between the SCH and the limited service facility 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 proposed that this percentage be set at 3 
percent.
    In the May 9, 2002 proposed rule, we solicited public comments on 
alternate appropriate levels of service overlap, as well as on the 
overall proposed change to the definition of like hospitals.
    In response to comments as discussed below, we are adopting 
inpatient days as the unit of measurement for determining whether a 
hospital applying for SCH status can exclude from consideration as a 
like hospital another hospital within its service area (rather than 
services, as discussed in the proposed rule). The threshold would be 
set so that a hospital with total inpatient days of 8 percent or less 
compared to an SCH (or SCH applicant) would not be considered a like 
hospital for purposes of SCH designation.
    We believe that Medicare inpatient days are a good proxy for 
service overlap. However, we will assess the impact of the overall 
change to the definition of like hospital and the service overlap proxy 
on SCHs and the prospective payment system. This assessment will 
determine whether refinements to this policy may be necessary in future 
years.
    Comment: Many organizations commented on this proposal. Most 
supported it, but to varying degrees, because there is additional 
information they believe they need in order to better evaluate the 
proposal. The commenters noted definitions are needed for terms such as 
``services'', ``overlap'', and ``provided services''. They also 
indicated that the data source (such as hospital cost reports or actual 
claims experience) and the methodology for measuring the services need 
to be defined and requested clarification of these issues in the final 
rule.
    For example, commenters asked how CMS will measure overlap of 
services between the specialty hospital and the SCH (or SCH applicant). 
Would there be a weighting for volume or the volume capacity of the 
limited service specialty hospital? Would it be 3 percent of service 
lines (for example, obstetrics, cancer care, or cardiac services), or 
discharges, or DRGs reported?
    Response: We appreciate the many helpful comments we received on 
this proposal. We proposed a 3-percent threshold of service overlap in 
an attempt to strike a balance between the need to ensure that SCHs do 
not lose their special status due to specialty hospitals opening nearby 
and the need to ensure that only hospitals that are the sole source of 
short-term acute hospital services for their community qualify as SCHs. 
We were concerned not to set the threshold too high because we wanted 
to ensure that only hospitals that truly are the sole source of care 
for their community continue to qualify as SCHs. Based on the comments 
we received, we are adopting alternative criteria, as described below. 
Adoption of this alternative criteria, comparing inpatient days, 
renders moot many of the questions raised by the commenters discussed 
above.
    Comment: Some commenters pointed out that specialty hospitals take 
away profitable services that subsidizes other critical services such 
as emergency room service, intensive care unit services, skilled 
nursing care, and home health and hospice care furnished by the 
hospitals that typically qualify as SCHs.
    These commenters believed SCH status was instituted to allow these 
types of providers the ability to provide access to a full range of 
services for Medicare patients, and that, as a result, these SCHs need 
to be protected.
    One commenter requested that we require a hospital, to be 
considered a like hospital for purposes of SCH determinations, to 
provide, on an ongoing basis, all of the services typically furnished 
by an SCH, such as 24-hour emergency service and surgery and obstetrics 
services.
    Some commenters recommended that the services provided by a 
limited-service specialty hospital should be defined so that, if the 
hospital had the capability of providing a service such as emergency 
service but was not staffed for 24-hour emergency service, was staffed 
only to the extent of referring its emergency patients to the SCH, or 
provided only its specialty-related emergency service, the hospital 
would not be considered to be furnishing emergency services, and, as a 
result, the hospital would not be considered a like hospital.
    Other commenters did not believe that percentages of specific DRGs 
or a similar calculation of limited services would be a fair and 
equitable method of determining SCH status, particularly when 
considering whether a hospital with SCH status should be permitted to 
retain such status.
    One commenter supported the proposal to amend the definition of SCH 
like hospitals to exclude any hospital that offers a very limited range 
of services. However, the commenter did not support the percent-of-
services methodology. The commenter stated that the administrative 
burden associated with making this determination would be too great for 
both providers and intermediaries.
    Response: Our proposal was intended to measure the extent of 
overlapping services because this would seem to be a useful indicator 
to determine whether another hospital in the community offers a 
plausible alternative to the SCH for residents in the area seeking 
inpatient acute care. For example, the existing regulations contemplate 
situations where hospitals with fewer than 50 beds may become eligible 
for SCH status despite the location of an otherwise like hospital 
within 35 miles, if the community hospital would admit at least 75 
percent of the area residents who become inpatients were it not for the 
fact that some beneficiaries or residents were forced to seek care 
outside the service area due to the unavailability of necessary 
specialty services at the community hospital (Sec. 412.92(a)(1)(ii)).
    Section 2810.B.3.d. of the Provider Reimbursement Manual contains 
instructions for excluding services not offered by the SCH applicant 
from the determination of whether the applicant admits at least 75 
percent of the area residents who become inpatients. Under this 
process, the hospital obtains information as to the diagnoses of and 
services furnished to those residents or Medicare beneficiaries who 
obtained care outside the SCH applicant hospital's service area during 
the survey period.
    In connection with the policy we proposed in the May 9, 2002 
proposed

[[Page 50055]]

rule, we contemplated using a similar process to determine whether a 
limited-service specialty hospital should be excluded from the 
definition of like hospitals. However, we recognize that this process 
would be labor and data intensive. As a result, we were interested in 
evaluating the recommendations submitted by commenters.
    Comment: Several commenters suggested using Medicare inpatient days 
in hospital units subject to the acute care hospital inpatient 
prospective payment system to identify whether a limited-service 
specialty hospital is likely to offer many of the services also offered 
by the SCH. Thus, for example, a specialty hospital that only provides 
orthopedic surgery with a 1-day recovery period would have its service 
weighted to reflect the limited intensity of such services.
    Commenters believe that using Medicare inpatient days would allow 
easy administration by both CMS and its fiscal intermediaries, because 
these data are readily available in hospital cost reports. They 
believed that by considering only inpatient days in units subject to 
the acute care hospital inpatient prospective payment system, the focus 
would be limited only to those services germane to the general acute 
care needs of the Medicare community. Other commenters suggested using 
actual gross payments for Part A services to Medicare beneficiaries as 
the unit of measurement for services provided.
    Response: We agree with the commenters who proposed using inpatient 
days as the comparative statistic to determine whether a limited-
service specialty hospital may be excluded from the like hospital 
definition. Although DRGs provide a comparison that more closely 
reflects service overlap, we believe that we will attain a similar 
outcome, with less administrative complexity, by comparing inpatient 
days. Accordingly, we are adopting patient days attributable to units 
that provide a level of care characteristic of the level of care 
payable under the acute care hospital inpatient prospective payment 
system as the unit of measurement for determining whether a hospital 
applying for SCH status can exclude from consideration as a like 
hospital another hospital within its service area. The number of 
inpatient days is readily available from all participating hospitals 
because it is already captured on the cost report.
    We believe that Medicare inpatient days are a good proxy for 
service overlap. However, we will assess the impact of the overall 
change to the definition of like hospital and the service overlap proxy 
on SCHs and the prospective payment system. This assessment will 
determine whether refinements to this policy may be necessary in future 
years.
    Comment: The commenters were in agreement that the overlapping 
services threshold of 3 percent was too low and would not accomplish 
our intent of distinguishing specialty hospitals from full-service 
acute care hospitals. Alternative suggestions included overlapping 
services thresholds of 8 percent, 10 to 15 percent, and setting the 
threshold after evaluating actual data. One commenter stated that 
adopting less than a 10-percent overlap threshold would not protect 
existing SCHs from losing their special status as a result of a 
limited-service specialty hospital opening in their community.
    Commenters offered the example where a heart hospital or other 
niche provider may perform inpatient services that represent closer to 
10 or 15 percent of the services performed by SCHs. In this situation 
the SCH continues to remain the sole source of the full range of acute 
care services in the community, including essential emergency services, 
and thus deserves to retain SCH status. However, if the specialty 
hospital is considered a like hospital, it would jeopardize the special 
status of the SCH.
    One commenter referred to the regulations, where, to qualify for 
SCH status, a hospital with another like hospital within 25 to 35 miles 
cannot have more than 25 percent of the admissions of residents within 
its service area admitted to other hospitals (Sec. 412.92(a)(1)(i)). 
The commenter suggested that, where the focus is on specialty hospitals 
that are not like hospitals, a threshold on the order of one-third of 
that 25-percent threshold would seem appropriate. The commenter 
suggests that a specialty hospital with only 8 percent service overlap 
with the community hospital would not be able to service the 
community's acute care needs.
    Response: As stated above, based on our evaluation of the public 
comments and the situations, of which we are aware, where an existing 
SCH's special status is being threatened by a nearby limited-service 
specialty hospital, we believe the best approach would be to revise our 
proposed definition of like hospital for SCH purposes to exclude any 
hospital where the inpatient services overlap compared to the SCH (or 
the SCH applicant) is less than 8 percent, as measured by inpatient 
days.
    The inpatient services would be measured by total inpatient days as 
reported on the hospitals' cost report, and should include all days 
attributable to units that provide a level of care characteristic of 
the level of care payable under the acute care hospital inpatient 
prospective payment system. We believe setting the threshold at 8 
percent would distinguish the specialty hospitals, which have very 
limited inpatient use and, therefore, limited inpatient days, from 
general, acute care hospitals typical of SCHs. Therefore, we are 
revising proposed Sec. 412.92 (c)(2) to reflect this change.
    To determine whether a hospital qualifies as an SCH, the fiscal 
intermediary would make a determination whether a nearby hospital paid 
under the acute care hospital inpatient prospective payment system is a 
like hospital by comparing the total acute inpatient days of the SCH 
applicant hospital with the total acute inpatient days of the nearby 
hospital. If the total acute inpatient days of the nearby hospital is 
greater than 8 percent of the total inpatient days reported by the SCH 
applicant hospital, the hospital is considered a like hospital for 
purposes of evaluating the application for SCH status. If the total 
acute inpatient days of the nearby hospital is 8 percent or less of the 
total acute inpatient days of the applicant hospital, the nearby 
hospital is not considered a like hospital for purposes of evaluating 
the application for SCH status under Sec. 412.92.
    Comment: Some commenters questioned the effective date of the 
proposal because they see the definition revision as a clarification of 
existing legislation that should be treated as such, applying to all 
open matters, not prospectively only.
    Response: This change is a revision to our current policy for 
defining like hospitals. Therefore, it is being implemented 
prospectively, starting with cost reporting periods that begin on or 
after October 1, 2002.
    Current regulations establish that an approved SCH classification 
remains in effect without need for reapproval unless there is a change 
in the circumstances under which the classification was approved 
(Sec. 412.92(b)(3)). It will be necessary, therefore, in situations 
where a SCH's eligibility is contingent on a nearby hospital being 
excluded from the like hospital comparison under this provision, for 
the fiscal intermediary to reevaluate periodically whether the 
exclusion is still appropriate, based on the most current inpatient 
days data.
    In the event that a new, limited-service specialty hospital opens 
within the service area of an existing SCH, the

[[Page 50056]]

fiscal intermediary will monitor the number of patient days at the two 
hospitals to ensure that the specialty hospital does not exceed the 8 
percent threshold.
    Comment: Some commenters stated that, without understanding how the 
test actually would be conducted, what data would be used, and why a 3 
percent threshold was selected, interested parties could not provide us 
with thoughtful, helpful comments. Accordingly, they recommended that 
we not finalize our proposal at this time. Instead, we should clarify 
our proposal and resolicit comments. In the interim, these commenters 
believed that we should grandfather SCH status for all existing SCHs 
while it further developing this policy. Similarly, several commenters 
suggested we further evaluate and develop this proposal and present it 
for public review and comment before finalizing the proposal.
    One commenter stated that we should also consider adopting an 
altogether different approach. Rather than implement an objective, one-
size-fits-all approach, we should instead develop review guidelines for 
our Regional Offices, and allow these Regional Offices to make case-by-
case, fact-specific determinations using the guidelines. Such 
guidelines could, for example, utilize a quantitative evaluation, 
similar to what we proposed. In addition, Regional Offices could be 
directed to examine whether area beneficiaries have a choice in the 
area for general-acute care hospital services.
    Response: We believe that, based on our understanding of the 
situations of which we are aware involving an SCH whose special status 
is being jeopardized by the opening of a limited-service specialty 
hospital in its service area, and similar situations described in the 
comments we received, an 8-percent threshold for the comparison of 
inpatient days as described above is appropriate. We are concerned that 
a case-by-case approach would result in inappropriate disparities 
across geographic areas in terms of how applications are reviewed.

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, in the May 9, 2002 proposed rule, we 
proposed 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.)
    We did not receive any comments on this technical change.

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.
    As discussed in Federal Register documents at 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 considered 
as a rural referral center for FY 1998 and later years so long as that 
hospital continues to be located in a rural area and does not 
voluntarily terminate its rural referral center status. Otherwise, a 
hospital seeking rural referral center status must satisfy applicable 
criteria.
    Also, effective October 1, 2000, if a hospital located in what is 
now an urban area was ever a rural referral center, it was reinstated 
to rural referral center status (65 FR 47089).
    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 
(Sec. 412.96(b)(ii)). 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 (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) (Sec. 412.96(c)(1) through (c)(5)). 
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 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 for FY 2003 in the May 9, 2002 proposed rule included 
all urban hospitals nationwide, and the proposed regional values for FY 
2003 were the median values of urban hospitals within each census 
region, excluding those with approved teaching programs (that is, those 
hospitals receiving indirect medical education payments as provided in 
Sec. 412.105). These values were 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.
    In the May 9, 2002 proposed rule, we proposed that, in addition to 
meeting

[[Page 50057]]

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. (See the table set forth in the May 9, 2002 
proposed rule at 67 FR 31460).
    Based on the latest data available (FY 2001 bills received through 
March 31, 2002), 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 2002 that is at 
least--
     1.3225; or
     The median case-mix index value for urban hospitals 
(excluding hospitals with approved teaching programs as identified in 
Sec. 412.105) calculated by CMS for the census region in which the 
hospital is located. The final median case-mix index values by region 
are set forth in the following table:

------------------------------------------------------------------------
                                                             Case-mix
                         Region                             index value
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT).................          1.2044
2. Middle Atlantic (PA, NJ, NY).........................          1.2247
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)..          1.3014
4. East North Central (IL, IN, MI, OH, WI)..............          1.2345
5. East South Central (AL, KY, MS, TN)..................          1.2418
6. West North Central (IA, KS, MN, MO, NE, ND, SD)......          1.1621
7. West South Central (AR, LA, OK, TX)..................          1.2595
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)............          1.3162
9. Pacific (AK, CA, HI, OR, WA).........................          1.2785
------------------------------------------------------------------------

    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). FY 2001 is the latest 
year for which we have complete discharge data available.
    Therefore, in the May 9, 2002 proposed rule, we proposed that, in 
addition to meeting other criteria, a hospital, if it is to qualify for 
initial rural referral center status for cost reporting periods 
beginning on or after October 1, 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. (See the table set 
forth in the May 9, 2002 proposed rule at 67 FR 31460.)
    Based on the latest discharge data available for FY 2001, the final 
median number of discharges for urban hospitals by census region areas 
are as follows:

------------------------------------------------------------------------
                                                             Number of
                         Region                             discharges
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT).................           6,905
2. Middle Atlantic (PA, NJ, NY).........................           8,644
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)..           8,893
4. East North Central (IL, IN, MI, OH, WI)..............           7,890
5. East South Central (AL, KY, MS, TN)..................           6,953
6. West North Central (IA, KS, MN, MO, NE, ND, SD)......           5,696
7. West South Central (AR, LA, OK, TX)..................           6,226
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.
    We reiterate that if an osteopathic hospital is to qualify for 
rural referral center status for cost reporting periods beginning on or 
after October 1, 2002, the hospital must have at least 3,000 discharges 
for its cost reporting period that began during FY 2001.
    We did not receive any comments on the criteria for rural referral 
centers.

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

[[Page 50058]]

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) (to be redesignated as Sec. 413.86(g)(9)) 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 a 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 final notice published in the Federal Register on 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 
regulations provide for the cap on the number of residents to be 
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 could 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 
number of 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.
    In the proposed regulation, we revisited this policy and explained 
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 actual FTE count decreases as the displaced residents finish 
their training. Therefore, the receiving hospital would not need a 
higher resident-to-bed ratio in the prior year to accommodate the 
remaining FTEs. Consequently, the higher resident-to-bed ratio cap in 
fact would not benefit the receiving hospital. Thus, in the May 9, 2002 
proposed rule, we proposed 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 proposed 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, as we explain below in response to a comment, in 
this final rule we are revising the proposed language of 
Sec. 412.105(a)(1)(iii) to state that the exception to the resident-to-
bed ratio cap for closed hospitals and closed programs applies only 
through the end of the first 12-month cost reporting period in which 
the receiving hospital trains the displaced FTE residents. We further 
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 proposed 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 explained that 
because we proposed 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 
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

[[Page 50059]]

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 proposed 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, which was reflected in proposed revised Sec. 412.105(a)(1).
    Comment: Numerous commenters expressed support for our proposal to 
allow an adjustment to the resident-to-bed ratio cap for residents 
displaced by the closure of another teaching hospital or another 
hospital's GME program. One commenter added that, although the proposed 
adjustment to the resident-to-bed ratio in the first year would 
equitably reimburse hospitals who commence training the displaced 
residents at the beginning of their respective fiscal year, this 
adjustment would result in the receiving hospital being under-
reimbursed in the first full year of residency training when a hospital 
or program closes toward the end of the receiving hospital's fiscal 
year. The commenter requested that CMS correct this inequity by 
extending the resident-to-bed ratio cap adjustment to include both the 
first partial and the first full year of training displaced residents 
at the receiving hospital.
    Response: We agree with the commenter that our proposal to limit 
the adjustment to the resident-to-bed ratio cap to the first (cost 
reporting) year in which the receiving hospital is training the 
displaced residents may result in reduced payments to the receiving 
hospital if the receiving hospital begins training those residents at 
some point other than the beginning of a full fiscal year. Therefore, 
in this final rule, we are revising the language proposed under 
Sec. 412.105(a)(1)(iii) to state that the exception to the resident-to-
bed ratio cap for closed hospitals and closed programs applies through 
the end of the first 12-month cost reporting period in which the 
receiving hospital trains the displaced FTE residents. We note that the 
effective date of this revised policy is for cost reporting periods 
beginning on or after October 1, 2002.
    For example, if receiving Hospital A has a fiscal year end (FYE) of 
December 31, 2003, and it begins training 3 displaced residents on 
November 1, 2003, for purposes of applying the resident-to-bed ratio 
cap, receiving Hospital A may add a 2 months' proportion of the 3 FTEs 
to the numerator of the resident-to-bed ratio cap from the prior cost 
reporting period (FYE December 31, 2002). Receiving Hospital A may also 
add the FTEs that continue training at the hospital during its cost 
reporting period ending December 31, 2004 to the numerator of the 
resident-to-bed ratio cap from the FY 2003 cost reporting period. 
However, no adjustment may be made for purposes of applying the 
resident-to-bed ratio cap for subsequent years. Other than the 
allowance for applying the resident-to-bed ratio cap adjustment through 
the end of the first 12-month cost reporting period in which the 
receiving hospital trains the displaced

[[Page 50060]]

residents, the policy is the same as that in the proposed rule.
    Comment: One commenter commended CMS for realizing that it would be 
appropriate to allow eligible hospitals to receive a temporary 
adjustment to the application of the IME resident-to-bed ratio cap. 
However, the commenter believed that in lieu of the rationale that CMS 
utilized in drafting the regulation published on August 1, 2001 and to 
avoid penalizing eligible hospitals, CMS should apply a retroactive 
effective date of October 1, 2001 to this policy.
    Response: We understand the commenter's concerns, and in proposing 
this policy, we acknowledged the need to allow for the temporary 
adjustment to the resident-to-bed ratio cap. However, because we do not 
have explicit statutory authority to do so, we are unable to apply this 
policy retroactively. Therefore, the effective date of this policy will 
be prospective; that is, for cost reporting periods beginning on or 
after October 1, 2002.
    Comment: Some commenters asserted that the proposal requiring that 
the resident-to-bed ratio cap be calculated in the cost reporting 
period following the departure of the last displaced residents as if 
the displaced residents had not trained at the receiving hospital in 
the prior year, adds more complexity to an already burdensome IME 
calculation. The commenters stated that the number of residents likely 
to be involved with this provision is minimal, and accordingly, CMS 
should not finalize this provision.
    Response: As we have explained in the proposed rule, we believe 
that in light of the addition of FTEs to the resident-to-bed ratio cap 
in the first full cost reporting period, it is equitable to remove 
those FTEs when calculating the resident-to-bed ratio cap in the year 
following the departure of the displaced residents. We disagree that 
requiring that the resident-to-bed ratio cap be calculated in the cost 
reporting period following the departure of the last displaced 
residents as if the displaced residents had not trained at the 
receiving hospital in the prior year is overly burdensome. It requires 
only a simple subtraction of FTEs from the numerator of the prior year 
ratio, and in the next issuance of the Medicare cost report 
instructions, we will be making a revision to the instructions for line 
3.19 of Worksheet E, Part A of the cost report to reflect this policy.
    Comment: One commenter was concerned about our proposal to adjust 
``the numerator of the prior year's resident-to-bed ratio by the number 
of FTE residents that has caused the receiving hospitals to exceed its 
FTE cap'' (emphasis added) (67 FR 31461, May 9, 2002). The commenter 
stated that, by describing the increase in the numerator in relation to 
the hospital's FTE cap, the intent of the provision will not be 
fulfilled unless the hospital is already at its FTE cap. The commenter 
explained that if, for example, Hospital A has 4 residents in both cost 
reporting years 2002 and 2003, has a FTE cap of 5 FTEs, and accepts 3 
displaced residents in 2003, it exceeds the FTE cap by only 2 
residents. Therefore, as proposed, the adjustment to the prior year 
resident-to-bed ratio would result in a ratio cap of 0.06 ((4+2)/100). 
The current year resident-to-bed ratio would be 0.07 ((4+3)/100). Since 
this exceeds the hospital's prior year resident-to-bed ratio, the 
resident-to-bed ratio for Hospital A will be held to 0.06. The 
commenter concluded that since our intent is not to penalize hospitals 
that accept displaced residents, the adjustment to the prior year 
resident-to-bed ratio must not rely on the FTE cap for a reference 
point, but rather, must equal the number of displaced residents.
    Response: The original regulations concerning temporary adjustments 
for hospital closure were written in response to requests from 
hospitals for an exception to the FTE cap, to allow the additional 
residents coming from a closed hospital to be counted by the receiving 
hospital (63 FR 26329 and 26329, May 12, 1998). Similarly, in the July 
30, 1999 final rule (64 FR 41522), we explained that we adopted this 
provision because hospitals had indicated a reluctance to accept 
additional residents from a closed hospital without a temporary 
adjustment to their FTE caps. Accordingly, the existing regulations 
discussing hospital and program closure at Sec. 413.86(g)(8) 
(Sec. 412.105(f)(1)(ix) for IME) state that ``a hospital may receive a 
temporary adjustment to its FTE cap to reflect residents added'' 
because of the closure of another hospital or another hospital's 
program. Furthermore, existing Secs. 413.86(g)(8)(ii)(B) and 
(g)(8)(iii)(A)(2) require that, in order for a hospital to receive this 
temporary FTE cap adjustment, the hospital must document ``that it is 
eligible for this temporary adjustment by identifying the residents who 
have * * * caused the hospital to exceed its cap. * * *'' (emphasis 
added). These regulations are only applicable in instances where the 
training of displaced residents causes a hospital to exceed its FTE 
cap; if a hospital has room under its FTE cap to train these residents, 
no FTE cap adjustment is needed. Thus, in order for a hospital to 
qualify for an adjustment to its resident-to-bed ratio cap (or 3-year 
rolling average count), the hospital must first qualify for a temporary 
adjustment to its FTE cap. To qualify for a temporary FTE cap 
adjustment, the hospital must demonstrate that accepting some number of 
displaced residents has caused the hospital to exceed its FTE cap. 
Therefore, the proposed resident-to-bed ratio cap adjustment is 
necessarily linked to ``the number of FTE residents that has caused the 
hospital to exceed its FTE cap.'' Accordingly, we are not accepting the 
commenter's request at this time. However, we may consider in the 
future proposing to allow hospitals that are below their FTE caps and 
train displaced residents to also receive an adjustment for those 
displaced residents that are under the cap for purposes of applying the 
resident-to-bed ratio cap and the 3-year rolling average. As a final 
note, we would like to point out an error in the example that the 
commenter provided. In the example, a hospital that has 4 FTEs and an 
FTE cap of 5, accepts 3 displaced FTE residents. The commenter stated 
that the current year resident-to-bed ratio would be 0.07 ((4+3)/100). 
This is incorrect. Since, as explained above, the regulations prescribe 
that the receiving hospital's FTE count is only adjusted for those FTEs 
that have caused the receiving hospital to exceed its FTE cap, the 
current year numerator (as well as the prior year numerator) would be 6 
(4+2), because only 2 of the 3 FTEs have caused the hospital to exceed 
its FTE cap of 5 FTEs.
    Comment: One commenter requested CMS to allow hospitals that train 
displaced residents to receive permanent, not temporary, adjustments to 
their FTE caps.
    Response: We are not addressing this comment in this final rule 
because it is outside the scope of what was specifically addressed in 
the proposed rule.
    3. Counting Beds for the IME and DSH Adjustments (Sec. 412.105(b) 
and Sec. 412.106(a)(l)(i))
    In the May 9, 2002 proposed rule, we discussed the regulations 
located at Sec. 412.105(b) for determining the number of beds to be 
used in calculating the resident-to-bed ratio for the IME adjustment. 
Those 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

[[Page 50061]]

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.
    We also discussed section 2405.3G of Part I of the Medicare 
Provider Reimbursement Manual (PRM), which further defines an 
``available'' bed as a bed that is permanently maintained and is 
available for use to lodge inpatients.
    These discussions were background for our proposal to clarify some 
of the uncertainty that had arisen concerning the application of the 
definition of ``available.'' For example, a question has arisen 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 proposed 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 stated that the 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 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 proposed 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 proposed to otherwise continue to determine a hospital's bed 
size using existing regulations and program manual instructions, 
including the application of the available bed policy.
    We believe that the policy in the May 9, 2002 proposed rule more 
accurately indicates the size of a hospital's operations. We proposed 
to specify under 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 proposed to make the proposed 
policy effective for discharges occurring on or after October 1, 2002.
    Comment: Numerous commenters questioned why we were interested in 
applying an occupancy adjustment to counting beds for IME and DSH 
purposes. The commenters strongly opposed the proposed policy, which 
they indicated would serve to increase a hospital's IME payment but 
would limit a hospital's bed size for DSH payment purposes, if the 
hospital's occupancy is below 35 percent. In addition, the commenters 
believed that there are other reasons why a hospital may have excess 
capacity that may include patients utilizing the outpatient services 
instead of inpatient services, and that, due to cost, patients may be 
moved sooner from acute care settings to the next level of care.
    The commenters contended that this proposal is contrary to the 
statutory language and congressional intent. The commenters further 
contended that the proposed policy would cause financial hardship to 
small urban hospitals that treat a disproportionate number of low-
income patients.
    MedPAC indicated that it believed that we are recognizing a real 
problem in maintaining integrity in the DSH payment procedures. 
However, MedPAC believed that the proposed policy illustrates the 
difficulties that arise when qualifying for DSH payments depends in 
part on the number of beds a hospital keeps in service. MedPAC 
recommended that a single formula apply to all hospitals regardless of 
location (urban/rural) or bed size. In addition, MedPAC recommended 
that the low-income shares used to determine each hospital's DSH 
adjustment reflect all low-income patients, which include patients 
receiving uncompensated care. MedPAC stated that a new DSH distribution 
formula will be needed when the uncompensated care data are complete, 
and that would be an opportune time to eliminate the use of a bed 
standard. Based on this information, MedPAC questioned whether it is 
worth changing the bed counting methodology now since a more 
fundamental change may occur in the next year or two.
    Response: We believe our proposed policy represents a reasonable 
approach to addressing situations where hospitals appear to be 
maintaining excess capacity in order to qualify for higher DSH 
payments. With respect to our authority to implement such a change, we 
point out that we have broad authority under the statute in 
establishing the methodology for determining the number of available 
beds.
    However, at this time, we have decided not to proceed with the 
proposed change. Instead, we will consider this issue as part of a 
future comprehensive analysis of our bed and patient day counting 
policies. That is, we believe there are other aspects of counting beds 
that need to be addressed as well and, upon further consideration, we 
have decided to proceed in a more comprehensive manner. We acknowledge 
MedPAC's comments as well and will take into account the potential that 
bed counting issues for DSH purposes may become less significant.
    Accordingly, in this final rule, we are not adopting the proposed 
change of Sec. 412.105(b)(3).

 Technical Correction

    Section 211(b) of Public Law 106-554 amended section 
1886(d)(5)(F)(iv)(III) of the Act to revise the calculation of the DSH 
payment adjustment for hospitals affected by the revised thresholds as 
specified in section 211(a) of Public Law

[[Page 50062]]

106-554. These changes were effective for discharges on or after April 
1, 2001, and no changes were made by section 211(b) for discharges 
prior to April 1, 2001. When we issued the June 13, 2001 interim final 
rule with comment period (66 FR 32172) to update the regulations to 
incorporate the changes made by section 211, we inadvertently changed 
the adjustment factor for rural hospitals with fewer than 100 beds from 
4 percent to 5 percent under Sec. 412.106(d)(2)(iv)(A) for discharges 
occurring before April 1, 2001. We are correcting this error in this 
final rule by revising Sec. 412.106(d)(2)(iv)(A) to specify that, for 
discharges before April 1, 2001, the applicable DSH adjustment factor 
for rural hospitals with fewer than 100 beds was 4 percent.
    This correction was not included in the May 9, 2002 proposed rule, 
as we were only made aware of it after publication of that proposed 
rule. The Administrative Procedure Act generally requires that agency 
rules be published in the Federal Register as a notice of proposed 
rulemaking with a period for public comment (5 U.S.C. 533(b)). This 
notice-and-comment procedure can be waived, however, if an agency finds 
good cause that the procedure is impracticable, unnecessary, or 
contrary to the public interest and incorporates a statement of the 
finding and its reasons in the rule issued. Since this change is being 
made to correct a technical error, we find that the notice-and-comment 
procedure is unnecessary, and, therefore, find good cause to waive the 
notice of proposed rulemaking and issue the correction in this final 
rule.

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 
(Pub. L. 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 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.
    In the May 9, 2002 proposed rule, we proposed 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 proposed 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 included 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

[[Page 50063]]

based on at least two of its three most recently settled cost reporting 
periods.
    In addition, we proposed (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 proposed 
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.
    Comment: Three commenters addressed our proposal to conduct ongoing 
reviews of hospitals to determine whether or not they continue to meet 
the MDH criteria. The first commenter opposed the proposal for ongoing 
reviews of MDHs because this type of review is not specified in the 
law, but is an interpretation by CMS. The commenter supported its 
position by pointing out that a hospital qualifying based on the 
original criterion (that is, 1987 data) is allowed to retain this 
status despite any changes in subsequent years. The commenter also 
stated this may cause instability in individual hospital payments from 
year-to-year, which will be disruptive for a hospital whose revenue 
depends heavily on Medicare. The commenter suggested that, if the 
proposed reviews are found to be consistent with Congressional intent, 
CMS adopt a policy that does not penalize hospitals for small changes 
in patient mix and provides stability in the payment system from year 
to year. Moreover, the commenter suggested granting MDH status for a 3-
year period before requiring requalification, similar to wage index 
reclassifications, or setting the level for requalification at a 
slightly lower level (perhaps 55 percent) so that a slight change in 
volume does not cause a loss of MDH status.
    The second commenter supported the proposal but recommended that 
the requirement that hospitals apply for MDH status be removed, since 
the fiscal intermediaries will be conducting annual reviews.
    The third commenter focused on the loss of MDH status effective 30 
days after the intermediary provides written notification to the 
hospital that it no longer qualifies for MDH status. The commenter 
stated that mid-year MDH status changes provide a number of claims 
processing and cost report settlement problems. The commenter 
recommended that the effective date for the change in MDH status should 
be the first day of the cost reporting period following the 
intermediary's notification of the hospital.
    Response: We agree that hospitals that qualify based on the 
original criteria were not required to requalify based on more recent 
data, since the original criteria, as dictated by law, was based on a 
specified period, here the 1987 data. However, the law was amended and 
specifies the new, additional criterion: ``two of the three most 
recently audited cost reporting periods for which the Secretary has a 
settled cost report.'' We believe this language supports an 
interpretation that a hospital is to qualify as an MDH based on its 
most recent data, not based on a one-time qualification, as is the case 
with the original criteria (which was based on data from a set period 
of time, the hospital's FY 1987 cost reporting period).
    With respect to the suggestion that the proposed ongoing reviews of 
hospitals MDH status should provide that, once approved, retention of a 
hospital's MDH status for a 3-year period, or that the level for 
requalification should be at a slightly lower percentage of inpatient 
days or discharges attributable to Medicare than 60 percent, the 
statute (section 1886(d)(5)(G)(iv)(IV) of the Act) does not provide 
such flexibility. Allowing hospitals to qualify using cost report data 
from other than two of the three most recently available cost reporting 
periods, or using a percentage less than 60 percent, would be 
inconsistent with the statutory language.
    Regarding the effective date of a status change, the effective date 
of 30 days after the date of the notice from the fiscal intermediary is 
consistent with current policy for approval of both MDH and SCH status 
as well as notices that the hospital no longer meets such eligibility 
criteria. Concerning the commenter's request to not require hospitals 
to reapply for MDHs status since the intermediaries would already be 
reviewing that status on an annual basis, we wish to clarify that the 
ongoing reviews would be of hospitals with existing MDHs status only. 
Therefore, hospitals that had lost their MDH status would not be 
included in an automatic annual review to determine whether or not the 
hospitals continue to meet the eligibility criteria for MDH status. 
Instead, such hospitals must reapply for MDH status based on two of 
their three most recently audited cost reports.
    Accordingly, we are adopting as final the proposed revised changes 
to the MDH policy under Sec. 412.108(b).

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 the services of CRNAs.\1\ 
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.
---------------------------------------------------------------------------

    \1\ 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:

[[Page 50064]]

     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 salary for a CRNA 
in rural areas in calendar year 2000 was $111,000, with a total annual 
compensation of $141,000. 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 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, in the May 9, 2002 proposed 
rule, we proposed to revise Secs. 412.113(c)(2)(ii) and (c)(2)(iii) to 
raise the 500-procedure threshold to 800 procedures.
    Comment: Several commenters supported our proposed changes and 
indicated that, without the proposed change in the regulations, rural 
hospitals will experience serious disruptions in their delivery of 
anesthesia services. CRNAs are the sole anesthesia providers in a 
number of rural hospitals. The commenters added that, without CRNAs, 
these rural hospitals will have difficulty in continuing to meet their 
patient's surgical and trauma stabilization services. Patients will be 
forced to travel outside of their communities, which could mean great 
distance.
    One commenter suggested that the threshold should be reviewed every 
3 years to ensure it continues to appropriately reflect market 
conditions for rural hospitals trying to maintain anesthetists 
services.
    Response: We agree that the existing regulation providing for 500 
procedures per year as a threshold could hinder the ability of some 
rural hospitals to sustain access to surgical procedures, which is the 
reason for our proposed change. We will continue to monitor this issue 
to determine whether future adjustments to the procedure threshold are 
warranted.
    Comment: Several commenters raised an issue concerning the fact 
that some Medicare fiscal intermediaries include nonanesthesia 
ancillary services provided by the CRNAs when counting the total number 
of surgical procedures. They indicated that many rural hospitals are 
not able to qualify for the reasonable cost payment for their CRNAs as 
a result.
    The commenters suggested a specific definition of surgical 
procedures that include cutting, abrading, suturing, and lasering of 
otherwise physically changing body tissues and organs. The commenters 
indicated that this suggested definition would clarify and eliminate 
the confusion in regulatory interpretation across fiscal 
intermediaries. One commenter indicated that anesthetists may provide 
therapeutic services for pain management unassociated with a surgical 
procedure.
    Response: In view of the comments on this issue, we believe that 
certain steps are needed to improve consistency in the counting of 
surgical procedures. We appreciate the commenter's recommended 
definition of surgical procedures, and will consider whether such 
instructions would reduce inconsistency in counting of procedures, 
while still being consistent with the legislative and regulatory intent 
of this provision. We also will review all aspects of the counting of 
procedures to consider what further actions may be necessary to improve 
consistency. Our goal is to facilitate greater consistency in the 
manner and criteria used by all intermediaries.
    Comment: Several commenters expressed concern that the existing 
regulations only allow hospitals in existence as of 1987 to qualify for 
reasonable cost pass-through and requested us to review this issue. The 
commenters indicated that this threatens new rural hospitals' ability 
to continue to provide surgical and anesthesia services to patients.
    Response: To enable rural hospitals to secure anesthesia services 
for their patients, these regulations include a rural hospital's option 
for reasonable cost pass-through for the services of one full-time 
equivalent CRNA, as long as the hospital qualifies for ``pass-through'' 
treatment. The statute specifies the criteria and the regulation tracks 
the statutory language. Therefore, we believe we do not have the 
authority to extend this provision to hospitals that do not otherwise 
meet the criteria as described by the statute.
    Comment: Some commenters sought clarification as to whether this 
provision is available to SCHs.
    Response: SCHs that otherwise meet the statutory criteria are 
eligible to receive this pass-through payment. We are not aware that 
there has been any confusion in the past on this issue, but we are 
clarifying the point here in response to the comment.
    Comment: Several commenters recommended that we eliminate the 
threshold altogether, or raise it even higher. One commenter stated 
that the need for the pass-through demonstrates that fee schedule 
payments for nonphysician anesthetists are inadequate to defray the 
costs associated with this service.

[[Page 50065]]

    Another commenter suggested that CAHs should be exempt from the 
qualifying criteria to receive these pass-through payments. The 
commenter suggested that removing this requirement for CAHs would 
eliminate the unnecessary paperwork required for these hospitals to 
demonstrate they continue to meet the minimum thresholds.
    A third commenter argued that the cost pass-through provision 
should permit rural hospitals to qualify on the basis of employing 
anesthesiologists as well. This commenter referred to survey data that 
purported to show a serious shortage of anesthesia providers in support 
of this argument.
    Response: As described above, we believe the statute is specific as 
to the threshold requirements to qualify for the CRNA pass-through 
payments. Accordingly, a hospital or CAH that wishes to qualify for 
CRNA pass-through payments must meet the statutory criteria, including 
the threshold requirement. We also believe the statute does not provide 
authority to expand this policy to pay pass-through costs to hospitals 
for anesthesiologists' services. We believe the change we are making, 
increase the threshold from 500 to 800 procedures per year, is 
appropriate and note that it is generally supported by the commenters.
    Comment: The AANA requested a technical correction to the reference 
in the proposed rule that, according to data from AANA, the average 
total annual compensation for CRNA in 2001 is approximately $155,000. 
According to the AANA, the most recent data for calendar year 2000 
reflect an average salary in rural areas of $111,000, with a total 
annual compensation of $141,000.
    Response: In the preamble of this final rule, we have revised the 
prior reference accordingly to avoid any potential confusion.
    Comment: One commenter questioned whether anesthesiologists 
assistants are recognized as qualified providers under this provision.
    Response: As we noted in the proposed rule and in the discussion 
above, our understanding of Congressional intent was that this pass-
through payment applied to the services of all qualified hospital-
employed nonphysician anesthetists (67 FR 31464). Therefore, a hospital 
otherwise meeting the criteria for this pass-through payment by 
employing an anesthesiologists assistant would be eligible for pass-
though payments.
    Comment: One commenter requested clarification of whether the 
requirement at Sec. 412.113(c)(2)(i)(D) that ``each qualified 
nonphysician anesthetist employed by or under contract with the 
hospital or CAH has agreed in writing not to bill on a reasonable 
charge basis for his or her patient care in that hospital or CAH'' 
applies only to Medicare beneficiaries or to all patients.
    Response: This requirement is to ensure that the nonphysician 
anesthetist is not also billing Medicare for Part B services under the 
fee schedule. Therefore, the requirement only pertains to services 
provided to Medicare beneficiaries. In this final rule, we are adding a 
revision to Sec. 412.113(c)(2)(i)(D) to reflect the limited 
applicability of this requirement.
    Accordingly, we are adopting as final the proposed changes to 
Sec. 412.113(c)(2)(ii) and (c)(2)(iii), with one change. We are 
revising Sec. 412.113(c)(2)(i)(D) to specify that each qualified 
nonphysician anesthetist employed by or under contract with the 
hospital or CAH has agreed in writing not to bill on a reasonable 
charge basis for his or her patient care to Medicare beneficiaries in 
that hospital or CAH.

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, Terminations, and Cancellations
    Under Sec. 412.273(a) of our regulations, a hospital or hospital 
group 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 after 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, the May 9, 2002 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. The 
procedure for canceling a withdrawal or termination is discussed in 
detail below.
    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 after 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 
August 1, 2001 (FY 2002) 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 covered in the August 1, 2001 final rule, which we are 
addressing in this final 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 after 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

[[Page 50066]]

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 to 
avoid a lapse in reclassification status the following year. Therefore, 
in the May 9, 2002 proposed rule, we proposed to clarify, in new 
paragraph (iii) of Sec. 412.273(b)(2), 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 reclassification options 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, in the May 9, 2002 proposed rule, 
we proposed 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 means 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. 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 adequately project their 
future revenues. Therefore, in the May 9, 2002 proposed rule, we 
proposed 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 also 
proposed 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, 
in the May 9, 2002 proposed rule, we proposed 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)).
    We did not receive any comments on these proposed changes. 
Therefore, in this final rule we are adopting the proposed changes as 
final.
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 weighted 3-year average of its average hourly wages using data from 
the CMS hospital wage survey used to construct the wage index in effect 
for prospective payment purposes.
    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 in the August 1, 2001 final rule 
(66 FR 39890), we have now determined that there is a need to clarify 
further 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 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 the new hospital does not 
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 when the parties agree to accept assignment 
of the provider agreement. 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, 
as we proposed in the May 9, 2002 proposed rule, in this final rule we 
are revising 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 will 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 will 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. Thus, we are revising 
Sec. 412.230 to clarify, under 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

[[Page 50067]]

used to determine the wage index, it is eligible to apply for 
reclassification on the basis of those data.
    Comment: One commenter indicated that our efforts to clarify our 
policy regarding change of ownership create a financial incentive for 
new owners to go through the ``onerous and costly'' process of 
obtaining new provider numbers in order to obtain geographic 
reclassification. The commenter believed that any valid change in 
ownership under Sec. 489.19 should allow a hospital the opportunity to 
request reclassification and that we should clarify that all payment 
areas impacted by the assignment of a new provider number should be 
consistently applied.
    Response: This clarification establishes clear, predictable 
guidelines as to how hospitals' data will be treated for 
reclassification purposes. The rule was not adopted to govern provider 
behavior, since we cannot predict hospitals' behavior in situations 
where they may perceive it to be to their financial advantage to change 
their ownership arrangements. Rather, given the guidelines established 
by CMS, hospitals are free to act in their best interests.

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 (Pub. L. 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 be 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. There must be at least three existing 
teaching hospitals with PRAs in the MSA for this calculation.
    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. 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

[[Page 50068]]

numbers of teaching hospitals in an MSA.
    In addition, as discussed in section V.I.1. of this final 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, in the May 9, 2002 proposed rule, we proposed 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 proposed to continue to calculate a weighted average PRA. However, 
rather than using 1984 base year data, we proposed 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 proposed 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, line 3.08, and line 3.11 of the Medicare cost report, 
CMS-2552-96,Worksheet E-3, Part IV.)
    (We note that, under step 2, we have added ``line 3.11'' of the 
cost report to capture dental and podiatry FTE counts as part of the 
nonprimary care FTE counts. We made this addition in response to a 
comment received, as discussed below under the comment and response 
section for this area.)
    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 years 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 this revised 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 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) $54,320,000/485FTEs = $112,000, the weighted average PRA for MSA 
1234 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.
    In the May 9, 2002 proposed rule, we proposed that the 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. We proposed 
a revision under a proposed new Sec. 413.86(e)(5)(i)(C).
    Comment: One commenter expressed concern about our proposed changes 
to the calculation of weighted average PRAs for new teaching hospitals. 
The

[[Page 50069]]

commenter believed that our proposed methodology is as administratively 
burdensome as the existing methodology, because the servicing 
intermediary would be required to solicit most recently settled cost 
report data from all other intermediaries servicing providers in the 
defined territory every time a new PRA needs to be calculated. As an 
alternative to using most recently settled cost report data, the 
commenter suggested that we specify a cost reporting period from which 
all future data can be updated (that is, cost reporting periods ending 
between October 1, 1998 and September 30, 1999). The commenter 
indicated that it would be helpful if we would provide all 
intermediaries with a nationwide listing of all teaching hospitals 
(extracted from the HCRIS and compiled in a database/spreadsheet 
format), including provider number, MSA number, county, PRAs, and 
primary and nonprimary care FTE counts from the specified cost 
reporting period.
    Response: We understand the commenter's concerns, but we believe 
that using data from most recently settled cost reports results in a 
weighted average PRA that more appropriately reflects the pertinent 
dynamics of residency training in a specific geographical area. We note 
that the requirement to use data from all hospitals in an MSA, 
regardless of whether they are serviced by different intermediaries, 
exists even under current regulations. In addition, generally, 
hospitals in the same MSA either use the same fiscal intermediary or 
one of two fiscal intermediaries and, therefore, we do not believe that 
it is unreasonably difficult to obtain information from another 
intermediary. Furthermore, as we have done in the past, we will 
continue to provide assistance to the intermediaries involved in the 
process of calculating the weighted average PRAs. Finally, we will 
consider the commenter's suggestion concerning the compilation of a 
nationwide database.
    Comment: One commenter asked whether, considering that dental and 
podiatry residents are also nonprimary care, the FTE count of dental 
and podiatry residents from line 3.11 of worksheet E-3 Part IV should 
be included in determining the FTE counts in step 2 of the calculation 
in the proposed rule (67 FR 31467).
    Response: Step 2 of the proposed calculation states, ``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).'' We agree with the commenter that the dental and podiatry FTE 
counts should also be included, and, therefore, we are revising step 2 
in the example in this final rule to state that intermediaries should 
use the FTE counts from line 3.07, line 3.08, and line 3.11 of the 
Medicare cost report.
    Accordingly, in this final rule, we are adopting as final the 
proposed revised Sec. 413.86(e)(5)(i)(B) and the proposed new 
Sec. 413.86(e)(5)(i)(C) without modification.
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 
members 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. Consistent with the broad authority conferred by the statute, we 
established criteria for defining an ``affiliated group'' and an 
``affiliation agreement'' in both the August 29, 1997 final rule (62 FR 
45965) and the May 12, 1998 final rule (63 FR 26317). Because we had 
received many inquiries from the hospital industry on this policy, we 
proposed in the May 9, 2002 proposed rule to clarify in regulations the 
requirements for participating in an affiliated group. Most of these 
requirements are explicitly derived from the policy explained in the 
August 29, 1997 and May 12, 1998 final rules.
    Specifically, we proposed to add under Sec. 413.86(b) a new 
definition of ``Affiliation agreement.'' Under this new definition, we 
proposed to specify 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 proposed 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) were proposed 
to be redesignated as Sec. 413.86(g)(5)(v) through (vii), respectively; 
and existing Secs. 413.86(g)(7) through (g)(12) were proposed to be 
redesignated as Secs. 413.86(g)(8) through (g)(13), respectively, to 
accommodate these additions.) Specifically, we proposed 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 the 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) was explicitly derived 
from policy stated in the May 12, 1998 final rule (63 FR 26336). We 
proposed

[[Page 50070]]

to incorporate in regulations policy that was previously established 
under the formal rulemaking process.
    We proposed 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 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, in virtually every agreement, 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 
abusive practices that do 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. As we explained in the preamble to the May 9, 2002 
proposed rule, 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 hospital-specific FTE cap on 
the number of residents. In addition, we have separately addressed 
issues that arise when residents are displaced because of a hospital 
closure. We have in place a policy at existing Sec. 413.86(g)(8) (which 
was proposed to be redesignated as Sec. 413.86(g)(9) in the May 9, 2002 
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, in the May 9, 2002 proposed rule, we proposed 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 the 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 proposed to make a conforming clarification at 
Sec. 412.105(f)(1)(vi) for purposes of IME payments.

Definition of ``Affiliation Agreement'' and the Requirements at Revised 
Sec. 413.86(g)(7)

    Comment: Several commenters were concerned about our requirement at 
proposed Sec. 413.86(b) in the definition of ``affiliation agreement'' 
that the agreement specify FTE cap adjustments based on a 12-month 
period that begins July 1 and ends June 30. Many commenters believed 
that the requirement should be changed so that hospitals may execute 
affiliation agreements at any time during the year. One commenter 
believed that since, regardless of the date it is executed, the 
resident count set forth in the agreement must be reconciled with the 
hospital's cost reporting period, permitting hospitals to execute 
agreements throughout the year would reduce the hospital's 
administrative burdens without imposing much, if any, additional 
hardship on Medicare program administration. Another commenter 
suggested that CMS could delay the filing date for affiliations from 
July 1 until either the first day of a hospital's next cost reporting 
period beginning after commencement of the July 1 residency period, or 
October 1, whichever time period is longer.
    Response: We set a July 1 deadline for submission of affiliation 
agreements (proposed Sec. 413.86(g)(7)(i)), as well as specifications 
of FTE cap adjustments in the affiliation agreements, based on the July 
1 residency training year because we believed that choosing one date 
was administratively less burdensome to our fiscal intermediaries for 
purposes of audit of the participating hospitals' Medicare cost 
reports. In addition, we chose July 1 because we believe that date is 
the start date of virtually all residency training programs across all 
specialties. We would be more sympathetic to the commenters' request 
for changes in the execution date if we had heard of residency training 
programs that begin on dates other than July 1. Until we hear of 
specific programs that begin on other than July 1, we continue to 
believe that it is appropriate and consistent with efficient 
administration of the Medicare program to maintain the existing policy 
based on the July 1 residency training program year. We believe that it 
is not only less burdensome for our fiscal intermediaries (as well as 
CMS) to receive affiliation agreements at one point in the year alone, 
but we also believe it is less burdensome to participating hospitals. 
We believe that the vast majority of participating hospitals will know 
prior to July 1 how many residents will be training at the hospital in 
any given residency program year and how many residents would be 
rotating in from other hospitals.
    Comment: One hospital commenter described a situation in which its 
existing affiliation agreement with another hospital, which was 
submitted to the fiscal intermediary with a copy to CMS (at that time 
HCFA) Central Office on July 1, 1998, states that the affiliation 
agreement ``shall continue in effect on an indefinite basis until 
terminated by the agreement of all Hospitals * * * of the affiliated 
group.'' The commenter asked us whether this term language meets the 
requirements in the proposed rule.
    The same commenter mentioned that its affiliation agreement from 
1998 does not specify each participating hospital's direct and indirect 
FTE cap, ``as this was not required in the August 29, 1997,

[[Page 50071]]

and May 12, 1998 final rules.'' In addition, the commenter asked 
whether changes in a hospital's FTE caps can be accounted for under the 
proposed rule. Finally, the commenter asked whether documents other 
than the affiliation agreement, such as attachments to the affiliation 
agreement, can be used to identify a hospital's direct and indirect FTE 
caps.
    Response: As we proposed at Sec. 413.86(b), each affiliation 
agreement should specify the term of the agreement ``which at a minimum 
is one year,'' beginning on July 1 of a year. We stated similarly in 
the May 12, 1998 final rule on affiliation agreements (63 FR 26341) 
that ``each agreement must be for a minimum of one year.'' However, 
there is nothing to prohibit affiliation agreements from being 
automatically renewable each year or from being for terms greater than 
one year in length. Therefore, the language that the commenter 
apparently used in its affiliation agreement would meet existing 
Medicare policy on affiliation agreements and their effectiveness. As 
long as the affiliation agreements cover a period of time of at least 
one year beginning July 1 of a year, the affiliation agreements meet 
the term requirement at Sec. 413.86(b).
    To address the commenter's statement that it did not report the 
direct and indirect GME FTE caps for the participating hospitals in its 
affiliation agreement because it was not previously required to do so, 
we stated clearly in the May 12, 1998 interim final rule that hospitals 
must specify the ``planned changes to individual hospital counts under 
an aggregate FTE cap'' (63 FR 26341). Although, under existing policy, 
hospitals might have reported ``planned changes'' to FTE caps in a 
number of ways, there is no question that they were required to do so. 
The revised requirements at Sec. 413.86(b) specify that the hospital 
must include in the affiliation agreement each participating hospital's 
direct and indirect GME FTE caps in effect prior to the affiliation. 
The reason for requiring that affiliation agreements specify the direct 
and indirect FTE caps for participating hospitals is so that all 
hospitals will report the ``planned changes'' in the same way, allowing 
for ease of administration for CMS and fiscal intermediaries.
    We also understand that some hospitals qualify for other FTE cap 
adjustments, such as those for new programs under 
Sec. 413.86(g)(6)(ii). Hospitals would report their most current FTE 
caps in effect in the period immediately prior to the effective date of 
the affiliation for both direct GME and indirect medical education, so 
that the caps are reflective of the other FTE cap adjustments.
    To respond to the commenter's question about whether attached 
documents to the affiliation agreement will suffice to identify direct 
and indirect GME FTE caps, we believe attached documents would be 
adequate, so long as they are considered part of the overall package of 
the affiliation agreement. We have stated repeatedly to the provider 
community that affiliation agreements need not be lengthy documents. In 
the past, we have received affiliation agreements that range in length 
from 2 pages to 30 pages. Each type of agreement (short or long) would 
be adequate as long as the affiliation agreement meets the provisions 
under proposed Sec. 413.86(b).
    Comment: One commenter asked how the proposed rule contemplates 
handling changes in the hospital's FTE adjustments if actual rotations 
in a given residency year turn out differently than what was stated in 
the affiliation agreement at the start of the residency year on July 1.
    Response: We stated in the May 12, 1998 final rule (63 FR 26339) 
that the hospitals in the affiliated group may submit modifications to 
the initially reported distribution of the aggregate FTE count by June 
30 of the current residency training year, if actual FTE counts for the 
program year are different than projected in the original agreement. 
While modifications to the original distribution of the aggregate FTE 
cap are permitted in order to allow for some fluctuations based on the 
actual placement of those residents within the affiliated hospitals, 
the overall affiliation agreement cannot be modified (for example, by 
adding other hospitals to increase the original aggregate cap). In most 
cases, we expect that the modifications to the affiliation agreements, 
which should be signed by all participating hospitals and submitted to 
the fiscal intermediary, will reflect the realities of what actually 
occurred as far as the number of residents that rotated in and out of 
each hospital during the program year. Accordingly, we would be 
skeptical of modifications that deviate significantly from the original 
affiliation agreement.
    Comment: One commenter that suggested a technical change in the 
terminology for affiliation agreements to ``resident limit aggregation 
agreements'' or ``aggregation agreements.'' The commenter believed that 
``affiliation agreement'' historically is a term of art in the academic 
community and generally relates to agreements made between hospitals 
and medical schools or among sponsors of medical residency education 
programs.
    Response: We are aware that there has been some confusion at times 
among members of the provider community when using the term 
``affiliation agreement,'' and we recognize that the term is utilized 
in contexts other than in the Medicare usage of the term for GME 
payment. However, we believe the Medicare use of the term is an 
appropriate one, rather than ``aggregation agreement'' or ``resident 
limit aggregation agreement.'' We note that section 1886(h)(4)(H)(ii) 
of the Act uses the term ``affiliated group'' and contemplates that the 
Secretary will define that term. Further, as we stated above, the point 
of the policy is that there are ``affiliations'' among the 
participating hospitals; that is, rotations of residents among the 
hospitals for purposes of applying the Medicare FTE caps. Therefore, we 
are not adopting the commenter's suggested technical change.

Cross-Training Requirement

    Comment: Numerous commenters inquired about or addressed our 
proposal at Sec. 413.86(g)(7)(ii) to clarify in regulations the 
requirement of a rotation of residents among the hospitals 
participating in every affiliated group. One commenter agreed that this 
requirement is appropriate in regard to nonrelated hospitals that join 
together in an affiliation agreement, since the cross-training is the 
only basis for the affiliation. However, the commenter believed it 
should not be applied to affiliation agreements involving only commonly 
owned or related hospitals because commonly owned hospitals in an 
affiliated group are already held to the aggregate resident cap. The 
commenter believed it is unnecessary and burdensome to add a further 
requirement that each hospital participate in a rotation to other 
hospitals in order to be included as part of the affiliated group.
    Another commenter disagreed that this provision on cross-training 
between all hospitals in an affiliated group joined by common ownership 
is a clarification instead of a new rule. Consequently, this commenter 
believed the implementation of the cross-training provision should be 
prospective and deferred to become effective with affiliations 
beginning July 1, 2003. The commenter stated that if its proposal is 
not accepted, hospitals not in compliance should be given an 
opportunity to file a new affiliation agreement rather than forfeit the 
ability to affiliate altogether for the 2002-2003 period.

[[Page 50072]]

    Response: We disagree with the commenter's statement that commonly 
owned hospitals in an affiliated group are ``already'' held to the 
aggregate resident cap. Hospitals are only held to an aggregate 
resident cap through the act of entering into a Medicare affiliation 
agreement, and a Medicare affiliation is not valid without the 
existence of a cross-training relationship. Our proposal to add an 
explicit cross-training requirement at Sec. 413.86(g)(7)(ii) resulted 
from our belief that all hospitals that affiliate, regardless of the 
criteria under which they qualify to affiliate, should meet the cross-
training requirement. The intent of affiliated groups is to provide 
flexibility within the FTE caps to hospitals that have a rotational 
relationship; affiliated groups are not meant to serve as a mechanism 
for circumventing the FTE caps. However, we acknowledge that the 
existing definition of ``affiliated group'' at Sec. 413.86(b) is silent 
with respect to whether the cross-training requirement applies to 
hospitals that affiliated based on the common ownership criterion.
    Nevertheless, we emphasize that the proposed cross-training 
requirement is derived from a broad-based cross-training policy 
expressed in previous final rules applying to all affiliated groups, 
including hospitals affiliated under common ownership. Specifically, in 
the May 12, 1998 final rule (63 FR 26336) we state, ``The criteria we 
established to determine whether two or more hospitals qualify to be an 
affiliated group were designed to identify hospitals that have 
relationships for training residents and to allow those hospitals to 
continue to have the flexibility to rotate residents under an aggregate 
FTE cap.'' Further, we initially amended the definition of an 
affiliated group at Sec. 413.86(b) (63 FR 26337) to include hospitals 
under common ownership in response to a commenter's statement that 
hospitals under a single health care system ``* * * functionally 
operate coordinated and centrally controlled GME programs and often 
rotate their residents among their various facilities depending on 
training needs and other considerations'' (emphasis added). Finally, we 
state, ``A hospital will be permitted to engage in multiple agreements 
with different hospitals, as illustrated below. For example, hospital A 
can have an agreement with hospital B for an internal medicine program 
and another agreement with hospital C for emergency medicine. Although 
hospitals B and C do not have an agreement for any program, the 
affiliated group is A, B, and C; that is, the FTE resident counts at 
hospitals A, B, and C cannot exceed the sum of the combined caps for 
the three hospitals'' (63 FR 26338-26339).
    Therefore, to be consistent with the cross-training requirement we 
proposed at Sec. 413.86(g)(7)(ii), we are adding a reference to the 
cross-training requirement in paragraph (3) of the definition of 
``affiliated group'' under Sec. 413.86(b). However, because our 
existing definition of affiliated group did not explicitly state the 
cross-training requirement for hospitals that affiliate based on common 
ownership, we recognize that our policy may have been subject to 
misinterpretation. Therefore, we are making this cross-training 
requirement for hospitals under common ownership effective for 
affiliation agreements beginning July 1, 2003, the date of the first 
training year beginning after publication of the final regulation. 
Accordingly, hospitals that have affiliated under the common ownership 
criterion but have not met, or currently are not meeting, the 
rotational requirement are not required to meet the cross-training 
requirement until July 1, 2003.
    We also address the application of the cross-training requirement 
at Sec. 413.86(g)(7)(ii) to the other bases for affiliation listed in 
the definition of ``affiliated group'' at existing regulations at 
Sec. 413.86(b). Concerning hospitals located in the same urban or rural 
area or in contiguous areas, we believe that application of the cross-
training requirement is explicit in existing policy and not a change. 
We believe that the existing regulations clearly express the cross-
training requirement that residents must rotate among hospitals within 
the affiliated group during the course of the program. Paragraph (1) of 
the existing definition states that hospitals may qualify as an 
affiliated group if the hospitals are in the same urban or rural area 
or in contiguous areas, and ``if individual residents work at each of 
the hospitals during the course of the program.'' However, to maintain 
consistency, we are revising the language under paragraph (1) of the 
definition of an ``affiliated group'' to reference the new cross-
training language at Sec. 413.86(g)(7)(ii).
    The language in paragraph (2) of the existing definition of 
``affiliated group'' comes from the May 12, 1998 final rule (63 FR 
26358). When we issued this language at existing paragraph (2) 
regarding affiliations of hospitals that are jointly listed as the 
sponsor of a program, we did not explicitly restate the cross-training 
requirement because it was assumed that these hospitals, by virtue of 
joint sponsorship, already meet the cross-training requirement. 
However, to be consistent, and to further emphasize that the cross-
training requirement applies to all affiliating hospitals, we are also 
adding an explicit cross-training requirement at paragraph (2) in the 
definition of ``affiliated group'' under Sec. 413.86(b) by referencing 
Sec. 413.86(g)(7)(ii).
     Comment: One commenter stated that our requirement concerning the 
cross-training of residents within an affiliated group is unwarranted 
due to the establishment of a single FTE cap for each hospital, rather 
than program-specific FTE caps for each hospital. The commenter 
contended that hospitals that agree to affiliate should be allowed to 
manage training of residents in a manner that ensures the most 
appropriate training is received, even if this means that there is no 
cross-training of residents. The commenter included the following 
example:
    AB Health system operates a pediatrics program and a geriatrics 
program in two hospitals, A and B. Individual hospital 1996 FTE caps 
were established at 10 FTEs for Hospital A and 10 FTEs for Hospital B. 
Historically, residents in both programs rotated between both 
hospitals. In 2002, the programs were reorganized so that Hospital A 
now specializes in pediatrics and Hospital B now specializes in 
geriatrics, and as a result, the hospitals no longer cross-train 
residents. Hospital A currently trains 12 pediatric FTEs and Hospital B 
currently trains 8 geriatric FTEs.
    The commenter explained that the cross-training requirement would 
effectively reduce the number of residents Medicare will recognize AB 
Health System in 2002 by 2 FTEs less than the number in 1996. The 
commenter asserted that, accordingly, the cross-training requirement is 
inconsistent with our establishment of one overall FTE cap per 
hospital.
    Response: As we stated above, the provision for affiliated groups 
was included by Congress to accommodate hospitals that have an existing 
rotational relationship. It was understood that because of the movement 
of residents between hospitals, the number of residents at each 
hospital could vary each year. Therefore, because of these existing 
rotational arrangements, Congress intended to allow hospitals to 
aggregate and modify the FTE caps on a temporary basis. We do not 
believe it is appropriate to allow hospitals that do not have a 
rotational relationship to aggregate their FTE caps simply as a means 
of maximizing their Medicare reimbursement. However, we note, as we 
have stated above, hospitals that

[[Page 50073]]

affiliate under the common ownership criteria do not have to meet the 
cross-training requirement until July 1, 2003.
    We emphasize again that the cross-training requirement for 
affiliations is not a new concept in policy regarding Medicare 
affiliated groups. Indeed, the May 12, 1998 final rule repeatedly 
stated the idea that the policy was established in order to ``allow 
those hospitals to continue to have the flexibility to rotate residents 
under an aggregate FTE cap'' (63 FR 26336). However, because much 
confusion or concern has been expressed in numerous inquiries and among 
several commenters about the proposed clarification of the cross-
training requirement, particularly when it relates to the common 
ownership scenario, we are amending our regulations to further specify 
how the cross-training requirement will be applied in each of the 
scenarios for affiliated groups, including common ownership. 
Specifically, we are revising Sec. 413.86(g)(7)(ii) to read as follows:


    Each hospital in the affiliated group must have a shared 
rotational arrangement, as defined in Sec. 413.86(b), with at least 
one other hospital within the affiliated group, and all the 
hospitals within the affiliated group must be connected by a series 
of such shared rotational arrangements.

    We are specifying here and also at Sec. 413.86(b) that ``shared 
rotational arrangement'' means a residency training program under which 
a resident(s) participates in training at two or more hospitals in that 
program. If residents rotate from one hospital to another at some point 
during the period of years required to complete training in a 
particular program, those hospitals have a ``shared rotational 
arrangement.'' In addition, all the hospitals within the affiliated 
group must be connected by a series of shared rotational arrangements. 
In other words, in order for the cross-training requirement to be met, 
there must be, at a minimum, a ``chain'' of rotations occurring from 
one hospital to the next within the affiliated group. For example, 
assume Hospitals A, B, C, and D form an affiliated group. Hospital A 
and Hospital B both train residents in an internal medicine program. In 
addition, Hospital B trains surgery residents, who also spend time 
training at Hospital C. Hospital C and Hospital D both operate an 
anesthesiology program and anesthesiology residents train in both 
Hospital C and Hospital D. Thus, Hospitals A and B, Hospitals B and C, 
and Hospitals C and D are connected by a series of shared rotational 
arrangements. This arrangement meets the cross-training requirement. 
All hospitals do not have to cross-train residents; this means that 
Hospital A does not have to send residents to Hospital B, Hospital C, 
and Hospital D, nor does Hospital B have to send residents to Hospital 
A, Hospital C, and Hospital D, nor does Hospital C have to send 
residents to Hospital A, Hospital B, and Hospital D, etc. A continuous 
linear chain is sufficient.
    In another example of a ``shared rotational arrangement,'' Hospital 
A and Hospital B affiliate and they both offer training in family 
practice. If, at some point during the 3 years required to complete the 
family practice program, residents rotate from either Hospital A to 
Hospital B, Hospital B to Hospital A, or back and forth between 
Hospital A and Hospital B, then Hospital A and Hospital B have a 
``shared rotational arrangement.'' Hospitals A and B may meet the 
definition of a ``shared rotational arrangement'' by rotating residents 
for a portion of a particular program year (PGY), or by rotating 
residents for an entire program year, so long as the family practice 
residents spend time at both hospitals to complete their training in 
family practice. For example, family practice residents may spend 3 
months of their PGY1 at Hospital A and 9 months at Hospital B, or, the 
residents may spend their entire PGY1 training at Hospital A, and spend 
their entire PGY2 and PGY3 training at Hospital B. In either case, 
Hospital A and Hospital B have a shared rotational arrangement because 
they rotate residents over the course of a common training program.
    Following are some examples of arrangements that do not meet the 
cross-training requirement:
     Hospitals A and B train residents at their respective 
hospitals but do not rotate residents between the 2 hospitals.
     Hospitals A, B, and C attest that they are aggregating 
their FTE caps, but only Hospitals A and B actually rotate residents 
between them, while Hospital C does not rotate residents to either 
Hospital A or Hospital B. In this scenario, Hospitals A and B may 
qualify as an affiliated group, but Hospital C may not be included for 
purposes of aggregating its FTE cap with Hospitals A and B, because 
Hospital C does not rotate residents with either Hospital A or Hospital 
B. Thus, Hospital C breaks the ``chain''; Hospital C is not connected 
to the other hospitals by a series of shared rotational arrangements.
     Hospitals A, B, C, and D attempt to aggregate their FTE 
caps. Hospitals A and B rotate residents between them, and Hospitals C 
and D rotate residents between them. In this scenario, Hospitals A and 
B may qualify as an affiliated group, and Hospitals C and D may qualify 
as a second affiliated group, but Hospitals A, B, C, and D may not 
qualify as a single affiliated group because the ``chain'' is broken by 
the lack of a series of shared rotational arrangements between 
Hospitals A or B and Hospitals C or D.
    Finally, we believe that our regulations would be more consistent 
if we also amended the proposed definition of ``affiliation agreement'' 
at Sec. 413.86(b) to require participating hospitals to specify the 
adjustment to each hospital's FTE counts resulting from the FTE 
resident's (or residents') participation in the shared rotational 
arrangement(s) at each hospital participating in the affiliated group 
for each year the affiliation agreement is in effect. We are also 
stating under this section that this adjustment to each participating 
hospital's FTE count is reflected in the total adjustments to each 
hospital's FTE caps under paragraph (3) of the definition for 
``affiliation agreement'' at Sec. 413.86(b). We believe this additional 
information will assist the fiscal intermediaries in tracking the FTE 
residents and ensuring that cross-training occurs in at least one 
program at each of the hospitals participating in the affiliated group, 
in accordance with the rotation requirement under revised proposed 
Sec. 413.86(g)(7)(ii).
    Example: Assume Hospital A has a direct GME FTE cap of 30 FTEs and 
an IME FTE cap of 29 FTEs. In the 2003-2004 residency year, Hospital A 
has an internal medicine residency program with 6 FTE residents 
training at Hospital A in each program year (a total of 18 FTEs). 
Hospital A also has a surgery residency program with 3 FTE residents 
training at Hospital A in each program year (a total of 9 FTEs). Note 
that Hospital A is not at its FTE cap for direct GME (there are 3 empty 
FTE slots) or IME (there are 2 empty FTE slots) in this fiscal year. 
Hospital A decides to rotate some of its residents over to Hospital B, 
which has an FTE cap of 5 FTEs for both direct GME and IME. Hospital B 
also rotates residents in a pediatric program to Hospital C. Hospital C 
has a direct GME cap of 9.5, and an IME cap of 10. The three hospitals 
affiliate to form an aggregate cap of 44.5 FTEs for direct GME and an 
aggregate cap of 44 FTEs for IME. Hospital A rotates 3 internal 
medicine FTEs and 1.5 surgery FTEs to Hospital B, for both direct GME 
and IME (for Hospitals A and B, this would be ``the adjustment to each 
participating hospital's FTE counts resulting from the FTE resident's 
(or residents') participation in the shared rotational arrangement(s) 
at each hospital

[[Page 50074]]

participating in the affiliated group''). In addition, Hospital A also 
moves more of its FTE cap to Hospital B: an additional 3 FTEs for 
direct GME and 2 FTEs for IME (as noted above, these FTEs were 
available in Hospital A's caps), because Hospital B would like to train 
more residents in other specialties than can be accommodated under its 
own cap of 5 FTEs. Hospital B sends 0.5 FTE for GME and 1 FTE for IME 
to Hospital C. These produce a net decrease to Hospital A's direct GME 
cap of 7.5 FTEs (to equal an adjusted cap of 22.5 for direct GME) and a 
net decrease to its IME cap of 6.5 FTEs (to equal an adjusted cap of 
22.5 for IME). The net increase to Hospital B's direct GME cap is 7.0 
(to equal an adjusted cap of 12.0 FTEs for direct GME) and a net 
increase to its IME cap of 5.5 FTEs (to equal an adjusted cap of 10.5 
FTEs for IME). The net increase to Hospital C's direct GME cap is 0.5 
(to equal an adjusted cap of 10 FTEs for direct GME and the net 
increase to its IME cap is 1.0 FTEs (to equal an adjusted cap of 11 
FTEs for IME).
    Accordingly, the requirements as specified under paragraphs (2), 
(3), and (4) of the definition of ``affiliation agreement'' at 
Sec. 413.86(b) may be met if affiliation agreements give the following 
information (although it may be stated in narrative form, as above), 
using the information for Hospitals A and B and C above:

                                        Direct Graduate Medical Education
                                                   [FTE caps]
----------------------------------------------------------------------------------------------------------------
                                                                                   Total cap
                                                                   FTE cap         adjustment      Revised caps
----------------------------------------------------------------------------------------------------------------
Hospital A...................................................             30               -7.5             22.5
Hospital B...................................................              5                7               12
Hospital C...................................................              9.5              0.5             10
Aggregate Cap................................................             44.5  ...............             44.5
----------------------------------------------------------------------------------------------------------------


                      Shared Rotational Arrangement
------------------------------------------------------------------------
                                            Minus             Plus
------------------------------------------------------------------------
Hospital A..........................              -4.5  ................
Hospital B..........................              -0.5               4.5
Hospital C..........................  ................               0.5
------------------------------------------------------------------------


                                           Indirect Medical Education
                                                   [FTE caps]
----------------------------------------------------------------------------------------------------------------
                                                                                   Total cap
                                                                   FTE cap         adjustment      Revised caps
----------------------------------------------------------------------------------------------------------------
Hospital A...................................................             29               -6.5             22.5
Hospital B...................................................              5                5.5             10.5
Hospital C...................................................             10                1               11
Aggregate Cap................................................             44    ...............             44
----------------------------------------------------------------------------------------------------------------


                      Shared Rotational Arrangement
------------------------------------------------------------------------
                                          Minus               Plus
------------------------------------------------------------------------
Hospital A........................               -4.5  .................
Hospital B........................               -1                  4.5
Hospital C........................  .................                1
------------------------------------------------------------------------

    Thus, while the respective hospitals aggregate their FTE caps as a 
whole, and list the upward and downward adjustments to the 
participating hospitals' direct and indirect FTE caps, under revised 
paragraph (3) of the definition of ``affiliation agreement'' under 
Sec. 413.86(b), the affiliation agreement must now separately list the 
positive and negative adjustment to each participating hospital's FTE 
counts resulting from the FTE resident's (or residents') participation 
in the shared rotational arrangement(s) at each hospital participating 
in the affiliated group for each year the affiliation agreement is in 
effect (this may be different than the total effect of the affiliation 
on the hospital's cap).
    In this final rule, we also are modifying Sec. 413.86(g)(7) to add 
a new paragraph (iii) to state that, in accordance with proposed 
Sec. 413.86(g)(7)(ii), during the shared rotational arrangements in the 
affiliation, more than one of the hospitals in the affiliated group 
must count the proportionate amount of the time spent by the 
resident(s) in their FTE resident counts, and that no resident may be 
counted in the aggregate as more than one FTE.

The Termination Clause

    We received numerous comments concerning our proposed policy change 
on the effect of an affiliation termination on each participating 
hospital's FTE cap. We proposed that, upon termination of an 
affiliation, each affiliated hospital will revert back to its original 
FTE caps for both direct GME and IME prior to the affiliation. Many 
commenters urged us to reconsider the proposal and to keep the existing 
policy allowing for FTE cap redistribution upon affiliation 
termination.

[[Page 50075]]

    Comment: Several commenters noted the Conference Report 
accompanying the Balanced Budget Act of 1997 (BBA) which stated that 
while CMS was given flexibility in implementing the resident limits, 
the flexibility is ``limited by the conference agreement that the 
aggregate number of FTE residents should not increase over current 
levels.'' (H.R. Conference Report, Rept. No. 105-217, 105th Cong., 1st 
Sess., 1997, pp. 821-822). One commenter stated that they believe the 
Conference Report makes clear that the conferees understood that ``a 
sizeable number of hospitals elect to initiate `as well as terminate' 
medical education programs over a period of time,'' and that the 
Conferees were ``concerned that within the principles of the cap * * * 
there is proper flexibility to respond to such changing needs * * *.'' 
These commenters believe that our policy change would therefore be 
contrary to Congress' wishes.
    Response: As we explain above, and also in the proposed rule, 
existing policy allows affiliated hospitals to redistribute their FTE 
caps (within the limits of the aggregate FTE caps) upon the termination 
of the affiliation agreement in order to enable hospitals by agreement 
to more closely reflect the realities of the residency rotational 
arrangement. However, we proposed to change this policy because we 
believed it was susceptible to abusive practices such as the formation 
of affiliation agreements solely for the purpose of obtaining permanent 
adjustments to FTE caps. In fact, the commenters who advocated 
retaining the existing policy argued that this provision is needed to 
allow hospitals to increase their caps, when another hospital closes.
    To address the commenters' belief that our proposed change is 
contrary to Congressional wishes, we note that the language quoted 
above from the Conference Agreement accompanying the BBA that the 
commenters use to support that assertion was actually intended to 
address Congress' newly enacted policy in the BBA on new residency 
program adjustments (see section 1886(h)(4)(H) of the Act for the 
statutory provision on this adjustment), rather than affiliated groups. 
In fact, the cited paragraph in the Conference Report starts out by 
stating: ``Among the specific issues that concerned the Conferees was 
application of a limit to new facilities, that is, hospitals or other 
entities which established programs after January 1, 1995.'' 
(Conference Report at 821). A separate provision on affiliations 
appears later in the Conference Report. The Report states: ``Another 
issue was the treatment of institutions which are members of an 
affiliated group. In some circumstances, the Conferees believe that the 
intent of this provision would best be met by providing an aggregate 
limit for such affiliates.'' Therefore, we believe that the language 
cited by the commenters was not meant to be applied to affiliated 
groups.
    In addition, section 1886(h)(4)(H)(ii) of the Act specifies that 
``The Secretary may prescribe rules which allow institutions which are 
members of the same affiliated group (as defined by the Secretary)'' to 
elect to apply the FTE cap on an aggregate basis (emphasis added). 
Thus, the statute granted the Secretary the discretion to promulgate 
regulations that specify what defines an affiliated group and when the 
FTE caps can be aggregated. Based on our analysis of the Conference 
Report language, as well as the statutory language, we believe the 
purpose of the affiliations provision is to provide temporary 
flexibility in the rotation of residents within the confines of the 
hospital-specific cap on the number of FTE residents. We do not believe 
the provision was meant to provide a vehicle for a hospital to 
circumvent the statutory FTE cap on the number of residents through 
permanent cap adjustments due to hospital closures.
    Comment: Several commenters believed that the existing termination 
clause policy allowing for permanent cap adjustment ``is currently the 
only option available to retain'' resident slots due to hospitals or 
program closure. One commenter stated that the permanent transfer of 
residents through the use of affiliation agreement termination 
provisions allows the programs to continue to benefit the community 
indefinitely. Several of the commenters suggested that our existing 
policies specified at Sec. 413.86(g)(8) that allow for temporary FTE 
cap adjustments to address hospital and residency program closure are 
``short-lived'' and inadequate to address community needs.
    Response: We understand that medical needs within a particular 
community may go unfulfilled whenever a hospital closes its doors, or 
even, in some communities, when a residency program closes. Our 
temporary FTE cap adjustments at Sec. 413.86(g)(8) for hospital 
closures and also program closures are meant to address the situation 
of the residents who become ``displaced'' in either of the scenarios; 
they are not intended to address community medical needs (although, we 
know that in many cases, the temporary adjustments produce an 
incidental beneficial result to the community).
    If Congress intended to provide permanent cap adjustments to 
address community needs because of hospital or program closures, we 
believe there would be such a provision in the Act. Until the law is 
amended to provide for such an explicit permanent adjustment to a 
hospital's FTE caps, we believe that our proposal for reverting back to 
pre-affiliation FTE caps upon affiliation termination is the proper 
policy.
    Comment: Several commenters stated that the fact that a few 
hospitals abused the policy should not be a reason to make this policy 
change that affects all hospitals. One commenter believed that other 
appropriate safeguards can and should be put in place to avoid abuse. 
This commenter believed that abuse could be limited by requiring a 
hospital to have been part of the affiliated group for at least a full 
year prior to the termination of the agreement and not be part of 
temporary adjustment provided for at Sec. 413.86(g)(8).
    Response: In proposing the policy change requiring that when a 
Medicare affiliation agreement terminates, the hospitals' FTE caps 
revert to their original levels, we did not intend to target all 
hospitals due to the actions of, what the commenter has labeled, a few 
``abusive hospitals.'' Rather, our intent was to clarify that we 
believe that any attempt to use affiliations to provide for a permanent 
increase in the FTE caps is not consistent with either the statute or 
Congressional intent.
    As we noted in the preamble to the proposed regulations, in 
reviewing affiliation agreements that hospitals have submitted, we 
found that very few hospitals have altered their FTE caps following the 
termination of their affiliation agreements. Instead, they opt to 
revert to their 1996 base year caps. In fact, it is typically only 
where a hospital is about to close and there is the possibility that 
the hospital's FTE cap will be ``lost,'' that a termination clause is 
created to be used to transfer those slots to another hospital.
    As stated above, section 1886(h)(4)(H)(ii) of the Act specifies 
that ``The Secretary may prescribe rules which allow institutions which 
are members of the same affiliated group (as defined by the 
Secretary)'' to elect to apply the FTE cap on an aggregate basis. We 
believe the basis of the policy on affiliations is to provide 
flexibility in the rotation of residents within the confines of the 
aggregate cap on the number of FTE residents. We do not believe this 
statutory provision was meant to provide a vehicle for a hospital to 
circumvent the statutory FTE cap on the number of residents through 
permanent cap adjustments due to

[[Page 50076]]

hospital closures. If Congress intended to provide for permanent cap 
adjustments to address situations where a hospital closes, we believe 
there would be a specific provision in the law to provide for such an 
adjustment.
    Comment: We stated in the proposed rule (67 FR 31469), and also 
above, that the policy was proposed to be effective October 1, 2002, 
for hospitals with affiliation agreements that would terminate (for any 
reason) on or after that date. One commenter believed that the change 
should become effective with affiliations beginning, not terminating 
after October 1, 2002. Several other commenters agreed; they suggested 
that ``under no circumstances should a change be made that would 
retroactively affect an existing lawful agreement.'' Finally, one 
commenter suggested the change should apply only to agreements that 
were executed after the publication of the proposed rule so that, ``at 
least, it applies only to agreements in which the parties had notice of 
the anticipated change in policy.''
    Response: We disagree with the commenters' suggestions. As we have 
stated above, we believe that the permanent FTE cap adjustment policy 
allows for the circumvention of the statutory caps. As such, we believe 
that the policy change should be applicable as soon as possible; that 
is, beginning with any terminations of affiliations that occur 
beginning with the effective date of this final rule.
    We also disagree with the commenters that our policy change is 
``retroactive''. If a hospital that is part of an already existing 
affiliated group decides for whatever reason to terminate the 
affiliation agreement, that termination would not retroactively affect 
the movement of the FTE caps back to their hospitals of origin. Rather, 
the reversion back to the pre-affiliation FTE caps occurs on a 
prospective basis after the termination has taken place.
    Finally, to address the comment suggesting that the change in 
termination policy be effective with affiliation agreements executed 
after the publication of the proposed rule (which was on May 9, 2002), 
since the policy depends upon the action of a hospital terminating the 
affiliation agreement rather than executing the agreement, we believe 
it is more appropriate to maintain our proposed effective date. And, as 
we stated above, we believe the provider community is receiving 
adequate notice of this change in policy on terminations of 
affiliations through the notice and comment rulemaking process. Thus, 
we are adopting our proposal to require that the FTE caps for each 
hospital in the affiliated group will revert back to each hospital's 
FTE cap prior to entering into the affiliation upon termination of the 
affiliation.
    Comment: Two commenters noted that the proposed rule stated that 
the FTE caps of hospitals in the affiliated group would revert back to 
their pre-affiliation levels upon termination. The commenters requested 
that, in cases where multiple hospitals enter into an affiliation 
agreement, but for whatever reason, one or more of the original 
affiliating hospitals wished to withdraw from the agreement, the 
remaining hospitals should be able to continue the affiliation 
agreement. One commenter stated that allowing affiliated groups to 
shrink from their original size to include only those hospitals that 
are interested in continuing their participation will ensure success of 
the affiliated group, while allowing CMS to reimburse hospitals subject 
to the limit of an aggregate cap. The commenter provided the following 
example: Hospitals A, B, and C enter into an affiliation agreement for 
the academic year beginning July 1, 2003. Each hospital has 1996 FTE 
caps of 8, respectively, which combine to equal an aggregate cap of 24. 
During this academic year, Hospital C decides to terminate its 
participation in the affiliated group. Hospital C takes back its 8 
FTEs, its original FTE cap. Hospital A and Hospital B wish to continue 
affiliating, and Hospital A's FTE cap increases by 4 to equal 12, and 
Hospital B's FTE cap decreases by 4 to equal 4, for an aggregate cap of 
16 FTEs.
    Response: We believe the commenters may be confusing our proposal 
to require FTE caps of hospitals in the affiliated group to revert back 
to their pre-affiliation levels upon termination, with our policy with 
respect to hospitals that continue to affiliate. Our proposal would 
only preclude hospitals from using termination agreements as a means of 
permanently adjusting FTE caps. However, our proposal does not preclude 
hospitals from terminating their participation in an affiliation 
agreement, as long as each formerly participating hospital's respective 
original FTE caps are not changed as a result of the termination. 
Therefore, no modification to our regulations is necessary to adopt the 
commenters' request to allow affiliated groups to be reduced from their 
original size. The scenario described by the commenters is permissible 
under existing regulations. When a hospital withdraws from the 
affiliation, the equivalent amount of its pre-affiliation FTE cap is 
subtracted from the original aggregate cap, and reverts back to that 
hospital. The hospitals that wish to continue participating in the 
affiliation must submit a modified agreement to their respective 
intermediaries by June 30 of that academic year indicating the revised 
aggregate FTE cap, and adjustments to each hospital's caps, based only 
on the FTE caps of the hospitals that continue to affiliate.

Other Issues on Affiliated Groups

    Comment: Two commenters requested that we remove our geographical 
restriction for hospitals to participate in an affiliated group; one 
commenter specifically requested that participants in an Osteopathic 
Postdoctoral Training Institution (OPTI) be permitted to participate in 
affiliated group without regard to geography. Two commenters requested 
that we change our policy at Sec. 413.86(g)(6)(i)(D) concerning the 
prohibition of new teaching hospitals from participating in affiliated 
groups once the new residency program has been established. Another 
commenter asked that we define ``displaced residents'' for purposes of 
our policies at Sec. 413.86(g)(8) on closed hospital and closed 
programs.
    Response: Since these comments do not address issues that were 
specifically proposed in the May 9, 2002 notice of proposed rulemaking, 
we are not responding to these comments in this regulation.

Technical Corrections

    We are making a technical change to the language under the 
definition of ``affiliated group'' under Sec. 413.86(b) under paragraph 
(2). Paragraph (2) refers to hospitals that are jointly listed as the 
sponsor, primary clinical site, or major participating institution for 
one or more of the programs as these terms are used in the ``Graduate 
Medical Education Directory, 1997-1998.'' We note that the usage of the 
referenced terms has not changed in more recent publications of the 
Directory and is not expected to change in the future. Therefore, in 
this final rule, as part of our revision to the definition of 
``affiliated group'' to incorporate the cross-training requirement for 
hospitals in an affiliation agreement, we are changing the reference to 
reflect use of the most current publication of that Directory.
    When we issued the May 9, 2002 proposed rule, due to a 
typographical error, we inadvertently indicated that we proposed to 
make changes to Sec. 413.86(g)(5)(iv) instead of Sec. 413.86(g)(4)(iv) 
to incorporate revised provisions relating to determining the weighted 
number of FTE residents for hospitals that are part of the same 
affiliated group. As a result, we erroneously stated that we proposed 
to add a new paragraph under

[[Page 50077]]

Sec. 413.86(g)(5)(iv) and to redesignate paragraphs (g)(5)(iv), 
(g)(5)(v), and (g)(5)(vi) as paragraphs (g)(5)(v), (g)(5)(vi), and 
(g)(5)(vii) respectively to accommodate the new paragraph. We are 
correcting these errors in this final rule, We are changing the 
reference from Sec. 413.86(g)(5)(iv) to Sec. 413.86(g)(4)(iv). In 
addition, since we are revising Sec. 413.86(g)(4)(iv) rather than 
inserting a new paragraph, there is no need to redesignate any 
paragraphs under Sec. 413.86(g)(4).
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.
    In the May 9, 2002 notice, we proposed clarifying 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).
    Comment: One commenter agreed that our clarification on the 
prohibition against a hospital counting residents training at other 
hospitals is one that is ``longstanding Medicare policy, based on 
language in both the regulations and the statute.'' As such, this 
commenter recommended that we amend our regulations to include this 
clarification as part of Sec. 413.86(f)(2), ``rather than remain as a 
footnote to longstanding Medicare policy.''
    Response: As we clarified in the proposed rule and also above, 
existing Sec. 413.86(f) states, in part, that a hospital may count 
residents 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. Thus, we believe our existing regulations are 
already very clear that hospitals cannot count resident rotations at 
other hospitals; indeed, the hospital can only count residents working 
``at the hospital''. However, because we continue to receive many 
questions on this policy, even though it is a longstanding one, in this 
final rule we are revising Secs. 413.86(f) and 412.105(f) to explicitly 
prohibit the counting of residents at other hospitals.
    As we stated above, and also in the proposed rule, we are aware of 
some scenarios where one hospital incurs the residency training costs 
of residents training at other hospitals. However, even in this 
scenario, the hospital incurring the costs of the residents at the 
other hospitals is precluded from claiming any FTEs for the proportion 
of time spent in training at the other hospitals.
    Comment: One commenter stated that CMS should consider allowing 
hospitals to enter into agreements that would permit one hospital to 
claim the resident FTE time worked at another hospital as long as the 
hospital claiming the resident time is incurring ``all or substantially 
all'' of the training costs at the other hospitals, similar to the 
regulations specified at existing Sec. 413.86(f)(4) for nonhospital 
sites.
    Another commenter stated that it disagrees with our clarification 
concerning the situation where a teaching hospital cannot count 
resident rotations to nonteaching hospitals, even when the teaching 
hospital incurs ``all or substantially all'' of the costs and the 
rotation is part of the accredited program. One commenter requested 
that it be allowed to count the ``round time'' at another hospital. One 
commenter requested clarification on whether our policy that prohibits 
a hospital from counting residents rotating to other hospitals applies 
to the situation where residents rotate to hospitals not participating 
in Medicare, such as State-operated psychiatric facilities and 
hospitals located in foreign countries.
    Response: We do not believe that it is consistent with the 
requirements at sections 1886(d)(5)(B)(iv) and 1886(h)(4)(E) of the Act 
to expand the policy at Sec. 413.86(f)(4) concerning counting residents 
in nonhospital settings to allow hospitals to count residents training 
at other hospitals even if the hospitals seeking to count the residents 
incur ``all or substantially all'' of the costs. In fact, it is only 
because the statute has specifically provided for counting residents 
training at nonhospital sites that it is appropriate to include any 
resident not training at the hospital in the hospital's FTE count.
    In addition, section 1886(h)(4)(A) of the Act requires the 
Secretary to establish rules for the computation of FTE residents in an 
approved medical residency training program. Furthermore, at paragraph 
(B) of that section, the statute requires that the regulations take 
into account individuals who serve as residents simultaneously with 
more than one

[[Page 50078]]

hospital. Therefore, we believe that the Secretary has the authority to 
allow a hospital to count only those residents actually training in 
that hospital. Even where the residents are training at other hospitals 
or foreign hospitals, it is not appropriate for the hospital to include 
those residents in its FTE count. Further, although the commenter 
refers to rotations occurring at ``nonteaching'' hospitals, we note 
that by virtue of the fact that residents are rotating and training at 
a hospital, the hospital is, by definition, a teaching hospital. In 
fact, each Medicare-participating hospital at which the residents are 
rotating over the course of the program year should be completing the 
direct GME and IME (if applicable) worksheets of the Medicare cost 
report in order to claim and receive Medicare payment for their 
respective portions of the FTE training time, regardless of whether the 
hospital incurs any costs for training those residents. Accordingly, we 
are not adopting the policy change suggested in these comments.

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

    In the May 9, 2002 proposed rule, we presented certain proposed 
policies to clarify areas of the regulations under Sec. 489.24 that 
implemented sections 1866(a)(1)(I), 1866(a)(1)(N), and 1867 of the Act 
and solicited comments from hospitals, physicians, patients, and 
beneficiary groups. These sections of the Act impose specific 
obligations on Medicare-participating hospitals that have an emergency 
department. 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 individuals, regardless 
of whether or not they are beneficiaries of any program under the Act. 
These provisions of the Act, taken together, are frequently referred to 
as the Emergency Medical Treatment and Labor Act (EMTALA), also known 
as the antidumping statute.
    In response to our proposals, we received approximately 600 pieces 
of correspondence, most of which contained multiple comments. A large 
number of the comments were received on the last day of the comment 
period for the proposed rule (July 8, 2002). Because of the number and 
nature of the public comments we received on our proposed 
clarifications and our limited timeframe for developing the final acute 
care hospital inpatient prospective payment system regulations for 
publication by the statutory deadline of August 1, we have decided, 
with one exception, to address the public comments and finalize the 
proposals in a separate document. The one proposal being finalized in 
this document is our proposed revision to the second sentence of 
Sec. 413.65(g)(1) to clarify the application of EMTALA to provider-
based entities. That proposal, and the action we are taking with 
respect to it, are described more fully in section V.L.2.g. 
(Clarification of Obligations of Hospital Outpatient Departments and 
Hospital-Based Entities) of this preamble.

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. Except where superseded by new 
legislation, Sec. 413.65 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.L.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 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

[[Page 50079]]

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 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 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. However, as we discussed in the May 9, 2002 proposed rule, we 
are providing for a further delay, as discussed below.
(3) Criteria for Temporary Treatment as Provider-Based
    Section 404(c) of BIPA 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. 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.
    The provision concerning temporary treatment as provider-based in 
section 404(c) of BIPA is effective only for requests filed before 
October 1, 2002. As explained further below, the procedures in new 
Sec. 413.65(b)(3) will be followed in making any determinations of 
provider-based status in response to attestations submitted on or after 
October 1, 2002.
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 May 9, 2002 Proposed Rule
    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, in the May 9, 2002

[[Page 50080]]

proposed rule, we proposed 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 proposed 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 is not necessary to resolve payment issues 
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 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 also proposed 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 the May 9, 2002 proposed document, we proposed 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 proposed 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 proposed 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 proposed this change because we believed it 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 clarified 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.''
    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 could exceed 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,

[[Page 50081]]

even if they are not provider-based, 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 proposed 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 proposed 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 proposed to retain the provision that, 
for purposes of Part 413, the term ``department of a provider'' does 
not include an RHC or, except as specified in Sec. 413.65(m), an FQHC. 
(As explained below, existing Sec. 413.65(m) is being redesignated as 
Sec. 413.65(n) in this final rule.)
    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 did not propose to apply the criteria at 
Sec. 413.65 to ambulance services.
    We note that, in the May 9, 2002 proposed rule, we inadvertently 
did not make a conforming change to the regulations at Sec. 413.65(a) 
to state that the provider-based rules do not apply to ambulances. 
Therefore, we are making this conforming change in this final rule.
    Comment: One commenter recommended that all inpatient departments 
be exempt from the provider-based rules, regardless of whether they are 
on campus or off campus, since, due to their ``very status as inpatient 
departments, they are necessarily integrated into the operations of the 
main provider. * * *'' Several other commenters recommended that 
ancillary or other departments located within a hospital (that is, on 
campus) be deemed to be provider-based and thus not be required to show 
actual compliance with provider-based criteria.
    Response: We do not agree that facilities that treat a patient 
population made up primarily or entirely of inpatients should 
necessarily be considered, on that basis alone, to be a fully 
subordinate and integral component of the main provider. There are 
instances where a Medicare payment differential exists between a 
hospital-based inpatient service and a freestanding service. For 
example, if an institution that primarily provides inpatient care is 
able to participate in Medicare as a part of a hospital, Medicare 
payment to the hospital will be made for the full range of inpatient 
hospital services defined in section 1861(b) of the Act. If the 
facility is not considered a part of a Medicare-participating hospital, 
Medicare payment would be made only for a much narrower range of 
services, such as physical and other therapies, which can be paid in 
ambulatory care settings. Compliance with the provider-based criteria 
is also needed to ensure that Medicare payment is made appropriately in 
merger situations, where the crucial issue is whether a facility is 
integral and subordinate to another that participates as a hospital. 
For example, under the TEFRA payment system applicable to psychiatric, 
children's and cancer hospitals, Medicare payment to the hospital for 
inpatient services usually is directly affected by the hospital-
specific TEFRA target rate. If a particular hospital chooses to 
reorganize to include a new site that otherwise could participate in 
Medicare only as a separate hospital or as a remote location or 
satellite of still another hospital, the amount of payment would be 
affected. Similarly, for the reasons explained in detail in the May 9, 
2002 proposed rule (67 FR 31482), a merger of two hospitals can 
significantly affect the payments made to them for their GME programs, 
even when each hospital is paid under the acute inpatient hospital 
prospective payment system. Under these circumstances, compliance with 
the provider-based criteria is also needed to warrant the higher 
payment level that would result.
    We also do not agree that location on the main campus of a hospital 
should be the sole determinant of provider-based status, since 
hospitals can and frequently do lease space on their campuses to 
physicians and other providers or suppliers of health services, and 
these providers or suppliers may have no more connection to or 
integration into the hospital's operations than the lease agreement and 
physical proximity. For example, a hospital may lease some of its space 
to an independent diagnostic testing facility (IDTF) that furnishes 
radiology services, which are frequently considered by hospitals to be 
among their ancillary services. Such a facility could be paid 
significantly more as a provider-based department than as a 
freestanding facility. Because of this payment difference, we believe 
it is important that the facility meet standards that establish that it 
is an integral and subordinate part of the main provider hospital, and 
thus that the higher payment level associated with provider-based 
status is warranted. Therefore, we are not revising this final rule to 
permit on-campus facilities to qualify as provider-based solely because 
of location.
    Comment: One commenter suggested that consolidations of facilities 
on separate campuses should not be subject to the provider-based 
requirements, but should be regulated only by the requirements on State 
licensure, Medicare certification, and Medicare enrollment.
    Response: For the reasons explained in the response to the 
preceding comment, consolidation of facilities under a single provider 
number frequently has significant implications for Medicare payment 
levels. In many cases, the amount paid for services of a consolidated 
facility can be significantly more than the sum of what would be paid 
to two or more separate facilities for the provision of identical 
services. Current State licensure and Medicare certification 
requirements are focused on the protection of patient health and 
safety, and the determination of whether a facility is part of the main 
provider is not central to that concern. On the contrary, licensure and 
certification requirements may be easily manipulated by providers 
seeking to maximize payment under Medicare or Medicaid

[[Page 50082]]

without improving either the quantity or the quality of care furnished. 
Thus, it is crucial that we establish criteria to ensure that 
consolidated facilities are truly integral and subordinate to a single 
main provider.
    Comment: Some commenters wrote on behalf of multicampus hospitals 
that operate under a single provider number and agreement, but include 
several campuses that are separately licensed by the State. The 
commenters stated that they have been structured in this way since 
before the inception of the Medicare program and thus did not adopt 
their current structures in an effort to maximize GME or DSH payments. 
The commenters explained that if multicampus hospitals are not exempted 
from the provider-based requirements, the hospitals would have to 
either designate one campus as the main campus and rearrange the 
clinical, financial, and other arrangements between the hospitals in 
order to comply with the provider-based requirements, or obtain a 
separate Medicare provider agreement and number for each campus. If the 
second course were chosen, total Medicare payment to the separate 
hospitals would be considerably less than what is currently being paid 
to them as multicampus organizations. Because the hospitals are 
unwilling to pursue either of the options outlined above, the commenter 
requested that either all multicampus hospitals be exempted from the 
provider-based requirements, or that an exemption be created for any 
such hospitals that have been structured as multicampus hospitals since 
the beginning of the Medicare program.
    Response: We understand the commenter's concern, but for the 
reasons cited earlier in this preamble believe that it is important to 
apply the provider-based criteria to multicampus hospitals in which 
each campus is separately licensed, as well as to those in which all 
components operate under a single State license. In particular, such an 
exemption could lead to increased levels of Medicare GME and DSH 
payments, relative to the amounts payable if the provider-based 
criteria were applied. In fact, the commenter admitted that Medicare 
payment to the separate hospitals would be considerably less than what 
is paid to them as a single but multicampus hospital. We continue to 
believe it is important to pay for services of hospital facilities as 
part of a single hospital only when they meet the provider-based 
criteria we have established. Therefore, we are not adopting this 
comment.
    Comment: One commenter requested more clarification of how the 
provider-based criteria apply to multicampus hospitals, and to 
multihospital systems (that is, chain organizations that include two or 
more hospitals, each of which participates separately in Medicare). The 
commenter was particularly interested in learning what would be the 
main campus of a multihospital system, and whether a facility or 
organization at one location of a multihospital system could be 
provider-based with respect to another hospital in that system.
    Response: If a hospital comprises several sites at which both 
inpatient and outpatient care are furnished, it will normally be 
necessary for the hospital to designate one site as its ``main'' campus 
for purposes of the provider-based rules. Each of the other sites 
(referred to in our regulations as ``remote locations'') would then be 
expected to meet the provider-based requirements with respect to that 
main campus. Thus, any facility not located on a hospital's main campus 
would be considered to be an ``off-campus'' facility. Hospitals would 
normally be given considerable discretion in selecting which site is to 
be the ``main'' campus for provider-based purposes. In such a case, any 
outpatient facility also providing services at a ``remote location'' 
that are to be billed as services of the hospital would be considered 
as a potential hospital department for purposes of provider-based 
status and would be expected to meet the provider-based criteria with 
respect to the location designated by the hospital as its main campus. 
However, it is important to note that the provider-based criteria apply 
to individual hospitals, not to multihospital systems (for example, 
systems owned and operated by chain organizations). Where such a system 
exists, its hospitals will participate separately in Medicare, and the 
provider-based criteria will apply separately to each hospital in the 
chain. If a facility or organization located on the campus of one 
hospital in the chain wishes to be treated as part of another, 
separately participating hospital in the chain, the facility or 
organization would have to meet the provider-based criteria with 
respect to that hospital, on the same basis as if the two hospitals 
were not part of the same chain organization.
    Comment: Several commenters stated that, in some areas, it is 
common for children's hospitals to set up and staff neonatal intensive 
care units (NICUs) in community hospitals, in order to extend these 
services into rural areas where they might not otherwise be available. 
The commenter noted that these units frequently cannot meet the 
location requirement for provider-based status in Sec. 413.65(e)(3) of 
the proposed regulations, and asked that the final rule be revised to 
create a special exception to this requirement, to allow these units to 
continue to be treated as provider-based once the grandfathering period 
ends and to permit the creation of new units of the same type.
    Response: We understand these commenters' concerns, but note that 
these units raise serious questions about the appropriate treatment of 
facilities located at long distances from the main children's hospital 
that nevertheless claim to be a part of that hospital. While these 
facilities may have very limited Medicare utilization, they frequently 
receive substantial amounts of payment under Medicaid, thus making it 
important to ensure that they are classified and paid appropriately. 
After considering these issues, we have concluded that it would not be 
appropriate to waive the location requirement for provider-based 
status, or make some other ad hoc exception to the provider-based 
criteria, for these facilities. However, we have explained in the FAQs 
the inability of units in certain locations to qualify for provider-
based status does not preclude States from adopting revisions to their 
Medicaid plans to provide more generous payment to such units. While we 
are not making a special exception for NICUs, we recognize the 
importance of further emphasizing that when a payment difference 
exists, compliance with the provider-based rules is needed to justify 
payment for services in a facility as provider-based. Therefore, in 
this final rule, we are clarifying the regulations at Sec. 413.65(a) to 
state that the determinations of provider-based status are made for 
payment purposes.
    Comment: Some commenters requested clarification of how the 
provider-based criteria apply to multicampus hospitals that participate 
in Medicare under a single provider number but comprise two or more 
campuses that are physically separate from one another. The commenters 
were particularly concerned about which campus is to be identified as 
the main campus and about whether clinics or other facilities located 
on one campus of a hospital may be considered provider-based with 
respect to another campus.
    Response: We agree that multicampus hospitals present special 
implementation issues. However, the following general principles will 
be applied. First, when hospital facilities are dispersed among two or 
more geographically separate campuses, it will be necessary for one of 
the campuses to be designated by the hospital as the main campus. 
Facilities at the other campus(es) would be

[[Page 50083]]

considered provider-based only if they meet the provider-based criteria 
in relation to the main campus. We would normally accept the provider's 
own selection of a main campus, unless the regional office concludes, 
in a particular case situation, that the campus selected by the 
provider clearly does not actually function as the main campus. The 
location requirements for a facility at a campus other than the main 
campus would be applied based on the distance between the facility and 
the main campus. Hospital chain organizations, which include a number 
of separately certified hospitals, would not be considered multicampus 
hospitals.
    Comment: One commenter stated that the provider-based criteria are 
being applied under Medicaid only because the same certification 
standards apply under Medicaid as under Medicare. The commenter also 
pointed out that States are not required to follow Medicare payment 
system rules in making payment under their Medicaid programs. The 
commenter then argued that this State flexibility to determine Medicaid 
payment means that CMS should prohibit States from applying the 
provider-based criteria in determining payment under Medicaid.
    Response: The commenter is correct in noting that the Medicaid 
regulations at 42 CFR 440.10 and 440.12 define inpatient and outpatient 
hospital services, for Medicaid purposes, as services furnished in or 
by an institution that meets the requirements for participation in 
Medicare as a hospital. Medicare participation by an institution as a 
hospital is contingent on the institution's compliance with many 
participation requirements, not merely the health and safety rules set 
forth in 42 CFR Part 482. The institution is also required under 
section 1866 of the Act and regulations at 42 CFR Part 489 to comply 
with various other statutory and regulatory provisions relating to 
(among other areas) charges to beneficiaries, maintenance of billing 
and other records, and the screening and stabilization, or appropriate 
transfer, of emergency cases. To the extent the hospital is required to 
comply with the provider-based criteria in Medicare regulations as part 
of its Medicare hospital participation obligations, the definitions of 
services in Sec. 440.10 and 440.12 also require that it comply with 
these requirements for Medicaid purposes.
    Regarding the commenter's remarks on State flexibility, we 
recognize that States are authorized to adopt, through their State 
plans, payment definitions and methods that differ from those used 
under Medicare. Thus, the commenter is correct in noting that a State 
may adopt payment methods that do not differentiate between facilities 
that meet the provider-based requirement and those that do not. To the 
extent that States amend their State plans to contain such payment 
methods, we do not object to these actions. However, we do not believe 
it would be consistent with State flexibility to prohibit States that 
wish to apply provider-based criteria in making their payment decisions 
from doing so. Such a prohibition would not benefit either States or 
their Medicaid recipients and, on the contrary, could increase State 
and Federal Medicaid spending unnecessarily. Therefore, we are not 
making any change in this final rule based on this comment.
    Comment: Several commenters noted that Indian Health Service (IHS) 
and tribal clinics and other facilities meeting the criteria in 
Sec. 413.65(l) (redesignated as Sec. 413.65(m) in this final rule) are 
in effect excluded from the scope of the provider-based criteria by the 
grandfathering provision included in that section. The commenters 
further noted that under Public Law 93-638, the Indian Self-
Determination Act, as amended, tribes have the right to contract for 
the management of all or a portion of the IHS programs that provide 
services in their communities. The commenters pointed out that tribal 
and IHS facilities remain the primary source of health care in many 
remote rural communities. However, because of the unique IHS and tribal 
administrative systems, many clinics and other facilities that might 
lose their grandfathered status under Sec. 413.65(l) (redesignated as 
Sec. 413.65(m) in this final rule) are not able to meet provider-based 
criteria. To avoid disrupting the operation of these vital sources of 
care in remote rural areas, and consistent with the objectives of the 
Indian Self-Determination Act, the commenters recommended that all 
clinics and other facilities operated by IHS or tribes should be 
exempted from the provider-based regulations.
    Response: We understand the concern about the need to preserve 
access to health care by patients using IHS facilities in rural 
communities. However, we note that existing Sec. 413.65(l) provides 
grandfathering protection for the facilities in operation when the 
existing provider-based rules were published, and that section 432 of 
BIPA amended the Medicare statute to permit payment for physician 
services in IHS clinics, thus providing an alternate funding source for 
facilities that become freestanding. Therefore, we do not believe a 
further change of the kind recommended by the commenter is needed.
    Comment: One commenter noted that excluding facilities providing 
only physical, occupational, or speech therapy to ambulatory patients 
from the provider-based requirements does not meet CMS' own stated 
criteria for such exclusions, in cases where those facilities are 
operated by CAHs. A payment difference based on provider-based or 
freestanding status would exist in such cases. If such facilities were 
operated as freestanding they would be paid on a fee schedule basis. 
However, if they were operated as integral and subordinate parts of 
CAHs, they would be paid on the same reasonable cost basis as other 
components of the CAH. The commenter recommended that the exclusion 
language in Sec. 413.65(a)(1)(ii)(H) be revised to state that the 
exclusion applies to such facilities other than those which are 
operated as part of a CAH.
    Response: We agree and are revising this final rule to reflect this 
comment.
    Accordingly, we are adopting as final the proposed revision to 
Sec. 413.65(a)(1)(ii)(G), the addition of Sec. 413.65(a)(1)(ii)(J), and 
the revisions of the definitions of ``Department of a provider,'' 
``Provider-based entity'' and ``Remote location of a hospital under 
Sec. 413.65(a)(2). In addition, in response to public comments, we are 
revising existing Sec. 413.65(a)(1)(ii)(H) to clarify that the 
exclusion of facilities providing only physical, occupational, or 
speech therapy to ambulatory patients applies to these facilities only 
if they are not operated as part of a CAH.
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.
    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 
believed an additional delay in the effective date of the provider-
based criteria is needed. Therefore, in the May 9, 2002 proposed rule 
we proposed 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

[[Page 50084]]

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 
proposed 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 proposed to make the new 
requirements effective on October 1, 2002, with respect to provider-
based status for facilities not qualifying for the grandfathering 
provision.
    Comment: One commenter requested clarification of how the proposed 
delay in effective date for the facilities grandfathered under section 
404(a) of BIPA will be applied. Specifically, the commenter asked 
whether facilities benefiting from the grandfathering would be able to 
take advantage of any additional flexibility provided under the final 
rules before the hospital's first cost reporting period beginning on or 
after July 1, 2003.
    Response: As explained in the preamble to the proposed rule, the 
purpose of the delayed effective date for grandfathered facilities is 
to allow more time for any necessary contractual or organizational 
changes that hospitals or their grandfathered facilities might need to 
undertake to achieve actual compliance with the provider-based 
criteria. Under our proposal, this would be accomplished by simply 
extending the BIPA mandated grandfathering provision until the 
hospital's first cost reporting period beginning on or after July 1, 
2003. To clarify the effect of the delay, we are revising the final 
rule to specify that the grandfathering provision applies to the 
requirements, limitations, and exclusions specified in paragraphs (d), 
(e), (f), (h), and (i) of Sec. 413.65 of this final rule. To the extent 
a particular grandfathered hospital might benefit from any other 
changes in paragraphs of Sec. 413.65 other than those listed in the 
immediately preceding sentence, it would be able to receive that 
benefit as of October 1, 2002, which is the effective date of any 
revisions to the other paragraphs.
    Comment: Several commenters requested that the grandfathering of 
facilities treated as provider-based on October 1, 2000 should continue 
indefinitely, not just until the start of the first cost reporting 
period on or after July 1, 2003, as we had proposed.
    Response: We are providing an extension in the effective date of 
the provider-based rules for grandfathered facilities until cost 
reporting periods beginning on or after July 1, 2003, to allow these 
facilities sufficient time to make any contractual and organizational 
changes needed to comply with the new rules. However, we do not believe 
it is appropriate to allow the facilities that were treated as 
provider-based in the past to continue to be treated that way 
permanently, without ever having to meet the same requirements as newer 
facilities. To do so would create a permanent double standard under 
which some older facilities would continue indefinitely to be rewarded 
for their previous inappropriate billing. We note that even the 
statutory provision under section 404(a) of BIPA was set for a limited 
2-year time period.
    Comment: One commenter suggested that grandfathering be provided 
for all hospital facilities for which affirmative determinations of 
provider-based status had been made by CMS (previously, HCFA) before 
October 1, 2000, or that such facilities be presumed to meet the 
provider-based criteria in the revised regulations without having to 
attest to compliance with those criteria, so that any future 
determination that a facility is not provider-based would be applied on 
a prospective basis only.
    Response: For the reasons noted above, we do not believe a general 
grandfathering of facilities is appropriate. In addition, the criteria 
in the program memorandum and instructions in effect before October 1, 
2000, differ from the new proposed rules to be effective on October 1, 
2002. Therefore, we do not believe it is appropriate to assume that 
facilities that received a provider-based determination under a prior 
set of criteria meet the new set of provider-based criteria in this 
final rule. Regarding the recommendation that any revised determination 
be made effective on a prospective-only basis, we note that, under 
Sec. 413.65(c)(2), providers that have received affirmative 
determinations of provider-based status with respect to facilities or 
organizations are required to report material changes in the 
relationships between themselves and any provider-based facility or 
organization. A provider having a determination of provider-based 
status will need to comply with this rule and, in particular, as stated 
in revised Sec. 413.65(l)(1), will need to report any aspect of its 
ownership or operation of the facility that it reasonably believes 
might not meet applicable provider-based requirements, to ensure that 
any redeterminations are made effective only prospectively.
    Accordingly, we are adopting as final the proposed revision to 
Sec. 413.65(b)(2), with a further clarification in response to a 
comment that the grandfathering provision applies to the requirements, 
limitations, and exclusions of Sec. 413.65 (d), (e), (f), (h), and (i) 
only.
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, in the May 9, 2002 proposed rule, we proposed to revise 
the application requirements as follows:
    First, we proposed to delete the existing application requirement 
under Sec. 413.65(b)(3). We proposed 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). We 
also proposed to require the provider to maintain documentation of the 
basis for its attestations and to make that documentation available to 
CMS upon request. We noted that, under this 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. It

[[Page 50085]]

could benefit the provider to obtain a determination because, under the 
proposed Sec. 413.65(l)(1) treatment of a facility as provider-based 
would cease only with the date that CMS determines that the facility no 
longer qualifies for provider-based status, 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. By contrast, a 
provider which did not seek such a determination or obtained a 
determination but failed to report a material change in its 
relationship with the facility, could face a partial recovery of past 
payments. Also, under proposed Sec. 413.65(j) (Inappropriate treatment 
of a facility or organization as provider-based) a provider that does 
not seek a provider-based determination and incorrectly bills as such 
could be subject to the partial recovery of payments for all cost 
reporting periods subject to reopening in accordance with 
Secs. 405.1885 and 405.1889. We further proposed 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 an 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 noted that, under the 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 
indicated that, alternatively, we would consider 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. In the May 9, 2002 proposed rule, we specifically 
solicited comments on the appropriateness of this or other alternative 
application procedures.
    Comment: Some commenters stated that although it appears that the 
mandatory application requirement under the existing regulations has 
been replaced with the voluntary attestation process, the preamble of 
the May 9, 2002 proposed rule made several references to procedures for 
applying for provider-based status. The commenters stated that if such 
references to an application in the final rule must be maintained in 
order to deal with applications submitted prior to the creation of the 
attestation process, such references should be clarified accordingly.
    Response: While we have proposed to replace the mandatory 
requirement for provider-based determinations under existing 
Sec. 413.65(b) with a voluntary attestation process, we note that 
providers still have the option of obtaining a determination of 
provider-based status for their facilities, which we encourage. The 
proposed method for doing so is through the attestation process. Under 
Sec. 413.65(b)(3), the provider may obtain a determination of provider-
based status by submitting an attestation stating that the facility 
meets the relevant provider-based requirements (depending on whether 
the facility is located on campus or off campus).
    As we stated in the May 9, 2002 proposed rule (67 FR 31481), 
``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.'' 
For purposes of this final rule, we are clarifying that, effective 
October 1, 2002, an attestation of provider-based status has the same 
effect as a request for provider-based status, in that approval of an 
attestation would result in a determination that a facility or 
organization is provider-based. Prior to October 1, 2002, the effective 
date of the final rule (or, in the case of grandfathered facilities, 
prior to the start of the provider's first cost reporting period 
beginning on or after July 1, 2003), the provider would submit a 
request for provider-based determination (as opposed to an 
attestation). (Until the effective date of these regulations on October 
1, 2002, providers should contact their CMS Regional Offices for 
information regarding application procedures). For providers wishing to 
obtain a provider-based determination after October 1, 2002, the 
providers would submit an attestation to CMS. Accordingly, until a 
uniform request or attestation form is available, at a minimum, the 
provider 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 request or 
attestation is submitted. The provider must also enumerate each 
facility and state its exact location (that is, its street address and 
whether it is on campus or off campus) and the date on which the 
facility became provider-based to the main provider. Documentation in 
support of the attestation of provider-based status must be submitted 
with the attestation for facilities located off campus. Main providers 
that submitted a request for a provider-based determination after 
October 1, 2000, but prior to the publication of this final rule, would 
be protected under section 404(c) of BIPA from recovery of overpayments 
in periods prior to the date on which CMS determines a facility is not 
provider-based.
    We note that even though we proposed to remove the current general 
requirement that a determination of provider-based status be obtained, 
we did not propose to revise paragraph (n) of Sec. 413.65 (redesignated 
in this final rule as paragraph (o)). That paragraph states that 
provider-based status cannot be effective before the earliest date on 
which a request for provider-based status has been made and all 
requirements of 42 CFR Part 413 have been met. To avoid creating 
confusion for providers and contractors and to allow the regulations to 
be implemented properly, we are making a conforming change to paragraph 
(o) to eliminate any reference to a mandatory application or 
determination, with one exception. As explained later in this preamble, 
we also state in Sec. 413.65(o) that if a facility or organization is 
found by CMS to have been inappropriately treated as provider-based 
under paragraph (j) for certain time periods, or previously was

[[Page 50086]]

determined by CMS to be provider-based but no longer qualifies as 
provider-based because of a material change occurring during those 
periods that was not reported to CMS, CMS will not treat the facility 
or organization as provider-based for payment until CMS has determined, 
based on documentation submitted by the provider, that the facility or 
organization meets all requirements for provider-based status under 
Part 413.
    Comment: One commenter stated that the proposed rules do not appear 
to provide hospitals that submit an attestation with any benefit with 
respect to recoupment of overpayments. For example, the commenter 
stated that, under the proposed rule, a provider could submit an 
attestation and begin providing and billing for provider-based services 
for years before receiving a determination from CMS that it is not 
provider-based and consequently be subject to the recovery of payments 
if CMS later determines that the facility is not provider-based. The 
commenter requested that a provider that submits a complete attestation 
not be liable for recovery of overpayments, but rather it should only 
be improper to bill as provider-based subsequent to a determination by 
CMS that a facility is not provider-based. Another commenter expressed 
concerns about possible long delays by CMS in reaching decisions on 
attestations and recommended that CMS require its regional offices to 
approve or disapprove provider-based status for each facility within 60 
days after having received the attestation regarding that facility. 
Another commenter stated that it would like a written response to the 
attestations and accompanying documentation from CMS for the providers 
to keep on file.
    Response: We do not agree that it would be appropriate to allow a 
provider that has attested inaccurately to being provider-based to 
retain payments made to the provider as if the facility were in full 
compliance with provider-based criteria. However, CMS would not recover 
all past payments for periods subject to reopening, but instead would 
recover only the difference between the amount of payment 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. At the time that CMS determines that a 
facility that submitted a complete attestation is actually not 
provider-based, payment would continue for up to 6 months but only at a 
reduced rate as described at Sec. 413.65(j)(5).
    Regarding the timeliness of action on attestations, we agree that 
providers should not be subject to long delays before action is taken. 
In response to this and other comments requesting further information 
on the procedures CMS will follow when an attestation is received, we 
are revising Sec. 413.65(b)(3) by adding new paragraphs (iii) and (iv). 
In new paragraph (b)(3)(iii), we are clarifying that whenever a 
provider submits an attestation of provider-based status for an on-
campus facility or organization, CMS will send the provider written 
acknowledgement of receipt of the attestation, review the attestation 
for completeness, consistency with the criteria in Sec. 413.65, and 
consistency with information in the possession of CMS at the time the 
attestation is received, and make a determination as to whether the 
facility is provider-based. In new paragraph (b)(3)(iv), we are 
clarifying that whenever a provider submits an attestation of provider-
based status for an off-campus facility or organization, CMS will send 
the provider written acknowledgement of receipt of the attestation, 
review the attestation for completeness, consistency with the criteria 
in Sec. 413.65, consistency with the documentation submitted with the 
attestation, and consistency with information in the possession of CMS 
at the time the attestation is received, and make a determination as to 
whether the facility is provider-based.
    We also will work with our regional offices and intermediaries as 
necessary to ensure that providers that submit attestations receive a 
prompt response. However, because of workload considerations and 
uncertainty about the volume of attestations that may be received, we 
have not yet specified a timeframe for completion of action on an 
attestation.
    Comment: One commenter recommended that if CMS finds an attestation 
to be incomplete, the provider be given an additional 30 days to submit 
supplementary information in support of the attestation.
    Response: We agree that providers who inadvertently omit needed 
information from an attestation should be given a reasonable 
opportunity to supplement that information. However, at the same time, 
we agree with the commenters who pointed out the importance to the 
provider of receiving a timely decision on whether a particular 
facility qualifies for provider-based status. If CMS were to delay a 
decision for a provider that repeatedly submitted incomplete 
attestations, this would prevent a timely response and could defeat the 
purpose of the attestation procedure. We intend to develop further 
implementing instructions and procedures that will strike a reasonable 
balance between the need for additional information and the need for a 
timely decision.
    Comment: One commenter requested that we reiterate that, since 
providers are no longer required under the proposed revised regulations 
to submit an attestation or an application for provider-based status as 
a precondition to billing for provider-based services, CMS would only 
consider a provider to be billing inappropriately if the provider was 
wrong in its conclusion that it meets the provider-based requirements. 
The commenter also asked that we clarify that facilities grandfathered 
under BIPA also need not submit an attestation, even at the expiration 
of the grandfathering period. Facilities grandfathered by BIPA will be 
treated the same as all other facilities on the date that their 
grandfathering period expires, which is the start of the cost reporting 
periods that begin on or after July 1, 2003.
    Response: The commenter is correct in the view that providers, 
regardless of whether they are grandfathered under BIPA, are not 
obligated to submit attestations or applications for provider-based 
status before they begin billing as provider-based, and that a provider 
would only be considered to be billing inappropriately if the facility 
actually did not meet the relevant provider-based rules. However, we 
note that if a provider does not submit a complete attestation of 
provider-based status, and CMS subsequently determines that the 
provider is billing inappropriately, the provider would be subject to 
recovery of overpayments under Sec. 413.65(j)(ii) for services at that 
facility(ies) for all prior cost reporting periods subject to reopening 
in accordance with Secs. 405.1885 and 405.1889.
    Comment: One commenter noted that all hospitals, even those 
previously subject to grandfathering, will be subject to the new 
regulations as of their first cost reporting periods starting on or 
after July 1, 2003. In view of this obligation, the commenter believed 
that it is unnecessary for attestations to be submitted for any 
facilities that are located on the campus of the hospital that claims 
them as provider-based. The commenter also recommended that if CMS 
later determines that the facility does not meet the provider-based 
criteria, CMS should not recover any past payments attributable to 
improper billing, but apply its determination only prospectively.

[[Page 50087]]

    Response: As explained more fully earlier in this preamble, under 
these final rules, while the provider-based criteria must be met, no 
provider is required to submit an attestation for any facility as a 
precondition to billing for its services as a provider-based facility. 
This is the case even where the facility is located on the main campus 
of a hospital. However, we believe an attestation has value, in that a 
provider that makes such an attestation presumably does so after having 
reviewed the provider-based criteria and assessed a particular 
facility's structure and operations in relation to them. Moreover, the 
attestation relates to compliance with only a minimal level of 
integration, and does not require any supporting documentation. 
Therefore, we do not believe that providing an attestation will require 
an unreasonable level of effort from the provider.
    Comment: One commenter recommended that off-campus facilities be 
required to submit attestations of compliance with the provider-based 
criteria before the date on which the revised regulations become 
effective for them. (For grandfathered facilities, Secs. 413.65(d), 
(e), (f), (h), and (i) of the revised regulations would become 
effective for the hospital's first cost reporting period starting on or 
after July 1, 2003.) The commenter also recommended that if these 
facilities are later found not to have met the provider-based 
requirements, any determination that they are not provider-based should 
be applied only prospectively.
    Response: As explained in response to a previous comment, we cannot 
agree that a provider should be allowed to retain payments made as if a 
facility were provider-based after a determination has been made that 
the provider-based criteria were not met. Therefore, this final rule 
provides for recovery of past payments to the extent necessary to make 
those payments relate more closely to what would have been paid if the 
facility's services had been billed on a freestanding basis.
    Comment: One commenter expressed approval of our proposal under 
which supporting documentation would not have to be submitted with the 
attestation for on-campus facilities. The commenter suggested that the 
paperwork burden for providers could be further reduced if the 
regulations were revised to eliminate the need for supporting 
documentation for attestations regarding off-campus facilities or 
organizations as well. Another commenter stated that hospital-licensed 
community health centers frequently are located within a few miles of 
the main provider-campus and are closely integrated with it. The 
commenter believed these facilities should not be required to submit 
supporting documentation.
    Response: We understand and share the commenters' interest in 
reducing the paperwork burden on providers. However, this important 
objective must be balanced against the equally important need to ensure 
proper accountability by providers for the status of the facilities or 
organizations for which they are claiming provider-based status. 
Determining whether an off-campus facility is truly integrated with a 
main provider is more difficult than for a facility located on the main 
campus of a provider, and this is why there are additional requirements 
for off-campus facilities to demonstrate provider-based status. In view 
of this, we believe it is reasonable to require that an attestation 
regarding an off-campus facility, including hospital-licensed community 
health centers, be accompanied by supporting documentation that clearly 
shows the basis for the attestation.
    Comment: One commenter noted that proposed Sec. 413.65(b)(3)(i) 
requires a provider that makes a provider-based attestation with regard 
to an on-campus facility to make documentation supporting that 
attestation available to CMS upon request. The commenter recommended 
that the regulation be revised to require that the supporting 
documentation also be made available to CMS contractors (fiscal 
intermediaries and carriers) upon request. Response: We agree, and are 
revising the final rule accordingly.
    Comment: One commenter asked CMS to provide guidance as to the type 
of documentation that is required to be submitted with an attestation 
for an off-campus facility. Another commenter suggested that before a 
uniform application is available, providers should be required to 
submit information regarding physical location, a contact person, and 
the date the facility became provider-based to the main provider.
    Response: As stated above, until a uniform attestation form is 
available, at a minimum, the attestation should include the identity of 
the main provider and the facility(ies) or organization(s) 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. The provider must also enumerate 
each facility and state its exact location (that is, its street address 
and whether it is on campus or off campus) and the date on which the 
facility became provider-based to the provider. We plan on issuing 
further guidance in program instructions after publication of this 
final rule.
    Comment: One commenter noted CMS' authority to terminate payment 
prospectively if a provider fails to provide all necessary information 
as part of the continuation of payment provisions under 
Sec. 413.65(j)(5). Given this authority, and because the commenter 
believed it will be difficult for providers to know what constitutes a 
complete attestation, the commenter recommended that CMS provide the 
opportunity for providers to supplement their original submissions with 
additional information within 30 days of receipt of notice from CMS 
that the submission is incomplete.
    Response: Under Sec. 413.65(b)(3), a complete request (or 
attestation) is one that includes all information needed to permit CMS 
to make a determination. We have stated above that we plan to issue 
further guidance as to what information should be included in an 
attestation. However, we note that, under Sec. 413.65(j)(5), a provider 
must notify CMS in writing within 30 days of the date that CMS issues 
its denial of provider-based status, of whether the provider intends to 
seek a determination of provider-based status for the facility or 
whether the practitioners will be seeking to enroll to bill Medicare or 
Medicaid for services at that location as a freestanding facility. If 
the provider notifies CMS of its intentions within 30 days, the 
provider has up to 6 months to take whatever steps are necessary to 
comply with the relevant rules, whether that means providing CMS with 
supplemental documentation or making changes to meet the regulatory 
requirements (for example, a provider is renegotiating its management 
contracts). Therefore, we believe it is unnecessary to add an 
additional 30 days to the interim period in which payment continues at 
a reduced rate.
    Comment: One commenter asserted that if CMS has concerns about the 
status of on-campus facilities, it should be incumbent on CMS to 
initiate an investigation and to provide notice to the provider and 
opportunity for the facilities to fix any discrepancies prior to losing 
provider-based status. The commenters added that it is still unclear 
whether every service on the hospital's campus would need to submit an 
attestation, or if one attestation is sufficient to cover all on-campus 
facilities. Some commenters also asked whether, and in what timeframe, 
these sites will receive a written response from CMS.

[[Page 50088]]

    Response: We do not agree with this commenter's suggestion that 
providers that have been inappropriately treating certain facilities as 
provider-based and have not attempted to obtain a provider-based 
determination should be protected from recovery of past overpayments. 
However, we note that Sec. 413.65(j)(5) of this final rule would allow 
such a provider up to 6 months of continued payment, at an adjusted 
rate, to meet applicable billing requirements.
    In regard to the commenter's request for clarification concerning 
whether every service on the hospital's campus would need to submit an 
attestation, or if one attestation is sufficient to cover all on-campus 
facilities, we emphasize that the provider-based rules do not apply to 
specific services; rather, these rules apply to facilities as a whole. 
That is, the facility in its entirety must be a subordinate and 
integrated part of the main provider. For example, a provider may have 
several outpatient facilities, some located on campus and some located 
off campus, yet each facility as a whole must meet the applicable rules 
for provider-based status. However, a main provider would not need to 
submit a separate application for each one of its facilities for which 
a provider-based determination is sought. A provider may attest in a 
single application package that each one of its facilities in which it 
intends to bill for services as if the facility is provider-based meets 
the applicable provider-based rules under Sec. 413.65. For those 
facilities that are located on campus, no documentation is required to 
be submitted with the attestation. Documentation must be submitted for 
those facilities located off campus. However, we are requiring that as 
part of its attestation, the main provider enumerate each facility and 
state its exact location (that is, its street address and whether it is 
on campus or off campus).
    As noted earlier, the commenters also asked whether, and in what 
timeframe, a provider that submits an attestation will receive a 
written response from CMS. While we are making revisions in these final 
rules to provide more information about the actions CMS will take in 
response to such an attestation, at this time, due to the uncertainty 
of the volume of requests that will be submitted by providers, we 
cannot state an exact timeframe in which the provider-based 
determinations will be made for on-campus or off-campus facilities. 
Each attestation will be received and processed by the appropriate CMS 
Regional Office (or fiscal intermediary) and will be reviewed as soon 
as possible.
    Comment: One commenter asked if a ``re-attestation'' is required 
after a certain period of time.
    Response: Just as providers are no longer explicitly required to 
submit an initial attestation, there is also no explicit requirement 
for hospitals to re-attest that their facilities continue to meet the 
provider-based requirements. However, we note that, under proposed 
Sec. 413.65(k) (revised as Sec. 413.65(l) in this final rule), if CMS 
determines that a facility that had previously been determined to be 
provider-based no longer qualifies for provider-based status, and the 
failure to qualify for provider-based status results from a material 
change in the relationship between the main provider and the facility 
that the main provider did report to CMS, treatment of the facility as 
provider-based would cease with the date that CMS determines that 
facility no longer qualifies for provider-based status. Conversely, if 
a main provider did not report a material change to CMS, the main 
provider will be subject to recovery of overpayments as described under 
Sec. 413.65(j)(1)(ii).
    Comment: One commenter stated that the use of the term ``advance 
determination'' is confusing because the rule does not provide for an 
advance determination of provider-based status.
    Response: We agree with the commenter and are removing all 
references to ``advance'' used in connection to provider-based 
determinations from this final rule. We note that, under proposed 
Sec. 413.65(k) (revised as Sec. 413.65(l) in this final rule), a 
provider that submits a complete attestation of compliance with the 
provider-based status requirements for a facility that has not 
previously been found by CMS to have been inappropriately treated as 
provider-based, may bill and be paid for services of the facility as 
provider-based from the date of its attestation of provider-based 
status until the date that CMS determines that the facility is not 
provider-based.
    Accordingly, we are adopting as final the proposed changes to 
Sec. 413.65(b)(3) with the following modifications: We are revising 
Sec. 413.65 by adding new paragraphs (b)(3)(iii) and (iv) to include 
further information on procedures for submitting and processing 
attestations; removing references to the term ``advance'' in connection 
with determinations in paragraphs (b)(3)(i) and (ii); and adding 
language under paragraph (b)(3)(i) regarding the availability of 
documentation to contractors.
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

[[Page 50089]]

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, in the May 9, 2002 proposed rule, we proposed 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 were 
proposed to 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, in the May 9, 2002 proposed rule, we 
proposed 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 was proposed to 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 proposed 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 proposed 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 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 proposed to relocate the 
requirement to paragraph (e) as described below.
    We also proposed 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 proposed other changes to paragraph (g).
    We did not receive any comments on these proposed changes. 
Therefore, in this final rule, we are adopting the proposed changes as 
final.
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 than for on-campus facilities or organizations, and 
such integration should not simply be presumed to exist. Therefore, to 
ensure that off-campus facilities or organizations seeking provider-
based status are appropriately integrated, in the May 9, 2002 proposed 
rule, we proposed to retain certain requirements to demonstrate 
integration that we proposed to remove for on-campus facilities or 
organizations. These requirements were set forth in proposed new 
Sec. 413.65(e). The requirements set forth in proposed paragraphs 
(e)(1), (e)(2), and (e)(3) included 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 did not receive any comments on these proposed changes. 
Therefore, in this final rule, we are adopting the proposed changes as 
final.
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, in the May 9, 2002 proposed 
rule, we proposed 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 proposed to 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 proposed to make minor changes to the second sentence 
of the redesignated paragraph (f) to clarify its meaning.
    Comment: One commenter noted that proposed Sec. 413.65(f) states 
that facilities or organizations operated by two or more providers 
engaged in a joint venture cannot be considered provider-based if they 
are not located on the campus of the potential main provider. The 
commenter believed that the rule would be more easily understood if 
paragraph (f) were revised to state that a facility or organization 
owned by two or more providers engaged in a joint venture cannot be 
considered provider-based unless it is located on the campus of at 
least one of the providers engaged in the joint venture.

[[Page 50090]]

    Response: We agree that clarification of the joint venture 
requirements is needed. Therefore, in this final rule we are revising 
Sec. 413.65(f) to clearly state that, in order for a facility or 
organization operated as a joint venture to be considered provider-
based, it must (1) be partially owned by at least one provider; (2) be 
located on the campus of a provider who is a partial owner; (3) be 
provider-based to that one provider whose campus on which the facility 
or organization is located; and (4) meet all of the requirements 
applicable to all provider-based facilities and organizations in 
Sec. 413.65(d). Therefore, to be treated as provider-based, the 
facility operated as a joint venture must be provider-based to the 
provider whose campus on which the facility is located, regardless of 
whether that provider is the majority owner.
    For example, if Hospital A owns 60 percent of Facility C and 
Hospital B owns 40 percent of Facility C, but Facility C is located on 
the campus of Hospital B, Facility C may only be provider-based to 
Hospital B.
    Comment: One commenter asked if the provider where the service is 
located has to be the billing provider of the joint venture. The 
commenter also had questions about the rules concerning public 
awareness and other criteria as they relate to a joint venture service. 
The commenter asked whether the facility had to advertise as a joint 
venture, as a service of the provider where the site is located, or as 
a service of the billing provider.
    Response: As we explained in the response to the previous comment, 
the facility owned by a joint venture must be provider-based to the 
provider whose campus on which the facility is located, regardless of 
whether that provider is the majority owner. The main provider does not 
have to advertise as a joint venture, but as a facility that is 
provider-based to the main provider. Accordingly, the services in the 
facility would be billed using the provider number of the provider 
whose campus on which the facility is located. (The facility cannot, of 
course, be provider-based with respect to both hospitals.) In addition, 
the facility owned by a joint venture must also meet all the 
requirements applicable to all provider-based facilities in 
Sec. 413.65(d).
    Comment: Some commenters requested that CMS allow facilities owned 
by a joint venture but not located on a hospital's campus to be 
considered provider-based. The commenters stated that joint ventures 
among and between hospitals in rural areas greatly help to improve 
access to care.
    Response: While it is not our intent to limit access to care, we 
continue to believe that facilities owned by joint ventures that are 
not located on a main provider's campus do not qualify as provider-
based. Thus, we are not adopting the commenter's request.
    Accordingly, we are adopting as final the proposed Sec. 413.65(f), 
with clarifying changes to the criteria for being determined a joint 
venture as discussed under the responses to comments.
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, in the 
May 9, 2002 proposed rule, we proposed 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 proposed to make 
three changes in existing Sec. 413.65(g). First, we proposed to revise 
paragraph (g)(1) by deleting the second sentence of that paragraph. In 
paragraph (g)(2), we proposed 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 
proposed 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. We believed that this clarification 
was 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. Further, we 
proposed to 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.
    We did not receive any comments on these proposed changes to 
Sec. 413.65(g)(2) and (g)(7). Therefore, in this final rule, we are 
adopting the proposed changes as final
    With regard to the proposed changes to Sec. 413.65(g)(1), although 
we stated above that we are planning to finalize EMTALA policy proposed 
on May 9, 2002 in a separate document to be published shortly, we are 
adopting as final the proposed change concerning the applicability of 
EMTALA to provider-based entities located on the hospital main campus. 
Currently, under Sec. 413.65(g)(1), if any individual comes to any 
hospital-based entity (including an RHC) located on the hospital main 
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. We stated in the proposed rule (67 FR 
31477) that, 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 of the Act, which 
restricts EMTALA applicability to hospitals. To avoid confusion on this 
point and the extension of EMTALA requirements to other nonhospital 
providers, we are clarifying at Sec. 413.65(g)(1) that EMTALA applies 
in this scenario to only those departments on the hospital's main 
campus that are provider-based. Accordingly, EMTALA does not apply to 
provider-based entities (such as RHCs) that are either on or off the 
hospital campus.
    Because we received no public comments on this proposed 
clarification on the applicability of EMTALA to provider-based 
entitles, we are adopting as final this one change at Sec. 413.65(g)(1) 
by deleting the second sentence at existing Sec. 413.65(g)(1) that 
addresses this policy. However, we note again that in this final rule 
we are not adopting other clarifications in the proposed rule 
concerning application of EMTALA to provider-based departments, on or 
off the campus, or any other proposals concerning EMTALA. We received 
over 600 pieces of correspondence on these subjects. In order to give 
proper consideration to these comments, we plan to issue a final policy 
on the EMTALA proposals in a separate document.
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 in the May 
2002 proposed rule to be redesignated as Sec. 413.65(h)).

[[Page 50091]]

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 proposed to restrict the 
applicability of proposed redesignated paragraph (h) to off-campus 
facilities or organizations. In addition, we proposed two additional 
changes that we believe are needed to respond to questions that are 
raised frequently about the regulation. First, we proposed to 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 did not propose to 
specify who may employ other support staff, such as maintenance or 
security personnel, and who are not directly involved in providing 
patient care, nor did we propose to require licensed professional 
caregivers such as physicians, physician assistants, or certified 
registered nurse anesthetists to become provider employees. We also 
proposed 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.
    Comment: One commenter supported the proposal eliminating 
restrictions on management contracts and joint ventures for on-campus 
facilities. The commenter also supported the modification to the 
management contract rules applicable to off-campus facilities that 
requires the main provider to employ only those staff who are directly 
involved in the delivery of patient care, other than staff who may be 
paid under the Medicare fee schedule, management staff, and other 
support staff. Another commenter recommended that CMS limit the 
management contract restrictions for off campus facilities by allowing 
the management company to employ at least some of the patient care 
staff at the facility, as long as the facility remains integrated with, 
and under the control of, the main provider.
    Response: We agree with the commenter who stated that it is 
appropriate to require the main provider to employ only those staff who 
are directly involved in the delivery of patient care, other than staff 
who may be paid under the Medicare fee schedule, management staff, and 
other support staff. We considered the comment suggesting that the 
regulations be further changed to allow at least some of these staff to 
be provided under a management contract. However, we are not adopting 
this change. We note that the revisions in the proposed rule would have 
significantly relaxed the requirements relating to management contracts 
by restricting the scope of those provisions to off-campus facilities 
and by expanding the range of services that may be furnished under 
management contracts in those facilities. Under our proposal, even if 
only the services described in this comment would have to be furnished 
by the provider, the provider would be permitted to bill as if it 
delivered the services itself. If we were to further weaken the 
management contract requirements, this would remove any effective 
control on such contracts, thereby allowing the provider to claim 
provider-based payment for a facility with which it has only a 
contractual relationship. We believe such a tenuous connection between 
the provider and the facility does not warrant payment for the 
facility's services as services of an ``integral and subordinate'' part 
of the provider. Therefore, we are not adopting this comment.
    Comment: One commenter recommended that inpatient facilities be 
exempted from the management contract requirements in proposed 
Sec. 413.65(h).
    Response: We note that our proposed rule accomplished much of what 
the commenter recommended, in that it would exempt on-campus 
facilities, including those facilities that treat a patient population 
made up largely or entirely of inpatients, from the management contract 
requirements in Sec. 413.65(h). We are adopting this proposal without 
change in the final rule. However, for the reasons discussed earlier in 
responding to comments on the scope of the provider-based requirements, 
we do not believe it would be appropriate to exclude off-campus 
facilities and organizations from the management contract requirements.
    Comment: One commenter recommended that CMS regional offices be 
authorized to exempt facilities or organizations from the management 
contract requirements on a case-by-case basis, depending on the 
circumstance in each case.
    Response: We agree that regional offices need to exercise judgment 
in application of the criteria, but do not agree that the exercise of 
that judgment should include discretion to entirely waive applicability 
of a requirement. This could lead to wide variations in the 
applicability of the provider-based criteria in different areas of the 
country. Therefore, we are not making any change in the final rule 
based on this suggestion.
    Comment: Some commenters requested clarification of the 
relationship between provision of services under management contracts 
and under arrangements of the kind described in section 1861(w)(1) of 
the Act. The commenters further recommended that proposed 
Sec. 413.65(i), which states that a facility or organization cannot 
qualify for provider-based status if all services at the facility are 
furnished under arrangements, be revised so that it does not apply to 
on-campus facilities. The commenters expressed concern that if that 
change is not made, management contracts for on-campus facilities or 
organizations that are permitted under proposed Secs. 413.65(d) and (h) 
would nevertheless be prohibited by Sec. 413.65(i).
    Response: Generally, we believe there is a substantial difference 
between the use of management contracts to obtain some or all input 
services needed to operate a health care facility, including not only 
management but professional and other staffing, security, maintenance, 
other support services, and the use of section 1861(w)(1) arrangements 
by a provider to obtain specialized health care services that it does 
not itself offer, and that are needed to supplement the range of 
services that the provider does offer its patients. In the first 
situation, it is possible that all or virtually all services needed to 
operate a facility could be obtained under contract, resulting in 
nothing more than a nominal connection between the facility and the 
provider that claims it as an integral and subordinate part. To prevent 
a facility operated in this way from inappropriately claiming to be 
part of a provider, reasonable controls on management contracts are 
needed. In the latter case, a provider may

[[Page 50092]]

legitimately obtain limited specific services under arrangements 
without sacrificing its ability to function independently as a provider 
and directly furnish care to its patients.
    In this context, we would agree with the commenter that a provider 
that operates a facility that qualifies legitimately as provider-based 
may choose to obtain some specialized services for its patients under 
arrangements without needing to meet the management contract 
requirements of Sec. 413.65(h) with respect to each individual service. 
As noted above, these requirements apply to facilities, not to 
individual services. However, we continue to believe it would be 
inappropriate for a facility, whether located on or off campus, to 
evade the provider-based requirements by claiming to provide all of its 
services under arrangements. Therefore, we are not making further 
changes to Sec. 413.65(i).
    Comment: One commenter stated that CMS' intentions were unclear in 
the proposed regulations at Sec. 413.65(h)(1) that state, ``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.'' The commenter added that it 
is unclear if this provision prohibits arrangements under which a 
management company employs clinical staff paid under a fee schedule 
that are subsequently leased to the main provider to provide services 
in the provider-based facility. The commenter suggested that we clarify 
this language and, in the final rule, state that the exception to the 
main provider employment requirement for patient care staff that 
furnish services paid for under a fee schedule also applies to leased 
employees from a management company.
    Response: In the proposed rule, we stated that the main provider is 
required to employ only those staff who are directly involved in the 
delivery of patient care other than staff who may be paid under the 
Medicare fee schedule, management staff, and other support staff. 
Therefore, the main provider may not use ``leased'' employees if those 
employees are directly involved in delivering patient care and cannot 
be paid under the Medicare fee schedule. However, this provision would 
not prohibit arrangements under which a management company employs 
clinical staff who may be paid under a fee schedule that are leased to 
the main provider to provide services in the provider-based facility. 
The management company may otherwise employ and provide the staff who 
furnishes patient care services that may be paid for by Medicare under 
a fee schedule. Accordingly, as the commenter recommended, we are 
clarifying the regulations text to state that, other than staff that 
may be paid under a Medicare fee schedule, the main provider may not 
utilize the services of leased employees who are directly involved in 
patient care in off-campus facilities.
    Comment: One commenter stated that the proposed regulation that 
would require the main provider to employ all staff who ``are directly 
involved in the delivery of patient care, except for management staff * 
* *'' is confusing, because in many instances, managers are involved 
both in management activities and in furnishing direct patient care.
    Response: If these managers are also medical professionals who may 
receive payment for their patient care services under a Medicare fee 
schedule, they do not need to be employed directly by the main 
provider.
    Comment: Some commenters stated that the prohibition of off-campus 
management contracts will have harmful consequences, particularly in 
areas where private hospitals have partnerships with local government 
to operate off-campus psychiatric facilities in remote, underserved 
areas. The commenter explained that the county government manages an 
off-campus psychiatric facility as an inpatient psychiatric unit of a 
private hospital, and that county employees provide all patient care 
services in the unit. Although the facility is currently grandfathered 
under section 404(a) of BIPA, the facility will be unable to qualify 
for provider-based status when the grandfathering period expires, 
resulting in a loss of essential mental health services to the 
surrounding communities. The commenters requested that counties that 
have partnerships with private entities in order to ensure access to 
care and meet all other provider-based criteria be exempted from the 
management contract prohibition.
    Response: While we are sympathetic to the needs of the medically 
underserved, we do not believe the management contract requirements to 
be overly restrictive. Rather, we believe the employment of the staff 
of an off-campus facility is a significant factor in determining the 
degree to which a facility or department is integrated (that is, 
provider-based) with its parent hospital. This is particularly 
important in a facility operated under a management contract. Because 
such a facility already receives management (and typically, many other 
services and supplies) from the management company, employment of the 
caregivers by the provider provides a strong link to the provider's 
other operations and demonstrates that the facility continues, despite 
the purchase of management services under contract, to be an integral 
and subordinate part of the provider. As such, we do not believe that 
it is appropriate to exempt any off-campus facilities from the 
management contract requirement.
    Accordingly, we are adopting as final the proposed Sec. 413.65(h) 
with one change to paragraph (h)(1) to clarify use of leased employees 
by a provider as discussed in the response to comments.
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 having submitted a complete attestation regarding 
provider-based status as described earlier, 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 
estimate 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 appropriate to do so, on a time-limited basis, 
to allow for an orderly transition to either provider-based or 
freestanding

[[Page 50093]]

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.
    In the May 9, 2002 proposed rule, we proposed 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 
proposed 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, we proposed (proposed Sec. 413.65(j)(1)(ii)) that 
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 proposed 
to make recovery for all cost reporting periods subject to reopening in 
accordance with Secs. 405.1885 and 405.1889. Also, we proposed to 
adjust future payments to estimate 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 proposed 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.
    Comment: One commenter stated that, under current policies, 
teaching hospitals may claim the time residents spend training at 
freestanding facilities (known as ``nonhospital sites'') only when 
there is a written agreement between the hospital and the nonhospital 
site. No written agreement is needed if the site is provider-based. The 
commenter asked that if CMS determines that a facility does not meet 
the provider-based rules, the indirect medical education (IME) payments 
that were received by the teaching hospital should not be affected.
    Response: If CMS determines that a provider, whether teaching or 
nonteaching, is inappropriately receiving payment in a facility since 
the facility is determined not to be provider-based, CMS would take 
several actions, including, as described under Sec. 413.65(j)(3), 
reviewing payments for past cost reporting periods in order to recover 
the difference between the amount of payment that was made to the 
provider and an estimate of payments that CMS would have made had the 
facility not been provider-based. It is conceivable that overpayments 
may have been made, not only for IME but also for direct GME, to a 
teaching hospital that incorrectly treated a facility as provider-
based, and, as such, we would recover an amount of payment for both IME 
and direct GME that would otherwise not have been received by the 
hospital had the facility been freestanding.
(2) Good Faith Effort
    We proposed to retain the existing exception for good faith effort 
(proposed redesignated Sec. 413.65(j)(2)). Under this exception, we 
specified that 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 Sec. 413.65(g)(2).
    Under Sec. 413.65(j)(5), we proposed that 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

[[Page 50094]]

provider, facility, or organization as of the date CMS issues notice 
that necessary applications or information have not been submitted.
    As clarified in Sec. 413.65(o) of this final rule, we would not 
resume provider-based payment to such a facility or organization based 
on an attestation of compliance. On the contrary, if a facility or 
organization is found by CMS to have been inappropriately treated as 
provider-based under paragraph (j) for any period on or after October 
1, 2002 (or, in the case of facilities or organizations described in 
Sec. 413.65(b)(2), for cost reporting periods starting on or after July 
1, 2003), CMS will not treat the facility or organization as provider-
based for payment until CMS has determined, based on documentation 
submitted by the provider, that the facility or organization meets all 
requirements for provider-based status under Part 413.
    Comment: One commenter suggested that, given the complexities 
surrounding the provider-based rules and the delays in implementing the 
regulations and establishing a uniform process, the final rule should 
provide that any provider that complies with the good faith exception 
under Sec. 413.65(j)(2) should also not be subject to any retroactive 
recoupment of payments under proposed paragraphs (j) and (k).
    Response: The regulations at Sec. 413.65(j)(2) state that recovery 
of overpayments will not be made for any period before the beginning of 
the hospital's first cost reporting period beginning on or after 
January 10, 2001, if the provider made a good faith effort to treat its 
facilities as provider-based during all that period. This good faith 
exception was originally included in the April 7, 2000 regulations 
(originally applicable to periods before October 10, 2000, the original 
effective date of the provider-based regulations, but subsequently 
delayed to January 10, 2001).
    We believe a good faith exception is appropriate for cost reporting 
periods beginning before January 10, 2001, when the provider-based 
regulations first became effective, since it would protect providers 
that were unaware of the new regulations, yet operated facilities that 
met a minimal threshold for integration. However, CMS has now published 
two proposed rules and one final rule on provider-based status, has 
published ``Qs and As'' on its website, and has consulted extensively 
with the hospital industry through teleconferences and meetings. Given 
the publicity that the provider-based regulations have received and the 
latest delayed effective date of these rules, we do not believe it is 
appropriate to extend the scope of the good faith exception.
    Accordingly, we are adopting the proposals discussed above as 
final. In addition, we are revising section 413.65(j)(2)(ii) to refer 
to ``billed with the correct site-of-service'' rather than ``site-of-
service indicator'', for consistency with the revision to 
Sec. 413.65(g)(2) described above.
j. Temporary Treatment as Provider-Based and Correction of Errors
    Under proposed revised Sec. 413.65(k), we proposed to 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 proposed 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 should have been made in the absence of 
compliance with the provider-based requirements. We indicated that 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 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 proposed 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 proposed not to recover payments for any period 
before the provider's first cost reporting period beginning on or after 
July 1, 2003.
    Also, we proposed that, as under regulations currently in effect, 
the exception for good faith concerning recovery of overpayments under 
proposed revised Secs. 413.65(j)(2) described above would only apply to 
any period before the beginning of the hospital's first cost reporting 
period beginning on or after January 10, 2001.
    Comment: One commenter requested that provider-based payment for 
services of a facility be allowed to continue while the facility is 
challenging any determination that it is not provider-based.
    Response: As we explain in the proposed revised regulations at 
Sec. 413.65(k), provider-based payment for services at a facility will 
continue until the date that CMS determines that the facility does not 
meet the provider-based rules. Once a determination concluding that a 
facility does not meet the provider-based rules is made, we believe it 
is inappropriate to continue paying for services at that facility as 
provider-based. Then, depending upon a number of factors, including 
whether the facility had previously been determined by CMS to be 
provider-based and whether the loss of provider-based status resulted 
from a material change that was or was not reported to CMS, CMS will 
take actions with respect to recovery of overpayments and continuation 
of payments at the appropriate nonprovider-based reduced rate, as 
described in the proposed revised Sec. 413.65(j).
    Comment: One commenter noted that proposed paragraph (k) contains 
some rules applicable to facilities for which there has not been a 
previous

[[Page 50095]]

determination of provider-based status (paragraph (k)(1)) and others 
that apply to facilities for which such a determination has been made 
(paragraphs (k)(2) and (k)(3)). The commenter believed these rules 
would be more clearly understood if the rules for each situation were 
stated in separate paragraphs.
    Response: We agree with the commenter. In this final rule, we are 
placing the text of proposed paragraph (k)(1) concerning facilities for 
which there has been no previous determination in new paragraph (k), 
and the text of proposed paragraphs (k)(2) and (k)(3) concerning 
facilities for which previous determinations have been made in 
paragraph (l). Proposed sections (l) through (n) are being redesignated 
as paragraphs (m) through (o).
    In addition, as noted earlier in this preamble, we state in 
Sec. 413.85(o) of this final rule that, effective for any period on or 
after October 1, 2002 (or, in the case of facilities or organizations 
described in Sec. 413.85(b)(2), for cost reporting periods starting on 
or after July l, 2003), if a facility or organization previously was 
determined by CMS to be provider-based but no longer qualifies as 
provider-based because of a material change occurring during those 
periods that was not reported to CMS, CMS will not treat the facility 
or organization as provider-based for payment until CMS has determined, 
based on documentation submitted by the provider, that the facility or 
organization meets all requirements for provider-based status under 
Part 413.
    Comment: Regarding the references in paragraphs (k)(1) and (k)(2) 
of proposed Sec. 413.65 (to be redesignated as (l)(2) and (l)(3), as 
explained above) to reporting of material changes in the relationship 
between a provider and a facility or organization that had been found 
to be provider based, one commenter recommended that the term 
``material change'' be defined more specifically, to give providers 
more direction as to what events to report. The commenter believed a 
material change should be defined as including only ``a change of 
ownership, adoption of a new management contract for an off-campus 
department of a provider or a provider-based entity, change to an off-
campus location, or a change in licensure status.''
    Response: We share the commenter's belief that the events listed 
would be considered material changes. However, we do not agree that the 
term ``material change'' should include only these events. On the 
contrary, other types of occurrences, such as formation of a separate 
medical staff for the facility or organization or discontinuation of a 
service on the main provider's campus that would prevent referral of 
patients from the facility organization to the main provider would also 
represent material changes. Because we believe limiting the definition 
of the term ``material change'' as suggested by the commenter would 
inappropriately restrict the range of events to be reported, we are not 
adopting this comment.
    Comment: One commenter recommended that reporting of material 
changes not be required for on-campus facilities. The commenter 
believed this reporting is unnecessary because adequate safeguards are 
already built into the provider enrollment requirements.
    Response: Several of the kinds of changes noted in response to the 
preceding comment, relating to the integration of clinical services of 
the facility or organization with those of the main provider, are not 
subject to any mandatory reporting under the provider enrollment 
process but could affect provider-based status. Therefore, we are not 
making any change in the final rule based on this comment.
    Comment: One commenter noted that, in the preamble to the proposed 
rule, CMS states that there would be `` * * * 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 following 
notification of the redetermination, but not less than 6 months after 
the date of notification'' (67 FR 31483). The commenter pointed out 
that this minimum 6-month compliance period is not included in the 
proposed Sec. 413.65(k)(2). Rather, this regulation states that under 
these circumstances, provider-based status ``ceases with the date that 
CMS determines that the facility or organization no longer qualifies 
for provider-based status.'' The commenter requested that CMS revise 
Sec. 413.65(k)(2) to reflect the minimum 6-month compliance period.
    Response: We agree that the language quoted by the commenter from 
page 31483 of the preamble to the proposed rule is inconsistent with 
the language in the proposed regulations text. While this language is 
consistent with the current policy as stated in existing 
Sec. 413.65(k), the inclusion of the language on page 31483 of the 
proposed rule was inadvertent on our part. We note that the correct 
proposed policy, which correctly mirrors the proposed regulation text 
at Sec. 413.65(k)(2), is stated on page 31487 of the proposed rule. 
Specifically, we state that ``if we determine that a facility of 
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 reported to CMS 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.'' We did not intend to 
propose to allow a 6-month grace period before a facility's status as 
provider-based would be revoked.
    While we regret the confusion caused, we are not adopting the 
commenter's request regarding a 6-month grace period prior to removal 
of a provider-based status designation, since we do not believe it 
would be appropriate to provide for payment to the provider as 
provider-based for a period for which the provider was clearly not 
provider-based. While we do not plan to recover overpayments from a 
facility or organization that no longer qualifies as provider-based if 
the provider reported a material change in the relationship between the 
provider and the facility or organization, CMS retains the authority to 
recoup overpayments and apply civil monetary penalties if a provider is 
in violation of section 1128A or 1128B of the Act.
    Accordingly, we are adopting our proposals as final with the 
following changes: We are reorganizing the text of proposed 
Sec. 413.65(k) into new paragraphs (k) and (1), without substantive 
change, to distinguish the rules applicable to facilities for which 
there has been no previous determination from those that apply to 
facilities for which a previous determination has been made. Proposed 
sections (l) through (n) are being redesignated as paragraphs (m) 
through (o).
k. Technical Amendments
    We proposed to correct a typographical error in the heading of 
paragraph (m) of Sec. 413.65 (redesignated as paragraph (n) in this 
final rule) so that it reads ``FQHCs and ``look alikes' ''.
    In paragraph (n) of Sec. 413.65 (redesignated as paragraph (o) in 
this final rule), we proposed to add a cross-reference to the 
requirements for

[[Page 50096]]

provider-based status described in paragraph (b), for purposes of 
specifying the effective date of provider-based status.
    We did not receive any public comments on these technical 
amendments and are adopting them as final without change except for the 
redesignation of paragraph codes indicated above.

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 we may issue. 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, we have 
prescribed, in Medicare Provider Reimbursement Manual, Part I 
(``PRM''), section 2931.2, criteria that guide the intermediary's 
reopening actions under Sec. 405.1885(a) in the absence of a particular 
CMS directive. Also, given that the intermediaries are our (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 Sec. 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 ``must 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 our 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 us 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 understood 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 understood 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 CMS 
Administrator (in the context of reviewing PRRB 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 
CMS Administrator (in the context of reviewing PRRB decisions), to 
limit our authority to direct the actions of our agents with respect to 
reopening matters. (See Your Home Visiting Nurse Services, Inc. v. 
Shalala, 525 U.S. 449, 452-53 (1999)(Sec. 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 our authority to 
direct the intermediary to reopen or not reopen a specific matter; 
instead, we have 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 CMS 
directives that may be issued 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, in the May 9, 2002 proposed rule, we 
proposed to revise Sec. 405.1885(b) to make clear that,

[[Page 50097]]

in order to trigger the intermediary's obligation to reopen, our notice 
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 also proposed to clarify Sec. 405.1885 to 
reflect our longstanding interpretation (discussed above) that a change 
of legal interpretation or policy through 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 Secs. 405.1885(a) and (c). We believe the court's decision is 
also inconsistent with our inherent authority to direct the activities 
of our contractor-agents, the fiscal intermediaries, with respect to 
particular reopening matters, just as with any other aspect of program 
administration. Therefore, we proposed, in a new paragraph (e) of 
Sec. 405.1885 (the existing paragraph was 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, we 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.
    We received a number of comments regarding the proposed revisions 
to the reopening rules. The commenters largely opposed the our proposed 
revisions to Sec. 405.1885. Their comments and our responses are as 
follows.
    Comment: A fiscal intermediary asked if CMS was implicitly 
proposing to make all reopening decisions. According to another 
commenter, the proposed rule would enhance CMS' control over the 
reopening process by displacing the intermediary's role as the 
evaluator of the merits of reopening matters.
    Response: The revisions to the reopening regulations are not 
intended to change the usual allocation of responsibilities between CMS 
and the fiscal intermediaries, which leaves most reopening decisions to 
the intermediaries. We are simply clarifying the regulations to reflect 
our longstanding interpretations, not revamping settled reopening 
policies and procedures.
    As the courts have recognized, the reopening regulations are based 
on the Secretary's general rulemaking authority. (See HCA Health Servs. 
of Oklahoma, Inc. v. Shalala, 27 F.3d 614, 618 (D.C. Cir. 1994).) In 
the past, our main role has been to provide general guidance regarding 
the reopening regulations, such as the instructions included in Chapter 
29 of the Medicare Provider Reimbursement Manual, Part 1 (``PRM''). The 
intermediaries have typically decided, without consulting with us, 
whether to reopen specific intermediary determinations or hearing 
decisions in accordance with Secs. 405.1885(a) and (c) and the PRM. Of 
course, our authority to require intermediary reopening has been 
recognized specifically in Sec. 405.1885(b). In certain instances, we 
have directed the intermediaries' reopening actions on a recurring 
reimbursement issue, such as the ``disproportionate share'' issue 
addressed in HCFA Ruling 97-2 (February 27, 1997). On occasion, we have 
instructed an intermediary to reopen a specific matter, such as in 
implementing the settlement of an administrative appeal or a lawsuit.
    The foregoing allocation of responsibilities is not altered by the 
revisions to the reopening regulations. Rather, we are clarifying the 
regulations to comport with our longstanding interpretation that the 
intermediary's duty to reopen a determination or decision under 
Sec. 405.1885(b) arises only if we specifically direct it to reopen in 
order to ensure consistency with a legal provision, as we understood 
such provision when the determination or decision was issued. Moreover, 
revised Sec. 405.1885(e) simply clarifies our interpretation that the 
intermediary's discretion whether to reopen under Secs. 405.1885(a) and 
(c) is subject to CMS' authority to direct the ``original 
jurisdiction'' of its own contractor over reopening matters, as with 
any other area of program administration. Thus, while the 
intermediaries will continue to decide most reopening matters without 
consulting with CMS, Sec. 405.1885(e) reflects our authority to direct 
the intermediaries as we deem necessary and appropriate.
    Comment: Two commenters stated that the reopening process has been 
the province of the intermediary. According to the commenters, the 
proposed changes to Sec. 405.1885(e) would give CMS the sole authority 
to decide reopening matters that were formerly the intermediary's 
responsibility, which would eliminate the discretionary character of 
intermediary reopening decisions. Thus, the commenters concluded, 
intermediary reopening denials would be subject to PRRB and judicial 
review despite the Supreme Court's decision in Your Home Visiting Nurse 
Services, Inc. v. Shalala, 525 U.S. 449 (1999).
    Response: We disagree with the commenters' assertion that the 
proposed revisions to the reopening regulations would affect the 
reviewability of intermediary reopening denials. As discussed above, 
although the intermediaries have typically decided, without consulting 
with CMS, whether to reopen specific intermediary determinations or 
hearing decisions, the contractors' reopening actions have always been 
subject to the general guidance and any particular directives issued by 
CMS. Again, the respective roles of CMS and the intermediaries are 
simply not changed by the revisions to the reopening regulations. Since 
the intermediaries will continue to decide most reopening matters 
without consulting with CMS, reopening decisions will typically reflect 
the usual exercise of the intermediary's unreviewable discretion.
    Although the revisions to the reopening regulations pertain to 
different issues than those resolved by the Supreme Court's Your Home 
Visiting Nurse decision, we believe that the revised regulations are 
consistent with the Court's decision and related precedent. The Supreme 
Court held that an intermediary's rejection of a provider's reopening 
request is not reviewable by the PRRB or the Federal courts. Your Home 
Visiting Nurse Services, Inc. v. Shalala, 525 U.S. at 452-58. The 
revisions to the reopening regulations do not address or affect the 
reviewability of intermediary reopening denials. Rather, the revisions 
clarify our settled policies regarding the intermediary's original 
jurisdiction over the reopening question. Id. at 453. Specifically, the 
revisions to

[[Page 50098]]

Sec. 405.1885(b) clarify our longstanding view that intermediary 
reopening is required only if we specifically mandate reopening in 
order to ensure consistency with a legal provision, as we understood 
such provision when the intermediary determination or decision was 
issued. Furthermore, as proposed, revised Sec. 405.1885(e) clarifies 
our understanding that the intermediary's discretion whether to reopen 
under Secs. 405.1885(a) and (c) is subject to our authority to direct 
the original jurisdiction of our contractor over reopening matters, as 
with any other area of program administration.
    We recognize that the Supreme Court, in rejecting mandamus relief 
in Your Home Visiting Nurse for lack of a ``clear nondiscretionary 
duty,'' reasoned that Sec. 405.1885(a) and PRM section 2931.2 permit 
but do not require reopening. Your Home Visiting Nurse Services, Inc. 
v. Shalala, 525 U.S. at 456-57. (However, we note that intermediary 
discretion did not figure in the Court's rejection of PRRB and Federal 
question jurisdiction over intermediary reopening denials. Id. at 452-
56.) Given that the intermediaries will decide most reopening matters 
without consulting us, as in the past, such decisions will still be 
based on the discretionary provisions of Sec. 405.1885(a) and PRM 
section 2931.2 and thus Your Home Visiting Nurse will be squarely on 
point.
    We believe that a reopening denial is no less discretionary--and 
unreviewable under Your Home Visiting Nurse and related precedent--when 
we mandate the intermediary's action. Notably, in both Monmouth Medical 
Center and Bartlett Memorial Medical Center, the courts rejected PRRB 
and federal question jurisdiction over the prohibition of intermediary 
reopening included in HCFA Ruling 97-2. Monmouth Medical Center v. 
Thompson, 257 F.3d at 810-13; Bartlett Memorial Medical Center. v. 
Thompson, 171 F. Supp. 2d at 1220-22. Mandamus relief was ordered in 
both cases, based on the courts' finding that the Ruling engendered a 
clear nondiscretionary duty to reopen under Sec. 405.1885(b). However, 
the Supreme Court has consistently held that reopening denials are 
``committed to agency discretion by law' within the meaning of the 
Administrative Procedure Act, and hence unreviewable.'' Your Home 
Visiting Nurse Services, Inc. v. Shalala, 525 U.S. at 457 (following 
ICC v. Locomotive Engineers, 482 U.S. 270, 282 (1987)). We believe 
that, under basic principles of agency law, it would be incongruous to 
suppose that reopening denials required by the principal, CMS, are 
somehow less discretionary than denials based on the judgment of our 
agents, the fiscal intermediaries. (See ICC v. Locomotive Engineers, 
482 U.S. at 277B84 (despite statutory authorization of reopening for 
material error, Interstate Commerce Commission's refusal to reopen is 
committed to the agency's unreviewable discretion by law).)
    Comment: A commenter stated that CMS should not restrict 
intermediaries' ability to reopen cost reports when they find it fair 
and appropriate to do so. The commenter explained that, in dealing with 
thousands of providers throughout the country, the intermediaries 
encounter numerous factual scenarios that different contractors might 
treat through varying means. The commenter concluded that, if a statute 
or regulation is ambiguous and CMS has not issued a policy statement on 
an issue, the intermediaries should be free to decide whether to reopen 
the matter and make revisions deemed suitable.
    Response: In the absence of a CMS directive, intermediary reopening 
decisions have been guided by the criteria of ``new and material 
evidence,'' ``clear and obvious error,'' and consistency with a legal 
provision. (See PRM section 2931.2.) The revisions to the reopening 
regulations do not change the PRM guidelines. Instead, revised 
Sec. 405.1885(e) clarifies our settled view that we have full authority 
to direct an intermediary to reopen, or not to reopen, under 
Secs. 405.1885(a) and (c) based on the PRM reopening criteria.
    However, as explained above, the intermediaries will continue to 
decide most reopening matters without consulting with CMS. In cases 
where we have not interpreted a statute or regulation or issued a 
policy statement on a reimbursement issue, the intermediaries will 
typically be free to decide whether to reopen the matter. Although the 
different intermediaries will be guided by the reopening guidelines in 
the PRM, different contractors may reach varying decisions on whether 
to reopen, or how to revise, a determination or decision. The 
traditional flexibility and variability of intermediary reopening 
decisions will not change as a result of the revisions to the reopening 
regulations.
    Comment: A commenter stated that if CMS publishes a policy 
statement clarifying a particular Medicare issue, the intermediaries 
should have the ability to reopen cost reports to ensure that all 
providers are treated uniformly. Another commenter stated that it is 
not reasonable to expect intermediaries to apply rulings retroactively 
in some instances.
    Response: We believe that an important component of a new 
reimbursement policy is the policy's scope of applicability. Given that 
Medicare is a uniform nationwide program, we typically do not leave to 
the discretion of the intermediaries questions about the scope of 
applicability of our reimbursement policy or policy clarification. 
Instead, a CMS regulation or policy guideline on a reimbursement issue 
usually includes an effective date. New reimbursement policies normally 
apply on a prospective-only basis. (See Bowen v. Georgetown University 
Hospital, 488 U.S. 204, 208-16 (1988) (Medicare statute does not permit 
retroactive rulemaking).) The alternative suggested by the commenter, 
of letting the intermediaries determine through reopening the scope of 
applicability of a new CMS reimbursement policy, would undermine the 
interests of nationally uniform program administration. Also, if the 
intermediaries were to reopen and apply a reimbursement policy that was 
not in place when payment was determined originally, such reopenings 
might involve impermissible retroactive rulemaking.
    Comment: A commenter asserted that the proposed revisions to 
Sec. 405.1885(b) would inappropriately expand CMS' authority by 
permitting the agency to order an intermediary to disregard a judicial 
decision holding a policy void ab initio, on the theory that CMS 
understood the disputed legal provision differently when the 
intermediary determination was rendered. Thus, the commenter concluded, 
the proposal violates fundamental principles of separation of powers.
    Response: The revisions to Sec. 405.1885(b) do not expand our 
reopening authority. Rather, revised paragraph (b)(1) clarifies our 
settled interpretation that an intermediary's duty to reopen a 
determination or decision under Sec. 405.1885(b) arises only if we 
specifically direct it to reopen in order to ensure consistency with a 
legal provision, as we understood such provision when the determination 
or decision was issued.
    We did not propose paragraph (b)(1) as a means of sidestepping a 
judicial decision holding a reimbursement policy void ab initio, on the 
theory that we understood the disputed legal provision differently when 
the intermediary determination at issue in the lawsuit was rendered. If 
a provider secures a final, nonappealable judgment rejecting a 
reimbursement policy, we would certainly comply with such a court 
judgment for the provider's fiscal

[[Page 50099]]

period at issue in the lawsuit-- even if we had a different 
understanding of the law when the intermediary determination at issue 
in the case was rendered. Given our compliance with the final, 
nonappealable judicial decision, there clearly would be no separation 
of powers problem.
    The commenter may be assuming that reopening is necessary for the 
implementation of a final, nonappealable judgment. That would be a 
debatable assumption for a number of reasons. For example, we would be 
required to redetermine reimbursement in accordance with a final, 
nonappealable court judgment for the fiscal period at issue in the 
lawsuit, even if the 3-year period for reopening the intermediary 
determination at issue in the case had expired long ago. Also, we often 
implement final adverse judgments and lawsuit settlement agreements 
outside the reopening process. Instead of reopening the reimbursement 
matter and issuing a revised notice of program reimbursement (see 
Secs. 405.1801(a), 405.1803, and 405.1889), we may simply recalculate 
reimbursement in accordance with the final court decision or settlement 
agreement, and issue an implementation notice detailing the 
reimbursement effect of the court judgment or settlement agreement.
    However, the comment does indicate that the proposed rule was 
susceptible to the interpretation that CMS would be precluded from 
requiring the reopening of a particular intermediary determination or 
decision in order to implement a specific final agency decision (see 
Secs. 405.1833, 405.1871(b), 405.1875, and 405.1877(a)); a particular 
final, nonappealable court judgment; or a specific agreement to settle 
an administrative appeal or a lawsuit. In order to allay the 
commenter's concern and make explicit our authority to use reopening 
procedures in such circumstances, as we deem appropriate, we have added 
a new paragraph (b)(3) to proposed Sec. 405.1885(b). Paragraph (b)(3) 
states that notwithstanding paragraph (b)(1)(i) of this section, CMS 
may direct the intermediary to reopen a particular intermediary 
determination or intermediary hearing decision in order to implement, 
for the same intermediary determination or intermediary decision-- (1) 
a final agency decision under Secs. 405.1833, 405.1871(b), 405.1875, or 
405.1877(a); (2) a final nonappealable court judgment; or (3) an 
agreement to settle an administrative appeal or a lawsuit.
    Comment: According to one commenter, the inclusion of the condition 
``as CMS understood those legal provisions, at the time the 
[intermediary] determination or decision was rendered,'' in the 
provisions of Sec. 405.1885(b) for mandatory intermediary reopening 
would give CMS unlimited and standardless discretion whether or not to 
reopen.
    Response: Paragraph (b)(1)(i) does include a guideline for CMS' 
decision whether to require intermediary reopening under 
Sec. 405.1885(b). If an intermediary determination or decision is 
inconsistent with the applicable law, regulations, CMS Ruling, or CMS 
general instructions in effect, as CMS understood such legal provisions 
when the intermediary rendered the determination or decision, then CMS 
may decide to direct the intermediary to reopen and revise the 
determination or decision. However, we are not required to mandate 
intermediary reopening in such cases. Thus, given the Supreme Court's 
decisions in Your Home Visiting Nurse and ICC v. Locomotive Engineers, 
if CMS directs the intermediary to not reopen, our instruction and the 
intermediary reopening denial are committed to the agency s 
unreviewable discretion under the Administrative Procedure Act, 5 
U.S.C. 701(a)(2).
    Moreover, we believe that our longstanding practice of looking to 
the law in effect, as we understood the law, when the intermediary 
determination or decision was rendered, is supported by analogous 
principles followed by the courts. For example, it is settled that `` 
`the legal effect of conduct should ordinarily be assessed under the 
law that existed when the conduct took place.' '' Landgraf v. USI Film 
Products, 511 U.S. 244, 265 (1994) (citation omitted). Also, the courts 
consistently hold that past judicial decisions, even if subsequently 
deemed erroneous, are res judicata and should not be resurrected and 
redecided. (See, Federated Department Stores, Inc. v. Moitie, 452 U.S. 
394, 398 (1981).) Of course, this principle works both ways: if a 
disposition benefiting a claimant becomes final before a contrary 
decision on the same issue in another case, the claimant is not 
required to surrender the benefit despite the intervening change in 
decisional law. (See, Aaron v. Kansas, 115 F.3d 813, 814 n.1 (10th Cir. 
1997).)
    Comment: One commenter asserted that when the courts find a CMS 
policy unlawful, and the agency revises its policy to comport with the 
courts' decisions, providers should be entitled to reopening and 
application of the new policy within applicable time limits. According 
to a hospital system, foreclosing reopening of a matter that was 
settled inconsistently with decisional law would lead to inconsistent 
decisions regarding different providers, and have the agency persist in 
conduct held unlawful by the courts.
    Response: We disagree. As proposed, paragraph (b)(2) clarifies our 
longstanding view that a change of legal interpretation or policy by 
CMS, whether made in response to judicial precedent or otherwise, is 
not a basis for reopening an intermediary determination or decision 
under Sec. 405.1885.
    The prospect of widespread reopening for application of a new legal 
interpretation or policy, whether in response to judicial precedent or 
otherwise, might involve impermissible retroactive rulemaking. (See 
Bowen v. Georgetown University Hospital, 488 U.S. at 208-16.) If we 
were to allow systemic reopening for application of a legal 
interpretation or policy adopted in response to judicial precedent, our 
fiduciary responsibilities for the Medicare trust funds would arguably 
call for similarly widespread reopening when a new legal interpretation 
or policy is not favored by providers. The result might be a spate of 
litigation involving alleged retroactive rulemaking and other complex 
legal issues.
    Furthermore, we have not viewed the reopening process as a ready 
alternative to the mechanism for administrative appeals and judicial 
review established by the Medicare statute and regulations. Under the 
statute (section 1878(a) of the Act) and the regulations 
(Secs. 405.1801(a), 405.1803, and 405.1807), an ``intermediary 
determination'' is, by definition, a ``final determination'' of program 
reimbursement. We believe that, if a provider does not file a timely 
appeal of a final determination on a reimbursement issue, there is no 
right to reopening of that issue in light of judicial decisions in 
other cases on the same issue. Put simply, reopening is not designed 
for the revival of stale claims, Albert Einstein Medical Center. v. 
Sullivan, 830 F. Supp. 846, 850 (E.D. Pa. 1992), aff'd, 6 F.3d 778 (3d 
Cir. 1993), or the addition of new claims. Saint Mary of Nazareth 
Hospital Center. v. Schweiker, 741 F.2d 1447, 1449 (D.C. Cir. 1984).
    In addition, we believe that our longstanding policy of not 
reopening for application of a new legal interpretation or policy, 
whether in response to judicial precedent or otherwise, comports with 
analogous judicial practice. When the Supreme Court decides a legal 
issue, the Court's ``controlling interpretation of federal law'' 
applies to ``all cases still open on

[[Page 50100]]

direct review,'' Harper v. Virginia Department of Taxation, 509 U.S. 
86, 97 (1993), but ``[n]ew legal principles * * * do not apply to cases 
already closed.'' Reynoldsville Casket Co. v. Hyde, 514 U.S. 749, 758 
(1995). Thus, while a provider that files a timely appeal may, if it 
ultimately prevails, be reimbursed differently for an item than 
providers that do not appeal timely, we do not believe that the 
decision in the prevailing provider's case should apply to other 
providers' cost reports that were closed and not appealed timely.
    Our settled reopening policy, clarified in Sec. 405.1885(b)(2), 
also furthers the interests of administrative finality in a program of 
extraordinary magnitude. For example, there were only 37 fiscal 
intermediaries in 1997 as compared to approximately 38,000 
participating providers. Of course, each provider submits an annual 
cost report containing thousands of cost items, any one of which may 
give rise to a reimbursement issue. (See Athens City Hospital, Inc. v. 
Schweiker, 743 F.2d 1, 3 (D.C. Cir. 1984) (detailing cost report 
contents).) We believe it would be unworkable to reopen thousands of 
final, unappealed cost reports each time a judicial decision calls into 
question one of our many reimbursement policies. Indeed, the Supreme 
Court concluded that, ``given the administrative realities we would not 
be shocked by a system in which underpayments could never be the basis 
for reopening'' since the ``few dozen fiscal intermediaries often need 
three years * * * to discover overpayments in the tens of thousands of 
NPRs that they issue, while each * * * sophisticated Medicare-provider 
* * * is generally capable of identifying an underpayment in its own 
NPR within the 180-day time period specified in 42 U.S.C. 
139500(a)(3)'' for an appeal to the PRRB. Your Home Visiting Nurse 
Services, Inc. v. Shalala, 525 U.S. at 455-56. Thus, instead of the 
``persistent'' unlawful conduct suggested by the commenter, we believe 
that our policy of not reopening closed cost reports in response to 
decisions in other cases is essential for maintaining administrative 
finality in a program of extraordinary magnitude that is administered 
with limited resources.
    Comment: A group of health law attorneys recommended that CMS 
propose more elaborate revisions to the reopening regulations. The 
commenter saw the need for an orderly process for the correction of 
factual errors and erroneous interpretations of Medicare law. Also, the 
commenter recommended that Sec. 405.1885(b) be amended so that CMS must 
require intermediary reopening for all providers located in the 
jurisdiction of a court that declares a Medicare policy unlawful. The 
commenter stated that, in light of the Supreme Court's Your Home 
Visiting Nurse decision, Sec. 405.1885(a) should be revised to require 
intermediaries to grant provider requests for reopening to correct 
factual errors and improper application of policy rather than leaving 
the reopening decision to the intermediaries' discretion. According to 
the same commenter, the regulations should also detail the 
circumstances, if any, in which the intermediary may reopen in light of 
a judicial decision or other change in law. In the same vein, a 
different commenter stated that some level of materiality should be 
established so that providers are not confronted with several sets of 
adjustments for various cost reporting years.
    Response: We proposed revisions to the reopening regulations in 
response to the Monmouth Medical Center and Bartlett Memorial Medical 
Center decisions. Our limited purpose was to clarify longstanding 
interpretations of the reopening regulations, which we believe were 
misapprehended by the courts.
    More elaborate revisions to the reopening regulations are beyond 
the scope of the proposed rule. In any event, we believe the reopening 
regulations and related provisions of the PRM provide an orderly 
process for the correction of factual errors and erroneous 
interpretations of the law in effect, as we understood the law, when 
the intermediary determination or decision was rendered. We also 
believe that the reopening criteria prescribed in PRM section 2931.2 
provide the intermediaries with sufficient guidance regarding the 
materiality of a potential reopening and revision to program 
reimbursement.
    In lieu of the commenter's suggestion that we allow reopening for 
application of a judicial decision in another case or for some other 
change in law, we have revised Sec. 405.1885(b) to reflect our 
longstanding practice of not reopening for application of a new legal 
interpretation or policy, whether in response to judicial precedent or 
otherwise. As explained above, we believe this reopening policy avoids 
retroactive rulemaking problems; comports with analogous judicial 
practice and the limited nature of the reopening process; and furthers 
the goals of administrative finality in a program of extraordinary 
magnitude that is administered with limited resources.
    We also do not believe that the Supreme Court's Your Home Visiting 
Nurse decision requires any revision to Sec. 405.1885(a) or any other 
reopening provision. As discussed above, the Court's rejection of PRRB 
and Federal court review of intermediary reopening denials continues 
the ``tradition of nonreviewability * * * [of] refusals to reconsider * 
* * by agencies as by lower courts; * * * another tradition that [the 
Administrative Procedure Act,] 5 U.S.C. 701(a)(2) was meant to 
preserve.'' ICC v. Locomotive Engineers, 482 U.S. at 282. Thus, we 
believe Your Home Visiting Nurse and related precedent apply equally to 
intermediary reopening denials directed by CMS and to denials by the 
intermediary acting alone.
    For the reasons discussed above and although the commenters largely 
opposed our proposed revisions to the reopening provisions, we are 
finalizing these provisions as proposed with a technical change to 
Sec. 405.1885(b)(3).

VI. 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 
hospital 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 inpatient capital-related costs. Beginning in FY 
2002, 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

[[Page 50101]]

Alaska and Hawaii)  x  (1 + DSH Adjustment Factor + IME Adjustment 
Factor, if applicable)
    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, 1991). 
During the 10-year transition period, under Sec. 412.324(b), a new 
hospital was exempt from the 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 
were 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, in the May 9, 
2002 proposed rule (67 FR 31488), we proposed, 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 proposed to 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 stated that we believe this amendment will 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 policy will 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, the new 
hospital exemption will 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 exemption from the capital prospective 
payment system for the first 2 years of operation will 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) will 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 will 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.
    Comment: Three commenters addressed our proposed policy for new 
hospitals after the 10-year transition period for cost reporting 
periods beginning on or after October 1, 2002. One commenter asked 
whether new providers would have the option of electing payment at 100 
percent of the Federal rate for their first 2 years of operation rather 
than the special payment provision of 85 percent of their reasonable 
costs. Another commenter expressed concern about the negative impact 
the proposed policy would have on its facility if the policy were 
applied retroactively, while still another commenter requested that the 
policy be effective for new hospitals with cost reporting periods 
beginning on or after October 1, 2001 rather than October 1, 2002.
    Response: We agree with the commenter's suggestion that new 
hospitals (as defined in Sec. 412.300(b)) should have the option of 
electing payment for their first 2 years of operation through either 
the special payment provision for new hospitals at 85 percent of their 
reasonable costs, or beginning immediately to receive payments based on 
100 percent of the Federal rate. However, the payment method that the 
new hospital selects would remain in effect through the hospital's 
first 2 years of operation; the hospital would not be allowed to revert 
to the alternate payment method. If 100 percent of the Federal rate is 
the payment method selected, the new hospital must make the request to 
the fiscal intermediary in writing by the later of December 1, 2002, or 
within 60 days of the start of the provider's cost reporting period. We 
are revising the regulations at Sec. 412.304(c)(2) to reflect this 
change.

[[Page 50102]]

    While we are making this change effective for cost reporting 
periods beginning on or after October 1, 2002, we are not making this 
change effective for any periods prior to that date because doing so 
would constitute retroactive rulemaking.
    Accordingly, in this final rule, we are adopting as final the 
proposed regulation change at Sec. 412.304(c), with modifications. In 
Sec. 412.304(c)(2)(i), we are specifying that a new hospital is paid 
(1) 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; or (2) if the new hospital elects, 
100 percent of the Federal rate under the capital prospective payment 
system. If the new hospital elects to be paid 100 percent of the 
Federal rate, it must make the request to the fiscal intermediary in 
writing by the later of December 1, 2002, or within 60 days of the 
start of the provider's cost reporting period. We are specifying that 
once a new hospital elects to be paid based on 100 percent of the 
Federal capital prospective payment rate, it may not revert to payment 
at 85 percent of its allowable Medicare inpatient hospital capital-
related costs.

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, in the May 9, 2002 proposed rule (67 FR 31489), 
we proposed 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, beginning on or after October 1, 2001.
    We did not receive any comments on this proposal. Accordingly, we 
are adopting as final the proposed new Sec. 412.312(e).

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, in the May 9, 2002 proposed rule 
(67 FR 31489), we proposed to revise Sec. 412.308(b) to add a new 
paragraph (b)(6) to restore the 2.1 percent reduction to the unadjusted 
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 proposed to restore 
the 2.1 percent reduction for discharges occurring on or after October 
1, 2002, under proposed Sec. 412.308(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.
    We did not receive any comments on this proposal and are, 
therefore, adopting as final the proposed new Sec. 412.308(b)(6).

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) are 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

[[Page 50103]]

questions regarding the current policy at Sec. 412.348(g). Therefore, 
in the May 9, 2002 proposed rule (67 FR 31490), we did not propose any 
changes to the special exceptions policy. However, we did provide 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 will 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.
    We did not receive any comments on this clarification.

VII. 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), 
where applicable, 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 will 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 and then 
multiplying this figure by the number of Medicare discharges. Effective 
for cost reporting periods beginning on or after October 1, 2002, 
rehabilitation hospitals and units are no longer paid on a reasonable 
cost basis but will be paid under the inpatient rehabilitation facility 
prospective payment system. Moreover, we have proposed the 
establishment of a DRG-based prospective payment system for long-term 
care hospitals (LTCHs) (67 FR 13415). As part of this process, we 
proposed a 5-year transition period from reasonable cost-based 
reimbursement to a fully Federal prospective payment system. However, a 
LTCH, subject to the blend methodology, may elect to be paid based on a 
100 percent of the Federal prospective rate. (See sections VII.A.3. and 
4. for a more detailed discussion.)
    Comment: One commenter requested clarification as to whether 
payment to excluded hospitals and units are subject to the TEFRA bonus 
and penalty provisions and continuous improvement bonuses.
    Response: Certain providers that are excluded from the acute care 
hospital inpatient prospective payment system will continue to receive 
bonus/relief payments as well as continuous improvement bonus payments, 
when appropriate, as provided for in Sec. 413.40(d).
    Comment: With regard to the expiration of the caps on target 
amounts for excluded hospitals and units, a commenter requested 
clarification as to how the FY 2003 target rate is to be determined.
    Response: Our regulations at Sec. 413.40(c)(4)(ii) state that ``the 
target amount equals the hospital's target amount for the previous cost 
reporting period, increased by the update factor for the subject cost 
reporting period * * *.'' Thus, for cost reporting periods beginning in 
FY 2003, the hospital or

[[Page 50104]]

unit should use its previous year's target amount, updated by the 
appropriate rate-of-increase percentage.
2. Updated Caps for New Excluded Hospitals and Units
    Section 1886(b)(7) of the Act establishes a payment limitation 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 statute, 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 will 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)(iii)(B)(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 amounts included in the following table reflect the updated 110 
percent of the national median target amounts for each class of new 
excluded hospitals and hospital units for cost reporting periods 
beginning during FY 2003. These figures are updated with the most 
recent data available to reflect the market basket increase percentage 
of 3.5 percent. This 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 CMS's 
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
                                                      labor-   nonlabor-
        Class of excluded hospital or unit           related    related
                                                      share      share
------------------------------------------------------------------------
Psychiatric.......................................    $ 7,054    $ 2,804
Long-Term Care....................................     17,286      6,872
------------------------------------------------------------------------

    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, subject to the blend methodology, 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 
proposed (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 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 
proposed a 5-year transition period from reasonable cost-based 
reimbursement to the fully Federal prospective rate. We also proposed 
that certain long-term care hospitals 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. We are in the process of developing a final rule for 
the long-term care prospective payment system.
5. Changes in the Types of Patients Served or Inpatient Care Services 
That Distort the Comparability of the Cost Reporting Period to the Base 
Year are Grounds for Requesting an Adjustment Payment in Accordance 
with Section 1886(b)(4) of the Act
    Section 4419(b) of Public Law 105-33 requires the Secretary to 
publish annually in the Federal Register a report describing the total 
amount of adjustment (exception) payments made to excluded hospitals 
and units, by reason of section 1886(b)(4) of the Act, during the 
previous fiscal year.

[[Page 50105]]

However, the data on adjustment payments made during the previous 
fiscal year are not available in time to publish a report describing 
the total amount of adjustment payments made to all excluded hospitals 
and units.
    The process of requesting, adjudicating, and awarding an adjustment 
payment for a given cost reporting period is likely to occur over a 2-
year period or longer. First, an excluded hospital or unit must file 
its cost report for a fiscal year with its intermediary within 5 months 
after the close of the fiscal year. The fiscal intermediary then 
reviews the cost report and issues a Notice of Program Reimbursement 
(NPR) in approximately 2 months after the filing of the cost report. If 
the hospital's operating costs are in excess of the ceiling, the 
hospital may file a request for an adjustment payment within 6 months 
from the date of the NPR. The intermediary, or CMS, depending on the 
type of adjustment requested, then reviews the request and determines 
if an adjustment payment is warranted. This determination is often not 
made until more than 6 months after the date the request is filed. 
Therefore, it is not possible to provide data in this final rule on 
adjustments granted for cost reports ending in the previous Federal 
fiscal year (that is, FY 2002), since those adjustments may not have 
been requested by the publication date of this final rule. However, in 
an attempt to provide interested parties with data on the most recent 
adjustments for which we do have data, we are publishing data on 
adjustments that were processed by the fiscal intermediaries or CMS 
during FY 2001.
    The table below includes the most recent data available from the 
fiscal intermediaries and CMS on adjustment payments that were 
adjudicated during FY 2001. As indicated above, the adjustments made 
during FY 2001 only pertain to cost reporting periods ending in years 
prior to FY 2000. Total adjustment payments awarded to excluded 
hospitals and units during FY 2001 are $23,148,456. The table depicts 
for each class of hospital, in the aggregate, the number of adjustment 
requests adjudicated, the excess operating cost over the ceiling, and 
the amount of the adjustment payment.

------------------------------------------------------------------------
                                               Excess cost   Adjustment
        Class of Hospital            Number   over ceiling     payment
------------------------------------------------------------------------
Psychiatric......................         38   $23,211,026   $11,724,665
Rehabilitation...................         16     8,761,312     3,860,336
Long-Term Care...................          3     5,665,211     4,868,889
Children.........................          3     2,696,518     1,043,565
Cancer...........................          2     2,846,386     1,651,001
------------------------------------------------------------------------

6. Technical Correction
    On June 13, 2001, we published in the Federal Register an interim 
final rule (66 FR 32172) implementing section 307(a) of the Medicare, 
Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 
(Public Law 106-554). Section 307(a) provided for a 25-percent increase 
in TEFRA target amounts for long-term care hospitals ``For cost 
reporting periods beginning during FY 2001 * * *.'' When we addressed 
this provision in the interim final rule, we stated the effective date 
correctly in the preamble language. However, in the regulation text, we 
inadvertently used an incorrect effective date. We are making the 
conforming change to reflect the correct date in this final rule.

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 
acute care hospitals in which they are located, but are, in fact, 
organizationally and functionally separate from those hospitals. 
Therefore, in the May 9, 2002 proposed rule, we proposed 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: (1) Not under the authority or control of the governing body or 
chief executive officer of the hospital in which it is located; and (2) 
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 
proposed 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 the satellite facility is not under the

[[Page 50106]]

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.
    Comment: One commenter stated that the use of the word 
``authority'' in the criteria under Sec. 412.25(e) of the proposed rule 
is ambiguous and unnecessary. The commenter expressed concern that the 
term could be construed in a manner that would undercut the ability of 
hospitals to provide necessary services. Therefore, the commenter 
believed that the word ``authority'' should be omitted from the final 
regulations. In addition, the commenter recommended that the most 
practical way to apply hospitalswithinhospitals criteria effectively to 
satellite facilities would be to amend Sec. 412.22(e) to make it apply 
to both types of facilities or to incorporate those criteria by 
reference in proposed Sec. 412.22(h)(2). The commenter believed that 
these revisions would be in keeping with CMS' intent and would result 
in a proper policy of treating hospitals-within-hospitals and satellite 
facilities equitably.
    Response: After a review of the pertinent regulations, we agree 
with the commenter that the word ``authority'' should not be referenced 
in the regulations. We believe that deleting the reference allows for 
consistency between those criteria set forth for satellite facilities 
and those for hospitals-within-hospitals. Accordingly, in this final 
rule, we are revising Secs. 412.22(h)(2)(iii)(A) and 
412.25(e)(2)(iii)(A) to delete the word ``authority'' from the 
criteria.
    However, we do not believe that revising Sec. 412.22(e) to apply to 
both satellite facilities and hospitals-within-hospitals would be 
appropriate. A number of the criteria that apply to hospitals-within-
hospitals would not be applicable to satellite facilities. One example 
is the requirement that the cost of services that the hospital-within-
a-hospital receives from the ``host'' hospital is not more than 15 
percent of the hospital's inpatient operating costs would not be an 
appropriate criterion. This criterion would not be appropriate for 
satellite facilities because the test would not only look at the costs 
incurred by the satellite facility but also at the costs incurred by 
the entire hospital, including both the satellite facility and the main 
hospital. For example, a main hospital has 100 beds and its satellite 
facility has 5 beds located in an acute care hospital. Since costs of 
the entire excluded hospital (at both the main hospital and the 
satellite facility) are reported on one cost report, by only looking at 
the costs that are shared between the satellite facility and the acute 
care hospital, the costs of services that the satellite facility 
receives from its ``host'' hospital will invariably be less than 15 
percent of the costs of the entire hospital, even if all the costs of 
the satellite facility were incurred by the ``host'' hospital.
    Comment: One commenter stated that given that long-term care 
hospitals and rehabilitation hospitals and units are now, or will be 
shortly, paid on prospective basis, the rule limiting the number of 
beds in a satellite facility may no longer be necessary. The commenter 
believed that the rules on hospitals-within-hospitals should be 
adequate to address CMS' concerns about payment advantage. Hence, the 
commenter recommended that the satellite facility rules be eliminated 
because they are no longer necessary and are burdensome.
    Response: We have solicited comments regarding the bed limit for 
satellite facilities in the March 22, 2002 proposed rule to implement 
the long-term care hospital prospective payment system (67 FR 13464-
13465). We will address the commenter's concerns along with any other 
comments received when we issue the final rule for the long-term care 
hospital prospective payment system.

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, in the May 9 proposed rule, we 
proposed 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.
    Comment: Several commenters recommended that the advanced notice 
period for CAHs to elect the all-inclusive billing option be set firmly 
at 30 days rather than allowing the fiscal intermediaries to choose a 
timeframe ranging from 15 days to 60 days. One commenter recommended 
retaining the 60-day notice to fiscal intermediaries. Another commenter 
stated that the implementation of such flexibility could pose problems 
and requested that intermediaries be required to communicate due dates 
effectively to CAHs. The commenters expressed concern that, by allowing 
each intermediary to set the period for advance notice confusion could 
arise, as well as result in different policies could be created across 
the country.

[[Page 50107]]

    Response: We have reviewed the commenters' concerns with regard to 
our proposal to allow the fiscal intermediaries to set the timeframe 
for election of the optional payment method for CAHs. We agree that, by 
allowing this type of flexibility, there exists the possibility of 
confusion between the fiscal intermediaries and the CAHs. In addition, 
we recognize that various policies might be established across the 
country, instead of one national policy. Therefore, we believe that to 
help provide some stability and uniformity to this policy, it would be 
in the best interest of all concerned if a definite period of time is 
set for the CAHs to notify their intermediaries of their decision to 
elect the optional payment method. Accordingly, in light of the 
commenters concerns and input from the intermediaries, we believe that 
a sufficient amount of time for CAHs to notify their fiscal 
intermediaries of an election of the optional payment method is 30 days 
before the beginning of the affected cost reporting period. We believe 
this will give the fiscal intermediaries enough time so that payments 
can be made accurately, avoiding possible delays in, or duplication of, 
payment.
    Accordingly, in this final rule, we are revising 
Sec. 413.70(b)(3)(i) to state that the CAH's election of the optional 
payment method must be made to the fiscal intermediary 30 days prior to 
the start of the affected cost reporting period.
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 the May 9, 
2002 proposed rule, we proposed 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. In addition, 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 can identify 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 proposed in the May 9, 2002 
proposed rule to eliminate the requirement for CAHs to complete an RAI 
believing it to be appropriate and would not jeopardize 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 additional 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 proposed to revise Sec. 485.645 to specify that CAHs are 
required to complete a comprehensive assessment, comprehensive care 
plan, and discharge plan 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).
    Comment: Fifteen commenters fully supported the elimination of the 
requirement that CAHs complete a lengthy patient assessment form for 
swing-bed patients, stating that the completion of the 400 plus 
question comprehensive assessment was an onerous and administrative 
burden, considering the RAI is not used for payment or quality 
purposes.
    Response: We appreciate the commenters' support. As we stated in 
the proposed rule, we believe there are sufficient safeguards in the 
CAH regulations to ensure the health and safety of each swing-bed 
patient in a CAH. The facility would still be required to develop a 
comprehensive care plan for each swing-bed patient that includes 
measurable objectives and a timetable to meet a patient's medical, 
nursing, and psychosocial needs that are identified in an assessment.
    Comment: One commenter disagreed with the elimination of the 
requirement. The commenter stated that CMS' failure to provide the 
basis for its decision to eliminate the RAI for CAHs violates the 
Administrative Procedure Act (APA). Further, the commenter stated that 
removing the RAI requirement would jeopardize quality of care for 
swing-bed patients in CAHs.
    Response: In order to promulgate a substantive rule, the APA 
requires the agency to observe notice-and-comment rulemaking 
procedures, which we have

[[Page 50108]]

done. We believe that in the May 9, 2002 proposed rule, we clearly 
stated the issue and provided rationale for proposing the change.
    Currently, all long-term care facilities are required to collect 
and submit assessment data to the State from the RAI for quality and 
payment purposes. There are no such collection and submission 
requirements for CAHs in the existing Medicare conditions of 
participation. On average, patients stay 10 days in a CAH swing bed. 
However, patients in SNFs have an average length of stay of 
approximately 25 days and patients in a nursing facility stay, on 
average, 230 days in a calendar year. The Medicare RAI assessment 
schedule for SNFs requires that the initial assessment be performed 
during days 1 through 5 of a patient's stay, but may be performed as 
late as days 6 through 8, termed ``grace days'', which gives staff 
additional flexibility in conducting the assessments. The initial 
assessment is used to assign patients to a resource utilization group 
(RUG), the case-mix group classification grouping that is used in 
establishing payments for the first 14 days of care. Subsequently, 
periodic assessments through the patient's stay at a SNF are performed 
to determine the RUG assignment and payment rate.
    We believe that the commenter's concern that the removal of the RAI 
requirement for CAH's would jeopardize quality of care is unfounded. At 
this time, we believe that the quality of care interest in a CAH is 
better served by eliminating a requirement in which a very limited 
staff resource is required to complete a document with 400 plus 
questions for each swing-bed patient and from which data are not 
submitted to CMS, or compared with other facilities. Also, the existing 
requirement for a post-discharge plan of care would address post-
hospital care needs of the patient.
    We emphasize that the focus of the proposed rule was not to make 
major revisions to swing-bed requirements for CAHs. The proposal was to 
only eliminate the use of a specific form, the RAI tool. CAHs would 
still be required to complete comprehensive assessments on their swing-
bed patients.
    Comment: One commenter stated that quality of care measurements for 
swing-beds should be consistent and compatible to the measurement 
system used by nursing homes. The commenter suggested that a quality 
indicators program should be implemented in all facilities with swing 
beds.
    Response: Quality measures currently are not calculated for CAHs 
because there are no data submitted to CMS to calculate. Further, even 
if data were available, the calculation of quality measures requires 
assessments to be conducted on days 5 and 14. The average length of 
stay in a CAH, which is 10 days, is inconsistent with this process.
    CMS plans to develop an assessment tool in the future that will 
have a ``modular format'' whereby a provider with shorter patient stays 
would be able to collect a smaller set of data. In the future, we may 
consider whether or not it is appropriate and feasible to require CAHs 
to use and submit data from this specific format.
    Comment: One commenter stated that there is no monitoring of 
compliance with conditions of participation in any swing beds. The 
commenter stated that surveys are infrequently conducted and when they 
are conducted, they are announced. The commenter also suggested that 
CMS apply the current long-term care transfer rule to all swing beds.
    Response: We acknowledge that the monitoring and survey issues 
addressed by the commenters are important issues. However, the issues 
are outside the purview of this rule. The commenter's concerns will be 
shared with our survey and certification group.

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 policies 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 decision 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 final 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 B to this final 
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. In our May 9, 2002 
proposed rule, we published a list of data files that are available for 
purchase (67 FR 31493 through 31495).

B. Information Collection Requirements

    Under the Paperwork Reduction Act of 1995 (PRA), we are required to 
provide 30-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 evaluate fairly 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.
    The majority of the information collection requirements contained 
in this final rule are currently approved. Section IX.B.1. below lists 
the OMB approval numbers and the current expiration dates for the 
information collection requirements, referenced by specific Parts under 
Title 42 of the Code of Federal Regulations, in this final rule that 
are currently approved.
    In the May 9, 2002 proposed rule, we solicited public comments on 
each of the information collection requirements referenced in the 
proposed rule that are described in section IX.B.2. of this final rule, 
as required under the PRA of 1995.
1. Currently Approved Requirements

[[Page 50109]]



----------------------------------------------------------------------------------------------------------------
     Regulation references in 42 CFR         OMB approval number               Current expiration date
----------------------------------------------------------------------------------------------------------------
Part 412................................  0938-0691                 September 30, 2002.
                                          0938-0050                 May 31, 2004.
                                          0938-0573                 September 30, 2002.
                                                                    October 31, 2003.
                                                                    September 30, 2002.
Part 413................................  0938-0050                 May 31, 2004.
                                          0938-0667                 October 31, 2002.
                                          0938-0477                 July 31, 2005.
----------------------------------------------------------------------------------------------------------------

2. Requirements for Which Public Comment Were Sought in the May 9, 2002 
Proposed Rule

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

Appropriate Wage Data
    As specified in Sec. 412.230, 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 that due to the fact that hospital's 
maintain this data for other business purposes or state reporting 
requirement, or both the burden associated with this requirement is 
exempt from the PRA as stipulated under 5 CFR 1320.3(b)(2) and (b)(3) 
or both.
    In addition, while this regulatory requirement is being added, the 
wage data collection requirement associated with this proposed 
regulatory requirement is currently approved under OMB collection 0938-
0573 (Medicare Geographic Reclassification Review Criteria), with a 
current expiration date of September 30, 2002.

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

Responsibility for Obtaining Provider-Based Determinations
    Under Sec. 413.65, 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 will 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 will be 
required to maintain documentation of the basis for its attestations 
and to make that documentation available to CMS upon request.
    We estimate that the burden associated with these requirements is 
an average of 1.5 hours per provider, for approximately 3,000 providers 
per year, for an annual burden of 4,500 hours. This estimate is based 
on the fact that 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 will 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 
that due to the fact that hospitals maintain this data for other 
business purposes or state reporting requirements or both, the burden 
associated with this requirement is exempt from the PRA as stipulated 
under 5 CFR 1320.3(b)(2) and (b)(3) or both.
    We did not receive any public comments on the proposed information 
collection and recordkeeping requirements. The total burden associated 
with the new and revised requirements referenced in this section are 
4,500 annual hours.
3. New Requirement in This Final Rule

Section 412.304(c)(2)(i)(A) Implementation of the Capital Prospective 
Payment System: Election by New Hospitals To Be Paid Based on 100 
Percent of the Federal Rate

    This section specifies that if a new hospital elects to be paid 
under the capital prospective payment system based on 100 percent of 
the Federal rate, instead of 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, 
the new hospital must submit a written request to the fiscal 
intermediary. This request must be submitted by the later of December 
1, 2002, or 60 days before the beginning of its cost reporting period.
    We estimate that the burden associated with these requirements is 
an average of 1 hour per provider, for approximately 100 providers per 
year, for an annual burden of 100 hours.
    The new information collection and recordkeeping requirements in 
this final rule will be submitted to the Office of Management and 
Budget (OMB) for review under the authority of the PRA. These 
requirements will not be effective until they have been approved by 
OMB.
    If you have any comments on the information collection and 
recordkeeping requirements under Sec. 412.304(c)(2)(i)(A), please mail 
the 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-F, 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.: Brenda Aguilar, CMS Desk Officer, Attn.: CMS-1203-F.

X. Waiver of Proposed Rulemaking

    The Administrative Procedure Act generally requires that agency 
rules be published in the Federal Register as a notice of proposed 
rulemaking with a period for public comment (5 U.S.C. 533(b)). This 
notice-and-comment procedure can be waived, however, if an agency finds 
good cause that the procedure is impracticable, unnecessary, or 
contrary to the public interest and incorporates a statement of the 
finding and its reasons in the rule issued.

A. Technical Correction to Regulations Relating to DSH Adjustment 
Factor

    On June 13, 2001, we Issued in the Federal Register an interim 
final with comment period (66 FR 32172) to

[[Page 50110]]

update the regulations to incorporate the changes made by section 
211(b) of Public Law 106-554. Section 211(b) of Public Law 106-554 
amended section 1886(d)(5)(F)(iv)(III) of the Act to revise the 
calculation of the DSH payment adjustment for hospitals affected by the 
revised thresholds as specified in section 211(a) of Public Law 106-
554. These changes were effective for discharges on or after April 1, 
2001, and no changes were made by section 211(b) for discharges prior 
to April 1, 2001. In the June 13, 2001 interim final rule with comment 
period, we inadvertently changed the adjustment factor for rural 
hospitals with fewer than 100 beds from 4 percent to 5 percent under 
Sec. 412.106(d)(2)(iv)(A) for discharges occurring before April l, 
2001. As indicated in section V.E.3 of this final rule, we are 
correcting this error
    Since this change is being made to correct a technical error, we 
find that the notice-and-comment procedure is unnecessary, and, 
therefore, find good cause to waive the notice of proposed rulemaking 
and issue the correction as final.

B. Technical Correction to Regulations Relating to TEFRA Target Amount 
for Long-Term Care Hospitals

    Also, in the June 13, 2001 interim final rule with comment period 
(66 FR 32172), we implemented section 307(a) of Public Law 106-554. 
Section 307(a) provided for a 25-percent increase in TEFRA target 
amounts for long-term care hospitals ``For cost reporting periods 
beginning during FY 2001 * * * .'' As indicated in section VII.A.6. of 
this preamble, in the June 2001 interim final rule with comment period, 
we stated the effective date correctly in the preamble language, but in 
the regulation text, we inadvertently used an incorrect effective date. 
We are making the conforming change to reflect the correct date in this 
final rule.
    We find it unnecessary to undertake notice-and-comment rulemaking 
with regard to this change because our change merely conforms the 
regulation text to existing policy and provides technical correction to 
the regulations. It does not make any substantive changes to policy. 
Therefore, for good cause, we are waiving the notice-and-comment 
procedure with regard to this change.

C. Technical Corrections Relating to Affiliated Groups

    As discussed in section V.I.3. of this preamble, we are making a 
technical change to the language under the definition of ``affiliated 
group'' under Sec. 413.86(b) under paragraph (2) to reference the use 
of the more recent publications of the Graduate Medical Education 
Directory. Since this change updates a technical reference to an annual 
publication, we find the notice- and comment procedure is unnecessary, 
and therefore find good cause to waive the notice of proposed 
rulemaking and issue the correction as final.
    When we issued the May 9, 2002 proposed rule, due to a 
typographical error, we inadvertently indicated that we proposed to 
make changes to Sec. 413.86(g)(5)(iv) instead of Sec. 413.86(g)(4)(iv) 
to incorporate revised provisions relating to determining the weighted 
number of FTE residents for hospitals that are part of the same 
affiliated group. As a result, we erroneously stated that we proposed 
to add a new paragraph under Sec. 413.86(g)(5)(iv) and to redesignate 
paragraphs (g)(5)(iv), (g)(5)(v), and (g)(5)(vi) and paragraphs 
(g)(5)(v), (g)(5)(vi), and (g)(5)(vii), respectively, to accommodate 
the new paragraph. As discussed in section V.I.3. of this preamble, we 
are correcting these errors in this final rule. Since we are making 
these changes to correct a technical error, we find that the notice-
and-comment procedure is unnecessary and therefore find good cause to 
waive the notice of proposed rulemaking and issue the correction in 
this final 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.

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 485 

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

    For the reasons stated in the preamble of this final rule, 42 CFR 
Chapter IV is 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 must be reopened and revised by the intermediary if, within 
the 3-year period specified in paragraph (a) of this section, 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.
    (3) Notwithstanding paragraph (b)(1)(i) of this section, CMS may 
direct the intermediary to reopen a particular intermediary 
determination or intermediary hearing decision in order to implement, 
for the same intermediary determination or intermediary decision--
    (i) A final agency decision under Secs. 405.1833, 405.1871(b), 
405.1875, or 405.1877(a) of this part;
    (ii) A final nonappealable court judgment; or
    (iii) An agreement to settle an administrative appeal or a lawsuit.
* * * * *
    (e) Notwithstanding 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

[[Page 50111]]

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).
    The revision, republication, and addition read as follows:


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 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 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).
    The revision, republication, and addition read as follows:


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 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 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 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 412.88 is amended by republishing the introductory text 
of paragraph (a) and revising paragraph (a)(1) to read as follows:


Sec. 412.88   Additional payment for new medical service or technology.

    (a) For discharges involving new medical services or technologies 
that meet the criteria specified in Sec. 412.87, Medicare payment will 
be:
    (1) One of the following:
    (i) The full DRG payment (including adjustments for indirect 
medical education and disproportionate share but excluding outlier 
payments);
    (ii) The payment determined under Sec. 412.4(f) for transfer cases;
    (iii) The payment determined under Sec. 412.92(d) for sole 
community hospitals; or
    (iv) The payment determined under Sec. 412.108(c) for Medicare-
dependent hospitals; plus
* * * * *

    8. 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, for purposes of a hospital seeking sole community 
hospital designation, CMS will not consider the nearby hospital to be a 
like hospital if the total inpatient days attributable to units of the 
nearby hospital that provides a level of care characteristic of the 
level of care payable under the acute care hospital inpatient 
prospective payment system are less than or equal to 8 percent of the 
similarly calculated total inpatient days of the hospital seeking sole 
community hospital designation.
* * * * *

    9. Section 412.105 is amended by--
    A. Republishing the introductory text of paragraph (a).
    B. Revising paragraph (a)(1).
    C. Revising paragraph (f)(1)(iii)(A).
    D. Revising paragraph (f)(1)(vi).
    E. Amending the following cross-references 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.

[[Page 50112]]

    iii. In paragraph (f)(1)(ix), the reference ``Sec. 413.86(g)(8)(i) 
and (g)(8)(ii) of the subchapter'' is removed and 
``Sec. 413.86(g)(9)(i) and (g)(9)(ii) of the subchapter'' is added in 
its place; the reference ``Sec. 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 ``Sec. 413.86(g)(8)(i) and (g)(8)(iii)(A) of the subchapter'' 
is removed and ``Sec. 413.86(g)(9)(i) and (g)(9)(iii)(A)'' 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 through 
the end of the first 12-month 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.
* * * * *
    (f) Determining the total number of full-time equivalent residents 
for cost reporting periods beginning on or after July 1, 1991. (1) * * 
*
    (iii)(A) Full-time equivalent status is based on the total time 
necessary to fill a residency slot. No individual may be counted as 
more than one full-time equivalent. If a resident is assigned to more 
than one hospital, the resident counts as a partial full-time 
equivalent based on the proportion of time worked in any areas of the 
hospital listed in paragraph (f)(1)(ii) of this section to the total 
time worked by the resident. A hospital cannot claim the time spent by 
residents training at another hospital. A part-time resident or one 
working in an area of the hospital other than those listed under 
paragraph (f)(1)(ii) of this section (such as a freestanding family 
practice center or an excluded hospital unit) would be counted as a 
partial full-time equivalent based on the proportion of time assigned 
to an area of the hospital listed in paragraph (f)(1)(ii) of this 
section, compared to the total time necessary to fill a full-time 
residency slot.
* * * * *
    (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.
* * * * *


Sec. 412.106  [Amended]

    10. In Sec. 412.106(d)(2)(iv)(A), the phrase ``5 percent'' is 
removed and the phase ``4 percent'' is added in its place.
* * * * *

    11. 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 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.
* * * * *

    12. Section 412.113 is amended by revising paragraphs (c)(2)(i)(D), 
(c)(2)(ii), and (c)(2)(iii) to read as follows:


Sec. 412.113  Other payments.

* * * * *

[[Page 50113]]

    (c) Anesthesia services furnished by hospital employed nonphysician 
anesthetists or obtained under arrangements.
* * * * *
    (2)(i) * * *
    (D) Each qualified nonphysician anesthetist employed by or under 
contract with the hospital or CAH has agreed in writing not to bill on 
a reasonable charge basis for his or her patient care to Medicare 
beneficiaries in that hospital or CAH.
    (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.
* * * * *

    13. 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 hospital's provider number 
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.
* * * * *
    14. Section 412.273 is amended by--
    A. Revising the section heading.
    B. Revising paragraphs (b)(2)(i) and (b)(2)(ii).
    C. Adding a new paragraph (b)(2)(iii).
    D. Redesignating paragraph (d) as paragraph (e).
    E. Adding a new paragraph (d).
    The revisions and additions read as follows:


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).
* * * * *

    15. 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 Secs. 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, unless the new hospital elects to 
be paid under the capital prospective payment system based on 100 
percent of the Federal rate.
    (A) If the new hospital elects to be paid based on 100 percent of 
the Federal rate, the new hospital must submit a written request to the 
fiscal intermediary by the later of December 1, 2002 or 60 days before 
the beginning of its cost reporting period.
    (B) Once a new hospital elects to be paid based on 100 percent of 
the Federal rate, it may not revert to payment at 85 percent of its 
allowable Medicare inpatient hospital capital-related costs.
    (ii) For the third year and subsequent years, the hospital is paid 
based on the Federal rate as described under Sec. 412.312.
* * * * *

    16. 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 determine the Federal rate each year under 
paragraph (c) of this section.
* * * * *

    17. Section 412.312 is amended by adding a new paragraph (e) to 
read as follows:


Sec. 412.312  Payment based on the Federal rate.

* * * * *

[[Page 50114]]

    (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 413.40 is amended by revising paragraph 
(c)(4)(iii)(A)(2) to read as follows:


Sec. 413.40  Ceiling on the rate of increase in hospital inpatient 
costs.

* * * * *
    (c) * * *
    (4) * * *
    (iii) * * *
    (A) * * *
    (2) In the case of long-term care hospitals, for cost reporting 
periods beginning on or after October 1, 2000, the hospital-specific 
target amount is the net allowable costs in a base period increased by 
the applicable update factors multiplied by 1.25.
* * * * *

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


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

    (a) Scope and definitions.--(1) Scope. * * *
    (ii) The determinations of provider-based status for payment 
purposes described in this section are not made as to whether the 
following facilities are provider-based:
* * * * *
    (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.
    (H) Facilities, other than those operating as parts of CAHs, 
furnishing only physical, occupational, or speech therapy to ambulatory 
patients, for as long as the $1,500 annual cap on coverage of physical, 
occupational, or speech therapy, as described in section 1833(g)(2) of 
the Act, remains suspended by the action of subsequent legislation.
* * * * *
    (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).
    (K) Ambulances.
    (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 (n) 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) Procedure for obtaining provider-based determinations. * * *
    (2) If a facility was treated as provider-based in relation to a 
hospital

[[Page 50115]]

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), (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 a determination of 
provider-based status for a facility that is located on the 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 
hospital-based entities described in paragraph (g) of this section. The 
provider seeking such a determination would also be required to 
maintain documentation of the basis for its attestations and to make 
that documentation available to CMS and to CMS contractors upon 
request.
    (ii) If the facility is not located on the campus of the potential 
main provider, the provider seeking a 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.
    (iii) Whenever a provider submits an attestation of provider-based 
status for an on-campus facility or organization, as described in 
paragraph (b)(3)(i) of this section, CMS will send the provider written 
acknowledgment of receipt of the attestation, review the attestation 
for completeness, consistency with the criteria in this section, and 
consistency with information in the possession of CMS at the time the 
attestation is received, and make a determination as to whether the 
facility or organization is provider-based.
    (iv) Whenever a provider submits an attestation of provider-based 
status for an off-campus facility or organization, as described in 
paragraph (b)(3)(ii) of this section, CMS will send the provider 
written acknowledgment of receipt of the attestation, review the 
attestation for completeness, consistency with the criteria in this 
section, consistency with the documentation submitted with the 
attestation and consistency with information in the possession of CMS 
at the time the attestation is received, and make a determination as to 
whether the facility or organization is provider-based.
* * * * *
    (c) Reporting of material changes in relationships. A main provider 
that has had one or more facilities or organizations considered 
provider-based also may report to CMS any material change in the 
relationship between it and any provider-based facility or 
organization, such as a change in ownership of the facility or 
organization or entry into a new or different management contract that 
would affect the provider-based status of the facility or organization.
    (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.

[[Page 50116]]

    (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 
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 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.

[[Page 50117]]

    (f) Provider-based status for joint ventures. In order for a 
facility or organization operated as a joint venture to be considered 
provider-based, the facility or organization must--
    (1) Be partially owned by at least one provider'
    (2) Be located on the main campus of a provider who is a partial 
owner;
    (3) Be provider-based to that one provider whose campus on which 
the facility or organization is located; and
    (4) Also meet all the requirements applicable to all provider-based 
facilities and organizations in paragraph (d) of this section. For 
example, where a provider 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 
provider 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.
    (1) Hospital outpatient departments located either on or off the 
campus of the hospital that is the main provider must comply with the 
antidumping rules in Secs. 489.20 (l), (m), (q), and (r) and 
Sec. 489.24 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 or 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.
    (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. Other than staff that may be paid under such 
a Medicare fee schedule, the main provider may not utilize the services 
of ``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) that are directly involved in the 
delivery of patient care.
    (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 a 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.

[[Page 50118]]

    (3) Notice to provider. If CMS determines that a facility or 
organization was inappropriately treated as provider-based, 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. If CMS determines that a facility or 
organization was inappropriately treated as provider-based, CMS will 
adjust future payments to the provider or the facility or organization, 
or both, to estimate 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 a determination of provider-based status 
for the facility or organization under 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 a 
determination for the facility or organization under 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 a 
determination for the facility or organization under 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 a 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 make a 
determination regarding provider-based status or process the enrollment 
application, as applicable, 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. If a provider submits a 
complete attestation of compliance with the requirements for provider-
based status 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 it submits the attestation and any required supporting 
documentation 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 attestation 
of compliance with provider-based requirements 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 attestation of compliance 
with provider-based requirements is one that includes all information 
needed to permit CMS to make a determination under paragraph (b)(3) of 
this section.
    (l) Correction of errors. (1) If CMS determines that a facility or 
organization that had previously been determined to be provider-based 
under 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 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.
    (2) If CMS determines that a facility or organization that had 
previously been determined to be provider-based under 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 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) Status of Indian Health Service and Tribal facilities and 
organizations.
* * * * *
    (n) FQHCs and ``look alikes.'' * * *
    (o) Effective date of provider-based status.--(1) General rule. 
Provider-based status for a facility or organization is effective on 
the earliest date all of the requirements of this part have been met.
    (2) Inappropriate treatment as provider-based or not reporting 
material change. Effective for any period on or after October 1, 2002 
(or, in the case of facilities or organizations described in paragraph 
(b)(2) of this section, for cost reporting periods starting on or after 
July 1, 2003), if a facility or organization is found by CMS to have 
been inappropriately treated as provider-based under paragraph (j) of 
this section for those periods, or previously was determined by CMS to 
be provider-based but no longer qualifies as provider-based because of 
a material change occurring during those periods that was not reported 
to CMS under paragraph (c) of this section, CMS will not treat the 
facility or organization as provider-based for payment purposes until 
CMS has determined, based on documentation submitted by the provider, 
that the facility or organization meets all requirements for provider-
based status under this part.

    4. 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 fiscal intermediary servicing the CAH at least 30 days 
before the start of each affected cost reporting period. An election of 
this

[[Page 50119]]

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.
* * * * *

    5. Section 413.86 is amended by--
    A. Revising the definition of ``Affiliated group'' under paragraph 
(b).
    B. Adding definitions of ``Affiliation agreement'' and ``Shared 
rotational arrangement'' in alphabetical order under paragraph (b).
    C. Revising the last sentence of paragraph (e)(5)(i), introductory 
text.
    D. Revising paragraph (e)(5)(i)(B).
    E. Adding a new paragraph (e)(5)(i)(C).
    F. Revising paragraph (f)(2).
    G. Republishing the introductory text of paragraph (g)(4) and 
revising paragraph (g)(4)(iv).
    H. Redesignating paragraphs (g)(7) through (g)(12) as paragraphs 
(g)(8) through (g)(13), respectively.
    I. Adding a new paragraph (g)(7).
    J. Amending the following cross-references:
    i. In paragraph (g)(5)(vi), ``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. * * *
    Affiliated group means--
    (1) Two or more hospitals that are located in the same urban or 
rural area (as those terms are defined in Sec. 412.62(f) of this 
subchapter) or in contiguous area and meet the rotation requirement in 
paragraph (g)(7)(ii) of this section.
    (2) Two or more hospitals that are not located in the same or in a 
contiguous urban or rural area, but meet the rotation requirement in 
paragraph (g)(7)(ii) of this section, and are jointly listed--
    (i) As the sponsor, primary clinical site or major participating 
institution for one or more programs as these terms are used in the 
most current publication of the Graduate Medical Education Directory; 
or
    (ii) As the sponsor or is listed under ``affiliations and outside 
rotations'' for one or more programs in operation in Opportunities, 
Directory of Osteopathic Postdoctoral Education Programs.
    (3) Two or more hospitals that are under common ownership and, 
effective for all affiliation agreements beginning July 1, 2003, meet 
the rotation requirement in paragraph (g)(7)(ii) of this section.
    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 GME FTE caps 
in effect prior to the affiliation;
    (3) The total 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;
    (4) The adjustment to each participating hospitals' FTE counts 
resulting from the FTE resident's (or residents') participation in a 
shared rotational arrangement at each hospital participating in the 
affiliated group for each year the affiliation agreement is in effect. 
This adjustment to each participating hospital's FTE count is also 
reflected in the total adjustment to each hospital's FTE caps (in 
accordance with paragraph (3) of this definition); and
    (5) The names of the participating hospitals and their Medicare 
provider numbers.
* * * * *
    Shared rotational arrangement means a residency training program 
under which a resident(s) participates in training at two or more 
hospitals in that program.
    (e) Determining per resident amounts for the base period.
    (5) Exceptions--(i) Base period for certain hospitals. * * * The 
per 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 
updated 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.
* * * * *
    (f) Determining the weighted number of FTE residents. * * *
    (2) No individual may be counted as more than one FTE. A hospital 
cannot claim the time spent by residents training at another hospital. 
Except as provided in paragraphs (f)(3) and (f)(4) of this section, if 
a resident spends time in more than one hospital or in a nonprovider 
setting, the resident counts as partial FTE based on the proportion of 
time worked at the hospital to the total time worked. A part-time 
resident counts as a partial FTE based on the proportion of allowable 
time worked compared to the total time necessary to fill a full-time 
internship or residency slot.
* * * * *
    (g) Determining the weighted number of FTE residents. * * *

[[Page 50120]]

    (4) 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) Each hospital in the affiliated group must have a shared 
rotational arrangement, as defined in paragraph (b) of this section, 
with at least one other hospital within the affiliated group, and all 
of the hospitals within the affiliated group must be connected by a 
series of such shared rotational arrangements.
    (iii) During the shared rotational arrangements under an 
affiliation agreement, as defined in paragraph (b) of this section, 
more than one of the hospitals in the affiliated group must count the 
proportionate amount of the time spent by the resident(s) in its FTE 
resident counts. No resident may be counted in the aggregate as more 
than one FTE.
    (iv) The net effect of the adjustments (positive or negative) on 
the affiliated hospitals' aggregate FTE cap for each affiliation 
agreement must not exceed zero.
    (v) 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 485--CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS

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

    Authority: Secs. 1102 and 1871 of the Act (42 U.S.C. 1302 and 
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).
* * * * *
(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare-- Hospital Insurance)

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

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

Addendum--Schedule of Standardized Amounts Effective With 
Discharges Occurring On or After October 1, 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 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 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. MDHs do not have the 
option to use their FY 1996 hospital-specific rate.
    For hospitals in Puerto Rico, the payment per discharge is based 
on the sum of 50 percent of a Puerto Rico rate and 50 percent of a 
Federal national rate. (See section II.D.3. of this Addendum for a 
complete description.)
    As discussed below in section II. of this Addendum, we are 
making changes in the determination of the prospective payment rates 
for Medicare inpatient operating costs for FY 2003. The changes, to 
be applied prospectively effective with discharges occurring on or 
after October 1, 2002, affect the calculation of the Federal rates. 
In section III. of this Addendum, we discuss our changes for 
determining the prospective payment rates for Medicare inpatient 
capital-related costs for FY 2003. Section IV. of this Addendum sets 
forth our 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 in section V. of this Addendum.

II. 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 standardized amounts set forth in Tables 1A and 
1C of section V. of this Addendum reflect--
     Updates of 2.95 percent for all areas (that is, the 
market basket percentage increase of 3.5 percent minus 0.55 
percentage points);
     An adjustment to ensure the 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

[[Page 50121]]

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 final rule, we are not revising 
the labor share of the standardized amount (the proportion adjusted 
by the wage index). The average labor share in Puerto Rico is 71.3 
percent. We are revising 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 Average Standardized Amounts

    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. In 
accordance with section 1886(b)(3)(B)(i) of the Act, the large urban 
average standardized amount is 1.6 percent higher than the other 
area average standardized amount.
    Section 1886(d)(2)(D) of the Act defines ``urban area'' as those 
areas within a Metropolitan Statistical Area (MSA). A ``large urban 
area'' is defined as an urban area with a population of more than 1 
million. In addition, section 4009(i) of Public Law 100-203 provides 
that a New England County Metropolitan Area (NECMA) with a 
population of more than 970,000 is classified as a large urban area. 
As required by section 1886(d)(2)(D) of the Act, population size is 
determined by the Secretary based on the latest population data 
published by the Bureau of the Census. Urban areas that do not meet 
the definition of a ``large urban area'' are referred to as ``other 
urban areas.'' Areas that are not included in MSAs are considered 
``rural areas'' under section 1886(d)(2)(D) of the Act. Payment for 
discharges from hospitals located in large urban areas will be based 
on the large urban standardized amount. Payment for discharges from 
hospitals located in other urban and rural areas will be based on 
the other standardized amount.
    Based on 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 updating 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 3.5 percent. Thus, for FY 
2003, the update to the average standardized amounts equals 2.95 
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.
    We do not remove the prior budget neutrality adjustment because, 
in accordance with section 1886(d)(4)(C)(iii) of the Act, 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.
    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. We have included our final 
recommendation on the update factors (which is required by sections 
1886(e)(4)(A) and (e)(5)(A) of the Act) in Appendix B to this final 
rule.

4. Other Adjustments to the Average Standardized Amounts

a. Recalibration of DRG Weights and Updated Wage Index--Budget 
Neutrality Adjustment

    Section 1886(d)(4)(C)(iii) of the Act specifies that, beginning 
in FY 1991, the annual DRG reclassification and recalibration of the 
relative weights must be made in a manner that ensures that 
aggregate payments to hospitals are not affected. As discussed in 
section II. of the preamble, we normalized the recalibrated DRG 
weights by an adjustment factor, so that the average case weight 
after recalibration is equal to the average case weight prior to 
recalibration. 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 making 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.
    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.
    In addition, we are required to ensure that any add-on payments 
for new technology under section 1886(d)(5)(K) of the Act are budget 
neutral. As discussed in section II.D. of this final rule, we are 
approving one new technology for add-on payments in FY 2003. We 
estimate that the total add-on payments for this new technology will 
be $74.8 million.
    To comply with the requirement of section 1886(d)(4)(C)(iii) of 
the Act that DRG

[[Page 50122]]

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 FY 2003 relative weights and wage index, plus the 
additional add-on payments for the new technology. The same 
methodology was used for the FY 2002 budget neutrality adjustment, 
except for the new technology add-on budget neutrality adjustment. 
Based on this comparison, we computed a budget neutrality adjustment 
factor equal to 0.993209. We also adjust the Puerto Rico-specific 
standardized amounts for the effect of DRG reclassification and 
recalibration. We computed a budget neutrality adjustment factor for 
Puerto Rico-specific standardized amounts equal to 0.994027. These 
budget neutrality adjustment factors are applied to the standardized 
amounts without removing the effects of the FY 2002 budget 
neutrality adjustments.
    In addition, we will 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).)
    Comment: One commenter questioned this budget neutrality 
calculation in the proposed rule and pointed out that the total 
numbers of cases in Table 7A, showing FY 2001 MedPAR records 
assigned to version 19 GROUPER DRGs, was different than the total 
number of cases in Table 7B, which shows FY 2001 MedPAR records 
assigned to version 20 GROUPER DRGs. The commenter noted that a 
similar discrepancy occurred in the FY 2002 final rule, yet there 
has been no discrepancy in the past. Based on the discrepancy in 
total cases, the commenter was concerned that the budget neutrality 
calculation may be incorrect.
    Response: The commenter correctly points out a discrepancy in 
the source files used to produce Tables 7A and 7B for the FY 2002 
final rule and the FY 2003 proposed rule. We have corrected this 
discrepancy in this final rule. The source of the discrepancy was 
the removal of statistical outliers for DRG recalibration. 
Statistical outliers are defined as cases with charges per case and 
charges per day beyond 3 standard deviations from the DRG mean. In 
the proposed rule, Table 7A had statistical outliers removed based 
on the GROUPER version 19 DRG assignment, and Table 7B had 
statistical outliers removed based on the GROUPER version 20 DRG 
assignment. In this final rule, we have removed only statistical 
outliers based on version 20 DRG assignment from both Table 7A and 
Table 7B.
    This discrepancy did not affect the budget neutrality 
calculation, however. This calculation uses only cases remaining 
after trimming statistical outliers based on GROUPER version 20 DRG 
assignment. Payments for these remaining cases are then compared 
using first their version 19 GROUPER DRG assignment, then their 
version 20 DRG assignment.

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 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 an 
adjustment factor of 0.991095 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 FY 2003 adjustment reflects FY 
2003 wage index and standardized amount reclassifications approved 
by the MGCRB or the Administrator, and the effects of section 
1886(d)(10)(D)(v) of the Act to extend wage index reclassifications 
for 3 years.

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. To qualify for outlier 
payments, a case must have costs above a fixed loss cost threshold 
amount. To determine whether the costs of a case exceed the fixed 
loss 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 the average standardized amounts by a factor to account for 
the estimated proportion of total DRG payments made to outlier 
cases. Similarly, section 1886(d)(9)(B)(iv) of the Act requires the 
Secretary to reduce the average 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 fixed loss cost thresholds. For FY 2002, the 
threshold is equal to the prospective payment rate for the DRG, plus 
any IME and DSH payments plus $21,025. The marginal cost factor (the 
percent of costs paid after costs for the case exceed the threshold) 
is 80 percent.
    For FY 2003, we proposed 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 for cases to 
qualify for both operating and capital outlier payments. We proposed 
to maintain the marginal cost factor at 80 percent.
    To calculate the FY 2003 outlier thresholds, we simulated 
payments by applying FY 2003 rates and policies to the March 2002 
update of the FY 2001 MedPAR file and the March 2002 update of the 
Provider-Specific File. Therefore, it was necessary to inflate the 
charges on the MedPAR claims by 2 years, from FY 2001 to FY 2003, in 
order to determine the appropriate FY 2003 thresholds.
    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 the 
proposed rule, the FY 2000 cost reports were not available to 
produce an updated cost inflation factor due to processing delays 
associated with implementing the hospital outpatient prospective 
payment system.
    As discussed in the May 9, 2002 proposed rule, 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 
proposed to use a 3-year moving average of the rate of change in 
costs for prior years to estimate the annual rates of inflation from 
FY 2001 to FY 2003. The calculation was discussed thoroughly in the 
proposed rule (67 FR 31510).
    Based on this methodology, we proposed 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.
    We pointed out that, using actual FY 2001 cases, our analysis 
indicated 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.
    Comment: Several commenters stated that the proposed 59 percent 
increase in the outlier threshold is an enormous increase based on 
old data and a new methodology, and as a result, puts hospitals at 
even greater risk for high-cost cases. One commenter wrote that this 
type of unpredictability makes sound management difficult.
    The commenters also believed that the proposed outlier policy, 
if implemented in a budget neutral manner, has the effect of 
reducing hospital payments by 1.87 percent, nearly wiping out any 
inflationary increase paid through the market basket increase.The 
commenters stated that, without more recent data and better 
rationale, the outlier threshold should remain unchanged at the FY 
2002 level of $21,025.

[[Page 50123]]

    Response: Our objective in setting the outlier threshold is to 
set it at a level that is projected to result in outlier payments 
during the upcoming Federal fiscal year that are equal to 5.1 
percent of operating DRG payments. In accordance with section 
1886(d)(3)(B) of the Act, we reduce the standardized amounts by 5.1 
percent to account for the projected 5.1 percent paid to outliers. 
This adjustment is intended to ensure that outlier payments are 
budget neutral: Total payments after making outlier payments are 
equal to what total payments would have been without making any 
outlier payments. Therefore, if our projections of outlier payments 
are perfectly accurate, there is no net change in total hospital 
payments related to outlier policy.
    We believe the reference to reducing hospital payments by 1.87 
percent relates to the fact that, for FY 2002, outlier payments will 
be greater than 5.1 percent of total DRG payments, and if outlier 
payments are projected to equal 5.1 percent of total DRG payments in 
FY 2003, hospitals will not receive the additional payments they 
otherwise would if outlier payments exceeded 5.1 percent. The 
statute requires that the outlier offset to the average standardized 
amounts equal the projected proportion of outlier payments relative 
to total operating DRG payments. Therefore, if we offset the average 
standardized amounts by 5.1 percent to account for outlier payments, 
we must set the outlier threshold at a level we project will result 
in outlier payments equal to 5.1 percent of total operating DRG 
payments.
    Moreover, we believe that in order to maintain the fiscal 
integrity of the Medicare Trust Fund, we must set the FY 2003 
outlier threshold so that, based on our best estimate, the 
proportion of FY 2003 outlier payments relative to total DRG 
payments is projected to equal the offset of the average 
standardized amounts.
    As discussed in further detail below, we now estimate FY 2002 
outlier payments to be 6.9 percent of total DRG payments, using the 
FY 2002 threshold of $21,025. Therefore, we estimate that we will be 
paying approximately $1.5 billion more in outlier payments during FY 
2002 than we would have if our outlier projections had been 
perfectly accurate (outlier payments 1.9 percentage points higher 
relative to total DRG payments of approximately $76 billion). The 
table below demonstrates that actual outlier payments since 1997 
have exceeded the 5.1 percent offset by an aggregate of 11.2 
percentage points, equating with approximately $8.5 billion in 
higher than anticipated payments. However, analysis over a longer 
time period demonstrates that years in which CMS has paid more than 
projected in outlier payments are offset by years in which CMS has 
paid less than projected.

------------------------------------------------------------------------
                                                             Payments in
                                                              excess of
                                                             5.1 percent
                            Year
                                                             (percentage
                                                               points)
------------------------------------------------------------------------
1997.......................................................          0.4
1998.......................................................          1.4
1999.......................................................          2.5
2000.......................................................          2.5
2001.......................................................          2.6
2002.......................................................          1.8
------------------------------------------------------------------------

    Based on available information (which was not available at the 
time we set the FY 2003 outlier thresholds), we now estimate that an 
outlier threshold of $30,525 would have resulted in outlier payments 
equal to 5.1 percent of total DRG payments for FY 2002. Therefore, 
barring any drastic reductions in hospital charges per case, 
maintaining the FY 2003 fixed loss outlier threshold at $21,025, 
while offsetting the standardized amount by only 5.1 percent, would 
almost certainly guarantee that FY 2003 total payments after outlier 
payments and the offset would exceed what total payments would have 
been without making any outlier payments or offset.
    Comment: Numerous commenters added that the proposed methodology 
for determining the estimate of cost inflation is flawed and, as a 
result, the new threshold is too high. The commenters expressed 
concern that increasing the threshold too fast will seriously 
undermine hospitals' ability to continue to care for high-cost frail 
and elderly patients.
    The commenters stated that the proposed 2-year cost inflation 
factor of 15.0 percent from FY 2001 to FY 2003 is more than triple 
the rate of change of cost inflation in FY 1999. The commenters also 
stated that this increase is also markedly different and 
significantly higher than all other government projections of cost 
inflation. For instance, they pointed out that, in its March 2002 
report, MedPAC measured hospital cost inflation at 4.8 percent for 
the time period FY 2001 to FY 2003; the Office of Management and 
Budget has projected cost inflation for the overall economy at a 
rate of 2.2 percent for FY 2003; and CMS' market basket for that 
time period is a 6.6 percent increase.
    Several commenters focused on the fact that, rather than 
proposing to calculate the inflation factor based on an annual rate 
of change, we proposed to calculate it using the difference in the 
annual rate of change (second derivative). The commenters submitted 
analysis indicating this proposed methodology was more volatile in 
its estimates than alternative approaches. In addition, the 
commenters stated that our data were outdated and therefore 
unreliable.
    The commenters proposed using one of three alternatives:
     Three-year moving average of annual rates of change in 
costs rather than a 3-year average of the differences in the annual 
rates of change in costs (as proposed). The projected increase in 
hospital cost inflation from FY 2001 to FY 2003 using this method 
would be 4.1 percent.
     CMS' usual method in predicting cost inflation, but 
substituting a 4-year lag in data rather than the typical 3-year lag 
due to the lack of FY 2000 cost reports. The projected increase in 
hospital cost inflation from FY 2001 to FY 2003 would be 4.8 
percent.
     Changes as measured in the hospital market basket 
index. The projected increase in hospital cost inflation from FY 
2001 to FY 2003 would be 7.1 percent.
    The commenters stated that the alternative that most closely 
approximates CMS' usual method is the 4-year lag approach. The 
commenters also recognized that the simulations of the market basket 
index approach they submitted tracks most closely with actual cost 
increases. The commenters stated that this method would result in a 
new outlier threshold between $26,254 and $27,810, which the 
commenters believe is a much more realistic increase.
    One commenter noted that determining the outlier threshold is 
dependent not only on changes in costs per case, but is also 
dependent on hospital charges and cost-to-charge ratios.
    Response: Our proposed methodology took into account that the 
most recent cost data we had available was approximately 3 years old 
by including a factor to measure the rate of growth in the annual 
change in costs per case. Using data from hospitals' cost reports, 
we calculated average annual rates of change to project cost growth 
from FYs 1999 through 2003. We believe this approach was preferable 
to a simple average rate of change when projecting over a 4-year 
time span because, by including a factor to measure the rate of 
change we account for the observed trend in cost growth over recent 
periods. We do not dispute that this methodology results in 
inflation factors higher than other estimates, including the market 
basket used to update the acute inpatient prospective payment 
system. However, we point out that our analysis in the proposed rule 
showed that, if this methodology had been used to estimate the 
threshold for FY 2002, it would have resulted in FY 2002 outlier 
payments much closer to 5.1 percent of total DRG payments than we 
are currently estimating (67 FR 31510).
    Nevertheless, we understand the commenters' concerns that our 
methodology to estimate cost inflation for purposes of setting the 
outlier threshold is much higher than other, more established 
methodologies and we considered the alternatives suggested by the 
commenters. Each of the three alternative are based on projecting 
cost increases.
    As noted above, commenters indicated they believe a FY 2003 
threshold between $26,254 and $27,810 would be realistic. However, 
we believe, based on our analysis of MedPAR data, that this 
threshold would be significantly inaccurate. To illustrate, we used 
actual MedPAR data for the past 2.5 years to determine what 
thresholds would have resulted in a 5.1 percent outlier payout for 
FYs 2000, 2001 and 2002.

[[Page 50124]]



----------------------------------------------------------------------------------------------------------------
                                                                                  Threshold that
                                                                     Threshold      would have     Actual payout
                           Fiscal year                               actually      paid out 5.1     percentage
                                                                      applied         percent
----------------------------------------------------------------------------------------------------------------
2000............................................................         $14,050         $21,825             7.6
2001............................................................          17,550          26,200             7.7
2002 *..........................................................          21,025        30,525 *            6.9
----------------------------------------------------------------------------------------------------------------
 *Using March 2002 Update of Fiscal Year 2002 MedPAR Cases.

    This table shows that, had we set the threshold each of the last 
3 fiscal years at a level that would have paid out 5.1 percent based 
on data now available, the FY 2002 threshold would have actually 
been $30,525. Based on this analysis, we believe a threshold of no 
more than $27,810, as suggested by the commenters, would be likely 
to result in payments in excess of 5.1 percent.
    Outlier payments are determined by multiple variables that 
change at different rates over time. As described above, to 
determine whether a case qualifies as an outlier, the hospital's 
cost-to-charge ratio is applied to the covered charges (which are 
adjusted for the area wage index applicable to the area where the 
hospital is located) of a case to estimate the costs. The estimated 
costs for the case are then compared to the outlier threshold to 
determine whether the case qualifies for outlier payments.
    Based on our analysis above, we believe that, due to current 
trends in hospital charging practices, using inflation factors based 
on annual cost growth results in underestimating the percentage of 
outlier payments. That is, if charges are growing at a faster rate 
than costs, inflating FY 2001 charges by the observed rate of change 
in costs will underestimate FY 2003 charges, thereby resulting in 
outlier payments greater than 5.1 percent. Therefore, we analyzed 
the rate of change in covered charges per case over the past 3 
years. Because charge data are available from claims data in the 
MedPAR file, they are more up-to-date than cost data taken from the 
cost reports.

------------------------------------------------------------------------
                                                            Percentage
                   FY                     Covered charge/    change in
                                               case         charge/case
------------------------------------------------------------------------
1999....................................         $15,215  ..............
2000....................................          16,376            7.63
2001....................................          18,015           10.00
------------------------------------------------------------------------

    This table illustrates the substantial increase recently in the 
growth of charges, indicating that charges have indeed been 
increasing faster than costs. Because charges serve as the basis to 
estimate costs for purposes of identifying outlier cases, higher 
than expected increases in charges would lead to more cases 
qualifying for outlier payments than expected (and more of the costs 
of qualifying cases in excess of the threshold).
    Over time, cost-to-charge ratios will reflect the differential 
increase in charges. However, due to the delay in processing the FY 
2000 cost reports, combined with the dramatically different rates of 
change in charges and costs, we believe it is appropriate, at least 
as far as determining the outlier thresholds for FY 2003, to change 
from our past methodology of basing the inflation factor on the rate 
of change in costs, and instead rely on the rate of change in 
charges. Therefore, we are not adopting our proposed methodology.
    Instead, we have determined that, for purposes of setting a FY 
2003 outlier threshold that we project will result in outlier 
payments of 5.1 percent of total DRG payments, the most appropriate 
methodology to use is to inflate charges using a 2-year average 
annual rate of change in charges per case. The 2-year average annual 
rate of change in charges per case from FY 1999 to FY 2000, and from 
FY 2000 to FY 2001, is 8.8199 percent annually, or 17.6398 percent 
over 2 years. Applying this charge inflation factor to FY 2001 cases 
results in a fixed loss outlier threshold of $33,560.
    We believe inflating charges by the 2-year average annual rate 
of change in charges per case is an appropriate revision to our 
prior inflation methodology used to set the threshold. That is, our 
analysis described above indicates that a 2-year average annual rate 
of change based on charges results in a threshold that is more 
consistent with what our analysis indicates recent thresholds would 
have resulted in actual outlier payments approximating 5.1 percent 
of actual total operating DRG payments. In addition, our analysis 
above demonstrates that charges have been growing at a much faster 
rate than recent estimates of cost growth, indicating that the 
average rate of change in charges will produce a more appropriate 
inflation factor at this time. We have selected a 2-year average 
rate of change in charges (from FY 1999 to FY 2000 and from FY 2000 
to FY 2001) rather than simply a 1-year rate of change in order to 
account for the greater variability of charges (due to the fact that 
hospitals have greater latitude in setting their charges than they 
do over their costs). We would point out that this analysis is based 
on recent data and does not reflect upon previous analysis used to 
support the use of cost inflation factors used in the Medicare cost 
reports.
    Using this revised methodology for setting the charge inflation 
factors for FY 2003, we are establishing 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 $33,560. This single threshold would be applicable 
to qualify for both operating and capital outlier payments. We are 
also maintaining the marginal cost factor for cost outliers at 80 
percent.
    Comment: Two commenters recommended that we increase the FY 2002 
threshold by the market basket inflation factor, then develop a new 
threshold using our previous cost inflation methodology when FY 2000 
cost reports come available later this year.
    Response: Based on our analysis of where prior years' thresholds 
would have been set if we knew at the time we set the thresholds 
what we know now, and our analysis showing the higher rate of change 
in charges than in costs, we are revising our methodology to 
establish the FY 2003 outlier thresholds to reflect the rate of 
change in charges. We believe this will establish the thresholds at 
an appropriate level using more recent data. Therefore, we are not 
accepting the commenters' recommendation.
    Comment: Some commenters predicted that, as a result of the 
large increase in the threshold from FY 2002, outlier payments would 
fall well below 5.1 percent.
    Response: We have taken the commenters' concerns and our further 
analysis into account in our methodology to set the FY 2003 
threshold. Based on our analysis as described above, we disagree 
with the commenters' prediction.
    Comment: One commenter attributed the high percentage of outlier 
payments relative to DRG payments to the increasing costs of medical 
technology, for which the commenter argued that there is no 
effective payment solution.
    Response: Our analysis indicates the higher than estimated 
outlier payments are attributable to charges rising faster than our 
inflation estimates. This may be associated with increasing costs 
and utilization of medical technology, as the commenter suggested. 
This effect would eventually be reflected in the DRG weights and the 
market basket estimate.
    However, we would point out that our analysis above indicates 
that charges are rising much faster than costs. This would indicate 
that costs estimated by applying cost-to-charge ratios from past 
periods to charges from current periods would result in estimated 
costs in excess of actual costs. Therefore, we disagree that rising 
costs due to new technology is the reason outlier payments have been 
higher than projected.
    Comment: Some commenters argued that the delay in processing 
cost reports is interrupting the gradually declining trend in cost-
to-charge ratios, leading to higher cost estimates than anticipated.
    Response: Our analysis shows that, despite the delay in 
processing cost reports alluded to above, the average cost-to-charge 
ratios have continued to decline. We note there is always a lag 
between the timeframe from which the cost-to-charge ratios are taken 
and the period to which they are applied to charges. We do not have 
any evidence that the higher than expected outlier payments result 
from any extra lag in updating cost-to-

[[Page 50125]]

charge ratios due to the delay in processing the cost reports.
    Comment: Some commenters referenced a joint letter from CMS' 
Center for Medicare Management, Office of Financial Management, 
issued April 22, 2002, on the issue of the correct calculation of 
hospital cost-to-charge ratios, as indicative of potential erroneous 
cost-to-charge ratios influencing the calculation of the outlier 
threshold.
    Response: The joint letter clarified instructions to all fiscal 
intermediaries on calculating the cost-to-charge ratios in response 
to isolated instances where we were made aware they had been 
calculated incorrectly. We have examined the cost-to-charge ratios 
and do not believe the issue addressed in the joint letter is 
systemic, and therefore, it should not materially affect our outlier 
threshold calculations.
    Comment: One commenter recommended increasing the estimated 
outlier payment percentage from 5.1 percent to 6.0 percent, the 
upper bound permissible under the statute. The commenter believed 
the proposed outlier change would cause an inequitable 
redistribution and that increasing the outlier target would address 
this inequity.
    Response: Although reducing the outlier threshold would result 
in a higher outlier payout, and we have authority under section 
1886(d)(5)(A)(iv) of the Act to set an outlier target of up to 6.0 
percent, we do not believe this approach would be appropriate. As 
noted previously, section 1886(d)(3)(B) of the Act requires the 
Secretary to reduce the average standardized amounts by the 
projected proportion of total DRG payments made to outlier cases. 
Therefore, adopting this suggestion would result in lower 
standardized amounts for all cases, reducing payments for hospitals 
that do not generally receive as high a proportion of outlier 
payments as other hospitals as a result of the lower standardized 
amount. These low-outlier hospitals would be negatively impacted by 
reducing the standardized amount without the benefit of continued 
high outlier payments.
    Comment: Commenters also suggested reducing the marginal cost 
factor below 80 percent. One commenter suggested raising the 
marginal cost factor from 80 percent to 90 percent. This commenter 
stated such a change would redistribute the negative impact of 
increasing the threshold in a more equitable manner.
    Response: Reducing the marginal cost factor would result in a 
lower outlier threshold (so more cases would qualify for outlier 
payments) but would also result in lower outlier payments per 
outlier case. While we considered this approach to alleviate the 
impact of the proposed increase in the outlier threshold, we decided 
not to adopt it without further analysis (the commenter presented no 
assessment of the impacts of such a change, for example). We note 
that the current 80 percent marginal cost factor was established for 
FY 1994 (from 75 percent) to further focus Medicare's cost outlier 
payments on the costliest cases (59 FR 45367). This change was 
consistent with a recommendation by the Prospective Payment 
Assessment Commission (MedPAC's predecessor) based on its analysis 
of outlier policy. We believe it would be necessary to conduct 
further analysis of the impacts of changing the marginal cost factor 
before making such a change in the marginal cost factor. Conversely, 
increasing the marginal cost factor would result in either raising 
the outlier threshold (which means fewer cases would qualify for 
outlier payments) or raising the offset to the standardized amount, 
or both. We believe that an 80 percent marginal cost factor and 5.1 
percent outlier target appropriately target payments to extremely 
high cost cases and, at the same time, provide adequate compensation 
to nonoutlier cases.
    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 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 thresholds for FY 2003 
will 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 were as follows:

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

    Based on simulations of payments using updated data, the final 
outlier adjustment factors applied to the standardized amounts for 
FY 2003 are as follows:

------------------------------------------------------------------------
                                             Operating
                                           standardized       Capital
                                              amounts      federal rate
------------------------------------------------------------------------
National................................        0.948999        0.946924
Puerto Rico.............................        0.981651        0.979669
------------------------------------------------------------------------

    As in the proposed rule, 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 0.194 or greater than 
1.258, or capital cost-to-charge ratios lower than 0.012 or greater 
than 0.163, 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 
updated 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 replace the 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 will 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 ranges noted above.
---------------------------------------------------------------------------

    \1\ This range represents 3.0 standard devitations (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 7.7 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 currently estimate that actual outlier payments for FY 2002 
will be approximately 6.9 percent of actual total DRG payments, 1.8 
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 March 2001 update of the Provider-Specific 
File and the March 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.

[[Page 50126]]

Table 1A contains the two national standardized amounts that are 
applicable to all hospitals, except hospitals in Puerto Rico. As 
described in section II.A.1. of this Addendum, we are not revising 
the labor share of the national standardized amount from 71.1 
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 will be used to 
calculate the prospective payment rates for hospitals located in the 
50 States, the District of Columbia, and Puerto Rico. This section 
addresses two types of adjustments to the standardized amounts that 
are made in determining the prospective payment rates as described 
in this Addendum.

1. Adjustment for Area Wage Levels

    Sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act require 
that we make an adjustment to the labor-related portion of the 
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 FY 2003 wage 
index. The wage index is set forth in Tables 4A, 4B, 4C, and 4F of 
this Addendum.

2. Adjustment for Cost-of-Living in Alaska and Hawaii

    Section 1886(d)(5)(H) of the Act authorizes an adjustment to 
take into account the unique circumstances of hospitals in Alaska 
and Hawaii. Higher labor-related costs for these two States are 
taken into account in the adjustment for area wages described above. 
For FY 2003, we are adjusting the payments for hospitals in Alaska 
and Hawaii by multiplying the nonlabor portion of the standardized 
amounts by the appropriate adjustment factor contained in the table 
below.

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

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

C. DRG Relative Weights

    As discussed in section II. of the preamble, we have developed a 
classification system for all hospital discharges, assigning them 
into DRGs, and have developed relative weights for each DRG that 
reflect the resource utilization of cases in each DRG relative to 
Medicare cases in other DRGs. Table 5 of section V. of this Addendum 
contains the relative weights that we will 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.
    The prospective payment rate for SCHs and MDHs equals the higher 
of the applicable Federal rate from Table 1A or the hospital-
specific rate as described below. The 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 average 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 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. MDHs do not have the option to use their FY 1996 
hospital-specific rate.
    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 
0.994027) 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 increasing the hospital-specific rates by 2.95 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:

[[Page 50127]]

    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. 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 used 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 
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 final 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 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 final rule published in the Federal Register on August 1, 
2001 (66 FR 39947), we established a Federal rate of $390.74 for FY 
2002. As a result of the changes to the factors used to establish 
the Federal rate that are explained in this addendum, the FY 2003 
Federal rate is $407.01.
    In the discussion that follows, we explain the factors that were 
used to determine the FY 2003 Federal rate. In particular, we 
explain why the FY 2003 Federal rate has increased 4.2 percent 
compared to the FY 2002 Federal rate. We also estimate aggregate 
capital payments will increase by 5.81 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 
final 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.

[[Page 50128]]

Specifically, we have adjusted the projected CIPI rate of increase 
as appropriate each year for case-mix index-related changes, for 
intensity, and for errors in previous CIPI forecasts. The proposed 
rule reflected an update factor for FY 2003 under that framework of 
1.1 percent, based on data available at that time. Under the update 
framework, the final update factor for FY 2003 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 
year 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 update for FY 2003.) 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 for FY 2003 to 
maintain budget neutrality.
    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 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 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 1999, -0.7 
percent for FY 2000, and -0.3 percent for FY 2001. Since we estimate 
that intensity has increased during that period, the intensity 
adjustment for FY 2003 is 1.0 percent.
    Above we described the basis of the components used to develop 
the 1.1 percent final capital update factor for FY 2003 as shown in 
Table 1 below.

    Table 1.--CMS's 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 Update...............................................        1.1
------------------------------------------------------------------------

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

[[Page 50129]]

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 5.31 percent of inpatient capital-
related payments based on the Federal rate in FY 2003. Therefore, we 
are establishing an outlier adjustment factor of 0.9469 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 change in the outlier adjustment to 
the Federal rate for FY 2003 is 1.0048 (0.9469/0.9424). The outlier 
adjustment increases the FY 2003 Federal rate by 0.48 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 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 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, based on calculations using updated data, we are applying an 
incremental budget neutrality adjustment of 0.9991 for FY 2003 to 
the previous cumulative FY 2002 adjustment of (0.9927), yielding a 
cumulative adjustment of 0.9918 through FY 2003. For the Puerto Rico 
GAF, we are applying an incremental budget neutrality adjustment of 
1.0081 for FY 2003 to the previous cumulative FY 2002 adjustment 
(0.9916), yielding a cumulative adjustment of 0.9997 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 FY 2003 DRG relative 
weights and the FY 2003 GAF. The incremental adjustment for DRG 
classifications and changes in relative weights is 0.9966 both 
nationally and for Puerto Rico. The cumulative adjustments for DRG 
classifications and changes in relative weights and for changes in 
the GAF through FY 2003 are 0.9885 nationally and 0.9963 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        ---------------------------------------------  Cumulative ---------------------------------------------  Cumulative
                            Geographic         DRG                                    Geographic         DRG
                            adjustment  Reclassifications    Combined                 adjustment  Reclassifications    Combined
                              factor    and recalibration                               factor    and 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\.................      0.99782         1.00009         0.99791      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.....................      0.99915         0.99662         0.99577      0.98848      1.00809         0.99662         1.00468     0.99628
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Factors effective for the first half of FY 2001 (October 2000 through March 2001).
\2\ Factors effective for the second half of FY 2001 (April 2001 through September 2001).
\3\ Incremental factors are applied to FY 2000 cumulative factors.
\4\ Incremental factors are applied to the cumulative factors for the first half of FY 2001.

    The methodology used to determine the recalibration and 
geographic (DRG/GAF) budget neutrality adjustment factor for FY 2003 
is similar to that used in establishing budget neutrality 
adjustments under the prospective payment system for operating

[[Page 50130]]

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. In the proposed rule, we proposed a GAF/DRG budget 
neutrality factor of 1.0024. For this final rule, based on updated 
data, we are establishing a GAF/DRG budget neutrality factor of 
0.9957 for FY 2003. 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 
incremental change in the adjustment from FY 2002 to FY 2003 is 
0.9957. The cumulative change in the rate due to this adjustment is 
0.9885 (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 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  
0.9957 = 0.9885).
    This 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 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 subsequent fiscal 
years, 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 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 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 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-
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 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 subsequent fiscal years. 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 June 2002.

------------------------------------------------------------------------
                                               Cost reporting periods
                 PPS year                        beginning in . . .
------------------------------------------------------------------------
IX........................................  FY 1992
X.........................................  FY 1993
XI........................................  FY 1994
XII.......................................  FY 1995
XIII......................................  FY 1996
XIV.......................................  FY 1997
XV........................................  FY 1998
XVI.......................................  FY 1999
XVII......................................  FY 2000
------------------------------------------------------------------------

    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). (Although some FY 2000 cost reports 
are available in HCRIS, only a few hospitals have submitted FY 2000 
costs. Consequently, too few cost reports are available to reliably 
model FY 2000 special exceptions payments.) 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:

[[Page 50131]]



------------------------------------------------------------------------
                                                               Special
                                                              exceptions
                                                 Number of       as a
                                                 hospitals   fraction of
                  Cost report                     eligible     capital
                                                for special  payments to
                                                 exceptions      all
                                                              hospitals
------------------------------------------------------------------------
PPS IX........................................           --           --
PPS X.........................................           --           --
PPS XI........................................            2           --
PPS XII.......................................            5       0.0001
PPS XIII......................................            7       0.0001
PPS XIV.......................................           14       0.0002
PPS XV........................................           18       0.0009
PPS XVI.......................................           27       0.0018
PPS XVII......................................          N/A          N/A
------------------------------------------------------------------------

    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 20 additional hospitals could qualify for special 
exceptions. Thus, we project that special exception payments as a 
fraction of capital payments to all hospitals to be approximately 
0.0030.
    Because special exceptions are budget neutral, in the May 9, 
2002 proposed rule (67 FR 31516), we proposed to offset the Federal 
capital rate by 0.40 percent for special exceptions for FY 2003. 
Therefore, we proposed the exceptions adjustment factor for special 
exception payments to equal 0.9960 (1-0.0040) to account for special 
exception payments in FY 2003. For this final rule, based on updated 
data, we are offsetting the Federal capital rate by a factor of 
0.9970 (1-0.0030) to account for special exceptions payments in FY 
2003.
    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, we estimate that exceptions payments for FY 2003 
will equal 0.30 percent of aggregate payments based on the Federal 
rate. Therefore, we are applying an exceptions payment reduction 
factor of 0.9970 (1-0.0030) to the Federal rate for FY 2003. The 
exceptions adjustment factor for FY 2003 is 0.41 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 net change in the 
exceptions adjustment to the FY 2003 Federal rate is 0.9970/0.9929, 
or 1.0041.

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 final 
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 revising 
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 final 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 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 applying 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. In this final 
rule, we are establishing a capital Federal rate of $407.01 for FY 
2003. The Federal rate for FY 2003 was calculated as follows:
     The FY 2003 update factor is 1.0110; that is, the 
update is 1.10 percent.
     The 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 0.9957.
     The FY 2003 outlier adjustment factor is 0.9469.
     The FY 2003 (special) exceptions payments adjustment 
factor is 0.9970.
     The special adjustment factor for FY 2003 to restore 
the 2.1 percent reduction to the standard Federal rate is 1.0255.
    Since the Federal rate has already been adjusted for differences 
in case-mix, wages, cost-of-living, indirect medical education 
costs, and payments to hospitals serving a disproportionate share of 
low-income patients, we have made no additional adjustments in the 
standard Federal rate for these factors, other than the budget 
neutrality factor for changes in the DRG relative weights and the 
GAF.
    We are providing a chart that shows how each of the factors and 
adjustments for FY 2003 affected the computation of the FY 2003 
Federal rate in comparison to the FY 2002 Federal rate. The 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 geographic 
and DRG budget neutrality factor has the effect of decreasing the 
Federal rate by 0.43 percent. The FY 2003 outlier adjustment factor 
has the effect of increasing the Federal rate by 0.48 percent 
compared to the FY 2002 Federal rate. The FY 2003 exceptions 
reduction factor has the effect of increasing the Federal rate by 
0.41 percent compared to the exceptions reduction for FY 2002. The 
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 changes is to increase the 
Federal rate by 4.16 percent compared to the FY 2002 Federal rate.

 Comparison of Factors and Adjustments: FY 2002 Federal Rate and FY 2003
                              Federal Rate
------------------------------------------------------------------------
                                                                Percent
                               FY 2002    FY 2003     Change     change
------------------------------------------------------------------------
Update factor \1\...........     1.0130     1.0110     1.0110       1.10
GAF/DRG Adjustment Factor        0.9934     0.9957     0.9957      -0.43
 \1\........................
Outlier Adjustment Factor        0.9424     0.9469     1.0048       0.48
 \2\........................
Exceptions Adjustment Factor     0.9929     0.9970     1.0041       0.41
 \2\........................
Special Adjustment \3\......        N/A     1.0255     1.0255       2.55
Federal Rate................    $390.74    $407.01     1.0416      4.16
------------------------------------------------------------------------
\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
  0.9957 GAF/DRG budget neutrality factor for FY 2003 is 0.9957.
\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 0.9469/0.9424, or 1.0048.

[[Page 50132]]

 
\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 final
  rule).

    We are also providing a chart that shows how the final FY 2003 
capital Federal rate differs from the proposed FY 2003 capital 
Federal rate.

Comparison of Factors and Adjustments: FY 2003 Proposed Federal Rate and
                       FY 2003 Final Federal Rate
------------------------------------------------------------------------
                               Proposed   Final FY              Percent
                               FY 2003      2003      Change     change
------------------------------------------------------------------------
Update factor...............     1.0110     1.0110     1.0000       0.00
GAF/DRG Adjustment Factor...     1.0024     0.9957     0.9933      -0.67
Outlier Adjustment Factor...     0.9460     0.9469     1.0010       0.10
Exceptions Adjustment Factor     0.9960     0.9970     1.0010       0.10
Special Adjustment..........     1.0255     1.0255     1.0000       0.00
Federal Rate................    $408.90     407.01     0.9954      -0.46
------------------------------------------------------------------------

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 was 1.0080, while the proposed DRG adjustment was 1.0034, for 
a proposed combined cumulative adjustment of 1.0115. For this final 
rule, based on updated data, the FY 2003 GAF budget neutrality 
factor is 1.0081, while the DRG adjustment is 0.9966, for a combined 
cumulative adjustment for Puerto Rico of 1.0047.
    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 proposed to 
the factors used to determine the rate, the proposed FY 2003 special 
rate for Puerto Rico was $199.70. For this final rule, based on the 
final factors, the FY 2003 capital rate for Puerto Rico is $198.29.

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 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 $33,560.
    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 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 final rule, under 
Sec. 412.304(c)(2), we will pay a new hospital 85 percent of their 
reasonable costs during the first 2 years of operation unless it 
elects to receive payment based on 100 percent of the Federal rate. 
Effective with

[[Page 50133]]

the third year of operation through the remainder of the transition 
period, we will 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 final 
rule, we are revising and rebasing the CIPI to a FY 1997 base year 
to reflect the more recent structure of capital costs. For further 
details on the rebasing and revision of the CIPI, see section IV.B. 
of this final rule.

2. Forecast of the CIPI for Federal Fiscal Year 2003

    We are forecasting the 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 3.0 percent increase in other capital expense 
prices in FY 2003, partially offset by a 2.3 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. 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 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 3.5 percent. This percentage change is 
estimated 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 providing that 
the update to a hospital's target amount for its cost reporting 
period beginning in FY 2003 is 3.5 percent.
    As discussed in section VII. of the preamble of this final rule, 
we are making 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, in the May 9, 
2002 proposed rule, we included the following proposed caps:

------------------------------------------------------------------------
                                                     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
------------------------------------------------------------------------

    In this final rule, using updated data, we have recalculated the 
proposed caps for cost reporting periods beginning in FY 2003. The 
final FY 2002 caps are listed below:

[[Page 50134]]



------------------------------------------------------------------------
                                                      FY 2003   FY 2003
                                                       labor-  nonlabor-
         Class of excluded hospital or unit           related   related
                                                       share     share
------------------------------------------------------------------------
Psychiatric.........................................   $7,054    $2,804
Long-Term Care......................................   17,286     6,872
------------------------------------------------------------------------

    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 final rule and in this Addendum. For purposes of this 
final 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
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 March 2002 GROUPER V19.0
Table 7B--Medicare Prospective Payment System Selected Percentile 
Lengths of Stay FY 2001 MedPAR Update March 2002 GROUPER V20.0
Table 8A--Statewide Average Operating Cost-to-Charge Ratios for Urban 
and Rural Hospitals (Case Weighted) July 2002
Table 8B--Statewide Average Capital Cost-to-Charge Ratios (Case 
Weighted) July 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
------------------------------------------------------------------------
      $3,022.60          $1,228.60          $2,974.75         $1,209.15
------------------------------------------------------------------------


               Table 1C.--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor
----------------------------------------------------------------------------------------------------------------
                                                         Large urban area                   Other Areas
                                                 ---------------------------------------------------------------
                                                       Labor         Nonlabor          Labor         Nonlabor
----------------------------------------------------------------------------------------------------------------
National........................................       $2,996.76       $1,218.10       $2,996.76       $1,218.10
Puerto Rico.....................................        1,464.13          589.35        1,440.95          580.02
----------------------------------------------------------------------------------------------------------------


            Table 1D.--Capital Standard Federal Payment Rate
------------------------------------------------------------------------
                                                               Rate
------------------------------------------------------------------------
National................................................         $407.01
Puerto Rico.............................................         $198.29
------------------------------------------------------------------------


[[Page 50135]]


  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
[Explanation of footnotes: * 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.]
----------------------------------------------------------------------------------------------------------------
                                                      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         17.9841         17.2930
010004..........................................         17.9732         19.0010         20.1613         19.0027
010005..........................................         17.5985         18.6554         19.9733         18.7567
010006..........................................         16.7480         17.6115         18.3931         17.6130
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         24.8922         22.5886
010012..........................................         17.7171         15.8686         20.3376         17.8002
010015..........................................         15.4510         19.1178         19.8205         18.1040
010016..........................................         17.2473         20.2198         20.3175         19.2142
010018..........................................         17.6449         18.9388         19.5519         18.7214
010019..........................................         16.3493         17.0856         17.6414         17.0165
010021..........................................         16.2919         15.1241         25.3335         17.8534
010022..........................................         18.5879         17.6435         22.1250         19.2162
010023..........................................         16.1025         16.3209         18.4567         16.9929
010024..........................................         16.2900         15.9034         17.3746         16.5229
010025..........................................         15.1356         15.1548         17.4702         15.9257
010027..........................................         11.7900         16.8595         16.5157         14.5941
010029..........................................         17.6461         18.3605         19.3393         18.4481
010031..........................................         18.7835         18.6402         19.2612         18.9043
010032..........................................         12.5995         15.3590         16.3967         14.8530
010033..........................................         20.3923         21.2986         21.9828         21.2187
010034..........................................         15.0959         15.3639         14.9379         15.1325
010035..........................................         20.1853         15.9439         20.7808         18.7551
010036..........................................         17.8140         17.7166         18.7158         18.0757
010038..........................................         18.2671         19.6098         19.6887         19.2225
010039..........................................         20.1045         20.3406         21.3550         20.6323
010040..........................................         18.9376         20.0983         20.4486         19.7782
010043..........................................         30.7489         18.6640         17.3567         20.8449
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         19.5667         19.1301
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         16.9721         14.6098
010064..........................................         20.4139         19.5256         20.5650         20.1572
010065..........................................         16.4049         16.8752         17.0557         16.7998
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         17.1612         16.8948
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         21.5860         19.9817
010086..........................................         16.6694         16.5711         16.8886         16.7103
010087..........................................         19.0033         18.0567         18.7915         18.6490
010089..........................................         16.8042         17.7800         19.5241         18.0099
010090..........................................         18.3866         18.9445         19.5635         18.9671
010091..........................................         13.9405         17.0799         17.1775         15.9756
010092..........................................         16.9900         17.8144         18.5478         17.8124

[[Page 50136]]

 
010095..........................................         12.4525         12.2597         12.3064         12.3323
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         18.9525         16.0723
010102..........................................         13.7933         13.8136         15.7777         14.4205
010103..........................................         17.9358         17.7242         22.0802         19.0882
010104..........................................         17.7126         16.8457         21.9457         18.6228
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
010112..........................................         15.1401         16.8271         15.6041         15.8270
010113..........................................         16.9683         16.8936         18.2774         17.3728
010114..........................................         15.2454         17.0760         19.3772         17.2041
010115..........................................         14.6268         14.2261         15.3510         14.7053
010118..........................................         18.8477         17.0834         17.4620         17.7157
010119..........................................         18.8024         19.3942         19.5163         19.3327
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         16.6899         15.2189
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         18.9084         17.7778
010144..........................................         17.1320         18.2040         18.8272         18.0453
010145..........................................         20.8434         20.5895         20.8157         20.7476
010146..........................................         18.5198         19.1415         18.3666         18.6687
010148..........................................         12.2214         15.8349         18.4591         15.1664
010149..........................................         18.6333         18.0156         19.0199         18.5806
010150..........................................         17.8951         18.9359         19.4819         18.7907
010152..........................................         17.8306         18.7677         19.8990         18.8539
010155..........................................          9.0300         15.0689         13.6136         11.6435
010157..........................................               *               *         17.7372         17.7373
010158..........................................         17.3227         18.3957         18.6052         18.1306
010159..........................................               *               *         19.3950         19.3950
020001..........................................         28.1747         28.0394         28.6530         28.2947
020002..........................................         24.5815         25.1987         28.2759         25.9928
020004..........................................         30.5667         25.4679         29.2351         28.4867
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         31.8878         30.7354
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         27.7870         26.6146
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

[[Page 50137]]

 
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         20.3017         20.0154
030016..........................................         19.3967         19.4785         22.2526         20.4395
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         23.7663         23.2450
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         20.5653         20.6716
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         21.2299         20.8174
030083..........................................         23.3355         23.5229         23.5049         23.4608
030085..........................................         21.0954         20.8690         21.6542         21.2320
030086..........................................         19.5436               *               *         19.5436
030087..........................................         21.4084         21.9465         23.1339         22.1276
030088..........................................         19.8682         20.5340         21.4491         20.6552
030089..........................................         20.4019         20.9516         22.0850         21.2122
030092..........................................         20.6986         21.8308         19.6625         20.5481
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..........................................               *               *         28.9308         28.9308
030104..........................................               *               *         32.8668         32.8669
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         22.5319         20.8769
040008..........................................         15.3040         14.7985         20.2121         16.6104
040010..........................................         18.6023         19.4913         19.8251         19.3459

[[Page 50138]]

 
040011..........................................         14.5319         16.0995         17.1337         15.8295
040014..........................................         17.6340         18.1434         19.3996         18.3693
040015..........................................         16.5891         15.5207         17.9602         16.7200
040016..........................................         19.0295         20.2321         19.8087         19.7068
040017..........................................         13.5098         15.4736         16.5648         15.1885
040018..........................................         17.6027         18.7463         18.8203         18.3807
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         17.1507         16.4393
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         15.2811         14.8024
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         18.2152         16.8577
040053..........................................         16.3610         15.0219         14.1508         15.1659
040054..........................................         15.3219         14.2577         16.5217         15.3669
040055..........................................         17.1269         18.0414         17.4236         17.5299
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         19.5619         19.1774
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         18.4956         17.6590
040072..........................................         16.0895         17.4960         21.3320         18.2060
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         19.6363         18.9943
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         18.3159         17.8055
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         17.0271         15.9393
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         18.6028         17.0376

[[Page 50139]]

 
040124..........................................         19.1349         19.2889               *         19.2100
040126..........................................         12.5368         11.6517         16.3391         13.4177
040132..........................................         17.5179         10.3875         24.6941         15.4438
040134..........................................         18.0787         19.0185         22.1291         19.8434
040135..........................................         22.6761         23.0084               *         22.8797
040136..........................................               *               *         21.4139         21.4138
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         16.5909         15.8441
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         24.8017         22.6740
050038..........................................         28.6528         29.9698         32.1757         30.1303
050039..........................................         22.7117         22.8288         23.8478         23.1402
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         22.2584         21.3963
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         23.0613         23.4423
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         26.6463         25.1713
050092..........................................         16.7969         17.1211         17.1883         17.0299

[[Page 50140]]

 
050093..........................................         25.2130         25.6647         27.2048         26.0447
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         33.1232         32.0303
050102..........................................         22.2937         24.0014         22.6741         22.9916
050103..........................................         24.7932         25.4133         23.5946         24.5653
050104..........................................         25.5797         26.9726         27.3260         26.6171
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         29.1268         27.0733
050113..........................................         28.8420         28.5224         32.4493         30.0540
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         26.9048         26.7269
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         23.7432         24.6166
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         29.8983         28.3985
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         34.5096         33.9668
050153..........................................         30.5714         32.3389         33.3333         32.1183
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         27.7693         25.2103
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
050191..........................................         20.8321         25.3516         29.4162         25.1452
050192..........................................         18.6701         14.1996         19.0400         17.0362
050193..........................................         22.6316         24.9444         25.5294         24.3542

[[Page 50141]]

 
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         34.6878         34.1675
050204..........................................         23.6105         22.7099         23.0192         23.1063
050205..........................................         23.6831         24.1691         24.1275         23.9917
050207..........................................         21.6214         22.9941         23.7774         22.8095
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         27.4697         26.8010
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         24.9469         23.6287
050240..........................................         26.3657         26.7620         28.8910         27.3259
050241..........................................         26.3740         29.8345               *         27.9992
050242..........................................         31.1576         32.0829         33.5646         32.2627
050243..........................................         28.9635         26.4627         26.0256         27.1221
050245..........................................         23.8124         23.2716         24.6092         23.8921
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         33.2270         33.7253
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         17.1935         20.7533
050295..........................................         21.2892         21.7883         25.4405         22.8697
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

[[Page 50142]]

 
050307..........................................         17.2147               *               *         17.2147
050308..........................................         29.3803         28.9284         30.3887         29.5604
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         22.5906         23.3600
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         31.1527         26.6180
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         22.0203         21.3892
050342..........................................         20.1841         20.8255         22.4510         21.1447
050343..........................................         17.2085               *               *         17.2084
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         41.4710         21.8695
050357..........................................         22.6545         24.5345         24.3540         23.9188
050359..........................................         17.7907         21.7548         19.7653         19.6431
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         11.6463         16.0071
050378..........................................         25.9810         26.9101         27.8389         26.9067
050379..........................................         15.2022         18.4278         24.2408         18.3635
050380..........................................         31.4343         31.9578         31.5962         31.6646
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         24.5471         24.8993
050417..........................................         21.5739         23.3005         23.3862         22.7800
050419..........................................         23.7584         23.4936         25.1449         24.1188
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         26.7941         26.9305
050427..........................................         20.1674         16.4330         31.4154         22.4396
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

[[Page 50143]]

 
050434..........................................         19.7591               *         24.0017         21.7788
050435..........................................         25.6676         23.3426         22.5428         23.8194
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         34.2116         33.6080
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         25.2723         24.7165
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         25.3450         25.4513
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         26.8814         25.6479
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         23.7778         22.7078
050541..........................................         34.4573         36.6149         37.0551         36.1147
050542..........................................         16.0892         17.7737         21.8129         18.4625
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         26.5515         25.6491
050551..........................................         25.4652         24.8084         26.1042         25.4556
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

[[Page 50144]]

 
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         26.2226         25.4641
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         25.1100         23.9970
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         20.9171         18.9982
050609..........................................         34.9935         33.5028         34.8949         34.4263
050613..........................................         23.3835         30.2413         34.9768         28.8604
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         29.3665         27.8711
050630..........................................         23.9159         24.2120         25.2915         24.5153
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               *               *         19.6781
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
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

[[Page 50145]]

 
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         21.4562         21.3343
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         24.2735         24.0195
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         25.7701         24.7918
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         19.7348         18.9920
060022..........................................         21.0558         21.0830         22.8059         21.6916
060023..........................................         19.2373         21.5475         22.4731         21.0953
060024..........................................         21.9955         22.9185         24.3658         23.1396
060027..........................................         20.9846         22.0713         22.1717         21.7670
060028..........................................         23.2065         23.1792         24.2985         23.5665
060029..........................................         20.8585         18.2938         19.8498         19.6763
060030..........................................         20.5002         20.3452         21.2612         20.7131
060031..........................................         21.1649         22.5067         23.3995         22.3074
060032..........................................         23.4162         22.8123         24.7678         23.6728
060033..........................................         15.9085         16.0760         17.8514         16.5805
060034..........................................         22.4791         23.2816         24.3652         23.3995
060036..........................................         15.0698         18.5988         18.6521         17.3368
060037..........................................         15.5611         15.4513         15.7495         15.5902
060038..........................................         14.0791         14.3249         16.6525         15.2260
060041..........................................         14.8934         19.1263         19.5872         17.5256
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         28.8746         24.1014

[[Page 50146]]

 
060065..........................................         21.6305         24.5572         24.4554         23.5808
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         22.9426         22.6703
060085..........................................         13.6277         14.3409         10.9724         12.8943
060088..........................................         25.2786         13.7174         20.7211         18.6295
060090..........................................         22.2974         16.3760         16.5321         18.2600
060096..........................................         21.9623         20.8937         21.9951         21.6204
060100..........................................         23.5986         23.9305         24.8116         24.1151
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         37.5917         28.5860
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         27.2423         26.9019
070024..........................................         25.2983         24.8948         26.3544         25.5382
070025..........................................         25.1315         25.4345         27.3592         25.9673
070027..........................................         23.6412         26.8450         25.9279         25.4322
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         34.1591         31.9816
070034..........................................         28.9200         29.4916         30.0744         29.4693
070035..........................................         23.0869         24.1423         24.5996         23.9254
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         20.9399         21.1768
080007..........................................         19.6213         21.3746         21.5415         20.9038
090001..........................................         21.7526         21.5751         23.0365         22.1027
090002..........................................         19.4191         21.5726         20.6550         20.5048
090003..........................................         22.1090         23.1268         27.1087         23.8330
090004..........................................         24.3367         25.5054         25.9717         25.2072
090005..........................................         23.8620         26.3074         26.8690         25.6346
090006..........................................         20.8675         22.0957         22.9658         21.9607
090007..........................................         22.1973         29.2840         24.6668         25.6566
090008..........................................         20.2166         25.2708               *         22.7566
090010..........................................         24.1287         23.6616         25.9373         24.5182
090011..........................................         27.4781         26.6349         27.6038         27.2394

[[Page 50147]]

 
100001..........................................         19.5796         20.2157         22.0101         20.5122
100002..........................................         20.7136         21.0222         21.5772         21.1199
100004..........................................         14.6283         15.4149         16.1638         15.4361
100006..........................................         20.1133         21.2293         21.6922         21.0708
100007..........................................         21.7242         22.1590         22.5317         22.1527
100008..........................................         20.4980         20.8381         21.6416         21.0118
100009..........................................         22.6419         22.1741         22.6370         22.4873
100010..........................................         21.9078         23.0637         23.9582         22.9492
100012..........................................         19.6177         20.4659         22.0244         20.7239
100014..........................................         19.8023         19.5770         21.9875         20.4440
100015..........................................         18.4779         18.0654         18.9383         18.4860
100017..........................................         19.0608         19.8655         20.1417         19.7084
100018..........................................         21.0332         21.6388         22.6587         21.7978
100019..........................................         22.6152         23.5462         25.8297         24.0395
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         20.3751         19.7063
100029..........................................         20.8745         20.8950         22.2553         21.3244
100030..........................................         22.8204         20.5952         19.5604         20.7196
100032..........................................         19.8127         19.7451         20.6543         20.0503
100034..........................................         17.8743         19.5282         20.0099         19.0752
100035..........................................         20.1540         23.8117         21.3519         21.7961
100038..........................................         23.3578         24.5864         24.9548         24.3305
100039..........................................         21.5297         21.7861         23.3111         22.2259
100040..........................................         19.0449         18.6321         19.5154         19.0650
100043..........................................         18.7993         18.8206         20.7688         19.4486
100044..........................................         21.4764         22.7236         22.9474         22.4012
100045..........................................         20.9216         21.0228         22.8096         21.6136
100046..........................................         21.6207         21.3028         23.2027         22.0159
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         19.3258         19.7301
100052..........................................         17.9537         18.1780         19.6620         18.5844
100053..........................................         20.1724         19.6800         21.6634         20.4905
100054..........................................         23.5491         21.1518         20.9612         21.8945
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         24.5277         23.1393
100062..........................................         19.4370         21.4424         21.9054         21.0072
100063..........................................         19.2629         18.4642         19.2510         19.0090
100067..........................................         18.0877         18.4851         19.2168         18.5203
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         20.4604         19.4085
100076..........................................         17.8733         17.8612         18.4815         18.0825
100077..........................................         22.3438         19.0640         20.9482         20.7726
100078..........................................         18.4499         19.2891         16.6003         18.0834
100080..........................................         22.1966         22.7153         22.9720         22.6367
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

[[Page 50148]]

 
100087..........................................         23.6090         23.6562         22.1764         23.1720
100088..........................................         20.3693         20.5566         20.6667         20.5318
100090..........................................         19.1479         19.7695         21.0431         20.0438
100092..........................................         17.9216         20.1760         21.4601         19.8695
100093..........................................         16.5128         16.8422         18.7153         17.3704
100098..........................................         19.2427         20.8315         21.1723         20.4066
100099..........................................         15.7823         15.7591         16.5271         16.0129
100102..........................................         18.9701         19.7673         19.0193         19.2459
100103..........................................         17.2364         18.7844         19.1222         18.3910
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         20.6007         20.7572
100110..........................................         20.8995         20.1853         22.8127         21.3407
100112..........................................         25.2570         15.2128         16.2109         17.7240
100113..........................................         23.2020         21.3489         23.3380         22.5455
100114..........................................         21.6262         22.8178         22.5326         22.3196
100117..........................................         20.7624         20.6962         21.3085         20.9272
100118..........................................         22.8702         20.7323         21.7067         21.7370
100121..........................................               *         18.5842         19.9033         19.2306
100122..........................................         19.8783         19.2643         24.9765         21.2147
100124..........................................         17.0713         20.4022         20.0867         19.1730
100125..........................................         18.9535         19.6097         20.3232         19.6414
100126..........................................         19.5413         19.3103         21.4349         20.0428
100127..........................................         19.9860         19.2122         20.5153         19.9091
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         24.6184         23.7719
100132..........................................         18.1167         18.7863         19.5259         18.7919
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         20.2288         18.8297
100142..........................................         19.6815         18.4113         17.7250         18.5714
100144..........................................         12.2877               *               *         12.2877
100146..........................................         18.1267         21.3359         20.8381         20.1028
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         23.3612         22.6650
100162..........................................         20.1411         20.3110         24.2950         21.5951
100165..........................................         19.0388         22.6622               *         21.0526
100166..........................................         20.0250         21.2309         22.2419         21.1141
100167..........................................         23.4075         23.2969         25.7676         24.1390
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         25.1037         24.6852
100179..........................................         22.3015         23.0849         23.9633         23.1372
100180..........................................         20.2130         21.5388         22.7781         21.4816
100181..........................................         23.0800         18.9510         17.9048         19.7877
100183..........................................         24.6121         23.0654         22.2063         23.2470

[[Page 50149]]

 
100187..........................................         20.2533         20.8535         21.4988         20.8818
100189..........................................         21.3147         26.5962         27.1295         24.9742
100191..........................................         19.9879         21.0647         22.0526         21.0151
100199..........................................         21.7193               *               *         21.7193
100200..........................................         22.4579         23.8729         24.8878         23.7939
100204..........................................         20.8995         20.2193         21.1922         20.7717
100206..........................................         19.5710         20.1171         20.3436         20.0192
100208..........................................         21.2117         20.7029         20.4678         20.8077
100209..........................................         22.4577         23.3903         22.8236         22.8823
100210..........................................         21.3575         21.8545         23.0431         22.0260
100211..........................................         20.6427         20.7516         21.6367         21.0021
100212..........................................         21.1187         21.1263         21.7239         21.3228
100213..........................................         20.6558         21.1818         22.0176         21.2986
100217..........................................         20.5909         22.7335         22.7116         21.9737
100220..........................................         21.2796         21.8246         24.6233         22.4044
100221..........................................         17.3965         21.2321         23.2263         20.3743
100223..........................................         20.6302         20.2233         21.8962         20.9551
100224..........................................         20.0251         21.8628         22.3567         21.3927
100225..........................................         20.6802         21.5059         22.4619         21.5424
100226..........................................         20.6858         21.8808         22.7301         21.8197
100228..........................................         21.3168         20.8810         24.9691         22.4542
100229..........................................         19.6908         18.2350         19.7259         19.2271
100230..........................................         20.5051         22.5650         23.4169         22.2637
100231..........................................         17.9226         18.7526         21.5712         19.2641
100232..........................................         19.3491         19.8002         20.1459         19.7694
100234..........................................         20.9104         21.6360         24.3355         22.1730
100235..........................................         17.1622               *               *         17.1622
100236..........................................         20.3766         20.6942         21.7886         20.9395
100237..........................................         22.0865         23.2408         23.2712         22.8481
100238..........................................         19.6367         20.8252         23.3747         21.2439
100239..........................................         21.3193         19.4481         23.2242         21.2389
100240..........................................         20.4340         21.0606         21.3495         20.9700
100241..........................................         14.7224         17.1063         14.1059         15.3322
100242..........................................         17.9260         18.6938         19.1097         18.5870
100243..........................................         21.2644         20.8041         22.4495         21.5381
100244..........................................         18.6227         20.5352         21.4386         20.2806
100246..........................................         19.6376         21.9247         23.5614         21.5790
100248..........................................         20.7007         21.2988         22.1553         21.4214
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         20.4410         19.8924
100255..........................................         25.2119         21.0284         20.7228         22.1421
100256..........................................         20.9356         21.2786         22.4844         21.5612
100258..........................................         21.3501         20.0300         22.0790         21.1494
100259..........................................         20.3815         21.1160         21.4991         21.0228
100260..........................................         21.0506         24.9183         21.2413         22.2814
100262..........................................         20.0433         21.0927         22.7137         21.2022
100264..........................................         19.1556         19.9491         21.7410         20.2633
100265..........................................         18.8301         18.2291         20.2664         19.1601
100266..........................................         18.2993         19.3623         20.2821         19.3534
100267..........................................         20.1141         21.7430         22.8054         21.5751
100268..........................................         23.9249         24.0538         23.5414         23.8302
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         23.2920         21.8964
100276..........................................         22.3646         24.1022         24.8251         23.8061
100277..........................................         16.6255         19.7241         14.9157         16.6327
100279..........................................         22.9095         22.5879         23.1776         22.8857
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         18.5716         18.7499
110001..........................................         19.1971         20.1150         22.4535         20.5583
110002..........................................         17.1406         19.5158         20.2149         18.9927

[[Page 50150]]

 
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         22.0325         21.3092
110007..........................................         21.9505         25.2523         25.9135         24.3734
110008..........................................         22.0081         18.5265         20.4972         20.3338
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         23.0577         21.6355
110020..........................................         18.3147         19.4617         20.9687         19.5535
110023..........................................         21.1994         22.0546         21.6512         21.6299
110024..........................................         20.7297         20.7345         21.3945         20.9529
110025..........................................         19.5749         20.4232         20.2493         20.0573
110026..........................................         17.2977         16.2484         16.9161         16.8269
110027..........................................         16.0642         14.7081         19.8976         16.6619
110028..........................................         20.1547         29.1670         28.1695         25.3235
110029..........................................         20.2906         21.2150         21.3694         20.9629
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         22.5481         23.1534
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
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         22.2424         21.1738
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         20.7825         20.4374
110056..........................................         15.6202         17.7959         17.9037         17.2909
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         18.8742         18.9828
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         25.7416         24.0644
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

[[Page 50151]]

 
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         18.9904         17.5350
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         21.2267         19.9924
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         20.6070         20.9564
110124..........................................         17.5732         18.3366         19.4093         18.3953
110125..........................................         19.1311         18.0090         19.5666         18.8882
110127..........................................         14.6143         20.3765         16.1107         17.0392
110128..........................................         18.1845         18.0835         20.3046         18.8711
110129..........................................         18.9388         19.0001         20.9442         19.6354
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         17.8499         17.1022
110149..........................................         17.7535         32.1975         25.2525         24.0956
110150..........................................         20.2644         21.2909         22.8322         21.4768
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         20.1183         19.7095
110164..........................................         20.2074         21.2160         22.6605         21.3867
110165..........................................         21.2577         20.8030         22.5604         21.5831
110166..........................................         20.5882         20.5049         22.3822         21.1111
110168..........................................         20.6646         21.8058         22.3181         21.6516
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

[[Page 50152]]

 
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         22.0258         23.3741
110189..........................................         22.2715         20.8786         19.8454         20.8993
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         22.1477         21.1908
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               *         27.1877
120001..........................................         27.9213         29.0427         29.4126         28.7754
120002..........................................         25.0744         25.2021         23.5667         24.5781
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         26.6302         25.8359
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         36.8286         25.9002
120022..........................................         21.7868         19.2614         22.2781         21.0242
120024..........................................         29.4808         32.2514         21.9657         28.3802
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         20.8748         18.5462
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         19.8240         19.3628
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         20.0563         19.8848
130019..........................................         18.6648         19.1711         19.5147         19.0953

[[Page 50153]]

 
130021..........................................         12.8588         15.6155         14.4430         14.2958
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         20.6641         20.8743
130028..........................................         19.1093         20.9674         21.2217         20.4234
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         17.2864         19.2295
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         18.7067         16.5045
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
130063..........................................         15.9441         18.8024         18.4797         18.1425
140001..........................................         16.3372         17.7990         18.1511         17.3657
140002..........................................         19.0248         19.9284         20.9959         19.9709
140003..........................................         21.2886         17.8595         18.0163         18.9220
140004..........................................         15.7042         17.4574         18.9713         17.4061
140005..........................................         11.6127         12.3002         12.4144         12.1009
140007..........................................         22.9799         23.8585         24.9847         23.9721
140008..........................................         21.6548         22.1111         24.2634         22.6646
140010..........................................         31.8207         28.5635         28.0863         29.4098
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         23.4062         22.7146
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         28.5670         25.8242
140030..........................................         21.9475         23.1760         25.3715         23.5785
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         23.8652         23.9681
140049..........................................         28.4958         26.9483         26.7160         27.4301
140051..........................................         23.8264         24.0796         24.7180         24.2214
140052..........................................         19.6409         17.9571         21.0450         19.4727

[[Page 50154]]

 
140053..........................................         19.1892         19.9620         20.9768         20.0131
140054..........................................         22.1921         23.1576         23.9459         23.0869
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         29.6998         27.8767
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         22.3622         21.2834
140069..........................................         16.7544         17.3879         17.7785         17.3221
140070..........................................         22.9678         22.7153         25.2646         23.5870
140074..........................................         19.3504         21.6052         22.2563         20.9569
140075..........................................         21.6313         21.6434         21.8472         21.6925
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
140082..........................................         23.8960         29.7262         26.5960         26.4591
140083..........................................         19.3145         21.0330         20.7704         20.3580
140084..........................................         20.9709         22.3467         23.0263         22.0990
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         23.5559         22.1482
140093..........................................         18.2899         20.1528         20.7564         19.6330
140094..........................................         21.4709         21.9383         22.8892         22.0901
140095..........................................         24.0549         24.2859         25.5716         24.6269
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         19.1834         18.8678
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         26.2393         21.3762
140114..........................................         21.1639         21.0976         23.0383         21.7813
140115..........................................         21.1926         21.0433         20.4587         20.8982
140116..........................................         23.1177         23.8993         25.5980         24.2533
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         17.7667         17.9340
140121..........................................         16.0397         16.6993         16.2607         16.3273
140122..........................................         24.6470         26.1270         26.7882         25.8138
140124..........................................         27.1906         27.9813         30.6820         28.5176
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         20.4807         18.6235
140138..........................................         16.7420         17.1968         14.5771         16.0861
140139..........................................         14.0619         11.0397               *         12.4249

[[Page 50155]]

 
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         28.9853         26.8988
140151..........................................         21.3896         20.0310         20.8820         20.7518
140152..........................................         24.6333         25.6011         28.3946         26.1493
140155..........................................         19.9738         20.2778         13.0438         17.2026
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
140166..........................................         17.5496         18.3833         19.3672         18.4196
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         24.8587         24.0563
140173..........................................         15.1487         16.3924         16.0030         15.8459
140174..........................................         20.5339         35.9320         22.0418         24.0179
140176..........................................         23.2866         24.5338         26.3468         24.7221
140177..........................................         18.2648         15.0827         20.3142         17.5964
140179..........................................         21.1948         21.9859         22.7345         21.9641
140180..........................................         22.4548         22.7996         22.7508         22.6646
140181..........................................         20.8709         21.9864         22.6643         21.8357
140182..........................................         22.0170         28.9515         25.1302         24.9068
140184..........................................         17.8155         17.2401         17.9169         17.6582
140185..........................................         17.6514         18.2867         18.8573         18.2635
140186..........................................         22.7890         23.5034         25.6807         23.9584
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         22.4626         21.9362
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         22.8223         22.2246
140207..........................................         21.9779         22.3905         25.4539         23.1447
140208..........................................         25.9900         26.2527         28.3112         26.8566
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         25.9030         25.4763
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         25.6766         27.8908
140228..........................................         19.6988         20.1688         21.8627         20.5743
140230..........................................         18.0918         18.2983         12.3494         15.7704
140231..........................................         23.9176         24.5019         26.0208         24.9246
140233..........................................         19.4542         21.2333         24.4419         21.6980
140234..........................................         18.9945               *         19.7266         19.3554
140236..........................................               *         12.9253               *         12.9252

[[Page 50156]]

 
140239..........................................         18.8127         20.3745         21.6074         20.3069
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         23.5128         22.3081
140252..........................................         25.2246         25.0220         26.4715         25.5870
140253..........................................         18.5511         19.5858         18.4567         18.8447
140258..........................................         23.2973         25.3622         25.0743         24.5818
140271..........................................         15.5079         12.0079         16.0350         14.2915
140275..........................................         20.1699         23.8171         22.9656         22.2969
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
140285..........................................         18.1181         18.5916         15.7435         17.3779
140286..........................................         20.3735         26.1290         24.0368         23.4605
140288..........................................         25.2327         24.4331         25.8717         25.1876
140289..........................................         17.1388         18.1747         17.7886         17.7207
140290..........................................         21.1784         22.8590         26.5055         23.5505
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         28.9830         27.4142
150001..........................................         22.8109         24.0620         22.6875         23.1822
150002..........................................         19.3401         20.7651         20.7353         20.3004
150003..........................................         19.7661         20.8636         21.4649         20.6945
150004..........................................         20.3685         21.2449         22.8060         21.4609
150005..........................................         20.6260         21.6806         22.8149         21.7447
150006..........................................         20.8158         20.6523         21.8435         21.1085
150007..........................................         20.1826         20.6635         21.2811         20.6934
150008..........................................         21.4545         21.8457         23.0208         22.1136
150009..........................................         18.7073         19.0030         19.5869         19.1023
150010..........................................         21.7125         20.5570         21.2466         21.1746
150011..........................................         18.3742         18.3275         19.9096         18.8524
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         20.6758         19.6741
150018..........................................         20.4947         21.0496         22.8922         21.5205
150019..........................................         16.6327         17.8585         19.8341         18.0075
150020..........................................         15.1120         16.6600         15.9405         15.8686
150021..........................................         19.5096         21.5944         23.3800         21.5139
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         20.7256         19.3281
150031..........................................         17.2429         18.3463         21.3494         18.9577
150033..........................................         21.8768         22.6741         23.0756         22.5535
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         18.0185         18.7252
150043..........................................         19.0120         20.1741         20.6301         19.8897
150044..........................................         18.4381         19.1309         19.8951         19.1600
150045..........................................         16.8121         18.1670         20.6406         18.4832
150046..........................................         17.6342         18.2543         19.4146         18.4518
150047..........................................         19.7441         22.0145         21.9824         21.1814

[[Page 50157]]

 
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         18.8345         17.3836
150053..........................................         19.1421         18.8632         18.3493         18.7874
150054..........................................         17.3825         18.3916         19.3424         18.3843
150056..........................................         22.4087         21.5774         23.0603         22.3391
150057..........................................         16.5882         16.9736         17.4044         16.9907
150058..........................................         20.8178         22.1409         23.0273         22.0105
150059..........................................         21.2535         22.7360         23.1398         22.3623
150060..........................................         17.0743         18.6159         19.5011         18.4069
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         20.5000         19.2693
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               *         19.8034         21.0773
150074..........................................         20.4175         20.2305         21.3500         20.6570
150075..........................................         15.5603         16.7532         17.2267         16.4858
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         24.9529         24.2038
150086..........................................         18.9735         18.3838         19.7763         19.0552
150088..........................................         18.9869         20.3366         22.3055         20.5100
150089..........................................         23.8791         22.1725         21.5664         22.4947
150090..........................................         20.7726         21.0945         21.9803         21.2765
150091..........................................         20.4053         22.4640         26.5235         23.0637
150092..........................................         16.7434         16.9179         18.2592         17.3164
150094..........................................         16.5788         17.5244         16.8351         16.9693
150095..........................................         17.1324         19.2749         22.3214         19.5343
150096..........................................         23.2764         20.8204               *         21.9551
150097..........................................         19.3802         19.7751         21.1462         20.1553
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         21.2025         19.3973
150102..........................................         19.7426         23.7180         20.8818         21.3162
150103..........................................         18.4781         18.7036         19.3653         18.9170
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         21.7870         20.1411
150110..........................................         18.6627         21.9336               *         20.0654
150111..........................................         18.4556         19.2355         24.1559         20.4298
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         22.0299         21.3571
150126..........................................         21.3697         20.6857         24.0000         22.0092
150127..........................................         17.1994         17.0052         18.0532         17.4224
150128..........................................         18.5100         19.5576         20.4742         19.4866
150129..........................................         24.7711         28.6211         29.9888         27.3320
150130..........................................         18.1971         18.4846         18.3852         18.3505

[[Page 50158]]

 
150132..........................................         20.1684         20.9443         21.2747         20.8045
150133..........................................         17.3966         18.4250         20.0320         18.5328
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
160005..........................................         17.6153         17.9405         19.3348         18.3156
160007..........................................         13.2101         15.1738         14.9137         14.4341
160008..........................................         15.9742         16.6193         16.7863         16.4539
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         22.9000         21.2124
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         22.2812         21.8210
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         25.2962         22.5781
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         20.5989         19.8301
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

[[Page 50159]]

 
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
160082..........................................         19.6499         19.5322         20.7306         19.9632
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         20.9959         20.2817
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         20.1682         18.9384
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         17.8643         18.3076
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         18.5120         18.1317
170004..........................................         15.0636         16.1442         17.2262         16.1274
170006..........................................         17.2192         17.5982         19.1982         18.0168
170008..........................................         14.9124         16.8412         17.7061         16.4380
170009..........................................         20.7795         23.1349         25.0508         23.0721
170010..........................................         18.7384         19.4584         19.5990         19.2633
170012..........................................         17.8719         18.4432         20.2412         18.8687
170013..........................................         18.6454         19.4667         20.1852         19.4537
170014..........................................         17.9349         18.4931         19.6044         18.6936

[[Page 50160]]

 
170015..........................................         16.5750         17.1302         17.2443         16.9768
170016..........................................         19.2130         20.0675         22.1023         20.4287
170017..........................................         17.7958         19.5994         19.7908         19.0428
170018..........................................         15.2984         15.3237         14.8794         15.1619
170019..........................................         15.2094         16.9362         17.4699         16.5180
170020..........................................         17.3400         18.1325         19.1418         18.2290
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         16.9094         15.6079
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         20.4533         18.7304
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         15.2814         14.7841
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         15.6412         15.4439
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         17.6543         17.5273
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         13.6517         13.0693
170085..........................................         15.4518         17.5422         21.8907         18.4877
170086..........................................         20.4068         19.7182         20.7298         20.2879
170088..........................................         13.4542         13.4860               *         13.4703
170089..........................................         18.8136         15.4860         20.2263         18.3293
170090..........................................         11.9147         10.9444         23.6837         13.5581
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         18.6023         17.6032
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         22.0671         21.2397

[[Page 50161]]

 
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         13.9726         14.8012
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         18.2832         17.8028
170122..........................................         20.0615         21.1769         21.4588         20.8791
170123..........................................         23.1697         23.6534         25.2122         23.9595
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         19.0547         18.3947
170143..........................................         15.6509         16.0415         16.3258         16.0049
170144..........................................         19.0929         20.4392         20.8488         20.0997
170145..........................................         17.1837         19.0142         20.1494         18.7616
170146..........................................         20.9075         21.7919         25.2520         22.7252
170147..........................................         22.3017         17.6717         18.4634         19.3887
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         20.8671         20.0207
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..........................................               *               *         26.8136         26.8136
170186..........................................               *               *         33.2457         33.2457
180001..........................................         17.9906         20.4885         20.8169         19.8393
180002..........................................         17.9669         17.5798         19.8195         18.4259
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         20.0950         19.3760
180014..........................................         21.4856         21.3361         23.0067         21.8859
180016..........................................         19.8892         21.1458         19.7242         20.2686
180017..........................................         15.4140         15.6583         16.7649         15.9422
180018..........................................         17.1692         15.4892         18.1529         16.9235
180019..........................................         17.3970         17.8285         19.5953         18.2719
180020..........................................         17.7288         18.0111         19.4391         18.3612
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
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

[[Page 50162]]

 
180028..........................................         19.5276         15.7005         26.2220         19.5655
180029..........................................         17.7729         17.7248         20.0841         18.4982
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         22.4651         21.2939
180036..........................................         19.8398         20.1860         20.6951         20.2522
180037..........................................         19.9737         21.2184         21.0177         20.7450
180038..........................................         17.7626         18.5923         19.3837         18.5916
180040..........................................         19.5337         21.2229         22.2270         20.9835
180041..........................................         15.0785         16.3699         17.5950         16.3724
180042..........................................         16.7691         17.1519         15.5660         16.4438
180043..........................................         16.8027         14.6526         17.2414         16.1261
180044..........................................         18.5571         19.4984         21.1057         19.7654
180045..........................................         17.7130         20.8455         20.7498         19.9529
180046..........................................         19.2523         21.2080         21.6955         20.6999
180047..........................................         16.2304         18.6938         17.8625         17.5927
180048..........................................         18.3442         17.7816         18.3151         18.1431
180049..........................................         16.4319         16.5459         17.8418         16.9262
180050..........................................         17.8540         17.1493         19.4992         18.1665
180051..........................................         16.3960         17.5441         18.3028         17.4095
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         18.7038         17.7559
180058..........................................         15.9685         14.5355         14.8840         15.0687
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         20.7907         19.9622
180067..........................................         20.6322         20.1712         20.2762         20.3589
180069..........................................         17.7911         16.2916         19.0836         17.6936
180070..........................................         13.1923         15.9362         15.4643         14.7849
180072..........................................         16.9021         17.2347         17.0576         17.0759
180078..........................................         21.1170         21.7116         23.7765         22.2300
180079..........................................         15.1636         15.9048         18.1683         16.3817
180080..........................................         16.4989         16.6428         17.6735         16.9434
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         17.7592         17.5305
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               *         21.0704         19.8124
180102..........................................         17.9618         18.5240         18.8169         18.4200
180103..........................................         19.8965         20.3490         20.9598         20.3951
180104..........................................         18.9281         19.3922         20.2731         19.5382
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         19.2389         18.6152
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
180122..........................................         18.5094         18.1930         18.7549         18.4922
180123..........................................         21.0613         21.1067         21.5962         21.2566
180124..........................................         17.4994         18.8487         19.7138         18.6761
180125..........................................         19.6416         14.9314         22.6609         18.1936
180126..........................................         12.9228         14.3551         14.8501         14.0804
180127..........................................         19.2581         17.6365         18.0498         18.2667

[[Page 50163]]

 
180128..........................................         17.6385         18.2817         18.7194         18.2299
180129..........................................         16.8378         22.3536         15.6637         17.9690
180130..........................................         19.8192         20.6450         21.9413         20.8049
180132..........................................         17.7744         19.5884         19.8393         19.0473
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         19.8198
180139..........................................         18.7198         20.5350         20.3816         19.9038
180140..........................................         16.8152         15.2719         14.6466         15.5892
180141..........................................         20.9820         23.8930         20.3404         21.5800
180142..........................................               *         20.7510               *         20.7510
180143..........................................               *               *         21.3197         21.3196
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         19.0994         17.9657
190006..........................................         17.8036         17.5911         17.7333         17.7115
190007..........................................         13.8189         14.4720         16.3633         14.9284
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         18.7344         18.5489
190020..........................................         17.5256         17.6840         18.7252         17.9732
190025..........................................         18.6369         16.8686         18.1892         17.9111
190026..........................................         18.1622         18.5015         19.0130         18.5687
190027..........................................         17.0827         17.4761         18.4070         17.6430
190029..........................................         16.5239         19.1967         18.7344         18.0923
190034..........................................         16.8503         18.0754         19.2007         18.0146
190036..........................................         20.1780         20.0300         21.2960         20.4842
190037..........................................         17.6945         19.9878         14.1323         17.4581
190039..........................................         19.4713         19.0376         18.7625         19.0694
190040..........................................         21.4634         21.7376         23.1819         22.1190
190041..........................................         17.6646         17.9535         19.5511         18.4761
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         19.7215         19.4539
190065..........................................         20.9927         18.3091         18.3280         19.0851
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
190079..........................................         17.7120         17.9403         18.8187         18.1527
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         21.4328         20.9915

[[Page 50164]]

 
190099..........................................         19.9018         19.0635         19.0545         19.3385
190102..........................................         20.0300         20.7870         21.1614         20.6813
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         21.3622         20.6278
190112..........................................         21.0232         22.0741         24.2806         22.3499
190113..........................................         12.5777               *         19.0411         16.0667
190114..........................................         12.6366         13.9209         13.5044         13.3578
190115..........................................         20.2473         22.7583         24.0098         22.2695
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         21.5869         21.0028
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         23.0213         22.0078
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         20.9312         21.3917
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         23.0144         20.9805
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         20.7351         20.4997
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
190196..........................................         17.9225         18.6138         19.1961         18.6202
190197..........................................         19.5569         20.2082         20.9871         20.3042
190199..........................................         16.0637         15.3522         17.8288         16.5088
190200..........................................         22.0391         21.6852         22.3510         22.0311
190201..........................................         18.7079         19.7421         21.7185         20.0957
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

[[Page 50165]]

 
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         16.0658         15.2775
200001..........................................         18.0527         18.2513         19.7903         18.7081
200002..........................................         19.3629         22.3035         22.3145         21.3548
200003..........................................         16.9566         18.4141         18.5779         17.9947
200006..........................................         17.6586         21.0922         18.9818         19.2222
200007..........................................         18.7992         18.1681         19.0387         18.6537
200008..........................................         21.7489         21.5556         23.2883         22.2282
200009..........................................         22.2280         21.4763         23.3090         22.3517
200012..........................................         18.3484         19.1047         20.5141         19.3396
200013..........................................         18.0566         17.9378         20.3793         18.8704
200016..........................................         18.0866         17.1187         16.2939         17.1580
200017..........................................         17.2930               *               *         17.2930
200018..........................................         18.5397         17.8675         19.8848         18.7682
200019..........................................         19.2348         19.9245         21.1893         20.1239
200020..........................................         22.4526         22.3355         24.7433         23.2161
200021..........................................         19.9133         20.7361         22.0144         20.8877
200023..........................................         16.1707         20.2063               *         18.0379
200024..........................................         19.4329         20.8336         21.0633         20.4533
200025..........................................         20.2259         20.4165         21.4247         20.7140
200026..........................................         18.1194         17.9021         18.1459         18.0573
200027..........................................         18.5659         19.4220         20.2100         19.4300
200028..........................................         19.5708         18.8763         19.8886         19.4531
200031..........................................         16.2217         16.1641         17.7875         16.7057
200032..........................................         18.9315         19.4613         20.9148         19.7712
200033..........................................         21.8634         22.4685         23.6298         22.6316
200034..........................................         20.1519         20.4941         21.8266         20.8418
200037..........................................         18.6713         20.3015         19.5004         19.5071
200038..........................................         23.3851         21.2632         22.9220         22.5107
200039..........................................         19.8589         20.1508         21.5695         20.5351
200040..........................................         19.5503         18.9580         20.7744         19.7656
200041..........................................         19.3563         18.8131         20.2986         19.5168
200043..........................................         16.7224         19.4295         20.0280         18.6069
200050..........................................         20.1214         20.2014         23.0314         21.0760
200051..........................................         22.1525         22.0712               *         22.1031
200052..........................................         17.2099         17.6271         18.9290         17.9376
200055..........................................         18.8422         18.5983         19.4998         18.9700
200062..........................................         17.2273         18.4279         18.0949         17.9025
200063..........................................         19.9331         21.2121         22.5265         21.2349
200066..........................................         17.0289         17.0570         18.4281         17.5199
210001..........................................         20.4841         18.6617         21.5280         20.1745
210002..........................................         19.9219         23.5132         26.5907         23.2386
210003..........................................         20.3446         26.0447         22.3090         22.6337
210004..........................................         24.2909         24.9760         27.2278         25.4898
210005..........................................         21.4929         21.3829         22.5304         21.8195
210006..........................................         18.9436         19.3682         20.8607         19.7283
210007..........................................         23.1007         23.8840         23.4582         23.4837
210008..........................................         21.1768         21.2895         21.0767         21.1826
210009..........................................         20.5447         20.7479         20.8476         20.7179
210010..........................................         18.7197         19.5908         20.4097         19.6002
210011..........................................         21.4862         21.4043         20.4017         21.0852
210012..........................................         20.7203         21.3977         24.8430         22.2484
210013..........................................         19.7288         19.4505         23.1649         20.7921
210015..........................................         16.1912         18.7448         23.9651         19.4078
210016..........................................         23.8739         26.5193         24.7441         25.0180
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

[[Page 50166]]

 
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         21.1659         20.0571
210038..........................................         23.4971         24.9762         25.9701         24.7755
210039..........................................         19.9901         21.3559         23.3583         21.5884
210040..........................................         21.5014         23.4252         23.7067         22.8761
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         22.6958         21.6241
210057..........................................         23.8289         26.0076         25.6142         25.1342
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         25.4158         24.6800
220003..........................................         16.9246         17.9319         17.6069         17.4814
220006..........................................         22.3085         22.6337         23.8920         22.9367
220008..........................................         24.4691         22.0796         24.2393         23.5663
220010..........................................         21.8582         22.0067         23.4009         22.4195
220011..........................................         26.1827         29.5290         20.6390         24.9566
220012..........................................         32.0829         31.2303         31.1041         31.4572
220015..........................................         22.5773         23.1893         24.1348         23.2890
220016..........................................         23.3750         23.0951         24.6149         23.6876
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         22.0003         21.8657
220028..........................................         22.8036         21.0630         24.1251         22.5899
220029..........................................         23.1509         25.6560         25.7660         24.8229
220030..........................................         18.5441         18.7429         18.9012         18.7275
220031..........................................         30.2430         29.3091         28.3832         29.0231
220033..........................................         20.0695         20.3609         21.8156         20.7051
220035..........................................         21.6396         23.1892         25.7456         23.4375
220036..........................................         24.6470         24.4091         25.5771         24.8579
220038..........................................         22.6518         22.3162         22.9821         22.6455
220041..........................................         23.4720         27.5034         28.6790         26.4083
220042..........................................         25.0779         26.0473         28.4675         26.3871
220046..........................................         22.7068         23.3149         24.1931         23.3833
220049..........................................         26.0025         27.2689         25.4358         26.2086
220050..........................................         22.0144         22.5265         23.3330         22.6222
220051..........................................         21.1033         21.7357         22.4826         21.7398
220052..........................................         23.7650         23.5225         25.4091         24.2083
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         28.3950         28.1907
220062..........................................         20.4685         20.2254         22.5567         21.0855
220063..........................................         20.3951         20.8079         21.8365         21.0404

[[Page 50167]]

 
220064..........................................         22.3260         22.7497         24.0982         22.9997
220065..........................................         20.1364         20.1424         21.5657         20.6303
220066..........................................         20.7826         23.4477         24.5463         22.8901
220067..........................................         26.4443         27.5405         28.2685         27.3486
220070..........................................         19.7528         20.9128         23.9850         21.5896
220071..........................................         25.6184         27.4151         27.7679         26.9213
220073..........................................         25.6025         26.1328         27.4778         26.3977
220074..........................................         25.6390         24.3057         25.3331         25.0103
220075..........................................         22.8057         22.5329         24.6982         23.3522
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         31.1326         30.0117
220082..........................................         21.6726         22.1453         23.2818         22.3672
220083..........................................         23.9156         22.5815         27.2605         24.4264
220084..........................................         23.6641         25.3761         26.0395         25.0431
220086..........................................         23.8705         26.7778         28.7324         26.2982
220088..........................................         22.9067         23.4258         25.0671         23.8081
220089..........................................         23.0965         25.4106         25.3521         24.5662
220090..........................................         22.0041         23.3049         26.0265         23.7769
220092..........................................         18.5239         24.7905         29.4173         22.0343
220095..........................................         21.4831         21.7851         22.6828         21.9956
220098..........................................         21.5906         23.1547         24.7180         23.1447
220100..........................................         25.7077         27.5841         26.8001         26.6854
220101..........................................         25.9204         27.0711         28.0856         27.0037
220104..........................................         28.0021         28.7258               *         28.3658
220105..........................................         21.4129         21.9185         25.5692         23.0562
220106..........................................         25.6577         25.9277         27.6812         26.4594
220108..........................................         21.9115         23.4975         24.5939         23.3257
220110..........................................         28.7071         29.1648         30.6173         29.5024
220111..........................................         23.8066         24.7510         26.7573         25.1031
220116..........................................         26.1662         32.0049         28.5716         28.7434
220119..........................................         23.3216         23.8785         24.6344         23.9280
220123..........................................         25.8994         32.4678         29.6084         29.3682
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         27.3487         25.7067
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
230004..........................................         23.1036         20.5005         22.4538         21.9617
230005..........................................         18.5644         17.0943         20.5596         18.6769
230006..........................................         19.1041         20.4978         20.6985         20.0828
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         28.8869         23.8899
230021..........................................         18.9636         19.8256         20.9145         19.9553
230022..........................................         18.8006         21.9129         21.8808         20.8639
230024..........................................         23.7326         24.9664         26.2155         24.8592
230027..........................................         14.6950         19.6393         22.5114         18.5396
230029..........................................         19.4911         22.1782         24.9754         22.1623
230030..........................................         18.3916         18.6406         19.2441         18.7650
230031..........................................         19.3162         19.9465         19.4676         19.5690
230032..........................................         21.8845         24.8930         22.8436         23.1984
230034..........................................         19.0473         19.4366         17.9276         18.7511
230035..........................................         17.5109         17.7490         20.5906         18.5317
230036..........................................         23.2119         23.8398         25.1507         24.0919

[[Page 50168]]

 
230037..........................................         20.4747         23.2751         22.7382         22.1469
230038..........................................         23.5251         21.9692         20.9389         22.1189
230040..........................................         21.4393         20.7841         20.2451         20.8039
230041..........................................         20.3131         21.7364         23.2870         21.7251
230042..........................................         22.1043         21.3870         20.7745         21.4261
230046..........................................         25.5696         25.3206         26.1787         25.6837
230047..........................................         21.5381         22.3595         23.7178         22.5293
230053..........................................         25.4968         26.8917         23.5702         25.3801
230054..........................................         20.6963         20.8014         22.2105         21.1829
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         21.0335
230059..........................................         19.9240         20.7092         20.6540         20.4211
230060..........................................         19.8021         19.8987         20.5120         20.0740
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         21.2476         21.1404
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         26.9662         25.2705
230077..........................................         21.0178         20.2823         22.6781         21.3201
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         20.1461         19.7538
230087..........................................         18.9034         19.9700         20.6619         19.7714
230089..........................................         23.9100         22.6994         23.1023         23.1968
230092..........................................         20.0145         20.7738         22.3437         21.0873
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         22.3422         21.7796
230100..........................................         17.1336         17.3842         18.2477         17.5807
230101..........................................         20.0932         20.5315         22.5159         20.9964
230103..........................................         22.7696         11.3429         18.5254         17.4039
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         21.0925         19.9233
230113..........................................         14.9411               *               *         14.9410
230115..........................................         18.4050         19.6281         21.0361         19.6522
230116..........................................         16.5419         14.5692         15.6064         15.5368
230117..........................................         25.9318         25.6797         25.5154         25.7018
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         21.4615         21.0465
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         27.3637         26.7267
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         25.0282         23.5411

[[Page 50169]]

 
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         26.5260         23.6730
230149..........................................         20.7691         18.8005         19.9577         19.8029
230151..........................................         22.1713         23.3967         24.3705         23.2857
230153..........................................         19.5633         18.7403         20.0098         19.4472
230154..........................................         15.4456         15.4362         16.7152         15.8739
230155..........................................         17.2076         20.5409         20.7546         19.4417
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         24.7959         23.8782
230167..........................................         21.5048         22.9745         24.1344         22.8771
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         24.9032         23.8211
230178..........................................         16.9156         17.3030         17.3428         17.1968
230180..........................................         15.8769         18.5744         19.6062         17.9856
230184..........................................         19.0604         19.7717         20.6406         19.8113
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         25.5312         24.5187
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         17.8118         16.8684
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         17.5940         17.3919
230236..........................................         24.3835         25.9676         25.3251         25.2517
230239..........................................         18.0942         17.8168         18.9790         18.2974
230241..........................................         19.1000         20.7297         21.8472         20.5923
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         18.6598         17.7284
230269..........................................         23.3105         24.0992         24.3772         23.9435
230270..........................................         22.6187         22.5985         25.2665         23.4475
230273..........................................         22.9199         22.8715         24.1278         23.2898
230275..........................................         17.7487         20.8985         32.0037         21.0819
230276..........................................         21.3722         25.8709         22.3313         22.8959
230277..........................................         23.1456         23.9771         24.3351         23.8587
230278..........................................         18.2110               *               *         18.2110

[[Page 50170]]

 
230279..........................................         17.6973         17.8074         18.3256         17.9471
230280..........................................         15.6654         18.3497               *         16.7057
230283..........................................         27.9480         22.5082               *         24.9202
230286..........................................               *               *         47.5925         47.5929
230287..........................................               *               *         22.5420         22.5420
240001..........................................         24.6207         25.6936         26.6372         25.6759
240002..........................................         22.7981         23.2307         24.2214         23.4301
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         20.6819         20.9116
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         22.5436         22.3299
240037..........................................         19.2345         20.1195         21.4275         20.2550
240038..........................................         25.3061         24.3957         26.4513         25.4092
240040..........................................         20.4813         23.1352         22.8191         22.1112
240041..........................................         19.2864         21.8655         21.9054         20.9373
240043..........................................         17.7335         16.9859         18.0186         17.5712
240044..........................................         18.8411         20.3339         22.5750         20.4995
240045..........................................         21.1396         24.1557         24.2936         23.2125
240047..........................................         22.6152         23.8098         25.3233         23.8993
240050..........................................         25.2983         21.6499         23.1109         22.6766
240051..........................................         19.9195         22.5855         23.2612         21.9129
240052..........................................         20.7749               *         22.3485         21.5706
240053..........................................         22.9611         23.8693         24.4191         23.8099
240056..........................................         23.4226         23.7139         24.8549         24.0398
240057..........................................         24.2159         24.8686         25.3984         24.8617
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         25.8594         24.6824
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         23.3373         21.6146
240071..........................................         20.2101         21.2463         22.6332         21.3841
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         23.6159         22.6457
240077..........................................         15.3794         20.3445         22.1509         19.1544
240078..........................................         23.9150         25.1082         26.2576         25.1181
240079..........................................         18.4338         18.8345         18.2929         18.5204
240080..........................................         24.3399         25.5619         26.3071         25.3922
240082..........................................         18.3555         18.7995         20.2018         19.1212
240083..........................................         19.7637         21.0317         22.3484         20.9968
240084..........................................         19.4739         21.7421         23.1951         21.4482

[[Page 50171]]

 
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         25.1139         23.9642
240105..........................................         14.3965               *               *         14.3966
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         24.6529         24.0991
240116..........................................         16.6731         18.3520         17.3460         17.3960
240117..........................................         18.0636         17.9941         18.6677         18.2608
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
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         24.5633         23.6102
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         19.1676         16.8305
240139..........................................         20.8053         20.5496         21.0163         20.7883
240141..........................................         23.8066         23.1009         23.6498         23.5064
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         18.6556         18.0746
240154..........................................         17.5769         21.5052         21.5859         20.1583
240155..........................................         19.8762         20.9385         23.6944         21.5112
240157..........................................         17.4168         13.7309         20.0571         17.0514
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

[[Page 50172]]

 
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         26.6381         21.1834
240196..........................................         24.3472         25.3479         26.2793         25.3808
240200..........................................         14.3415         14.9076         18.7517         15.8336
240207..........................................         24.1127         25.2814         26.0927         25.2080
240210..........................................         24.2218         24.5664         25.6060         24.8336
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         19.4531         17.9224
250007..........................................         19.2913         19.7562         20.9757         19.9959
250008..........................................         14.1760         15.8506         15.8096         15.2607
250009..........................................         18.5610         17.7283         18.0463         18.1158
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
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         18.8231         17.5333
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         19.0321         17.2885
250045..........................................         22.0839         21.8988         22.7225         22.2606
250047..........................................         13.3706         14.7461         16.0109         14.4887
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         16.6316         16.2556
250058..........................................         15.5327         15.7197         16.2623         15.8399
250059..........................................         16.2845         16.6494         17.9507         16.9440
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         18.5782         17.7677
250071..........................................         14.3781         12.3488         13.1934         13.2742
250072..........................................         18.2218         18.9487         21.0602         19.2655

[[Page 50173]]

 
250076..........................................         10.5098               *               *         10.5097
250077..........................................         12.2564         13.7404         13.9479         13.2870
250078..........................................         15.6336         15.9739         17.4118         16.3692
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         18.8163         16.4425
250099..........................................         14.8528         15.1265         15.9867         15.3437
250100..........................................         17.1682         17.8688         19.7559         18.3193
250101..........................................         18.4685         17.7194         17.6704         17.9924
250102..........................................         23.9329         18.9348         19.8487         20.8096
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
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         14.4008         13.6109
250125..........................................         20.8895         21.2660         21.9366         21.3768
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               *         21.8600
260001..........................................         18.0971         20.1560         20.9620         19.7027
260002..........................................         22.1183         21.6597         23.4259         22.4118
260003..........................................         14.6553         15.4482         16.2023         15.4433
260004..........................................         13.0133         13.7035         15.2735         13.9164
260005..........................................         19.5554         23.9681         22.5860         22.0140
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         18.3849         17.5418
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

[[Page 50174]]

 
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         20.3847         20.0821
260034..........................................         17.4233         20.4902         20.5439         19.5050
260035..........................................         13.1065         13.0071         15.1611         13.8141
260036..........................................         16.7430         18.8104         20.1242         18.6072
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         20.2724         19.4793
260048..........................................         20.0885         21.0602         22.4800         21.2299
260050..........................................         15.6908         16.8520         17.8142         16.7717
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         22.0091         21.1981
260063..........................................         18.2309         18.8973         19.7231         18.9234
260064..........................................         16.5934         17.8033         18.3749         17.5653
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

[[Page 50175]]

 
260138..........................................         22.6491         23.2364         23.6502         23.1620
260141..........................................         19.1580         19.1893         19.0444         19.1314
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         16.3874         15.4903
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         22.9112         22.0696
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
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

[[Page 50176]]

 
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         23.6058         22.9865
280005..........................................         19.2405         23.6949         22.8981         22.0010
280009..........................................         19.8145         20.9643         23.2300         21.3319
280010..........................................         17.4859         20.0462         22.0137         19.0287
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
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         17.3340
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         16.9344
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

[[Page 50177]]

 
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
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         19.7688         20.3886
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         24.3681         23.3363
290002..........................................         17.2554         16.5419         16.7948         16.8714
290003..........................................         22.8840         24.2175         25.4303         24.1777
290005..........................................         19.4888         21.9814         22.7804         21.4325
290006..........................................         21.8070         22.4063         22.4832         22.2310
290007..........................................         29.7706         30.9075         34.9911         31.9541
290008..........................................         20.6190         24.1255         26.9216         23.3785
290009..........................................         23.3620         23.9373         24.8816         24.0545
290010..........................................         15.6423         16.4476         20.8387         17.4968
290011..........................................         20.1564         21.1234         19.7410         20.3076
290012..........................................         21.8275         25.0430         25.5647         24.2464
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         24.1397         22.9083
290022..........................................         24.5468         25.5011         25.3914         25.1625
290027..........................................         16.7786         13.3769         13.1463         14.2467
290032..........................................         22.8447         23.9504         26.9846         24.7498
290036..........................................               *         12.9074               *         12.9073
290038..........................................         20.6753         27.7030         26.0836         23.3519
290039..........................................         25.3864         25.5024         26.6283         25.8754
290041..........................................               *         25.9905         27.7740         27.0523
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         22.3258         21.7858
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

[[Page 50178]]

 
300009..........................................         18.0602         20.0938         20.1486         19.3957
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         20.0269         19.7788
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         22.8379         21.9548
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
300022..........................................         18.3507         19.1875         20.1209         19.2058
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         31.1568         28.9609
310002..........................................         28.3434         27.9728         28.7786         28.3714
310003..........................................         29.1096         27.5624         29.3522         28.6667
310005..........................................         22.1146         22.9712         23.9477         22.9918
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         28.1367         27.1332
310013..........................................         21.2251         22.5603         23.2424         22.3596
310014..........................................         27.4614         23.1956         31.0834         27.0285
310015..........................................         27.4331         27.9684         29.1340         28.1965
310016..........................................         24.3838         24.5206         26.0738         24.9281
310017..........................................         25.7902         24.5976         25.1634         25.1866
310018..........................................         22.8428         22.4779         24.1428         23.1619
310019..........................................         24.0542         24.9914         28.5952         25.8565
310020..........................................         24.1848         24.4152         25.0803         24.5523
310021..........................................         23.9369         25.4393         27.8958         25.6657
310022..........................................         21.2706         20.8258         23.3412         21.7795
310024..........................................         24.2353         24.9521         27.0459         25.4016
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         24.4290         23.5772
310031..........................................         26.1567         26.6831         26.7174         26.5090
310032..........................................         24.3528         24.7404         24.9133         24.6820
310034..........................................         23.2729         24.1150         24.8567         24.0848
310036..........................................         20.1905         21.7187         23.0320         21.6137
310037..........................................         27.7823         28.1289         28.7738         28.2289
310038..........................................         26.7209         28.4893         28.1756         27.8036
310039..........................................         22.1754         22.7317         23.6605         22.8221
310040..........................................         26.1492         26.3573         26.5769         26.3634
310041..........................................         24.8960         23.5559         23.8857         24.0951
310042..........................................         23.2472         24.7678         24.9702         24.3057
310043..........................................         21.9022         21.6128         24.0238         22.3478
310044..........................................         21.6677         23.1549         23.1489         22.6676
310045..........................................         28.4854         28.9274         29.4877         28.9512
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         28.6248         27.7362
310052..........................................         22.9326         23.3973         24.9773         23.7348
310054..........................................         26.1726         27.7376         27.6290         27.1447

[[Page 50179]]

 
310057..........................................         21.1686         22.2572         22.2630         21.9057
310058..........................................         26.5308         26.3765         25.3983         26.1966
310060..........................................         19.1992         20.0997         21.4455         20.2153
310061..........................................         23.2646         33.9582         23.4283         26.0987
310062..........................................         22.9073               *               *         22.9073
310063..........................................         21.9045         22.1080         21.2619         21.7577
310064..........................................         24.8567         25.4822         25.9350         25.4143
310067..........................................         25.0888         23.9278         24.1943         24.4277
310069..........................................         23.7531         24.2329         25.3464         24.4561
310070..........................................         26.0903         28.2220         29.5101         27.8193
310072..........................................         21.7605         22.5611         24.4480         22.8822
310073..........................................         28.5149         26.2937         26.7954         27.1681
310074..........................................         23.8340         22.3588         24.2009         23.4890
310075..........................................         23.3266         24.4788         23.9771         23.9276
310076..........................................         30.0797         27.9918         29.6667         29.2818
310077..........................................         25.2500         26.1251         26.7092         26.0055
310078..........................................         23.8841         24.0587         24.5862         24.1519
310081..........................................         22.0762         22.4086         23.3310         22.6044
310083..........................................         23.8852         24.8204         25.0191         24.5773
310084..........................................         26.6753         24.6049         25.4946         25.5858
310086..........................................         22.1674         23.1719         23.4966         22.9208
310087..........................................         20.7243         21.1215         20.6847         20.8455
310088..........................................         22.3160         23.1722         23.0610         22.8414
310090..........................................         23.8284         24.8986         23.6661         24.1303
310091..........................................         22.7978         23.2969         24.5357         23.5110
310092..........................................         20.5165         21.6964         22.9721         21.7350
310093..........................................         22.4291         23.7251         23.9404         23.3192
310096..........................................         25.1572         24.5759         26.6588         25.4191
310105..........................................         25.5891         26.2537         28.1317         26.5767
310108..........................................         22.4756         23.8308         25.1368         23.7798
310110..........................................         21.8341         23.2146         23.3461         22.8546
310111..........................................         21.1066         22.1151         23.3646         22.1990
310112..........................................         23.6701         24.7914         24.2999         24.2528
310113..........................................         23.6841         23.1961         24.2708         23.7328
310115..........................................         21.7320         21.1645         23.5148         22.1431
310116..........................................         22.9812         23.6366         24.2696         23.6118
310118..........................................         26.4625         26.1315         26.8760         26.4761
310119..........................................         33.6686         32.7858         29.1045         31.7976
310120..........................................         23.9681         23.3200         22.6526         23.3189
320001..........................................         19.1150         20.6225         21.5564         20.4107
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         19.1476         19.2439
320012..........................................         16.4355         17.1764         17.1317         16.8928
320013..........................................         22.9573         24.5543         25.5403         24.4572
320014..........................................         16.3598         16.8412         22.9026         18.5503
320016..........................................         20.5398         18.8519         18.8763         19.4121
320017..........................................         18.6388         19.4498         20.4390         19.4898
320018..........................................         18.8479         19.2336         20.3141         19.4697
320019..........................................         24.4707         26.9637         25.1210         25.6183
320021..........................................         17.8705         19.1265         20.0089         18.9760
320022..........................................         16.1777         18.0606         20.9797         18.5397
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         21.4815         20.2510
320033..........................................         25.0777         21.0621         21.9804         22.5777
320035..........................................         21.5186         15.0612         17.8058         17.7193
320037..........................................         17.0305         17.8280         17.6724         17.5157
320038..........................................         16.8117         22.2664         23.1987         20.9645
320046..........................................         18.3190         18.9607         19.4732         18.9435
320048..........................................         19.9642         16.8769               *         18.3467

[[Page 50180]]

 
320063..........................................         18.3237         17.9089         18.5600         18.2484
320065..........................................         16.7933         18.6525         22.5428         19.0210
320067..........................................         33.8654         15.3228         16.8015         18.3132
320068..........................................         17.4785         18.5103         15.6864         17.1411
320069..........................................         13.0094         14.4212         15.7350         14.3622
320074..........................................         19.3406         20.2290         22.3403         20.2679
320079..........................................         18.2828         19.8555         20.2473         19.4478
330001..........................................         26.5533         27.3996         28.6214         27.5633
330002..........................................         26.5370         26.9341         27.1811         26.8727
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         19.5836         18.5046
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         17.9161         17.7212
330055..........................................         36.1109         32.8910         34.2159         34.3472
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         20.1615         19.9917
330066..........................................         19.5611         18.8707         19.3644         19.2586
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         18.9326         18.2224
330075..........................................         17.2298         17.6385         19.2938         18.0353
330078..........................................         16.7949         18.7884         18.0362         17.8405
330079..........................................         17.4555         18.7622         18.9398         18.3917
330080..........................................         29.2686         31.4424         34.6880         31.6540
330084..........................................         18.0435         19.3216         19.0261         18.8002
330085..........................................         20.2926         20.6203         20.9332         20.6126
330086..........................................         31.2980         23.6496         26.2979         27.1579

[[Page 50181]]

 
330088..........................................         25.6626         25.7940         26.7583         26.0739
330090..........................................         19.3954         19.2112         20.1344         19.5790
330091..........................................         19.0953         19.7776         21.6004         20.1526
330092..........................................         14.0671         13.3723         17.2083         14.8861
330094..........................................         17.5585         18.1582         18.8941         18.2051
330095..........................................         20.1073         21.1096         21.1809         20.7563
330096..........................................         17.9641         18.5149         20.0370         18.8403
330097..........................................         16.2169         16.4433         16.1945         16.2798
330100..........................................         27.0661         29.0916         28.9956         28.3021
330101..........................................         32.4105         31.5914         35.3618         33.2017
330102..........................................         17.5755         19.0058         21.0057         19.0881
330103..........................................         15.7197         16.8110         17.3511         16.6312
330104..........................................         31.6471         31.2074         31.9746         31.6063
330106..........................................         40.2686         35.3775         36.2526         37.1762
330107..........................................         28.5580         27.7797         28.9225         28.4199
330108..........................................         17.3605         18.0786         18.5849         17.9950
330111..........................................         19.5314         15.9321         13.3352         15.9787
330114..........................................         17.3522         17.0581         19.1162         17.8316
330115..........................................         17.4430         17.4684         18.5911         17.8343
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         20.5922         20.0689
330126..........................................         23.7938         23.8957         25.1175         24.2981
330127..........................................         31.9046         30.7356         40.0112         34.3173
330128..........................................         29.0222         30.8242         34.3468         31.2952
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         20.4124         19.5654
330140..........................................         19.1438         19.3615         21.1841         19.9069
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         33.5587         31.5460
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         20.2753         19.6267
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         22.0699         20.9292
330166..........................................         15.0954         15.4420         17.0637         15.8309
330167..........................................         29.3634         30.2346         32.0541         30.4443
330169..........................................         37.2655         35.4794         36.3690         36.3400
330171..........................................         25.5307         24.8035         25.1567         25.1635
330175..........................................         17.3290         18.3116         18.8701         18.1413
330177..........................................         17.2907         16.3704         16.6059         16.7542
330179..........................................         13.4999         13.8953         16.0113         14.4058
330180..........................................         16.8787         17.9877         19.2670         17.9995
330181..........................................         32.5192         33.0908         34.6065         33.3779
330182..........................................         32.9371         33.6531         33.3363         33.3137
330183..........................................         19.9207         20.6164         20.3520         20.2984
330184..........................................         30.0400         31.3706         28.4726         30.0103
330185..........................................         25.6112         26.8612         27.8894         26.7722
330188..........................................         20.9587         18.8000         20.2849         20.0186
330189..........................................         15.1253         18.4498         23.5589         18.7634
330191..........................................         18.6206         19.0348         19.5623         19.0759
330193..........................................         36.5481         30.2260         32.5496         32.9872
330194..........................................         34.6785         35.2036         35.6486         35.1819
330195..........................................         33.3254         34.8966         34.4689         34.2028
330196..........................................         30.8165         30.5799         28.9488         30.1409

[[Page 50182]]

 
330197..........................................         17.6646         18.3527         19.2237         18.4045
330198..........................................         24.6038         24.8590         25.6669         25.0413
330199..........................................         28.7609         30.5409         28.0374         29.1320
330201..........................................         32.1149         28.7861         30.0524         30.3389
330202..........................................         31.4435         31.2575         35.4943         32.7201
330203..........................................         20.7575         25.0345         25.9211         23.7716
330204..........................................         29.4418         32.2005         31.1366         30.8772
330205..........................................         20.5793         22.3490         24.9040         22.5611
330208..........................................         26.1822         26.6682         27.3170         26.7219
330209..........................................         23.9924         25.1281         27.0257         25.4421
330211..........................................         19.5064         19.5405         20.0006         19.6855
330212..........................................         21.7705         24.7681         24.8554         23.7568
330213..........................................         18.7722         19.6796         20.1166         19.4878
330214..........................................         36.4447         32.4292         32.3130         33.3200
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         32.5044         31.2700
330222..........................................         18.3666         18.5571         19.3148         18.7515
330223..........................................         17.6199         17.8306         19.1604         18.2153
330224..........................................         19.6410         20.4309         20.5881         20.2163
330225..........................................         25.5823         27.0379         28.0523         26.7760
330226..........................................         16.6711         23.1859         21.6368         20.2080
330229..........................................         16.8026         17.5326         18.2554         17.5103
330230..........................................         29.7626         29.6283         30.6937         29.9984
330231..........................................         30.0923         32.7200         32.4163         31.6314
330232..........................................         17.9083         19.1787         20.0924         19.0447
330233..........................................         30.9241         44.1265         43.1186         38.2032
330234..........................................         35.1777         35.0720         35.8327         35.3617
330235..........................................         21.0842         19.5880         20.1255         20.2820
330236..........................................         29.5913         31.3463         32.1246         30.9874
330238..........................................         15.6245         17.3976         17.8867         16.9394
330239..........................................         17.4462         18.5079         18.9953         18.2764
330240..........................................         29.7082         30.7321         35.6576         31.8043
330241..........................................         24.6076         23.8638         24.7545         24.4065
330242..........................................         28.2612         27.6384         28.3561         28.0883
330245..........................................         17.6767         18.5161         20.7605         19.0556
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         20.8742         20.1545
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         24.9714         23.5858
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         33.0375         34.5188
330273..........................................         23.1511         26.0565         27.0454         25.3482
330275..........................................         19.0548         18.7268               *         18.9109
330276..........................................         18.2870         19.0228         19.6572         18.9869
330277..........................................         18.3169         19.1761         20.7851         19.4340
330279..........................................         19.5983         20.7107         21.7827         20.6371
330285..........................................         23.5264         24.0491         24.5388         24.0351
330286..........................................         26.7633         27.7762         28.0994         27.5677
330290..........................................         33.5056         30.4706         34.3439         32.7503
330293..........................................         16.2158         16.9238         17.3180         16.7809
330304..........................................         26.7683         27.3562         29.2207         27.7999
330306..........................................         27.3798         29.5937         29.6641         28.8531
330307..........................................         21.0673         21.7257         23.2838         22.0498
330314..........................................         24.5444         25.9937         25.5405         25.3155
330316..........................................         27.6102         27.9543         27.9277         27.8310
330327..........................................         16.4611         20.3874         20.1705         18.8688

[[Page 50183]]

 
330331..........................................         31.6216         33.1276         32.3249         32.3864
330332..........................................         27.6914         25.3689         27.6955         26.9473
330333..........................................         29.1931               *         28.8819         29.0166
330336..........................................         29.7689         29.8294         27.9163         29.1955
330338..........................................         22.4581         21.2670         23.6142         22.4472
330339..........................................         20.0111         20.1028         20.2382         20.1121
330340..........................................         28.8419         28.4129         28.2732         28.5256
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         23.5381         28.1605
330381..........................................         31.0091         31.8602               *         31.4219
330385..........................................         35.6722         33.2246         37.5523         35.5897
330386..........................................         17.6383         20.4231         21.4363         19.4104
330389..........................................         30.2505         37.3749         33.1192         33.1975
330390..........................................         31.1577         30.8744         31.7344         31.2381
330393..........................................         26.4958         27.8352         31.9272         28.5908
330394..........................................         19.2392         18.9343         19.6892         19.2847
330395..........................................         32.8749         32.7494         33.2318         32.9405
330396..........................................         34.8648         30.7961         32.8517         32.9044
330397..........................................         33.9061         32.6068         34.6435         33.6607
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         22.0257         19.9576
340002..........................................         20.8858         20.5253         22.9425         21.5738
340003..........................................         20.2540         19.5145         19.6545         19.8018
340004..........................................         19.0695         20.9863         23.0890         21.0811
340005..........................................         15.8205         16.7176         16.6909         16.4458
340006..........................................         16.9818         16.5709         16.1379         16.5756
340007..........................................         17.2356         18.3399         18.3760         17.9959
340008..........................................         21.2889         20.4157         22.6570         21.4924
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         19.9023         19.2892
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         23.9505         22.4602
340031..........................................         14.6951         14.6370         15.4935         14.9011
340032..........................................         20.0049         20.7444         22.0245         20.9102
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         22.4020         21.4803
340040..........................................         20.4282         20.7237         21.1397         20.7708
340041..........................................         15.1419         15.5873         16.3200         15.6803
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         21.5178         20.5318
340049..........................................         19.2050         19.5127         17.2986         18.6550

[[Page 50184]]

 
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         23.2410         21.3227
340054..........................................         15.5993         15.5090         16.6208         15.8560
340055..........................................         19.6056         19.4035         20.8253         19.9607
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         17.6106         18.8953
340065..........................................         17.5414         17.3530         23.2606         18.9401
340067..........................................         19.3785         19.7187         22.4054         20.2943
340068..........................................         16.6305         17.8065         18.8758         17.7729
340069..........................................         21.0840         21.6728         22.5995         21.8080
340070..........................................         19.7796         20.6829         21.3511         20.6142
340071..........................................         17.1424         18.0767         19.3679         18.2275
340072..........................................         16.7400         17.7129         18.7920         17.7544
340073..........................................         21.9761         23.5832         24.0794         23.2689
340075..........................................         18.7090         20.0081         19.7450         19.4817
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         21.2665         20.7762
340093..........................................         16.3276         16.8903         16.5452         16.5873
340094..........................................         19.0406               *         21.0091         20.0488
340096..........................................         17.8189         19.4696         20.9686         19.4268
340097..........................................         18.8412         18.2399         20.0302         19.0440
340098..........................................         21.4135         21.9578         23.4949         22.3232
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         24.4222         22.5465
340114..........................................         21.2166         20.7261         21.7750         21.2327
340115..........................................         19.7578         21.7586         24.7924         21.8733
340116..........................................         20.4255         20.6800         21.6744         20.9328
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         21.2045         19.7489
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         17.5170         17.0631
340137..........................................         21.0249         31.7702         39.9826         26.4042
340138..........................................         20.7618               *               *         20.7618
340141..........................................         21.3754         21.4986         23.2961         22.0643
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

[[Page 50185]]

 
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         25.0965         22.9070
340158..........................................         18.1439         19.0843         20.0921         19.1509
340159..........................................         17.3893         19.0338         19.4992         18.6617
340160..........................................         16.1778         16.7170         17.1963         16.7262
340162..........................................         14.3472               *               *         14.3474
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         23.4052         22.0656
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         17.8145         17.1631
350014..........................................         16.8403         18.0999         18.6786         17.8036
350015..........................................         16.3397         17.1071         17.5658         16.9655
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         18.7993         18.2025
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         19.5497         18.9137
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         16.8322         16.4660
350050..........................................         11.4921         12.2183         25.2747         13.9652
350051..........................................         17.7279         17.0653         16.9201         17.2392
350053..........................................         14.6398         15.9160         16.7456         15.7135
350055..........................................         14.5691         15.7916         16.1691         15.5004
350056..........................................         14.8293         15.0995         15.7752         15.2147
350058..........................................         15.9378         16.7034         16.1013         16.2607
350060..........................................         10.3666         10.3076         10.5325         10.3988
350061..........................................         15.7269         18.8790         19.6460         18.1394
360001..........................................         17.0791         19.6655         20.3515         18.9788
360002..........................................         18.0139         18.2613         19.6145         18.5918
360003..........................................         22.7471         22.7521         23.2905         22.9196
360006..........................................         21.8048         22.4436         22.6333         22.2902
360007..........................................         18.0941         14.8213         15.3656         16.0665
360008..........................................         18.5439         18.7961         19.8034         19.0500
360009..........................................         18.9322         18.9935         19.6277         19.2000

[[Page 50186]]

 
360010..........................................         19.2288         19.1852         20.5934         19.6922
360011..........................................         19.3835         21.3659         19.5383         20.0283
360012..........................................         19.9881         20.0525         23.0125         21.0366
360013..........................................         20.6021         21.3690         22.3407         21.4314
360014..........................................         20.2390         20.7419         22.9930         21.3333
360016..........................................         17.8065         21.2505         21.3967         20.0182
360017..........................................         21.7543         22.2740         22.7446         22.2365
360018..........................................         23.5219         24.6686         24.6694         24.2429
360019..........................................         18.7147         20.6480         21.4708         20.1693
360020..........................................         21.7806         22.1751         21.6607         21.8722
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         22.8098         21.8716
360028..........................................         17.0177         18.7174               *         17.7935
360029..........................................         18.7622         19.2928         19.7466         19.2762
360030..........................................         17.5748         17.6058         19.0551         18.0921
360031..........................................         19.3858         21.0687         21.0481         20.5037
360032..........................................         18.6559         19.8020         19.8367         19.4058
360034..........................................         14.9534         17.9594         19.4982         17.4782
360035..........................................         20.5557         21.0674         22.6982         21.4596
360036..........................................         20.2107         20.9916         21.4486         20.8814
360037..........................................         23.5094         23.1674         23.7504         23.5019
360038..........................................         21.2467         19.9415         21.4804         20.8884
360039..........................................         18.7791         19.0013         19.3703         19.0512
360040..........................................         18.1618         18.7425         19.9750         18.9827
360041..........................................         19.5744         19.7968         21.9093         20.5114
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         19.8037         19.4032
360054..........................................         17.2574         17.4911         17.5714         17.4428
360055..........................................         21.5585         21.4112         22.8755         21.9415
360056..........................................         19.0474         20.6968         23.4405         21.1066
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         20.7659         20.4360
360065..........................................         20.0532         19.6199         22.3443         20.6667
360066..........................................         21.6015         22.8175         24.1295         22.8841
360067..........................................         15.3157         14.2745         17.3734         15.6086
360068..........................................         21.2789         22.6227         22.6027         22.1750
360069..........................................         16.6982         14.6597         18.5382         16.4901
360070..........................................         17.3758         18.8406         19.4700         18.5552
360071..........................................         17.9756         19.0302         19.6873         18.9152
360072..........................................         18.1467         19.0166         20.8819         19.3874
360074..........................................         20.8275         18.5889         19.9947         19.7927
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         22.7743         22.2897
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

[[Page 50187]]

 
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         20.8049         20.0522
360099..........................................         18.5855         19.6241         20.8801         19.7171
360100..........................................         17.8989         18.0442         19.9768         18.5656
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         21.9939         21.3334
360108..........................................         17.5832         20.0681         19.0649         18.8939
360109..........................................         20.1032         19.9237         17.3564         18.9331
360112..........................................         22.5589         24.6335         25.7920         24.1917
360113..........................................         24.2654         20.8154         22.8088         22.5276
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         17.5557         16.8979
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         21.6081         21.0768
360136..........................................         17.7827         18.2194         18.5687         18.1837
360137..........................................         20.1756         22.3648         23.1867         21.8635
360140..........................................         20.2791         21.2881         18.3463         19.9463
360141..........................................         23.0016         23.5343         23.5980         23.3798
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
360151..........................................         16.6019         19.2788         20.5594         18.6756
360152..........................................         20.8328         21.6005         20.9704         21.1340
360153..........................................         15.4132         16.7399         16.1021         16.0822
360154..........................................         14.3270         14.3593         14.9606         14.5355
360155..........................................         22.5347         22.2112         22.3347         22.3576
360156..........................................         17.8787         18.9095         19.9382         18.8811
360159..........................................         20.2841         21.5695         22.7992         21.5782
360161..........................................         19.1983         20.6160         19.6266         19.8098
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         19.7980         18.7693
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         17.6743         16.7422
360177..........................................         18.7898         18.9576         19.6992         19.1509

[[Page 50188]]

 
360178..........................................         18.8704         16.7962         18.0773         17.9514
360179..........................................         21.1309         20.7069         21.3520         21.0546
360180..........................................         21.3826         21.0146         22.9260         21.7254
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         21.2801         20.6088
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         21.0473         21.6050
360236..........................................         17.8426         21.4628         20.5683         19.8573
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               *         25.4330
360250..........................................               *               *         50.5106         50.5105
370001..........................................         22.5214         24.1929         22.0586         22.8881
370002..........................................         14.7315         15.4333         16.1853         15.4106
370004..........................................         19.3236         18.5233         22.5027         20.0512
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         18.9169         18.8656
370016..........................................         19.1191         19.1613         20.0888         19.4559
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         18.4568         17.1242
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         22.7015         19.0508
370040..........................................         14.4672         15.5109         16.8127         15.5746

[[Page 50189]]

 
370041..........................................         16.7356         16.2316         14.7346         15.7346
370042..........................................         14.9175         15.2764         15.9005         15.3820
370043..........................................         15.9534         17.0892         20.0991         17.5940
370045..........................................         10.1994         11.3560         11.6163         10.9883
370046..........................................         18.8334               *               *         18.8333
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         19.2867         18.6158
370057..........................................         16.7261         15.1228         16.0301         15.9579
370059..........................................         18.1386         18.3314         21.3103         19.2182
370060..........................................         16.5403         19.3051         17.9469         17.9209
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         13.7216         15.1761
370086..........................................         15.4404         11.1900               *         13.0199
370089..........................................         16.0966         17.2638         17.9243         17.0970
370091..........................................         19.1698         20.1822         20.8536         20.0799
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         19.3793         21.5888
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         21.8937         20.2077
370108..........................................         12.3279         12.7470         14.0190         13.0228
370112..........................................         14.8539         15.3039         14.3384         14.8216
370113..........................................         16.1046         17.6107         20.3439         17.9275
370114..........................................         16.5268         17.8941         17.9757         17.4836
370121..........................................         22.5611         21.3099         20.5488         21.4026
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         22.6237         21.3227
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         25.5592         24.1706
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

[[Page 50190]]

 
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..........................................               *               *         16.5384         16.5384
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         19.9606         19.4970
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
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         26.1370         21.8465
380063..........................................         20.4077               *               *         20.4077
380064..........................................         19.9826         22.9160         27.0627         23.2662
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         25.9113         24.6318
380072..........................................         19.1553         19.4346         20.6568         19.7391
380075..........................................         22.3625         22.4139         23.1910         22.6625

[[Page 50191]]

 
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         20.8831         20.8859
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         21.7867         21.0548
390007..........................................         21.7506         21.3839               *         21.5715
390008..........................................         17.8297         18.2743         19.5439         18.5382
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         22.2060         21.3101
390013..........................................         19.2698         19.6562         20.2186         19.7244
390015..........................................         13.1337         13.7352         14.3138         13.7169
390016..........................................         16.9892         17.1133         17.4931         17.1968
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         25.2980         23.8721
390023..........................................         21.8270         22.1044         23.9246         22.7927
390024..........................................         24.9437         25.4606         27.7643         26.0343
390025..........................................         15.6155         15.5523         14.0077         15.0571
390026..........................................         22.3902         22.9718         23.6317         23.0154
390027..........................................         26.8878         29.5940         29.4334         28.6169
390028..........................................         22.7700         23.6571         22.7820         23.0704
390029..........................................         21.5729         21.2661         24.4753         22.2475
390030..........................................         17.9580         18.6887         18.9121         18.5104
390031..........................................         19.2755         18.8162         19.2040         19.0999
390032..........................................         17.8041         21.5105         18.5545         19.2157
390035..........................................         20.2029         22.3591         21.9325         21.4746
390036..........................................         19.9880         19.7671         20.2103         19.9884
390037..........................................         21.0616         20.4263         19.9175         20.4619
390039..........................................         17.1046         17.5300         17.6181         17.4169
390040..........................................         15.9612         16.6876         17.4451         16.6853
390041..........................................         19.8080         20.4397         19.6159         19.9368
390042..........................................         22.7693         22.5775         22.0668         22.4719
390043..........................................         17.2607         17.4764         17.6739         17.4691
390044..........................................         20.2813         20.9831         21.3382         20.8726
390045..........................................         18.5574         19.4677         20.2107         19.4227
390046..........................................         20.7303         21.7445         21.3960         21.2868
390047..........................................         27.6661         26.9709               *         27.3457
390048..........................................         19.0920         19.7992         18.9776         19.2752
390049..........................................         21.1217         22.1586         22.8196         22.0220
390050..........................................         22.8808         22.2639         24.9156         23.2311
390051..........................................         25.7910         28.1385               *         26.8617
390052..........................................         20.9306         20.1195         21.2729         20.7554
390054..........................................         17.8852         18.4975         19.4686         18.5971
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         19.0132         19.2529

[[Page 50192]]

 
390067..........................................         20.9688         20.8162         21.9885         21.2544
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         16.9445         16.6922
390073..........................................         20.5581         21.2623         22.2703         21.3817
390074..........................................         18.4806         18.3093         19.7446         18.8130
390075..........................................         17.9840         18.7695         19.5840         18.6669
390076..........................................         20.2475         21.3290         19.7719         20.4342
390078..........................................         19.2089         19.0156         20.6483         19.5808
390079..........................................         18.3312         18.9269         19.5982         18.9583
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         19.7645         18.9070
390088..........................................         23.6173         23.9506               *         23.7777
390090..........................................         21.6437         21.3759         20.5433         21.2027
390091..........................................         18.1569         18.3770         19.0355         18.5125
390093..........................................         17.7171         18.4442         20.0135         18.7217
390095..........................................         16.3357         16.6930         17.9697         16.9815
390096..........................................         19.1171         22.4382         22.2974         21.1662
390097..........................................         23.5963         25.2845         24.7853         24.5092
390100..........................................         20.7859         20.9263         21.1186         20.9469
390101..........................................         17.9499         18.5039         19.0180         18.4836
390102..........................................         19.0461         21.5496         19.3111         19.9785
390103..........................................         18.4312         18.8667         20.4422         19.2092
390104..........................................         15.9008         16.3255         16.2440         16.1553
390106..........................................         16.6666         16.8439         17.4747         16.9857
390107..........................................         19.5178         20.9841         20.6024         20.3811
390108..........................................         21.0899         21.3142         22.0444         21.4659
390109..........................................         16.4597         16.5299         17.4540         16.8127
390110..........................................         21.5282         21.6464         21.6005         21.5915
390111..........................................         27.5193         33.3971         27.1429         29.3913
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         22.3545         22.3386
390116..........................................         21.4877         21.3671         22.6783         21.8481
390117..........................................         17.9393         18.0769         18.9764         18.3315
390118..........................................         18.3440         18.9507         17.2668         18.1975
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         21.8897         21.3699
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         19.1931         18.1205
390132..........................................         21.1931         22.8414         24.1878         22.7048
390133..........................................         23.3489         24.7561         24.1590         24.0369
390135..........................................         21.5782         22.1905         22.2501         22.0004
390136..........................................         16.9737         20.6286         16.8505         18.1580
390137..........................................         17.5687         18.5397         19.4769         18.4683
390138..........................................         19.6212         20.6936         20.7726         20.3703
390139..........................................         24.4515         23.9757         24.8347         24.4216
390142..........................................         26.8086         28.8877         28.4680         28.1212
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

[[Page 50193]]

 
390153..........................................         23.7013         22.9707         23.9039         23.5281
390154..........................................         17.4036         16.7052         17.8774         17.3537
390156..........................................         21.8498         22.6398         24.0034         22.7950
390157..........................................         19.6578         19.1783         20.2647         19.6975
390160..........................................         21.4810         19.4463         19.4793         20.0709
390161..........................................         16.4799               *               *         16.4799
390162..........................................         21.4095         21.9188         21.3379         21.5605
390163..........................................         16.8013         17.7564         18.1831         17.5889
390164..........................................         24.6765         24.9750         26.1698         25.2621
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         18.8265         18.6759
390174..........................................         25.4189         25.3307         26.3891         25.6959
390176..........................................         17.8740         20.8368         21.7650         20.0495
390178..........................................         16.6993         17.0534         17.1142         16.9526
390179..........................................         21.6901         21.8593         21.5792         21.7082
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         19.6186         20.0014
390191..........................................         16.3240         17.2270         17.1919         16.8998
390192..........................................         17.4537         17.6597         16.6469         17.2541
390193..........................................         16.7874         18.1209         17.3804         17.3866
390194..........................................         20.7953         21.2689         21.0549         21.0283
390195..........................................         24.6855         24.1793         24.2891         24.3890
390197..........................................         19.2690         20.7998         22.1974         20.7901
390198..........................................         15.9721         15.8833         16.6803         16.1535
390199..........................................         17.0515         17.3865         17.7782         17.3993
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         22.7282         21.9570
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         20.1152         19.3527
390215..........................................         20.7084         21.2032         23.5953         21.7981
390217..........................................         19.1406         19.9837         19.7578         19.6158
390219..........................................         18.8292         19.6226         20.1311         19.5227
390220..........................................         18.7178         17.7916         22.7617         19.7037
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         22.8588         22.1457
390228..........................................         19.4083         19.8180         19.6212         19.6177
390231..........................................         22.7544         19.4798         21.0757         20.9857
390233..........................................         19.4887         20.2309         20.5800         20.1134
390235..........................................         25.0857         21.4200         19.9925         22.7713
390236..........................................         16.2397         17.8735         19.1427         17.7118
390237..........................................         19.5230         22.3011         21.7847         21.1302
390238..........................................         17.8211         17.1055         18.1956         17.6820
390244..........................................         15.4611         15.6402         14.2136         15.1054
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

[[Page 50194]]

 
390263..........................................         20.6855         20.3796         20.6348         20.5647
390265..........................................         20.3580         20.4950         20.4760         20.4411
390266..........................................         17.1666         17.1966         17.6223         17.3305
390267..........................................         21.2974         19.2665         20.2424         20.3797
390268..........................................         21.3486         22.0909         22.2046         21.8827
390270..........................................         19.0925         19.2074         20.7957         19.6567
390278..........................................         18.2865         17.7176         18.5776         18.2038
390279..........................................         14.3241         14.8655         15.8080         14.9814
390283..........................................               *         22.5490               *         22.5489
390284..........................................               *         34.3904               *         34.3902
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         23.5284
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
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         12.1251         11.2505
400021..........................................         10.6988         12.1434         12.7462         11.9145
400022..........................................         11.5861         12.2199         13.0915         12.2933
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          9.1794          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          9.4600          8.7591
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         12.2080         11.7082
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          9.3000          8.9540
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

[[Page 50195]]

 
400121..........................................          7.8052          9.8322          8.7584          8.8340
400122..........................................          8.1911          7.6413          9.1638          8.3405
400123..........................................          7.8099         10.2367         10.9047          9.6438
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         23.5408         22.3806
410005..........................................         23.1444         22.7170         24.0086         23.2835
410006..........................................         23.3968         23.8700         22.8959         23.3695
410007..........................................         22.1452         23.1325         24.9846         23.3527
410008..........................................         23.0662         24.9726         24.4792         24.1739
410009..........................................         24.4899         24.3895         24.3760         24.4190
410010..........................................         26.9813         28.4589         29.7315         28.3794
410011..........................................         25.2926         26.1183         27.4880         26.2586
410012..........................................         24.5811         24.1695         26.4570         25.0414
410013..........................................         24.5122         24.8800         25.3688         24.9319
420002..........................................         19.4845         20.7804         22.6182         20.9552
420004..........................................         19.7968         20.9588         22.4680         21.0257
420005..........................................         17.3510         17.9694         17.8202         17.7153
420006..........................................         18.3439         19.1760         18.7153         18.7343
420007..........................................         18.2096         18.6456         19.0199         18.6081
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
420014..........................................         16.6065         18.0519         19.0455         17.8775
420015..........................................         18.8411         20.1164         20.8736         19.8858
420016..........................................         15.6241         15.5485         16.6448         15.9623
420018..........................................         19.7367         21.8775         20.7779         20.7419
420019..........................................         16.9990         17.1726         19.0199         17.6834
420020..........................................         20.9449         20.3193         20.5801         20.5993
420023..........................................         19.4855         20.4053         20.8600         20.2789
420026..........................................         20.3476         21.8749         23.3072         21.9035
420027..........................................         18.8457         19.2594         19.7322         19.2883
420030..........................................         19.1453         20.6448         22.5159         20.8443
420031..........................................         14.1855          8.2516         15.3605         11.6044
420033..........................................         21.7279         23.1303         23.7974         22.8884
420036..........................................         17.6136         21.3222         19.8285         19.5069
420037..........................................         21.7908         22.7099         23.5244         22.7289
420038..........................................         17.6726         18.6568         19.9829         18.7495
420039..........................................         15.8385         18.3017         18.0055         17.3738
420043..........................................         19.4521         19.7570         19.6834         19.6347
420048..........................................         18.4367         18.8070         20.5531         19.2732
420049..........................................         17.5854         19.4049         20.1765         19.0818
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         20.8524         19.8567
420068..........................................         18.5030         18.5481         20.2580         19.1326
420069..........................................         17.0788         18.1298         18.9017         18.0129
420070..........................................         18.0057         17.3876         19.2186         18.1995
420071..........................................         19.4482         20.3902         20.1897         20.0146
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

[[Page 50196]]

 
420080..........................................         22.3443         21.9968         23.2871         22.5856
420082..........................................         20.4653         21.7210         22.8516         21.6895
420083..........................................         20.1472         22.6376         24.4499         22.3616
420085..........................................         19.9603         21.6791         22.0071         21.2571
420086..........................................         25.7179         20.2878         23.5303         23.0156
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         33.4634
420096..........................................               *               *         26.4863         26.4864
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
430015..........................................         18.0019         18.2875         18.8998         18.3871
430016..........................................         19.4759         20.8850         22.7585         20.9797
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

[[Page 50197]]

 
440010..........................................         19.9829         16.3283         13.3692         16.2699
440011..........................................         17.6948         18.3375         19.3165         18.4706
440012..........................................         15.9837         19.5739         19.8949         18.4979
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         20.4705         20.1721
440018..........................................         16.4115         17.4995         18.1620         17.3534
440019..........................................         20.0416         21.5402         22.8463         21.4594
440020..........................................         18.1154         17.8879         20.2189         18.7233
440022..........................................         15.8459               *               *         15.8461
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
440032..........................................         13.9775         13.8140         13.9784         13.9249
440033..........................................         14.5304         13.7328         16.4679         14.8744
440034..........................................         19.5470         20.0309         21.1672         20.2667
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         21.6132         20.8900
440049..........................................         17.9292         18.7967         19.6920         18.7945
440050..........................................         19.1328         18.2511         19.7915         19.0510
440051..........................................         13.1901         16.0421         17.7067         15.5027
440052..........................................         16.6541         19.8075         18.6589         18.2811
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         20.7722         19.5723
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         18.8072         19.3003
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         19.5428         19.4608
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         17.2905         18.2386
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

[[Page 50198]]

 
440125..........................................         15.6588         19.4115         20.0599         18.4060
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         22.2257         22.2659
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         18.3850         17.9146
440147..........................................         21.4304         26.1464         25.3766         24.0818
440148..........................................         19.2435         19.4598         19.3769         19.3574
440149..........................................         16.6923         18.4281         19.8304         18.3721
440150..........................................         20.1411         20.3006         21.2942         20.5974
440151..........................................         17.4248         18.3928         19.8977         18.5439
440152..........................................         21.0287         22.7664         21.7382         21.7452
440153..........................................         16.7769         16.5716         18.1781         17.1656
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         23.6805         22.8012
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         19.9022         19.4845
440176..........................................         18.0294         19.2208         19.8448         19.0126
440180..........................................         19.7773         20.2184         20.2057         20.0681
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         20.8600         20.0053
440187..........................................         18.9713         17.5872         18.3729         18.3113
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         18.7302         18.8422
440203..........................................         18.3400         16.2861         16.9819         17.1896
440206..........................................         16.4429               *               *         16.4428
440210..........................................         11.0218         11.9815         12.7622         11.9731
440211..........................................         14.8972               *               *         14.8972
440212..........................................         17.0685               *               *         17.0686
440213..........................................         19.5760               *               *         19.5758
440214..........................................               *         28.0285               *         28.0287
440215..........................................               *         22.2928               *         22.2928
440217..........................................               *               *         19.2834         19.2834
450002..........................................         21.3749         21.4836         21.5141         21.4583
450004..........................................         16.6723         16.7850         15.9452         16.5074
450005..........................................         18.3600         16.6396         16.6354         17.2368
450007..........................................         16.9681         19.1910         18.0269         18.0419
450008..........................................         17.0832         17.6582         19.3745         18.0076
450010..........................................         16.5001         17.6677         19.8998         18.3388
450011..........................................         17.1942         20.8102         20.2963         19.3771
450014..........................................         17.9495         17.5815         19.8846         18.4700
450015..........................................         18.9895         21.6773         22.9820         21.1074
450016..........................................         18.4463         18.3456         19.1522         18.6447
450018..........................................         21.4788         23.2293         21.9921         22.1397
450020..........................................         17.8415         19.1153         18.4642         18.4858
450021..........................................         23.0843         23.3630         23.7663         23.4150

[[Page 50199]]

 
450023..........................................         16.0831         17.6360         19.2808         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         19.9505         18.4194
450031..........................................         22.2222         29.6945         29.6772         27.1869
450032..........................................         17.3317         14.6530         20.8525         17.3455
450033..........................................         19.7437         21.0222         21.3766         20.7326
450034..........................................         19.6721         18.8823         19.5233         19.3523
450035..........................................         20.0951         20.3599         20.3146         20.2513
450037..........................................         19.5411         19.9140         19.6532         19.7050
450039..........................................         19.8143         19.7176         20.4660         19.9969
450040..........................................         16.8534         19.6370         24.8621         21.1896
450042..........................................         19.8921         18.8357         20.6041         19.7840
450044..........................................         24.7961         21.0909         23.4476         22.9976
450046..........................................         18.6536         17.3631         20.2917         19.2568
450047..........................................         13.4486         16.9028         15.9525         15.2979
450050..........................................         14.7669         17.7209         19.1390         17.0907
450051..........................................         21.0236         21.1008         23.0010         21.6800
450052..........................................         13.8881         15.5890         20.3702         16.6434
450053..........................................         17.0467         17.2781         19.3347         17.8122
450054..........................................         22.8960         19.2431         23.0492         21.9091
450055..........................................         15.0433         15.8526         16.4789         15.8195
450056..........................................         21.8436         21.8605         22.5341         22.0863
450058..........................................         18.0967         18.6172         20.0424         18.9513
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         22.5626         22.9345
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         19.8414         18.6088
450081..........................................         16.3448         17.5737         19.0276         17.6152
450082..........................................         16.1585         16.8677         18.0688         17.0258
450083..........................................         21.5884         23.3754         20.7446         21.8692
450085..........................................         18.3602         20.0085         17.5001         18.5675
450087..........................................         22.0273         21.9320         23.4141         22.4951
450090..........................................         15.0939         15.5796         15.6090         15.4353
450092..........................................         16.8260         17.9520         17.2058         17.3255
450094..........................................         21.3158         23.2863         25.2158         23.1854
450096..........................................         17.8813         18.6802         19.4430         18.6508
450097..........................................         19.5723         19.7187         20.7653         20.0316
450098..........................................         20.5754         19.0454         19.8469         19.8192
450099..........................................         19.2258         20.4181         19.3493         19.6218
450101..........................................         17.1330         17.7928         17.6368         17.5088
450102..........................................         18.6707         19.8793         21.4361         19.9466
450104..........................................         16.6744         17.0821         17.8219         17.1908
450107..........................................         25.1986         24.1094         24.5034         24.5948
450108..........................................         15.6324         15.2797         17.9596         16.3778
450109..........................................         13.8127         10.5973         18.1085         13.5597
450110..........................................         19.5821               *               *         19.5821
450111..........................................         19.6350         21.4908               *         20.6248
450112..........................................         16.0441         18.1026         17.9624         17.4193
450113..........................................         20.9777         20.8306         20.7782         20.8679
450118..........................................         17.9053               *               *         17.9053
450119..........................................         20.2853         20.2030         20.1436         20.2055
450121..........................................         20.4641         21.9198         22.0485         21.4762
450123..........................................         15.7618         14.1755         17.5051         15.6216
450124..........................................         22.7480         22.5208         22.9853         22.7584
450126..........................................         21.7233         21.4789         22.9423         22.0532
450128..........................................         18.2184         18.1446         18.7067         18.3642
450130..........................................         20.4156         18.9211         20.2613         19.8921
450131..........................................         19.2589         17.4168         18.1401         18.2336

[[Page 50200]]

 
450132..........................................         18.1713         21.8089         20.8908         20.3184
450133..........................................         23.6366         26.0763         24.5319         24.7178
450135..........................................         21.0306         20.4068         21.7038         21.0684
450137..........................................         22.4590         23.4346         22.8653         22.9109
450140..........................................         20.2280         17.3370         19.6205         19.0889
450143..........................................         14.5270         15.0871         17.8206         15.8389
450144..........................................         18.1121         17.4309         21.9135         19.1672
450145..........................................         15.6078         16.1895         18.0437         16.6039
450146..........................................         17.8572         15.5030         17.4391         16.8224
450147..........................................         18.9363         19.0477         20.3019         19.4231
450148..........................................         18.6758         20.4923         21.4982         20.3512
450149..........................................         19.7521         21.7219         22.6138         21.3072
450150..........................................         16.3719         17.8612         17.8804         17.3567
450151..........................................         15.2906         16.4209         16.3279         16.0117
450152..........................................         18.0061         17.7265         19.6105         18.4659
450153..........................................         19.4419         18.6514         20.9651         19.5973
450154..........................................         13.8731         13.9119         16.8748         14.8870
450155..........................................         11.5841         13.3456         20.2582         14.4198
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         19.7675         18.3370
450164..........................................         16.9741         17.7180         18.7103         17.7836
450165..........................................         13.9218         17.3283         16.1010         15.6645
450166..........................................         11.4772         11.0541         12.6627         11.7456
450169..........................................         13.1990               *               *         13.1990
450170..........................................         14.2997         14.3234         15.8525         14.8194
450176..........................................         16.9674         17.2576         19.2397         17.7972
450177..........................................         14.9241         15.2419         16.4503         15.5457
450178..........................................         17.8508         16.0280         15.8597         16.5717
450181..........................................         15.5622         18.6936         18.3600         17.5713
450184..........................................         21.1263         20.0821         22.7744         21.3241
450185..........................................         14.0714         11.5228         13.2015         12.8206
450187..........................................         16.6945         18.5053         20.8105         18.6152
450188..........................................         14.3938         15.1954         16.9800         15.5696
450191..........................................         20.1222         20.9512         20.5883         20.5559
450192..........................................         20.3795         21.2497         20.8315         20.8154
450193..........................................         23.1963         23.1639         25.1215         23.8401
450194..........................................         20.5187         20.7745         20.7152         20.6727
450196..........................................         17.1955         17.8993         21.1226         18.6516
450200..........................................         18.7387         19.2228         19.6496         19.1969
450201..........................................         16.9908         17.1463         18.0646         17.4134
450203..........................................         20.6712         19.3978         19.7978         19.9564
450209..........................................         19.0811         20.0140         21.3218         20.0963
450210..........................................         13.9758         16.3470         16.8532         15.7918
450211..........................................         17.9857         18.8114         18.7305         18.5258
450213..........................................         17.7631         19.0651         19.3440         18.7353
450214..........................................         19.0475         20.5070         21.3448         20.2748
450217..........................................         12.8457         12.7647         13.1840         12.9276
450219..........................................         15.3976         17.6884         18.5534         17.2282
450221..........................................         16.3700         15.2120         16.2308         15.9182
450222..........................................         20.3129         19.8967         23.2779         21.1824
450224..........................................         24.9046         20.1579         20.1723         21.4823
450229..........................................         16.4503         16.7853         17.0346         16.7617
450231..........................................         19.1564         19.1746         20.7709         19.7438
450234..........................................         16.1945         16.3003         17.9478         16.9370
450235..........................................         15.2332         16.3115         17.0143         16.2190
450236..........................................         16.6703         16.4957         18.4551         17.2049
450237..........................................         20.7930         19.0325         21.6497         20.5284
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         18.3361         13.3340
450253..........................................         12.2402         13.2177         14.5492         13.3367

[[Page 50201]]

 
450258..........................................         16.0466         16.7337         17.0724         16.6100
450264..........................................         13.8929         14.5956         17.2825         15.2193
450269..........................................         12.3594         12.7717         12.2970         12.4710
450270..........................................         12.8381         14.4792         13.8881         13.6870
450271..........................................         16.6319         16.7831         17.9570         17.1607
450272..........................................         19.9331         18.4344         20.5888         19.6562
450276..........................................         13.1155         14.0745         14.0779         13.7681
450278..........................................         14.8291         15.2950         14.3931         14.8081
450280..........................................         22.2984         22.2936         22.2648         22.2845
450283..........................................         14.5664         15.1950         15.8224         15.2295
450288..........................................         16.2502         18.8935         17.4817         17.4808
450289..........................................         20.3104         20.3460         22.4656         21.0290
450292..........................................         16.9693         20.5335         21.1511         19.3669
450293..........................................         16.0132         16.2721         16.4077         16.2364
450296..........................................         21.6000         22.3430         21.5998         21.8526
450299..........................................         21.5672               *         21.2754         21.4132
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         16.0363         14.2012
450315..........................................         22.8140         21.4684         23.8151         22.6579
450320..........................................         20.0946         20.6596         24.8602         21.5440
450321..........................................         13.1752         14.7344         17.2289         14.9366
450322..........................................         22.7667         29.1884         28.9834         26.4969
450324..........................................         17.7886         19.1692         20.9081         19.2343
450327..........................................         11.7511         13.3639         11.0983         11.9405
450330..........................................         18.9425         19.8066         21.0921         19.9853
450334..........................................         12.8051         13.8392         13.9812         13.5350
450337..........................................         17.1073         25.5708               *         20.0638
450340..........................................         17.6914               *         19.2611         18.4733
450341..........................................         18.9429               *         20.8814         19.8654
450346..........................................         17.5367         18.9475         19.2769         18.6527
450347..........................................         17.1099         19.3475         20.1899         18.8713
450348..........................................         13.9535         13.3585         15.0069         14.1063
450351..........................................         18.4116         19.3159         21.2842         19.6777
450352..........................................         18.7480         20.1871         21.2035         20.1227
450353..........................................         17.7539         16.0003         17.3274         17.0034
450355..........................................         11.9473         11.8933         12.8876         12.2285
450358..........................................         22.3235         23.0206         25.5767         23.5999
450362..........................................         15.8847         18.1983         18.7687         17.5865
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         18.5716         17.9576
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         16.7237         16.6241
450388..........................................         19.2499         19.7408         20.7989         19.9913
450389..........................................         18.1797         18.8448         19.3156         18.7899
450393..........................................         20.2784         22.4992         21.4405         21.3365
450395..........................................         18.3768         18.0024         17.5236         17.9433
450399..........................................         15.7845         15.3491         16.3333         15.8319
450400..........................................         19.5379         18.6668         19.1345         19.0923
450403..........................................         20.1989         22.8430         24.7657         22.7036
450411..........................................         14.4832         15.1121         15.9165         15.1694
450417..........................................         13.4983         15.3591         15.2713         14.6933
450418..........................................         21.9161         21.9690         22.2511         22.0447
450419..........................................         20.6325         23.2551         22.9522         22.3158
450422..........................................         26.4848         28.0257         28.0395         27.5279
450423..........................................         22.7132               *               *         22.7132
450424..........................................         18.9741         18.7895         20.7634         19.5561
450429..........................................         13.8723               *               *         13.8722
450431..........................................         19.6304         22.0361         22.6766         21.4257
450438..........................................         19.5028         15.4553         21.0474         18.4017

[[Page 50202]]

 
450446..........................................         13.0986         20.7592         13.8011         15.2461
450447..........................................         18.0376         18.0377         19.7532         18.5828
450451..........................................         18.8948         18.2988         18.9519         18.7274
450457..........................................         24.7880         19.6569               *         21.9578
450460..........................................         15.1765         14.6523         15.9446         15.2519
450462..........................................         22.6212         22.1144         22.5413         22.4225
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         19.5505         18.4862
450488..........................................         19.3457         19.2173         22.0927         20.2121
450489..........................................          9.9326         16.3584         17.8779         13.9861
450497..........................................         15.0886         16.2997         15.9654         15.7937
450498..........................................         13.8551         14.4713         15.9479         14.7991
450508..........................................         18.8069         19.0991         19.3274         19.0816
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         23.8270         21.6109
450530..........................................         22.8623         21.1634         21.8988         21.9395
450534..........................................         19.9376         20.1520         19.7410         19.9371
450535..........................................         19.6645         21.0513         21.5449         20.7286
450537..........................................         20.8438         20.1161         20.8849         20.6189
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         20.5049         17.8141
450551..........................................         16.9439         16.6237         16.1437         16.5621
450558..........................................         22.2574         20.7404         21.3116         21.4292
450563..........................................         19.9218         22.0708         21.9935         21.4039
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         17.6157         15.5831
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         17.8224         16.7968
450583..........................................         15.6580         14.4411         15.9430         15.3488
450584..........................................         14.2321         14.6735         14.9237         14.6266
450586..........................................         14.3773         13.8248         14.7433         14.3053
450587..........................................         17.0230         18.0219         18.0014         17.6684
450591..........................................         17.8981         17.7795         18.6714         18.1275
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         18.7465         17.6322
450605..........................................         21.1400         19.4580         19.7400         20.0918
450609..........................................         15.9753         17.0986         14.1776         15.7466
450610..........................................         18.9924         21.5191         23.5626         21.7315
450614..........................................         17.9853         16.5754               *         17.2230
450615..........................................         14.8562         15.2956         15.0621         15.0692
450617..........................................         20.3387         20.8919         21.5004         20.9383
450620..........................................         15.8380         16.0987         16.4330         16.1476
450623..........................................         22.1950         23.1270         25.1122         23.4424
450626..........................................         18.1673         18.4349         20.5225         19.1158
450628..........................................         20.5611         18.6093         20.0411         19.7604
450630..........................................         21.6876         20.9605         23.1840         21.9334
450631..........................................         20.0417         21.6736         21.8940         21.1769
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 50203]]

 
450639..........................................         23.1936         21.6421         23.0496         22.6205
450641..........................................         16.5125         15.7578         15.3652         15.8807
450643..........................................         18.7054         16.8152         18.9088         18.1638
450644..........................................         23.6587         22.7721         24.5834         23.7084
450646..........................................         19.8274         19.1433         23.1240         20.5802
450647..........................................         24.7981         24.2763         25.0549         24.7111
450648..........................................         14.8488         15.0305         14.4884         14.7695
450649..........................................         16.4496         16.6577         16.8505         16.6612
450651..........................................         22.7664         22.7112         25.4679         23.6985
450652..........................................         13.4389         17.2445               *         14.7103
450653..........................................         18.1834         19.2349         20.2436         19.1660
450654..........................................         14.5258         14.5423         15.5858         14.8899
450656..........................................         17.6723         18.2606         18.5874         18.1828
450658..........................................         16.2657         17.2630         19.4139         17.5926
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         14.5158         15.2939
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         19.7696         19.0807
450672..........................................         21.8559         21.4927         23.2623         22.2025
450673..........................................         13.9620         13.7005         14.9115         14.2386
450674..........................................         22.2796         22.2426         21.9624         22.1483
450675..........................................         22.4961         21.4479         23.3954         22.4703
450677..........................................         22.6839         20.6556         21.7366         21.6615
450678..........................................         23.2617         24.1301         25.1841         24.1797
450683..........................................         20.9143         22.8699         22.1965         21.9453
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         14.2055         14.9219
450702..........................................         20.8223         21.3739         19.8094         20.6324
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         22.0123         21.7006
450711..........................................         19.8126         19.8581         20.8047         20.1736
450712..........................................         13.6240         15.9298         11.1086         13.3744
450713..........................................         20.8065         22.6986         23.6189         22.4743
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         23.0051         21.6764
450723..........................................         19.7563         20.8213         22.0633         20.9085
450724..........................................         20.3235         20.3706         23.3799         21.3424
450727..........................................         13.5458         17.9172         24.6125         17.9196
450728..........................................         17.5284         19.8879         14.9265         17.3299
450730..........................................         22.0819         23.0054         24.5952         23.2900
450733..........................................         20.7693         20.2199         21.9921         20.9887
450735..........................................         13.8767               *               *         13.8768
450742..........................................         22.7655         21.8392         22.8135         22.4714
450743..........................................         18.8937         19.6015         20.5017         19.6892
450746..........................................         12.7904         30.2657         14.6683         17.1933
450747..........................................         19.2585         20.3914         20.3870         20.0318
450749..........................................         16.2130         19.1678         18.7138         18.1992
450750..........................................         14.6914         13.8098               *         14.2686
450751..........................................         21.2198         19.9995         19.8170         20.4240
450754..........................................         16.0860         16.7145         17.8497         17.0113
450755..........................................         17.9904         19.8743         20.0667         19.3563

[[Page 50204]]

 
450757..........................................         13.8675         14.9434         15.6425         14.7901
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         17.9879         16.6578
450770..........................................         16.5458         19.0183         20.0632         18.5467
450771..........................................         22.4542         21.8268         21.6946         21.9479
450774..........................................         17.9964         16.2948               *         17.1404
450775..........................................         19.8897         21.3504         22.6526         21.2920
450776..........................................         15.7750         14.1720         13.4263         14.1832
450777..........................................         21.0682         19.0380         18.3119         19.5171
450779..........................................         21.4546         21.6642         22.6216         21.9593
450780..........................................         19.1498         19.0914         20.0824         19.4503
450785..........................................         18.4976               *               *         18.4975
450788..........................................         19.1463         19.6469         19.9817         19.6564
450794..........................................         18.2229               *               *         18.2229
450795..........................................         16.6494         22.5753         27.0250         21.6046
450796..........................................         16.5362         19.2059         26.8539         22.7324
450797..........................................         15.9188         16.4923         20.2356         17.4420
450798..........................................          9.4634               *               *          9.4634
450801..........................................         17.5669         17.9548         18.0598         17.8661
450802..........................................         19.9168         17.1435         18.2460         18.3472
450803..........................................         18.3767         21.6653         37.0925         26.9538
450804..........................................         19.4846         19.0893         20.5225         19.7061
450806..........................................               *               *         20.7906         20.7906
450807..........................................         11.3192         13.4306         18.4410         13.7054
450808..........................................         16.9915         17.4917         18.1728         17.5602
450809..........................................         20.0202         19.7899         21.9845         20.5837
450811..........................................         19.0961         19.9168         21.6115         20.3503
450813..........................................         15.9166         14.5392         15.3780         15.2272
450815..........................................               *         21.2741               *         21.2742
450819..........................................               *         16.5521               *         16.5521
450820..........................................               *         26.8348         24.6542         25.7074
450822..........................................               *         22.8556         24.8702         23.9136
450823..........................................               *               *         17.9756         17.9757
450824..........................................               *               *         25.7488         25.7488
450825..........................................               *               *         16.0793         16.0793
450827..........................................               *               *         20.1310         20.1309
450828..........................................               *               *         19.2902         19.2902
450829..........................................               *               *         14.7121         14.7122
460001..........................................         21.7996         22.2735         23.5485         22.5533
460003..........................................         20.0452         22.6289         22.9549         21.8157
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         23.1933         22.5366
460010..........................................         21.9830         22.4948         24.0907         22.8868
460011..........................................         18.8660         19.7674         25.3818         20.9922
460013..........................................         20.7326         20.1936         21.2360         20.7330
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         19.0724         18.5937
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
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

[[Page 50205]]

 
460029..........................................         20.5154         20.8366         23.7148         21.6548
460030..........................................         17.6071         17.1383         18.7655         17.8282
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         19.7531         19.4200
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         23.5447         23.1136
460049..........................................         19.6483         20.8283         21.5241         20.8906
460051..........................................         19.4761         22.1758         21.8950         21.1889
460052..........................................               *         19.8961         20.1989         20.0325
470001..........................................         20.2299         21.3817         21.7774         21.1523
470003..........................................         23.6949         22.0563         23.3612         23.0272
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         24.8493         22.4355
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         20.7616         19.8936
490005..........................................         20.5517         21.3318         23.1708         21.7445
490006..........................................         15.9537         12.3253         19.8977         16.1242
490007..........................................         18.7740         19.8938         20.7896         19.8261
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         19.6594         19.1681
490018..........................................         18.3435         18.5508         19.8955         18.9343
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         19.7491         18.7525
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
490033..........................................         21.1723         19.2908         23.2088         21.1528
490037..........................................         16.3759         17.0113         17.2117         16.8638
490038..........................................         21.0218         17.6324         18.6012         18.9881
490040..........................................         22.7061         24.1266         25.5461         24.1416
490041..........................................         18.3589         18.7987         17.9942         18.3695
490042..........................................         16.4666         17.0972         18.1864         17.2848
490043..........................................         22.1574         22.1068         23.5367         22.5696
490044..........................................         18.3137         19.7842         18.4845         18.8757
490045..........................................         20.5468         20.5558         22.5238         21.2366

[[Page 50206]]

 
490046..........................................         18.4825         19.9102         19.8518         19.4329
490047..........................................         25.0438         18.7614         20.1660         20.7033
490048..........................................         18.4361         19.5417         20.9110         19.5970
490050..........................................         23.0729         23.3668         23.8519         23.4357
490052..........................................         16.8600         16.4787         18.5693         17.2849
490053..........................................         15.6996         16.8410         17.7363         16.7991
490054..........................................         15.4734         19.5780         22.5136         19.1813
490057..........................................         19.9210         20.3160         21.1871         20.4871
490059..........................................         20.8662         21.4801         24.1516         22.0719
490060..........................................         17.6308         18.5917         19.3525         18.5249
490063..........................................         28.6536         26.1930         28.0906         27.6046
490066..........................................         20.6972         19.8352         21.5920         20.7067
490067..........................................         17.0195         17.8487         18.6469         17.8519
490069..........................................         17.3297         20.7582         18.8335         18.9275
490071..........................................         21.8879         23.3511         24.1882         23.1205
490073..........................................         20.7960         26.0957               *         23.1759
490075..........................................         18.6983         19.2156         20.5801         19.4875
490077..........................................         21.3670         22.6504         21.9175         21.9708
490079..........................................         17.0815         17.7016         17.5839         17.4571
490084..........................................         16.7834         18.0555         18.9679         17.9259
490085..........................................         17.4584         17.6158         19.4261         18.1708
490088..........................................         16.4362         17.9141         19.1924         17.7544
490089..........................................         17.7692         18.2290         19.7936         18.6306
490090..........................................         17.0199         17.5799         19.2094         17.9357
490091..........................................         20.8734         25.0272         23.7493         22.9790
490092..........................................         16.9533         16.4360         27.1805         18.9439
490093..........................................         17.3711         17.8275         19.1131         18.1170
490094..........................................         18.9204         22.3033         20.2020         20.4445
490097..........................................         15.5780         16.9518         16.6563         16.3410
490098..........................................         15.1403         16.0488         18.5133         16.5089
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         17.1683         24.3080
490105..........................................         18.5765         21.4428         28.7831         21.5414
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         19.9552         18.3170
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         17.1723         15.3528
490118..........................................         21.4674         23.2022         24.2668         22.9444
490119..........................................         17.9147         18.6046         18.9535         18.4822
490120..........................................         19.3707         20.5777         20.6828         20.2247
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
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         25.3478         23.9717
500002..........................................         21.6332         19.8476         22.9942         21.4749
500003..........................................         24.2814         24.4333         25.1200         24.6216
500005..........................................         22.3955         24.3870         26.2066         24.2052
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

[[Page 50207]]

 
500014..........................................         24.3419         24.0990         25.0490         24.4936
500015..........................................         23.9297         24.9923         25.9465         24.9911
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         27.3697         26.1011
500026..........................................         23.8005         26.9884         26.6108         25.7916
500027..........................................         22.2158         25.1125         27.7429         25.0474
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         24.5695         23.7818
500079..........................................         24.2036         23.1041         24.7946         24.0303
500080..........................................         15.6630         18.3883         18.8188         17.4053
500084..........................................         23.4032         24.4044         25.0556         24.3257
500085..........................................         21.4403         20.4517         20.7422         20.8523
500086..........................................         23.3288         22.8829         24.2556         23.4907
500088..........................................         23.2701         25.2478         26.4212         24.8779
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         17.8453         16.4653
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

[[Page 50208]]

 
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               *               *         21.6002
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         22.9326         21.9765
510008..........................................         18.3296         19.0513         19.9176         19.1112
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         18.9000         18.3777
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         21.8290         18.6848
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         21.2885         20.6282
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
510062..........................................         19.3881         18.1588         19.7202         19.0675
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         19.7131         17.6898
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         20.2691         19.9110
520003..........................................         17.1248         18.7956         18.7507         18.2896
520004..........................................         19.6512         20.4591         21.1549         20.3927

[[Page 50209]]

 
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         25.5623         23.5734
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         22.4779         21.6324
520027..........................................         19.9324         21.5868         22.1450         21.2250
520028..........................................         21.2852         22.5941         22.0333         21.9368
520029..........................................         19.5750         21.4197         21.5561         20.8404
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         21.5275         19.7188
520035..........................................         18.9452         18.7135         19.8917         19.2020
520037..........................................         20.6686         21.6017         23.0801         21.8015
520038..........................................         19.6294         20.6130         21.4208         20.5296
520039..........................................         20.7641         23.3687         21.1719         21.6634
520040..........................................         20.4677         21.2023         23.0710         21.5679
520041..........................................         17.1959         18.4117         18.2997         17.9850
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         18.9512         18.1443
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         22.1618         21.5868
520060..........................................         17.9258         18.8232         20.3357         19.0291
520062..........................................         19.1482         19.7038         21.2865         20.0649
520063..........................................         19.6136         20.5262         21.2774         20.4843
520064..........................................         22.7423         22.0917         23.8181         22.8706
520066..........................................         22.8837         24.0087         25.4528         24.0196
520068..........................................         18.9943         19.6855         20.6112         19.7565
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         21.7414         21.6174
520082..........................................         17.7405               *               *         17.7405
520083..........................................         23.8849         23.5787         24.2401         23.9015
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         23.2335         22.2891
520090..........................................         18.9343         20.3645         20.9069         20.0854
520091..........................................         20.9927         20.9440         22.2218         21.3884
520092..........................................         17.6500         18.6248         19.7181         18.6927

[[Page 50210]]

 
520094..........................................         20.3611         20.6179         21.3082         20.7652
520095..........................................         20.3269         18.6425         21.9177         20.2122
520096..........................................         19.7757         20.6668         21.6803         20.7358
520097..........................................         20.2354         20.8016         22.2375         21.1096
520098..........................................         22.3348         23.4707         25.0055         23.6219
520100..........................................         18.3832         19.4788         20.5366         19.4712
520101..........................................         19.5186         19.9875         20.0164         19.8451
520102..........................................         20.1898         21.0138         22.3640         21.1849
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               *               *         18.7436
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         23.1498         22.3142
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
520153..........................................         15.9753         17.0863         18.5986         17.1925
520154..........................................         18.5403         19.5994         21.0486         19.7479
520156..........................................         21.3377         20.9638         20.7808         21.0122
520157..........................................         17.1974         19.6008         21.6821         19.4299
520159..........................................         18.6760         17.7649         21.8783         19.4305
520160..........................................         19.4173         20.5154         21.5871         20.5304
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         25.0908         23.8719
520178..........................................         18.6936         20.9010         23.1509         20.7167
520188..........................................         13.9135               *               *         13.9135
520189..........................................               *               *         22.0889         22.0889
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         18.4391         15.7635
530006..........................................         18.5894         19.1305         20.7661         19.4956
530007..........................................         18.5161         17.7897         18.5286         18.3005
530008..........................................         18.8349         19.0113         19.5386         19.1231
530009..........................................         22.5009         21.7795         23.5839         22.6178
530010..........................................         21.6092         13.9536         17.8687         17.3468
530011..........................................         18.7354         19.4606         19.9212         19.3808

[[Page 50211]]

 
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
----------------------------------------------------------------------------------------------------------------

          
  

  

  Federal Register / Vol. 67, No. 148 / Thursday, August 1, 2002 / 
Rules and Regulations  

[[Page 50211]]


      

   Table 3A.--FY 2003 and 3-Year* Average Hourly Wage for Urban Areas
   [*Based on the sum of the salaries and hours computed for FYs 2001,
                             2002, and 2003]
------------------------------------------------------------------------
                                                     FY 2003     3-Year
                                                     average    average
                    Urban area                        hourly     hourly
                                                       wage       wage
------------------------------------------------------------------------
Abilene, TX.......................................    18.0997    17.9346
Aguadilla, PR.....................................    10.6548    10.3692
Akron, OH.........................................    22.2995    21.8274
Albany, GA........................................    24.6091    23.3345
Albany-Schenectady-Troy, NY.......................    19.4753    19.0093
Albuquerque, NM...................................    21.6385    21.0779
Alexandria, LA....................................    18.2564    17.9570
Allentown-Bethlehem-Easton, PA....................    22.6149    22.2151
Altoona, PA.......................................    21.4284    20.7196
Amarillo, TX......................................    20.9866    19.8100
Anchorage, AK.....................................    28.7078    28.2120
Ann Arbor, MI.....................................    25.7925    25.0051
Anniston, AL......................................    18.6862    18.3987
Appleton-Oshkosh-Neenah, WI.......................    20.9007    20.4194
Arecibo, PR.......................................    10.0744    10.0865
Asheville, NC.....................................    22.9425    21.4360
Athens, GA........................................    23.7189    22.3278
Atlanta, GA.......................................    23.2091    22.5586
Atlantic-Cape May, NJ.............................    25.5908    25.0328
Auburn-Opelika, AL................................    19.3393    18.4481
Augusta-Aiken, GA-SC..............................    23.8429    21.9436
Austin-San Marcos, TX.............................    22.3866    21.5758
Bakersfield, CA...................................    22.9941    21.7697
Baltimore, MD.....................................    23.0654    21.7957
Bangor, ME........................................    22.4487    21.5421
Barnstable-Yarmouth, MA...........................    30.6686    30.4086
Baton Rouge, LA...................................    19.2668    18.9000
Beaumont-Port Arthur, TX..........................    19.3363    19.0595
Bellingham, WA....................................    28.5297    26.6182
Benton Harbor, MI.................................    21.0032    19.8689
Bergen-Passaic, NJ................................    28.2237    26.6914
Billings, MT......................................    20.9586    20.9004
Biloxi-Gulfport-Pascagoula, MS....................    20.3430    19.0627
Binghamton, NY....................................    19.3760    19.0441
Birmingham, AL....................................    21.4215    19.7657
Bismarck, ND......................................    18.5193    17.6555
Bloomington,IN....................................    20.6895    19.8190
Bloomington-Normal, IL............................    21.1609    20.3703
Boise City, ID....................................    21.6276    20.5028
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH..    26.0991    25.2557
Boulder-Longmont, CO..............................    22.5070    21.8737
Brazoria, TX......................................    19.8267    19.0174
Bremerton, WA.....................................    25.4225    24.4379
Brownsville-Harlingen-San Benito, TX..............    20.6287    19.9271
Bryan-College Station, TX.........................    20.4911    19.6440
Buffalo-Niagara Falls, NY.........................    21.7541    21.2343
Burlington, VT....................................    23.3505    22.9143
Caguas, PR........................................    10.1529    10.1915
Canton-Massillon, OH..............................    20.7477    19.7875
Casper, WY........................................    22.5084    20.9252
Cedar Rapids, IA..................................    21.0377    19.8268
Champaign-Urbana, IL..............................    24.7040    21.7883
Charleston-North Charleston, SC...................    21.4522    20.5545
Charleston, WV....................................    20.6688    20.4836
Charlotte-Gastonia-Rock Hill, NC-SC...............    22.8817    21.3842
Charlottesville, VA...............................    24.2460    23.7478
Chattanooga, TN-GA................................    20.8502    21.0493
Cheyenne, WY......................................    20.0422    18.9065
Chicago, IL.......................................    25.6542    24.8517
Chico-Paradise, CA................................    22.6375    22.0699
Cincinnati, OH-KY-IN..............................    21.7907    21.1359
Clarksville-Hopkinsville, TN-KY...................    19.5257    18.6578
Cleveland-Lorain-Elyria, OH.......................    22.4627    21.4566
Colorado Springs, CO..............................    23.0332    21.9728
Columbia, MO......................................    19.7346    19.5385
Columbia, SC......................................    21.6187    21.2189
Columbus, GA-AL...................................    19.4516    18.9827
Columbus, OH......................................    22.6508    21.6208
Corpus Christi, TX................................    20.2762    19.3824
Corvallis, OR.....................................    26.6038    25.7705
Cumberland, MD-WV.................................    18.2292    18.3160
Dallas, TX........................................    23.2252    22.3304
Danville, VA......................................    20.5801    19.4875

[[Page 50212]]

 
Davenport-Moline-Rock Island, IA-IL...............    20.5222    19.7346
Dayton-Springfield, OH............................    21.5613    20.8864
Daytona Beach, FL.................................    21.0510    20.3725
Decatur, AL.......................................    20.8446    19.7238
Decatur, IL.......................................    18.7105    18.0859
Denver, CO........................................    24.6248    23.2619
Des Moines, IA....................................    20.4201    19.9495
Detroit, MI.......................................    24.2703    23.5057
Dothan, AL........................................    18.9020    17.9750
Dover, DE.........................................    21.7344    22.1849
Dubuque, IA.......................................    20.4304    19.4823
Duluth-Superior, MN-WI............................    24.0835    22.9655
Dutchess County, NY...............................    24.8186    23.5537
Eau Claire, WI....................................    20.7949    19.9455
El Paso, TX.......................................    21.5232    20.8151
Elkhart-Goshen, IN................................    22.5833    21.3571
Elmira, NY........................................    19.5496    18.9705
Enid, OK..........................................    19.4579    18.9430
Erie, PA..........................................    20.7316    19.9094
Eugene-Springfield, OR............................    25.4233    24.9294
Evansville, Henderson, IN-KY......................    18.9947    18.5939
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.........................................    25.8662    24.8502
Florence, AL......................................    18.1004    17.3804
Florence, SC......................................    20.3953    19.6524
Fort Collins-Loveland, CO.........................    23.3824    22.9964
Fort Lauderdale, FL...............................    23.9183    22.9781
Fort Myers-Cape Coral, FL.........................    22.4867    21.1683
Fort Pierce-Port St. Lucie, FL....................    22.8186    22.1142
Fort Smith, AR-OK.................................    18.3399    17.9436
Fort Walton Beach, FL.............................    22.5165    21.1838
Fort Wayne, IN....................................    21.9677    20.4543
Fort Worth-Arlington, TX..........................    21.9417    21.2344
Fresno, CA........................................    23.7314    22.6694
Gadsden, AL.......................................    19.7567    19.2100
Gainesville, FL...................................    22.9298    21.9827
Galveston-Texas City, TX..........................    21.9867    22.1243
Gary, IN..........................................    22.2630    21.3794
Glens Falls, NY...................................    19.2366    18.6783
Goldsboro, NC.....................................    20.6547    19.5049
Grand Forks, ND-MN................................    20.6675    19.9946
Grand Junction, CO................................    21.9661    21.0658
Grand Rapids-Muskegon-Holland, MI.................    22.1261    22.2833
Great Falls, MT...................................    20.7913    20.0975
Greeley, CO.......................................    21.4562    21.3343
Green Bay, WI.....................................    22.0738    20.9151
Greensboro-Winston-Salem-High Point, NC...........    21.5609    20.8887
Greenville, NC....................................    21.1397    20.7708
Greenville-Spartanburg-Anderson, SC...............    21.1902    20.4530
Hagerstown, MD....................................    21.5280    20.1745
Hamilton-Middletown, OH...........................    21.8770    20.8017
Harrisburg-Lebanon-Carlisle, PA...................    21.4246    21.2205
Hartford, CT......................................    26.8283    25.7523
Hattiesburg, MS...................................    17.7923    16.9367
Hickory-Morganton-Lenoir, NC......................    20.9718    20.4830
Honolulu, HI......................................    26.6135    26.0576
Houma, LA.........................................    19.4770    18.2833
Houston, TX.......................................    22.9793    21.8906
Huntington-Ashland, WV-KY-OH......................    22.3832    21.7861
Huntsville, AL....................................    20.6802    19.9807
Indianapolis, IN..................................    22.5719    21.8463
Iowa City, IA.....................................    22.2708    21.7514
Jackson, MI.......................................    22.1433    20.9286
Jackson, MS.......................................    19.9947    19.3644
Jackson, TN.......................................    21.5461    20.3227
Jacksonville, FL..................................    21.7926    20.8047
Jacksonville, NC..................................    19.1386    17.6977
Jamestown, NY.....................................    18.5274    17.7979
Janesville-Beloit, WI.............................    22.8793    21.7876
Jersey City, NJ...................................    25.9930    25.3096
Johnson City-Kingsport-Bristol, TN-VA.............    19.2068    18.8084
Johnstown, PA.....................................    19.3478    19.3566
Jonesboro, AR.....................................    18.0006    17.9165
Joplin, MO........................................    20.0072    19.0679
Kalamazoo-Battlecreek, MI.........................    24.6108    23.6975
Kankakee, IL......................................    18.8681    20.7325
Kansas City, KS-MO................................    22.6159    21.5239
Kenosha, WI.......................................    22.4996    21.6484
Killeen-Temple, TX................................    22.2296    21.1752
Knoxville, TN.....................................    20.8376    19.6060
Kokomo, IN........................................    20.8390    20.6388
La Crosse, WI-MN..................................    21.8354    20.8331
Lafayette, LA.....................................    19.6879    19.0782
Lafayette, IN.....................................    21.5534    20.3600
Lake Charles, LA..................................    18.5034    17.2671
Lakeland-Winter Haven, FL.........................    21.7369    20.7023
Lancaster, PA.....................................    21.0878    20.6617
Lansing-East Lansing, MI..........................    22.5939    21.9285
Laredo, TX........................................    19.6806    18.3545
Las Cruces, NM....................................    20.3141    19.4697
Las Vegas, NV-AZ..................................    26.7621    25.1310
\1\ Lawrence, KS..................................  .........    17.8290
Lawton, OK........................................    19.3161    19.4211
Lewiston-Auburn, ME...............................    21.3222    20.5843
Lexington, KY.....................................    19.9333    19.6141
Lima, OH..........................................    22.0292    21.1697
Lincoln, NE.......................................    22.9794    22.2323
Little Rock-North Little Rock, AR.................    21.1311    20.1533
Longview-Marshall, TX.............................    20.0437    19.5274
Los Angeles-Long Beach, CA........................    27.8780    26.8744
Louisville, KY-IN.................................    21.5487    21.0505
Lubbock, TX.......................................    22.4063    20.0797
Lynchburg, VA.....................................    21.4142    20.3464
Macon, GA.........................................    21.3800    20.3043
Madison, WI.......................................    24.3133    23.2497
Mansfield, OH.....................................    20.6732    19.6809
Mayaguez, PR......................................    11.4145    10.7192
McAllen-Edinburg-Mission, TX......................    19.5785    18.9844
Medford-Ashland, OR...............................    24.3865    23.3354
Melbourne-Titusville-Palm Bay, FL.................    23.8179    22.3779
Memphis, TN-AR-MS.................................    20.7202    19.9037
Merced, CA........................................    22.8511    21.9541
Miami, FL.........................................    22.7695    22.2828
Middlesex-Somerset-Hunterdon, NJ..................    26.0484    25.2231
Milwaukee-Waukesha, WI............................    22.9802    22.1540
Minneapolis-St. Paul, MN-WI.......................    25.3271    24.5840
Missoula, MT......................................    21.2713    20.8023
Mobile, AL........................................    18.8354    18.2108
Modesto, CA.......................................    24.3874    23.6713
Monmouth-Ocean, NJ................................    24.7950    24.5325
Monroe, LA........................................    18.9030    18.4972
Montgomery, AL....................................    17.9647    17.0004
Muncie, IN........................................    21.5664    22.4947
Myrtle Beach, SC..................................    20.8503    19.6435
Naples, FL........................................    22.6587    21.7978
Nashville, TN.....................................    22.2485    21.5537
Nassau-Suffolk, NY................................    31.0283    30.5926
New Haven-Bridgeport-Stamford-Waterbury-Danbury,      28.8227    27.6131
 CT...............................................
New London-Norwich, CT............................    27.3351    26.4541
New Orleans, LA...................................    21.0139    20.4714
New York, NY......................................    33.4837    32.5033
Newark, NJ........................................    26.4381    26.0353
Newburgh, NY-PA...................................    26.4506    24.9836
Norfolk-Virginia Beach-Newport News, VA-NC........    19.9175    19.1247
Oakland, CA.......................................    35.0108    33.9487
Ocala, FL.........................................    21.8400    21.1289
Odessa-Midland, TX................................    21.8283    21.4760
Oklahoma City, OK.................................    20.6736    19.7312
Olympia, WA.......................................    25.4588    24.6677
Omaha, NE-IA......................................    23.1783    21.8976
Orange County, CA.................................    26.6537    25.4571
Orlando, FL.......................................    22.3924    21.6364
Owensboro, KY.....................................    19.3837    18.5916
Panama City, FL...................................    20.5934    20.1588
Parkersburg-Marietta, WV-OH.......................    18.8778    18.3560
Pensacola, FL.....................................    20.0814    18.8080
Peoria-Pekin, IL..................................    20.2998    19.5517
Philadelphia, PA-NJ...............................    24.8854    24.3569
Phoenix-Mesa, AZ..................................    22.8121    21.8188

[[Page 50213]]

 
Pine Bluff, AR....................................    18.4956    17.6590
Pittsburgh, PA....................................    21.7554    21.4243
Pittsfield, MA....................................    23.7753    23.0116
Pocatello, ID.....................................    21.7708    20.8557
Ponce, PR.........................................    12.0073    11.5031
Portland, ME......................................    22.7505    21.6716
Portland-Vancouver, OR-WA.........................    24.7790    24.4439
Providence-Warwick, RI............................    25.2127    24.3041
Provo-Orem, UT....................................    23.1919    22.3508
Pueblo, CO........................................    20.4888    19.6349
Punta Gorda, FL...................................    21.4140    20.8215
Racine, WI........................................    21.6818    20.8941
Raleigh-Durham-Chapel Hill, NC....................    23.2057    22.0194
Rapid City, SD....................................    20.5485    19.8947
Reading, PA.......................................    21.5927    20.9553
Redding, CA.......................................    25.8663    25.3801
Reno, NV..........................................    24.7352    23.6658
Richland-Kennewick-Pasco, WA......................    26.6936    25.3323
Richmond-Petersburg, VA...........................    22.0137    21.5043
Riverside-San Bernardino, CA......................    26.4013    25.2038
Roanoke, VA.......................................    20.0106    19.2432
Rochester, MN.....................................    28.1983    26.1811
Rochester, NY.....................................    21.3577    20.7104
Rockford, IL......................................    22.3577    20.7042
Rocky Mount, NC...................................    21.4359    20.3593
Sacramento, CA....................................    26.7146    26.3841
Saginaw-Bay City-Midland, MI......................    22.4172    21.5444
St. Cloud, MN.....................................    22.5321    22.1278
\1\ St. Joseph, MO................................  .........    19.7467
St. Louis, MO-IL..................................    20.5705    20.0669
Salem, OR.........................................    24.0818    22.8500
Salinas, CA.......................................    33.9674    32.7871
Salt Lake City-Ogden, UT..........................    23.1018    22.1636
San Angelo, TX....................................    19.4526    18.4524
San Antonio, TX...................................    20.3327    19.4056
San Diego, CA.....................................    25.8562    25.5485
San Francisco, CA.................................    32.8516    31.7473
San Jose, CA......................................    32.8581    31.3747
San Juan-Bayamon, PR..............................    11.0133    10.6132
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........................    31.6979    31.1452
Santa Fe, NM......................................    24.8842    23.5075
Santa Rosa, CA....................................    30.3046    28.9555
Sarasota-Bradenton, FL............................    21.8931    21.9128
Savannah, GA......................................    21.7802    21.7267
Scranton-Wilkes Barre-Hazleton, PA................    19.9745    19.2042
Seattle-Bellevue-Everett, WA......................    26.6536    25.3076
Sharon, PA........................................    18.2797    17.7479
Sheboygan, WI.....................................    20.2034    19.0865
Sherman-Denison, TX...............................    21.4996    20.4082
Shreveport-Bossier City, LA.......................    20.8773    20.0586
Sioux City, IA-NE.................................    21.0135    19.6404
Sioux Falls, SD...................................    21.5029    20.3200
South Bend, IN....................................    22.7694    22.2819
Spokane, WA.......................................    25.2082    23.9695
Springfield, IL...................................    20.1137    19.4530
Springfield, MO...................................    19.5680    19.0448
Springfield, MA...................................    25.3838    24.2450
State College, PA.................................    20.7690    20.2726
Steubenville-Weirton, OH-WV.......................    20.4503    19.4333
Stockton-Lodi, CA.................................    24.4040    23.8853
Sumter, SC........................................    19.2186    18.1995
Syracuse, NY......................................    22.5655    21.5986
Tacoma, WA........................................    25.4131    25.5054
Tallahassee, FL...................................    19.7552    19.1410
Tampa-St. Petersburg-Clearwater, FL...............    21.0569    20.1666
Terre Haute, IN...................................    19.9743    19.0303
Texarkana, AR-Texarkana, TX.......................    18.7873    18.5257
Toledo, OH........................................    22.7892    22.0065
Topeka, KS........................................    21.3678    20.3537
Trenton, NJ.......................................    24.2326    23.1923
Tucson, AZ........................................    20.6996    19.9488
Tulsa, OK.........................................    19.3548    19.2001
Tuscaloosa, AL....................................    18.8861    18.2479
Tyler, TX.........................................    22.1176    21.3312
Utica-Rome, NY....................................    19.6631    18.9748
Vallejo-Fairfield-Napa, CA........................    31.0202    29.7206
Ventura, CA.......................................    25.7748    24.7503
Victoria, TX......................................    20.3401    18.8925
Vineland-Millville-Bridgeton, NJ..................    23.3023    23.1595
Visalia-Tulare-Porterville, CA....................    21.9029    21.3706
Waco, TX..........................................    18.7525    18.3223
Washington, DC-MD-VA-WV...........................    25.2063    24.3514
Waterloo-Cedar Falls, IA..........................    18.7434    18.3360
Wausau, WI........................................    22.7239    21.6241
West Palm Beach-Boca Raton, FL....................    23.0874    21.9924
Wheeling, OH-WV...................................    17.8161    17.4926
Wichita, KS.......................................    22.1149    21.4272
Wichita Falls, TX.................................    19.7397    18.0189
Williamsport, PA..................................    19.8470    19.0895
Wilmington-Newark, DE-MD..........................    25.9552    24.8359
Wilmington, NC....................................    22.3936    21.3149
Yakima, WA........................................    24.5502    23.1867
Yolo, CA..........................................    21.9147    21.8929
York, PA..........................................    20.9666    20.7327
Youngstown-Warren, OH.............................    21.7376    21.2695
Yuba City, CA.....................................    23.8705    23.4396
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 FYs 2001,
                             2002, and 2003]
------------------------------------------------------------------------
                                                     FY 2003     3-Year
                                                     average    average
                   Nonurban area                      hourly     hourly
                                                       wage       wage
------------------------------------------------------------------------
Alabama...........................................    17.7942    16.8216
Alaska............................................    28.5563    27.3243
Arizona...........................................    19.7296    19.0885
Arkansas..........................................    17.8073    16.9136
California........................................    22.8571    21.9706
Colorado..........................................    20.9408    20.0323
Connecticut.......................................    28.7895    27.0512
Delaware..........................................    21.2047    20.8163
Florida...........................................    20.4742    19.8491
Georgia...........................................    19.1171    18.5968
Hawaii............................................    23.8213    24.2205
Idaho.............................................    20.3186    19.5606
Illinois..........................................    19.0570    18.2606
Indiana...........................................    20.3365    19.5067
Iowa..............................................    19.3165    18.3182
Kansas............................................    18.4037    17.4835
Kentucky..........................................    18.7680    17.9289
Louisiana.........................................    17.5769    17.0854
Maine.............................................    20.6147    19.7179
Maryland..........................................    20.7803    19.8080
Massachusetts.....................................    26.2222    25.3808
Michigan..........................................    20.9071    20.1900
Minnesota.........................................    21.2579    20.2475
Mississippi.......................................    17.8404    16.9773
Missouri..........................................    18.6314    17.6923
Montana...........................................    19.7008    19.3096
Nebraska..........................................    19.0579    18.2930
Nevada............................................    22.2480    21.3212
New Hampshire.....................................    22.7567    22.0081
New Jersey \1\....................................  .........  .........
New Mexico........................................    20.6102    19.5025
New York..........................................    19.8433    19.1359
North Carolina....................................    20.1296    19.1805
North Dakota......................................    18.0907    17.4679
Ohio..............................................    20.0074    19.4121
Oklahoma..........................................    17.6313    16.9258
Oregon............................................    23.9324    22.8031
Pennsylvania......................................    19.6560    19.1733
Puerto Rico.......................................    10.1187    10.0248
Rhode Island \1\..................................  .........  .........
South Carolina....................................    19.9939    19.0908
South Dakota......................................    18.1545    17.3648
Tennessee.........................................    18.2990    17.6792
Texas.............................................    18.1667    17.2395
Utah..............................................    21.6314    20.5109

[[Page 50214]]

 
Vermont...........................................    21.7086    21.0072
Virginia..........................................    19.7552    18.6545
Washington........................................    23.6461    23.0555
West Virginia.....................................    18.5259    18.1465
Wisconsin.........................................    21.2831    20.2857
Wyoming...........................................    20.9222   19.8670
------------------------------------------------------------------------
\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  \2\ Abilene, TX...............................    0.7827    0.8455
  Taylor, TX
0060  Aguadilla, PR.................................    0.4587    0.5864
  Aguada, PR
  Aguadilla, PR
  Moca, PR
0080  Akron, OH.....................................    0.9600    0.9724
  Portage, OH
  Summit, OH
0120  Albany, GA....................................    1.0594    1.0403
  Dougherty, GA
  Lee, GA
0160  \2\ Albany-Schenectady-Troy, NY...............    0.8542    0.8977
  Albany, NY
  Montgomery, NY
  Rensselaer, NY
  Saratoga, NY
  Schenectady, NY
  Schoharie, NY
0200  Albuquerque, NM...............................    0.9390    0.9578
  Bernalillo, NM
  Sandoval, NM
  Valencia, NM
0220  Alexandria, LA................................    0.7883    0.8497
  Rapides, LA
0240  Allentown-Bethlehem-Easton, PA................    0.9735    0.9818
  Carbon, PA
  Lehigh, PA
  Northampton, PA
0280  Altoona, PA...................................    0.9225    0.9463
  Blair, PA
0320  Amarillo, TX Potter, TX.......................    0.9034    0.9328
  Randall, TX
0380  Anchorage, AK.................................    1.2490    1.1645
  Anchorage, AK
0440  Ann Arbor, MI.................................    1.1103    1.0743
  Lenawee, MI
  Livingston, MI
  Washtenaw, MI
0450  Anniston, AL..................................    0.8044    0.8615
  Calhoun, AL
0460  \2\ Appleton-Oshkosh-Neenah, WI...............    0.9162    0.9418
  Calumet, WI
  Outagamie, WI
  Winnebago, WI
0470  \2\ Arecibo, PR...............................    0.4356    0.5660
  Arecibo, PR
  Camuy, PR
  Hatillo, PR
0480  Asheville, NC.................................    0.9876    0.9915
  Buncombe, NC
  Madison, NC
0500  Athens, GA....................................    1.0211    1.0144
  Clarke, GA
  Madison, GA
  Oconee, GA
0520  \1\ Atlanta, GA...............................    0.9991    0.9994
  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.........................    1.1017    1.0686
  Atlantic, NJ
  Cape May, NJ
0580  Auburn-Opelika, AL............................    0.8325    0.8820
  Lee, AL
0600  Augusta-Aiken, GA-SC..........................    1.0264    1.0180
  Columbia, GA
  McDuffie, GA
  Richmond, GA
  Aiken, SC
  Edgefield, SC
0640  \1\ Austin-San Marcos, TX.....................    0.9637    0.9750
  Bastrop, TX
  Caldwell, TX
  Hays, TX
  Travis, TX
  Williamson, TX
0680  Bakersfield, CA...............................    0.9899    0.9931
  Kern, CA
0720  \1\ Baltimore, MD.............................    0.9929    0.9951
  Anne Arundel, MD
  Baltimore, MD
  Baltimore City, MD
  Carroll, MD
  Harford, MD
  Howard, MD
  Queen Anne's, MD
0733  Bangor, ME....................................    0.9664    0.9769
  Penobscot, ME
0743  Barnstable-Yarmouth, MA.......................    1.3202    1.2095
  Barnstable, MA
0760  Baton Rouge, LA...............................    0.8294    0.8798
  Ascension, LA
  East Baton Rouge, LA
  Livingston, LA
  West Baton Rouge, LA
0840  Beaumont-Port Arthur, TX......................    0.8324    0.8819
  Hardin, TX
  Jefferson, TX
  Orange, TX
0860  Bellingham, WA................................    1.2282    1.1511
  Whatcom, WA
0870  Benton Harbor, MI.............................    0.9106    0.9379
  Berrien, MI
0875  \1\ Bergen-Passaic, NJ........................    1.2207    1.1463
  Bergen, NJ
  Passaic, NJ
0880  Billings, MT..................................    0.9022    0.9319
  Yellowstone, MT
0920  Biloxi-Gulfport-Pascagoula, MS................    0.8757    0.9131
  Hancock, MS
  Harrison, MS
  Jackson, MS
0960  \2\ Binghamton, NY............................    0.8542    0.8977
  Broome, NY
  Tioga, NY
1000  Birmingham, AL................................    0.9222    0.9460
  Blount, AL
  Jefferson, AL
  St. Clair, AL
  Shelby, AL
1010  Bismarck, ND..................................    0.7972    0.8562
  Burleigh, ND
  Morton, ND
1020  Bloomington, IN...............................    0.8907    0.9238
  Monroe, IN
1040  Bloomington-Normal, IL........................    0.9109    0.9381
  McLean, IL
1080  Boise City, ID................................    0.9310    0.9522
  Ada, ID
  Canyon, ID
1123  \1,2\ Boston-Worcester-Lawrence-Lowell-           1.1288    1.0865
 Brockton, MA-NH (MA Hospitals).....................
  Bristol, MA
  Essex, MA
  Middlesex, MA
  Norfolk, MA
  Plymouth, MA
  Suffolk, MA
  Worcester, MA
  Hillsborough, NH
  Merrimack, NH
  Rockingham, NH
  Strafford, NH

[[Page 50215]]

 
1123  \1\ Boston-Worcester-Lawrence-Lowell-Brockton,    1.1235    1.0830
 MA-NH (NH Hospitals)...............................
  Bristol, MA
  Essex, MA
  Middlesex, MA
  Norfolk, MA
  Plymouth, MA
  Suffolk, MA
  Worcester, MA
  Hillsborough, NH
  Merrimack, NH
  Rockingham, NH
  Strafford, NH
1125  Boulder-Longmont, CO..........................    0.9689    0.9786
  Boulder, CO
1145  Brazoria, TX..................................    0.8535    0.8972
  Brazoria, TX
1150  Bremerton, WA.................................    1.0944    1.0637
  Kitsap, WA
1240  Brownsville-Harlingen-San Benito, TX..........    0.8880    0.9219
  Cameron, TX
1260  Bryan-College Station, TX.....................    0.8821    0.9177
  Brazos, TX
1280  \1\ Buffalo-Niagara Falls, NY.................    0.9365    0.9561
  Erie, NY
  Niagara, NY
1303  Burlington, VT................................    1.0052    1.0036
  Chittenden, VT
  Franklin, VT
  Grand Isle, VT
1310  Caguas, PR....................................    0.4408    0.5707
  Caguas, PR
  Cayey, PR
  Cidra, PR
  Gurabo, PR
  San Lorenzo, PR
1320  Canton-Massillon, OH..........................    0.8932    0.9256
  Carroll, OH
  Stark, OH
1350  Casper, WY....................................    0.9690    0.9787
  Natrona, WY
1360  Cedar Rapids, IA..............................    0.9056    0.9344
  Linn, IA
1400  Champaign-Urbana, IL..........................    1.0635    1.0431
  Champaign, IL
1440  Charleston-North Charleston, SC...............    0.9235    0.9470
  Berkeley, SC
  Charleston, SC
  Dorchester, SC
1480  Charleston, WV................................    0.8898    0.9232
  Kanawha, WV
  Putnam, WV
1520  \1\ Charlotte-Gastonia-Rock Hill, NC-SC.......    0.9850    0.9897
  Cabarrus, NC
  Gaston, NC
  Lincoln, NC
  Mecklenburg, NC
  Rowan, NC
  Stanly, NC
  Union, NC
  York, SC
1540  Charlottesville, VA...........................    1.0438    1.0298
  Albemarle, VA
  Charlottesville City, VA
  Fluvanna, VA
  Greene, VA
1560  Chattanooga, TN-GA............................    0.8976    0.9287
  Catoosa, GA
  Dade, GA
  Walker, GA
  Hamilton, TN
  Marion, TN
1580  \2\ Cheyenne, WY..............................    0.9007    0.9309
  Laramie, WY
1600  \1\ Chicago, IL...............................    1.1044    1.0704
  Cook, IL
  DeKalb, IL
  DuPage, IL
  Grundy, IL
  Kane, IL
  Kendall, IL
  Lake, IL
  McHenry, IL
  Will, IL
1620  \2\ Chico-Paradise, CA........................    0.9840    0.9890
  Butte, CA
1640  \1\ Cincinnati, OH-KY-IN......................    0.9389    0.9577
  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...............    0.8419    0.8888
  Christian, KY
  Montgomery, TN
1680  \1\ Cleveland-Lorain-Elyria, OH...............    0.9670    0.9773
  Ashtabula, OH
  Cuyahoga, OH
  Geauga, OH
  Lake, OH
  Lorain, OH
  Medina, OH
1720  Colorado Springs, CO..........................    0.9916    0.9942
  El Paso, CO
1740  Columbia, MO..................................    0.8515    0.8958
  Boone, MO
1760  Columbia, SC..................................    0.9307    0.9520
  Lexington, SC
  Richland, SC
1800  Columbus, GA-AL...............................    0.8374    0.8856
  Russell, AL
  Chattahoochee, GA
  Harris, GA
  Muscogee, GA
1840  \1\ Columbus, OH..............................    0.9751    0.9829
  Delaware, OH
  Fairfield, OH
  Franklin, OH
  Licking, OH
  Madison, OH
  Pickaway, OH
1880  Corpus Christi, TX............................    0.8729    0.9111
  Nueces, TX
  San Patricio, TX
1890  Corvallis, OR.................................    1.1453    1.0974
  Benton, OR
1900  \2\ Cumberland, MD-WV (MD Hospitals)..........    0.8946    0.9266
  Allegany, MD
  Mineral, WV
1900  \2\ Cumberland, MD-WV (WV Hospitals)..........    0.7975    0.8565
  Allegany, MD
  Mineral, WV
1920  \1\ Dallas, TX................................    0.9998    0.9999
  Collin, TX
  Dallas, TX
  Denton, TX
  Ellis, TX
  Henderson, TX
  Hunt, TX
  Kaufman, TX
  Rockwall, TX
1950  Danville, VA..................................    0.8859    0.9204
  Danville City, VA
  Pittsylvania, VA
1960  Davenport-Moline-Rock Island, IA-IL...........    0.8835    0.9187
  Scott, IA
  Henry, IL
  Rock Island, IL
2000  Dayton-Springfield, OH........................    0.9282    0.9503
  Clark, OH
  Greene, OH
  Miami, OH
  Montgomery, OH
2020  Daytona Beach, FL.............................    0.9062    0.9348
  Flagler, FL
  Volusia, FL
2030  Decatur, AL...................................    0.8973    0.9285
  Lawrence, AL
  Morgan, AL
2040  \2\ Decatur, IL...............................    0.8204    0.8732
  Macon, IL
2080  \1\ Denver, CO................................    1.0601    1.0408
  Adams, CO
  Arapahoe, CO
  Broomfield, CO
  Denver, CO

[[Page 50216]]

 
  Douglas, CO
  Jefferson, CO
2120  Des Moines, IA................................    0.8827    0.9181
  Dallas, IA
  Polk, IA
  Warren, IA
2160  \1\ Detroit, MI...............................    1.0448    1.0305
  Lapeer, MI
  Macomb, MI
  Monroe, MI
  Oakland, MI
  St. Clair, MI
  Wayne, MI
2180  Dothan, AL....................................    0.8158    0.8699
  Dale, AL
  Houston, AL
2190  Dover, DE.....................................    0.9356    0.9554
  Kent, DE
2200  Dubuque, IA...................................    0.8795    0.9158
  Dubuque, IA
2240  Duluth-Superior, MN-WI........................    1.0368    1.0251
  St. Louis, MN
  Douglas, WI
2281  Dutchess County, NY...........................    1.0684    1.0463
  Dutchess, NY
2290  \2\ Eau Claire, WI............................    0.9162    0.9418
  Chippewa, WI
  Eau Claire, WI
2320  El Paso, TX...................................    0.9265    0.9491
  El Paso, TX
2330  Elkhart-Goshen, IN............................    0.9722    0.9809
  Elkhart, IN
2335  \2\ Elmira, NY................................    0.8542    0.8977
  Chemung, NY
2340  Enid, OK......................................    0.8376    0.8857
  Garfield, OK
2360  Erie, PA......................................    0.8925    0.9251
  Erie, PA
2400  Eugene-Springfield, OR........................    1.0944    1.0637
  Lane, OR
2440  \2\ Evansville-Henderson, IN-KY (IN Hospitals)    0.8755    0.9130
  Posey, IN
  Vanderburgh, IN
  Warrick, IN
  Henderson, KY
2440  Evansville-Henderson, IN-KY (KY Hospitals)....    0.8177    0.8713
  Posey, IN
  Vanderburgh, IN
  Warrick, IN
  Henderson, KY
2520  Fargo-Moorhead, ND-MN.........................    0.9684    0.9783
  Clay, MN
  Cass, ND
2560  Fayetteville, NC..............................    0.8992    0.9298
  Cumberland, NC
2580  Fayetteville-Springdale-Rogers, AR............    0.8100    0.8656
  Benton, AR
  Washington, AR
2620  Flagstaff, AZ-UT..............................    1.0682    1.0462
  Coconino, AZ
  Kane, UT
2640  Flint, MI.....................................    1.1135    1.0764
  Genesee, MI
2650  Florence, AL..................................    0.7819    0.8449
  Colbert, AL
  Lauderdale, AL
2655  Florence, SC..................................    0.8780    0.9148
  Florence, SC
2670  Fort Collins-Loveland, CO.....................    1.0066    1.0045
  Larimer, CO
2680  \1\ Ft. Lauderdale, FL........................    1.0704    1.0477
  Broward, FL
2700  Fort Myers-Cape Coral, FL.....................    0.9680    0.9780
  Lee, FL
2710  Fort Pierce-Port St. Lucie, FL................    0.9931    0.9953
  Martin, FL
  St. Lucie, FL
2720  Fort Smith, AR-OK.............................    0.7895    0.8506
  Crawford, AR
  Sebastian, AR
  Sequoyah, OK
2750  Fort Walton Beach, FL.........................    0.9693    0.9789
  Okaloosa, FL
2760  Fort Wayne, IN................................    0.9457    0.9625
  Adams, IN
  Allen, IN
  De Kalb, IN
  Huntington, IN
  Wells, IN
  Whitley, IN
2800  \1\ Forth Worth-Arlington, TX.................    0.9446    0.9617
  Hood, TX
  Johnson, TX
  Parker, TX
  Tarrant, TX
2840  Fresno, CA....................................    1.0216    1.0147
  Fresno, CA
  Madera, CA
2880  Gadsden, AL...................................    0.8599    0.9018
  Etowah, AL
2900  Gainesville, FL...............................    0.9871    0.9911
  Alachua, FL
2920  Galveston-Texas City, TX......................    0.9465    0.9630
  Galveston, TX
2960  Gary, IN......................................    0.9584    0.9713
  Lake, IN
  Porter, IN
2975  \2\ Glens Falls, NY...........................    0.8542    0.8977
  Warren, NY
  Washington, NY
2980  Goldsboro, NC.................................    0.8892    0.9227
  Wayne, NC
2985  Grand Forks, ND-MN............................    0.9243    0.9475
  Polk, MN
  Grand Forks, ND
2995  Grand Junction, CO............................    0.9679    0.9779
  Mesa, CO
3000  \1\ Grand Rapids-Muskegon-Holland, MI.........    0.9548    0.9688
  Allegan, MI
  Kent, MI
  Muskegon, MI
  Ottawa, MI
3040  Great Falls, MT...............................    0.8966    0.9280
  Cascade, MT
3060  Greeley, CO...................................    0.9336    0.9540
  Weld, CO
3080  Green Bay, WI.................................    0.9668    0.9771
  Brown, WI
3120  \1\ Greensboro-Winston-Salem-High Point, NC...    0.9282    0.9503
  Alamance, NC
  Davidson, NC
  Davie, NC
  Forsyth, NCGuilford, NC
  Randolph, NC
  Stokes, NC
  Yadkin, NC
3150  Greenville, NC................................    0.9174    0.9427
  Pitt, NC
3160  Greenville-Spartanburg-Anderson, SC...........    0.9122    0.9390
  Anderson, SC
  Cherokee, SC
  Greenville, SC
  Pickens, SC
  Spartanburg, SC
3180  Hagerstown, MD................................    0.9268    0.9493
  Washington, MD
3200  Hamilton-Middletown, OH.......................    0.9418    0.9598
  Butler, OH
3240  Harrisburg-Lebanon-Carlisle, PA...............    0.9223    0.9461
  Cumberland, PA
  Dauphin, PA
  Lebanon, PA
  Perry, PA
3283  \1,2\ Hartford, CT............................    1.2394    1.1583
  Hartford, CT
  Litchfield, CT
  Middlesex, CT
  Tolland, CT
3285  \2\ Hattiesburg, MS...........................    0.7680    0.8346
  Forrest, MS
  Lamar, MS
3290  Hickory-Morganton-Lenoir, NC..................    0.9028    0.9324
  Alexander, NC
  Burke, NC
  Caldwell, NC
  Catawba, NC
3320  Honolulu, HI..................................    1.1457    1.0976
  Honolulu, HI
3350  Houma, LA.....................................    0.8385    0.8864

[[Page 50217]]

 
  Lafourche, LA
  Terrebonne, LA
3360  \1\ Houston, TX...............................    0.9892    0.9926
  Chambers, TX
  Fort Bend, TX
  Harris, TX
  Liberty, TX
  Montgomery, TX
  Waller, TX
3400  Huntington-Ashland, WV-KY-OH..................    0.9636    0.9749
  Boyd, KY
  Carter, KY
  Greenup, KY
  Lawrence, OH
  Cabell, WV
  Wayne, WV
3440  Huntsville, AL................................    0.8903    0.9235
  Limestone, AL
  Madison, AL
3480  \1\ Indianapolis, IN..........................    0.9717    0.9805
  Boone, IN
  Hamilton, IN
  Hancock, IN
  Hendricks, IN
  Johnson, IN
  Madison, IN
  Marion, IN
  Morgan, IN
  Shelby, IN
3500  Iowa City, IA.................................    0.9587    0.9715
  Johnson, IA
3520  Jackson, MI...................................    0.9532    0.9677
  Jackson, MI
3560  Jackson, MS...................................    0.8607    0.9024
  Hinds, MS
  Madison, MS
  Rankin, MS
3580  Jackson, TN...................................    0.9275    0.9498
  Madison, TN
  Chester, TN
3600  \1\ Jacksonville, FL..........................    0.9381    0.9572
  Clay, FL
  Duval, FL
  Nassau, FL
  St. Johns, FL
3605  \2\ Jacksonville, NC..........................    0.8666    0.9066
  Onslow, NC
3610  \2\ Jamestown, NY.............................    0.8542    0.8977
  Chautauqua, NY
3620  Janesville-Beloit, WI.........................    0.9849    0.9896
  Rock, WI
3640  Jersey City, NJ...............................    1.1190    1.0800
  Hudson, NJ
3660  Johnson City-Kingsport-Bristol, TN-VA (TN         0.8337    0.8829
 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     0.8504    0.8950
 Hospitals).........................................
  Carter, TN
  Hawkins, TN
  Sullivan, TN
  Unicoi, TN
  Washington, TN
  Bristol City, VA
  Scott, VA
  Washington, VA
3680  \2\ Johnstown, PA.............................    0.8462    0.8919
  Cambria, PA
  Somerset, PA
3700  Jonesboro, AR.................................    0.7843    0.8467
  Craighead, AR
3710  Joplin, MO....................................    0.8613    0.9028
  Jasper, MO
  Newton, MO
3720  Kalamazoo-Battlecreek, MI.....................    1.0595    1.0404
  Calhoun, MI
  Kalamazoo, MI
  Van Buren, MI
3740  \2\ Kankakee, IL..............................    0.8204    0.8732
  Kankakee, IL
3760  \1\ Kansas City, KS-MO........................    0.9736    0.9818
  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...................................    0.9686    0.9784
  Kenosha, WI
3810  Killeen-Temple, TX............................    0.9570    0.9704
  Bell, TX
  Coryell, TX
3840  Knoxville, TN.................................    0.8970    0.9283
  Anderson, TN
  Blount, TN
  Knox, TN
  Loudon, TN
  Sevier, TN
  Union, TN
3850  Kokomo, IN....................................    0.9038    0.9331
  Howard, IN
  Tipton, IN
3870  La Crosse, WI-MN..............................    0.9400    0.9585
  Houston, MN
  La Crosse, WI
3880  Lafayette, LA.................................    0.8475    0.8929
  Acadia, LA
  Lafayette, LA
  St. Landry, LA
  St. Martin, LA
3920  Lafayette, IN.................................    0.9278    0.9500
  Clinton, IN
  Tippecanoe, IN
3960  Lake Charles, LA..............................    0.7965    0.8557
  Calcasieu, LA
3980  Lakeland-Winter Haven, FL.....................    0.9357    0.9555
  Polk, FL
4000  Lancaster, PA.................................    0.9078    0.9359
  Lancaster, PA
4040  Lansing-East Lansing, MI......................    0.9726    0.9812
  Clinton, MI
  Eaton, MI
  Ingham, MI
4080  Laredo, TX....................................    0.8472    0.8927
  Webb, TX
4100  \2\ Las Cruces, NM............................    0.8872    0.9213
  Dona Ana, NM
4120  \1\ Las Vegas, NV-AZ..........................    1.1521    1.1018
  Mohave, AZ
  Clark, NV
  Nye, NV
4150  Lawrence, KS..................................    0.7923    0.8526
  Douglas, KS
4200  Lawton, OK....................................    0.8315    0.8813
  Comanche, OK
4243  Lewiston-Auburn, ME...........................    0.9179    0.9430
  Androscoggin, ME
4280  Lexington, KY.................................    0.8581    0.9005
  Bourbon, KY
  Clark, KY
  Fayette, KY
  Jessamine, KY
  Madison, KY
  Scott, KY
  Woodford, KY
4320  Lima, OH......................................    0.9483    0.9643
  Allen, OH
  Auglaize, OH
4360  Lincoln, NE...................................    0.9892    0.9926
  Lancaster, NE
4400  Little Rock-North Little Rock, AR.............    0.9097    0.9372
  Faulkner, AR
  Lonoke, AR
  Pulaski, AR
  Saline, AR
4420  Longview-Marshall, TX.........................    0.8629    0.9040
  Gregg, TX
  Harrison, TX
  Upshur, TX
4480  \1\ Los Angeles-Long Beach, CA................    1.2011    1.1337
  Los Angeles, CA
4520  \1\Louisville, KY-IN..........................    0.9276    0.9498
  Clark, IN
  Floyd, IN
  Harrison, IN
  Scott, IN
  Bullitt, KY
  Jefferson, KY
  Oldham, KY

[[Page 50218]]

 
4600  Lubbock, TX...................................    0.9646    0.9756
  Lubbock, TX
4640  Lynchburg, VA.................................    0.9219    0.9458
  Amherst, VA
  Bedford, VA
  Bedford City, VA
  Campbell, VA
  Lynchburg City, VA
4680  Macon, GA.....................................    0.9250    0.9480
  Bibb, GA
  Houston, GA
  Jones, GA
  Peach, GA
  Twiggs, GA
4720  Madison, WI...................................    1.0467    1.0317
  Dane, WI
4800  Mansfield, OH.................................    0.8900    0.9233
  Crawford, OH
  Richland, OH
4840  Mayaguez, PR..................................    0.4914    0.6147
  Anasco, PR
  Cabo Rojo, PR
  Hormigueros, PR
  Mayaguez, PR
  Sabana Grande, PR
  San German, PR
4880  McAllen-Edinburg-Mission, TX..................    0.8428    0.8895
  Hidalgo, TX
4890  Medford-Ashland, OR...........................    1.0498    1.0338
  Jackson, OR
4900  Melbourne-Titusville-Palm Bay, FL.............    1.0253    1.0173
  Brevard, Fl
4920  \1\ Memphis, TN-AR-MS.........................    0.8920    0.9247
  Crittenden, AR
  DeSoto, MS
  Fayette, TN
  Shelby, TN
  Tipton, TN
4940  \2\ Merced, CA................................    0.9840    0.9890
  Merced, CA
5000  \1\ Miami, FL.................................    0.9815    0.9873
  Dade, FL
5015  \1\ Middlesex-Somerset-Hunterdon, NJ..........    1.1213    1.0816
  Hunterdon, NJ
  Middlesex, NJ
  Somerset, NJ
5080  \1\ Milwaukee-Waukesha, WI....................    0.9893    0.9927
  Milwaukee, WI
  Ozaukee, WI
  Washington, WI
  Waukesha, WI
5120  \1\ Minneapolis-St. Paul, MN-WI...............    1.0903    1.0610
  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..................................    0.9157    0.9415
  Missoula, MT
5160  Mobile, AL....................................    0.8110    0.8664
  Baldwin, AL
  Mobile, AL
5170  Modesto, CA...................................    1.0498    1.0338
  Stanislaus, CA
5190  \1\ Monmouth-Ocean, NJ........................    1.0814    1.0551
  Monmouth, NJ
  Ocean, NJ
5200  Monroe, LA....................................    0.8137    0.8683
  Ouachita, LA
5240  Montgomery, AL................................    0.7734    0.8386
  Autauga, AL
  Elmore, AL
  Montgomery, AL
5280  Muncie, IN....................................    0.9284    0.9504
  Delaware, IN
5330  Myrtle Beach, SC..............................    0.8976    0.9287
  Horry, SC
5345  Naples, FL....................................    0.9754    0.9831
  Collier, FL
5360  \1\ Nashville, TN.............................    0.9578    0.9709
  Cheatham, TN
  Davidson, TN
  Dickson, TN
  Robertson, TN
  Rutherford TN
  Sumner, TN
  Williamson, TN
  Wilson, TN
5380  \1\ Nassau-Suffolk, NY........................    1.3357    1.2192
  Nassau, NY
  Suffolk, NY
5483  \1\ New Haven-Bridgeport-Stamford-Waterbury-..    1.2459    1.1625
  Danbury, CT
  Fairfield, CT
  New Haven, CT
5523  \2\ New London-Norwich, CT....................    1.2394    1.1583
  New London, CT
5560  \1\ New Orleans, LA...........................    0.9046    0.9336
  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..............................    1.4414    1.2845
  Bronx, NY
  Kings, NY
  New York, NY
  Putnam, NY
  Queens, NY
  Richmond, NY
  Rockland, NY
  Westchester, NY
5640  \1\ Newark, NJ................................    1.1406    1.0943
  Essex, NJ
  Morris, NJ
  Sussex, NJ
  Union, NJ
  Warren, NJ
5660  Newburgh, NY-PA...............................    1.1387    1.0930
  Orange, NY
  Pike, PA
5720  \1\ Norfolk-Virginia Beach-Newport News, VA-NC    0.8574    0.9000
  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...............................    1.5185    1.3312
  Alameda, CA
  Contra Costa, CA
5790  Ocala, FL.....................................    0.9402    0.9587
  Marion, FL
5800  Odessa-Midland, TX............................    0.9397    0.9583
  Ector, TX
  Midland, TX
5880  \1\ Oklahoma City, OK.........................    0.8900    0.9233
  Canadian, OK
  Cleveland, OK
  Logan, OK
  McClain, OK
  Oklahoma, OK
  Pottawatomie, OK
5910  Olympia, WA...................................    1.0960    1.0648
  Thurston, WA
5920  Omaha, NE-IA..................................    0.9978    0.9985
  Pottawattamie, IA
  Cass, NE
  Douglas, NE
  Sarpy, NE
  Washington, NE
5945  \1\ Orange County, CA.........................    1.1594    1.1066
  Orange, CA
5960  \1\ Orlando, FL...............................    0.9640    0.9752

[[Page 50219]]

 
  Lake, FL
  Orange, FL
  Osceola, FL
  Seminole, FL
5990  Owensboro, KY.................................    0.8344    0.8834
  Daviess, KY
6015  Panama City, FL...............................    0.8865    0.9208
  Bay, FL
6020  Parkersburg-Marietta, WV-OH (WV Hospitals)....    0.8127    0.8676
  Washington, OH
  Wood, WV
6020  \2\ Parkersburg-Marietta, WV-OH (OH Hospitals)    0.8613    0.9028
  Washington, OH
  Wood, WV
6080  \2\ Pensacola, FL.............................    0.8814    0.9172
  Escambia, FL
  Santa Rosa, FL
6120  Peoria-Pekin, IL..............................    0.8739    0.9118
  Peoria, IL
  Tazewell, IL
  Woodford, IL
6160  \1\ Philadelphia, PA-NJ.......................    1.0713    1.0483
  Burlington, NJ
  Camden, NJ
  Gloucester, NJ
  Salem, NJ
  Bucks, PA
  Chester, PA
  Delaware, PA
  Montgomery, PA
  Philadelphia, PA
6200  \1\ Phoenix-Mesa, AZ..........................    0.9820    0.9876
  Maricopa, AZ
  Pinal, AZ
6240  Pine Bluff, AR................................    0.7962    0.8555
  Jefferson, AR
6280  \1\ Pittsburgh, PA............................    0.9365    0.9561
  Allegheny, PA
  Beaver, PA
  Butler, PA
  Fayette, PA
  Washington, PA
  Westmoreland, PA
6323  \2\ Pittsfield, MA............................    1.1288    1.0865
  Berkshire, MA
6340  Pocatello, ID.................................    0.9674    0.9776
  Bannock, ID
6360  Ponce, PR.....................................    0.5169    0.6364
  Guayanilla, PR
  Juana Diaz, PR
  Penuelas, PR
  Ponce, PR
  Villalba, PR
  Yauco, PR
6403  Portland, ME..................................    0.9794    0.9858
  Cumberland, ME
  Sagadahoc, ME
  York, ME
6440  \1\ Portland-Vancouver, OR-WA.................    1.0684    1.0463
  Clackamas, OR
  Columbia, OR
  Multnomah, OR
  Washington, OR
  Yamhill, OR
  Clark, WA
6483  \1\ Providence-Warwick-Pawtucket, RI..........    1.0854    1.0577
  Bristol, RI
  Kent, RI
  Newport, RI
  Providence, RI
  Washington, RI
6520  Provo-Orem, UT................................    0.9984    0.9989
  Utah, UT
6560  \2\ Pueblo, CO................................    0.9015    0.9315
  Pueblo, CO
6580  Punta Gorda, FL...............................    0.9218    0.9458
  Charlotte, FL
6600  Racine, WI....................................    0.9334    0.9539
  Racine, WI
6640  \1\ Raleigh-Durham-Chapel Hill, NC............    0.9990    0.9993
  Chatham, NC
  Durham, NC
  Franklin, NC
  Johnston, NC
  Orange, NC
  Wake, NC
6660  Rapid City, SD................................    0.8846    0.9195
  Pennington, SD
6680  Reading, PA...................................    0.9295    0.9512
  Berks, PA
6690  Redding, CA...................................    1.1135    1.0764
  Shasta, CA
6720  Reno, NV......................................    1.0648    1.0439
  Washoe, NV
6740  Richland-Kennewick-Pasco, WA..................    1.1491    1.0998
  Benton, WA
  Franklin, WA
6760  Richmond-Petersburg, VA.......................    0.9477    0.9639
  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..............    1.1365    1.0916
  Riverside, CA
  San Bernardino, CA
6800  Roanoke, VA...................................    0.8614    0.9029
  Botetourt, VA
  Roanoke, VA
  Roanoke City, VA
  Salem City, VA
6820  Rochester, MN.................................    1.2139    1.1420
  Olmsted, MN
6840  \1\ Rochester, NY.............................    0.9194    0.9441
  Genesee, NY
  Livingston, NY
  Monroe, NY
  Ontario, NY
  Orleans, NY
  Wayne, NY
6880  Rockford, IL..................................    0.9625    0.9742
  Boone, IL
  Ogle, IL
  Winnebago, IL
6895  Rocky Mount, NC...............................    0.9228    0.9465
  Edgecombe, NC
  Nash, NC
6920  \1\ Sacramento, CA............................    1.1513    1.1013
  El Dorado, CA
  Placer, CA
  Sacramento, CA
6960  Saginaw-Bay City-Midland, MI..................    0.9650    0.9759
  Bay, MI
  Midland, MI
  Saginaw, MI
6980  St. Cloud, MN.................................    0.9785    0.9852
  Benton, MN
  Stearns, MN
7000  \2\ St. Joseph, MO............................    0.8026    0.8602
  Andrew, MO
  Buchanan, MO
7040  \1\ St. Louis, MO-IL..........................    0.8855    0.9201
  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.....................................    1.0367    1.0250
  Marion, OR
  Polk, OR
7120  Salinas, CA...................................    1.4623    1.2972
  Monterey, CA
7160  \1\ Salt Lake City-Ogden, UT..................    0.9945    0.9962
  Davis, UT
  Salt Lake, UT
  Weber, UT
7200  San Angelo, TX................................    0.8374    0.8856
  Tom Green, TX
7240  \1\ San Antonio, TX...........................    0.8753    0.9128
  Bexar, TX
  Comal, TX
  Guadalupe, TX
  Wilson, TX
7320  \1\ San Diego, CA.............................    1.1135    1.0764

[[Page 50220]]

 
  San Diego, CA
7360  \1\ San Francisco, CA.........................    1.4142    1.2679
  Marin, CA
  San Francisco, CA
  San Mateo, CA
7400  \1\ San Jose, CA..............................    1.4145    1.2680
  Santa Clara, CA
7440  \1\ San Juan-Bayamon, PR......................    0.4741    0.5998
  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....    1.1271    1.0854
  San Luis Obispo, CA
7480  Santa Barbara-Santa Maria-Lompoc, CA..........    1.0481    1.0327
  Santa Barbara, CA
7485  Santa Cruz-Watsonville, CA....................    1.3646    1.2372
  Santa Cruz, CA
7490  Santa Fe, NM..................................    1.0712    1.0482
  Los Alamos, NM
  Santa Fe, NM
7500  Santa Rosa, CA................................    1.3046    1.1997
  Sonoma, CA
7510  Sarasota-Bradenton, FL........................    0.9449    0.9619
  Manatee, FL
  Sarasota, FL
7520  Savannah, GA..................................    0.9376    0.9568
  Bryan, GA
  Chatham, GA
  Effingham, GA
7560  Scranton--Wilkes-Barre--Hazleton, PA..........    0.8599    0.9018
  Columbia, PA
  Lackawanna, PA
  Luzerne, PA
  Wyoming, PA
7600  \1\ Seattle-Bellevue-Everett, WA..............    1.1474    1.0987
  Island, WA
  King, WA
  Snohomish, WA
7610  \2\ Sharon, PA................................    0.8462    0.8919
  Mercer, PA
7620  \2\ Sheboygan, WI.............................    0.9162    0.9418
  Sheboygan, WI
7640  Sherman-Denison, TX...........................    0.9255    0.9484
  Grayson, TX
7680  Shreveport-Bossier City, LA...................    0.8987    0.9295
  Bossier, LA
  Caddo, LA
  Webster, LA
7720  Sioux City, IA-NE.............................    0.9046    0.9336
  Woodbury, IA
  Dakota, NE
7760  Sioux Falls, SD...............................    0.9257    0.9485
  Lincoln, SD
  Minnehaha, SD
7800  South Bend, IN................................    0.9802    0.9864
  St. Joseph, IN
7840  Spokane, WA...................................    1.0852    1.0576
  Spokane, WA
7880  Springfield, IL...............................    0.8659    0.9061
  Menard, IL
  Sangamon, IL
7920  Springfield, MO...............................    0.8424    0.8892
  Christian, MO
  Greene, MO
  Webster, MO
8003  \2\ Springfield, MA...........................    1.1288    1.0865
  Hampden, MA
  Hampshire, MA
8050  State College, PA.............................    0.8941    0.9262
  Centre, PA
8080  Steubenville-Weirton, OH-WV...................    0.8804    0.9165
  Jefferson, OH
  Brooke, WV
  Hancock, WV
8120  Stockton-Lodi, CA.............................    1.0650    1.0441
  San Joaquin, CA
8140  \2\ Sumter, SC................................    0.8607    0.9024
  Sumter, SC
8160  Syracuse, NY..................................    0.9714    0.9803
  Cayuga, NY
  Madison, NY
  Onondaga, NY
  Oswego, NY
8200  Tacoma, WA....................................    1.0940    1.0635
  Pierce, WA
8240  \2\ Tallahassee, FL...........................    0.8814    0.9172
  Gadsden, FL
  Leon, FL
8280  \1\ Tampa-St. Petersburg-Clearwater, FL.......    0.9171    0.9425
  Hernando, FL
  Hillsborough, FL
  Pasco, FL
  Pinellas, FL
8320  \2\ Terre Haute, IN...........................    0.8755    0.9130
  Clay, IN
  Vermillion, IN
  Vigo, IN
8360  Texarkana,AR-Texarkana, TX....................    0.8126    0.8675
  Miller, AR
  Bowie, TX
8400  Toledo, OH....................................    0.9810    0.9869
  Fulton, OH
  Lucas, OH
  Wood, OH
8440  Topeka, KS....................................    0.9199    0.9444
  Shawnee, KS
8480  Trenton, NJ...................................    1.0432    1.0294
  Mercer, NJ
8520  Tucson, AZ....................................    0.8911    0.9241
  Pima, AZ
8560  Tulsa, OK.....................................    0.8332    0.8825
  Creek, OK
  Osage, OK
  Rogers, OK
  Tulsa, OK
  Wagoner, OK
8600  Tuscaloosa, AL................................    0.8203    0.8731
  Tuscaloosa, AL
8640  Tyler, TX.....................................    0.9521    0.9669
  Smith, TX
8680  \2\ Utica-Rome, NY............................    0.8542    0.8977
  Herkimer, NY
  Oneida, NY
8720  Vallejo-Fairfield-Napa, CA....................    1.3421    1.2232
  Napa, CA
  Solano, CA
8735  Ventura, CA...................................    1.1096    1.0738
  Ventura, CA
8750  Victoria, TX..................................    0.8756    0.9130
  Victoria, TX
8760  Vineland-Millville-Bridgeton, NJ..............    1.0031    1.0021
  Cumberland, NJ
8780  \2\ Visalia-Tulare-Porterville, CA............    0.9840    0.9890
  Tulare, CA
8800  Waco, TX......................................    0.8088    0.8647
  McLennan, TX
8840  \1\ Washington, DC-MD-VA-WV...................    1.0851    1.0575
  District of Columbia, DC
  Calvert, MD
  Charles, MD
  Frederick, MD
  Montgomery, MD
  Prince Georges, MD
  Alexandria City, VA
  Arlington, VA
  Clarke, VA

[[Page 50221]]

 
  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......................    0.8902    0.9234
  Black Hawk, IA
8940  Wausau, WI....................................    0.9782    0.9850
  Marathon, WI
8960  \1\ West Palm Beach-Boca Raton, FL............    0.9939    0.9958
  Palm Beach, FL
9000  \2\ Wheeling, WV-OH (WV Hospitals)............    0.7975    0.8565
  Belmont, OH
  Marshall, WV
  Ohio, WV
9000  \2\ Wheeling, WV-OH (OH Hospitals)............    0.8613    0.9028
  Belmont, OH
  Marshall, WV
  Ohio, WV
9040  Wichita, KS...................................    0.9520    0.9669
  Butler, KS
  Harvey, KS
  Sedgwick, KS
9080  Wichita Falls, TX.............................    0.8498    0.8945
  Archer, TX
  Wichita, TX
9140  Williamsport, PA..............................    0.8544    0.8978
  Lycoming, PA
9160  Wilmington-Newark, DE-MD......................    1.1173    1.0789
  New Castle, DE
  Cecil, MD
9200  Wilmington, NC................................    0.9640    0.9752
  New Hanover, NC
  Brunswick, NC
9260  Yakima, WA....................................    1.0569    1.0386
  Yakima, WA
9270  \2\ Yolo, CA..................................    0.9840    0.9890
  Yolo, CA
9280  York, PA......................................    0.9026    0.9322
  York, PA
9320  Youngstown-Warren, OH.........................    0.9358    0.9556
  Columbiana, OH
  Mahoning, OH
  Trumbull, OH
9340  Yuba City, CA.................................    1.0276    1.0188
  Sutter, CA
  Yuba, CA
9360  Yuma, AZ......................................    0.8589    0.9011
  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.............................................    0.7727    0.8381
Alaska..............................................    1.2293    1.1519
Arizona.............................................    0.8493    0.8942
Arkansas............................................    0.7666    0.8336
California..........................................    0.9840    0.9890
Colorado............................................    0.9015    0.9315
Connecticut.........................................    1.2394    1.1583
Delaware............................................    0.9128    0.9394
Florida.............................................    0.8814    0.9172
Georgia.............................................    0.8230    0.8751
Hawaii..............................................    1.0255    1.0174
Idaho...............................................    0.8747    0.9124
Illinois............................................    0.8204    0.8732
Indiana.............................................    0.8755    0.9130
Iowa................................................    0.8315    0.8813
Kansas..............................................    0.7923    0.8526
Kentucky............................................    0.8079    0.8641
Louisiana...........................................    0.7647    0.8322
Maine...............................................    0.8874    0.9215
Maryland............................................    0.8946    0.9266
Massachusetts.......................................    1.1288    1.0865
Michigan............................................    0.9013    0.9313
Minnesota...........................................    0.9151    0.9411
Mississippi.........................................    0.7680    0.8346
Missouri............................................    0.8026    0.8602
Montana.............................................    0.8481    0.8933
Nebraska............................................    0.8204    0.8732
Nevada..............................................    0.9577    0.9708
New Hampshire.......................................    0.9796    0.9860
New Jersey \1\......................................  ........  ........
New Mexico..........................................    0.8872    0.9213
New York............................................    0.8542    0.8977
North Carolina......................................    0.8666    0.9066
North Dakota........................................    0.7788    0.8427
Ohio................................................    0.8613    0.9028
Oklahoma............................................    0.7590    0.8279
Oregon..............................................    1.0303    1.0207
Pennsylvania........................................    0.8462    0.8919
Puerto Rico.........................................    0.4356    0.5660
Rhode Island1.......................................  ........  ........
South Carolina......................................    0.8607    0.9024
South Dakota........................................    0.7815    0.8447
Tennessee...........................................    0.7877    0.8492
Texas...............................................    0.7827    0.8455
Utah................................................    0.9312    0.9524
Vermont.............................................    0.9345    0.9547
Virginia............................................    0.8504    0.8950
Washington..........................................    1.0179    1.0122
West Virginia.......................................    0.7975    0.8565
Wisconsin...........................................    0.9162    0.9418
Wyoming.............................................    0.9007   0.9309
------------------------------------------------------------------------
\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.........................................    0.7827    0.8455
Akron, OH...........................................    0.9600    0.9724
Albany, GA..........................................    1.0427    1.0290
Albuquerque, NM.....................................    0.9390    0.9578
Alexandria, LA......................................    0.7883    0.8497
Allentown-Bethlehem-Easton, PA......................    0.9735    0.9818
Altoona, PA.........................................    0.9225    0.9463
Amarillo, TX........................................    0.8884    0.9222
Anchorage, AK.......................................    1.2490    1.1645
Ann Arbor, MI.......................................    1.1103    1.0743
Anniston, AL........................................    0.7910    0.8517
Asheville, NC.......................................    0.9575    0.9707
Athens, GA..........................................    1.0066    1.0045
Atlanta, GA.........................................    0.9889    0.9924
Augusta-Aiken, GA-SC................................    0.9887    0.9922
Austin-San Marcos, TX...............................    0.9637    0.9750
Barnstable-Yarmouth, MA.............................    1.2943    1.1932
Baton Rouge, LA.....................................    0.8190    0.8722
Bellingham, WA......................................    1.1642    1.1097
Benton Harbor, MI...................................    0.9106    0.9379
Bergen-Passaic, NJ..................................    1.2207    1.1463
Billings, MT........................................    0.9022    0.9319
Biloxi-Gulfport-Pascagoula, MS......................    0.8368    0.8851
Binghamton, NY......................................    0.8462    0.8919
Birmingham, AL......................................    0.9222    0.9460
Bismarck, ND........................................    0.7972    0.8562
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH....    1.1235    1.0830
Burlington, VT......................................    0.9572    0.9705
Caguas, PR..........................................    0.4408    0.5707
Casper, WY..........................................    0.9586    0.9715
Champaign-Urbana, IL................................    0.9772    0.9843
Charleston-North Charleston, SC.....................    0.9235    0.9470
Charleston, WV......................................    0.8649    0.9054
Charlotte-Gastonia-Rock Hill, NC-SC.................    0.9743    0.9823
Charlottesville, VA.................................    1.0120    1.0082
Chattanooga, TN-GA..................................    0.8843    0.9192
Chicago, IL.........................................    1.0905    1.0611
Cincinnati, OH-KY-IN................................    0.9389    0.9577
Clarksville-Hopkinsville, TN-KY.....................    0.8419    0.8888
Cleveland-Lorain-Elyria, OH.........................    0.9670    0.9773
Columbia, MO........................................    0.8515    0.8958
Columbia, SC........................................    0.9194    0.9441
Columbus, GA-AL (GA Hospitals)......................    0.8230    0.8751

[[Page 50222]]

 
Columbus, GA-AL (AL Hospitals)......................    0.7985    0.8572
Columbus, OH........................................    0.9549    0.9689
Corpus Christi, TX..................................    0.8729    0.9111
Dallas, TX..........................................    0.9998    0.9999
Davenport-Moline-Rock Island, IA-IL.................    0.8835    0.9187
Dayton-Springfield, OH..............................    0.9282    0.9503
Denver, CO..........................................    1.0484    1.0329
Des Moines, IA......................................    0.8827    0.9181
Detroit, MI.........................................    1.0448    1.0305
Dothan, AL..........................................    0.8158    0.8699
Dover, DE...........................................    0.9254    0.9483
Duluth-Superior, MN-WI..............................    1.0368    1.0251
Eau Claire, WI......................................    0.9162    0.9418
Elkhart-Goshen, IN..................................    0.9516    0.9666
Erie, PA............................................    0.8761    0.9134
Eugene-Springfield, OR..............................    1.0944    1.0637
Fargo-Moorhead, ND-MN...............................    0.9468    0.9633
Fayetteville, NC....................................    0.8992    0.9298
Flagstaff, AZ-UT....................................    1.0131    1.0090
Flint, MI...........................................    1.0963    1.0650
Florence, AL........................................    0.7819    0.8449
Florence, SC........................................    0.8780    0.9148
Fort Collins-Loveland, CO...........................    1.0066    1.0045
Ft. Lauderdale, FL..................................    1.0704    1.0477
Fort Pierce-Port St. Lucie, FL......................    0.9931    0.9953
Fort Smith, AR-OK...................................    0.7738    0.8389
Fort Walton Beach, FL...............................    0.9430    0.9606
Forth Worth-Arlington, TX...........................    0.9446    0.9617
Gadsden, AL.........................................    0.8599    0.9018
Gainesville, FL.....................................    0.9871    0.9911
Grand Forks, ND-MN..................................    0.9243    0.9475
Grand Junction, CO..................................    0.9679    0.9779
Grand Rapids-Muskegon-Holland, MI...................    0.9548    0.9688
Great Falls, MT.....................................    0.8966    0.9280
Greeley, CO.........................................    0.9336    0.9540
Green Bay, WI.......................................    0.9668    0.9771
Greensboro-Winston-Salem-High Point, NC.............    0.9129    0.9395
Greenville, NC......................................    0.9174    0.9427
Harrisburg-Lebanon-Carlisle, PA.....................    0.9223    0.9461
Hartford, CT........................................    1.1549    1.1036
Hattiesburg, MS.....................................    0.7680    0.8346
Hickory-Morganton-Lenoir, NC........................    0.8926    0.9251
Houston, TX.........................................    0.9792    0.9857
Huntington-Ashland, WV-KY-OH........................    0.9167    0.9422
Huntsville, AL......................................    0.8771    0.9141
Indianapolis, IN....................................    0.9717    0.9805
Iowa City, IA.......................................    0.9442    0.9614
Jackson, MS.........................................    0.8607    0.9024
Jackson, TN.........................................    0.9002    0.9305
Jacksonville, FL....................................    0.9237    0.9471
Johnson City-Kingsport-Bristol, TN-VA (VA Hospitals)    0.8504    0.8950
Johnson City-Kingsport-Bristol, TN-VA (KY Hospitals)    0.8337    0.8829
Jonesboro, AR (AR Hospitals)........................    0.7843    0.8467
Jonesboro, AR (MO Hospitals)........................    0.8026    0.8602
Joplin, MO..........................................    0.8613    0.9028
Kalamazoo-Battlecreek, MI...........................    1.0400    1.0272
Kansas City, KS-MO..................................    0.9736    0.9818
Knoxville, TN.......................................    0.8970    0.9283
Kokomo, IN..........................................    0.9038    0.9331
Lafayette, LA.......................................    0.8316    0.8814
Lakeland-Winter Haven, FL...........................    0.9357    0.9555
Las Vegas, NV-AZ....................................    1.1521    1.1018
Lawton, OK..........................................    0.8077    0.8639
Lexington, KY.......................................    0.8581    0.9005
Lima, OH............................................    0.9483    0.9643
Lincoln, NE.........................................    0.9711    0.9801
Little Rock-North Little Rock, AR...................    0.8951    0.9269
Longview-Marshall, TX...............................    0.8629    0.9040
Los Angeles-Long Beach, CA..........................    1.2011    1.1337
Louisville, KY-IN...................................    0.9163    0.9419
Lubbock, TX.........................................    0.9646    0.9756
Lynchburg, VA.......................................    0.8909    0.9239
Macon, GA...........................................    0.9250    0.9480
Madison, WI.........................................    1.0467    1.0317
Medford-Ashland, OR.................................    1.0303    1.0207
Memphis, TN-AR-MS...................................    0.8712    0.9099
Miami, FL...........................................    0.9815    0.9873
Milwaukee-Waukesha, WI..............................    0.9893    0.9927
Minneapolis-St. Paul, MN-WI.........................    1.0903    1.0610
Missoula, MT........................................    0.9047    0.9337
Mobile, AL..........................................    0.8110    0.8664
Modesto, CA.........................................    1.0498    1.0338
Monmouth-Ocean, NJ..................................    1.0814    1.0551
Monroe, LA..........................................    0.8137    0.8683
Montgomery, AL......................................    0.7734    0.8386
Nashville, TN.......................................    0.9375    0.9568
New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT.    1.2459    1.1625
New London-Norwich, CT..............................    1.1626    1.1087
New Orleans, LA.....................................    0.9046    0.9336
New York, NY........................................    1.4220    1.2726
Newark, NJ..........................................    1.1406    1.0943
Newburgh, NY-PA.....................................    1.0747    1.0506
Norfolk-Virginia Beach-Newport News, VA-NC..........    0.8666    0.9066
Oakland, CA.........................................    1.5185    1.3312
Odessa-Midland, TX..................................    0.9180    0.9431
Oklahoma City, OK...................................    0.8900    0.9233
Omaha, NE-IA........................................    0.9978    0.9985
Orange County, CA...................................    1.1594    1.1066
Orlando, FL.........................................    0.9640    0.9752
Peoria-Pekin, IL....................................    0.8739    0.9118
Philadelphia, PA-NJ.................................    1.0713    1.0483
Phoenix-Mesa, AZ....................................    0.9820    0.9876
Pine Bluff, AR......................................    0.7798    0.8434
Pittsburgh, PA......................................    0.9224    0.9462
Pittsfield, MA......................................    0.9863    0.9906
Pocatello, ID.......................................    0.9674    0.9776
Portland, ME........................................    0.9620    0.9738
Portland-Vancouver, OR-WA...........................    1.0684    1.0463
Provo-Orem, UT......................................    0.9984    0.9989
Raleigh-Durham-Chapel Hill, NC......................    0.9990    0.9993
Rapid City, SD......................................    0.8846    0.9195
Reading, PA.........................................    0.9108    0.9380
Redding, CA.........................................    1.1135    1.0764
Reno, NV............................................    1.0466    1.0317
Richland-Kennewick-Pasco, WA........................    1.0800    1.0541
Richmond-Petersburg, VA.............................    0.9477    0.9639
Roanoke, VA.........................................    0.8614    0.9029
Rochester, MN.......................................    1.2139    1.1420
Rockford, IL........................................    0.9399    0.9584
Sacramento, CA......................................    1.1513    1.1013
Saginaw-Bay City-Midland, MI........................    0.9543    0.9685
St. Cloud, MN.......................................    0.9785    0.9852
St. Joseph, MO......................................    0.8240    0.8758
St. Louis, MO-IL....................................    0.8855    0.9201
Salinas, CA.........................................    1.4623    1.2972
Salt Lake City-Ogden, UT............................    0.9945    0.9962
San Antonio, TX.....................................    0.8753    0.9128
San Diego, CA.......................................    1.1135    1.0764
Santa Fe, NM........................................    0.9891    0.9925
Santa Rosa, CA......................................    1.2761    1.1817
Sarasota-Bradenton, FL..............................    0.9449    0.9619
Savannah, GA........................................    0.9376    0.9568
Seattle-Bellevue-Everett, WA........................    1.1474    1.0987
Sherman-Denison, TX.................................    0.9008    0.9310
Shreveport-Bossier City, LA.........................    0.8987    0.9295
Sioux City, IA-NE...................................    0.8647    0.9052
Sioux Falls, SD.....................................    0.9059    0.9346
South Bend, IN......................................    0.9802    0.9864
Spokane, WA.........................................    1.0663    1.0449
Springfield, IL.....................................    0.8659    0.9061
Springfield, MO.....................................    0.8153    0.8695
Stockton-Lodi, CA...................................    1.0650    1.0441
Syracuse, NY........................................    0.9612    0.9733
Tampa-St. Petersburg-Clearwater, FL.................    0.9171    0.9425
Texarkana,AR-Texarkana, TX..........................    0.8126    0.8675
Toledo, OH..........................................    0.9810    0.9869
Topeka, KS..........................................    0.9031    0.9326
Tucson, AZ..........................................    0.8911    0.9241
Tulsa, OK...........................................    0.8332    0.8825
Tuscaloosa, AL......................................    0.8203    0.8731
Tyler, TX...........................................    0.9195    0.9441
Vallejo-Fairfield-Napa, CA..........................    1.3421    1.2232
Victoria, TX........................................    0.8756    0.9130
Waco, TX............................................    0.8088    0.8647
Washington, DC-MD-VA-WV.............................    1.0851    1.0575

[[Page 50223]]

 
Waterloo-Cedar Falls, IA............................    0.8902    0.9234
Wausau, WI..........................................    0.9782    0.9850
West Palm Beach-Boca Raton, FL......................    0.9939    0.9958
Wichita, KS.........................................    0.9179    0.9430
Wichita Falls, TX...................................    0.8498    0.8945
Wilmington-Newark, DE-MD............................    1.0862    1.0583
Wilmington, NC......................................    0.9425    0.9603
York, PA............................................    0.9026    0.9322
Youngstown-Warren, OH...............................    0.9358    0.9556
Rural Alabama.......................................    0.7727    0.8381
Rural Florida.......................................    0.8814    0.9172
Rural Illinois (IA Hospitals).......................    0.8315    0.8813
Rural Illinois (MO Hospitals).......................    0.8204    0.8732
Rural Kentucky......................................    0.8079    0.8641
Rural Louisiana.....................................    0.7647    0.8322
Rural Michigan......................................    0.9013    0.9313
Rural Minnesota.....................................    0.9151    0.9411
Rural Missouri......................................    0.8026    0.8602
Rural Montana.......................................    0.8481    0.8933
Rural Nebraska......................................    0.8204    0.8732
Rural Nevada........................................    0.9117    0.9387
Rural Texas.........................................    0.7827    0.8455
Rural Washington....................................    1.0179    1.0122
Rural Wyoming.......................................    0.9007    0.9309
------------------------------------------------------------------------


                Table 4F.--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF)
----------------------------------------------------------------------------------------------------------------
                                                                                    Wage index--
                         Area                            Wage index      GAF          reclass.     GAF--reclass.
                                                                                     hospitals       hospitals
----------------------------------------------------------------------------------------------------------------
Aguadilla, PR.........................................       0.9679       0.9779  ...............  .............
\1\ Arecibo, PR.......................................       0.9192       0.9439  ...............  .............
Caguas, PR............................................       0.9302       0.9517         0.9302          0.9517
Mayaguez, PR..........................................       1.0369       1.0251  ...............  .............
Ponce, PR.............................................       1.0907       1.0613  ...............  .............
San Juan-Bayamon, PR..................................       1.0004       1.0003  ...............  .............
Rural Puerto Rico.....................................       0.9192       0.9439  ...............  .............
----------------------------------------------------------------------------------------------------------------
\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.............................................    0.7820
  Taylor, TX
0060  Aguadilla, PR...........................................    0.4587
  Aguada, PR
  Aguadilla, PR
  Moca, PR
0080  Akron, OH...............................................    0.9599
  Portage, OH
  Summit, OH
0120  Albany, GA..............................................    1.0594
  Dougherty, GA
  Lee, GA
0160  Albany-Schenectady-Troy, NY.............................    0.8542
  Albany, NY
  Montgomery, NY
  Rensselaer, NY
  Saratoga, NY
  Schenectady, NY
  Schoharie, NY
0200  Albuquerque, NM.........................................    0.9315
  Bernalillo, NM
  Sandoval, NM
  Valencia, NM
0220  Alexandria, LA..........................................    0.7859
  Rapides, LA
0240  Allentown-Bethlehem-Easton, PA..........................    0.9735
  Carbon, PA
  Lehigh, PA
  Northampton, PA
0280  Altoona, PA.............................................    0.9224
  Blair, PA
0320  Amarillo, TX Potter, TX.................................    0.9034
  Randall, TX
0380  Anchorage, AK...........................................    1.2358
  Anchorage, AK
0440  Ann Arbor, MI...........................................    1.1103
  Lenawee, MI
  Livingston, MI
  Washtenaw, MI
0450  Anniston, AL............................................    0.8044
  Calhoun, AL
0460  Appleton-Oshkosh-Neenah, WI.............................    0.9162
  Calumet, WI
  Outagamie, WI
  Winnebago, WI
0470  Arecibo, PR.............................................    0.4356
  Arecibo, PR
  Camuy, PR
  Hatillo, PR
0480  Asheville, NC...........................................    0.9876
  Buncombe, NC
  Madison, NC
0500  Athens, GA..............................................    1.0210
  Clarke, GA
  Madison, GA
  Oconee, GA
0520  Atlanta, GA.............................................    0.9991
  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...................................    1.1016
  Atlantic, NJ
  Cape May, NJ
0580  Auburn-Opelika, AL......................................    0.8325
  Lee, AL
0600  Augusta-Aiken, GA-SC....................................    1.0264
  Columbia, GA
  McDuffie, GA
  Richmond, GA
  Aiken, SC
  Edgefield, SC
0640  Austin-San Marcos, TX...................................    0.9637
  Bastrop, TX
  Caldwell, TX
  Hays, TX
  Travis, TX

[[Page 50224]]

 
  Williamson, TX
0680  Bakersfield, CA.........................................    0.9898
  Kern, CA
0720  Baltimore, MD...........................................    0.9929
  Anne Arundel, MD
  Baltimore, MD
  Baltimore City, MD
  Carroll, MD
  Harford, MD
  Howard, MD
  Queen Anne's, MD
0733  Bangor, ME..............................................    0.9664
  Penobscot, ME
0743  Barnstable-Yarmouth, MA.................................    1.3202
  Barnstable, MA
0760  Baton Rouge, LA.........................................    0.8294
  Ascension, LA
  East Baton Rouge, LA
  Livingston, LA
  West Baton Rouge, LA
0840  Beaumont-Port Arthur, TX................................    0.8324
  Hardin, TX
  Jefferson, TX
  Orange, TX
0860  Bellingham, WA..........................................    1.2281
  Whatcom, WA
0870  Benton Harbor, MI.......................................    0.9041
  Berrien, MI
0875  Bergen-Passaic, NJ......................................    1.2150
  Bergen, NJ
  Passaic, NJ
0880  Billings, MT............................................    0.9022
  Yellowstone, MT
0920  Biloxi-Gulfport-Pascagoula, MS..........................    0.8757
  Hancock, MS
  Harrison, MS
  Jackson, MS
0960  Binghamton, NY..........................................    0.8542
  Broome, NY
  Tioga, NY
1000  Birmingham, AL..........................................    0.9221
  Blount, AL
  Jefferson, AL
  St. Clair, AL
  Shelby, AL
1010  Bismarck, ND............................................    0.7972
  Burleigh, ND
  Morton, ND
1020  Bloomington, IN.........................................    0.8906
  Monroe, IN
1040  Bloomington-Normal, IL..................................    0.9109
  McLean, IL
1080  Boise City, ID..........................................    0.9310
  Ada, ID
  Canyon, ID
1123  Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH (NH        1.1288
 Hospitals)...................................................
  Bristol, MA
  Essex, MA
  Middlesex, MA
  Norfolk, MA
  Plymouth, MA
  Suffolk, MA
  Worcester, MA
  Hillsborough, NH
  Merrimack, NH
  Rockingham, NH
  Strafford, NH
1125  Boulder-Longmont, CO....................................    0.9689
  Boulder, CO
1145  Brazoria, TX............................................    0.8535
  Brazoria, TX
1150  Bremerton, WA...........................................    1.0944
  Kitsap, WA
1240  Brownsville-Harlingen-San Benito, TX....................    0.8880
  Cameron, TX
1260  Bryan-College Station, TX...............................    0.8821
  Brazos, TX
1280  Buffalo-Niagara Falls, NY...............................    0.9365
  Erie, NY
  Niagara, NY
1303  Burlington, VT..........................................    1.0052
  Chittenden, VT
  Franklin, VT
  Grand Isle, VT
1310  Caguas, PR..............................................    0.4371
  Caguas, PR
  Cayey, PR
  Cidra, PR
  Gurabo, PR
  San Lorenzo, PR
1320  Canton-Massillon, OH....................................    0.8931
  Carroll, OH
  Stark, OH
1350  Casper, WY..............................................    0.9689
  Natrona, WY
1360  Cedar Rapids, IA........................................    0.9056
  Linn, IA
1400  Champaign-Urbana, IL....................................    1.0635
  Champaign, IL
1440  Charleston-North Charleston, SC.........................    0.9235
  Berkeley, SC
  Charleston, SC
  Dorchester, SC
1480  Charleston, WV..........................................    0.8897
  Kanawha, WV
  Putnam, WV
1520  Charlotte-Gastonia-Rock Hill, NC-SC.....................    0.9850
  Cabarrus, NC
  Gaston, NC
  Lincoln, NC
  Mecklenburg, NC
  Rowan, NC
  Stanly, NC
  Union, NC
  York, SC
1540  Charlottesville, VA.....................................    1.0437
  Albemarle, VA
  Charlottesville City, VA
  Fluvanna, VA
  Greene, VA
1560  Chattanooga, TN-GA......................................    0.8976
  Catoosa, GA
  Dade, GA
  Walker, GA
  Hamilton, TN
  Marion, TN
1580  Cheyenne, WY............................................    0.9007
  Laramie, WY
1600  Chicago, IL.............................................    1.1044
  Cook, IL
  DeKalb, IL
  DuPage, IL
  Grundy, IL
  Kane, IL
  Kendall, IL
  Lake, IL
  McHenry, IL
  Will, IL
1620  Chico-Paradise, CA......................................    0.9839
  Butte, CA
1640  Cincinnati, OH-KY-IN....................................    0.9380
  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.........................    0.8405
  Christian, KY
  Montgomery, TN
1680  Cleveland-Lorain-Elyria, OH.............................    0.9670
  Ashtabula, OH
  Cuyahoga, OH
  Geauga, OH
  Lake, OH
  Lorain, OH
  Medina, OH
1720  Colorado Springs, CO....................................    0.9915
  El Paso, CO
1740  Columbia, MO............................................    0.8495
  Boone, MO
1760  Columbia, SC............................................    0.9306
  Lexington, SC
  Richland, SC
1800  Columbus, GA-AL Russell, AL.............................    0.8374
  Chattahoochee, GA
  Harris, GA
  Muscogee, GA
1840  Columbus, OH............................................    0.9751
  Delaware, OH
  Fairfield, OH
  Franklin, OH
  Licking, OH
  Madison, OH
  Pickaway, OH
1880  Corpus Christi, TX......................................    0.8728
  Nueces, TX
  San Patricio, TX
1890  Corvallis, OR...........................................    1.1452
  Benton, OR
1900  Cumberland, MD-WV (WV Hospital).........................    0.7975
  Allegany, MD
  Mineral, WV
1920  Dallas, TX..............................................    0.9998
  Collin, TX
  Dallas, TX
  Denton, TX
  Ellis, TX
  Henderson, TX
  Hunt, TX
  Kaufman, TX
  Rockwall, TX
1950  Danville, VA............................................    0.8859
  Danville City, VA
  Pittsylvania, VA

[[Page 50225]]

 
1960  Davenport-Moline-Rock Island, IA-IL.....................    0.8834
  Scott, IA
  Henry, IL
  Rock Island, IL
2000  Dayton-Springfield, OH..................................    0.9282
  Clark, OH
  Greene, OH
  Miami, OH
  Montgomery, OH
2020  Daytona Beach, FL.......................................    0.9062
  Flagler, FL
  Volusia, FL
2030  Decatur, AL.............................................    0.8973
  Lawrence, AL
  Morgan, AL
2040  Decatur, IL.............................................    0.8204
  Macon, IL
2080  Denver, CO..............................................    1.0600
  Adams, CO
  Arapahoe, CO
  Broomfield, CO
  Denver, CO
  Douglas, CO
  Jefferson, CO
2120  Des Moines, IA..........................................    0.8790
  Dallas, IA
  Polk, IA
  Warren, IA
2160  Detroit, MI.............................................    1.0448
  Lapeer, MI
  Macomb, MI
  Monroe, MI
  Oakland, MI
  St. Clair, MI
  Wayne, MI
2180  Dothan, AL..............................................    0.8137
  Dale, AL
  Houston, AL
2190  Dover, DE...............................................    0.9356
  Kent, DE
2200  Dubuque, IA.............................................    0.8795
  Dubuque, IA
2240  Duluth-Superior, MN-WI..................................    1.0367
  St. Louis, MN
  Douglas, WI
2281  Dutchess County, NY.....................................    1.0684
  Dutchess, NY
2290  Eau Claire, WI..........................................    0.9162
  Chippewa, WI
  Eau Claire, WI
2320  El Paso, TX.............................................    0.9265
  El Paso, TX
2330  Elkhart-Goshen, IN......................................    0.9722
  Elkhart, IN
2335  Elmira, NY..............................................    0.8542
  Chemung, NY
2340  Enid, OK................................................    0.8376
  Garfield, OK
2360  Erie, PA................................................    0.8925
  Erie, PA
2400  Eugene-Springfield, OR..................................    1.0944
  Lane, OR
2440  Evansville-Henderson, IN-KY (IN Hospitals)..............    0.8754
  Posey, IN
  Vanderburgh, IN
  Warrick, IN
  Henderson, KY
2520  Fargo-Moorhead, ND-MN...................................    0.9684
  Clay, MN
  Cass, ND
2560  Fayetteville, NC........................................    0.8889
  Cumberland, NC
2580  Fayetteville-Springdale-Rogers, AR......................    0.8099
  Benton, AR
  Washington, AR
2620  Flagstaff, AZ-UT........................................    1.0682
  Coconino, AZ
  Kane, UT
2640  Flint, MI...............................................    1.1135
  Genesee, MI
2650  Florence, AL............................................    0.7792
  Colbert, AL
  Lauderdale, AL
2655  Florence, SC............................................    0.8780
  Florence, SC
2670  Fort Collins-Loveland, CO...............................    1.0066
  Larimer, CO
2680  Ft. Lauderdale, FL......................................    1.0296
  Broward, FL
2700  Fort Myers-Cape Coral, FL...............................    0.9680
  Lee, FL
2710  Fort Pierce-Port St. Lucie, FL..........................    0.9823
  Martin, FL
  St. Lucie, FL
2720  Fort Smith, AR-OK.......................................    0.7895
  Crawford, AR
  Sebastian, AR
  Sequoyah, OK
2750  Fort Walton Beach, FL...................................    0.9693
  Okaloosa, FL
2760  Fort Wayne, IN..........................................    0.9457
  Adams, IN
  Allen, IN
  De Kalb, IN
  Huntington, IN
  Wells, IN
  Whitley, IN
2800  Forth Worth-Arlington, TX...............................    0.9445
  Hood, TX
  Johnson, TX
  Parker, TX
  Tarrant, TX
2840  Fresno, CA..............................................    1.0216
  Fresno, CA
  Madera, CA
2880  Gadsden, AL.............................................    0.8505
  Etowah, AL
2900  Gainesville, FL.........................................    0.9871
  Alachua, FL
2920  Galveston-Texas City, TX................................    0.9465
  Galveston, TX
2960  Gary, IN................................................    0.9584
  Lake, IN
  Porter, IN
2975  Glens Falls, NY.........................................    0.8542
  Warren, NY
  Washington, NY
2980  Goldsboro, NC...........................................    0.8891
  Wayne, NC
2985  Grand Forks, ND-MN......................................    0.8897
  Polk, MN
  Grand Forks, ND
2995  Grand Junction, CO......................................    0.9456
  Mesa, CO
3000  Grand Rapids-Muskegon-Holland, MI.......................    0.9525
  Allegan, MI
  Kent, MI
  Muskegon, MI
  Ottawa, MI
3040  Great Falls, MT.........................................    0.8950
  Cascade, MT
3060  Greeley, CO.............................................    0.9236
  Weld, CO
3080  Green Bay, WI...........................................    0.9502
  Brown, WI
3120  Greensboro-Winston-Salem-High Point, NC.................    0.9282
  Alamance, NC
  Davidson, NC
  Davie, NC
  Forsyth, NCGuilford, NC
  Randolph, NC
  Stokes, NC
  Yadkin, NC
3150  Greenville, NC..........................................    0.9100
  Pitt, NC
3160  Greenville-Spartanburg-Anderson, SC.....................    0.9122
  Anderson, SC
  Cherokee, SC
  Greenville, SC
  Pickens, SC
  Spartanburg, SC
3180  Hagerstown, MD..........................................    0.9267
  Washington, MD
3200  Hamilton-Middletown, OH.................................    0.9418
  Butler, OH
3240  Harrisburg-Lebanon-Carlisle, PA.........................    0.9223
  Cumberland, PA
  Dauphin, PA
  Lebanon, PA
  Perry, PA
3283  Hartford, CT............................................    1.2393
  Hartford, CT
  Litchfield, CT
  Middlesex, CT
  Tolland, CT
3285  2Hattiesburg, MS........................................    0.7680
  Forrest, MS
  Lamar, MS
3290  Hickory-Morganton-Lenoir, NC............................    0.9028
  Alexander, NC
  Burke, NC
  Caldwell, NC
  Catawba, NC
3320  Honolulu, HI............................................    1.1457
  Honolulu, HI
3350  Houma, LA...............................................    0.8384
  Lafourche, LA
  Terrebonne, LA
3360  Houston, TX.............................................    0.9892
  Chambers, TX
  Fort Bend, TX
  Harris, TX
  Liberty, TX
  Montgomery, TX
  Waller, TX
3400  Huntington-Ashland, WV-KY-OH............................    0.9635
  Boyd, KY
  Carter, KY
  Greenup, KY
  Lawrence, OH

[[Page 50226]]

 
  Cabell, WV
  Wayne, WV
3440  Huntsville, AL..........................................    0.8902
  Limestone, AL
  Madison, AL
3480  Indianapolis, IN........................................    0.9717
  Boone, IN
  Hamilton, IN
  Hancock, IN
  Hendricks, IN
  Johnson, IN
  Madison, IN
  Marion, IN
  Morgan, IN
  Shelby, IN
3500  Iowa City, IA...........................................    0.9587
  Johnson, IA
3520  Jackson, MI.............................................    0.9532
  Jackson, MI
3560  Jackson, MS.............................................    0.8607
  Hinds, MS
  Madison, MS
  Rankin, MS
3580  Jackson, TN.............................................    0.9275
  Madison, TN
  Chester, TN
3600  Jacksonville, FL........................................    0.9381
  Clay, FL
  Duval, FL
  Nassau, FL
  St. Johns, FL
3605  Jacksonville, NC........................................    0.8665
  Onslow, NC
3610  Jamestown, NY...........................................    0.8542
  Chautauqua, NY
3620  Janesville-Beloit, WI...................................    0.9849
  Rock, WI
3640  Jersey City, NJ.........................................    1.1189
  Hudson, NJ
3660  Johnson City-Kingsport-Bristol, TN-VA...................    0.8268
  Carter, TN
  Hawkins, TN
  Sullivan, TN
  Unicoi, TN
  Washington, TN
  Bristol City, VA
  Scott, VA
  Washington, VA
3680  Johnstown, PA...........................................    0.8461
  Cambria, PA
  Somerset, PA
3700  Jonesboro, AR...........................................    0.7749
  Craighead, AR
3710  Joplin, MO..............................................    0.8613
  Jasper, MO
  Newton, MO
3720  Kalamazoo-Battlecreek, MI...............................    1.0594
  Calhoun, MI
  Kalamazoo, MI
  Van Buren, MI
3740  Kankakee, IL............................................    0.8204
  Kankakee, IL
3760  Kansas City, KS-MO......................................    0.9736
  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.............................................    0.9686
  Kenosha, WI
3810  Killeen-Temple, TX......................................    0.9569
  Bell, TX
  Coryell, TX
3840  Knoxville, TN...........................................    0.8970
  Anderson, TN
  Blount, TN
  Knox, TN
  Loudon, TN
  Sevier, TN
  Union, TN
3850  Kokomo, IN..............................................    0.8971
  Howard, IN
  Tipton, IN
3870  La Crosse, WI-MN........................................    0.9400
  Houston, MN
  La Crosse, WI
3880  Lafayette, LA...........................................    0.8475
  Acadia, LA
  Lafayette, LA
  St. Landry, LA
  St. Martin, LA
3920  Lafayette, IN...........................................    0.9278
  Clinton, IN
  Tippecanoe, IN
3960  Lake Charles, LA........................................    0.7965
  Calcasieu, LA
3980  Lakeland-Winter Haven, FL...............................    0.9357
  Polk, FL
4000  Lancaster, PA...........................................    0.9078
  Lancaster, PA
4040  Lansing-East Lansing, MI................................    0.9726
  Clinton, MI
  Eaton, MI
  Ingham, MI
4080  Laredo, TX..............................................    0.8472
  Webb, TX
4100  Las Cruces, NM..........................................    0.8872
  Dona Ana, NM
4120  Las Vegas, NV-AZ........................................    1.1520
  Mohave, AZ
  Clark, NV
  Nye, NV
4150  Lawrence, KS............................................    0.7922
  Douglas, KS
4200  Lawton, OK..............................................    0.8315
  Comanche, OK
4243  Lewiston-Auburn, ME.....................................    0.9179
  Androscoggin, ME
4280  Lexington, KY...........................................    0.8581
  Bourbon, KY
  Clark, KY
  Fayette, KY
  Jessamine, KY
  Madison, KY
  Scott, KY
  Woodford, KY
4320  Lima, OH................................................    0.9483
  Allen, OH
  Auglaize, OH
4360  Lincoln, NE.............................................    0.9892
  Lancaster, NE
4400  Little Rock-North Little Rock, AR.......................    0.9096
  Faulkner, AR
  Lonoke, AR
  Pulaski, AR
  Saline, AR
4420  Longview-Marshall, TX...................................    0.8628
  Gregg, TX
  Harrison, TX
  Upshur, TX
4480  Los Angeles-Long Beach, CA..............................    1.2001
  Los Angeles, CA
4520  1Louisville, KY-IN......................................    0.9276
  Clark, IN
  Floyd, IN
  Harrison, IN
  Scott, IN
  Bullitt, KY
  Jefferson, KY
  Oldham, KY
4600  Lubbock, TX.............................................    0.9645
  Lubbock, TX
4640  Lynchburg, VA...........................................    0.9218
  Amherst, VA
  Bedford, VA
  Bedford City, VA
  Campbell, VA
  Lynchburg City, VA
4680  Macon, GA...............................................    0.9204
  Bibb, GA
  Houston, GA
  Jones, GA
  Peach, GA
  Twiggs, GA
4720  Madison, WI.............................................    1.0466
  Dane, WI
4800  Mansfield, OH...........................................    0.8899
  Crawford, OH
  Richland, OH
4840  Mayaguez, PR............................................    0.4914
  Anasco, PR
  Cabo Rojo, PR
  Hormigueros, PR
  Mayaguez, PR
  Sabana Grande, PR
  San German, PR
4880  McAllen-Edinburg-Mission, TX............................    0.8428
  Hidalgo, TX
4890  Medford-Ashland, OR.....................................    1.0498
  Jackson, OR
4900  Melbourne-Titusville-Palm Bay, FL.......................    1.0253
  Brevard, Fl
4920  Memphis, TN-AR-MS.......................................    0.8920
  Crittenden, AR
  DeSoto, MS
  Fayette, TN
  Shelby, TN
  Tipton, TN
4940  Merced, CA..............................................    0.9839
  Merced, CA
5000  Miami, FL...............................................    0.9802
  Dade, FL
5015  Middlesex-Somerset-Hunterdon, NJ........................    1.1213
  Hunterdon, NJ
  Middlesex, NJ
  Somerset, NJ
5080  Milwaukee-Waukesha, WI..................................    0.9892
  Milwaukee, WI

[[Page 50227]]

 
  Ozaukee, WI
  Washington, WI
  Waukesha, WI
5120  Minneapolis-St. Paul, MN-WI.............................    1.0903
  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............................................    0.9157
  Missoula, MT
5160  Mobile, AL..............................................    0.8108
  Baldwin, AL
  Mobile, AL
5170  Modesto, CA.............................................    1.0498
  Stanislaus, CA
5190  Monmouth-Ocean, NJ......................................    1.0674
  Monmouth, NJ
  Ocean, NJ
5200  Monroe, LA..............................................    0.8137
  Ouachita, LA
5240  Montgomery, AL..........................................    0.7733
  Autauga, AL
  Elmore, AL
  Montgomery, AL
5280  Muncie, IN..............................................    0.9284
  Delaware, IN
5330  Myrtle Beach, SC........................................    0.8976
  Horry, SC
5345  Naples, FL..............................................    0.9754
  Collier, FL
5360  Nashville, TN...........................................    0.9577
  Cheatham, TN
  Davidson, TN
  Dickson, TN
  Robertson, TN
  Rutherford TN
  Sumner, TN
  Williamson, TN
  Wilson, TN
5380  Nassau-Suffolk, NY......................................    1.3357
  Nassau, NY
  Suffolk, NY
5483  New Haven-Bridgeport-Stamford-Waterbury-................    1.2408
  Danbury, CT
  Fairfield, CT
  New Haven, CT
5523  New London-Norwich, CT..................................    1.2393
  New London, CT
5560  New Orleans, LA.........................................    0.9046
  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............................................    1.4414
  Bronx, NY
  Kings, NY
  New York, NY
  Putnam, NY
  Queens, NY
  Richmond, NY
  Rockland, NY
  Westchester, NY
5640  Newark, NJ..............................................    1.1381
  Essex, NJ
  Morris, NJ
  Sussex, NJ
  Union, NJ
  Warren, NJ
5660  Newburgh, NY-PA.........................................    1.1386
  Orange, NY
  Pike, PA
5720  Norfolk-Virginia Beach-Newport News, VA-NC..............    0.8574
  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.............................................    1.5071
  Alameda, CA
  Contra Costa, CA
5790  Ocala, FL...............................................    0.9402
  Marion, FL
5800  Odessa-Midland, TX......................................    0.9397
  Ector, TX
  Midland, TX
5880  Oklahoma City, OK.......................................    0.8900
  Canadian, OK
  Cleveland, OK
  Logan, OK
  McClain, OK
  Oklahoma, OK
  Pottawatomie, OK
5910  Olympia, WA.............................................    1.0959
  Thurston, WA
5920  Omaha, NE-IA............................................    0.9978
  Pottawattamie, IA
  Cass, NE
  Douglas, NE
  Sarpy, NE
  Washington, NE
5945  Orange County, CA.......................................    1.1474
  Orange, CA
5960  Orlando, FL.............................................    0.9639
  Lake, FL
  Orange, FL
  Osceola, FL
  Seminole, FL
5990  Owensboro, KY...........................................    0.8344
  Daviess, KY
6015  Panama City, FL.........................................    0.8865
  Bay, FL
6020  Parkersburg-Marietta, WV-OH.............................    0.8126
  Washington, OH
  Wood, WV
6080  Pensacola, FL...........................................    0.8814
  Escambia, FL
  Santa Rosa, FL
6120  Peoria-Pekin, IL........................................    0.8739
  Peoria, IL
  Tazewell, IL
  Woodford, IL
6160  Philadelphia, PA-NJ.....................................    1.0713
  Burlington, NJ
  Camden, NJ
  Gloucester, NJ
  Salem, NJ
  Bucks, PA
  Chester, PA
  Delaware, PA
  Montgomery, PA
  Philadelphia, PA
6200  Phoenix-Mesa, AZ........................................    0.9820
  Maricopa, AZ
  Pinal, AZ
6240  Pine Bluff, AR..........................................    0.7962
  Jefferson, AR
6280  Pittsburgh, PA..........................................    0.9365
  Allegheny, PA
  Beaver, PA
  Butler, PA
  Fayette, PA
  Washington, PA
  Westmoreland, PA
6323  Pittsfield, MA..........................................    1.1288
  Berkshire, MA
6340  Pocatello, ID...........................................    0.9372
  Bannock, ID
6360  Ponce, PR...............................................    0.5169
  Guayanilla, PR
  Juana Diaz, PR
  Penuelas, PR
  Ponce, PR
  Villalba, PR
  Yauco, PR
6403  Portland, ME............................................    0.9794
  Cumberland, ME
  Sagadahoc, ME
  York, ME
6440  Portland-Vancouver, OR-WA...............................    1.0667
  Clackamas, OR
  Columbia, OR
  Multnomah, OR
  Washington, OR
  Yamhill, OR
  Clark, WA
6483  Providence-Warwick-Pawtucket, RI........................    1.0854
  Bristol, RI
  Kent, RI
  Newport, RI
  Providence, RI
  Washington, RI
6520  Provo-Orem, UT..........................................    0.9984
  Utah, UT
6560  Pueblo, CO..............................................    0.9015
  Pueblo, CO
6580  Punta Gorda, FL.........................................    0.9218
  Charlotte, FL
6600  Racine, WI..............................................    0.9334
  Racine, WI
6640  Raleigh-Durham-Chapel Hill, NC..........................    0.9990

[[Page 50228]]

 
  Chatham, NC
  Durham, NC
  Franklin, NC
  Johnston, NC
  Orange, NC
  Wake, NC
6660  Rapid City, SD..........................................    0.8846
  Pennington, SD
6680  Reading, PA.............................................    0.9295
  Berks, PA
6690  Redding, CA.............................................    1.1135
  Shasta, CA
6720  Reno, NV................................................    1.0648
  Washoe, NV
6740  Richland-Kennewick-Pasco, WA............................    1.1491
  Benton, WA
  Franklin, WA
6760  Richmond-Petersburg, VA.................................    0.9476
  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............................    1.1365
  Riverside, CA
  San Bernardino, CA
6800  Roanoke, VA.............................................    0.8614
  Botetourt, VA
  Roanoke, VA
  Roanoke City, VA
  Salem City, VA
6820  Rochester, MN...........................................    1.2139
  Olmsted, MN
6840  Rochester, NY...........................................    0.9194
  Genesee, NY
  Livingston, NY
  Monroe, NY
  Ontario, NY
  Orleans, NY
  Wayne, NY
6880  Rockford, IL............................................    0.9625
  Boone, IL
  Ogle, IL
  Winnebago, IL
6895  Rocky Mount, NC.........................................    0.9228
  Edgecombe, NC
  Nash, NC
6920  Sacramento, CA..........................................    1.1500
  El Dorado, CA
  Placer, CA
  Sacramento, CA
6960  Saginaw-Bay City-Midland, MI............................    0.9650
  Bay, MI
  Midland, MI
  Saginaw, MI
6980  St. Cloud, MN...........................................    0.9700
  Benton, MN
  Stearns, MN
7000  St. Joseph, MO..........................................    0.8020
  Andrew, MO
  Buchanan, MO
7040  St. Louis, MO-IL........................................    0.8855
  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...............................................    1.0367
  Marion, OR
  Polk, OR
7120  Salinas, CA.............................................    1.4622
  Monterey, CA
7160  Salt Lake City-Ogden, UT................................    0.9945
  Davis, UT
  Salt Lake, UT
  Weber, UT
7200  San Angelo, TX..........................................    0.8374
  Tom Green, TX
7240  San Antonio, TX.........................................    0.8753
  Bexar, TX
  Comal, TX
  Guadalupe, TX
  Wilson, TX
7320  San Diego, CA...........................................    1.1131
  San Diego, CA
7360  San Francisco, CA.......................................    1.4142
  Marin, CA
  San Francisco, CA
  San Mateo, CA
7400  San Jose, CA............................................    1.4145
  Santa Clara, CA
7440  San Juan-Bayamon, PR....................................    0.4741
  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..............    1.1271
  San Luis Obispo, CA
7480  Santa Barbara-Santa Maria-Lompoc, CA....................    1.0481
  Santa Barbara, CA
7485  Santa Cruz-Watsonville, CA..............................    1.3645
  Santa Cruz, CA
7490  Santa Fe, NM............................................    1.0712
  Los Alamos, NM
  Santa Fe, NM
7500  Santa Rosa, CA..........................................    1.3045
  Sonoma, CA
7510  Sarasota-Bradenton, FL..................................    0.9425
  Manatee, FL
  Sarasota, FL
7520  Savannah, GA............................................    0.9376
  Bryan, GA
  Chatham, GA
  Effingham, GA
7560  Scranton--Wilkes-Barre--Hazleton, PA....................    0.8599
  Columbia, PA
  Lackawanna, PA
  Luzerne, PA
  Wyoming, PA
7600  Seattle-Bellevue-Everett, WA............................    1.1474
  Island, WA
  King, WA
  Snohomish, WA
7610  Sharon, PA..............................................    0.8461
  Mercer, PA
7620  Sheboygan, WI...........................................    0.9162
  Sheboygan, WI
7640  Sherman-Denison, TX.....................................    0.9255
  Grayson, TX
7680  Shreveport-Bossier City, LA.............................    0.8987
  Bossier, LA
  Caddo, LA
  Webster, LA
7720  Sioux City, IA-NE.......................................    0.9046
  Woodbury, IA
  Dakota, NE
7760  Sioux Falls, SD.........................................    0.9257
  Lincoln, SD
  Minnehaha, SD
7800  South Bend, IN..........................................    0.9802
  St. Joseph, IN
7840  Spokane, WA.............................................    1.0852
  Spokane, WA
7880  Springfield, IL.........................................    0.8659
  Menard, IL
  Sangamon, IL
7920  Springfield, MO.........................................    0.8424
  Christian, MO
  Greene, MO
  Webster, MO
8003  Springfield, MA.........................................    1.1288
  Hampden, MA
  Hampshire, MA
8050  State College, PA.......................................    0.8941
  Centre, PA
8080  Steubenville-Weirton, OH-WV (WV Hospitals)..............    0.8803
  Jefferson, OH
  Brooke, WV
  Hancock, WV
8120  Stockton-Lodi, CA.......................................    1.0505
  San Joaquin, CA

[[Page 50229]]

 
8140  Sumter, SC..............................................    0.8607
  Sumter, SC
8160  Syracuse, NY............................................    0.9714
  Cayuga, NY
  Madison, NY
  Onondaga, NY
  Oswego, NY
8200  Tacoma, WA..............................................    1.0940
  Pierce, WA
8240  Tallahassee, FL.........................................    0.8814
  Gadsden, FL
  Leon, FL
8280  Tampa-St. Petersburg-Clearwater, FL.....................    0.9065
  Hernando, FL
  Hillsborough, FL
  Pasco, FL
  Pinellas, FL
8320  Terre Haute, IN.........................................    0.8754
  Clay, IN
  Vermillion, IN
  Vigo, IN
8360  Texarkana,AR-Texarkana, TX..............................    0.8088
  Miller, AR
  Bowie, TX
8400  Toledo, OH..............................................    0.9810
  Fulton, OH
  Lucas, OH
  Wood, OH
8440  Topeka, KS..............................................    0.9198
  Shawnee, KS
8480  Trenton, NJ.............................................    1.0432
  Mercer, NJ
8520  Tucson, AZ..............................................    0.8911
  Pima, AZ
8560  Tulsa, OK...............................................    0.8332
  Creek, OK
  Osage, OK
  Rogers, OK
  Tulsa, OK
  Wagoner, OK
8600  Tuscaloosa, AL..........................................    0.8130
  Tuscaloosa, AL
8640  Tyler, TX...............................................    0.9521
  Smith, TX
8680  Utica-Rome, NY..........................................    0.8542
  Herkimer, NY
  Oneida, NY
8720  Vallejo-Fairfield-Napa, CA..............................    1.3354
  Napa, CA
  Solano, CA
8735  Ventura, CA.............................................    1.1095
  Ventura, CA
8750  Victoria, TX............................................    0.8756
  Victoria, TX
8760  Vineland-Millville-Bridgeton, NJ........................    1.0031
  Cumberland, NJ
8780  Visalia-Tulare-Porterville, CA..........................    0.9839
  Tulare, CA
8800  Waco, TX................................................    0.8073
  McLennan, TX
8840  Washington, DC-MD-VA-WV.................................    1.0851
  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................................    0.8315
  Black Hawk, IA
8940  Wausau, WI..............................................    0.9782
  Marathon, WI
8960  West Palm Beach-Boca Raton, FL..........................    0.9939
  Palm Beach, FL
9000  Wheeling, WV-OH.........................................    0.7975
  Belmont, OH
  Marshall, WV
  Ohio, WV
9040  Wichita, KS.............................................    0.9520
  Butler, KS
  Harvey, KS
  Sedgwick, KS
9080  Wichita Falls, TX.......................................    0.8498
  Archer, TX
  Wichita, TX
9140  Williamsport, PA........................................    0.8544
  Lycoming, PA
9160  Wilmington-Newark, DE-MD................................    1.1173
  New Castle, DE
  Cecil, MD
9200  Wilmington, NC..........................................    0.9640
  New Hanover, NC
  Brunswick, NC
9260  Yakima, WA..............................................    1.0568
  Yakima, WA
9270  Yolo, CA................................................    0.9839
  Yolo, CA
9280  York, PA................................................    0.9026
  York, PA
9320  Youngstown-Warren, OH...................................    0.9358
  Columbiana, OH
  Mahoning, OH
  Trumbull, OH
9340  Yuba City, CA...........................................    1.0276
  Sutter, CA
  Yuba, CA
9360  Yuma, AZ................................................    0.8589
  Yuma, AZ
------------------------------------------------------------------------


         Table 4H.--Pre-Reclassified Wage Index for Rural Areas
------------------------------------------------------------------------
                                                                  Wage
                         Nonurban area                            index
------------------------------------------------------------------------
Alabama.......................................................    0.7660
Alaska........................................................    1.2293
Arizona.......................................................    0.8493
Arkansas......................................................    0.7666
California....................................................    0.9839
Colorado......................................................    0.9015
Connecticut...................................................    1.2393
Delaware......................................................    0.9128
Florida.......................................................    0.8814
Georgia.......................................................    0.8230
Hawaii........................................................    1.0255
Idaho.........................................................    0.8747
Illinois......................................................    0.8204
Indiana.......................................................    0.8754
Iowa..........................................................    0.8315
Kansas........................................................    0.7922
Kentucky......................................................    0.8079
Louisiana.....................................................    0.7566
Maine.........................................................    0.8874
Maryland......................................................    0.8945
Massachusetts.................................................    1.1288
Michigan......................................................    0.9000
Minnesota.....................................................    0.9151
Mississippi...................................................    0.7680
Missouri......................................................    0.8020
Montana.......................................................    0.8481
Nebraska......................................................    0.8204
Nevada........................................................    0.9577
New Hampshire.................................................    0.9796
New Jersey \1\................................................  ........
New Mexico....................................................    0.8872
New York......................................................    0.8542
North Carolina................................................    0.8665
North Dakota..................................................    0.7788
Ohio..........................................................    0.8613
Oklahoma......................................................    0.7590
Oregon........................................................    1.0302
Pennsylvania..................................................    0.8461
Puerto Rico...................................................    0.4356
Rhode Island \1\..............................................  ........
South Carolina................................................    0.8607
South Dakota..................................................    0.7815
Tennessee.....................................................    0.7877
Texas.........................................................    0.7820
Utah..........................................................    0.9528
Vermont.......................................................    0.9345
Virginia......................................................    0.8504
Washington....................................................    1.0179
West Virginia.................................................    0.7975
Wisconsin.....................................................    0.9162
Wyoming.......................................................   0.9007
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban.


[[Page 50230]]


  Table 5.--List of Diagnosis-Related Groups (DRGS), Relative Weighting Factors, Geometric and Arithmetic Mean
                                              Length of Stay (LOS)*
[Explanation of footnotes: * Medicare Data Have Been Supplemented by Data From 19 States for Low Volume DRGS. **
DRGS 469 and 470 Contain Cases Which Could not be Assigned to Valid DRGS.      Note: Geometric Mean is Used Only
   to Determine Payment for Transfer Cases.      Note: Arithmetic Mean is Presented for Informational Purposes
    only.      Note: Relative Weights are Based on Medicare Patient Data and May Not be Appropriate for Other
                                                   Patients.]
----------------------------------------------------------------------------------------------------------------
                                                                               Relative    Geometric  Arithmetic
       DRG          MDC            Type                   DRG Title             weights    mean LOS    mean LOS
----------------------------------------------------------------------------------------------------------------
1...............       01  SURG                  CRANIOTOMY AGE >17 W CC....      3.7399         8.1        11.2
2...............       01  SURG                  CRANIOTOMY AGE >17 W/O CC..      1.9730         4.0         5.2
3...............       01  SURG                  *CRANIOTOMY AGE 0-17.......      1.9504        12.7        12.7
4...............       01  SURG                  SPINAL PROCEDURES..........      2.3184         4.5         7.2
5...............       01  SURG                  EXTRACRANIAL VASCULAR            1.3837         2.1         3.1
                                                  PROCEDURES.
6...............       01  SURG                  CARPAL TUNNEL RELEASE......      0.8242         2.1         2.9
7...............       01  SURG                  PERIPH & CRANIAL NERVE &         2.5807         6.5         9.8
                                                  OTHER NERV SYST PROC W CC.
8...............       01  SURG                  PERIPH & CRANIAL NERVE &         1.4967         1.9         2.8
                                                  OTHER NERV SYST PROC W/O
                                                  CC.
9...............       01  MED                   SPINAL DISORDERS & INJURIES      1.3769         4.6         6.6
10..............       01  MED                   NERVOUS SYSTEM NEOPLASMS W       1.2598         4.8         6.6
                                                  CC.
11..............       01  MED                   NERVOUS SYSTEM NEOPLASMS W/      0.8689         3.0         4.0
                                                  O CC.
12..............       01  MED                   DEGENERATIVE NERVOUS SYSTEM      0.8918         4.4         5.9
                                                  DISORDERS.
13..............       01  MED                   MULTIPLE SCLEROSIS &             0.7968         4.1         5.0
                                                  CEREBELLAR ATAXIA.
14..............       01  MED                   INTRACRANIAL HEMORRHAGE &        1.2943         4.8         6.2
                                                  STROKE W INFARCT.
15..............       01  MED                   NONSPECIFIC CVA &                0.9858         4.0         5.0
                                                  PRECEREBRAL OCCLUSION W/O
                                                  INFARCT.
16..............       01  MED                   NONSPECIFIC CEREBROVASCULAR      1.2413         4.7         6.2
                                                  DISORDERS W CC.
17..............       01  MED                   NONSPECIFIC CEREBROVASCULAR      0.6672         2.5         3.1
                                                  DISORDERS W/O CC.
18..............       01  MED                   CRANIAL & PERIPHERAL NERVE       0.9727         4.2         5.4
                                                  DISORDERS W CC.
19..............       01  MED                   CRANIAL & PERIPHERAL NERVE       0.6944         2.8         3.5
                                                  DISORDERS W/O CC.
20..............       01  MED                   NERVOUS SYSTEM INFECTION         2.8156         8.0        10.7
                                                  EXCEPT VIRAL MENINGITIS.
21..............       01  MED                   VIRAL MENINGITIS...........      1.5369         5.0         6.6
22..............       01  MED                   HYPERTENSIVE ENCEPHALOPATHY      1.0343         3.9         5.0
23..............       01  MED                   NONTRAUMATIC STUPOR & COMA.      0.8220         3.1         4.3
24..............       01  MED                   SEIZURE & HEADACHE AGE >17       0.9978         3.6         4.9
                                                  W CC.
25..............       01  MED                   SEIZURE & HEADACHE AGE >17       0.6085         2.5         3.2
                                                  W/O CC.
26..............       01  MED                   SEIZURE & HEADACHE AGE 0-17      0.7847         2.5         4.6
27..............       01  MED                   TRAUMATIC STUPOR & COMA,         1.3164         3.1         5.0
                                                  COMA >1 HR.
28..............       01  MED                   TRAUMATIC STUPOR & COMA,         1.3447         4.5         6.3
                                                  COMA 1 HR AGE >17 W CC.
29..............       01  MED                   TRAUMATIC STUPOR & COMA,         0.7086         2.7         3.6
                                                  COMA 1 HR AGE >17 W/O CC.
30..............       01  MED                   *TRAUMATIC STUPOR & COMA,        0.3299         2.0         2.0
                                                  COMA 1 HR AGE 0-17.
31..............       01  MED                   CONCUSSION AGE >17 W CC....      0.8806         3.0         4.1
32..............       01  MED                   CONCUSSION AGE >17 W/O CC..      0.5336         1.9         2.4
33..............       01  MED                   *CONCUSSION AGE 0-17.......      0.2072         1.6         1.6
34..............       01  MED                   OTHER DISORDERS OF NERVOUS       0.9978         3.7         5.0
                                                  SYSTEM W CC.
35..............       01  MED                   OTHER DISORDERS OF NERVOUS       0.6385         2.5         3.2
                                                  SYSTEM W/O CC.
36..............       02  SURG                  RETINAL PROCEDURES.........      0.6830         1.2         1.5
37..............       02  SURG                  ORBITAL PROCEDURES.........      1.0568         2.6         3.8
38..............       02  SURG                  PRIMARY IRIS PROCEDURES....      0.5418         1.9         2.5
39..............       02  SURG                  LENS PROCEDURES WITH OR          0.5936         1.5         1.9
                                                  WITHOUT VITRECTOMY.
40..............       02  SURG                  EXTRAOCULAR PROCEDURES           0.8756         2.5         3.6
                                                  EXCEPT ORBIT AGE >17.
41..............       02  SURG                  *EXTRAOCULAR PROCEDURES          0.3358         1.6         1.6
                                                  EXCEPT ORBIT AGE 0-17.
42..............       02  SURG                  INTRAOCULAR PROCEDURES           0.6593         1.7         2.4
                                                  EXCEPT RETINA, IRIS & LENS.
43..............       02  MED                   HYPHEMA....................      0.4992         2.4         3.0
44..............       02  MED                   ACUTE MAJOR EYE INFECTIONS.      0.6409         4.1         5.1
45..............       02  MED                   NEUROLOGICAL EYE DISORDERS.      0.7080         2.6         3.2
46..............       02  MED                   OTHER DISORDERS OF THE EYE       0.7832         3.4         4.6
                                                  AGE >17 W CC.
47..............       02  MED                   OTHER DISORDERS OF THE EYE       0.5209         2.5         3.2
                                                  AGE >17 W/O CC.
48..............       02  MED                   *OTHER DISORDERS OF THE EYE      0.2958         2.9         2.9
                                                  AGE 0-17.
49..............       03  SURG                  MAJOR HEAD & NECK                1.7796         3.3         4.6
                                                  PROCEDURES.
50..............       03  SURG                  SIALOADENECTOMY............      0.8332         1.5         1.8
51..............       03  SURG                  SALIVARY GLAND PROCEDURES        0.9461         1.9         3.1
                                                  EXCEPT SIALOADENECTOMY.
52..............       03  SURG                  CLEFT LIP & PALATE REPAIR..      0.7983         1.5         1.9
53..............       03  SURG                  SINUS & MASTOID PROCEDURES       1.2005         2.1         3.4
                                                  AGE >17.
54..............       03  SURG                  *SINUS & MASTOID PROCEDURES      0.4795         3.2         3.2
                                                  AGE 0-17.
55..............       03  SURG                  MISCELLANEOUS EAR, NOSE,         0.9595         1.9         3.1
                                                  MOUTH & THROAT PROCEDURES.
56..............       03  SURG                  RHINOPLASTY................      0.9666         2.0         3.0
57..............       03  SURG                  T&A PROC, EXCEPT                 0.9927         2.4         3.7
                                                  TONSILLECTOMY &/OR
                                                  ADENOIDECTOMY ONLY, AGE
                                                  >17.
58..............       03  SURG                  *T&A PROC, EXCEPT                0.2722         1.5         1.5
                                                  TONSILLECTOMY &/OR
                                                  ADENOIDECTOMY ONLY, AGE 0-
                                                  17.
59..............       03  SURG                  TONSILLECTOMY &/OR               0.7528         1.8         2.6
                                                  ADENOIDECTOMY ONLY, AGE
                                                  >17.
60..............       03  SURG                  *TONSILLECTOMY &/OR              0.2073         1.5         1.5
                                                  ADENOIDECTOMY ONLY, AGE 0-
                                                  17.
61..............       03  SURG                  MYRINGOTOMY W TUBE               1.3065         2.9         4.8
                                                  INSERTION AGE >17.
62..............       03  SURG                  *MYRINGOTOMY W TUBE              0.2936         1.3         1.3
                                                  INSERTION AGE 0-17.
63..............       03  SURG                  OTHER EAR, NOSE, MOUTH &         1.4363         3.0         4.5
                                                  THROAT O.R. PROCEDURES.
64..............       03  MED                   EAR, NOSE, MOUTH & THROAT        1.3119         4.4         6.6
                                                  MALIGNANCY.

[[Page 50231]]

 
65..............       03  MED                   DYSEQUILIBRIUM.............      0.5484         2.3         2.8
66..............       03  MED                   EPISTAXIS..................      0.5653         2.4         3.1
67..............       03  MED                   EPIGLOTTITIS...............      0.7774         2.8         3.6
68..............       03  MED                   OTITIS MEDIA & URI AGE           0.6696         3.1         3.8
                                                  >17 W CC.
69..............       03  MED                   OTITIS MEDIA & URI AGE           0.5025         2.4         3.0
                                                  >17 W/O CC.
70..............       03  MED                   OTITIS MEDIA & URI AGE 0-17      0.4638         2.8         3.5
71..............       03  MED                   LARYNGOTRACHEITIS..........      0.6895         2.8         3.4
72..............       03  MED                   NASAL TRAUMA & DEFORMITY...      0.7185         2.6         3.6
73..............       03  MED                   OTHER EAR, NOSE, MOUTH &         0.7961         3.2         4.4
                                                  THROAT DIAGNOSES AGE >17.
74..............       03  MED                   *OTHER EAR, NOSE, MOUTH &        0.3337         2.1         2.1
                                                  THROAT DIAGNOSES AGE 0-17.
75..............       04  SURG                  MAJOR CHEST PROCEDURES.....      3.1077         7.7        10.1
76..............       04  SURG                  OTHER RESP SYSTEM O.R.           2.8647         8.5        11.5
                                                  PROCEDURES W CC.
77..............       04  SURG                  OTHER RESP SYSTEM O.R.           1.2097         3.5         4.9
                                                  PROCEDURES W/O CC.
78..............       04  MED                   PULMONARY EMBOLISM.........      1.3022         5.7         6.7
79..............       04  MED                   RESPIRATORY INFECTIONS &         1.6193         6.7         8.5
                                                  INFLAMMATIONS AGE >17 W CC.
80..............       04  MED                   RESPIRATORY INFECTIONS &         0.8757         4.4         5.5
                                                  INFLAMMATIONS AGE >17 W/O
                                                  CC.
81..............       04  MED                   *RESPIRATORY INFECTIONS &        1.5107         6.1         6.1
                                                  INFLAMMATIONS AGE 0-17.
82..............       04  MED                   RESPIRATORY NEOPLASMS......      1.3943         5.2         7.0
83..............       04  MED                   MAJOR CHEST TRAUMA W CC....      0.9728         4.3         5.5
84..............       04  MED                   MAJOR CHEST TRAUMA W/O CC..      0.5125         2.6         3.2
85..............       04  MED                   PLEURAL EFFUSION W CC......      1.2145         4.8         6.4
86..............       04  MED                   PLEURAL EFFUSION W/O CC....      0.6963         2.9         3.8
87..............       04  MED                   PULMONARY EDEMA &                1.3658         4.8         6.4
                                                  RESPIRATORY FAILURE.
88..............       04  MED                   CHRONIC OBSTRUCTIVE              0.9028         4.1         5.1
                                                  PULMONARY DISEASE.
89..............       04  MED                   SIMPLE PNEUMONIA & PLEURISY      1.0420         4.8         5.9
                                                  AGE >17 W CC.
90..............       04  MED                   SIMPLE PNEUMONIA & PLEURISY      0.6262         3.4         4.0
                                                  AGE >17 W/O CC.
91..............       04  MED                   SIMPLE PNEUMONIA & PLEURISY      0.7034         3.2         4.0
                                                  AGE 0-17.
92..............       04  MED                   INTERSTITIAL LUNG DISEASE W      1.2273         5.0         6.4
                                                  CC.
93..............       04  MED                   INTERSTITIAL LUNG DISEASE W/     0.7306         3.3         4.1
                                                  O CC.
94..............       04  MED                   PNEUMOTHORAX W CC..........      1.1624         4.7         6.4
95..............       04  MED                   PNEUMOTHORAX W/O CC........      0.5940         2.9         3.7
96..............       04  MED                   BRONCHITIS & ASTHMA AGE >17      0.7530         3.7         4.6
                                                  W CC.
97..............       04  MED                   BRONCHITIS & ASTHMA AGE >17      0.5593         2.9         3.5
                                                  W/O CC.
98..............       04  MED                   BRONCHITIS & ASTHMA AGE 0-       0.9540         3.7         5.1
                                                  17.
99..............       04  MED                   RESPIRATORY SIGNS &              0.7034         2.4         3.2
                                                  SYMPTOMS W CC.
100.............       04  MED                   RESPIRATORY SIGNS &              0.5350         1.7         2.1
                                                  SYMPTOMS W/O CC.
101.............       04  MED                   OTHER RESPIRATORY SYSTEM         0.8592         3.3         4.4
                                                  DIAGNOSES W CC.
102.............       04  MED                   OTHER RESPIRATORY SYSTEM         0.5467         2.0         2.6
                                                  DIAGNOSES W/O CC.
103.............      PRE  SURG                  HEART TRANSPLANT...........     20.5419        30.5        52.1
104.............       05  SURG                  CARDIAC VALVE & OTH MAJOR        7.9916        12.3        14.4
                                                  CARDIOTHORACIC PROC W CARD
                                                  CATH.
105.............       05  SURG                  CARDIAC VALVE & OTH MAJOR        5.8063         8.3        10.0
                                                  CARDIOTHORACIC PROC W/O
                                                  CARD CATH.
106.............       05  SURG                  CORONARY BYPASS W PTCA.....      7.4425         9.6        11.4
107.............       05  SURG                  CORONARY BYPASS W CARDIAC        5.3850         9.2        10.5
                                                  CATH.
108.............       05  SURG                  OTHER CARDIOTHORACIC             5.4758         7.8        10.3
                                                  PROCEDURES.
109.............       05  SURG                  CORONARY BYPASS W/O PTCA OR      3.9795         6.8         7.7
                                                  CARDIAC CATH.
110.............       05  SURG                  MAJOR CARDIOVASCULAR             4.1218         6.5         9.1
                                                  PROCEDURES W CC.
111.............       05  SURG                  MAJOR CARDIOVASCULAR             2.4580         3.5         4.4
                                                  PROCEDURES W/O CC.
112.............       05  SURG                  NO LONGER VALID............      0.0000         0.0         0.0
113.............       05  SURG                  AMPUTATION FOR CIRC SYSTEM       3.0261        10.4        13.4
                                                  DISORDERS EXCEPT UPPER
                                                  LIMB & TOE.
114.............       05  SURG                  UPPER LIMB & TOE AMPUTATION      1.6551         6.2         8.5
                                                  FOR CIRC SYSTEM DISORDERS.
115.............       05  SURG                  PRM CARD PACEM IMPL W            3.4466         5.9         8.3
                                                  AMI,HRT FAIL OR SHK,OR
                                                  AICD LEAD OR GN.
116.............       05  SURG                  OTHER PERMANENT CARDIAC          2.3078         3.2         4.5
                                                  PACEMAKER IMPLANT.
117.............       05  SURG                  CARDIAC PACEMAKER REVISION       1.3345         2.6         4.2
                                                  EXCEPT DEVICE REPLACEMENT.
118.............       05  SURG                  CARDIAC PACEMAKER DEVICE         1.5689         1.9         2.9
                                                  REPLACEMENT.
119.............       05  SURG                  VEIN LIGATION & STRIPPING..      1.3045         3.0         5.1
120.............       05  SURG                  OTHER CIRCULATORY SYSTEM         2.2383         5.3         8.8
                                                  O.R. PROCEDURES.
121.............       05  MED                   CIRCULATORY DISORDERS W AMI      1.6216         5.3         6.6
                                                  & MAJOR COMP, DISCHARGED
                                                  ALIVE.
122.............       05  MED                   CIRCULATORY DISORDERS W AMI      1.0679         3.0         3.8
                                                  W/O MAJOR COMP, DISCHARGED
                                                  ALIVE.
123.............       05  MED                   CIRCULATORY DISORDERS W          1.5529         2.8         4.7
                                                  AMI, EXPIRED.

[[Page 50232]]

 
124.............       05  MED                   CIRCULATORY DISORDERS            1.4415         3.3         4.4
                                                  EXCEPT AMI, W CARD CATH &
                                                  COMPLEX DIAG.
125.............       05  MED                   CIRCULATORY DISORDERS            1.0844         2.1         2.7
                                                  EXCEPT AMI, W CARD CATH W/
                                                  O COMPLEX DIAG.
126.............       05  MED                   ACUTE & SUBACUTE                 2.7280         9.5        12.2
                                                  ENDOCARDITIS.
127.............       05  MED                   HEART FAILURE & SHOCK......      1.0039         4.1         5.3
128.............       05  MED                   DEEP VEIN THROMBOPHLEBITIS.      0.7230         4.7         5.5
129.............       05  MED                   CARDIAC ARREST, UNEXPLAINED      1.0767         1.8         2.8
130.............       05  MED                   PERIPHERAL VASCULAR              0.9439         4.5         5.7
                                                  DISORDERS W CC.
131.............       05  MED                   PERIPHERAL VASCULAR              0.5706         3.3         4.1
                                                  DISORDERS W/O CC.
132.............       05  MED                   ATHEROSCLEROSIS W CC.......      0.6564         2.3         2.9
133.............       05  MED                   ATHEROSCLEROSIS W/O CC.....      0.5353         1.8         2.3
134.............       05  MED                   HYPERTENSION...............      0.5877         2.5         3.2
135.............       05  MED                   CARDIAC CONGENITAL &             0.9011         3.3         4.5
                                                  VALVULAR DISORDERS AGE >17
                                                  W CC.
136.............       05  MED                   CARDIAC CONGENITAL &             0.5711         2.1         2.6
                                                  VALVULAR DISORDERS AGE >17
                                                  W/O CC.
137.............       05  MED                   *CARDIAC CONGENITAL &            0.8139         3.3         3.3
                                                  VALVULAR DISORDERS AGE 0-
                                                  17.
138.............       05  MED                   CARDIAC ARRHYTHMIA &             0.8274         3.1         4.0
                                                  CONDUCTION DISORDERS W CC.
139.............       05  MED                   CARDIAC ARRHYTHMIA &             0.5126         2.0         2.5
                                                  CONDUCTION DISORDERS W/O
                                                  CC.
140.............       05  MED                   ANGINA PECTORIS............      0.5382         2.1         2.6
141.............       05  MED                   SYNCOPE & COLLAPSE W CC....      0.7296         2.8         3.6
142.............       05  MED                   SYNCOPE & COLLAPSE W/O CC..      0.5613         2.1         2.6
143.............       05  MED                   CHEST PAIN.................      0.5391         1.7         2.1
144.............       05  MED                   OTHER CIRCULATORY SYSTEM         1.1992         3.8         5.5
                                                  DIAGNOSES W CC.
145.............       05  MED                   OTHER CIRCULATORY SYSTEM         0.5899         2.1         2.7
                                                  DIAGNOSES W/O CC.
146.............       06  SURG                  RECTAL RESECTION W CC......      2.7203         8.8        10.2
147.............       06  SURG                  RECTAL RESECTION W/O CC....      1.5562         5.8         6.4
148.............       06  SURG                  MAJOR SMALL & LARGE BOWEL        3.4503        10.2        12.3
                                                  PROCEDURES W CC.
149.............       06  SURG                  MAJOR SMALL & LARGE BOWEL        1.5251         5.9         6.5
                                                  PROCEDURES W/O CC.
150.............       06  SURG                  PERITONEAL ADHESIOLYSIS W        2.8484         9.1        11.2
                                                  CC.
151.............       06  SURG                  PERITONEAL ADHESIOLYSIS W/O      1.3296         4.5         5.7
                                                  CC.
152.............       06  SURG                  MINOR SMALL & LARGE BOWEL        1.9506         6.9         8.3
                                                  PROCEDURES W CC.
153.............       06  SURG                  MINOR SMALL & LARGE BOWEL        1.1770         4.8         5.4
                                                  PROCEDURES W/O CC.
154.............       06  SURG                  STOMACH, ESOPHAGEAL &            4.1533         9.8        13.3
                                                  DUODENAL PROCEDURES AGE
                                                  >17 W CC.
155.............       06  SURG                  STOMACH, ESOPHAGEAL &            1.3082         3.0         4.0
                                                  DUODENAL PROCEDURES AGE
                                                  >17 W/O CC.
156.............       06  SURG                  *STOMACH, ESOPHAGEAL &           0.8382         6.0         6.0
                                                  DUODENAL PROCEDURES AGE 0-
                                                  17.
157.............       06  SURG                  ANAL & STOMAL PROCEDURES W       1.2612         3.9         5.6
                                                  CC.
158.............       06  SURG                  ANAL & STOMAL PROCEDURES W/      0.6503         2.0         2.5
                                                  O CC.
159.............       06  SURG                  HERNIA PROCEDURES EXCEPT         1.3612         3.7         5.1
                                                  INGUINAL & FEMORAL AGE >17
                                                  W CC.
160.............       06  SURG                  HERNIA PROCEDURES EXCEPT         0.8065         2.2         2.6
                                                  INGUINAL & FEMORAL AGE >17
                                                  W/O CC.
161.............       06  SURG                  INGUINAL & FEMORAL HERNIA        1.1264         2.8         4.2
                                                  PROCEDURES AGE >17 W CC.
162.............       06  SURG                  INGUINAL & FEMORAL HERNIA        0.6325         1.6         1.9
                                                  PROCEDURES AGE >17 W/O CC.
163.............       06  SURG                  *HERNIA PROCEDURES AGE 0-17      0.6877         2.1         2.1
164.............       06  SURG                  APPENDECTOMY W COMPLICATED       2.2962         7.0         8.3
                                                  PRINCIPAL DIAG W CC.
165.............       06  SURG                  APPENDECTOMY W COMPLICATED       1.2609         4.0         4.6
                                                  PRINCIPAL DIAG W/O CC.
166.............       06  SURG                  APPENDECTOMY W/O                 1.4690         3.7         4.9
                                                  COMPLICATED PRINCIPAL DIAG
                                                  W CC.
167.............       06  SURG                  APPENDECTOMY W/O                 0.9088         2.1         2.5
                                                  COMPLICATED PRINCIPAL DIAG
                                                  W/O CC.
168.............       03  SURG                  MOUTH PROCEDURES W CC......      1.3038         3.3         4.9
169.............       03  SURG                  MOUTH PROCEDURES W/O CC....      0.7444         1.8         2.3
170.............       06  SURG                  OTHER DIGESTIVE SYSTEM O.R.      2.8555         7.6        11.1
                                                  PROCEDURES W CC.
171.............       06  SURG                  OTHER DIGESTIVE SYSTEM O.R.      1.2025         3.1         4.3
                                                  PROCEDURES W/O CC.
172.............       06  MED                   DIGESTIVE MALIGNANCY W CC..      1.3624         5.1         7.0
173.............       06  MED                   DIGESTIVE MALIGNANCY W/O CC      0.7540         2.7         3.7
174.............       06  MED                   G.I. HEMORRHAGE W CC.......      0.9952         3.9         4.8
175.............       06  MED                   G.I. HEMORRHAGE W/O CC.....      0.5551         2.5         2.9
176.............       06  MED                   COMPLICATED PEPTIC ULCER...      1.0826         4.1         5.3
177.............       06  MED                   UNCOMPLICATED PEPTIC ULCER       0.9170         3.7         4.5
                                                  W CC.
178.............       06  MED                   UNCOMPLICATED PEPTIC ULCER       0.6806         2.6         3.1
                                                  W/O CC.
179.............       06  MED                   INFLAMMATORY BOWEL DISEASE.      1.0786         4.6         6.0
180.............       06  MED                   G.I. OBSTRUCTION W CC......      0.9443         4.1         5.4
181.............       06  MED                   G.I. OBSTRUCTION W/O CC....      0.5331         2.8         3.4

[[Page 50233]]

 
182.............       06  MED                   ESOPHAGITIS, GASTROENT &         0.7986         3.3         4.4
                                                  MISC DIGEST DISORDERS AGE
                                                  >17 W CC.
183.............       06  MED                   ESOPHAGITIS, GASTROENT &         0.5723         2.3         2.9
                                                  MISC DIGEST DISORDERS AGE
                                                  >17 W/O CC.
184.............       06  MED                   ESOPHAGITIS, GASTROENT &         0.4836         2.3         2.8
                                                  MISC DIGEST DISORDERS AGE
                                                  0-17.
185.............       03  MED                   DENTAL & ORAL DIS EXCEPT         0.8986         3.3         4.7
                                                  EXTRACTIONS &
                                                  RESTORATIONS, AGE >17.
186.............       03  MED                   *DENTAL & ORAL DIS EXCEPT        0.3195         2.9         2.9
                                                  EXTRACTIONS &
                                                  RESTORATIONS, AGE 0-17.
187.............       03  MED                   DENTAL EXTRACTIONS &             0.8665         3.1         4.2
                                                  RESTORATIONS.
188.............       06  MED                   OTHER DIGESTIVE SYSTEM           1.0985         4.1         5.6
                                                  DIAGNOSES AGE >17 W CC.
189.............       06  MED                   OTHER DIGESTIVE SYSTEM           0.5825         2.4         3.1
                                                  DIAGNOSES AGE >17 W/O CC.
190.............       06  MED                   OTHER DIGESTIVE SYSTEM           0.7006         3.3         4.8
                                                  DIAGNOSES AGE 0-17.
191.............       07  SURG                  PANCREAS, LIVER & SHUNT          4.3282         9.8        13.8
                                                  PROCEDURES W CC.
192.............       07  SURG                  PANCREAS, LIVER & SHUNT          1.7144         4.7         6.1
                                                  PROCEDURES W/O CC.
193.............       07  SURG                  BILIARY TRACT PROC EXCEPT        3.4245        10.5        12.8
                                                  ONLY CHOLECYST W OR W/O
                                                  C.D.E. W CC.
194.............       07  SURG                  BILIARY TRACT PROC EXCEPT        1.6033         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       3.0071         8.6        10.4
                                                  CC.
196.............       07  SURG                  CHOLECYSTECTOMY W C.D.E. W/      1.6046         4.6         5.4
                                                  O CC.
197.............       07  SURG                  CHOLECYSTECTOMY EXCEPT BY        2.4857         7.3         9.0
                                                  LAPAROSCOPE W/O C.D.E. W
                                                  CC.
198.............       07  SURG                  CHOLECYSTECTOMY EXCEPT BY        1.2250         3.8         4.4
                                                  LAPAROSCOPE W/O C.D.E. W/O
                                                  CC.
199.............       07  SURG                  HEPATOBILIARY DIAGNOSTIC         2.4345         7.0         9.9
                                                  PROCEDURE FOR MALIGNANCY.
200.............       07  SURG                  HEPATOBILIARY DIAGNOSTIC         2.9740         6.5        10.5
                                                  PROCEDURE FOR NON-
                                                  MALIGNANCY.
201.............       07  SURG                  OTHER HEPATOBILIARY OR           3.7858        10.4        14.5
                                                  PANCREAS O.R. PROCEDURES.
202.............       07  MED                   CIRRHOSIS & ALCOHOLIC            1.2941         4.8         6.4
                                                  HEPATITIS.
203.............       07  MED                   MALIGNANCY OF HEPATOBILIARY      1.3555         5.0         6.8
                                                  SYSTEM OR PANCREAS.
204.............       07  MED                   DISORDERS OF PANCREAS            1.1858         4.4         5.8
                                                  EXCEPT MALIGNANCY.
205.............       07  MED                   DISORDERS OF LIVER EXCEPT        1.2003         4.6         6.2
                                                  MALIG,CIRR,ALC HEPA W CC.
206.............       07  MED                   DISORDERS OF LIVER EXCEPT        0.7061         3.0         3.9
                                                  MALIG,CIRR,ALC HEPA W/O CC.
207.............       07  MED                   DISORDERS OF THE BILIARY         1.1405         4.0         5.3
                                                  TRACT W CC.
208.............       07  MED                   DISORDERS OF THE BILIARY         0.6531         2.3         2.9
                                                  TRACT W/O CC.
209.............       08  SURG                  MAJOR JOINT & LIMB               2.0782         4.5         5.0
                                                  REATTACHMENT PROCEDURES OF
                                                  LOWER EXTREMITY.
210.............       08  SURG                  HIP & FEMUR PROCEDURES           1.8622         6.1         7.0
                                                  EXCEPT MAJOR JOINT AGE >17
                                                  W CC.
211.............       08  SURG                  HIP & FEMUR PROCEDURES           1.2848         4.6         5.0
                                                  EXCEPT MAJOR JOINT AGE >17
                                                  W/O CC.
212.............       08  SURG                  *HIP & FEMUR PROCEDURES          0.8418        11.1        11.1
                                                  EXCEPT MAJOR JOINT AGE 0-
                                                  17.
213.............       08  SURG                  AMPUTATION FOR                   1.8694         6.6         9.2
                                                  MUSCULOSKELETAL SYSTEM &
                                                  CONN TISSUE DISORDERS.
214.............       08  SURG                  NO LONGER VALID............      0.0000         0.0         0.0
215.............       08  SURG                  NO LONGER VALID............      0.0000         0.0         0.0
216.............       08  SURG                  BIOPSIES OF MUSCULOSKELETAL      2.2225         6.6         9.6
                                                  SYSTEM & CONNECTIVE TISSUE.
217.............       08  SURG                  WND DEBRID & SKN GRFT            3.0272         9.1        13.5
                                                  EXCEPT HAND,FOR MUSCSKELET
                                                  & CONN TISS DIS.
218.............       08  SURG                  LOWER EXTREM & HUMER PROC        1.5475         4.3         5.5
                                                  EXCEPT HIP,FOOT,FEMUR AGE
                                                  >17 W CC.
219.............       08  SURG                  LOWER EXTREM & HUMER PROC        1.0266         2.7         3.2
                                                  EXCEPT HIP,FOOT,FEMUR AGE
                                                  >17 W/O CC.
220.............       08  SURG                  *LOWER EXTREM & HUMER PROC       0.5807         5.3         5.3
                                                  EXCEPT HIP,FOOT,FEMUR AGE
                                                  0-17.
221.............       08  SURG                  NO LONGER VALID............      0.0000         0.0         0.0
222.............       08  SURG                  NO LONGER VALID............      0.0000         0.0         0.0
223.............       08  SURG                  MAJOR SHOULDER/ELBOW PROC,       1.0261         2.1         2.9
                                                  OR OTHER UPPER EXTREMITY
                                                  PROC W CC.
224.............       08  SURG                  SHOULDER,ELBOW OR FOREARM        0.7859         1.6         1.9
                                                  PROC,EXC MAJOR JOINT PROC,
                                                  W/O CC.
225.............       08  SURG                  FOOT PROCEDURES............      1.1476         3.5         5.0
226.............       08  SURG                  SOFT TISSUE PROCEDURES W CC      1.5730         4.6         6.7
227.............       08  SURG                  SOFT TISSUE PROCEDURES W/O       0.8152         2.1         2.7
                                                  CC.

[[Page 50234]]

 
228.............       08  SURG                  MAJOR THUMB OR JOINT             1.1379         2.6         4.1
                                                  PROC,OR OTH HAND OR WRIST
                                                  PROC W CC.
229.............       08  SURG                  HAND OR WRIST PROC, EXCEPT       0.7004         1.7         2.2
                                                  MAJOR JOINT PROC, W/O CC.
230.............       08  SURG                  LOCAL EXCISION & REMOVAL OF      1.2763         3.3         5.1
                                                  INT FIX DEVICES OF HIP &
                                                  FEMUR.
231.............       08  SURG                  LOCAL EXCISION & REMOVAL OF      1.4007         3.1         4.9
                                                  INT FIX DEVICES EXCEPT HIP
                                                  & FEMUR.
232.............       08  SURG                  ARTHROSCOPY................      1.0011         1.8         2.7
233.............       08  SURG                  OTHER MUSCULOSKELET SYS &        2.1159         5.1         7.8
                                                  CONN TISS O.R. PROC W CC.
234.............       08  SURG                  OTHER MUSCULOSKELET SYS &        1.2428         2.3         3.2
                                                  CONN TISS O.R. PROC W/O CC.
235.............       08  MED                   FRACTURES OF FEMUR.........      0.7692         3.8         5.1
236.............       08  MED                   FRACTURES OF HIP & PELVIS..      0.7350         3.9         4.9
237.............       08  MED                   SPRAINS, STRAINS, &              0.5840         2.9         3.6
                                                  DISLOCATIONS OF HIP,
                                                  PELVIS & THIGH.
238.............       08  MED                   OSTEOMYELITIS..............      1.4039         6.6         8.9
239.............       08  MED                   PATHOLOGICAL FRACTURES &         1.0065         4.9         6.3
                                                  MUSCULOSKELETAL & CONN
                                                  TISS MALIGNANCY.
240.............       08  MED                   CONNECTIVE TISSUE DISORDERS      1.3372         5.0         6.7
                                                  W CC.
241.............       08  MED                   CONNECTIVE TISSUE DISORDERS      0.6511         3.1         3.9
                                                  W/O CC.
242.............       08  MED                   SEPTIC ARTHRITIS...........      1.1281         5.1         6.7
243.............       08  MED                   MEDICAL BACK PROBLEMS......      0.7418         3.7         4.7
244.............       08  MED                   BONE DISEASES & SPECIFIC         0.7072         3.7         4.7
                                                  ARTHROPATHIES W CC.
245.............       08  MED                   BONE DISEASES & SPECIFIC         0.4698         2.7         3.4
                                                  ARTHROPATHIES W/O CC.
246.............       08  MED                   NON-SPECIFIC ARTHROPATHIES.      0.5658         2.9         3.8
247.............       08  MED                   SIGNS & SYMPTOMS OF              0.5733         2.6         3.4
                                                  MUSCULOSKELETAL SYSTEM &
                                                  CONN TISSUE.
248.............       08  MED                   TENDONITIS, MYOSITIS &           0.8357         3.8         4.9
                                                  BURSITIS.
249.............       08  MED                   AFTERCARE, MUSCULOSKELETAL       0.6902         2.5         3.7
                                                  SYSTEM & CONNECTIVE TISSUE.
250.............       08  MED                   FX, SPRN, STRN & DISL OF         0.6904         3.2         4.2
                                                  FOREARM, HAND, FOOT AGE
                                                  >17 W CC.
251.............       08  MED                   FX, SPRN, STRN & DISL OF         0.4623         2.2         2.8
                                                  FOREARM, HAND, FOOT AGE
                                                  >17 W/O CC.
252.............       08  MED                   *FX, SPRN, STRN & DISL OF        0.2521         1.8         1.8
                                                  FOREARM, HAND, FOOT AGE 0-
                                                  17.
253.............       08  MED                   FX, SPRN, STRN & DISL OF         0.7394         3.7         4.7
                                                  UPARM,LOWLEG EX FOOT AGE
                                                  >17 W CC.
254.............       08  MED                   FX, SPRN, STRN & DISL OF         0.4440         2.6         3.1
                                                  UPARM,LOWLEG EX FOOT AGE
                                                  >17 W/O CC.
255.............       08  MED                   *FX, SPRN, STRN & DISL OF        0.2937         2.9         2.9
                                                  UPARM,LOWLEG EX FOOT AGE 0-
                                                  17.
256.............       08  MED                   OTHER MUSCULOSKELETAL            0.8069         3.8         5.1
                                                  SYSTEM & CONNECTIVE TISSUE
                                                  DIAGNOSES.
257.............       09  SURG                  TOTAL MASTECTOMY FOR             0.8994         2.1         2.7
                                                  MALIGNANCY W CC.
258.............       09  SURG                  TOTAL MASTECTOMY FOR             0.7101         1.6         1.8
                                                  MALIGNANCY W/O CC.
259.............       09  SURG                  SUBTOTAL MASTECTOMY FOR          0.9155         1.7         2.7
                                                  MALIGNANCY W CC.
260.............       09  SURG                  SUBTOTAL MASTECTOMY FOR          0.6827         1.2         1.4
                                                  MALIGNANCY W/O CC.
261.............       09  SURG                  BREAST PROC FOR NON-             0.9817         1.6         2.2
                                                  MALIGNANCY EXCEPT BIOPSY &
                                                  LOCAL EXCISION.
262.............       09  SURG                  BREAST BIOPSY & LOCAL            0.9301         2.9         4.3
                                                  EXCISION FOR NON-
                                                  MALIGNANCY.
263.............       09  SURG                  SKIN GRAFT &/OR DEBRID FOR       2.2854         9.3        12.5
                                                  SKN ULCER OR CELLULITIS W
                                                  CC.
264.............       09  SURG                  SKIN GRAFT &/OR DEBRID FOR       1.1644         5.5         7.2
                                                  SKN ULCER OR CELLULITIS W/
                                                  O CC.
265.............       09  SURG                  SKIN GRAFT &/OR DEBRID           1.6039         4.2         6.8
                                                  EXCEPT FOR SKIN ULCER OR
                                                  CELLULITIS W CC.
266.............       09  SURG                  SKIN GRAFT &/OR DEBRID           0.8590         2.2         3.1
                                                  EXCEPT FOR SKIN ULCER OR
                                                  CELLULITIS W/O CC.
267.............       09  SURG                  PERIANAL & PILONIDAL             0.9394         2.5         4.2
                                                  PROCEDURES.
268.............       09  SURG                  SKIN, SUBCUTANEOUS TISSUE &      1.1026         2.3         3.6
                                                  BREAST PLASTIC PROCEDURES.
269.............       09  SURG                  OTHER SKIN, SUBCUT TISS &        1.7172         5.8         8.4
                                                  BREAST PROC W CC.
270.............       09  SURG                  OTHER SKIN, SUBCUT TISS &        0.7693         2.4         3.4
                                                  BREAST PROC W/O CC.
271.............       09  MED                   SKIN ULCERS................      1.0303         5.6         7.3
272.............       09  MED                   MAJOR SKIN DISORDERS W CC..      1.0050         4.6         6.1
273.............       09  MED                   MAJOR SKIN DISORDERS W/O CC      0.5587         3.0         3.9
274.............       09  MED                   MALIGNANT BREAST DISORDERS       1.1927         4.8         6.8
                                                  W CC.
275.............       09  MED                   MALIGNANT BREAST DISORDERS       0.5526         2.2         3.0
                                                  W/O CC.
276.............       09  MED                   NON-MALIGANT BREAST              0.6805         3.5         4.5
                                                  DISORDERS.
277.............       09  MED                   CELLULITIS AGE >17 W CC....      0.8593         4.7         5.8
278.............       09  MED                   CELLULITIS AGE >17 W/O CC..      0.5495         3.6         4.3

[[Page 50235]]

 
279.............       09  MED                   *CELLULITIS AGE 0-17.......      0.6601         4.2         4.2
280.............       09  MED                   TRAUMA TO THE SKIN, SUBCUT       0.6981         3.2         4.2
                                                  TISS & BREAST AGE >17 W CC.
281.............       09  MED                   TRAUMA TO THE SKIN, SUBCUT       0.4644         2.3         2.9
                                                  TISS & BREAST AGE >17 W/O
                                                  CC.
282.............       09  MED                   *TRAUMA TO THE SKIN, SUBCUT      0.2553         2.2         2.2
                                                  TISS & BREAST AGE 0-17.
283.............       09  MED                   MINOR SKIN DISORDERS W CC..      0.7221         3.5         4.7
284.............       09  MED                   MINOR SKIN DISORDERS W/O CC      0.4311         2.4         3.1
285.............       10  SURG                  AMPUTAT OF LOWER LIMB FOR        2.0499         8.0        10.7
                                                  ENDOCRINE,NUTRIT,& METABOL
                                                  DISORDERS.
286.............       10  SURG                  ADRENAL & PITUITARY              2.0937         4.5         5.9
                                                  PROCEDURES.
287.............       10  SURG                  SKIN GRAFTS & WOUND DEBRID       1.8722         7.7        10.6
                                                  FOR ENDOC, NUTRIT & METAB
                                                  DISORDERS.
288.............       10  SURG                  O.R. PROCEDURES FOR OBESITY      2.2239         4.3         5.4
289.............       10  SURG                  PARATHYROID PROCEDURES.....      0.9773         1.8         2.8
290.............       10  SURG                  THYROID PROCEDURES.........      0.8951         1.7         2.2
291.............       10  SURG                  THYROGLOSSAL PROCEDURES....      0.6331         1.4         1.6
292.............       10  SURG                  OTHER ENDOCRINE, NUTRIT &        2.6826         7.3        10.7
                                                  METAB O.R. PROC W CC.
293.............       10  SURG                  OTHER ENDOCRINE, NUTRIT &        1.3164         3.4         5.1
                                                  METAB O.R. PROC W/O CC.
294.............       10  MED                   DIABETES AGE >35...........      0.7571         3.4         4.5
295.............       10  MED                   DIABETES AGE 0-35..........      0.7928         3.0         4.0
296.............       10  MED                   NUTRITIONAL & MISC               0.8471         3.9         5.1
                                                  METABOLIC DISORDERS AGE
                                                  >17 W CC.
297.............       10  MED                   NUTRITIONAL & MISC               0.5043         2.7         3.4
                                                  METABOLIC DISORDERS AGE
                                                  >17 W/O CC.
298.............       10  MED                   NUTRITIONAL & MISC               0.5814         2.9         4.3
                                                  METABOLIC DISORDERS AGE 0-
                                                  17.
299.............       10  MED                   INBORN ERRORS OF METABOLISM      0.9420         3.8         5.4
300.............       10  MED                   ENDOCRINE DISORDERS W CC...      1.0940         4.7         6.2
301.............       10  MED                   ENDOCRINE DISORDERS W/O CC.      0.6319         2.8         3.7
302.............       11  SURG                  KIDNEY TRANSPLANT..........      3.3000         7.4         8.7
303.............       11  SURG                  KIDNEY,URETER & MAJOR            2.4282         6.7         8.3
                                                  BLADDER PROCEDURES FOR
                                                  NEOPLASM.
304.............       11  SURG                  KIDNEY,URETER & MAJOR            2.3343         6.2         8.7
                                                  BLADDER PROC FOR NON-NEOPL
                                                  W CC.
305.............       11  SURG                  KIDNEY,URETER & MAJOR            1.2016         2.9         3.6
                                                  BLADDER PROC FOR NON-NEOPL
                                                  W/O CC.
306.............       11  SURG                  PROSTATECTOMY W CC.........      1.2709         3.6         5.5
307.............       11  SURG                  PROSTATECTOMY W/O CC.......      0.6323         1.8         2.2
308.............       11  SURG                  MINOR BLADDER PROCEDURES W       1.6387         4.0         6.3
                                                  CC.
309.............       11  SURG                  MINOR BLADDER PROCEDURES W/      0.8959         1.7         2.2
                                                  O CC.
310.............       11  SURG                  TRANSURETHRAL PROCEDURES W       1.1270         2.9         4.3
                                                  CC.
311.............       11  SURG                  TRANSURETHRAL PROCEDURES W/      0.6262         1.5         1.8
                                                  O CC.
312.............       11  SURG                  URETHRAL PROCEDURES, AGE         1.0623         3.0         4.5
                                                  >17 W CC.
313.............       11  SURG                  URETHRAL PROCEDURES, AGE         0.6703         1.7         2.1
                                                  >17 W/O CC.
314.............       11  SURG                  *URETHRAL PROCEDURES, AGE 0-     0.4921         2.3         2.3
                                                  17.
315.............       11  SURG                  OTHER KIDNEY & URINARY           2.1046         3.9         7.2
                                                  TRACT O.R. PROCEDURES.
316.............       11  MED                   RENAL FAILURE..............      1.3284         4.9         6.6
317.............       11  MED                   ADMIT FOR RENAL DIALYSIS...      0.6629         2.0         3.1
318.............       11  MED                   KIDNEY & URINARY TRACT           1.1868         4.4         6.1
                                                  NEOPLASMS W CC.
319.............       11  MED                   KIDNEY & URINARY TRACT           0.6017         2.1         2.8
                                                  NEOPLASMS W/O CC.
320.............       11  MED                   KIDNEY & URINARY TRACT           0.8551         4.3         5.3
                                                  INFECTIONS AGE >17 W CC.
321.............       11  MED                   KIDNEY & URINARY TRACT           0.5638         3.1         3.8
                                                  INFECTIONS AGE >17 W/O CC.
322.............       11  MED                   KIDNEY & URINARY TRACT           0.4987         3.2         3.7
                                                  INFECTIONS AGE 0-17.
323.............       11  MED                   URINARY STONES W CC, &/OR        0.8041         2.4         3.1
                                                  ESW LITHOTRIPSY.
324.............       11  MED                   URINARY STONES W/O CC......      0.4638         1.5         1.8
325.............       11  MED                   KIDNEY & URINARY TRACT           0.6517         2.9         3.8
                                                  SIGNS & SYMPTOMS AGE >17 W
                                                  CC.
326.............       11  MED                   KIDNEY & URINARY TRACT           0.4446         2.2         2.7
                                                  SIGNS & SYMPTOMS AGE >17 W/
                                                  O CC.
327.............       11  MED                   *KIDNEY & URINARY TRACT          0.3680         3.1         3.1
                                                  SIGNS & SYMPTOMS AGE 0-17.
328.............       11  MED                   URETHRAL STRICTURE AGE >17       0.7321         2.8         3.8
                                                  W CC.
329.............       11  MED                   URETHRAL STRICTURE AGE >17       0.4904         1.7         2.2
                                                  W/O CC.
330.............       11  MED                   *URETHRAL STRICTURE AGE 0-       0.3170         1.6         1.6
                                                  17.
331.............       11  MED                   OTHER KIDNEY & URINARY           1.0597         4.2         5.6
                                                  TRACT DIAGNOSES AGE >17 W
                                                  CC.
332.............       11  MED                   OTHER KIDNEY & URINARY           0.6023         2.4         3.2
                                                  TRACT DIAGNOSES AGE >17 W/
                                                  O CC.
333.............       11  MED                   OTHER KIDNEY & URINARY           0.7795         3.3         4.7
                                                  TRACT DIAGNOSES AGE 0-17.
334.............       12  SURG                  MAJOR MALE PELVIC                1.5207         4.0         4.8
                                                  PROCEDURES W CC.
335.............       12  SURG                  MAJOR MALE PELVIC                1.1255         2.9         3.2
                                                  PROCEDURES W/O CC.
336.............       12  SURG                  TRANSURETHRAL PROSTATECTOMY      0.8707         2.6         3.4
                                                  W CC.
337.............       12  SURG                  TRANSURETHRAL PROSTATECTOMY      0.6033         1.8         2.1
                                                  W/O CC.
338.............       12  SURG                  TESTES PROCEDURES, FOR           1.2293         3.5         5.6
                                                  MALIGNANCY.
339.............       12  SURG                  TESTES PROCEDURES, NON-          1.1074         2.9         4.6
                                                  MALIGNANCY AGE >17.

[[Page 50236]]

 
340.............       12  SURG                  *TESTES PROCEDURES, NON-         0.2817         2.4         2.4
                                                  MALIGNANCY AGE 0-17.
341.............       12  SURG                  PENIS PROCEDURES...........      1.2142         1.9         3.1
342.............       12  SURG                  CIRCUMCISION AGE >17.......      0.7922         2.4         3.2
343.............       12  SURG                  *CIRCUMCISION AGE 0-17.....      0.1531         1.7         1.7
344.............       12  SURG                  OTHER MALE REPRODUCTIVE          1.2658         1.6         2.4
                                                  SYSTEM O.R. PROCEDURES FOR
                                                  MALIGNANCY.
345.............       12  SURG                  OTHER MALE REPRODUCTIVE          1.1852         2.9         4.8
                                                  SYSTEM O.R. PROC EXCEPT
                                                  FOR MALIGNANCY.
346.............       12  MED                   MALIGNANCY, MALE                 1.0468         4.5         6.0
                                                  REPRODUCTIVE SYSTEM, W CC.
347.............       12  MED                   MALIGNANCY, MALE                 0.5649         2.0         2.7
                                                  REPRODUCTIVE SYSTEM, W/O
                                                  CC.
348.............       12  MED                   BENIGN PROSTATIC                 0.7106         3.2         4.2
                                                  HYPERTROPHY W CC.
349.............       12  MED                   BENIGN PROSTATIC                 0.3974         1.9         2.5
                                                  HYPERTROPHY W/O CC.
350.............       12  MED                   INFLAMMATION OF THE MALE         0.7182         3.6         4.5
                                                  REPRODUCTIVE SYSTEM.
351.............       12  MED                   *STERILIZATION, MALE.......      0.2349         1.3         1.3
352.............       12  MED                   OTHER MALE REPRODUCTIVE          0.7283         2.9         4.0
                                                  SYSTEM DIAGNOSES.
353.............       13  SURG                  PELVIC EVISCERATION,             1.8769         5.0         6.5
                                                  RADICAL HYSTERECTOMY &
                                                  RADICAL VULVECTOMY.
354.............       13  SURG                  UTERINE,ADNEXA PROC FOR NON-     1.5499         4.8         5.8
                                                  OVARIAN/ADNEXAL MALIG W CC.
355.............       13  SURG                  UTERINE,ADNEXA PROC FOR NON-     0.9144         3.0         3.2
                                                  OVARIAN/ADNEXAL MALIG W/O
                                                  CC.
356.............       13  SURG                  FEMALE REPRODUCTIVE SYSTEM       0.7657         1.9         2.2
                                                  RECONSTRUCTIVE PROCEDURES.
357.............       13  SURG                  UTERINE & ADNEXA PROC FOR        2.3330         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        0.8345         2.4         2.6
                                                  NON-MALIGNANCY W/O CC.
360.............       13  SURG                  VAGINA, CERVIX & VULVA           0.8851         2.3         2.8
                                                  PROCEDURES.
361.............       13  SURG                  LAPAROSCOPY & INCISIONAL         1.1095         2.3         3.6
                                                  TUBAL INTERRUPTION.
362.............       13  SURG                  *ENDOSCOPIC TUBAL                0.3003         1.4         1.4
                                                  INTERRUPTION.
363.............       13  SURG                  D&C, CONIZATION & RADIO-         0.8840         2.6         3.6
                                                  IMPLANT, FOR MALIGNANCY.
364.............       13  SURG                  D&C, CONIZATION EXCEPT FOR       0.8391         2.7         3.9
                                                  MALIGNANCY.
365.............       13  SURG                  OTHER FEMALE REPRODUCTIVE        1.9491         5.2         7.7
                                                  SYSTEM O.R. PROCEDURES.
366.............       13  MED                   MALIGNANCY, FEMALE               1.2885         4.9         6.9
                                                  REPRODUCTIVE SYSTEM W CC.
367.............       13  MED                   MALIGNANCY, FEMALE               0.5416         2.3         3.0
                                                  REPRODUCTIVE SYSTEM W/O CC.
368.............       13  MED                   INFECTIONS, FEMALE               1.2032         5.2         6.7
                                                  REPRODUCTIVE SYSTEM.
369.............       13  MED                   MENSTRUAL & OTHER FEMALE         0.5950         2.4         3.2
                                                  REPRODUCTIVE SYSTEM
                                                  DISORDERS.
370.............       14  SURG                  CESAREAN SECTION W CC......      0.9848         4.4         5.7
371.............       14  SURG                  CESAREAN SECTION W/O CC....      0.6745         3.2         3.6
372.............       14  MED                   VAGINAL DELIVERY W               0.6259         2.6         3.7
                                                  COMPLICATING DIAGNOSES.
373.............       14  MED                   VAGINAL DELIVERY W/O             0.3934         2.0         2.3
                                                  COMPLICATING DIAGNOSES.
374.............       14  SURG                  VAGINAL DELIVERY W               0.7727         2.5         2.9
                                                  STERILIZATION &/OR D&C.
375.............       14  SURG                  *VAGINAL DELIVERY W O.R.         0.5733         4.4         4.4
                                                  PROC EXCEPT STERIL &/OR
                                                  D&C.
376.............       14  MED                   POSTPARTUM & POST ABORTION       0.4851         2.6         3.5
                                                  DIAGNOSES W/O O.R.
                                                  PROCEDURE.
377.............       14  SURG                  POSTPARTUM & POST ABORTION       1.4354         3.0         4.2
                                                  DIAGNOSES W O.R. PROCEDURE.
378.............       14  MED                   ECTOPIC PREGNANCY..........      0.8368         2.0         2.5
379.............       14  MED                   THREATENED ABORTION........      0.3916         2.1         3.0
380.............       14  MED                   ABORTION W/O D&C...........      0.3631         1.6         2.0
381.............       14  SURG                  ABORTION W D&C, ASPIRATION       0.5896         1.6         2.1
                                                  CURETTAGE OR HYSTEROTOMY.
382.............       14  MED                   FALSE LABOR................      0.1683         1.2         1.3
383.............       14  MED                   OTHER ANTEPARTUM DIAGNOSES       0.5474         2.7         4.0
                                                  W MEDICAL COMPLICATIONS.
384.............       14  MED                   OTHER ANTEPARTUM DIAGNOSES       0.4204         1.8         2.8
                                                  W/O MEDICAL COMPLICATIONS.
385.............       15  MED                   *NEONATES, DIED OR               1.3680         1.8         1.8
                                                  TRANSFERRED TO ANOTHER
                                                  ACUTE CARE FACILITY.
386.............       15  MED                   *EXTREME IMMATURITY........      4.5111        17.9        17.9
387.............       15  MED                   *PREMATURITY W MAJOR             3.0810        13.3        13.3
                                                  PROBLEMS.
388.............       15  MED                   *PREMATURITY W/O MAJOR           1.8590         8.6         8.6
                                                  PROBLEMS.
389.............       15  MED                   *FULL TERM NEONATE W MAJOR       3.1648         4.7         4.7
                                                  PROBLEMS.
390.............       15  MED                   *NEONATE W OTHER                 1.1201         3.4         3.4
                                                  SIGNIFICANT PROBLEMS.
391.............       15  MED                   *NORMAL NEWBORN............      0.1517         3.1         3.1
392.............       16  SURG                  SPLENECTOMY AGE >17........      3.1665         6.9         9.5
393.............       16  SURG                  *SPLENECTOMY AGE 0-17......      1.3400         9.1         9.1

[[Page 50237]]

 
394.............       16  SURG                  OTHER O.R. PROCEDURES OF         1.8110         4.3         7.1
                                                  THE BLOOD AND BLOOD
                                                  FORMING ORGANS.
395.............       16  MED                   RED BLOOD CELL DISORDERS         0.8156         3.2         4.4
                                                  AGE >17.
396.............       16  MED                   RED BLOOD CELL DISORDERS         0.6591         2.4         3.8
                                                  AGE 0-17.
397.............       16  MED                   COAGULATION DISORDERS......      1.2421         3.7         5.2
398.............       16  MED                   RETICULOENDOTHELIAL &            1.2700         4.6         5.9
                                                  IMMUNITY DISORDERS W CC.
399.............       16  MED                   RETICULOENDOTHELIAL &            0.6890         2.8         3.6
                                                  IMMUNITY DISORDERS W/O CC.
400.............       17  SURG                  LYMPHOMA & LEUKEMIA W MAJOR      2.6787         5.5         9.0
                                                  O.R. PROCEDURE.
401.............       17  SURG                  LYMPHOMA & NON-ACUTE             2.7850         8.0        11.3
                                                  LEUKEMIA W OTHER O.R. PROC
                                                  W CC.
402.............       17  SURG                  LYMPHOMA & NON-ACUTE             1.1248         2.7         3.9
                                                  LEUKEMIA W OTHER O.R. PROC
                                                  W/O CC.
403.............       17  MED                   LYMPHOMA & NON-ACUTE             1.7709         5.7         8.0
                                                  LEUKEMIA W CC.
404.............       17  MED                   LYMPHOMA & NON-ACUTE             0.8587         3.0         4.2
                                                  LEUKEMIA W/O CC.
405.............       17  MED                   *ACUTE LEUKEMIA W/O MAJOR        1.8998         4.9         4.9
                                                  O.R. PROCEDURE AGE 0-17.
406.............       17  SURG                  MYELOPROLIF DISORD OR            2.8059         6.9         9.7
                                                  POORLY DIFF NEOPL W MAJ
                                                  O.R.PROC W CC.
407.............       17  SURG                  MYELOPROLIF DISORD OR            1.2905         3.3         4.1
                                                  POORLY DIFF NEOPL W MAJ
                                                  O.R.PROC W/O CC.
408.............       17  SURG                  MYELOPROLIF DISORD OR            2.0623         4.7         7.9
                                                  POORLY DIFF NEOPL W OTHER
                                                  O.R.PROC.
409.............       17  MED                   RADIOTHERAPY...............      1.2077         4.5         6.1
410.............       17  MED                   CHEMOTHERAPY W/O ACUTE           1.0456         3.1         4.0
                                                  LEUKEMIA AS SECONDARY
                                                  DIAGNOSIS.
411.............       17  MED                   HISTORY OF MALIGNANCY W/O        0.3898         2.2         2.9
                                                  ENDOSCOPY.
412.............       17  MED                   HISTORY OF MALIGNANCY W          0.2792         1.6         2.0
                                                  ENDOSCOPY.
413.............       17  MED                   OTHER MYELOPROLIF DIS OR         1.3696         5.3         7.3
                                                  POORLY DIFF NEOPL DIAG W
                                                  CC.
414.............       17  MED                   OTHER MYELOPROLIF DIS OR         0.6931         3.0         4.0
                                                  POORLY DIFF NEOPL DIAG W/O
                                                  CC.
415.............       18  SURG                  O.R. PROCEDURE FOR               3.6798        10.4        14.5
                                                  INFECTIOUS & PARASITIC
                                                  DISEASES.
416.............       18  MED                   SEPTICEMIA AGE >17.........      1.5985         5.6         7.5
417.............       18  MED                   SEPTICEMIA AGE 0-17........      1.1847         4.5         6.2
418.............       18  MED                   POSTOPERATIVE & POST-            1.0459         4.8         6.2
                                                  TRAUMATIC INFECTIONS.
419.............       18  MED                   FEVER OF UNKNOWN ORIGIN AGE      0.8674         3.6         4.7
                                                  >17 W CC.
420.............       18  MED                   FEVER OF UNKNOWN ORIGIN AGE      0.5908         2.8         3.4
                                                  >17 W/O CC.
421.............       18  MED                   VIRAL ILLNESS AGE >17......      0.7062         2.9         3.8
422.............       18  MED                   VIRAL ILLNESS & FEVER OF         0.4381         2.4         3.0
                                                  UNKNOWN ORIGIN AGE 0-17.
423.............       18  MED                   OTHER INFECTIOUS &               1.7896         5.9         8.3
                                                  PARASITIC DISEASES
                                                  DIAGNOSES.
424.............       19  SURG                  O.R. PROCEDURE W PRINCIPAL       2.3048         8.1        13.0
                                                  DIAGNOSES OF MENTAL
                                                  ILLNESS.
425.............       19  MED                   ACUTE ADJUSTMENT REACTION &      0.6822         2.9         3.9
                                                  PSYCHOSOCIAL DYSFUNCTION.
426.............       19  MED                   DEPRESSIVE NEUROSES........      0.5167         3.2         4.5
427.............       19  MED                   NEUROSES EXCEPT DEPRESSIVE.      0.5188         3.1         4.4
428.............       19  MED                   DISORDERS OF PERSONALITY &       0.7408         4.4         7.4
                                                  IMPULSE CONTROL.
429.............       19  MED                   ORGANIC DISTURBANCES &           0.8448         4.7         6.3
                                                  MENTAL RETARDATION.
430.............       19  MED                   PSYCHOSES..................      0.7128         5.7         8.0
431.............       19  MED                   CHILDHOOD MENTAL DISORDERS.      0.5940         4.2         5.9
432.............       19  MED                   OTHER MENTAL DISORDER            0.6348         2.9         4.6
                                                  DIAGNOSES.
433.............       20  MED                   ALCOHOL/DRUG ABUSE OR            0.2755         2.2         3.0
                                                  DEPENDENCE, LEFT AMA.
434.............       20  MED                   NO LONGER VALID............      0.0000         0.0         0.0
435.............       20  MED                   NO LONGER VALID............      0.0000         0.0         0.0
436.............       20  MED                   NO LONGER VALID............      0.0000         0.0         0.0
437.............       20  MED                   NO LONGER VALID............      0.0000         0.0         0.0
438.............       20  ....................  NO LONGER VALID............      0.0000         0.0         0.0
439.............       21  SURG                  SKIN GRAFTS FOR INJURIES...      1.6965         5.4         8.5
440.............       21  SURG                  WOUND DEBRIDEMENTS FOR           1.9156         5.7         9.1
                                                  INJURIES.
441.............       21  SURG                  HAND PROCEDURES FOR              0.9314         2.1         3.1
                                                  INJURIES.
442.............       21  SURG                  OTHER O.R. PROCEDURES FOR        2.4136         5.6         8.6
                                                  INJURIES W CC.
443.............       21  SURG                  OTHER O.R. PROCEDURES FOR        1.0679         2.6         3.5
                                                  INJURIES W/O CC.
444.............       21  MED                   TRAUMATIC INJURY AGE >17 W       0.7614         3.2         4.3
                                                  CC.
445.............       21  MED                   TRAUMATIC INJURY AGE >17 W/      0.4881         2.3         2.9
                                                  O CC.
446.............       21  MED                   *TRAUMATIC INJURY AGE 0-17.      0.2945         2.4         2.4
447.............       21  MED                   ALLERGIC REACTIONS AGE >17.      0.4992         1.8         2.4
448.............       21  MED                   *ALLERGIC REACTIONS AGE 0-       0.0969         2.9         2.9
                                                  17.
449.............       21  MED                   POISONING & TOXIC EFFECTS        0.8267         2.6         3.7
                                                  OF DRUGS AGE >17 W CC.
450.............       21  MED                   POISONING & TOXIC EFFECTS        0.4260         1.6         2.0
                                                  OF DRUGS AGE >17 W/O CC.
451.............       21  MED                   *POISONING & TOXIC EFFECTS       0.2615         2.1         2.1
                                                  OF DRUGS AGE 0-17.
452.............       21  MED                   COMPLICATIONS OF TREATMENT       1.0433         3.5         5.0
                                                  W CC.

[[Page 50238]]

 
453.............       21  MED                   COMPLICATIONS OF TREATMENT       0.5146         2.1         2.8
                                                  W/O CC.
454.............       21  MED                   OTHER INJURY, POISONING &        0.8281         3.0         4.3
                                                  TOXIC EFFECT DIAG W CC.
455.............       21  MED                   OTHER INJURY, POISONING &        0.4582         1.8         2.4
                                                  TOXIC EFFECT DIAG W/O CC.
456.............       22  ....................  NO LONGER VALID............      0.0000         0.0         0.0
457.............       22  MED                   NO LONGER VALID............      0.0000         0.0         0.0
458.............       22  SURG                  NO LONGER VALID............      0.0000         0.0         0.0
459.............       22  SURG                  NO LONGER VALID............      0.0000         0.0         0.0
460.............       22  MED                   NO LONGER VALID............      0.0000         0.0         0.0
461.............       23  SURG                  O.R. PROC W DIAGNOSES OF         1.2060         2.2         4.1
                                                  OTHER CONTACT W HEALTH
                                                  SERVICES.
462.............       23  MED                   REHABILITATION.............      1.1298         9.3        11.5
463.............       23  MED                   SIGNS & SYMPTOMS W CC......      0.6957         3.2         4.2
464.............       23  MED                   SIGNS & SYMPTOMS W/O CC....      0.4959         2.4         3.0
465.............       23  MED                   AFTERCARE W HISTORY OF           0.6786         1.8         2.9
                                                  MALIGNANCY AS SECONDARY
                                                  DIAGNOSIS.
466.............       23  MED                   AFTERCARE W/O HISTORY OF         0.7500         2.2         4.1
                                                  MALIGNANCY AS SECONDARY
                                                  DIAGNOSIS.
467.............       23  MED                   OTHER FACTORS INFLUENCING        0.6012         2.1         8.5
                                                  HEALTH STATUS.
468.............  .......  ....................  EXTENSIVE O.R. PROCEDURE         3.7267         9.2        13.0
                                                  UNRELATED TO PRINCIPAL
                                                  DIAGNOSIS.
469.............  .......  ....................  **PRINCIPAL DIAGNOSIS            0.0000         0.0         0.0
                                                  INVALID AS DISCHARGE
                                                  DIAGNOSIS.
470.............  .......  ....................  **UNGROUPABLE..............      0.0000         0.0         0.0
471.............       08  SURG                  BILATERAL OR MULTIPLE MAJOR      3.1053         4.8         5.5
                                                  JOINT PROCS OF LOWER
                                                  EXTREMITY.
472.............       22  SURG                  NO LONGER VALID............      0.0000         0.0         0.0
473.............       17  SURG                  ACUTE LEUKEMIA W/O MAJOR         3.5411         7.3        12.6
                                                  O.R. PROCEDURE AGE >17.
474.............       04  SURG                  NO LONGER VALID............      0.0000         0.0         0.0
475.............       04  MED                   RESPIRATORY SYSTEM               3.6632         8.0        11.4
                                                  DIAGNOSIS WITH VENTILATOR
                                                  SUPPORT.
476.............  .......  SURG                  PROSTATIC O.R. PROCEDURE         2.2592         8.0        11.3
                                                  UNRELATED TO PRINCIPAL
                                                  DIAGNOSIS.
477.............  .......  SURG                  NON-EXTENSIVE O.R.               1.8618         5.3         8.2
                                                  PROCEDURE UNRELATED TO
                                                  PRINCIPAL DIAGNOSIS.
478.............       05  SURG                  OTHER VASCULAR PROCEDURES W      2.3725         4.9         7.4
                                                  CC.
479.............       05  SURG                  OTHER VASCULAR PROCEDURES W/     1.4321         2.5         3.3
                                                  O CC.
480.............      PRE  SURG                  LIVER TRANSPLANT...........     10.3805        15.7        21.8
481.............      PRE  SURG                  BONE MARROW TRANSPLANT.....      7.1307        19.3        22.1
482.............      PRE  SURG                  TRACHEOSTOMY FOR FACE,MOUTH      3.5614         9.7        12.6
                                                  & NECK DIAGNOSES.
483.............      PRE  SURG                  TRAC W MECH VENT 96+HRS OR      17.0510        34.8        42.2
                                                  PDX EXCEPT FACE,MOUTH &
                                                  NECK DX.
484.............       24  SURG                  CRANIOTOMY FOR MULTIPLE          5.5768         8.8        13.1
                                                  SIGNIFICANT TRAUMA.
485.............       24  SURG                  LIMB REATTACHMENT, HIP AND       3.0493         7.7         9.5
                                                  FEMUR PROC FOR MULTIPLE
                                                  SIGNIFICANT TRAUMA.
486.............       24  SURG                  OTHER O.R. PROCEDURES FOR        4.8153         8.3        12.3
                                                  MULTIPLE SIGNIFICANT
                                                  TRAUMA.
487.............       24  MED                   OTHER MULTIPLE SIGNIFICANT       2.0055         5.5         7.8
                                                  TRAUMA.
488.............       25  SURG                  HIV W EXTENSIVE O.R.             4.6556        11.4        16.9
                                                  PROCEDURE.
489.............       25  MED                   HIV W MAJOR RELATED              1.7997         6.0         8.6
                                                  CONDITION.
490.............       25  MED                   HIV W OR W/O OTHER RELATED       1.0261         3.7         5.3
                                                  CONDITION.
491.............       08  SURG                  MAJOR JOINT & LIMB               1.7037         2.9         3.5
                                                  REATTACHMENT PROCEDURES OF
                                                  UPPER EXTREMITY.
492.............       17  MED                   CHEMOTHERAPY W ACUTE             3.9528         9.2        15.0
                                                  LEUKEMIA AS SECONDARY
                                                  DIAGNOSIS.
493.............       07  SURG                  LAPAROSCOPIC                     1.8152         4.3         5.9
                                                  CHOLECYSTECTOMY W/O C.D.E.
                                                  W CC.
494.............       07  SURG                  LAPAROSCOPIC                     1.0107         1.9         2.5
                                                  CHOLECYSTECTOMY W/O C.D.E.
                                                  W/O CC.
495.............      PRE  SURG                  LUNG TRANSPLANT............      9.2016        14.4        17.3
496.............       08  SURG                  COMBINED ANTERIOR/POSTERIOR      5.7988         7.1         9.5
                                                  SPINAL FUSION.
497.............       08  SURG                  SPINAL FUSION EXCEPT             3.3938         5.4         6.5
                                                  CERVICAL W CC.
498.............       08  SURG                  SPINAL FUSION EXCEPT             2.4738         3.7         4.1
                                                  CERVICAL W/O CC.
499.............       08  SURG                  BACK & NECK PROCEDURES           1.4399         3.3         4.6
                                                  EXCEPT SPINAL FUSION W CC.
500.............       08  SURG                  BACK & NECK PROCEDURES           0.9489         2.0         2.5
                                                  EXCEPT SPINAL FUSION W/O
                                                  CC.
501.............       08  SURG                  KNEE PROCEDURES W PDX OF         2.5922         8.4        10.6
                                                  INFECTION W CC.
502.............       08  SURG                  KNEE PROCEDURES W PDX OF         1.5368         5.2         6.4
                                                  INFECTION W/O CC.
503.............       08  SURG                  KNEE PROCEDURES W/O PDX OF       1.2128         2.9         3.9
                                                  INFECTION.
504.............       22  SURG                  EXTENSIVE 3RD DEGREE BURNS      14.6542        26.7        34.9
                                                  W SKIN GRAFT.
505.............       22  MED                   EXTENSIVE 3RD DEGREE BURNS       2.0178         2.2         3.7
                                                  W/O SKIN GRAFT.
506.............       22  SURG                  FULL THICKNESS BURN W SKIN       4.6725        12.7        17.3
                                                  GRAFT OR INHAL INJ W CC OR
                                                  SIG TRAUMA.

[[Page 50239]]

 
507.............       22  SURG                  FULL THICKNESS BURN W SKIN       1.7246         6.5         9.0
                                                  GRFT OR INHAL INJ W/O CC
                                                  OR SIG TRAUMA.
508.............       22  MED                   FULL THICKNESS BURN W/O          1.4330         5.8         8.4
                                                  SKIN GRFT OR INHAL INJ W
                                                  CC OR SIG TRAUMA.
509.............       22  MED                   FULL THICKNESS BURN W/O          0.9691         4.1         5.7
                                                  SKIN GRFT OR INH INJ W/O
                                                  CC OR SIG TRAUMA.
510.............       22  MED                   NON-EXTENSIVE BURNS W CC OR      1.2301         4.6         6.7
                                                  SIGNIFICANT TRAUMA.
511.............       22  MED                   NON-EXTENSIVE BURNS W/O CC       0.7006         3.0         4.4
                                                  OR SIGNIFICANT TRAUMA.
512.............      PRE  SURG                  SIMULTANEOUS PANCREAS/           5.8613        11.9        14.5
                                                  KIDNEY TRANSPLANT.
513.............      PRE  SURG                  PANCREAS TRANSPLANT........      6.3271         9.4        10.8
514.............       05  SURG                  CARDIAC DEFIBRILLATOR            6.3376         5.0         7.3
                                                  IMPLANT W CARDIAC CATH.
515.............       05  SURG                  CARDIAC DEFIBRILLATOR            5.0562         3.3         5.5
                                                  IMPLANT W/O CARDIAC CATH.
516.............       05  SURG                  PERCUTANEOUS CARDIOVASCULAR      2.7273         3.7         4.8
                                                  PROC W AMI.
517.............       05  SURG                  PERC CARDIO PROC W NON-DRUG      2.1789         1.9         2.6
                                                  ELUTING STENT W/O AMI.
518.............       05  SURG                  PERC CARDIO PROC W/O             1.7297         2.3         3.4
                                                  CORONARY ARTERY STENT OR
                                                  AMI.
519.............       08  SURG                  CERVICAL SPINAL FUSION W CC      2.3551         3.2         5.2
520.............       08  SURG                  CERVICAL SPINAL FUSION W/O       1.5389         1.7         2.1
                                                  CC.
521.............       20  MED                   ALCOHOL/DRUG ABUSE OR            0.7300         4.3         5.8
                                                  DEPENDENCE W CC.
522.............       20  MED                   ALC/DRUG ABUSE OR DEPEND W       0.5818         7.5         9.5
                                                  REHABILITATION THERAPY W/O
                                                  CC.
523.............       20  MED                   ALC/DRUG ABUSE OR DEPEND W/      0.3999         3.3         4.1
                                                  O REHABILITATION THERAPY W/
                                                  O CC.
524.............       01  MED                   TRANSIENT ISCHEMIA.........      0.7238         2.7         3.4
525.............       05  SURG                  HEART ASSIST SYSTEM IMPLANT     11.6479         9.4        16.6
526.............       05  SURG                  PERCUTANEOUS CARDIOVASCULAR      3.1176         3.7         4.7
                                                  PROC W DRUG ELUTING STENT
                                                  W AMI.
527.............       05  SURG                  PERCUTANEOUS CARDIOVASCULAR      2.5342         1.9         2.6
                                                  PROC W DRUG ELUTING STENT
                                                  W/O AMI.
----------------------------------------------------------------------------------------------------------------


                                         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.
     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

[[Page 50240]]

 
     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  Dielulafoy 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
     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         N                             13  358, 359, 369
              changes of undetermined
              significance favor benign
              (ASCUS favor benign).
     795.02  Atypical squamous cell         N                             13  358, 359, 369
              changes of undetermined
              significance favor dysplasia
              (ASCUS favor dysplasia).
     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

[[Page 50241]]

 
     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          Y                             18  416, 417
              response syndrome due to
              infectious process without
              organ dysfunction.
     995.92  Systemic inflammatory          Y                             18  416, 417
              response syndrome due to
              infectious process with
              organ dysfunction.
     995.93  Systemic inflammatory          Y                             18  416, 417
              response syndrome due to non-
              infectious process without
              organ dysfunction.
     995.94  Systemic inflammatory          Y                             18  416, 417
              response syndrome due to non-
              infectious process with
              organ dysfunction.
     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    N                             15  391 \1\
              communicable diseases, other                                23  467
              communicable diseases.
     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.
     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.

[[Page 50242]]

 
      00.13  Injection or infusion of       N
              nesiritide.
      00.14  Injection or infusion of       N
              oxazolidinone class of
              antibiotics.
      00.50  Implantation of cardiac        Y                              5  115 \1\, 116 \1\
              resynchronization pacemaker
              without mention of
              defibrillation, total 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    Y                              5  115 \2\, 116 \3\, 514 \4\, 515 \4\
              of transvenous lead
              (electrode) into left
              ventricular coronary venous
              system.
      00.53  Implantation or replacement    Y                              5  115 \2\, 116 \3\, 118
              of cardiac resynchronization
              pacemaker pulse generator
              only [CRT-P].
      00.54  Implantation or replacement    Y                              5  115 \1\, 514 \4\, 515 \4\
              of cardiac resynchronization
              defibrillator pulse
              generator only [CRT-D].
      00.55  Insertion of drug-eluting non- N
              coronary artery stent(s).
      36.07  Insertion of drug-eluting      N \*\                          5  526, 527
              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.
  89.60 \5\  Continuous intra-arterial      N
              blood gas monitoring.
      99.76  Extracorporeal                 N
              immunoadsorption.
      99.77  Application or administration  N
              of an adhesion barrier
              substance.
----------------------------------------------------------------------------------------------------------------
* Nonoperating 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.
\5\ This code was discussed at the April 18, 2002 meeting of the ICD-9-CM Coordination and Maintenance Committee
  and included in the final addendum for ICD-9-CM.


                                       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
      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
----------------------------------------------------------------------------------------------------------------


[[Page 50243]]


                   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   Y                              5  134
              disease, malignant, without
              mention of heart failure or
              renal failure.
     404.01  Hypertensive heart and renal   Y                              5  115, 121, 124, 127
              disease, malignant, with
              heart failure.
     404.03  Hypertensive heart and renal   Y                              5  115, 121, 124, 127
              disease, malignant, with
              heart failure and renal
              failure.
     404.10  Hypertensive heart and renal   N                              5  134
              disease, benign, without
              mention of heart failure or
              renal failure.
     404.11  Hypertensive heart and renal   Y                              5  115, 121, 124, 127
              disease, benign, with heart
              failure.
     404.13  Hypertensive heart and renal   Y                              5  115, 121, 124, 127
              disease, benign, with heart
              failure and renal failure.
     404.90  Hypertensive heart and renal   N                              5  134
              disease, unspecified,
              without mention of heart
              failure or renal failure.
     404.91  Hypertensive heart and renal   Y                              5  115, 121, 124, 127
              disease, unspecified, with
              heart failure.
     404.93  Hypertensive heart and renal   Y                              5  115, 121, 124, 127
              disease, unspecified, with
              heart failure and renal
              failure.
     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
----------------------------------------------------------------------------------------------------------------
  02.41 \1\  Irrigation and exploration of  N
              ventricular shunt.
      36.06  Insertion of non-drug-eluting  N*                             5  517
              coronary artery stents(s).
      39.79  Other endovascular repair of   Y                              1  1, 2, 3
              aneurysm of other vessels.                                   5  110, 111
                                                                          11  315
                                                                          21  442, 443
                                                                          24  486
      39.90  Insertion of non-drug-         N
              eluting, noncoronary artery
              stents(s).
----------------------------------------------------------------------------------------------------------------
* Nonoperating room procedure, but affects DRG.
\1\ This code title revision was discussed at the April 18, 2002 meeting of the ICD-9-CM Coordination and
  Maintenance Committee and included in the final addendum for ICD-9-CM.


[[Page 50244]]


             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
  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

[[Page 50245]]

 
  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
  76505     76506     769      76508    7703     7713     78039    03811
  76506     76507     7700     7670     7704     77181    7817     03819
  76507     76508     7701     7685     7705     77183    7854     0382

[[Page 50246]]

 
  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
  03843     99591
  03844     99592

[[Page 50247]]

 
  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 50248]]


             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 50249]]


                                Table 7A.--Medicare Prospective Payment System Selected Percentile Lengths of Stay (LOS)
                                                    [FY 2001 MEDPAR Update March 2002 Grouper V19.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                             Number of      Arithmetic         10th            25th            50th            75th            90th
                   DRG                      discharges       mean LOS       percentile      percentile      percentile      percentile      percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1.......................................           34885          8.9770               2               3               6              12              19
2.......................................            7211          9.9230               3               5               8              13              20
3.......................................               7          7.4290               1               1               3               4              10
4.......................................            6510          7.1900               1               2               5               9              16
5.......................................           93559          3.0670               1               1               2               3               7
6.......................................             398          2.9200               1               1               2               4               6
7.......................................           14289          9.7760               1               4               7              12              20
8.......................................            4389          2.7520               1               1               1               3               6
9.......................................            1755          6.4550               1               3               5               8              13
10......................................           18163          6.5160               2               3               5               8              13
11......................................            3444          4.0010               1               2               3               5               8
12......................................           49862          5.8770               2               3               4               7              11
13......................................            6731          5.0160               2               3               4               6               9
14......................................          321915          5.8150               2               3               5               7              11
15......................................          152910          3.4740               1               2               3               4               6
16......................................           11519          6.0130               2               3               5               7              12
17......................................            3744          3.2760               1               2               3               4               6
18......................................           28192          5.4260               2               3               4               7              10
19......................................            8749          3.5380               1               2               3               5               7
20......................................            5666         10.4560               3               5               8              13              20
21......................................            1445          6.5690               2               3               5               8              13
22......................................            2737          5.0080               2               2               4               6              10
23......................................           11274          4.2370               1               2               3               5               8
24......................................           55738          4.8890               1               2               4               6              10
25......................................           27443          3.2300               1               2               3               4               6
26......................................              35          4.6290               1               1               2               4               6
27......................................            3897          5.0160               1               1               3               6              11
28......................................           12468          6.2410               1               3               5               8              13
29......................................            4987          3.5570               1               2               3               5               7
31......................................            3887          4.0710               1               2               3               5               8
32......................................            1940          2.4380               1               1               2               3               5
34......................................           21924          5.0460               1               2               4               6               9
35......................................            6903          3.2410               1               1               3               4               6
36......................................            2513          1.4700               1               1               1               1               2
37......................................            1437          3.8040               1               1               2               4               8
38......................................              93          2.4950               1               1               1               3               6
39......................................             671          1.9400               1               1               1               2               4
40......................................            1534          3.6140               1               1               2               5               8
42......................................            1951          2.3660               1               1               1               3               5
43......................................             111          3.0270               1               1               2               4               6
44......................................            1302          5.0340               2               3               4               6               9
45......................................            2619          3.2440               1               2               3               4               6
46......................................            3394          4.5840               1               2               4               6               9
47......................................            1359          3.1660               1               1               3               4               6
48......................................               1          2.0000               2               2               2               2               2
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50......................................            2492          1.8210               1               1               1               2               3
51......................................             254          3.1260               1               1               1               3               7
52......................................             242          1.9130               1               1               1               2               3
53......................................            2528          3.3780               1               1               2               4               8
54......................................               1          4.0000               4               4               4               4               4
55......................................            1583          3.0580               1               1               1               3               6
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57......................................             696          3.7400               1               1               2               4               8
59......................................             129          2.6740               1               1               1               3               6
60......................................               6          3.3330               1               1               2               5               5
61......................................             244          4.7830               1               1               3               6              10
62......................................               3          1.6670               1               1               1               3               3
63......................................            2951          4.4780               1               1               3               6               9
64......................................            3168          6.5990               1               2               4               8              14
65......................................           39160          2.7980               1               1               2               3               5
66......................................            7719          3.1100               1               1               2               4               6
67......................................             441          3.5940               1               2               3               4               6
68......................................            8805          3.8300               1               2               3               5               7
69......................................            3059          2.9940               1               2               2               4               5
70......................................              25          3.4800               1               2               3               4               8
71......................................              87          3.4370               1               2               3               4               6
72......................................             934          3.5630               1               1               3               4               7
73......................................            7115          4.3800               1               2               3               6               9
75......................................           40165         10.0590               3               5               7              12              20

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77......................................            2458          4.8650               1               2               4               7              10
78......................................           35476          6.6620               3               4               6               8              11
79......................................          166958          8.5080               3               4               7              11              16
80......................................            8364          5.4950               2               3               5               7              10
81......................................               2          8.0000               3               3              13              13              13
82......................................           63860          6.9900               2               3               6               9              14
83......................................            6521          5.4790               2               3               4               7              10
84......................................            1602          3.2040               1               2               3               4               6
85......................................           21367          6.3180               2               3               5               8              12
86......................................            2192          3.8090               1               2               3               5               8
87......................................           59754          6.3130               1               3               5               8              12
88......................................          398448          5.1060               2               3               4               6               9
89......................................          504650          5.8910               2               3               5               7              11
90......................................           47050          4.0300               2               2               3               5               7
91......................................              55          4.0180               2               2               3               5               9
92......................................           14891          6.3630               2               3               5               8              12
93......................................            1721          4.1100               1               2               3               5               8
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95......................................            1704          3.7280               1               2               3               5               7
96......................................           54007          4.5510               2               2               4               6               8
97......................................           28779          3.5190               1               2               3               4               6
98......................................              15          5.0000               1               2               3               4              13
99......................................           21402          3.1730               1               1               2               4               6
100.....................................            9013          2.1320               1               1               2               3               4
101.....................................           21303          4.3870               1               2               3               6               9
102.....................................            5618          2.5720               1               1               2               3               5
103.....................................             453         51.8520               9              14              27              64             130
104.....................................           19919         14.4420               6               8              12              17              25
105.....................................           27571          9.9950               5               6               8              12              18
106.....................................            3320         11.4070               5               7              10              14              20
107.....................................           86073         10.4600               5               7               9              12              17
108.....................................            6235         10.2790               3               5               8              13              20
109.....................................           59810          7.7310               4               5               6               9              13
110.....................................           53439          9.0380               2               4               7              11              18
111.....................................            9446          4.4130               1               2               4               6               8
113.....................................           41687         12.4870               4               6               9              15              24
114.....................................            8909          8.5190               2               4               7              11              17
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116.....................................          109696          4.4720               1               2               3               6               9
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118.....................................            8135          2.8930               1               1               1               3               7
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121.....................................          167946          6.3300               2               3               5               8              12
122.....................................           82148          3.6130               1               2               3               5               7
123.....................................           41344          4.7020               1               1               3               6              11
124.....................................          137904          4.3540               1               2               3               5               8
125.....................................           91635          2.7840               1               1               2               4               5
126.....................................            5061         11.9020               4               6               9              15              22
127.....................................          684796          5.2710               2               3               4               7              10
128.....................................            8303          5.4670               2               3               5               7               9
129.....................................            4150          2.8310               1               1               1               3               6
130.....................................           89193          5.6610               2               3               5               7              10
131.....................................           27944          4.0540               1               2               4               5               7
132.....................................          152950          2.9290               1               1               2               4               5
133.....................................            8979          2.2630               1               1               2               3               4
134.....................................           39813          3.1770               1               2               2               4               6
135.....................................            7584          4.4210               1               2               3               5               8
136.....................................            1243          2.5710               1               1               2               3               5
138.....................................          204244          3.9830               1               2               3               5               8
139.....................................           90369          2.4820               1               1               2               3               5
140.....................................           66769          2.5570               1               1               2               3               5
141.....................................          102878          3.5910               1               2               3               4               7
142.....................................           51988          2.5540               1               1               2               3               5
143.....................................          251435          2.0830               1               1               2               3               4
144.....................................           89218          5.4560               1               2               4               7              11
145.....................................            7647          2.6530               1               1               2               3               5
146.....................................           10845         10.2150               5               7               8              12              17
147.....................................            2812          6.3970               3               5               6               8              10

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148.....................................          130042         12.2930               5               7              10              15              22
149.....................................           19445          6.4620               4               5               6               8              10
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151.....................................            5000          5.6690               1               3               5               8              10
152.....................................            4436          8.3290               3               5               7              10              14
153.....................................            2027          5.3860               3               4               5               7               8
154.....................................           29150         13.2280               3               7              10              16              26
155.....................................            7319          3.9840               1               2               3               6               8
156.....................................               3         15.0000              11              11              13              21              21
157.....................................            8205          5.5530               1               2               4               7              11
158.....................................            4604          2.5160               1               1               2               3               5
159.....................................           17212          5.0630               1               2               4               6              10
160.....................................           12260          2.6480               1               1               2               3               5
161.....................................           11221          4.1550               1               1               3               5               9
162.....................................            7337          1.9150               1               1               1               2               4
163.....................................               3          3.0000               1               1               3               5               5
164.....................................            5142          8.2640               3               5               7              10              14
165.....................................            2201          4.6460               2               3               4               6               8
166.....................................            3935          4.8750               1               2               4               6               9
167.....................................            3833          2.5130               1               1               2               3               4
168.....................................            1409          4.8810               1               2               3               6              10
169.....................................             887          2.3160               1               1               2               3               5
170.....................................           12237         10.9980               2               4               8              14              22
171.....................................            1367          4.3180               1               2               3               6               9
172.....................................           30816          6.9650               2               3               5               9              14
173.....................................            2736          3.7380               1               1               3               5               8
174.....................................          248283          4.8070               2               3               4               6               9
175.....................................           35359          2.9190               1               2               3               4               5
176.....................................           15279          5.2510               2               3               4               6              10
177.....................................            9466          4.5110               2               2               4               6               8
178.....................................            3770          3.0770               1               2               3               4               6
179.....................................           12641          5.9620               2               3               5               7              11
180.....................................           88694          5.3720               2               3               4               7              10
181.....................................           27227          3.3760               1               2               3               4               6
182.....................................          262087          4.3630               1               2               3               5               8
183.....................................           91760          2.8830               1               1               2               4               5
184.....................................              94          2.8400               1               1               2               4               6
185.....................................            5155          4.6870               1               2               3               6               9
186.....................................               3          4.6670               2               2               3               9               9
187.....................................             698          4.1790               1               2               3               6               8
188.....................................           79822          5.5600               1               2               4               7              11
189.....................................           13196          3.0550               1               1               2               4               6
190.....................................              78          4.7690               1               2               3               5               8
191.....................................            9286         13.7420               3               6              10              17              28
192.....................................            1267          6.1130               1               3               5               8              11
193.....................................            4893         12.7480               5               7              10              16              23
194.....................................             738          6.8510               2               4               6               8              12
195.....................................            4171         10.3630               4               6               9              12              18
196.....................................            1056          5.4220               2               3               5               7               9
197.....................................           18696          8.9790               3               5               7              11              16
198.....................................            5707          4.4310               2               3               4               6               8
199.....................................            1663          9.9180               2               4               7              13              21
200.....................................            1049         10.4500               1               3               7              14              22
201.....................................            1468         14.5860               3               6              11              18              29
202.....................................           26324          6.3730               2               3               5               8              13
203.....................................           29515          6.7410               2               3               5               9              13
204.....................................           61935          5.8110               2               3               4               7              11
205.....................................           24648          6.1690               2               3               5               8              12
206.....................................            2068          3.9160               1               2               3               5               8
207.....................................           32279          5.1810               1               2               4               7              10
208.....................................           10815          2.8610               1               1               2               4               5
209.....................................          373009          4.9900               3               3               4               6               8
210.....................................          122166          6.8910               3               4               6               8              11
211.....................................           32764          4.9270               3               4               5               6               7
212.....................................               7          3.2860               1               2               2               2               4
213.....................................            9936          9.1390               2               4               7              11              18
216.....................................            6966          9.5420               2               4               7              12              19
217.....................................           17192         13.4090               3               5               9              16              28
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[[Page 50252]]

 
220.....................................               1          2.0000               2               2               2               2               2
223.....................................           13773          2.8810               1               1               2               3               6
224.....................................           12585          1.8630               1               1               1               2               3
225.....................................            6183          5.0260               1               2               3               7              11
226.....................................            5746          6.6640               1               3               5               8              14
227.....................................            4975          2.6700               1               1               2               3               5
228.....................................            2509          4.0880               1               1               2               5               9
229.....................................            1194          2.2140               1               1               2               3               4
230.....................................            2432          5.0670               1               2               3               6              11
231.....................................           12627          4.8920               1               1               3               6              11
232.....................................             885          2.7380               1               1               1               3               7
233.....................................            7255          7.2080               1               3               5               9              15
234.....................................            4649          3.1560               1               1               2               4               7
235.....................................            5116          5.0300               1               2               4               6               9
236.....................................           40046          4.7420               1               3               4               6               9
237.....................................            1761          3.6000               1               2               3               4               7
238.....................................            8678          8.8670               3               4               7              11              17
239.....................................           48474          6.2820               2               3               5               8              12
240.....................................           11901          6.7280               2               3               5               8              13
241.....................................            3252          3.8840               1               2               3               5               7
242.....................................            2531          6.5780               2               3               5               8              13
243.....................................           94344          4.6810               1               2               4               6               9
244.....................................           13655          4.7310               1               2               4               6               9
245.....................................            5760          3.3620               1               2               3               4               6
246.....................................            1350          3.7580               1               2               3               5               7
247.....................................           19731          3.3700               1               1               3               4               7
248.....................................           12158          4.8690               1               2               4               6               9
249.....................................           12733          3.6440               1               1               2               4               7
250.....................................            3838          4.1640               1               2               3               5               7
251.....................................            2517          2.7750               1               1               2               4               5
253.....................................           21017          4.6730               1               3               4               6               9
254.....................................           10910          3.1320               1               2               3               4               6
255.....................................               1          2.0000               2               2               2               2               2
256.....................................            6435          5.1150               1               2               4               6              10
257.....................................           16786          2.6640               1               1               2               3               5
258.....................................           17062          1.8180               1               1               2               2               3
259.....................................            3835          2.6770               1               1               1               2               6
260.....................................            5111          1.3670               1               1               1               1               2
261.....................................            1927          2.1650               1               1               1               2               4
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263.....................................           24727         11.8360               3               5               8              14              23
264.....................................            4016          6.9110               2               3               5               8              14
265.....................................            4092          6.7790               1               2               4               8              14
266.....................................            2697          3.1350               1               1               2               4               6
267.....................................             272          4.2170               1               1               2               4               8
268.....................................             925          3.5950               1               1               2               4               8
269.....................................            9136          8.2100               2               3               6              10              17
270.....................................            2765          3.2770               1               1               2               4               7
271.....................................           19734          7.2900               2               4               6               9              13
272.....................................            5508          6.1320               2               3               5               7              12
273.....................................            1389          3.9270               1               2               3               5               7
274.....................................            2368          6.7490               1               3               5               8              14
275.....................................             255          3.0120               1               1               2               4               6
276.....................................            1337          4.5030               1               2               4               6               8
277.....................................           94462          5.7610               2               3               5               7              10
278.....................................           31992          4.2750               2               3               4               5               7
279.....................................               4          6.7500               3               3               6               8              10
280.....................................           17235          4.1620               1               2               3               5               8
281.....................................            7951          2.9070               1               1               2               4               5
283.....................................            5674          4.6490               1               2               4               6               9
284.....................................            1960          3.0550               1               1               2               4               6
285.....................................            6641         10.6710               3               5               8              13              20
286.....................................            2193          5.9450               2               3               4               7              11
287.....................................            6513         10.5590               3               5               8              12              20
288.....................................            3757          5.3890               2               3               4               6               8
289.....................................            6449          2.8110               1               1               1               3               6
290.....................................            9553          2.2290               1               1               1               2               4
291.....................................              78          1.6030               1               1               1               2               3
292.....................................            5462          9.9410               2               4               8              13              20
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295.....................................            3387          3.9770               1               2               3               5               7
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297.....................................           47995          3.3570               1               2               3               4               6
298.....................................             109          4.2750               1               2               3               5               7
299.....................................            1225          5.3900               1               2               4               6              10
300.....................................           17627          6.1590               2               3               5               8              12
301.....................................            3661          3.6680               1               2               3               5               7
302.....................................            8130          8.6850               4               5               7              10              15
303.....................................           20792          8.2750               3               4               6               9              15
304.....................................           12047          8.6780               2               4               6              11              18
305.....................................            2997          3.5710               1               2               3               4               6
306.....................................            7239          5.4920               1               2               3               7              13
307.....................................            2175          2.1990               1               1               2               3               4
308.....................................            7397          6.3290               1               2               4               8              14
309.....................................            4393          2.1880               1               1               2               3               4
310.....................................           24716          4.3420               1               1               3               5               9
311.....................................            8387          1.8230               1               1               1               2               3
312.....................................            1557          4.4950               1               1               3               6              10
313.....................................             646          2.1250               1               1               1               2               4
314.....................................               1          5.0000               5               5               5               5               5
315.....................................           31462          6.8980               1               1               4               9              16
316.....................................          117216          6.6330               2               3               5               8              13
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318.....................................            5785          6.0350               1               3               4               8              12
319.....................................             503          2.8330               1               1               2               3               6
320.....................................          194230          5.3020               2               3               4               7              10
321.....................................           30917          3.7520               1               2               3               5               7
322.....................................              68          3.7350               1               2               3               5               7
323.....................................           18745          3.1420               1               1               2               4               6
324.....................................            7509          1.8440               1               1               1               2               3
325.....................................            8989          3.7900               1               2               3               5               7
326.....................................            2820          2.6710               1               1               2               3               5
327.....................................               2          2.5000               1               1               4               4               4
328.....................................             690          3.7720               1               1               3               5               7
329.....................................             105          2.2000               1               1               1               2               5
331.....................................           49529          5.5840               1               3               4               7              11
332.....................................            5171          3.1690               1               1               2               4               6
333.....................................             321          4.6980               1               2               3               6              10
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335.....................................           12477          3.1770               2               2               3               4               5
336.....................................           36484          3.4270               1               2               2               4               7
337.....................................           29676          2.0680               1               1               2               2               3
338.....................................            1057          5.5560               1               2               3               8              13
339.....................................            1518          4.6420               1               1               3               6              10
340.....................................               1          1.0000               1               1               1               1               1
341.....................................            3693          3.0630               1               1               2               3               6
342.....................................             726          3.1640               1               1               2               4               6
343.....................................               1          5.0000               5               5               5               5               5
344.....................................            3824          2.2880               1               1               1               2               4
345.....................................            1188          3.8760               1               1               2               4               8
346.....................................            4590          6.0320               1               3               5               8              12
347.....................................             379          2.6830               1               1               2               3               6
348.....................................            3308          4.1570               1               2               3               5               8
349.....................................             605          2.4740               1               1               2               3               5
350.....................................            6535          4.5040               2               2               4               6               8
351.....................................               1          1.0000               1               1               1               1               1
352.....................................             774          3.9810               1               2               3               5               8
353.....................................            2685          6.4640               2               3               5               7              12
354.....................................            7532          5.8240               3               3               4               7              10
355.....................................            5709          3.2350               2               2               3               4               5
356.....................................           26094          2.1720               1               1               2               3               4
357.....................................            5753          8.4210               3               4               6              10              16
358.....................................           20771          4.3060               2               3               3               5               7
359.....................................           31334          2.6370               1               2               3               3               4
360.....................................           15680          2.8180               1               2               2               3               5
361.....................................             371          3.6500               1               1               2               4               8
362.....................................               4          1.2500               1               1               1               1               2
363.....................................            2701          3.6410               1               2               2               4               7
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366.....................................            4469          6.8500               2               3               5               9              14
367.....................................             526          3.0080               1               1               2               4               6
368.....................................            3302          6.7190               2               3               5               8              13
369.....................................            3304          3.1880               1               1               2               4               6
370.....................................            1286          5.6890               3               3               4               5               9
371.....................................            1479          3.5800               2               3               3               4               5
372.....................................             939          3.7150               1               2               2               3               5
373.....................................            3974          2.2870               1               2               2               3               3
374.....................................             122          2.8770               1               2               2               3               5
375.....................................               8          5.2500               1               3               5               5               9
376.....................................             266          3.5080               1               2               2               4               6
377.....................................              31          4.1940               1               2               3               4               7
378.....................................             173          2.4800               1               1               2               3               5
379.....................................             416          2.9760               1               1               2               3               6
380.....................................              81          1.9750               1               1               1               2               4
381.....................................             187          2.1230               1               1               1               3               4
382.....................................              27          1.3330               1               1               1               1               2
383.....................................            1881          3.9530               1               1               3               4               8
384.....................................             156          2.7820               1               1               1               3               6
386.....................................               1        119.0000             119             119             119             119             119
389.....................................               7          8.7140               1               2               4               8              10
390.....................................               8          2.7500               1               1               1               4               5
392.....................................            2275          9.5310               2               4               7              12              20
393.....................................               1          2.0000               2               2               2               2               2
394.....................................            1971          6.3180               1               2               4               8              14
395.....................................          101315          4.3510               1               2               3               5               9
396.....................................              11          3.8180               1               1               2               4               6
397.....................................           18036          5.1720               1               2               4               7              10
398.....................................           17243          5.8910               2               3               5               7              11
399.....................................            1806          3.5480               1               2               3               5               7
400.....................................            6533          8.9770               1               3               6              11              20
401.....................................            5878         11.2420               2               5               9              15              23
402.....................................            1606          3.8890               1               1               3               5               8
403.....................................           32232          8.0040               2               3               6              10              17
404.....................................            4627          4.1950               1               2               3               5               9
406.....................................            2508          9.7210               2               4               7              12              20
407.....................................             704          4.1210               1               2               3               5               8
408.....................................            2142          7.8730               1               2               5              10              18
409.....................................            2534          6.1220               2               3               4               6              12
410.....................................           30971          4.0150               1               2               4               5               6
411.....................................              14          2.9290               1               1               2               4               6
412.....................................              18          2.0000               1               1               1               2               4
413.....................................            5811          7.3080               2               3               6               9              14
414.....................................             771          4.0100               1               2               3               5               8
415.....................................           40210         14.5010               4               6              11              18              29
416.....................................          181965          7.4660               2               4               6               9              15
417.....................................              41          6.1710               1               2               4               8              14
418.....................................           23577          6.1810               2               3               5               8              12
419.....................................           15866          4.6500               1               2               4               6               9
420.....................................            2980          3.4310               1               2               3               4               6
421.....................................            9327          3.7870               1               2               3               4               7
422.....................................              70          2.9570               1               1               2               3               6
423.....................................            7327          8.2410               2               3               6              10              17
424.....................................            1308         12.9440               2               5               9              16              26
425.....................................           16394          3.8990               1               2               3               5               8
426.....................................            4535          4.4740               1               2               3               5               9
427.....................................            1609          4.4410               1               2               3               5               9
428.....................................             757          7.3750               1               2               4               8              15
429.....................................           27186          6.1440               2               3               4               7              12
430.....................................           63771          7.9550               2               3               6              10              16
431.....................................             328          5.9390               1               2               4               7              13
432.....................................             423          4.5820               1               1               3               5               9
433.....................................            5584          2.9750               1               1               2               3               6
439.....................................            1473          8.5030               1               3               6              10              17
440.....................................            5503          9.0500               2               3               6              11              20
441.....................................             625          3.0740               1               1               2               4               7
442.....................................           16855          8.5610               1               3               6              10              18
443.....................................            3849          3.5180               1               1               3               4               7
444.....................................            5747          4.3170               1               2               3               5               8

[[Page 50255]]

 
445.....................................            2784          2.8980               1               1               2               4               5
447.....................................            6305          2.4430               1               1               2               3               5
448.....................................               1          1.0000               1               1               1               1               1
449.....................................           30763          3.6800               1               1               3               4               8
450.....................................            7473          1.9840               1               1               1               2               4
451.....................................               5          1.6000               1               1               2               2               2
452.....................................           25447          5.0230               1               2               3               6              10
453.....................................            5690          2.7650               1               1               2               3               5
454.....................................            4688          4.3390               1               2               3               5               9
455.....................................            1114          2.3700               1               1               2               3               5
461.....................................            4611          4.1010               1               1               2               4              10
462.....................................           12023         11.3750               4               6              10              14              21
463.....................................           25420          4.1700               1               2               3               5               8
464.....................................            7177          3.0080               1               1               2               4               6
465.....................................             227          2.8770               1               1               1               3               5
466.....................................            1824          4.0780               1               1               2               4               7
467.....................................            1063          8.4440               1               1               2               3               6
468.....................................           57546         12.8910               3               6              10              16              25
471.....................................           12545          5.5070               3               3               4               6               9
473.....................................            8303         12.3500               1               3               7              17              32
475.....................................          104500         11.2180               2               5               9              15              22
476.....................................            3821         11.2580               2               5              10              15              21
477.....................................           25818          8.1450               1               3               6              11              17
478.....................................          109191          7.3850               1               3               5               9              16
479.....................................           24297          3.3010               1               1               3               4               7
480.....................................             649         21.7670               7               9              14              28              51
481.....................................             750         22.0970              13              17              20              25              34
482.....................................            5619         13.2190               4               7              10              16              25
483.....................................           43462         39.9080              15              22              33              49              72
484.....................................             331         13.0510               2               5              10              18              27
485.....................................            3084          9.4890               4               5               7              11              18
486.....................................            1988         12.2010               1               5              10              16              25
487.....................................            3690          7.6740               1               3               6              10              16
488.....................................             782         16.8530               3               6              13              22              35
489.....................................           13676          8.5500               2               3               6              10              18
490.....................................            5331          5.2610               1               2               4               6              10
491.....................................           13680          3.4640               1               2               3               4               6
492.....................................            2898         15.0290               2               5               7              25              34
493.....................................           58389          5.8760               1               3               5               7              11
494.....................................           31161          2.4740               1               1               2               3               5
495.....................................             215         17.3070               8              10              13              20              31
496.....................................            1866          9.4750               3               4               7              11              19
497.....................................           20076          6.5420               3               4               5               7              11
498.....................................           14808          4.1250               2               3               4               5               6
499.....................................           32826          4.6350               1               2               3               6               9
500.....................................           49835          2.4640               1               1               2               3               5
501.....................................            2366         10.6200               4               5               8              13              20
502.....................................             643          6.3840               2               4               5               7              11
503.....................................            5941          3.8850               1               2               3               5               7
504.....................................             124         34.7980               9              15              27              44              66
505.....................................             149          3.7250               1               1               1               5               9
506.....................................             939         17.2470               4               8              14              22              36
507.....................................             289          8.9790               2               4               7              12              18
508.....................................             667          8.2220               2               3               6              10              17
509.....................................             179          5.6200               1               2               5               7              10
510.....................................            1679          6.6240               1               3               5               8              13
511.....................................             622          4.3750               1               1               3               5               9
512.....................................             481         14.4570               6               8              11              16              25
513.....................................             152         10.7570               5               7               9              11              20
514.....................................           19636          7.3000               1               3               6              10              15
515.....................................            4638          5.5020               1               1               3               7              13
516.....................................           76643          4.7310               2               2               4               6               9
517.....................................          192533          2.6120               1               1               2               3               6
518.....................................           51888          3.3920               1               1               2               4               7
519.....................................            7288          5.1560               1               2               3               6              12
520.....................................           11196          2.1150               1               1               2               2               4
521.....................................           28838          5.7890               2               3               4               7              12
522.....................................            6195          9.4550               3               4               8              12              20
523.....................................           15001          4.0880               1               2               3               5               7
                                         ----------------

[[Page 50256]]

 
                                                11483663
--------------------------------------------------------------------------------------------------------------------------------------------------------


                                Table 7B.--Medicare Prospective Payment System Selected Percentile Lengths of Stay (LOS)
                                                    [FY 2001 MEDPAR Update March 2002 Grouper V20.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                             Number of      Arithmetic         10th            25th            50th            75th            90th
                   DRG                      discharges       mean LOS       percentile      percentile      percentile      percentile      percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1.......................................           27930         11.1260               3               5               8              14              22
2.......................................           14166          5.2220               1               3               4               7              10
3.......................................               7          7.4290               1               1               3               4              10
4.......................................            6510          7.1900               1               2               5               9              16
5.......................................           93559          3.0670               1               1               2               3               7
6.......................................             398          2.9200               1               1               2               4               6
7.......................................           14289          9.7760               1               4               7              12              20
8.......................................            4389          2.7520               1               1               1               3               6
9.......................................            1755          6.4550               1               3               5               8              13
10......................................           18163          6.5160               2               3               5               8              13
11......................................            3444          4.0010               1               2               3               5               8
12......................................           49862          5.8770               2               3               4               7              11
13......................................            6731          5.0160               2               3               4               6               9
14......................................          236626          6.0820               2               3               5               7              12
15......................................          102255          4.9520               2               3               4               6               9
16......................................            9310          6.1410               2               3               5               8              12
17......................................            2882          3.1380               1               1               2               4               6
18......................................           28194          5.4260               2               3               4               7              10
19......................................            8749          3.5380               1               2               3               5               7
20......................................            5666         10.4560               3               5               8              13              20
21......................................            1445          6.5690               2               3               5               8              13
22......................................            2737          5.0080               2               2               4               6              10
23......................................           11274          4.2370               1               2               3               5               8
24......................................           55738          4.8890               1               2               4               6              10
25......................................           27443          3.2300               1               2               3               4               6
26......................................              35          4.6290               1               1               2               4               6
27......................................            3897          5.0160               1               1               3               6              11
28......................................           12468          6.2410               1               3               5               8              13
29......................................            4987          3.5570               1               2               3               5               7
31......................................            3887          4.0710               1               2               3               5               8
32......................................            1940          2.4380               1               1               2               3               5
34......................................           22860          5.0270               1               2               4               6               9
35......................................            7575          3.2120               1               1               3               4               6
36......................................            2513          1.4700               1               1               1               1               2
37......................................            1437          3.8040               1               1               2               4               8
38......................................              93          2.4950               1               1               1               3               6
39......................................             671          1.9400               1               1               1               2               4
40......................................            1534          3.6140               1               1               2               5               8
42......................................            1951          2.3660               1               1               1               3               5
43......................................             111          3.0270               1               1               2               4               6
44......................................            1302          5.0340               2               3               4               6               9
45......................................            2619          3.2440               1               2               3               4               6
46......................................            3394          4.5840               1               2               4               6               9
47......................................            1359          3.1660               1               1               3               4               6
48......................................               1          2.0000               2               2               2               2               2
49......................................            2347          4.6230               1               2               3               5               9
50......................................            2492          1.8210               1               1               1               2               3
51......................................             254          3.1260               1               1               1               3               7
52......................................             242          1.9130               1               1               1               2               3
53......................................            2528          3.3780               1               1               2               4               8
54......................................               1          4.0000               4               4               4               4               4
55......................................            1583          3.0580               1               1               1               3               6
56......................................             535          2.9780               1               1               2               3               6
57......................................             696          3.7400               1               1               2               4               8
59......................................             129          2.6740               1               1               1               3               6
60......................................               6          3.3330               1               1               2               5               5
61......................................             244          4.7830               1               1               3               6              10
62......................................               3          1.6670               1               1               1               3               3
63......................................            2951          4.4780               1               1               3               6               9
64......................................            3168          6.5990               1               2               4               8              14
65......................................           39160          2.7980               1               1               2               3               5

[[Page 50257]]

 
66......................................            7719          3.1100               1               1               2               4               6
67......................................             441          3.5940               1               2               3               4               6
68......................................            8805          3.8300               1               2               3               5               7
69......................................            3059          2.9940               1               2               2               4               5
70......................................              25          3.4800               1               2               3               4               8
71......................................              87          3.4370               1               2               3               4               6
72......................................             934          3.5630               1               1               3               4               7
73......................................            7115          4.3800               1               2               3               6               9
75......................................           40165         10.0590               3               5               7              12              20
76......................................           41905         11.4330               3               5               9              14              22
77......................................            2458          4.8650               1               2               4               7              10
78......................................           35476          6.6620               3               4               6               8              11
79......................................          166958          8.5080               3               4               7              11              16
80......................................            8364          5.4950               2               3               5               7              10
81......................................               2          8.0000               3               3              13              13              13
82......................................           63860          6.9900               2               3               6               9              14
83......................................            6521          5.4790               2               3               4               7              10
84......................................            1602          3.2040               1               2               3               4               6
85......................................           21367          6.3180               2               3               5               8              12
86......................................            2192          3.8090               1               2               3               5               8
87......................................           59754          6.3130               1               3               5               8              12
88......................................          398448          5.1060               2               3               4               6               9
89......................................          504650          5.8910               2               3               5               7              11
90......................................           47050          4.0300               2               2               3               5               7
91......................................              55          4.0180               2               2               3               5               9
92......................................           14891          6.3630               2               3               5               8              12
93......................................            1721          4.1100               1               2               3               5               8
94......................................           12688          6.3310               2               3               5               8              13
95......................................            1704          3.7280               1               2               3               5               7
96......................................           54007          4.5510               2               2               4               6               8
97......................................           28779          3.5190               1               2               3               4               6
98......................................              15          5.0000               1               2               3               4              13
99......................................           21402          3.1730               1               1               2               4               6
100.....................................            9013          2.1320               1               1               2               3               4
101.....................................           21303          4.3870               1               2               3               6               9
102.....................................            5618          2.5720               1               1               2               3               5
103.....................................             453         51.8520               9              14              27              64             130
104.....................................           19595         14.4100               6               8              12              17              25
105.....................................           27398          9.9560               5               6               8              11              18
106.....................................            3320         11.4070               5               7              10              14              20
107.....................................           86073         10.4600               5               7               9              12              17
108.....................................            6235         10.2790               3               5               8              13              20
109.....................................           59810          7.7310               4               5               6               9              13
110.....................................           53439          9.0380               2               4               7              11              18
111.....................................            9446          4.4130               1               2               4               6               8
113.....................................           41687         12.4870               4               6               9              15              24
114.....................................            8909          8.5190               2               4               7              11              17
115.....................................           15348          8.2670               1               4               7              11              16
116.....................................          109696          4.4720               1               2               3               6               9
117.....................................            4196          4.1630               1               1               2               5              10
118.....................................            8135          2.8930               1               1               1               3               7
119.....................................            1322          5.1060               1               1               3               6              12
120.....................................           37631          8.7880               1               2               6              11              20
121.....................................          167946          6.3300               2               3               5               8              12
122.....................................           82148          3.6130               1               2               3               5               7
123.....................................           41344          4.7020               1               1               3               6              11
124.....................................          138962          4.3690               1               2               3               6               8
125.....................................           90577          2.7430               1               1               2               4               5
126.....................................            5061         11.9020               4               6               9              15              22
127.....................................          684796          5.2710               2               3               4               7              10
128.....................................            8303          5.4670               2               3               5               7               9
129.....................................            4150          2.8310               1               1               1               3               6
130.....................................           89193          5.6610               2               3               5               7              10
131.....................................           27944          4.0540               1               2               4               5               7
132.....................................          152950          2.9290               1               1               2               4               5
133.....................................            8979          2.2630               1               1               2               3               4
134.....................................           39813          3.1770               1               2               2               4               6
135.....................................            7584          4.4210               1               2               3               5               8
136.....................................            1243          2.5710               1               1               2               3               5
138.....................................          204244          3.9830               1               2               3               5               8

[[Page 50258]]

 
139.....................................           90369          2.4820               1               1               2               3               5
140.....................................           66769          2.5570               1               1               2               3               5
141.....................................          102878          3.5910               1               2               3               4               7
142.....................................           51988          2.5540               1               1               2               3               5
143.....................................          251435          2.0830               1               1               2               3               4
144.....................................           89218          5.4560               1               2               4               7              11
145.....................................            7647          2.6530               1               1               2               3               5
146.....................................           10845         10.2150               5               7               8              12              17
147.....................................            2812          6.3970               3               5               6               8              10
148.....................................          130042         12.2930               5               7              10              15              22
149.....................................           19445          6.4620               4               5               6               8              10
150.....................................           20434         11.2310               4               7              10              14              20
151.....................................            5000          5.6690               1               3               5               8              10
152.....................................            4436          8.3290               3               5               7              10              14
153.....................................            2027          5.3860               3               4               5               7               8
154.....................................           29150         13.2280               3               7              10              16              26
155.....................................            7319          3.9840               1               2               3               6               8
156.....................................               3         15.0000              11              11              13              21              21
157.....................................            8205          5.5530               1               2               4               7              11
158.....................................            4604          2.5160               1               1               2               3               5
159.....................................           17212          5.0630               1               2               4               6              10
160.....................................           12260          2.6480               1               1               2               3               5
161.....................................           11221          4.1550               1               1               3               5               9
162.....................................            7337          1.9150               1               1               1               2               4
163.....................................               3          3.0000               1               1               3               5               5
164.....................................            5142          8.2640               3               5               7              10              14
165.....................................            2201          4.6460               2               3               4               6               8
166.....................................            3935          4.8750               1               2               4               6               9
167.....................................            3833          2.5130               1               1               2               3               4
168.....................................            1409          4.8810               1               2               3               6              10
169.....................................             887          2.3160               1               1               2               3               5
170.....................................           15002         11.0580               2               5               8              14              22
171.....................................            1472          4.2760               1               2               3               6               8
172.....................................           30816          6.9650               2               3               5               9              14
173.....................................            2736          3.7380               1               1               3               5               8
174.....................................          248283          4.8070               2               3               4               6               9
175.....................................           35359          2.9190               1               2               3               4               5
176.....................................           15279          5.2510               2               3               4               6              10
177.....................................            9466          4.5110               2               2               4               6               8
178.....................................            3770          3.0770               1               2               3               4               6
179.....................................           12641          5.9620               2               3               5               7              11
180.....................................           88694          5.3720               2               3               4               7              10
181.....................................           27227          3.3760               1               2               3               4               6
182.....................................          262087          4.3630               1               2               3               5               8
183.....................................           91760          2.8830               1               1               2               4               5
184.....................................              94          2.8400               1               1               2               4               6
185.....................................            5155          4.6870               1               2               3               6               9
186.....................................               3          4.6670               2               2               3               9               9
187.....................................             698          4.1790               1               2               3               6               8
188.....................................           79822          5.5600               1               2               4               7              11
189.....................................           13196          3.0550               1               1               2               4               6
190.....................................              78          4.7690               1               2               3               5               8
191.....................................            9286         13.7420               3               6              10              17              28
192.....................................            1267          6.1130               1               3               5               8              11
193.....................................            4893         12.7480               5               7              10              16              23
194.....................................             738          6.8510               2               4               6               8              12
195.....................................            4171         10.3630               4               6               9              12              18
196.....................................            1056          5.4220               2               3               5               7               9
197.....................................           18696          8.9790               3               5               7              11              16
198.....................................            5707          4.4310               2               3               4               6               8
199.....................................            1663          9.9180               2               4               7              13              21
200.....................................            1049         10.4500               1               3               7              14              22
201.....................................            2020         14.5070               4               6              11              18              29
202.....................................           26324          6.3730               2               3               5               8              13
203.....................................           29515          6.7410               2               3               5               9              13
204.....................................           61935          5.8110               2               3               4               7              11
205.....................................           24648          6.1690               2               3               5               8              12
206.....................................            2068          3.9160               1               2               3               5               8
207.....................................           32279          5.1810               1               2               4               7              10
208.....................................           10815          2.8610               1               1               2               4               5

[[Page 50259]]

 
209.....................................          373009          4.9900               3               3               4               6               8
210.....................................          122166          6.8910               3               4               6               8              11
211.....................................           32764          4.9270               3               4               5               6               7
212.....................................               7          3.2860               1               2               2               2               4
213.....................................            9936          9.1390               2               4               7              11              18
216.....................................            6966          9.5420               2               4               7              12              19
217.....................................           17192         13.4090               3               5               9              16              28
218.....................................           23017          5.4590               2               3               4               7              10
219.....................................           21116          3.2120               1               2               3               4               5
220.....................................               1          2.0000               2               2               2               2               2
223.....................................           13773          2.8810               1               1               2               3               6
224.....................................           12585          1.8630               1               1               1               2               3
225.....................................            6183          5.0260               1               2               3               7              11
226.....................................            5746          6.6640               1               3               5               8              14
227.....................................            4975          2.6700               1               1               2               3               5
228.....................................            2509          4.0880               1               1               2               5               9
229.....................................            1194          2.2140               1               1               2               3               4
230.....................................            2432          5.0670               1               2               3               6              11
231.....................................           12627          4.8920               1               1               3               6              11
232.....................................             885          2.7380               1               1               1               3               7
233.....................................            7875          7.7800               1               3               6              10              16
234.....................................            4676          3.1670               1               1               2               4               7
235.....................................            5116          5.0300               1               2               4               6               9
236.....................................           40046          4.7420               1               3               4               6               9
237.....................................            1761          3.6000               1               2               3               4               7
238.....................................            8678          8.8670               3               4               7              11              17
239.....................................           48474          6.2820               2               3               5               8              12
240.....................................           11901          6.7280               2               3               5               8              13
241.....................................            3252          3.8840               1               2               3               5               7
242.....................................            2531          6.5780               2               3               5               8              13
243.....................................           94344          4.6810               1               2               4               6               9
244.....................................           13655          4.7310               1               2               4               6               9
245.....................................            5760          3.3620               1               2               3               4               6
246.....................................            1350          3.7580               1               2               3               5               7
247.....................................           19731          3.3700               1               1               3               4               7
248.....................................           12158          4.8690               1               2               4               6               9
249.....................................           12733          3.6440               1               1               2               4               7
250.....................................            3838          4.1640               1               2               3               5               7
251.....................................            2517          2.7750               1               1               2               4               5
253.....................................           21017          4.6730               1               3               4               6               9
254.....................................           10910          3.1320               1               2               3               4               6
255.....................................               1          2.0000               2               2               2               2               2
256.....................................            6435          5.1150               1               2               4               6              10
257.....................................           16786          2.6640               1               1               2               3               5
258.....................................           17062          1.8180               1               1               2               2               3
259.....................................            3835          2.6770               1               1               1               2               6
260.....................................            5111          1.3670               1               1               1               1               2
261.....................................            1927          2.1650               1               1               1               2               4
262.....................................             688          4.2920               1               1               3               5              10
263.....................................           24727         11.8360               3               5               8              14              23
264.....................................            4016          6.9110               2               3               5               8              14
265.....................................            4092          6.7790               1               2               4               8              14
266.....................................            2697          3.1350               1               1               2               4               6
267.....................................             272          4.2170               1               1               2               4               8
268.....................................             925          3.5950               1               1               2               4               8
269.....................................            9738          8.4120               2               3               6              11              17
270.....................................            2865          3.3910               1               1               2               4               7
271.....................................           19734          7.2900               2               4               6               9              13
272.....................................            5508          6.1320               2               3               5               7              12
273.....................................            1389          3.9270               1               2               3               5               7
274.....................................            2368          6.7490               1               3               5               8              14
275.....................................             255          3.0120               1               1               2               4               6
276.....................................            1337          4.5030               1               2               4               6               8
277.....................................           94462          5.7610               2               3               5               7              10
278.....................................           31992          4.2750               2               3               4               5               7
279.....................................               4          6.7500               3               3               6               8              10
280.....................................           17235          4.1620               1               2               3               5               8
281.....................................            7951          2.9070               1               1               2               4               5
283.....................................            5674          4.6490               1               2               4               6               9
284.....................................            1960          3.0550               1               1               2               4               6

[[Page 50260]]

 
285.....................................            6641         10.6710               3               5               8              13              20
286.....................................            2193          5.9450               2               3               4               7              11
287.....................................            6513         10.5590               3               5               8              12              20
288.....................................            3757          5.3890               2               3               4               6               8
289.....................................            6449          2.8110               1               1               1               3               6
290.....................................            9553          2.2290               1               1               1               2               4
291.....................................              78          1.6030               1               1               1               2               3
292.....................................            6125         10.6910               2               4               8              14              22
293.....................................             371          5.0650               1               2               3               7              11
294.....................................           95967          4.5380               1               2               3               6               9
295.....................................            3387          3.9770               1               2               3               5               7
296.....................................          252270          5.1150               1               2               4               6              10
297.....................................           47995          3.3570               1               2               3               4               6
298.....................................             109          4.2750               1               2               3               5               7
299.....................................            1225          5.3900               1               2               4               6              10
300.....................................           17627          6.1590               2               3               5               8              12
301.....................................            3661          3.6680               1               2               3               5               7
302.....................................            8130          8.6850               4               5               7              10              15
303.....................................           20806          8.2750               3               4               6               9              15
304.....................................           12148          8.6900               2               4               6              11              18
305.....................................            3033          3.6060               1               2               3               5               6
306.....................................            7239          5.4920               1               2               3               7              13
307.....................................            2175          2.1990               1               1               2               3               4
308.....................................            7283          6.2730               1               2               4               8              14
309.....................................            4356          2.1520               1               1               2               3               4
310.....................................           24716          4.3420               1               1               3               5               9
311.....................................            8387          1.8230               1               1               1               2               3
312.....................................            1557          4.4950               1               1               3               6              10
313.....................................             646          2.1250               1               1               1               2               4
314.....................................               1          5.0000               5               5               5               5               5
315.....................................           34008          7.2120               1               1               4               9              17
316.....................................          115890          6.5900               2               3               5               8              13
317.....................................            1913          3.0910               1               1               2               3               7
318.....................................            5785          6.0350               1               3               4               8              12
319.....................................             503          2.8330               1               1               2               3               6
320.....................................          194230          5.3020               2               3               4               7              10
321.....................................           30917          3.7520               1               2               3               5               7
322.....................................              68          3.7350               1               2               3               5               7
323.....................................           18745          3.1420               1               1               2               4               6
324.....................................            7509          1.8440               1               1               1               2               3
325.....................................            8989          3.7900               1               2               3               5               7
326.....................................            2820          2.6710               1               1               2               3               5
327.....................................               2          2.5000               1               1               4               4               4
328.....................................             690          3.7720               1               1               3               5               7
329.....................................             105          2.2000               1               1               1               2               5
331.....................................           49529          5.5840               1               3               4               7              11
332.....................................            5171          3.1690               1               1               2               4               6
333.....................................             321          4.6980               1               2               3               6              10
334.....................................           10358          4.7820               2               3               4               5               8
335.....................................           12477          3.1770               2               2               3               4               5
336.....................................           36484          3.4270               1               2               2               4               7
337.....................................           29676          2.0680               1               1               2               2               3
338.....................................            1057          5.5560               1               2               3               8              13
339.....................................            1518          4.6420               1               1               3               6              10
340.....................................               1          1.0000               1               1               1               1               1
341.....................................            3693          3.0630               1               1               2               3               6
342.....................................             726          3.1640               1               1               2               4               6
343.....................................               1          5.0000               5               5               5               5               5
344.....................................            3852          2.3750               1               1               1               2               5
345.....................................            1343          4.7770               1               1               3               6              11
346.....................................            4590          6.0320               1               3               5               8              12
347.....................................             379          2.6830               1               1               2               3               6
348.....................................            3308          4.1570               1               2               3               5               8
349.....................................             605          2.4740               1               1               2               3               5
350.....................................            6535          4.5040               2               2               4               6               8
351.....................................               1          1.0000               1               1               1               1               1
352.....................................             774          3.9810               1               2               3               5               8
353.....................................            2685          6.4640               2               3               5               7              12
354.....................................            7532          5.8240               3               3               4               7              10
355.....................................            5709          3.2350               2               2               3               4               5

[[Page 50261]]

 
356.....................................           26094          2.1720               1               1               2               3               4
357.....................................            5753          8.4210               3               4               6              10              16
358.....................................           20771          4.3060               2               3               3               5               7
359.....................................           31334          2.6370               1               2               3               3               4
360.....................................           15680          2.8180               1               2               2               3               5
361.....................................             371          3.6500               1               1               2               4               8
362.....................................               4          1.2500               1               1               1               1               2
363.....................................            2701          3.6410               1               2               2               4               7
364.....................................            1643          3.8820               1               1               3               5               8
365.....................................            1863          7.7040               2               3               5              10              17
366.....................................            4469          6.8500               2               3               5               9              14
367.....................................             526          3.0080               1               1               2               4               6
368.....................................            3302          6.7190               2               3               5               8              13
369.....................................            3304          3.1880               1               1               2               4               6
370.....................................            1286          5.6890               3               3               4               5               9
371.....................................            1479          3.5800               2               3               3               4               5
372.....................................             939          3.7150               1               2               2               3               5
373.....................................            3974          2.2870               1               2               2               3               3
374.....................................             122          2.8770               1               2               2               3               5
375.....................................               8          5.2500               1               3               5               5               9
376.....................................             266          3.5080               1               2               2               4               6
377.....................................              31          4.1940               1               2               3               4               7
378.....................................             173          2.4800               1               1               2               3               5
379.....................................             416          2.9760               1               1               2               3               6
380.....................................              81          1.9750               1               1               1               2               4
381.....................................             187          2.1230               1               1               1               3               4
382.....................................              27          1.3330               1               1               1               1               2
383.....................................            1881          3.9530               1               1               3               4               8
384.....................................             156          2.7820               1               1               1               3               6
386.....................................               1        119.0000             119             119             119             119             119
389.....................................               7          8.7140               1               2               4               8              10
390.....................................               8          2.7500               1               1               1               4               5
392.....................................            2275          9.5310               2               4               7              12              20
393.....................................               1          2.0000               2               2               2               2               2
394.....................................            2349          7.0870               1               2               5               9              15
395.....................................          101315          4.3510               1               2               3               5               9
396.....................................              11          3.8180               1               1               2               4               6
397.....................................           18036          5.1720               1               2               4               7              10
398.....................................           17243          5.8910               2               3               5               7              11
399.....................................            1806          3.5480               1               2               3               5               7
400.....................................            6533          8.9770               1               3               6              11              20
401.....................................            5878         11.2420               2               5               9              15              23
402.....................................            1606          3.8890               1               1               3               5               8
403.....................................           32232          8.0040               2               3               6              10              17
404.....................................            4627          4.1950               1               2               3               5               9
406.....................................            2508          9.7210               2               4               7              12              20
407.....................................             704          4.1210               1               2               3               5               8
408.....................................            2142          7.8730               1               2               5              10              18
409.....................................            2534          6.1220               2               3               4               6              12
410.....................................           30971          4.0150               1               2               4               5               6
411.....................................              14          2.9290               1               1               2               4               6
412.....................................              18          2.0000               1               1               1               2               4
413.....................................            5811          7.3080               2               3               6               9              14
414.....................................             771          4.0100               1               2               3               5               8
415.....................................           40210         14.5010               4               6              11              18              29
416.....................................          181965          7.4660               2               4               6               9              15
417.....................................              41          6.1710               1               2               4               8              14
418.....................................           23577          6.1810               2               3               5               8              12
419.....................................           15866          4.6500               1               2               4               6               9
420.....................................            2980          3.4310               1               2               3               4               6
421.....................................            9327          3.7870               1               2               3               4               7
422.....................................              70          2.9570               1               1               2               3               6
423.....................................            7327          8.2410               2               3               6              10              17
424.....................................            1308         12.9440               2               5               9              16              26
425.....................................           16394          3.8990               1               2               3               5               8
426.....................................            4535          4.4740               1               2               3               5               9
427.....................................            1609          4.4410               1               2               3               5               9
428.....................................             757          7.3750               1               2               4               8              15
429.....................................           27186          6.1440               2               3               4               7              12
430.....................................           63771          7.9550               2               3               6              10              16

[[Page 50262]]

 
431.....................................             328          5.9390               1               2               4               7              13
432.....................................             423          4.5820               1               1               3               5               9
433.....................................            5584          2.9750               1               1               2               3               6
439.....................................            1473          8.5030               1               3               6              10              17
440.....................................            5503          9.0500               2               3               6              11              20
441.....................................             625          3.0740               1               1               2               4               7
442.....................................           16855          8.5610               1               3               6              10              18
443.....................................            3849          3.5180               1               1               3               4               7
444.....................................            5747          4.3170               1               2               3               5               8
445.....................................            2784          2.8980               1               1               2               4               5
447.....................................            6305          2.4430               1               1               2               3               5
448.....................................               1          1.0000               1               1               1               1               1
449.....................................           30763          3.6800               1               1               3               4               8
450.....................................            7473          1.9840               1               1               1               2               4
451.....................................               5          1.6000               1               1               2               2               2
452.....................................           25447          5.0230               1               2               3               6              10
453.....................................            5690          2.7650               1               1               2               3               5
454.....................................            4688          4.3390               1               2               3               5               9
455.....................................            1114          2.3700               1               1               2               3               5
461.....................................            4611          4.1010               1               1               2               4              10
462.....................................           12023         11.3750               4               6              10              14              21
463.....................................           25420          4.1700               1               2               3               5               8
464.....................................            7177          3.0080               1               1               2               4               6
465.....................................             227          2.8770               1               1               1               3               5
466.....................................            1824          4.0780               1               1               2               4               7
467.....................................            1063          8.4440               1               1               2               3               6
468.....................................           50164         12.9990               3               6              10              17              25
471.....................................           12545          5.5070               3               3               4               6               9
473.....................................            8303         12.3500               1               3               7              17              32
475.....................................          104500         11.2180               2               5               9              15              22
476.....................................            3821         11.2580               2               5              10              15              21
477.....................................           25809          8.1370               1               3               6              11              17
478.....................................          109191          7.3850               1               3               5               9              16
479.....................................           24297          3.3010               1               1               3               4               7
480.....................................             649         21.7670               7               9              14              28              51
481.....................................             750         22.0970              13              17              20              25              34
482.....................................            5372         12.5700               4               7               9              15              24
483.....................................           43709         39.8370              14              22              33              49              71
484.....................................             331         13.0510               2               5              10              18              27
485.....................................            3084          9.4890               4               5               7              11              18
486.....................................            1988         12.2010               1               5              10              16              25
487.....................................            3690          7.6740               1               3               6              10              16
488.....................................             782         16.8530               3               6              13              22              35
489.....................................           13676          8.5500               2               3               6              10              18
490.....................................            5329          5.2600               1               2               4               6              10
491.....................................           13680          3.4640               1               2               3               4               6
492.....................................            2898         15.0290               2               5               7              25              34
493.....................................           58389          5.8760               1               3               5               7              11
494.....................................           31161          2.4740               1               1               2               3               5
495.....................................             215         17.3070               8              10              13              20              31
496.....................................            1866          9.4750               3               4               7              11              19
497.....................................           20076          6.5420               3               4               5               7              11
498.....................................           14808          4.1250               2               3               4               5               6
499.....................................           32826          4.6350               1               2               3               6               9
500.....................................           49835          2.4640               1               1               2               3               5
501.....................................            2366         10.6200               4               5               8              13              20
502.....................................             643          6.3840               2               4               5               7              11
503.....................................            5941          3.8850               1               2               3               5               7
504.....................................             124         34.7980               9              15              27              44              66
505.....................................             149          3.7250               1               1               1               5               9
506.....................................             939         17.2470               4               8              14              22              36
507.....................................             289          8.9790               2               4               7              12              18
508.....................................             667          8.2220               2               3               6              10              17
509.....................................             179          5.6200               1               2               5               7              10
510.....................................            1679          6.6240               1               3               5               8              13
511.....................................             622          4.3750               1               1               3               5               9
512.....................................             481         14.4570               6               8              11              16              25
513.....................................             152         10.7570               5               7               9              11              20
514.....................................           19636          7.3000               1               3               6              10              15
515.....................................            4638          5.5020               1               1               3               7              13

[[Page 50263]]

 
516.....................................           61977          4.7310               2               2               4               6               9
517.....................................          151552          2.6120               1               1               2               3               6
518.....................................           51888          3.3920               1               1               2               4               7
519.....................................            7288          5.1560               1               2               3               6              12
520.....................................           11196          2.1150               1               1               2               2               4
521.....................................           28838          5.7890               2               3               4               7              12
522.....................................            6195          9.4550               3               4               8              12              20
523.....................................           15001          4.0880               1               2               3               5               7
524.....................................          137407          3.3970               1               2               3               4               6
525.....................................             497         16.3000               2               5               9              18              36
526.....................................           14666            N.A.            N.A.            N.A.            N.A.            N.A.            N.A.
527.....................................           40981            N.A.            N.A.            N.A.            N.A.            N.A.            N.A.
                                         ----------------
                                                11483663
--------------------------------------------------------------------------------------------------------------------------------------------------------


 Table 8A.--Statewide Average Operating Cost-to-Charge Ratios for Urban
              and Rural Hospitals (Case Weighted) July 2002
------------------------------------------------------------------------
                        State                           Urban     Rural
------------------------------------------------------------------------
ALABAMA.............................................     0.338     0.395
ALASKA..............................................     0.408     0.676
ARIZONA.............................................     0.345     0.473
ARKANSAS............................................     0.430     0.435
CALIFORNIA..........................................     0.328     0.412
COLORADO............................................     0.411     0.532
CONNECTICUT.........................................     0.494     0.509
DELAWARE............................................     0.516     0.484
DISTRICT OF COLUMBIA................................     0.415
FLORIDA.............................................     0.343     0.358
GEORGIA.............................................     0.457     0.453
HAWAII..............................................     0.410     0.519
IDAHO...............................................     0.558     0.543
ILLINOIS............................................     0.392     0.487
INDIANA.............................................     0.488     0.526
IOWA................................................     0.471     0.596
KANSAS..............................................     0.380     0.587
KENTUCKY............................................     0.477     0.487
LOUISIANA...........................................     0.389     0.482
MAINE...............................................     0.580     0.517
MARYLAND............................................     0.759     0.821
MASSACHUSETTS.......................................     0.514     0.560
MICHIGAN............................................     0.460     0.562
MINNESOTA...........................................     0.460     0.585
MISSISSIPPI.........................................     0.444     0.424
MISSOURI............................................     0.397     0.474
MONTANA.............................................     0.504     0.536
NEBRASKA............................................     0.428     0.547
NEVADA..............................................     0.282     0.473
NEW HAMPSHIRE.......................................     0.524     0.587
NEW JERSEY..........................................     0.356
NEW MEXICO..........................................     0.472     0.516
NEW YORK............................................     0.487     0.595
NORTH CAROLINA......................................     0.512     0.465
NORTH DAKOTA........................................     0.609     0.555
OHIO................................................     0.492     0.566
OKLAHOMA............................................     0.390     0.474
OREGON..............................................     0.545     0.577
PENNSYLVANIA........................................     0.375     0.499
PUERTO RICO.........................................     0.470     0.561
RHODE ISLAND........................................     0.486
SOUTH CAROLINA......................................     0.438     0.456
SOUTH DAKOTA........................................     0.490     0.552
TENNESSEE...........................................     0.429     0.457
TEXAS...............................................     0.381     0.483
UTAH................................................     0.495     0.584
VERMONT.............................................     0.580     0.599
VIRGINIA............................................     0.451     0.543
WASHINGTON..........................................     0.581     0.595
WEST VIRGINIA.......................................     0.569     0.549
WISCONSIN...........................................     0.518     0.595
WYOMING.............................................     0.446     0.614
------------------------------------------------------------------------


    Table 8B.--Statewide Average Capital Cost-to-Charge Ratios (Case
                           Weighted) July 2002
------------------------------------------------------------------------
                             State                                Ratio
------------------------------------------------------------------------
ALABAMA.......................................................     0.042
ALASKA........................................................     0.053
ARIZONA.......................................................     0.037
ARKANSAS......................................................     0.045
CALIFORNIA....................................................     0.032
COLORADO......................................................     0.046
CONNECTICUT...................................................     0.036
DELAWARE......................................................     0.048
DISTRICT OF COLUMBIA..........................................     0.033
FLORIDA.......................................................     0.041
GEORGIA.......................................................     0.048
HAWAII........................................................     0.039
IDAHO.........................................................     0.047
ILLINOIS......................................................     0.039
INDIANA.......................................................     0.050
IOWA..........................................................     0.047
KANSAS........................................................     0.047
KENTUCKY......................................................     0.046
LOUISIANA.....................................................     0.045
MAINE.........................................................     0.037
MARYLAND......................................................     0.013
MASSACHUSETTS.................................................     0.050
MICHIGAN......................................................     0.044
MINNESOTA.....................................................     0.042
MISSISSIPPI...................................................     0.042
MISSOURI......................................................     0.042
MONTANA.......................................................     0.051
NEBRASKA......................................................     0.047
NEVADA........................................................     0.031
NEW HAMPSHIRE.................................................     0.059
NEW JERSEY....................................................     0.031
NEW MEXICO....................................................     0.045
NEW YORK......................................................     0.048
NORTH CAROLINA................................................     0.047
NORTH DAKOTA..................................................     0.068
OHIO..........................................................     0.047
OKLAHOMA......................................................     0.043
OREGON........................................................     0.042
PENNSYLVANIA..................................................     0.037
PUERTO RICO...................................................     0.041
RHODE ISLAND..................................................     0.031
SOUTH CAROLINA................................................     0.046
SOUTH DAKOTA..................................................     0.051
TENNESSEE.....................................................     0.049
TEXAS.........................................................     0.043
UTAH..........................................................     0.046
VERMONT.......................................................     0.049
VIRGINIA......................................................     0.056
WASHINGTON....................................................     0.067
WEST VIRGINIA.................................................     0.045
WISCONSIN.....................................................     0.050
WYOMING.......................................................     0.055
------------------------------------------------------------------------


[[Page 50264]]


             Table 9.--Hospital Reclassifications and Redesignations by Individual Hospital--FY 2003
----------------------------------------------------------------------------------------------------------------
                                                                                                  Standardized
                       Provider No.                           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
010072....................................................                01              0450              0450
010101....................................................                01              0450              0450
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  ................
050228....................................................              7360              5775  ................
050230....................................................              5945              4480  ................
050236....................................................              8735              4480  ................
050296....................................................                05              7120  ................
050301....................................................                05              7500  ................
050325....................................................                05              5170  ................
050335....................................................                05              5170  ................
050419....................................................                05              6690  ................
050457....................................................              7360              5775  ................
050464....................................................              5170              8120  ................
050494....................................................                05              6920  ................
050510....................................................              7360              5775  ................
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  ................

[[Page 50265]]

 
060023....................................................              2995              6520  ................
060027....................................................              1125              2080              2080
060044....................................................                06              2080  ................
060049....................................................                06              2080  ................
060075....................................................                06              2995  ................
060076....................................................                06              3060  ................
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  ................
100049....................................................                10              3980  ................
100098....................................................                10              8960              8960
100103....................................................                10              3600              3600
100105....................................................                10              2710  ................
100109....................................................                10              5960  ................
100150....................................................                10              5000  ................
100157....................................................              3980              8280  ................
100176....................................................              8960              2710  ................
100217....................................................                10              2710  ................
100232....................................................                10              2900              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  ................
130002....................................................                13                29  ................
130003....................................................                13              6740  ................
130011....................................................                13                50  ................
130049....................................................                13              7840  ................
140012....................................................                14              1600  ................
140015....................................................                14              7040  ................
140031....................................................                14              1400  ................
140032....................................................                14              7040  ................
140034....................................................                14              7040  ................
140040....................................................                14              1960  ................
140043....................................................                14              6880  ................
140046....................................................                14              7040  ................
140058....................................................                14              7880  ................
140064....................................................                14              6120  ................

[[Page 50266]]

 
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              6880  ................
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 50267]]

 
170131....................................................                17  ................              8440
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  ................
190054....................................................                19              3880  ................
190083....................................................                19              5200  ................
190086....................................................                19              5200  ................
190099....................................................                19              3880  ................
190106....................................................                19              3880  ................
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              3000
230054....................................................                23              3080  ................
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
230199....................................................                23              0870              0870
230235....................................................                23              6960              6960
230253....................................................                23              2160  ................
240008....................................................                24              6820  ................

[[Page 50268]]

 
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                01  ................
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  ................
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  ................
270051....................................................                27              5140  ................
270057....................................................                27              0880  ................
270083....................................................                27              5140  ................
280009....................................................                28              4360  ................
280023....................................................                28              4360  ................

[[Page 50269]]

 
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
300019....................................................                30              1123  ................
300024....................................................                30  ................              1123
310001....................................................              0875              5600  ................
310002....................................................              5640              5600  ................
310003....................................................              3640              5600  ................
310015....................................................              5640              0875  ................
310021....................................................              8480              5190  ................
310031....................................................              6160              5190  ................
310038....................................................              5015              5600  ................
310045....................................................              0875              5600  ................
310048....................................................              5015              5640  ................
310049....................................................              3640  ................              5640
310070....................................................              5015              5640  ................
310076....................................................              5640              5600  ................
310087....................................................              8760              6160  ................
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  ................
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  ................

[[Page 50270]]

 
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  ................
360039....................................................                36              1840  ................
360046....................................................              3200              1640  ................
360046....................................................              3200  ................              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  ................
360107....................................................                36              8400  ................
360109....................................................                36              1840  ................
360112....................................................              8400              0440  ................
360121....................................................                36              0440  ................
360132....................................................              3200              1640              1640
360142....................................................                36  ................              1640
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  ................
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  ................

[[Page 50271]]

 
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  ................
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              9280              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  ................
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  ................

[[Page 50272]]

 
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              0320  ................
460007....................................................                46              2620  ................
460011....................................................                46              6520  ................
460021....................................................                46              4120  ................
460027....................................................                46              6520  ................
460032....................................................                46              6520  ................
460036....................................................                46              6520  ................
460039....................................................                46              7160  ................
470001....................................................                47              1303  ................
470003....................................................              1303              1123  ................
470011....................................................                47              1123  ................
470012....................................................                47              6323  ................
470018....................................................                47              1123  ................
490001....................................................                49              3660  ................
490004....................................................                49              1540  ................
490005....................................................                49              8840  ................
490013....................................................                49              4640  ................
490013....................................................                49              4640  ................
490018....................................................                49              4640  ................
490038....................................................                49              3660  ................

[[Page 50273]]

 
490047....................................................                49              8840  ................
490060....................................................                49              3660  ................
490066....................................................              5720              6760  ................
490079....................................................                49              3120  ................
490126....................................................                49              6800  ................
500002....................................................                50              6740  ................
500003....................................................                50              0860  ................
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  ................
----------------------------------------------------------------------------------------------------------------


  Table 10.--Means and Standard Deviations, by Diagnosis Related Groups
                               (DRGs) \1\
------------------------------------------------------------------------
                                                               Mean + 1
                      DRG                          Cases       standard
                                                              deviation
------------------------------------------------------------------------
1.............................................       27,927      $67,404
2.............................................       14,163      $34,673
3.............................................            7      $55,408
4.............................................        6,509      $42,448
5.............................................       93,493      $23,377
6.............................................          398      $14,176
7.............................................       14,289      $47,294
8.............................................        4,388      $28,479
9.............................................        1,755      $24,328
10............................................       18,159      $22,402
11............................................        3,442      $15,623
12............................................       49,827      $15,545
13............................................        6,724      $14,071
14............................................      236,532      $22,079
15............................................      102,208      $17,030
16............................................        9,310      $21,738
17............................................        2,881      $11,621
18............................................       28,178      $17,142
19............................................        8,743      $12,381
20............................................        5,664      $52,181
21............................................        1,445      $27,499
22............................................        2,736      $18,514
23............................................       11,272      $14,333
24............................................       55,718      $17,446
25............................................       27,441      $10,729
26............................................           35      $13,582
27............................................        3,897      $23,356

[[Page 50274]]

 
28............................................       12,463      $23,965
29............................................        4,983      $12,571
31............................................        3,886      $15,438
32............................................        1,938       $9,262
34............................................       22,854      $17,458
35............................................        7,567      $11,230
36............................................        2,500      $11,056
37............................................        1,436      $18,198
38............................................           93       $9,804
39............................................          670      $10,605
40............................................        1,534      $15,129
42............................................        1,949      $11,426
43............................................          111       $8,988
44............................................        1,302      $11,316
45............................................        2,617      $12,432
46............................................        3,392      $13,759
47............................................        1,359       $9,362
49............................................        2,347      $31,479
50............................................        2,487      $14,084
51............................................          254      $16,545
52............................................          241      $13,058
53............................................        2,527      $20,711
55............................................        1,581      $16,320
56............................................          533      $16,518
57............................................          696      $17,549
59............................................          128      $13,267
60............................................            6      $11,274
61............................................          244      $22,144
62............................................            3       $6,890
63............................................        2,951      $25,340
64............................................        3,167      $24,013
65............................................       39,149       $9,556
66............................................        7,717       $9,940
67............................................          440      $13,390
68............................................        8,803      $11,627
69............................................        3,058       $8,692
70............................................           25       $8,204
71............................................           87      $12,273
72............................................          934      $12,534
73............................................        7,112      $13,972
75............................................       40,140      $53,811
76............................................       41,890      $50,645
77............................................        2,458      $21,413
78............................................       35,432      $22,310
79............................................      166,819      $29,146
80............................................        8,348      $15,446
81............................................            2      $17,847
82............................................       63,839      $25,767
83............................................        6,516      $17,174
84............................................        1,601       $8,832
85............................................       21,359      $21,704
86............................................        2,191      $12,369
87............................................       59,718      $24,643
88............................................      398,067      $15,709
89............................................      504,109      $18,189
90............................................       47,012      $10,687
91............................................           55      $12,834
92............................................       14,880      $21,707
93............................................        1,720      $13,033
94............................................       12,685      $20,773
95............................................        1,704      $10,355
96............................................       53,963      $13,061
97............................................       28,764       $9,660
98............................................           15      $16,638
99............................................       21,397      $12,340
100...........................................        9,004       $9,303
101...........................................       21,294      $15,036
102...........................................        5,616       $9,571
103...........................................          453     $367,290
104...........................................       19,589     $131,533
105...........................................       27,384      $95,106
106...........................................        3,319     $121,971
107...........................................       85,921      $86,478
108...........................................        6,230      $96,053
109...........................................       59,743      $64,368
110...........................................       53,431      $71,935
111...........................................        9,445      $42,825
113...........................................       41,664      $49,537
114...........................................        8,907      $29,181
115...........................................       15,346      $58,990
116...........................................      109,614      $38,674
117...........................................        4,196      $23,243
118...........................................        8,129      $27,230
119...........................................        1,322      $22,803
120...........................................       37,629      $39,645
121...........................................      167,925      $27,188
122...........................................       82,126      $17,938
123...........................................       41,332      $28,224
124...........................................      138,910      $24,070
125...........................................       90,494      $18,102
126...........................................        5,060      $48,433
127...........................................      684,227      $17,486
128...........................................        8,288      $12,396
129...........................................        4,144      $19,235
130...........................................       89,165      $16,499
131...........................................       27,920       $9,868
132...........................................      152,896      $11,175
133...........................................        8,967       $9,360
134...........................................       39,803      $10,380
135...........................................        7,582      $15,485
136...........................................        1,243      $10,044
138...........................................      204,170      $14,405
139...........................................       90,329       $8,871
140...........................................       66,747       $9,167
141...........................................      102,861      $12,675
142...........................................       51,974       $9,733
143...........................................      251,298       $9,258
144...........................................       89,188      $21,492
145...........................................        7,643      $10,459
146...........................................       10,841      $46,208
147...........................................        2,810      $26,054
148...........................................      129,948      $59,703
149...........................................       19,421      $24,836
150...........................................       20,430      $49,593
151...........................................        4,999      $22,731
152...........................................        4,435      $33,464
153...........................................        2,026      $19,581
154...........................................       29,142      $74,212
155...........................................        7,318      $21,983
156...........................................            3      $32,555
157...........................................        8,202      $22,136
158...........................................        4,600      $11,003
159...........................................       17,205      $23,466
160...........................................       12,246      $13,619
161...........................................       11,219      $19,197
162...........................................        7,321      $10,715
163...........................................            3       $7,938
164...........................................        5,140      $39,260
165...........................................        2,200      $20,663
166...........................................        3,934      $24,735
167...........................................        3,833      $14,845
168...........................................        1,408      $22,688
169...........................................          887      $12,798
170...........................................       15,000      $50,814
171...........................................        1,472      $20,737
172...........................................       30,796      $24,650
173...........................................        2,735      $13,887
174...........................................      248,141      $17,311
175...........................................       35,336       $9,600
176...........................................       15,273      $18,631
177...........................................        9,458      $15,796
178...........................................        3,768      $11,708
179...........................................       12,638      $18,986
180...........................................       88,639      $16,610
181...........................................       27,216       $9,290
182...........................................      262,029      $14,023
183...........................................       91,740      $10,011
184...........................................           94       $8,737
185...........................................        5,154      $15,723
186...........................................            3      $17,875
187...........................................          696      $15,067
188...........................................       79,797      $19,450
189...........................................       13,187      $10,387
190...........................................           78      $12,670
191...........................................        9,283      $78,241
192...........................................        1,267      $31,130
193...........................................        4,890      $60,095
194...........................................          738      $27,831
195...........................................        4,164      $50,676
196...........................................        1,055      $26,257
197...........................................       18,684      $43,002
198...........................................        5,702      $21,036
199...........................................        1,663      $43,294
200...........................................        1,049      $53,896
201...........................................        2,020      $67,946
202...........................................       26,312      $23,150
203...........................................       29,505      $24,900
204...........................................       61,908      $20,516
205...........................................       24,637      $21,268
206...........................................        2,067      $12,532
207...........................................       32,271      $19,957
208...........................................       10,811      $11,475
209...........................................      372,279      $31,962
210...........................................      122,061      $29,462
211...........................................       32,711      $19,985
212...........................................            7      $12,150
213...........................................        9,933      $32,907
216...........................................        6,966      $39,219
217...........................................       17,187      $54,066
218...........................................       23,006      $25,987
219...........................................       21,106      $16,879
223...........................................       13,759      $17,261
224...........................................       12,552      $12,912
225...........................................        6,183      $19,662
226...........................................        5,746      $27,178
227...........................................        4,970      $13,622
228...........................................        2,509      $19,610
229...........................................        1,194      $11,847
230...........................................        2,432      $22,178
231...........................................       12,624      $24,201
232...........................................          883      $16,540
233...........................................        7,874      $37,126
234...........................................        4,676      $22,187
235...........................................        5,113      $13,085
236...........................................       40,000      $12,274
237...........................................        1,760       $9,994
238...........................................        8,670      $25,013
239...........................................       48,442      $17,681
240...........................................       11,894      $23,382
241...........................................        3,248      $11,495
242...........................................        2,530      $20,034
243...........................................       94,301      $13,030
244...........................................       13,641      $12,510
245...........................................        5,755       $8,412

[[Page 50275]]

 
246...........................................        1,350       $9,972
247...........................................       19,727      $10,064
248...........................................       12,150      $14,678
249...........................................       12,731      $11,854
250...........................................        3,835      $11,911
251...........................................        2,517       $8,099
253...........................................       20,998      $12,813
254...........................................       10,902       $7,704
256...........................................        6,431      $14,288
257...........................................       16,772      $14,857
258...........................................       17,039      $11,449
259...........................................        3,835      $15,369
260...........................................        5,097      $11,113
261...........................................        1,923      $16,946
262...........................................          688      $15,991
263...........................................       24,718      $38,028
264...........................................        4,016      $19,611
265...........................................        4,092      $27,441
266...........................................        2,697      $14,755
267...........................................          272      $16,075
268...........................................          925      $19,327
269...........................................        9,735      $30,555
270...........................................        2,865      $13,392
271...........................................       19,721      $18,266
272...........................................        5,507      $17,536
273...........................................        1,389      $10,100
274...........................................        2,368      $22,159
275...........................................          255      $10,372
276...........................................        1,336      $12,114
277...........................................       94,344      $15,014
278...........................................       31,948       $9,512
279...........................................            4      $17,604
280...........................................       17,227      $12,112
281...........................................        7,944       $8,057
283...........................................        5,671      $12,657
284...........................................        1,960       $7,644
285...........................................        6,638      $36,255
286...........................................        2,193      $35,893
287...........................................        6,511      $33,003
288...........................................        3,757      $37,255
289...........................................        6,442      $16,278
290...........................................        9,537      $14,936
291...........................................           78      $10,617
292...........................................        6,124      $48,257
293...........................................          371      $24,926
294...........................................       95,924      $13,312
295...........................................        3,386      $13,866
296...........................................      252,123      $14,853
297...........................................       47,964       $8,755
298...........................................          109      $10,034
299...........................................        1,225      $16,331
300...........................................       17,611      $19,532
301...........................................        3,657      $11,338
302...........................................        8,130      $55,527
303...........................................       20,794      $41,559
304...........................................       12,145      $41,008
305...........................................        3,031      $20,757
306...........................................        7,236      $22,022
307...........................................        2,171      $10,310
308...........................................        7,283      $28,400
309...........................................        4,351      $15,334
310...........................................       24,707      $19,400
311...........................................        8,377      $10,521
312...........................................        1,557      $18,584
313...........................................          646      $11,827
315...........................................       34,005      $37,125
316...........................................      115,837      $23,854
317...........................................        1,913      $12,529
318...........................................        5,782      $21,457
319...........................................          503      $11,336
320...........................................      194,070      $14,798
321...........................................       30,891       $9,599
322...........................................           68       $9,132
323...........................................       18,744      $14,366
324...........................................        7,505       $8,164
325...........................................        8,988      $11,522
326...........................................        2,819       $7,922
327...........................................            2      $10,762
328...........................................          690      $13,079
329...........................................          105       $8,710
331...........................................       49,515      $18,870
332...........................................        5,169      $10,822
333...........................................          321      $14,080
334...........................................       10,350      $25,041
335...........................................       12,465      $18,158
336...........................................       36,467      $14,411
337...........................................       29,659       $9,712
338...........................................        1,057      $21,551
339...........................................        1,518      $18,614
341...........................................        3,693      $21,558
342...........................................          726      $13,124
344...........................................        3,851      $22,634
345...........................................        1,342      $19,650
346...........................................        4,587      $19,105
347...........................................          379      $10,965
348...........................................        3,306      $12,913
349...........................................          605       $7,299
350...........................................        6,529      $12,505
352...........................................          774      $12,969
353...........................................        2,680      $32,047
354...........................................        7,526      $25,751
355...........................................        5,700      $14,571
356...........................................       26,077      $12,521
357...........................................        5,750      $40,024
358...........................................       20,759      $20,246
359...........................................       31,287      $13,396
360...........................................       15,672      $14,701
361...........................................          371      $18,705
362...........................................            4       $8,407
363...........................................        2,700      $15,699
364...........................................        1,643      $14,803
365...........................................        1,863      $34,638
366...........................................        4,465      $23,452
367...........................................          525      $10,167
368...........................................        3,299      $21,265
369...........................................        3,302      $10,746
370...........................................        1,284      $16,225
371...........................................        1,476      $10,644
372...........................................          939       $9,848
373...........................................        3,971       $6,378
374...........................................          122      $12,746
375...........................................            8      $21,571
376...........................................          265       $8,744
377...........................................           31      $23,435
378...........................................          173      $15,122
379...........................................          416       $6,917
380...........................................           81       $6,607
381...........................................          186      $10,262
382...........................................           27       $3,014
383...........................................        1,881       $9,372
384...........................................          156       $7,467
389...........................................            7      $34,427
390...........................................            8      $13,005
392...........................................        2,274      $56,008
394...........................................        2,346      $31,726
395...........................................      101,259      $14,419
396...........................................           11      $12,914
397...........................................       17,989      $21,897
398...........................................       17,236      $22,492
399...........................................        1,806      $12,364
400...........................................        6,531      $47,849
401...........................................        5,876      $50,482
402...........................................        1,606      $19,867
403...........................................       32,218      $32,326
404...........................................        4,622      $15,977
406...........................................        2,507      $49,500
407...........................................          703      $21,974
408...........................................        2,142      $36,720
409...........................................        2,532      $21,881
410...........................................       30,961      $18,459
411...........................................           14       $7,772
412...........................................           18       $5,007
413...........................................        5,810      $25,090
414...........................................          771      $12,969
415...........................................       40,196      $66,869
416...........................................      181,882      $28,337
417...........................................           41      $22,272
418...........................................       23,567      $18,479
419...........................................       15,855      $15,249
420...........................................        2,978      $10,242
421...........................................        9,323      $11,975
422...........................................           70       $7,706
423...........................................        7,321      $32,051
424...........................................        1,308      $41,557
425...........................................       16,388      $11,974
426...........................................        4,533       $9,233
427...........................................        1,609       $9,317
428...........................................          756      $13,065
429...........................................       27,167      $14,265
430...........................................       63,752      $12,736
431...........................................          327      $10,872
432...........................................          423      $11,180
433...........................................        5,581       $4,920
439...........................................        1,473      $29,717
440...........................................        5,498      $33,013
441...........................................          625      $15,811
442...........................................       16,846      $42,862
443...........................................        3,849      $17,778
444...........................................        5,746      $13,130
445...........................................        2,782       $8,545
447...........................................        6,305       $8,528
449...........................................       30,756      $14,340
450...........................................        7,469       $7,247
451...........................................            5       $4,128
452...........................................       25,432      $18,482
453...........................................        5,687       $9,170
454...........................................        4,687      $14,486
455...........................................        1,113       $8,155
461...........................................        4,611      $21,349
462...........................................       12,012      $20,019
463...........................................       25,409      $12,194
464...........................................        7,163       $8,706
465...........................................          227      $10,413
466...........................................        1,822      $11,632
467...........................................        1,063       $9,841
468...........................................       50,149      $67,712
470...........................................           56     $320,694
471...........................................       12,460      $47,823
473...........................................        8,302      $64,225
475...........................................      104,462      $67,821
476...........................................        3,820      $41,084
477...........................................       25,807      $32,999
478...........................................      109,163      $42,312
479...........................................       24,294      $24,477

[[Page 50276]]

 
480...........................................          649     $180,578
481...........................................          750     $127,638
482...........................................        5,371      $62,963
483...........................................       43,690     $292,070
484...........................................          331     $100,727
485...........................................        3,084      $51,800
486...........................................        1,988      $86,227
487...........................................        3,687      $36,110
488...........................................          782      $88,702
489...........................................       13,667      $32,494
490...........................................        5,324      $18,378
491...........................................       13,649      $27,118
492...........................................        2,897      $75,913
493...........................................       58,366      $30,941
494...........................................       31,075      $16,839
495...........................................          215     $160,061
496...........................................        1,864      $99,536
497...........................................       20,068      $58,040
498...........................................       14,786      $41,923
499...........................................       32,816      $24,399
500...........................................       49,773      $15,631
501...........................................        2,362      $44,558
502...........................................          642      $25,718
503...........................................        5,937      $20,667
504...........................................          124     $284,775
505...........................................          149      $32,946
506...........................................          939      $85,181
507...........................................          289      $30,660
508...........................................          667      $24,870
509...........................................          179      $16,930
510...........................................        1,679      $20,594
511...........................................          622      $11,693
512...........................................          481      $98,319
513...........................................          152     $102,359
514...........................................       19,616     $104,642
515...........................................        4,636      $88,517
516...........................................       76,556      $42,776
517...........................................      191,887      $34,456
518...........................................       51,871      $30,445
519...........................................        7,284      $40,177
520...........................................       11,165      $25,193
521...........................................       28,831      $12,761
522...........................................        6,193      $10,048
523...........................................       14,988       $6,937
524...........................................      137,361      $12,413
525...........................................          497     $214,078
526...........................................       68,336      $34,435
527...........................................      189,145     $27,295
------------------------------------------------------------------------
\1\ Cases are taken from the FY 2001 MedPAR file; DRGs are from GROUPER
  V20.0.

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 Mandates 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 final 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 final 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 acute care hospital 
inpatient prospective payment systems, we classify these hospitals 
as urban hospitals.
    It is clear that the changes being made in this document will 
affect both a substantial number of small rural hospitals as well as 
other classes of hospitals, and the effects on some may be 
significant. Therefore, the discussion below, in combination with 
the rest of this final rule, constitutes a combined regulatory 
impact analysis and regulatory flexibility analysis.
    Section 202 of the Unfunded Mandates Reform Act of 1995 (Public 
Law 104-4) also requires that agencies assess anticipated costs and 
benefits before issuing 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 final rule will 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 final 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 
final 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 changes in this final rule will 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 changes will 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 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 solicited 
comments and information about the anticipated effects of these 
changes on hospitals and our methodology for estimating them.
    We received several comments on the impact analysis for our May 
9, 2002 proposed rule.
    Comment: Several commenters noted that the effects of the 
proposed expansion to the postacute transfer policy were not 
included in the May 9, 2002 proposed rule impact tables. These 
commenters were concerned that the effect of implementing either of 
the two proposed expansions of this policy would result in an 
overall decrease in per case payments in FY 2003.
    Response: We did not analyze the postacute care transfer policy 
in the impact tables in the proposed rule because we did not propose 
a specific policy expansion. We did include overall savings 
estimates attributable to the provision in the preamble discussion.
    Comment: Several commenters noted the impact that the large 
legislated decreases in IME payments and the update factor (market 
basket increase minus 0.55 percentage point) will have on many 
hospitals. They argued that these decreases in payments, in 
combination with our proposals and an update factor of less than 
inflation, will have an even larger overall impact than indicated

[[Page 50277]]

in our impact tables. The commenters indicated that, in a time when 
other health care costs are escalating due to nursing shortages, 
rising drug and technology costs, and ``skyrocketing'' professional 
and general insurance premiums, hospitals cannot absorb a reduction 
in inpatient Medicare payments. They argued that decreasing payments 
and increasing costs will make hospitals less able to make decisions 
based solely on the needs of the beneficiary and make more decisions 
based on solvency.
    Response: As the commenters pointed out, these reductions are 
legislated by Congress. However, as discussed further below, one of 
the biggest impacts on the changes in payments from FY 2002 to FY 
2003 is the high outlier payments hospitals are receiving in FY 2002 
(approximately 7.2 percent of total DRG payments) compared to the FY 
2003 estimated 5.1 percent. The net effect of this difference is to 
reduce the rate of change by 2.1 percentage points.

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 acute care hospital inpatient prospective 
payment system under the waiver at section 1814(b)(3) of the Act.
    There are approximately 631 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 hospital inpatient 
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 July 2002, we have included 4,230 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

    There were 1,065 specialty hospitals excluded from the acute 
care hospital inpatient prospective payment system. 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 3.5 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 final 
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 estimate of the 
excluded hospital market basket (or 3.5 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 Policy Changes Under the 
Hospital Inpatient Prospective Payment System for Operating Costs

A. Basis and Methodology of Estimates

    In this final rule, we are announcing policy changes and payment 
rate updates for the 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 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 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 
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 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 FY 
2003 changes to the capital prospective payment system are discussed 
in section IX. of this Appendix.
    The changes discussed separately below are the following:
     The effects of the annual reclassification of diagnoses 
and procedures and the recalibration of the DRG relative weights 
required by section 1886(d)(4)(C) of the Act.
     The effects of the changes in hospitals' wage index 
values reflecting wage data from

[[Page 50278]]

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 GME and CRNAs.
     The effects of geographic reclassifications by the 
MGCRB that will be effective in FY 2003.
     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 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 final 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 updating 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 3.5 percent minus 0.55 percentage points (for an 
update of 2.95 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 3.5 percent 
minus 0.55 percentage points (for an update of 2.95 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 7.2 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 average standardized amounts were offset 
correspondingly. The effects of the higher than expected outlier 
payments during FY 2002 (as discussed in the Addendum to this final 
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 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.
    Comment: Numerous commenters expressed concern about the 
statutory reduction to the IME formula multiplier for FY 2003 of 
1.35. The commenters stated that this cut in IME reimbursement will 
have any extremely detrimental impact on the teaching hospital 
community.
    Response: Congress establishes the IME formula multiplier for FY 
2003 by law. Any changes to the multiplier must be made through the 
legislative process.
    Comment: One commenter stated that the reduction to the IME 
formula multiplier was not considered in the impact analysis table 
(67 FR 31670) in the proposed rule. The commenter requested that the 
large impact due to reduction in IME payments be acknowledged and 
weighed against the cost to hospitals that would be incurred by the 
proposed outlier reduction, transfer payment expansion, and the 
removal of resident salary costs from the wage index.
    Response: In the May 9, 2002 proposed rule at 67 FR 31670 and 
31671, we included several footnotes that explain the various 
calculations in the impact analysis for FY 2003. Footnote number 9 
states that the impact of the reduction in IME adjustment payments 
is reflected in column 8 of the table, which contains all FY 2003 
changes. Thus, we have incorporated the reduction to the IME formula 
multiplier in the impact analysis of total Medicare hospital 
expenditures for FY 2003, and have similarly done so in this final 
rule.
    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 4,230 hospitals included in the analysis. This number 
is 555 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 2,620 
hospitals located in urban areas (MSAs or NECMAs) included in our 
analysis. Among these, there are 1,519 hospitals located in large 
urban areas (populations over 1 million), and 1,101 hospitals in 
other urban areas (populations of 1 million or fewer). In addition, 
there are 1,610 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 2,650, 
1,576, 1,074, and 1,580, 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 3,119 nonteaching hospitals in our 
analysis, 870 teaching hospitals with fewer than 100 residents, and 
241 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 (160), SCHs (526), MDHs 
(241), and hospitals that are both SCH and RRC (76) shown here were 
not reclassified for purposes of the standardized amount.
    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 177 hospitals. Similarly, the data needed to determine Medicare 
utilization were unavailable for 126 hospitals.
    The next series of groupings concern the geographic 
reclassification status of hospitals. The first grouping displays 
all hospitals that were reclassified by the

[[Page 50279]]

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   Remove GME
                                                     Number of     Drg      New wage   GMS and    and CRNA   DRG and WI         MCGRB           All FY
                                                     Hosps.\1\   Changes    data \3\   CRNA 80/      100       changes     reclassification      2003
                                                                                        20 \4\     percent       \6\             \7\            changes
                                                           (1)        (2)        (3)        (4)         (5)         (6)             (7)              (8)
--------------------------------------------------------------------------------------------------------------------------------------------------------
By Geographic Location:
    All hospitals..................................      4,230        0.4        0.0        0.0         0.1       0.0 0              .0              0.4
    Urban hospitals................................      2,620        0.5        0.0        0.0         0.1         0.0            -0.4              0.1
    Large urban areas (populations over 1 million).      1,519        0.4        0.0        0.0         0.0         0.1            -0.5              0.2
    Other urban areas (populations of 1 million of       1,101        0.5        0.0        0.1         0.1         0.1             0.4              0.7
     fewer)........................................
    Rural hospitals................................      1,610         .1        0.2        0.1         0.1         0.1             2.4              2.1
    Bed Size (Urban):
        0-99 beds..................................        645        0.3        0.0        0.1         0.1         0.0            -0.6              1.3
        100-199 beds...............................        909        0.3       -0.2        0.1         0.1        -0.3            -0.5              0.8
        200-299 beds...............................        523        0.5        0.0        0.1         0.1         0.0            -0.4              0.4
        300-499 beds...............................        398        0.6       -0.2        0.0         0.1         0.0            -0.4             -0.1
        500 or more beds...........................        145        0.6        0.2        0.0         0.0         0.2            -0.5             -0.6
    Bed Size (Rural):
        0-49 beds..................................        747       -0.3        0.3        0.1         0.1        -0.2             0.5              2.4
        50-99 beds.................................        501       -0.1        0.2        0.1         0.1        -0.1             0.9              2.3
        100-149 beds...............................        215        0.1        0.3        0.1         0.1         0.1             2.8              2.1
        150-199 beds...............................         78        0.2        0.2        0.1         0.1         0.1             4.9              1.8
        200 or more beds...........................         69        0.6        0.1        0.1         0.1         0.4             3.9              1.6
    Urban by Region:
        New England................................        135        0.3       -0.1        0.1         0.1         0.6            -0.1             -0.3
        Middle Atlantic............................        404        0.6       -0.4        0.0        -0.1        -0.5             0.1             -1.4
        South Atlantic.............................        384        0.5        0.0        0.1         0.1         0.0            -0.5              0.7
        East North Central.........................        429        0.5        0.1        0.0         0.1         0.0            -0.5              0.2
        East South Central.........................        159        0.4       -0.1        0.0         0.0        -0.3            -0.7              0.6
        West North Central.........................        178        0.5        0.2        0.1         0.1         0.3            -0.7              0.6
        West South Central.........................        335        0.5        0.5        0.0         0.0         0.3            -0.7              1.0
        Mountain...................................        132        0.7        0.5        0.1         0.1         0.8             0.6              1.7
        Pacific....................................        417        0.3       -0.3        0.1         0.2        -0.3            -0.5              0.0
        Puerto Rico................................         47        0.3       -0.8        0.0         0.0        -0.7            -0.8              0.6
    Rural by Region:
        New England................................         40        0.2        0.2        0.0         0.0         0.1             2.7              1.1
        Middle Atlantic............................         67        0.1       -0.5        0.0         0.0        -0.7             2.6              1.3
        South Atlantic.............................        232        0.1        0.1        0.1         0.1        -0.1             2.9              1.6
        East North Central.........................        215        0.3        0.1        0.1         0.1         0.2             2.3              2.6
        East South Central.........................        239       -0.1        0.7        0.1         0.1         0.3             2.5              2.0
        West North Central.........................        279        0.3        0.4        0.0         0.0         0.5             1.6              2.5
        West South Central.........................        285       -0.1        0.3        0.1         0.1        -0.1             3.2              2.0
        Mountain...................................        145        0.2        0.1        0.0         0.0         0.2             1.1              2.5
        Pacific....................................        103        0.1        0.3        0.1         0.1         0.2             2.3              2.3
        Puerto Rico................................          5        0.1       -5.4        0.1         0.1        -5.6            -0.6             -2.7
By Payment Classification:
    Urban hospitals................................      2,650        0.5        0.0        0.0         0.1         0.0            -0.4              0.1
    Large urban areas (populations over 1 million).      1,576        0.4       -0.1          1         0.0        -0.1            -0.4             -0.2
    Other urban areas (populations of 1 million of       1,074        0.5        0.0        0.1         0.1         0.2            -0.4              0.7
     fewer)........................................
    Rural areas....................................      1,580        0.1        0.2        0.1         0.1         0.1             2.3              2.1
    Teaching Status:
        Non-teaching...............................      3,119        0.3        0.0        0.1         0.1         0.0             0.3              1.3
        Fewer than 100 Residents...................        870        0.6       -0.1        0.0         0.1         0.0            -0.3              0.5
        100 or more Residents......................        241        0.5        0.0        0.0         0.0         0.0            -0.3             -1.4
    Urban DSH:.....................................
        Non-DSH....................................      1,549        0.6        0.0        0.0         0.1         0.1             0.2              0.6
        100 or more beds...........................      1,361        0.4        0.0        0.0         0.1        -0.1            -0.5              0.0
        Less than 100 beds.........................        286        0.0        0.1        0.1         0.1        -0.2            -0.4              1.2
    Rural DSH:
 
        Sole Community (SCH).......................        470       -0.2        0.2        0.1         0.1        -0.1             0.2              2.5
        Referral Center (RRC)......................        156        0.2        0.3        0.1         0.1         0.2             4.7              1.6
    Other Rural:
        100 or more beds...........................         76        0.0        0.3        0.1         0.1        -0.1             1.3              1.6

[[Page 50280]]

 
        Less than 100 beds.........................        332       -0.2        0.4        0.1         0.1        -0.2             0.6              2.0
    Urban teaching and DSH:
        DSH........................................        757        0.5       -0.1        0.0         0.0         0.0            -0.6             -0.4
        Teaching and no DSH........................        284        0.7        0.0        0.0         0.0         0.1             0.0             -0.1
        No teaching and DSH........................        890        0.3        0.0        0.1         0.1        -0.1            -0.4              1.1
        No teaching and no DSH.....................        719        0.5       -0.1        0.1         0.1         0.0            -0.4              0.7
    Rural Hospital Types:
        Non special status hospitals...............        577       -0.1        0.4        0.1         0.1        -0.1             1.2              1.9
        RRC........................................        160        0.3        0.2        0.1         0.1         0.1             6.2              1.1
        SCH........................................        526       -0.1        0.2        0.0         0.0         0.0             0.2              2.7
        Medicare-dependent hospitals (MDH).........        241       -0.2        0.4        0.1         0.1        -0.1             0.6              2.5
        SCH and RRC................................         76        0.5        0.1        0.0         0.0         0.6             1.3              3.1
    Type of Ownership:
        Voluntary..................................      2,461        0.5        0.0        0.0         0.1         0.0             0.0              0.4
        Proprietary................................        723        0.4        0.1      0.1 0          .1         0.0            -0.1              0.4
        Government.................................        869        0.2        0.2        0.1         0.1         0.0             0.2              0.6
        Unknown....................................          5        177        0.4       -0.2         0.0         0.1            -0.3             -0.5
    Medicare Utilization as a Percent of Inpatient
     Days:
        0-25.......................................        310        0.3       -0.1        0.1         0.1        -0.3            -0.3             -0.6
        25-50......................................      1,613        0.5        0.0        0.0         0.1         0.0            -0.3              0.0
        50-65......................................      1,677        0.4        0.0        0.1         0.1         0.0             0.3              1.0
        Over 65....................................        504        0.3       -0.1        0.0         0.1        -0.2             0.5              0.7
        Unknown....................................        126        0.9        0.1        0.0         0.0         0.3            -0.7              0.2
    Hospitals Reclassified by the Medicare
     Geographic Classification Review Board: FY
     2003 Reclassifications:
        All Reclassified Hospitals.................        628        0.4        0.0        0.1         0.1         0.2             4.5              1.2
    Standardized Amount Only.......................         28        0.2       -0.1        0.1         0.1        -0.3             0.3              1.0
    Wage Index Only................................        521        0.4        0.1        0.1         0.1         0.2             4.7              0.8
    Both...........................................         38        0.4        0.0        0.1         0.1        -0.1             5.5              0.8
    Nonreclassified Hospitals......................      3,605        0.4        0.0        0.0         0.1         0.0            -0.7              0.3
    All Reclassified Urban Hospitals...............        113        0.6       -0.2        0.0         0.1         0.1             4.5              0.1
    Standardized Amount Only.......................     11 0.2       -0.9        0.1        0.1        -1.2        -0.9             0.2
    Wage Index Only................................         87        0.7       -0.2        0.0         0.0         0.2             4.8             -0.2
    Both...........................................         15        0.5        0.2        0.1         0.2         0.4             4.3              3.0
    Urban Nonreclassified Hospitals................      2,473        0.5        0.0        0.0         0.1         0.0            -0.7              0.1
    All Reclassified Rural Hospitals...............        515        0.3        0.2        0.1         0.1         0.2             4.5              1.9
    Standardized Amount Only.......................         11        0.5        0.4        0.1         0.1         0.4             3.7              3.1
    Wage Index Only................................        485        0.3        0.2        0.1         0.1         0.2             4.5              1.9
    Both...........................................         19        0.3       -0.1        0.1         0.1        -0.1             5.9              1.8
    Rural Nonreclassified Hospitals................      1,094       -0.1        0.3        0.1         0.1        -0.1            -0.6              2.3
    Other Reclassified Hospitals (Section                   35       -0.1       -0.2        0.0         0.0        -0.9            -1.3             2.7
     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 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.
\3\ This column displays the impact of updating the wage index with wage data from hospitals' FY 1999 cost reports.
\4\ This column displays the impact of an 80/20 percent blend of removing the labor costs and hours associated with graduate medical education (GME) and
  for the Part A costs of certified registered nurse anesthetists (CRNAs).
\5\ This column displays the impact of completely removing the labor costs and hours associated with GME and for the Part A costs of CRNAs.
\6\ This column displays the combined impact of the reclassification and recalibration of the DRGs, the updated and revised wage data used to calculate
  the wage index, the 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 0.993209.
\7\ 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.
\8\ This column shows changes in payments from FY 2002 to FY 2003. It incorporates all of the changes displayed in columns 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.


[[Page 50281]]

B. Impact of the Changes to the DRG Reclassifications and 
Recalibration of Relative Weights (Column 2)

    In column 2 of Table I, we present the combined effects of the 
DRG reclassifications and recalibration, as discussed in section II. 
of the preamble to this final rule. Section 1886(d)(4)(C)(i) of the 
Act requires us to annually make appropriate classification changes 
and to recalibrate the DRG weights in order to reflect changes in 
treatment patterns, technology, and any other factors that may 
change the relative use of hospital resources.
    We compared aggregate payments using the FY 2002 DRG relative 
weights (GROUPER version 19.0) to aggregate payments using the FY 
2003 DRG relative weights (GROUPER version 20.0). 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 
0.993209 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 making will result in 0.4 percent higher 
payments to hospitals overall. This effect is largely attributable 
to the anticipated higher payments after April 1, 2003 for drug-
eluting stents, as described in section II.B. of this final rule. 
Specifically, we created two new DRGs (526 and 527) to be effective 
April 1, 2003. The relative weights for these new DRGs are 14 and 16 
percent higher, respectively, than the weights for current DRGs 516 
and 517, the current DRGs for stents. Hospitals that are currently 
doing these procedures benefit demonstrate positive impacts from 
this change in this impact analysis.
    Another change is to DRGs 14 (retitled, Intracranial Hemorrhage 
and Stroke with Infarction) and 15 (retitled, Nonspecific 
Cerebrovascular Accident and Precerebral Occlusion without 
Infarction), and new DRG 524 (Transient Ischemia). With the new 
configuration of these DRGs, over 100,000 cases that previously 
would have been assigned to DRG 14 (with a FY 2003 relative weight 
of 1.2943) will now be assigned to DRG 15 (with a FY 2003 relative 
weight of 0.9858).
    Urban hospitals with 300 or more beds, and rural hospitals with 
200 or more beds benefit from these changes. Rural hospitals with 
fewer than 50 beds would experience a 0.3 percent decrease due to 
these changes, and rural hospitals with between 50 and 99 beds would 
experience a 0.1 percent decrease. Among rural hospitals categorized 
by region, the East South Central and West South Central would 
experience a 0.1 percent decrease in payments. Among special rural 
hospital categories, SCHs would experience a 0.1 percent decrease 
and MDHs would experience a 0.2 percent decrease.

C. 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 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-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 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 5.4 percent decrease). 
Rural hospitals in the East South Central region experience the next 
largest impact, a 0.7 percent increase. Among urban hospitals, 
Puerto Rico and the Middle Atlantic regions would experience a 0.8 
and 0.4 percent decreases, respectively. The Mountain region would 
experience a 0.5 percent increase.
    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 have been the fourth year of the 
phaseout. This would have meant 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 removing 100 percent of GME and CRNA costs 
from the FY 2003 wage index. To demonstrate the impacts of this 
provision, 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 
0.2 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 no change in payments.
    We note that the wage data used for the final wage index are 
based upon the data available as of July 2002 and, therefore, do not 
reflect revision requests received and processed by the fiscal 
intermediaries after that date.
    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 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 (343) 
experience less than a 5-percent change. A total of 11 labor market 
areas experience an increase of more than 5 percent and less than 10 
percent. Three areas experience an increase greater than 10 percent. 
A total of 15 areas experience decreases of more than 5 percent and 
less than 10 percent. Finally, 1 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            3
Increase more than 5 percent and less than 10            26           11
 percent......................................
Increase or decrease less than 5 percent......          335          343
Decrease more than 5 percent and less than 10            10           15
 percent......................................
Decrease more than 10 percent.................            1            1
------------------------------------------------------------------------

    Among urban hospitals, 42 would experience an increase of 
between 5 and 10 percent and 9 more than 10 percent. A total of 22 
rural hospitals have increases greater than 5 percent, but none have 
greater than 10-percent increases. On the negative side, 55 urban 
hospitals have decreases in their wage index values of at least 5 
percent but less than 10 percent. Two urban hospitals have decreases 
in their wage index values greater than 10 percent. There are 17 
rural hospitals with decreases in their wage index values greater 
than 5 percent or with increases of more than 10 percent. The 
following chart

[[Page 50282]]

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.................            9            0
Increase more than 5 percent and less than 10            42           22
 percent......................................
Increase or decrease less than 5 percent......         2553         1975
Decrease more than 5 percent and less than 10            55           17
 percent......................................
Decrease more than 10 percent.................            2            0
------------------------------------------------------------------------

D. 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 final rule, 
we compared simulated aggregate payments using the FY 2002 DRG 
relative weights and wage index to simulated aggregate payments 
using the FY 2003 DRG relative weights and blended wage index. In 
addition, we are required to ensure that any add-on payments for new 
technology under section 1886(d)(5)(K) of the Act are budget 
neutral. As discussed in section II.D. of this final rule, we are 
approving one new technology for add-on payments in FY 2003. We 
estimate the total add-on payments for this new technology will be 
$74.8 million.
    We computed a wage and recalibration budget neutrality factor of 
0.993209. 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.
    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.
    The changes in this column are the sum of the changes in columns 
2, 3, 4, and 5, combined with the budget neutrality factor and the 
wage index floor for urban areas. There also may be some variation 
of plus or minus 0.1 percentage point due to rounding.

E. 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 final 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.
    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 0.990672 to ensure that the effects of 
reclassification are budget neutral. (See section II.A.4.b. of the 
Addendum to this final rule.)
    As a group, rural hospitals benefit from geographic 
reclassification. Their payments rise 2.4 percent in column 7. 
Payments to urban hospitals decline 0.4 percent. Hospitals in other 
urban areas see a decrease in payments of 0.4 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 
1.1 and 1.6 percent for Mountain and West North Central regions, 
respectively. The largest increases are in rural South Atlantic and 
West South Central regions. These regions receive increases of 2.9 
and 3.2 percent, respectively.
    Among all the hospitals that were reclassified for FY 2003 
(including hospitals that received wage index reclassifications in 
FY 2001 or FY 2002 that extend for 3-years), the MGCRB changes are 
estimated to provide a 4.5 percent increase in payments. Urban 
hospitals reclassified for FY 2003 are expected to receive an 
increase of 4.5 percent, while rural reclassified hospitals are 
expected to benefit from the MGCRB changes with a 4.5 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 4.7 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 0.6 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 1.3 percent.

F. 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. 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 2.95 percent update to the 
standardized amounts and the hospital-specific rates for MDHs and 
SCHs. It also reflects the 2.1 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 (7.2 percent), as described in the 
introduction to this Appendix and the Addendum to this final 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.
    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

[[Page 50283]]

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. Hospitals in urban areas experience a 0.1 
percent increase in payments per case compared to FY 2002. Hospitals 
in rural areas, meanwhile, experience a 2.1 percent payment 
increase. Hospitals in large urban areas experience a 0.2 percent 
decline in payments, largely due to the 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 1.4 percent.
    Among urban census divisions, the largest payment increase was 
1.7 percent in the Mountain region. Hospitals in urban Middle 
Atlantic would experience an overall decrease of 1.4 percent and 
hospitals in the New England region would experience a decrease of 
0.3 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 only hospital category 
experiencing overall payment decreases is Puerto Rico, where 
payments decrease by 2.7 percent, largely due to the updated wage 
data. In the East North Central region, payments appear to increase 
by 2.6 percent. Mountain and West North Central regions also 
benefited, both with 2.5 percent increases.
    Among special categories of rural hospitals, those hospitals 
receiving payment under the hospital-specific methodology (SCHs, 
MDHs, and SCH/RRCs) experience payment increases of 2.7 percent, 2.5 
percent, and 3.1 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 
as do hospitals paid based on the national standardized amounts.
    Hospitals that were reclassified for FY 2003 are estimated to 
receive a 1.2 percent increase in payments. Urban hospitals 
reclassified for FY 2003 are anticipated to receive an increase of 
0.1 percent, while rural reclassified hospitals are expected to 
benefit from reclassification with a 1.9 percent increase in 
payments. Overall, among hospitals reclassified for purposes of the 
standardized amount, a payment increase of 1.0 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 2.7 percent.

 
             Table II.--Impact Analysis of Changes for FY 2003 Operating Prospective Payment System
                                               [Payments per case]
----------------------------------------------------------------------------------------------------------------
                                                             Average FY 2002   Average FY 2003
                                           Num. of hosps.      payment per       payment per       All FY 2003
                                                                 case\1\           case\1\           changes
                                                       (1)               (2)               (3)               (4)
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
    All hospitals.......................             4,230             7,218            7247.2               0.4
    Urban hospitals.....................             2,620             7,718            7727.8               0.1
    Large urban areas (populations over              1,519             8,269            8249.2              -0.2
     1 million).........................
    Other urban areas (populations of 1              1,101             7,002            7050.4               0.7
     million of fewer)..................
    Rural hospitals.....................             1,610             5,168            5275.0               2.1
Bed Size (Urban):
    0-99 beds...........................               645             5,309            5376.3               1.3
    100-199 beds........................               909             6,424            6474.8               0.8
    200-299 beds........................               523             7,394            7422.6               0.4
    300-499 beds........................               398             8,345            8332.6              -0.1
    500 or more beds....................               145            10,007            9943.6              -0.6
Bed Size (Rural):
    0-49 beds...........................               747             4,260            4362.7               2.4
    50-99 beds..........................               501             4,776            4887.0               2.3
    100-149 beds........................               215             5,106            5211.2               2.1
    150-199 beds........................                78             5,515            5617.2               1.8
    200 or more beds....................                69             6,750            6860.1               1.6
Urban by Region:
    New England.........................               135             8,224            8203.0              -0.3
    Middle Atlantic.....................               404             8,789            8667.9              -1.4
    South Atlantic......................               384             7,311            7360.5               0.7
    East North Central..................               429             7,293            7311.6               0.2
    East South Central..................               159             6,956            7000.5               0.6
    West North Central..................               178             7,358            7404.2               0.6
    West South Central..................               335             7,103            7172.5               1.0
    Mountain............................               132             7,417            7546.6               1.7
    Pacific.............................               417             9,386            9385.9               0.0
    Puerto Rico.........................                47             3,319            3338.5               0.6
Rural by Region:
    New England.........................                40             6,405            6475.6               1.1
    Middle Atlantic.....................                67             5,267            5338.0               1.3
    South Atlantic......................               232             5,245            5330.7               1.6
    East North Central..................               215             5,139            5275.2               2.6
    East South Central..................               239             4,746            4843.1               2.0
    West North Central..................               279             5,223            5354.7               2.5
    West South Central..................               285             4,536            4626.7               2.0
    Mountain............................               145             5,789            5933.2               2.5
    Pacific.............................               103             6,652            6803.3               2.3

[[Page 50284]]

 
    Puerto Rico.........................                 5             2,753            2677.6              -2.7
By Payment Classification:
    Urban hospitals.....................             2,650             7,703            7713.5               0.1
    Large urban areas (populations over              1,576             8,196            8180.0              -0.2
     1 million).........................
    Other urban areas (populations of 1              1,074             7,027            7075.0               0.7
     million of fewer)..................
    Rural areas.........................             1,580             5,155            5261.6               2.1
Teaching Status:
    Non-teaching........................             3,119             5,890            5965.9               1.3
    Fewer than 100 Residents............               870             7,475            7511.1               0.5
    100 or more Residents...............               241            11,352           11196.8              -1.4
Urban DSH:
    Non-DSH.............................             1,549             6,567            6604.7               0.6
    100 or more beds....................             1,361             8,296            8299.2               0.0
    Less than 100 beds..................               286             5,168            5232.1               1.2
Rural DSH:
    Sole Community (SCH)................               470             4,942            5067.0               2.5
    Referral Center (RRC)...............               156             5,974            6067.9               1.6
    Other Rural:
    100 or more beds....................                76             4,517            4589.9               1.6
    Less than 100 beds..................               332             4,089            4172.8               2.0
Urban teaching and DSH:
    Both teaching and DSH...............               757             9,177            9140.8              -0.4
    Teaching and no DSH.................               284             7,773            7763.4              -0.1
    No teaching and DSH.................               890             6,535            6608.4               1.1
    No teaching and no DSH..............               719             6,041            6086.3               0.7
Rural Hospital Types:
    Non special status hospitals........               577             4,261            4341.7               1.9
    RRC.................................               160             5,677            5737.5               1.1
    SCH.................................               526             5,280            5420.1               2.7
    Medicare-dependent hospitals (MDH)..               241             4,048            4150.6               2.5
    SCH and RRC.........................                76             6,626            6829.3               3.1
Type of Ownership:
    Voluntary...........................             2,461             7,342            7369.6               0.4
    Proprietary.........................               723             6,945            6969.7               0.4
    Government..........................               869             6,809            6851.5               0.6
    Unknown.............................               177             7,302            7318.9               0.2
Medicare Utilization as a Percent of
 Inpatient Days:
    0-25................................               310             9,845            9786.3              -0.6
    25-50...............................             1,613             8,267            8268.6               0.0
    50-65...............................             1,677             6,257            6318.9               1.0
    Over 65.............................               504             5,647            5684.7               0.7
    Unknown.............................               126             8,992            9011.1               0.2
Hospitals Reclassified by the Medicare
 Geographic Classification Review Board:
 FY 2002 Reclassifications:
    All Reclassified Hospitals..........               628             6,530            6609.5               1.2
    Standardized Amount Only............                28             5,971            6029.0               1.0
    Wage Index Only.....................               521             6,749            6805.1               0.8
    Both................................                38             5,901            5947.1               0.8
    All Nonreclassified Hospitals.......             3,605             7,327            7351.4               0.3
    All Urban Reclassified Hospitals....               113             8,610            8615.0               0.1
    Urban Nonreclassified Hospitals.....                11             5,794            5804.7               0.2
    Standardized Amount Only............                87             9,211            9195.4              -0.2
    Wage Index Only.....................                15             5,870            6047.1               3.0
    Both................................             2,473             7,690            7699.1               0.1
    All Reclassified Rural Hospitals....               515             5,721            5829.0               1.9
    Standardized Amount Only............                11             4,848            5000.7               3.1
    Wage Index Only.....................               485             5,728            5835.5               1.9
    Both................................                19             5,875            5981.2               1.8
    Rural Nonreclassified Hospitals.....             1,094             4,516            4621.1               2.3
    Other Reclassified Hospitals                        35             4,894            5026.9              2.7
     (Section 1886(D)(8)(B))............
----------------------------------------------------------------------------------------------------------------
\1\ These payment amounts per case do not reflect any estimates of annual case-mix increase.


[[Page 50285]]

    Table II presents the projected impact of the 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 Policy Changes

A. Impact of Changes Relating to Payment for the Clinical Training 
Portion of Clinical Psychology Training Programs

    In section V.I.5. of the preamble to this final rule, we have 
revised our policy on Medicare payment for approved nursing and 
allied health education programs to permit payment for the costs 
incurred by a provider for the clinical training portion of clinical 
psychology training programs.
    Our actuarial estimates indicate that there will be a fiscal 
impact of $40 million the first year after payments begin, growing 
to $50 million by the 5th year ($220 million over 5 years). Costs 
are expected to increase because we believe that Medicare's support 
through its education regulations will encourage hospitals to report 
more costs for clinical psychology training programs than are 
reported today. This estimate is based on assumptions as to how much 
Medicare could pay for additional educational programs and how 
quickly other providers with clinical training portions would begin 
seeking those payments.
    The following chart shows projected costs to the Medicare 
program for the next 5 years:

------------------------------------------------------------------------
                                                               Medicare
                                                               program
                        Fiscal year                           costs (in
                                                              millions)
------------------------------------------------------------------------
2003.......................................................          $40
2004.......................................................           40
2005.......................................................           40
2006.......................................................           50
2007.......................................................           50
------------------------------------------------------------------------

B. Impact of Changes Relating to EMTALA Provisions

    We are addressing proposed changes related to the EMTALA 
provisions in a separate final rule to be published at a later date.

C. Impact of 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 grandfathering provision for these entities 
expires on September 30, 2002.
    Because we believed it would be difficult to quantify the impact 
of these changes, in the May 9, 2002 proposed rule, we solicited 
comments on these issues. However, we received no comments that 
would assist us in developing a quantitative analysis of impact. 
Therefore, we are not able to prepare such an analysis.

VIII. Impact of Policies Affecting Rural Hospitals

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

    In section V. of the preamble of this final rule, we are raising 
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 change.

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

    In section VII. of the preamble of this final rule, we are 
eliminating 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, or approximately 270 CAHs, provide SNF level care. The 
elimination of the requirement to use the State RAI will greatly 
reduce the burden on CAHs because facilities will 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 will reduce the amount of time required to 
perform patient assessments and allow more time for direct patient 
care.

IX. Impact of 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 final 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 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 threshold established for each 
fiscal year.
    The data used in developing the impact analysis presented below 
are taken from the March 2002 update of the FY 2001 MedPAR file and 
the March 2002 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 June 2002 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 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 March 2002 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 final 
rule, payments will no longer be made under the regular

[[Page 50286]]

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 FY 2003 update is 1.1 percent (see 
section III.A.1.a. of the Addendum to this final rule).
     In addition to the FY 2003 update factor, the FY 2003 
Federal rate was calculated based on a GAF/DRG budget neutrality 
factor of 0.9957, an outlier adjustment factor of 0.9469, an 
exceptions adjustment factor of 0.9970, and a special adjustment for 
FY 2003 of 1.0255 (see section III.A. of the Addendum of this final 
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 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 changes for FY 2003 on total capital 
payments per case, using a universe of 4,230 hospitals. As described 
above, the individual hospital payment parameters are taken from the 
best available data, including the March 2002 update of the FY 2001 
MedPAR file, the March 2002 update to the Provider-Specific File, 
and the most recent cost report data from the June 2002 update of 
HCRIS. In Table III, we present a comparison of total payments per 
case for FY 2002 compared to FY 2003 based on 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 update to 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 3.8 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 (3.6 percent and 4.8 
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 final rule). Changes by region vary from a 
minimum increase of 2.7 percent (Pacific urban region) to a maximum 
increase of 5.3 percent (East North Central rural region). Hospitals 
located in Puerto Rico are expected to experience an increase in 
total capital payments per case of 4.4 percent.
    By type of ownership, government hospitals are projected to have 
the largest rate of increase of total payment changes (4.2 percent). 
Similarly, payments to voluntary hospitals will increase 4.1 
percent, while payments to proprietary hospitals will increase 2.1 
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 4.5 percent increase in payments. Payments to 
nonreclassified hospitals will increase slightly less (3.7 percent) 
than reclassified hospitals, overall. Hospitals reclassified during 
both FY 2002 and FY 2003 are projected to receive an increase in 
payments of 4.1 percent. Hospitals reclassified during FY 2003 only 
are projected to receive an increase in payments of 8.6 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.......................................         4,230           668           693           3.8
    Large urban areas (populations over 1 million)......         1,519           772           798           3.4
    Other urban areas (populations of 1 million or               1,101           653           679           4.0
     fewer).............................................
    Rural areas.........................................         1,610           451           472           4.8
    Urban hospitals.....................................         2,620           720           746           3.6
        0-99 beds.......................................           645           511           532           4.2
        100-199 beds....................................           909           607           630           3.7
        200-299 beds....................................           523           692           718           3.7
        300-499 beds....................................           398           767           794           3.6
        500 or more beds................................           145           933           964           3.4
    Rural hospitals.....................................         1,610           451           472           4.8
        0-49 beds.......................................           747           371           392           5.5
        50-99 beds......................................           501           412           434           5.3
        100-149 beds....................................           215           456           478           4.8

[[Page 50287]]

 
        150-199 beds....................................            78           494           517           4.7
        200 or more beds................................            69           569           591           3.8
By Region:
    Urban by Region.....................................         2,620           720           746           3.6
        New England.....................................           135           771           805           4.4
        Middle Atlantic.................................           404           807           829           2.8
        South Atlantic..................................           384           692           717           3.6
        East North Central..............................           429           688           720           4.6
        East South Central..............................           159           654           677           3.6
        West North Central..............................           178           706           736           4.3
        West South Central..............................           335           671           693           3.4
        Mountain........................................           132           694           728           4.8
        Pacific.........................................           417           840           862           2.7
        Puerto Rico.....................................            47           306           320           4.4
    Rural by Region.....................................         1,610           451           472           4.8
        New England.....................................            40           549           574           4.6
        Middle Atlantic.................................            67           473           496           4.9
        South Atlantic..................................           232           469           490           4.3
        East North Central..............................           215           457           482           5.3
        East South Central..............................           239           415           434           4.8
        West North Central..............................           279           443           466           5.2
        West South Central..............................           285           405           424           4.7
        Mountain........................................           145           467           490           5.0
        Pacific.........................................           103           531           556           4.7
By Payment Classification:
    All hospitals.......................................         4,230           668           693           3.8
    Large urban areas (populations over 1 million)......         1,576           765           792           3.4
    Other urban areas (populations of 1 million or               1,074           655           681           4.0
     fewer).............................................
    Rural areas.........................................         1,580           449           470           4.8
    Teaching Status:
        Non-teaching....................................         3,119           546           568           4.0
        Fewer than 100 Residents........................           870           698           725           3.8
        100 or more Residents...........................           241         1,030         1,064           3.3
        Urban DSH:
            100 or more beds............................         1,361           758           784           3.4
            Less than 100 beds..........................           286           482           502           4.2
        Rural DSH:
            Sole Community (SCH/EACH)...................           470           394           414           5.1
            Referral Center (RRC/EACH)..................           156           516           537           4.1
            Other Rural:
                100 or more beds........................            76           419           438           4.6
                Less than 100 beds......................           332           379           399           5.2
    Urban teaching and DSH:
        Both teaching and DSH...........................           757           836           864           3.4
        Teaching and no DSH.............................           284           750           781           4.2
        No teaching and DSH.............................           890           602           624           3.6
        No teaching and no DSH..........................           719           596           619           3.8
    Rural Hospital Types:
        Non special status hospitals....................           577           399           419           5.0
        RRC/EACH........................................           160           528           549           4.0
        SCH/EACH........................................           526           417           438           5.1
        Medicare-dependent hospitals (MDH)..............           241           372           394           5.9
        SCH, RRC and EACH...............................            76           507           532           5.0
Hospitals Reclassified by the Medicare Geographic
 Classification Review Board:
    Reclassification Status During FY2002 and FY2003:
        Reclassified During Both FY2002 and FY2003......           573           585           610           4.1
            Reclassified During FY2003 Only.............            54           525           570           8.6
            Reclassified During FY2002 Only.............            77           764           758          -0.7
        FY2003 Reclassifications:
            All Reclassified Hospitals..................           628           581           606           4.5
            All Nonreclassified Hospitals...............         3,567           684           709           3.7
            All Urban Reclassified Hospitals............           113           780           814           4.4
            Urban Nonreclassified Hospitals.............         2,473           719           745           3.6
            All Reclassified Rural Hospitals............           515           503           525           4.5
            Rural Nonreclassified Hospitals.............         1,094           389           409           5.2
        Other Reclassified Hospitals (Section                       35           455           483           6.2
         1886(D)(8)(B)).................................
    Type of Ownership:
        Voluntary.......................................         2,461           680           708           4.0
        Proprietary.....................................           723           659           673           2.1

[[Page 50288]]

 
        Government......................................           869           604           629           4.2
    Medicare Utilization as a Percent of Inpatient Days:
        0-25............................................           310           864           892           3.3
        25-50...........................................         1,613           766           792           3.5
        50-65...........................................         1,677           583           607           4.1
        Over 65.........................................           504           523           546           4.3
----------------------------------------------------------------------------------------------------------------

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

I. Background

    Consistent with section 1886(e)(5)(B) of the Act, in this final 
rule we are publishing our final recommendations for updating 
hospital payments for FY 2003. In accordance with section 
1886(d)(3)(A) and section 1886(b)(3)(B)(i)(XVIII) of the Act, we are 
updating the standardized amounts for FY 2003 equal to the rate of 
increase in the hospital market basket minus 0.55 percentage points 
for acute inpatient prospective payments to 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 of increase in the market basket minus 0.55 
percentage points.
    Based on the revised and rebased second quarter 2002 forecast of 
the FY 2003 market basket increase of 3.5 percent, the update to the 
standardized amounts for hospitals subject to the acute inpatient 
prospective payment system is 2.95 percent (that is, the market 
basket rate of increase minus 0.55 percentage points) for hospitals 
in both large urban and other areas. The update to the hospital-
specific rate applicable to SCHs and MDHs is also 2.95 percent. In 
the proposed rule, the market basket was 3.3 percent, for proposed 
update factors of 2.75 percent.
    Under section 1886(b)(3)(B)(ii)(VIII) of the Act, the FY 2003 
percentage increase in the rate-of-increase limits for hospitals and 
hospital units excluded from the acute inpatient prospective payment 
system is equal to the market basket percentage increase. Facilities 
excluded from the acute 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 
acute 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 update is the 
percentage increase in the excluded hospital market basket 
(currently estimated at 3.5 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 have proposed that long-term care hospitals would be paid under a 
prospective payment system based on a 5-year transition period (see 
the March 22, 2002 proposed rule (67 FR 13416)). We also proposed 
that a long-term care hospital may elect to be paid on 100 percent 
of the Federal prospective payment 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 3.5 
percent).
    Section 1886(e)(4) of the Act requires that the Secretary, 
taking into consideration the recommendations of the Medicare 
Payment Advisory Commission (MedPAC), recommend update factors for 
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, we published the FY 2003 update factors 
recommended by the Secretary as Appendix C in the May 9, 2002 
proposed rule (67 FR 31685). In that appendix, we discussed the 
recommendations of appropriate update factors and the analysis 
underlying our recommendations. We also responded to MedPAC's 
recommendations concerning the update factors.

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

    In recommending an update, the Secretary takes into account the 
factors in the update framework, as well as other factors such as 
the recommendations of MedPAC, the long-term solvency of the 
Medicare Trust Funds, and the capacity of the hospital industry to 
continually provide access to high quality care to Medicare 
beneficiaries through adequate reimbursement to health care 
providers.
    Comment: Numerous commenters pointed out the negative impact of 
reducing the market basket estimate by 0.55 percentage points. 
However, the commenters acknowledged that the statute requires an 
update to payments for FY 2002 of the market basket percentage 
increase minus 0.55 percentage points. One commenter stated that 
another year of ``market basket minus'' update was unsustainable.
    Response: The commenters are correct that the 0.55 percentage 
point reduction from the market basket in calculating the update 
factor is required by statute.
    Our final recommendation of the update is market basket minus 
0.55 percentage points, which is consistent with current law, and 
does not differ from the proposed recommendation. However, the 
second quarter forecast of the market basket percentage increase is 
3.5 for prospective payment hospitals (up from 3.3 percent estimated 
in the proposed rule). Thus, the Secretary's final recommendation is 
that the update to the prospective payment system standardized 
amounts for both large urban and other urban areas is 2.95 
percentage points. The update to the hospital-specific rate 
applicable to SCHs and MDHs is also 2.95 percent (or consistent with 
current law, market basket percentage increase minus 0.55 percentage 
points).

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

    We received no comments concerning our proposed recommendation 
for updating the rate-of-increase for excluded hospitals and 
hospital units. Our final recommendation does not differ from the 
proposed recommendation. However, the second quarter forecast of the 
market basket percentage increase is 3.5 for excluded hospitals and 
hospital units (up from 3.4 percent estimated in the proposed rule).
    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.
    For purposes of the proposed long-term care hospital prospective 
payment system update factor, the portion of the 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

[[Page 50289]]

the most recent available estimate of the increase in the excluded 
hospital operating market basket (or 3.5 percent).
    Thus, the Secretary's final recommendation is that the update 
for the remaining hospitals and hospital units excluded from the 
acute inpatient prospective payment system is 3.5 percent.

[FR Doc. 02-19292 Filed 7-31-02; 8:45 am]
BILLING CODE 4120-01-P