[Federal Register Volume 68, Number 96 (Monday, May 19, 2003)]
[Proposed Rules]
[Pages 27154-27422]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 03-11966]
[[Page 27153]]
-----------------------------------------------------------------------
Part II
Department of Health and Human Services
-----------------------------------------------------------------------
Centers for Medicare & Medicaid Services
-----------------------------------------------------------------------
42 CFR Parts 412 and 413
Medicare Program; Proposed Changes to the Hospital Inpatient
Prospective Payment Systems and Fiscal Year 2004 Rates; Proposed Rule
Federal Register / Vol. 68, No. 96 / Monday, May 19, 2003 / Proposed
Rules
[[Page 27154]]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 412 and 413
[CMS-1470-P]
RIN 0938-AL89
Medicare Program; Proposed Changes to the Hospital Inpatient
Prospective Payment Systems and Fiscal Year 2004 Rates
AGENCY: Centers for Medicare and Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
-----------------------------------------------------------------------
SUMMARY: We are proposing to revise the Medicare hospital inpatient
prospective payment systems (IPPS) for operating and capital costs to
implement changes arising from our continuing experience with these
systems. In addition, in the Addendum to this proposed rule, we are
describing proposed changes to the amounts and factors used to
determine the rates for Medicare hospital inpatient services for
operating costs and capital-related costs. These changes would be
applicable to discharges occurring on or after October 1, 2003. We also
are setting forth proposed rate-of-increase limits as well as proposed
policy changes for hospitals and hospital units excluded from the IPPS.
Among other changes that we are proposing are changes to the
policies governing postacute care transfers, payments to hospitals for
the direct and indirect costs of graduate medical education,
determination of hospital beds and patient days for payment adjustment
purposes, and payments to critical access hospitals (CAHs).
DATES: Comments will be considered if received at the appropriate
address, as provided below, no later than 5 p.m. on July 18, 2003.
ADDRESSES: Mail written comments (an original and three copies) to the
following address only: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-1470-P, P.O.
Box 8010, Baltimore, MD 21244-1850.
If you prefer, you may deliver, by hand or courier, your written
comments (an original and three copies) to one of the following
addresses:
Room 443-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW.,
Washington, DC 20201, or
Room C5-14-03, Central Building, 7500 Security Boulevard, Baltimore, MD
21244-1850.
(Because access to the interior of the Humphrey Building is not readily
available to persons without Federal Government identification,
commenters are encouraged to leave their comments in the CMS drop slots
located in the main lobby of the building. A stamp-in clock is
available for commenters who wish to retain proof of filing by stamping
in and keeping an extra copy of the comments being filed.)
Comments mailed to those addresses specified as appropriate for
courier delivery may be delayed and could be considered late.
Because of staffing and resource limitations, we cannot accept
comments by facsimile (FAX) transmission. In commenting, please refer
to file code CMS-1470-P.
For information on viewing public comments see the beginning of the
SUPPLEMENTARY INFORMATION section.
For comments that relate to information collection requirements,
mail a copy of comments to the following addresses:
Centers for Medicare & Medicaid Services, Office of Strategic
Operations and Regulatory Affairs, Security and Standards Group, Office
of Regulations Development and Issuances, Room N2-14-26, 7500 Security
Boulevard, Baltimore, Maryland 21244-1850. Attn: Julie Brown, CMS-1470-
P; and
Office of Information and Regulatory Affairs, Office of Management and
Budget, Room 3001, New Executive Office Building, Washington, DC 20503,
Attn: Brenda Aguilar, CMS Desk Officer.
FOR FURTHER INFORMATION CONTACT:
Stephen Phillips, (410) 786-4548, Operating Prospective Payment,
Diagnosis-Related Groups (DRGs), Wage Index, New Medical Services and
Technology, Patient Transfers, Counting Beds and Patient Days, and
Hospital Geographic Reclassifications Issues;
Tzvi Hefter, (410) 786-4487, Capital Prospective Payment, Excluded
Hospitals, Nursing and Allied Health Education, Graduate Medical
Education, and Critical Access Hospital Issues.
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments
Comments received timely will be available for public inspection as
they are received, generally beginning approximately 3 weeks after
publication of a document, in Room C5-12-08 of the Centers for Medicare
& Medicaid Services, 7500 Security Blvd., Baltimore, MD, on Monday
through Friday of each week from 8:30 a.m. to 5 p.m. Please call (410)
786-7197 to schedule an appointment to view public comments.
Availability of Copies and Electronic Access
Copies: To order copies of the Federal Register containing this
document, send your request to: New Orders, Superintendent of
Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. Specify the date
of the issue requested and enclose a check or money order payable to
the Superintendent of Documents, or enclose your Visa or Master Card
number and expiration date. Credit card orders can also be placed by
calling the order desk at (202) 512-1800 or by faxing to (202) 512-
2250. The cost for each copy is $10.00. As an alternative, you can view
and photocopy the Federal Register document at most libraries
designated as Federal Depository Libraries and at many other public and
academic libraries throughout the country that receive the Federal
Register.
This Federal Register document is also available from the Federal
Register online database through GPO Access, a service of the U.S.
Government Printing Office. Free public access is available on a Wide
Area Information Server (WAIS) through the Internet and via
asynchronous dial-in. Internet users can access the database by using
the World Wide Web; the Superintendent of Documents home page address
is http://www.access.gpo.gov/nara_docs/, by using local WAIS client
software, or by telnet to swais.access.gpo.gov, then login as guest (no
password required). Dial-in users should use communications software
and modem to call (202) 512-1661; type swais, then login as guest (no
password required).
Table of Contents
I. Background
A. Summary
B. Major Contents of This Proposed Rule
II. Proposed Changes to DRG Classifications and Relative Weights
A. Background
B. DRG Reclassification
1. General
2. Review of DRGs for CC Split
3. MDC 1 (Diseases and Disorders of the Nervous System)
a. Revisions of DRGs 1 and 2
b. DRG 23 (Nontraumatic Stupor and Coma)
4. MDC 5 (Diseases and Disorders of the Circulatory System)
a. DRG 478 (Other Vascular Procedures With CC) and DRG 479
(Other Vascular Procedures Without CC)
b. DRGs 514 (Cardiac Defibrillator Implant With Cardiac
Catheterization) and 515
[[Page 27155]]
(Cardiac Defibrillator Implant Without Cardiac Catheterization)
5. MDC 8 (Diseases and Disorders of the Musculoskeletal System
and Connective Tissue)
6. MDC 15 (Newborns and Other Neonates with Conditions
Originating in the Perinatal Period)
a. Nonneonate Diagnoses
b. Heart Failure Codes for Newborns and Neonates
7. MDC 17 (Myeloproliferative Diseases and Disorders and Poorly
Differentiated Neoplasms)
8. MDC 23 (Factors Influencing Health Status and Other Contracts
with Health Services)
a. Implantable Devices
b. Malignancy Codes
9. Medicare Code Editor (MCE) Change
10. Surgical Hierarchies
11. Refinement of Complications and Comorbidities (CC)
12. Review of Procedure Codes in DRGs 468, 476, and 477
a. Moving Procedure Codes from DRG 468 or DRG 477 to MDCs
b. Reassignment of Procedures among DRGs 468, 476, and 477
c. Adding Diagnosis Codes to MDCs
13. Changes to the ICD-9-CM Coding System
14. Other Issues
a. Cochlear Implants
b. Burn Patients on Mechanical Ventilation
c. Multiple Level Spinal Fusion
d. Heart Assist System Implant
e. Drug-Eluting Stents
f. Artificial Anal Spincter
C. Recalibration of DRG Weights
D. Proposed LTC-DRG Reclassifications and Relative Weights for
LTCHs for FY 2004
1. Background
2. Proposed Changes in the LTC-DRG Classifications
a. Background
b. Patient Classifications into DRGs
3. Development of the Proposed FY 2004 LTC-DRG Relative Weights
a. General Overview of Development of the LTC-DRG Relative
Weights
b. Data
c. Hospital-Specific Relative Value Methodology
d. Low Volume LTC-DRGs
4. Steps for Determining the Proposed FY 2004 LTC-DRG Relative
Weights
E. Add-On Payments for New Services and Technologies
1. Background
2. FY 2004 Status of Technology Approved for FY 2003 Add-On
Payments: Drotrecogin Alfa (Activated)--Xigris[reg]
3. FY 2004 Applicants for New Technology Add-On Payments
a. Bone Morphogenetic Proteins (BMPs) for Spinal Fusions
b. GLIADEL[reg] Wafer
4. Review of the High-Cost Threshold
5. Technical Changes
III. Proposed Changes to the Hospital Wage Index
A. Background
B. Proposed FY 2004 Wage Index Update
C. FY 2004 Wage Index Proposals
1. Elimination of Wage Costs Associated with Rural Health
Clinics and Federally Qualified Health Centers
2. Paid Hours
D. Verification of Wage Data from the Medicare Cost Reports
E. Computation of the Proposed FY 2004 Wage Index
F. Proposed Revisions to the Wage Index Based on Hospital
Redesignation
1. General
2. Effects of Reclassification
G. Requests for Wage Data Corrections
H. Modification of the Process and Timetable for Updating the
Wage Index
IV. Other Decisions and Proposed Changes to the IPPS for Operating
Costs and GME Costs
A. Transfer Payment Policy
1. Transfers to Another Acute Care Hospital
2. Technical Correction
3. Expanding the Postacute Care Transfer Policy to Additional
DRGs
B. Rural Referral Centers
1. Case-Mix Index
2. Discharges
C. Indirect Medical Education (IME) Adjustment and
Disproportionate Share Hospital (DSH) Adjustment
1. Available Beds and Patient Days: Background
2. Unoccupied Beds
3. Nonacute Care Beds and Days
4. Observation Beds and Swing-Beds
5. Labor, Delivery, Recovery, and Postpartum Beds and Days
6. Days Associated with Demonstration Projects under Section
1115 of the Act
7. Dual-Eligible Patient Days
8. Medicare+Choice (M+C) Days
D. Medicare Geographic Classification Review Board (MGCRB)
Reclassification Process
E. Costs of Approved Nursing and Allied Health Education
Activities
1. Background
2. Continuing Education Issue for Nursing and Allied Health
Education Activities
3. Programs Operated by Wholly Owned Subsidiary Educational
Institutions of Hospitals
F. Payment for Direct Costs of Graduate Medical Education
1. Background
2. Prohibition Against Counting Residents Where Other Entities
First Incur the Training Costs
3. Rural Track FTE Limitation for Purposes of Direct GME and IME
for Urban Hospitals that Establish Separately Accredited Approved
Medical Programs in a Rural Area
a. Change in the Amount of Rural Training Time Required for an
Urban Hospital to Qualify for an Increase in the Rural Track FTE
Limitation
b. Inclusion of Rural Track FTE Residents in the Rolling Average
Calculation
4. Technical Changes Related to Affiliated Groups and Affiliated
Agreements
G. Notification of Updates to the Reasonable Compensation
Equivalent (RCE) Limits
1. Background
2. Publication of the Updated RCE Limits
V. PPS for Capital-Related Costs
VI. Proposed Changes for Hospitals and Hospital Units Excluded from
the IPPS
A. Payments to Excluded Hospitals and Hospital Units
1. Payments to Existing Excluded Hospitals and Hospital Units
2. Updated Caps for New Excluded Hospitals and Units
3. Implementation of a PPS for IRFs
4. Implementation of a PPS for LTCHs
B. Payment for Services Furnished at Hospitals-Within-Hospitals
and Satellite Facilities
C. Clarification of Classification Requirements for LTCHs
D. Criteria for Payment on a Reasonable Cost Basis for Clinical
Diagnostic Laboratory Services Performed by CAHs
E. Technical Changes
VII. MedPAC Recommendations
VIII. Other Required Information
A. Requests for Data from the Public
B. Collection of Information Requirements
Regulation Text
Addendum--Proposed Schedule of Standardized Amounts Effective
with Discharges Occurring On or After October 1, 2003 and Update
Factors and Rate-of-Increase Percentages Effective With Cost
Reporting Periods Beginning On or After October 1, 2003
Tables
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 2002
(1998 Wage Data), 2003 (1999 Wage Data), and 2004 (2000 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, and Geometric and Arithmetic Mean Length of Stay (LOS)
Table 6A--New Diagnosis Codes
Table 6B--New Procedure Codes
Table 6C--Invalid Diagnosis Codes
Table 6D--Invalid Procedure Codes
[[Page 27156]]
Table 6E--Revised Diagnosis Code Titles
Table 6F--Revised Procedure Code Titles
Table 6G--Additions to the CC Exclusions List
Table 6H--Deletions from the CC Exclusions List
Table 7A--Medicare Prospective Payment System Selected Percentile
Lengths of Stay FY 2002 MedPAR Update December 2002 GROUPER V20.0
Table 7B--Medicare Prospective Payment System Selected Percentile
Lengths of Stay FY 2002 MedPAR Update December 2002 GROUPER V21.0
Table 8A--Statewide Average Operating Cost-to-Charge Ratios for
Urban and Rural Hospitals (Case Weighted) March 2003
Table 8B--Statewide Average Capital Cost-to-Charge Ratios (Case
Weighted) March 2003
Table 9--Hospital Reclassifications and Redesignations by Individual
Hospital--FY 2004
Table 10--Mean and Standard Deviations by Diagnosis-Related Groups
(DRGs)--FY 2004
Table 11--Proposed LTC-DRGs Relative Weights and Geometric and Five-
Sixths of the Average Length of Stay--FY 2004
Appendix A--Regulatory Impact Analysis
Appendix B--Recommendation of Update Factors for Operating Cost
Rates of Payment for Inpatient Hospital Services
Acronyms
AHIMA American Health Information Management Association
AHA American Hospital Association
CAH Critical access hospital
CBSAs Core Based Statistical Areas
CC Complication or comorbidity
CMS Centers for Medicare & Medicaid Services
CMSA Consolidated Metropolitan Statistical Areas
COBRA Consolidated Omnibus Reconciliation Act of 1985, Pub. L. 99-
272
CPI Consumer Price Index
CRNA Certified registered nurse anesthetist
DRG Diagnosis-related group
DSH Disproportionate share hospital
FDA Food and Drug Administration
FQHC Federally qualified health center
FTE Full-time eguivalent
FY Federal fiscal year
GME Graduate medical education
HIPC Health Information Policy Council
HIPAA Health Insurance Portability and Accountability Act, Pub. L.
104-191
HHA Home health agency
ICD-9-CM International Classification of Diseases, Ninth Revision,
and Clinical Modification
ICD-10-PCS International Classification of Diseases Tenth Edition,
and Procedure Coding System
IME Indirect medical education
IPPS Acute care hospital inpatient prospective payment system
IRF Inpatient Rehabilitation Facility
LDRP Labor, delivery room, and postpartum
LTC-DRG Long-term care diagnosis-related group
LTCH Long-term care hospital
MCE Medicare Code Editor
MDC Major diagnostic category
MDH Medicare-dependent small rural hospital
MedPAC Medicare Payment Advisory Commission
MedPAR Medicare Provider Analysis and Review File
MEI Medicare Economic Index
MGCRB Medicare Geographic Classification Review Board
MPFS Medicare Physician Fee Schedule
MSA Metropolitan Statistical Area
NECMA New England County Metropolitan Areas
NCHS National Center for Health Statistics
NCHVS National Committee on Health and Vital Statistics
O.R. Operating room
PPS Prospective payment system
PRA Per resident amount
ProPAC Prospective Payment Assessment Commission
PRRB Provider Reimbursement Review Board
RCE Reasonable compensation equivalent
RHC Rural health center
RRC Rural referral center
SCH Sole community hospital
SNF Skilled nursing facility
TEFRA Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-
248
UHDDS Uniform Hospital Discharge Data Set
I. Background
A. Summary
1. Acute Care Hospital Inpatient Prospective Payment System (IPPS)
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 (PPS). Under these PPSs,
Medicare payment for hospital inpatient operating and capital-related
costs is made at predetermined, specific rates for each hospital
discharge. Discharges are classified according to a list of diagnosis-
related groups (DRGs).
The base payment rate is comprised of a standardized amount that is
divided into a labor-related share and a nonlabor-related share. The
labor-related share is adjusted by the wage index applicable to the
area where the hospital is located; and if the hospital is located in
Alaska or Hawaii, the nonlabor-related share is adjusted by a cost-of-
living adjustment factor. This base payment rate is multiplied by the
DRG relative weight.
If the hospital treats a high percentage of low-income patients, it
receives a percentage add-on payment applied to the DRG-adjusted base
payment rate. This add-on payment, known as the disproportionate share
hospital (DSH) adjustment, provides for a percentage increase in
Medicare payments to hospitals that qualify under either of two
statutory formulas designed to identify hospitals that serve a
disproportionate share of low-income patients. For qualifying
hospitals, the amount of this adjustment may vary based on the outcome
of the statutory calculations.
If the hospital is an approved teaching hospital, it receives a
percentage add-on payment for each case paid under the IPPS (known as
the indirect medical education (IME) adjustment). 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, a new technology must demonstrate that it is a substantial
clinical improvement over technologies otherwise available, and that,
absent an add-on payment, it would be inadequately paid 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,
plus any DSH, IME, and new technology add-on adjustments.
Although payments to most hospitals under the IPPS 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 FY 1982, FY 1987, or FY 1996) or the IPPS rate
based on the standardized amount. For example, sole community hospitals
(SCHs) are the sole source of care in their areas, and Medicare-
dependent, small rural hospitals (MDHs) are a major source of care for
Medicare beneficiaries in their areas. Both of these categories of
hospitals are afforded this special payment protection in order to
maintain access to services for beneficiaries (although MDHs receive
only 50 percent of the difference between the IPPS rate and their
hospital-specific rates if the hospital-specific rate is higher than
the IPPS rate).
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
[[Page 27157]]
system established by the Secretary.'' The basic methodology for
determining capital prospective payments is set forth in our
regulations at 42 CFR 412.308 and 412.312. Under the capital PPS,
payments are adjusted by the same DRG for the case as they are under
the operating IPPS. Similar adjustments are also made for IME and DSH
as under the operating IPPS. In addition, hospitals may receive an
outlier payment for those cases that have unusually high costs.
The existing regulations governing payments to hospitals under the
IPPS are located in 42 CFR part 412, subparts A through M.
2. Hospitals and Hospital Units Excluded From the IPPS
Under section 1886(d)(1)(B) of the Act, as amended, certain
specialty hospitals and hospital units are excluded from the IPPS.
These hospitals and units are: Psychiatric hospitals and units,
rehabilitation hospitals and units; long-term care hospitals (LTCHs);
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 PPSs for rehabilitation
hospitals and units (referred to as inpatient rehabilitation facilities
(IRFs)), psychiatric hospitals and units, and LTCHs, as discussed
below. Children's hospitals and cancer hospitals continue to be paid
under reasonable cost-based reimbursement.
The existing regulations governing payments to excluded hospitals
and hospital units are located in 42 CFR parts 412 and 413.
a. Inpatient Rehabilitation Facilities. Under section 1886(j) of
the Act, as amended, rehabilitation hospitals and units (IRFs) have
been transitioned from payment based on a blend of reasonable cost
reimbursement subject to a hospital-specific annual limit under section
1886(b) of the Act and prospective payments for cost reporting periods
beginning January 1, 2002 through September 30, 2002, to payment on a
full prospective payment system basis effective for cost reporting
periods beginning on or after October 1, 2002 (66 FR 41316, August 7,
2001 and 67 FR 49982, August 1, 2002). The existing regulations
governing payments under the IRF PPS are located in 42 CFR part 412,
subpart P.
b. LTCHs. Under the authority of sections 123(a) and (c) of Pub. L.
106-113 and section 307(b)(1) of Pub. L. 106-554, LTCHs are being
transitioned from being paid for inpatient hospital services based on a
blend of reasonable cost-based reimbursement under section 1886(b) of
the Act to fully Federal prospective rates during a 5-year period,
beginning with cost reporting periods that start on or after October 1,
2002. For cost reporting periods beginning on or after October 1, 2006,
LTCHs will be paid under the fully Federal prospective payment rate
(the August 30, 2002 LTCH PPS final rule (67 FR 55954)). LTCHs may
elect to be paid based on full PPS payments instead of a blended
payment in any year during the 5-year transition period. The existing
regulations governing payment under the LTCH PPS are located in 42 CFR
part 412, subpart O.
c. Psychiatric Hospitals and Units. Sections 124(a) and (c) of Pub.
L. 106-113 provide for the development of a per diem PPS for payment
for inpatient hospital services furnished in 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 maintain
budget neutrality. We are in the process of developing a proposed rule,
to be followed by a final rule, to implement the PPS 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 payments to the various
types of hospitals are located in 42 CFR part 413.
B. Major Contents of This Proposed Rule
In this proposed rule, we are setting forth proposed changes to the
Medicare IPPS for operating costs and for capital-related costs in FY
2004. We also are proposing changes relating to payments for GME costs,
payments to CAHs, and payments to providers classified as psychiatric
hospitals and units that continue to be excluded from the IPPS and paid
on a reasonable cost basis. The proposed changes would be effective for
discharges occurring on or after October 1, 2003.
The following is a summary of the major changes that we are
proposing to make:
1. Proposed Changes to the DRG Reclassifications and Recalibrations of
Relative Weights
As required by section 1886(d)(4)(C) of the Act, we adjust the DRG
classifications and relative weights annually. Based on analyses of
Medicare claims data, we are proposing to establish a number of new
DRGs and make changes to the designation of diagnosis and procedure
codes under other existing DRGs. Our proposed changes for FY 2004 are
set forth in section II. of this preamble.
Among the proposed changes discussed are:
[sbull] Expanding the number of DRGs that are split on the basis of
the presence or absence of complications or comorbidities (CCs). The
DRGs we are proposing to split are: DRG 4 (Spinal Procedures), DRG 5
(Extracranial Vascular Procedures), DRG 231 (Local Excision and Removal
of Internal Fixation Devices Except Hip and Femur) and DRG 400
(Lymphoma and Leukemia With Major O.R. Procedure).
[sbull] Creating two new DRGs to differentiate current DRG 514
(Cardiac Defibrillator Implant With Cardiac Catheterization) on the
basis of whether the patient does or does not experience any of the
following symptoms: acute myocardial infarction, heart failure, or
shock.
[sbull] Changing the DRG assignments of certain congenital
anomalies that currently result in patients being assigned to newborn
DRGs even when the patient is actually an adult. We also are adding to
the list of major problems in newborns that affect DRG assignment.
[sbull] Modifying DRG 492 (Chemotherapy With Acute Leukemia as
Secondary Diagnosis) to include in this DRG cases receiving high-dose
Interleukin-2 (IL-2)
[[Page 27158]]
chemotherapy for patients with advanced renal cell cancer and advanced
melanoma.
We also are presenting our analysis of applicants for add-on
payments for high-cost new medical technologies.
2. Proposed Changes to the Hospital Wage Index
In section III. of this preamble, we discuss proposed revisions to
the wage index and the annual update of the wage data. Specific issues
addressed in this section include the following:
[sbull] The proposed FY 2004 wage index update, using wage data
from cost reporting periods that began during FY 2000.
[sbull] Proposed exclusion of the wage data for rural health
centers (RHCs) and Federally qualified health centers (FQHCs) from the
calculation of the FY 2004 wage index.
[sbull] Proposed exclusion of paid hours associated with military
and jury duty leave from the wage index calculation, and request for
comments on possible exclusion of paid lunch or meal break hours.
[sbull] Proposed revisions to the wage index based on hospital
redesignations and reclassifications.
[sbull] Proposed amendments to the timetable for reviewing and
verifying the wage data that will be in effect for the FY 2005 wage
index.
3. Other Decisions and Proposed Changes to the PPS for Inpatient
Operating and GME Costs
In section IV. of this preamble, we discuss several provisions of
the regulations in 42 CFR parts 412 and 413 and set forth certain
proposed changes concerning the following:
[sbull] Proposed expansion of the current postacute transfer policy
to 19 additional DRGs.
[sbull] Proposed clarification of our policies that would be
applied to counting hospital beds and patient days, in particular with
regard to the treatment of swing-beds and observation beds, for
purposes of the IME and DSH adjustments.
[sbull] Proposed changes in our policy relating to nursing and
allied health education payments to wholly owned subsidiary educational
institutions of hospitals.
[sbull] Proposed clarification of policy relating to application of
redistribution of costs and community support funds in determining a
hospital's resident training costs.
[sbull] Proposed change in the amount of rural training time
required for an urban hospital to qualify for an increase in the rural
track FTE limitation.
[sbull] Proposed inclusion of FTE residents training in rural
tracks in a hospital's rolling average calculation.
4. PPS for Capital-Related Costs
In section V., of this preamble, we discuss the payment
requirements for capital-related costs. We are not proposing any
changes to the policies on payments to hospitals for capital-related
costs.
5. Proposed Changes for Hospitals and Hospital Units Excluded from
the IPPS
In section VI., of this preamble, we discuss the following
proposals concerning excluded hospitals and hospital units and CAHs:
[sbull] Revisions relating to the operation of excluded
``grandfathered'' hospitals-within-hospitals in effect on September 30,
1999.
[sbull] Clarification of the classification criteria for LTCHs.
[sbull] Clarification of the policy on payments for laboratory
services provided by a CAH to patients outside a CAH.
6. Determining Prospective Payment Operating and Capital Rates and
Rate-of-Increase Limits
In the Addendum to this proposed rule, we set forth proposed
changes to the amounts and factors for determining the FY 2004
prospective payment rates for operating costs and capital-related
costs. We also establish the proposed threshold amounts for outlier
cases. In addition, we address update factors for determining the rate-
of-increase limits for cost reporting periods beginning in FY 2004 for
hospitals and hospital units excluded from the PPS.
7. Impact Analysis
In Appendix A, we set forth an analysis of the impact that the
proposed changes described in this proposed rule would have on affected
hospitals.
8. Proposed Recommendation of Update Factor for Hospital Inpatient
Operating Costs
As required by sections 1886(e)(4) and (e)(5) of the Act, Appendix
B provides our recommendation of the appropriate percentage change for
FY 2004 for the following:
[sbull] 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 IPPS for operating costs.
[sbull] Target rate-of-increase limits to the allowable operating
costs of hospital inpatient services furnished by hospitals and
hospital units excluded from the IPPS.
9. 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, no
later than March 1 of each year, that reviews and makes recommendations
on Medicare payment policies. This annual report makes recommendations
concerning hospital inpatient payment policies. In section VII., of
this preamble, we discuss the MedPAC recommendations and any actions we
are proposing to take with regard to them (when an action is
recommended). For further information relating specifically to the
MedPAC March 1 report or to obtain a copy of the report, contact MedPAC
at (202) 653-7220 or visit MedPAC's Web site at: http://www.medpac.gov.
II. Proposed Changes to DRG Classifications and Relative Weights
A. Background
Section 1886(d) of the Act specifies that the Secretary shall
establish a classification system (referred to as DRGs) for inpatient
discharges and adjust payments under the IPPS based on appropriate
weighting factors assigned to each DRG. Therefore, under the IPPS, we
pay for inpatient hospital services on a rate per discharge basis that
varies according to the DRG to which a beneficiary's stay is assigned.
The formula used to calculate payment for a specific case multiplies an
individual hospital's payment rate per case by the weight of the DRG to
which the case is assigned. Each DRG weight represents the average
resources required to care for cases in that particular DRG relative to
the average resources used to treat cases in all DRGS.
Congress recognized that it would be necessary to recalculate the
DRG relative weights periodically to account for changes in resource
consumption. Accordingly, section 1886(d)(4)(C) of the Act requires
that the Secretary adjust the DRG classifications and relative weights
at least annually. These adjustments are made to reflect changes in
treatment patterns, technology, and any other factors that may change
the relative use of hospital resources. The proposed changes to the DRG
classification system and the proposed recalibration of the DRG weights
for discharges occurring on or after October 1, 2003 are discussed
below.
[[Page 27159]]
B. DRG Reclassification
1. General
Cases are classified into DRGs for payment under the IPPS based on
the principal diagnosis, up to eight additional diagnoses, and up to
six procedures performed during the stay. In a small number of DRGs,
classification is also based on the 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. This approach is used because the clinical care is
generally organized in accordance with the organ system affected.
However, some MDCs are not constructed on this basis because they
involve multiple organ systems (for example, MDC 22 (Burns)). The table
below lists the 25 MDCs.
------------------------------------------------------------------------
Major Diagnostic Categories
------------------------------------------------------------------------
1 Diseases and Disorders of the Nervous System.
2 Diseases and Disorders of the Eye.
3 Diseases and Disorders of the Ear, Nose, Mouth, and Throat.
4 Diseases and Disorders of the Respiratory System.
5 Diseases and Disorders of the Circulatory System.
6 Diseases and Disorders of the Digestive System.
7 Diseases and Disorders of the Hepatobiliary System and Pancreas.
8 Diseases and Disorders of the Musculoskeletal System and
Connective Tissue.
9 Diseases and Disorders of the Skin, Subcutaneous Tissue and
Breast.
10 Endocrine, Nutritional and Metabolic Diseases and Disorders.
11 Diseases and Disorders of the Kidney and Urinary Tract.
12 Diseases and Disorders of the Male Reproductive System.
13 Diseases and Disorders of the Female Reproductive System.
14 Pregnancy, Childbirth, and the Puerperium.
15 Newborns and Other Neonates with Conditions Originating in the
Perinatal Period.
16 Diseases and Disorders of the Blood and Blood Forming Organs and
Immunological Disorders.
17 Myeloproliferative Diseases and Disorders and Poorly
Differentiated Neoplasms.
18 Infectious and Parasitic Diseases (Systemic or Unspecified
Sites).
19 Mental Diseases and Disorders.
20 Alcohol/Drug Use and Alcohol/Drug Induced Organic Mental
Disorders.
21 Injuries, Poisonings, and Toxic Effects of Drugs.
22 Burns.
23 Factors Influencing Health Status and Other Contacts with Health
Services.
24 Multiple Significant Trauma.
25 Human Immunodeficiency Virus Infections.
------------------------------------------------------------------------
In general, cases are assigned to an MDC based on the patient's
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 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 (less than or greater than 17 years of age).
Some surgical and medical DRGs are further differentiated based on the
presence or absence of a complication or a comorbidity (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).
After cases are screened through the MCE and assigned to a DRG by
the GROUPER, a payment is calculated by the PRICER software. The PRICER
calculates the payments for each case covered by the IPPS based on the
DRG relative weight and factors associated with each hospital, such as
IME and DSH adjustments.
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 IPPS 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 for
consideration in conjunction with the next year's proposed rule, 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 by early December for consideration in conjunction with
the next year's proposed rule.
Many of the changes to the DRG classifications are the result of
specific issues brought to our attention by interested parties. We
encourage individuals with concerns about the DRG classifications to
bring those concerns to our attention in a timely manner so they can be
carefully considered for possible inclusion in the next proposed rule
and so any proposed changes may be subjected to public review and
comment. Therefore, similar to the timetable for interested parties to
submit non-MedPAR data for consideration in the DRG recalibration
process, concerns about DRG classification issues should be brought to
our attention no later than early December in order to be considered
and possibly included in the next annual proposed rule updating the
IPPS.
The changes we are proposing to the DRG classification system for
FY 2004 GROUPER version 21.0 and to the methodology to recalibrate the
DRG weights are set forth below. Unless otherwise noted, our DRG
analysis is based on data from the December 2002 update of the FY 2002
MedPAR file, which contains hospital bills received
[[Page 27160]]
through December 31, 2002, for discharges in FY 2002.
2. Review of DRGs for CC Split
In an effort to improve the clinical and cost cohesiveness of the
DRG classification system, we have evaluated whether additional DRGs
should be split based on the presence or absence of a CC. There are
currently 116 paired CC split DRGs. We last performed a systematic
evaluation and considered changes to the DRGs to recognize the within-
DRG cost differences based on the presence or absence of CCs in 1994
(May 27, 1994 IPPS proposed rule, 59 FR 27715). In 1994, we described a
refined DRG system based on a list of secondary diagnoses that have a
major effect on the resources used by hospitals in treating patients
across DRGs. We analyzed how the presence of the secondary diagnosis
affected resource use compared to other secondary diagnoses, and
classified these secondary diagnoses as non-CC, CC, or major CC. After
finalizing the classification of secondary diagnoses, we evaluated
which collapsed DRGs should be split on the basis of the presence 8 of
a major CC, other CC, or both.\1\ However, this refined system was not
implemented because we did not believe it would be prudent policy to
make changes for which we could not predict the effect on the case-mix
(the average DRG relative weight for all cases) and, thus, payments (60
FR 29209). We were concerned that we would be unable to fulfill the
requirement of section 1886(d)(4)(C)(iii) of the Act that aggregate
payments may not be affected by DRG reclassification and recalibration
of weighting factors. That is, our experience has been that hospitals
respond to major changes to the DRGs by changing their coding practices
in ways that increase total payments (for example, by beginning to
include ICM-9-CM codes that previously did not affect payment for a
case). Because changes in coding behavior do not represent a real
increase in the severity of the overall mix of cases, total payments
should not increase. The only way to ensure this behavioral response
does not lead to higher total payments is to make an offsetting
adjustment to the system in advance of the fiscal year when the changes
are effective.
---------------------------------------------------------------------------
\1\ The complete description of the analysis was published in
the Health Care Financing Review (Edwards, N., Honemann, D., Burley,
D., Navarro, M., ``Refinement of the Medicare Diagnosis-Related
Groups to Incorporate a Measure of Severity,'' Health Care Financing
Review, Winter 1994, Vol. 16, No. 2, p. 45).
---------------------------------------------------------------------------
Section 301(e) of the Medicare, Medicaid, and SCHIP Benefits
Improvement and Protection Act of 2000 Public Law 106-554 authorized
the Secretary to make such a prospective adjustment to the average
standardized amounts for discharges occurring on or after October 1,
2001, to ensure the total payment impacts of changes to the DRGs do not
result in any more or less total spending than would otherwise occur
without the changes (budget neutrality).
Pending a decision whether to replace ICD-9-CM with another
classification system, we are not proposing to proceed with
implementing a refined DRG system at this time. The refined DRG system
discussed in the 1994 Federal Register involved a complete and thorough
assessment of all of the ICD-9-CM diagnosis codes in order to establish
an illness severity level associated with each code. Rather than
undertaking the time-consuming process of establishing illness severity
levels for all ICD-9-CM codes at this time, we believe the more prudent
course would be to delay this evaluation pending the potential
replacement of ICD-9-CM. For example, the National Committee on Health
and Vital Statistics (NCHVS) is considering making a recommendation to
the Secretary on whether to recommend the adoption of ICD-10-CM and the
ICD-10-Procedure Coding System (PCS) as the national uniform standard
coding system for inpatient reporting.
In the meantime, we have undertaken an effort to identify groups of
DRGs where a CC-split appears most justified. Our analysis identified
existing DRGs that meet the following criteria: a reduction in variance
in charges within the DRG of at least 4 percent; fewer than 75 percent
of all patients in the current DRG would be assigned to the with-CC
DRG; and the overall payment impact (higher payments for cases in the
with-CC DRG offset by lower payments for cases in the without-CC DRG)
is at least $40 million.
The following four DRGs meet these criteria: DRG 4 (Spinal
Procedures) and DRG 5 (Extracranial Vascular Procedures) in MDC 1
(Diseases and Disorders of the Nervous System); DRG 231 (Local Excision
and Removal of Internal Fixation Devices Except Hip and Femur) in MDC 8
(Diseases and Disorders of the Musculoskeletal and Connective Tissue);
and DRG 400 (Lymphoma and Leukemia with Major O.R. Procedure) in MDC 17
(Myeloproliferative Diseases and Disorders and Poorly Differentiated
Neoplasms).
The following data indicate that the presence or absence of a CC
was found to have a significant impact on patient charges and average
length of stays in these four DRGs.
----------------------------------------------------------------------------------------------------------------
Number of Average Average length
DRG cases charges of stay
----------------------------------------------------------------------------------------------------------------
DRG 4 (Current)................................................. 4,488 $35,074 7.3
With CC..................................................... 2,514 46,071 10.0
Without CC.................................................. 1,974 21,070 3.9
DRG 5 (Current)................................................. 64,942 18,613 2.9
With CC..................................................... 29,296 23,213 4.1
Without CC.................................................. 35,646 14,833 2.0
DRG 231 (Current)............................................... 8,971 20,147 4.9
With CC..................................................... 4,565 25,948 6.9
Without CC.................................................. 4,406 14,136 2.9
DRg 400 (Current)............................................... 4,275 39,953 9.0
With CC..................................................... 2,990 49,044 11.2
Without CC.................................................. 1,285 18,799 4.0
----------------------------------------------------------------------------------------------------------------
Therefore, we are proposing to establish the following new DRGs:
proposed DRG 531 (Spinal Procedures With CC) and proposed DRG 532
(Spinal Procedures Without CC) in MDC 1; proposed DRG 533 (Extracranial
Vascular Procedures With CC) and proposed DRG 534 (Extracranial
Vascular Procedures Without CC) in
[[Page 27161]]
MDC 1; proposed DRG 537 (Local Excision and Removal of Internal
Fixation Devices Except Hip and Femur With CC) and proposed DRG 538
(Local Excision and Removal of Internal Fixation Devices Except Hip and
Femur Without CC) in MDC 8; and proposed DRG 539 (Lymphoma and Leukemia
With Major O.R. Procedure With CC) and DRG 540 (Lymphoma and Leukemia
With Major O.R. Procedure Without CC) in MDC 17. We are proposing that
DRGs 4, 5, 231, and 400 would become invalid.
3. MDC 1 (Diseases and Disorders of the Nervous System)
a. Revisions of DRGs 1 and 2. In the FY 2003 IPPS final rule, we
split DRGs 1 and 2 (Craniotomy Age 17 With and Without CC,
respectively) based on the presence or absence of a CC (67 FR 49986).
We have received several proposals related to devices or procedures
that are used in a small subset of cases from these DRGs. These
proposals argue that the current payment for these devices or
procedures under DRGs 1 and 2 is inadequate.\2\
---------------------------------------------------------------------------
\2\ We also examined the issue of treating brain tumors through
the implantation of chemotherapy wafers. This analysis is discussed
later in this preamble under section II.E.2.b. relative to the
application for new technology add-on payments for the GLIADEL[reg]
Wafer.
---------------------------------------------------------------------------
Therefore, we undertook an analysis of the charges of various
procedures and diagnoses within DRGs 1 and 2 to assess whether further
changes to these DRGs may be warranted. Currently, the average charges
for cases assigned to DRGs 1 and 2 are approximately $55,000 and
$30,000, respectively. We are proposing to create two separate new DRGs
for: Cases with an intracranial vascular procedure and a principal
diagnosis of an intracranial hemorrhage; and craniotomy cases with a
ventricular shunt procedure (absent another procedure). The former set
of cases are much more expensive than those presently in DRGs 1 and 2;
the latter set of cases are much less expensive.
(1) Intracranial Vascular Procedures
Our analysis indicated that patients with an intracranial vascular
procedure and a principal diagnosis of an intracranial hemorrhage were
significantly more costly than other cases in DRGs 1 and 2. These
patients have an acute condition with a high severity of illness and
risk of mortality. There were 917 cases in DRGs 1 and 2 with an
intracranial vascular procedure and a principal diagnosis of hemorrhage
with average charges of approximately $113,884, which are much higher
than the average charges of DRGs 1 and 2 noted above.
We also found 890 cases that had an intracranial vascular procedure
without a principal diagnosis of hemorrhage (for example, nonruptured
aneurysms). These cases are generally less acutely ill than those
involving ruptured aneurysms, and have a lower risk of mortality. Among
these 890 cases, the average charges were approximately $52,756, which
are much more similar to the average charges for all cases in DRGs 1
and 2.
Based on this analysis, we are proposing to create new DRG 528
(Intracranial Vascular Procedure With a Principal Diagnosis of
Hemorrhage) for patients with an intracranial vascular procedure and an
intracranial hemorrhage. We are proposing that cases involving
intracranial vascular procedures without a principal diagnosis of
hemorrhage would remain in DRGs 1 and 2.
Proposed new DRG 528 would have the following principal diagnoses:
[sbull] 094.87, Syphilitic ruptured cerebral aneurysm
[sbull] 430, Subarachnoid hemorrhage
[sbull] 431, Intracerebral hemorrhage
[sbull] 432.0, Nontraumatic extradural hemorrhage
[sbull] 432.1, Subdural hemorrhage
[sbull] 432.9, Unspecified intracranial hemorrhage
And operating room procedures:
[sbull] 02.13, Ligation of meningeal vessel
[sbull] 38.01, Incision of vessel, intracranial vessels
[sbull] 38.11, Endarterectomy, intracranial vessels
[sbull] 38.31, Resection of vessel with anastomosis, intracranial
vessels
[sbull] 38.41, Resection of vessel with replacement, intracranial
vessels
[sbull] 38.51, Ligation and stripping of varicose veins, intracranial
vessels
[sbull] 38.61, Other excision of vessels, intracranial vessels
[sbull] 38.81, Other surgical occlusion of vessels, intracranial
vessels
[sbull] 39.28, Extracranial-intracranial (EC-IC) vascular bypass
[sbull] 39.51, Clipping of aneurysm
[sbull] 39.52, Other repair of aneursym
[sbull] 39.53, Repair of arteriovenous fistula
[sbull] 39.72, Endovascular repair or occlusion of head and neck
vessels
[sbull] 39.79, Other endovascular repair of aneurysm of other vessels
(2) Ventricular Shunt Procedures
We also found that craniotomy patients who had a ventricular shunt
procedure (absent another procedure) were significantly less costly
than other craniotomy patients in DRGs 1 and 2. Ventricular shunts are
normally performed for draining intracranial fluid. A ventricular shunt
is a less extensive procedure than the other intracranial procedures in
DRGs 1 and 2. As a result, if a ventricular shunt is the only
intracranial procedure performed, these cases will typically be less
costly.
There were 4,373 cases in which only ventricular shunt procedures
were performed. These cases had average charges of approximately
$27,188. However, the presence or absence of a CC had a significant
impact on patient charges and lengths of stay. There were 2,533 cases
with CC, with average charges of approximately $33,907 and an average
length of stay of 8.2 days. In contrast, there were 1,840 cases without
CC, with average charges of approximately $17,939 and an average length
of stay of 3.7 days.
Therefore, we are proposing to create two new DRGs, splitting on
CC, for patients with only a vascular shunt procedure: proposed new DRG
529 (Ventricular Shunt Procedures With CC) and proposed new DRG 530
(Ventricular Shunt Procedures Without CC).
Proposed new DRG 529 would consist of any principal diagnosis in
MDC 5, with the presence of a CC and one of the following operating
room procedures:
[sbull] 02.31, Ventricular shunt to structure in head and neck
[sbull] 02.32, Ventricular shunt to circulatory system
[sbull] 02.33, Ventricular shunt to thoracic cavity
[sbull] 02.34, Ventricular shunt to abdominal cavity and organs
[sbull] 02.35, Ventricular shunt to urinary system
[sbull] 02.39, Other operations to establish drainage of ventricle
[sbull] 02.42, Replacement of ventricular shunt
[sbull] 02.43, Removal of ventricular shunt
Proposed new DRG 530 would consist of any principal diagnosis in
MDC 5 with one of the operating room procedures listed above for the
proposed new DRG 529, but without the presence of a CC.
b. DRG 23 (Nontraumatic Stupor and Coma). In DRG 23 (Nontraumatic
Stupor and Coma), there are currently six principal diagnoses
identified by the following ICD-9-CM diagnosis codes: 348.4,
Compression of the brain; 348.5, Cerebral edema; 780.01, Coma; 780.02,
Transient alteration of awareness; 780.03, Persistent vegetative state;
and 780.09, Other alteration of consciousness. Code 780.02 is often
used to describe the diagnosis of psychiatric patients rather than the
diagnosis of patients with severe
[[Page 27162]]
neurological disorders. The treatment plan for a patient with
``transient alteration of awareness'' is clinically very different from
the treatment plan for a coma patient. Furthermore, many patients with
this diagnosis are treated in psychiatric facilities rather than in
acute care hospitals.
Although there are neurological patients who present with the
complaint of ``transient alteration of awareness,'' the cause of this
alteration of consciousness is commonly identified, and the principal
diagnosis for the hospital admission is the etiology of the alteration
of consciousness rather than the symptom itself. For the few remaining
neurological patients for whom the cause is not identified and for whom
code 780.02 is assigned as the principal diagnosis, we still believe
that the care of these patients is different than the care of patients
with coma or cerebral edema.
Because we believe the patients with a principal diagnosis of
``transient alteration of consciousness'' are more clinically related
to the patients in DRG 429 (Organic Disturbances and Mental
Retardation) in MDC 19 (Mental Diseases and Disorders), we are
proposing that patients who are assigned a principal diagnosis of code
780.02 will be assigned to DRG 429 instead of DRG 23. DRG 429 also
contains similar diagnoses, such as code 293.81, Organic delusional
syndrome and code 293.82, Organic hallucinosis syndrome. We note that
the charges for the patient cases in DRGs 23 and 429 are very similar
($11,559 and $11,713, respectively), so the proposed movement of code
780.02 from DRG 23 to DRG 429 would have minimal payment impact. Moving
this diagnosis code would also consolidate diagnoses treated frequently
in psychiatric hospitals in those DRGs that are likely to be a part of
the upcoming proposed Medicare psychiatric facility PPS.
4. MDC 5 (Diseases and Disorders of the Circulatory System)
a. DRG 478 (Other Vascular Procedures With CC) and DRG 479 (Other
Vascular Procedures Without CC)
Code 37.64 (Removal of heart assist system) in DRGs 478 and 479
describes the operative, as opposed to bedside, removal of a heart
assist system. Based on comments we received suggesting that code 37.64
was inappropriately assigned to DRGs 478 and 479, we reviewed the
MedPAR data for both DRGs 478 and 479 and DRG 110 (Major Cardiovascular
Procedures With CC) and DRG 111 (Major Cardiovascular Procedures
Without CC) to assess the appropriate assignment of code 37.64.
We found that there were only 17 cases of code 37.64 in DRGs 478
and 479, with an average length of stay of 14.1 days and average
charges of $105,153. There were a total of 90,591 cases in DRGs 478 and
479 that did not contain code 37.64. These cases had an average length
of stay of 6.6 days and average charges of $31,879. In DRGs 110 and
111, we found an average length of stay of 8.1 days, with average
charges of $54,653.
We are proposing to remove code 37.64 from DRGs 478 and 479 and
reassign it to DRGs 110 and 111. The surgical removal of a heart assist
system is a major cardiovascular procedure and, therefore, more
appropriately assigned to DRGs 110 and 111. Accordingly, we believe
this DRG assignment for this procedure is more clinically and
financially appropriate.
b. DRGs 514 (Cardiac Defibrillator Implant With Cardiac
Catheterization) and 515 (Cardiac Defibrillator Implant Without Cardiac
Catheterization)
(1) Cardiac Defibrillator Implant With Cardiac Catheterization With
Acute Myocardial Infarction
We received a recommendation that we modify DRG 514 (Cardiac
Defibrillator Implant With Cardiac Catheterization) and DRG 515
(Cardiac Defibrillator Implant Without Cardiac Catheterization) so that
these DRGs are split based on the presence or absence of acute
myocardial infarction, heart failure, or shock. We note that the
increased cost of treating cardiac patients with acute myocardial
infarction, heart failure, or shock is recognized in the payment logic
for pacemaker implants (DRG 115 (Permanent Cardiac Pacemaker Implant
With Acute Myocardial Infarction, Heart Failure or Shock, or AICD Lead
or Generator) and DRG 116 (Other Permanent Cardiac Pacemaker Implant)).
We examined FY 2002 MedPAR data regarding the number of cases and
the average charges for DRGs 514 and 515. The results of our
examination are summarized in the following table.
----------------------------------------------------------------------------------------------------------------
With AMI,
DRG Number of Average heart failure, Average
cases charges or shock count charges
----------------------------------------------------------------------------------------------------------------
514............................................. 16,743 $97,133 3,623 $120,852
515............................................. 4,674 76,537 935 84,140
----------------------------------------------------------------------------------------------------------------
A cardiac catheterization is generally performed to establish the
nature of the patient's cardiac problem and determine if implantation
of a cardiac defibrillator is appropriate. Generally, the cardiac
catheterization can be done on an outpatient basis. Patients who are
admitted with acute myocardial infarction, heart failure, or shock and
have a cardiac catheterization are generally acute patients who require
emergency implantation of the defibrillator. Thus, there are very high
costs associated with these patients.
We found that the average charges for patients with cardiac
catheterizations who also had acute myocardial infarction, heart
failure, or shock were $120,852, compared to the average charges for
all DRG 514 cases of $97,133. Therefore, we are proposing to split DRG
514 and create a new DRG for patients receiving a cardiac defibrillator
implant with cardiac catheterization and with acute myocardial
infarction, heart failure, or shock.
Patients without cardiac catheterization generally have had the
need for the defibrillator established on an outpatient basis prior to
admission. We found 935 cases with acute myocardial infarction, heart
failure, or shock, with average charges of $84,140. The average charges
for all cases in DRG 515 were $76,537. Because of the relatively small
number of patients and the less-than-10-percent charge difference for
patients in DRG 515 who have acute myocardial infarction, heart
failure, or shock, we are not proposing to create a separate DRG for
patients with a cardiac defibrillator implant without cardiac
catheterization with acute myocardial infarction, heart failure, or
shock.
Specifically, we are proposing to create two new DRGs that would
replace the current DRG 514. The two new DRGs would have the same
procedures currently listed for DRG 514, but would be split based on
the presence or absence of acute myocardial infarction, heart failure,
or shock. The proposed new DRGs would be DRG 535 (Cardiac
[[Page 27163]]
Defibrillator Implant With Cardiac Catheterization and With Acute
Myocardial Infarction, Heart Failure, or Shock) and DRG 536 (Cardiac
Defibrillator Implant With Cardiac Catheterization and Without Acute
Myocardial Infarction, Heart Failure, or Shock). Proposed new DRG 536
would exclude the following principal diagnosis codes from MDC 5
associated with acute myocardial infarction, heart failure, or shock.
[sbull] 398.91, Rheumatic heart failure
[sbull] 402.01, Malignant hypertensive heart disease with heart
failure
[sbull] 402.11, Benign hypertensive heart disease with heart
failure
[sbull] 402.91, Hypertensive heart disease not otherwise specified
with heart failure
[sbull] 404.01, Malignant hypertensive heart and renal disease with
heart failure
[sbull] 404.03, Malignant hypertensive heart and renal disease with
heart failure and renal failure
[sbull] 404.11, Benign hypertensive heart and renal disease with
heart failure
[sbull] 404.13, Benign hypertensive heart and renal disease with
heart failure and renal failure
[sbull] 404.91, Hypertensive heart and renal disease not otherwise
specified with heart failure
[sbull] 404.93, Hypertensive heart and renal disease not otherwise
specified with heart failure and renal failure
[sbull] 410.01, AMI anterolateral, initial
[sbull] 410.11, AMI anterior wall, initial
[sbull] 410.21, AMI inferolateral, initial
[sbull] 410.31, AMI inferopost, initial
[sbull] 410.41, AMI inferior wall, initial
[sbull] 410.51, AMI lateral not elsewhere classified, initial
[sbull] 410.61, True posterior infarction, initial
[sbull] 410.71, Subendocardial infarction, initial
[sbull] 410.81, AMI not elsewhere classified, initial
[sbull] 410.91, AMI not otherwise specified, initial
[sbull] 428.0, Congestive heart failure, not otherwise specified
[sbull] 428.1, Left heart failure
[sbull] 428.20, Systolic heart failure, not otherwise specified
[sbull] 428.21, Acute systolic heart failure
[sbull] 428.22, Chronic systolic heart failure
[sbull] 428.23, Acute on chronic systolic heart failure
[sbull] 428.30, Diastolic heart failure, not otherwise specified
[sbull] 428.31, Acute diastolic heart failure
[sbull] 428.32, Chronic diastolic heart failure
[sbull] 428.33, Acute on chronic diastolic heart failure
[sbull] 428.40, Combined systolic and diastolic heart failure not
otherwise specified
[sbull] 428.41, Acquired combined systolic and diastolic heart
failure
[sbull] 428.42, Chronic combined systolic and diastolic heart
failure
[sbull] 428.43, Acute on chronic combined systolic and diastolic
heart failure
[sbull] 428.9, Heart failure, not otherwise specified
[sbull] 785.50, Shock, not otherwise specified
[sbull] 785.51, Cardiogenic shock
(2) Cardiac Resynchronization Therapy (CRT)
We received a comment from a provider who pointed out that we did
not include the following combination of codes under the list of
procedure combinations that would lead to an assignment of DRG 514 or
DRG 515:
[sbull] 39.75, Implantation of automatic cardioverter/defibrillator
lead(s) only
[sbull] 00.54, Implantation or replacement of cardiac
resynchronization defibrillator, pulse generator device only [CRT-D]
The commenter pointed out that cases are assigned to DRGS 514 and
515 when a total cardiodefibrillator or CRT-D system is implanted. In
addition, cases are assigned to DRGs 514 and 515 when implantation of a
variety of combinations of defibrillator leads and device combinations
are reported. The commenter indicated that total defibrillator and CRT-
D system may be replaced with completely new systems or all new devices
and leads, and added that it is also possible to replace a generator, a
lead, or a combination of generators and up to three leads.
When the CRT-D generator (code 00.54) and one of the cardioverter/
defibrillator leads are replaced, the case currently is assigned to DRG
115 (Permanent Cardiac Pacemaker Implant with AMI, Heart Failure, or
Shock or AICD Lead or Generator Procedure). The commenter recommended
that we include the combination of codes 39.75 and 00.54 as a
combination that would result in assignment to DRG 514 or DRG 515, as
do other combinations of generators and leads. Our medical advisors
agree with this recommendation. As discussed previously, we are
proposing to delete DRG 514 and replace it with proposed new DRGs 535
and 536. Therefore, we are proposing to add codes 39.75 and 00.54 to
the list of procedure combinations that would result in assignment to
DRG 515 or new proposed DRGs 535 and 536.
5. MDC 8 (Diseases and Disorders of the Musculoskeletal System and
Connective Tissue)
We received a comment that two codes for cervical fusion of the
spine are not included within DRG 519 (Cervical Spinal Fusion With CC)
and DRG 520 (Cervical Spinal Fusion Without CC). The two cervical
fusion codes are:
[sbull] 81.01, Atlas-axis spinal fusion
[sbull] 81.31, Refusion of atlas-axis
The atlas-axis includes the first two vertebrae of the cervical
spine (C1 and C2). These two cervical fusion codes are currently
assigned to DRG 497 (Spinal Fusion Except Cervical With CC) and DRG 498
(Spinal Fusion Except Cervical Without CC). Because codes 81.01 and
81.31 involve the cervical spine, we are proposing to remove these
codes from DRGs 497 and 498 and reassign them to DRGs 519 and 520.
6. MDC 15 (Newborns and Other Neonates With Conditions Originating in
the Perinatal Period)
a. Nonneonate Diagnoses. As indicated earlier, ICD-9-CM diagnosis
codes are assigned to MDCs based on 25 groupings corresponding to a
single organ system or etiology and, in general, are associated with a
particular medical specialty. MDC 15 is comprised of diagnoses that
relate to newborns and other neonates with conditions originating in
the perinatal period. Some of the codes included in MDC 15 consist of
conditions that originate in the neonatal period but can persist
throughout life. These conditions are referred to as congenital
anomalies. When an older (not neonate) population is treated for a
congenital anomaly, DRG assignment problems can arise. For instance, if
a patient is over 65 years old and is admitted with a congenital
anomaly, it is not appropriate to assign the patient to a newborn DRG.
This situation occurs when a congenital anomaly code is classified
within MDC 15.
We have received a recommendation to move the following congenital
anomaly codes from MDC 15 and reassign them to other appropriate MDCs
based on the body system being treated:
[sbull] 758.9, Chromosome anomaly, not otherwise specified
[sbull] 759.4, Conjoined twins
[sbull] 759.7, Multiple congenital anomalies, not elsewhere
classified
[sbull] 759.81, Prader-Willi syndrome
[sbull] 759.83, Fragile X syndrome
[sbull] 759.89, Specified congenital anomalies, not elsewhere
classified
[sbull] 759.9, Congenital anomaly, not otherwise specified
[[Page 27164]]
[sbull] 779.7, Periventricular leukomalacia
[sbull] 795.2, Abnormal chromosomal analysis
Each of the congenital anomaly diagnosis codes recommended for
reassignment represents a condition that is frequently addressed beyond
the neonatal period. In addition, the assignment of these congenital
anomaly codes as principal diagnosis currently results in assignment to
MDC 15.
We have evaluated the recommendation and agree that each of the
identified codes represents a condition that is frequently addressed
beyond the neonate period and should therefore be removed from the list
of principal diagnoses that result in assignment to MDC 15. Therefore,
we are proposing to change the MDC and DRG assignments of the
congenital anomaly codes as specified in the following table. The table
shows the principal diagnosis code for the congenital anomaly and the
proposed MDC and DRG to which the code would be assigned.
----------------------------------------------------------------------------------------------------------------
Proposed MDC
Principal diagnosis code in MDC 15 Code title assignment Proposed DRG assignment
----------------------------------------------------------------------------------------------------------------
758.9................................... Chromosome anomaly, not 23 467 (Other Factors
otherwise specified. Influencing Health
Status).
759.4................................... Conjoined twins........... 6 188, 189, and 190 (Other
Digestive System
Diagnoses, Age 17 with CC, Age 17 without CC, and
Age 0-17, respectively).
759.7................................... Multiple congenital 8 256 (Other Musculoskeletal
anomalies, not elsewhere System and Connective
classified. Tissue Diagnoses).
759.81.................................. Prader-Willi syndrome..... 8 256 (Other Musculoskeletal
System and Connective
Tissue Diagnoses).
759.83.................................. Fragile X syndrome........ 19 429 (Organic Disturbances
and Mental Retardation).
759.89.................................. Specified congenital 8 256 (Other Musculoskeletal
anomalies, not elsewhere System and Connective
classified. Tissue Diagnoses).
759.9................................... Congenital anomaly, not 23 467 (Other Factors
otherwise specified. Influencing Health
Status).
779.7................................... Periventricular 1 34 and 35 (Other Disorders
leukomalacia. of Nervous System with
CC, and without CC,
respectively).
795.2................................... Abnormal chromosomal 23 467 (Other Factors
analysis. Influencing Health
Status).
----------------------------------------------------------------------------------------------------------------
b. Heart Failure Codes for Newborns and Neonates. Under MDC 15,
cases of newborns and neonates with major problems may be assigned to
DRG 387 (Prematurity With Major Problems) or DRG 389 (Full-Term Neonate
With Major Problems). Existing DRG 387 has three components: (1)
Principal or secondary diagnosis of prematurity; (2) principal or
secondary diagnosis of major problem (these are the diagnoses that
define MDC 15); or (3) secondary diagnosis of major problem (these are
diagnoses that do not define MDC 15, so they will only be secondary
diagnosis codes for patients assigned to MDC 15). To be assigned to DRG
389, the neonate must have one of the principal or secondary diagnoses
listed under the DRG.
We have received correspondence suggesting that the following
diagnosis codes for heart failure, which are currently in MDC 5, be
added to the list of major problems for neonates under MDC 15.
------------------------------------------------------------------------
Diagnosis code Title
------------------------------------------------------------------------
428.20............................. Systolic heart failure, not
otherwise specified.
428.21............................. Acute systolic heart failure.
428.22............................. Chronic systolic heart failure.
428.23............................. Acute on chronic systolic heart
failure.
428.30............................. Diastolic heart failure, not
otherwise specified.
428.31............................. Acute diastolic heart failure.
428.32............................. Chronic diastolic heart failure.
428.33............................. Acute on chronic diastolic heart
failure.
428.40............................. Systolic/diastolic heart failure,
not otherwise specified.
428.41............................. Acute systolic/diastolic heart
failure.
428.42............................. Chronic systolic/diastolic heart
failure.
428.43............................. Acute on chronic systolic/diastolic
heart failure.
------------------------------------------------------------------------
These heart failure-related diagnosis codes were new codes as of
October 1, 2002. They were an expansion of the previous 4-digit codes
for heart failure and provided additional detail about the specific
type of heart failure. The other codes for heart failure that existed
prior to October 1, 2002, are classified as major problems within MDC
15 and are currently assigned to DRGs 387 and DRG 389.
We agree that diagnosis codes 428.20 through 428.43 listed in the
chart above should be included as principal diagnosis of major problem
codes within MDC 15 and, therefore, are proposing to add them to DRG
387 and 389.
7. MDC 17 (Myeloproliferative Diseases and Disorders and Poorly
Differentiated Neoplasms)
High-dose Interleukin-2 (IL-2) Chemotherapy is a hospital
inpatient-based regimen requiring administration by experienced
oncology professionals. It is used for the treatment of patients with
advanced renal cell cancer and advanced melanoma. Unlike traditional
cytotoxic chemotherapies that attack cancer cells themselves,
Interleukin-2 is designed to enhance the body's defenses by mimicking
the way natural IL-2 activates the immune system and stimulates the
growth and activity of cancer-killing cells. The IL-2 product on the
market was approved for use by the Food and Drug Administration (FDA)
in 1992.
High-dose IL-2 therapy is performed only in very specialized
treatment settings, such as an intensive care unit or a bone marrow
transplant unit. This therapy requires oversight by oncology health
care professionals experienced in the administration and management of
patients undergoing this intensive treatment because of the severity of
the side effects. Unlike most cancer
[[Page 27165]]
therapies, high-dose IL-2 therapy is associated with predictable
toxicities that require extensive monitoring. Often patients require
one-on-one nursing or physician care for extended portions of their
stay.
High-dose IL-2 therapy is significantly different from conventional
chemotherapy in terms of the resources required to administer it.
Conventional chemotherapy may be given to patients either on an
outpatient basis or through a series of short (that is, 1 to 3 day)
inpatient stays.
High-dose IL-2 therapy is given during two separate hospital
admissions. For the first cycle, the IL-2 is administered every 8 hours
over 5 days. Patients are then discharged to rest at home for several
days and then are admitted for the second cycle of therapy, in which
the same regimen and dosing is repeated. The two cycles complete the
first course of high-dose IL-2 therapy. This regimen may be repeated at
8 to 12 weeks if the patient is responding. The maximum number of
courses for any one patient is predicted to be five courses.
Not all patients with end-stage renal cell carcinoma or end-stage
melanoma are appropriate candidates for high-dose IL-2 chemotherapy. It
is estimated that there are between 15,000 and 20,000 patients in the
United States who have one of these two types of cancer. However, only
20 percent of those patients will be appropriate candidates for the
rigors of the treatment regimen. It is further estimated that,
annually, approximately 1,300 of these patients will be Medicare
beneficiaries. However, allegedly due to the level of payment for the
DRGs to which these cases are currently assigned, we have been informed
by industry sources that only between 100 and 200 Medicare patients
receive the treatment each year. According to these industry sources,
several treatment centers have had to discontinue their high-dose IL-2
therapy programs for end-stage renal cell carcinoma or end-stage
melanoma because of the low Medicare payment.
According to industry sources, the wholesale cost of IL-2 is
approximately $700 per vial. Dosages range between 15 and 20 vials per
treatment, or between $10,500 and $14,000 per patient, per cycle, for
the cost of the IL-2 drug alone. There is no ICD-9-CM procedure code
that currently identifies patients receiving this therapy. Therefore,
it is not possible to identify directly these cases in the MedPAR data.
Currently, this therapy is coded using the more general ICD-9-CM code
99.28 (Injection or infusion of biologic response modifier). When we
addressed this issue previously in the August 1, 2000 IPPS final rule
(65 FR 47067) by examining cases for which procedure code 99.28 was
present, our analysis was inconclusive due to the wide range of cases
identified (1,179 cases across in 136 DRGs). However, recent data
collected by the industry on 30 Medicare beneficiaries who received
high-dose IL-2 therapy during FY 2002 show average charges for these
cases of approximately $54,000.
Depending on the principal diagnosis reported, patients receiving
high-dose IL-2 therapy may be assigned to one of the following five
DRGs: DRG 272 (Major Skin Disorder With CC) and DRG 273 (Major Skin
Disorder Without CC) in MDC 9; DRG 318 (Kidney and Urinary Tract
Neoplasms With CC) and DRG 319 (Kidney and Urinary Tract Neoplasms
Without CC) in MDC 11; and DRG 410 (Chemotherapy Without Leukemia as
Secondary Diagnosis) in MDC 17. The following table illustrates the
average charges for patients in these DRGs.
------------------------------------------------------------------------
Average
DRG charges
------------------------------------------------------------------------
272........................................................ $14,997
273........................................................ 9,128
318........................................................ 16,892
319........................................................ 9,583
410........................................................ 16,103
------------------------------------------------------------------------
Because of the need to identify the subset of patients receiving
this type of treatment, the ICD-9-CM Coordination and Maintenance
Committee determined, based on its consideration at the December 6,
2002 public meeting, that a new code for high-dose IL-2 therapy was
warranted. Therefore, a new code has been created in the 00 Chapter of
ICD-9-CM (Procedures and Interventions, Not Elsewhere Classified), in
category 00.1 (Pharmaceuticals) at 00.15 (High-dose infusion
Interleukin-2 (IL-2)), effective October 1, 2003.
We believe patients receiving high-dose IL-2 therapy are clinically
similar to other cases currently assigned to DRG 492 (Chemotherapy With
Acute Leukemia as Secondary Diagnosis) in MDC 17. The average charge
for patients currently assigned to DRG 492 is $55,581. Currently, DRG
492 requires one of the following two principal diagnoses:
[sbull] V58.1, Encounter for chemotherapy
[sbull] V67.2, Followup examination following chemotherapy
[sbull] And one of the following secondary diagnoses:
[sbull] 204.00, Acute lymphoid leukemia without mention of
remission
[sbull] 204.01, Acute lymphoid leukemia with remission
[sbull] 205.00, Acute myeloid leukemia without mention of remission
[sbull] 205.01, Acute myeloid leukemia with remission
[sbull] 206.00, Acute monocytic leukemia without mention of
remission
[sbull] 206.01, Acute monocytic leukemia with remission
[sbull] 207.00, Acute erythremia and erythroleukemia without
mention of remission
[sbull] 207.01, Acute erythremia and erythroleukemia with remission
[sbull] 208.00, Acute leukemia of unspecified cell type without
mention of remission
[sbull] 208.01, Acute leukemia of unspecified cell type without
mention of remission
We are proposing to modify DRG 492 by adding new procedure code
00.15 to the logic. Assignment to this DRG would require the same two
V-code principal diagnosis codes as listed above (V58.1 and V67.2), but
would require either one of the leukemia codes listed as a secondary
diagnosis, or would require the procedure code 00.15. In addition, we
are proposing to change the title of DRG 492 to ``Chemotherapy With
Acute Leukemia or With Use of High Dose Chemotherapy Agent''.
We will monitor cases with procedure code 00.15 as these data
become available, and consider potential further refinements to DRG 492
as necessary.
8. MDC 23 (Factors Influencing Health Status and Other Contacts With
Health Services)
a. Implantable Devices. We received a comment regarding three ICD-
9-CM diagnosis codes that are currently assigned to MDC 23: V53.01
(Fitting and adjustment of cerebral ventricular (communicating) shunt);
V53.02 (Neuropacemaker (brain) (peripheral nerve) (spinal cord)); and
V53.09 (Fitting and adjustment of other devices related to nervous
system and special senses). The commenter suggested that we move these
three codes from MDC 23 to MDC 1 (Diseases and Disorders of the Nervous
System) because these codes are used as the principal diagnosis for
admissions involving removal, replacement, and reprogramming of devices
such as cerebral ventricular shunts, neurostimulators, intrathecal
infusion pumps and thalamic stimulators.
Currently, if these diagnosis codes are reported alone without an
O.R. procedure, the case would be assigned to DRG 467 (Other Factors
Influencing Health Status). However, if an O.R. procedure is reported
with the principal
[[Page 27166]]
diagnosis of V53.01, V53.02, or V53.09, the case would be assigned to
DRG 461 (O.R. Procedure with Diagnoses of Other Contact with Health
Services).
In our analysis of the MedPAR data, we found 30 cases assigned to
DRG 467 and 179 cases assigned to DRG 461 with one of these codes as
principal diagnosis. We found that the procedures reported with one of
these diagnosis codes were procedures in MDC 1. The most frequent
procedure was 86.06 (Insertion of totally implantable infusion pump).
Because the procedures that are routinely used with these codes are
in MDC 1, it would be appropriate to assign these diagnosis codes to
MDC 1. As the commenter also stated, this assignment would be
consistent with how fitting and adjustments of devices are handled
within other MDCs, such as in MDC 5 (Disease and Disorders of the
Circulatory System) and MDC 11 (Diseases and Disorders of the Kidney
and Urinary Tract). Diagnosis codes V53.31 (Cardiac pacemaker), V53.32
(Automatic implantable cardiac defibrillator), and V53.39 (Other
cardiac device) are used for fitting and adjustment of cardiac devices
and are assigned to MDC 5. Diagnosis code V53.6 (Urinary devices) is
used for fitting and adjustment of urinary devices and is assigned to
MDC 11.
Therefore, we are proposing to move V53.01, V53.02, and V53.09 from
MDC 23 to MDC 1 when an O.R. procedure is performed. If no O.R.
procedure is performed, these diagnosis codes would be assigned to DRG
34 (Other Disorders of Nervous System With CC) or DRG 35 (Other
Disorders of Nervous System Without CC). If an O.R. procedure is
performed on a patient assigned with one of these codes as the
principal diagnosis, the case would be assigned to the DRG in MDC 1 to
which the O.R. procedure is assigned.
b. Malignancy Codes. We received correspondence that indicated that
when we recognized code V10.48 (History of malignancy, epididymis) as a
new code for FY 2002, we did not include the code as a history of
malignancy code in DRG 465 (Aftercare with History of Malignancy as
Secondary Diagnosis). All other history of malignancy codes were
included in DRG 465.
We agree that code V10.48 should have been included in the list of
history of malignancy codes within DRG 465 and, therefore, are
proposing to add it to the list of secondary diagnoses in DRG 465.
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.
We received a request to examine the MCE edit ``Adult Diagnosis--
Age Greater than 14'' because currently the edit rejects claims for
patients under age 15 who are being treated for gall bladder disease.
We reviewed this issue with our pediatric consultants and determined
that, although incidence is rare, gallbladder disease does occur in
patients under age 15. Therefore, we are proposing to modify the MCE by
removing the following codes from the edit ``Adult Diagnosis--Age
Greater Than 14'':
[sbull] 574.00, Calculus of gallbladder with acute cholecystitis
without mention of obstruction
[sbull] 574.01, Calculus of gallbladder with acute cholecystitis
with obstruction
[sbull] 574.10, Calculus of gallbladder with other cholecystitis
without mention of obstruction
[sbull] 574.11, Calculus of gallbladder with other cholecystitis
with obstruction
[sbull] 574.20, Calculus of gallbladder without mention of
cholecystitis without mention of obstruction
[sbull] 574.21, Calculus of gallbladder without mention of
cholecystitis with obstruction
[sbull] 574.30, Calculus of bile duct with acute cholecystitis
without mention of obstruction
[sbull] 574.31, Calculus of bile duct with acute cholecystitis with
obstruction
[sbull] 574.40, Calculus of bile duct with other cholecystitis
without mention of obstruction
[sbull] 574.41, Calculus of bile duct with other cholecystitis with
obstruction
[sbull] 574.50, Calculus of bile duct without mention of
cholecystitis without mention of obstruction
[sbull] 574.51, Calculus of bile duct without mention of
cholecystitis with obstruction
[sbull] 574.60, Calculus of gallbladder and bile duct with acute
cholecystitis without mention of obstruction
[sbull] 574.61, Calculus of gallbladder and bile duct with acute
cholecystitis with obstruction)
[sbull] 574.70, Calculus of gallbladder and bile duct with other
cholecystitis without mention of obstruction
[sbull] 574.71, Calculus of gallbladder and bile duct with other
cholecystitis with obstruction
[sbull] 574.80, Calculus of gallbladder and bile duct with acute
and chronic cholecystitis without mention of obstruction
[sbull] 574.81, Calculus of gallbladder and bile duct with acute
and chronic cholecystitis with obstruction
[sbull] 574.90, Calculus of gallbladder and bile duct without
cholecystitis without mention of obstruction
[sbull] 574.90, Calculus of gallbladder and bile duct without
cholecystitis with obstruction
[sbull] 575.0, Acute cholecystitis
[sbull] 575.10, Cholecystitis, not otherwise specified
[sbull] 575.11, Chronic cholecystitis
[sbull] 575.12, Acute and chronic cholecystitis
[sbull] 575.2, Obstruction of gallbladder
[sbull] 575.3, Hydrops of gallbladder
[sbull] 576.0, Postcholecystectomy syndrome
[sbull] 577.1, Chronic pancreatitis
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. Application of
this hierarchy 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
[[Page 27167]]
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 search 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, assignment to these surgical classes should
only occur if no other surgical class more closely related to the
diagnoses in the MDC is appropriate.
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
because, as a result of reassigning cases on the basis of the hierarchy
change, the average charges are likely to shift such that the higher-
ordered surgical class has a lower average charge than the class
ordered below it.
Based on the preliminary recalibration of the DRGs, we are
proposing modifications of the surgical hierarchy as set forth below.
At this time, we are proposing to revise the surgical hierarchy for
the pre-MDC DRGs, MDC 1 (Diseases and Disorders of the Nervous System),
MDC 5 (Diseases and Disorders of the Circulatory System), MDC 8
(Diseases and Disorders of the Musculoskeletal System and Connective
Tissue), and MDC 17 (Myeloproliferative Disease and Disorders, Poorly
Differentiated Neoplasms for Lymphoma and Leukemia) as follows:
[sbull] In the pre-MDC DRGs, we are proposing to reorder DRG 513
(Pancreas Transplant) above DRG 512 (Simultaneous Pancreas/Kidney
Transplant).
[sbull] In MDC 1, we are proposing to reorder DRG 3 (Craniotomy Age
0-17) above DRG 528 (Intracranial Vascular Procedures with Principal
Diagnosis Hemorrhage); DRG 528 above DRGs 1 and 2 (Craniotomy Age
17 With and Without CC, respectively); DRGs 1 and 2 above
DRGs 529 and 530 (Ventricular Shunt Procedures With and Without CC,
respectively); DRGs 529 and 530 above DRGs 531 and 532 (Spinal
Procedures With and Without CC, respectively); DRGs 531 and 532 above
DRGs 533 and 534 (Extracranial Procedures With and Without CC,
respectively); and DRGs 533 and 534 above DRG 6 (Carpal Tunnel
Release).
[sbull] In MDC 5, we are proposing to reorder DRG 535 (Cardiac
Defibrillator Implant With Cardiac Catheterization With AMI, Heart
Failure, or Shock) above DRG 536 (Cardiac Defibrillator Implant With
Cardiac Catheterization Without AMI, Heart Failure, or Shock), and DRG
536 above DRG 515 (Cardiac Defibrillator Implant Without Cardiac
Catheterization).
[sbull] In MDC 8, we are proposing to reorder DRGs 537 and 538
(Local Excision and Removal of Internal Fixation Devices Except Hip and
Femur With and Without CC, respectively) above DRG 230 (Local Excision
and Removal of Internal Fixation Devices of Hip and Femur).
[sbull] In MDC 17, we are proposing to reorder DRGs 539 and 540
(Lymphoma and Leukemia With Major O.R. Procedure With and Without CC,
respectively) above DRGs 401 and 402 (Lymphoma and Non-Acute Leukemia
With Other O.R. Procedures With and Without CC, respectively).
11. Refinement of Complications and Comorbidities (CC) List
In the September 1, 1987 final notice (52 FR 33143) concerning
changes to the DRG classification system, we modified the GROUPER logic
so that certain diagnoses included on the standard list of CCs would
not be considered valid CCs in combination with a particular principal
diagnosis. Thus, we created the CC Exclusions List. We made these
changes for the following reasons: (1) To preclude coding of CCs for
closely related conditions; (2) to preclude duplicative coding or
inconsistent coding from being treated as CCs; and (3) to ensure that
cases are appropriately classified between the complicated and
uncomplicated DRGs in a pair. We developed this standard list of
diagnoses, using physician panels, to include those diagnoses that,
when present as a secondary condition, would be considered a
substantial complication or comorbidity. In previous years, we have
made changes to the standard list of CCs, either by adding new CCs or
deleting CCs already on the list. At this time, we are not proposing to
delete any of the diagnosis codes on the CC list.
In the May 19, 1987 proposed notice (52 FR 18877) concerning
changes to the DRG classification system, we explained that the
excluded secondary diagnoses were established using the following five
principles:
[sbull] 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)).
[sbull] Specific and nonspecific (that is, not otherwise specified
(NOS)) diagnosis codes for the same condition should not be considered
CCs for one another.
[sbull] 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.
[sbull] Codes for the same condition in anatomically proximal sites
should not be considered CCs for one another.
[sbull] 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
[[Page 27168]]
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; the August 1,
2001 final rule (66 FR 39851) for the FY 2002 revisions; and the August
1, 2002 final rule (67 FR 49998) for the FY 2003 revisions.) In the
July 30, 1999 final rule (64 FR 41490), we did not modify the CC
Exclusions List for FY 2000 because we did not make any changes to the
ICD-9-CM codes for FY 2000.
We are proposing a limited revision of the CC Exclusions List to
take into account the proposed changes that will be made in the ICD-9-
CM diagnosis coding system effective October 1, 2003. (See section
II.B.13. of this preamble for a discussion of ICD-9-CM changes.) These
proposed changes are being made in accordance with the principles
established when we created the CC Exclusions List in 1987.
Tables 6G and 6H in the Addendum to this proposed rule contain the
revisions to the CC Exclusions List that would be effective for
discharges occurring on or after October 1, 2003. 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, 2003,
the indented diagnoses would not be recognized by the GROUPER as valid
CCs for the asterisked principal diagnosis.
CCs that are deleted from the list are in Table 6H--Deletions from
the CC Exclusions List. Beginning with discharges on or after October
1, 2003, the indented diagnoses would be recognized by the GROUPER as
valid CCs for the asterisked principal diagnosis.
Copies of the original CC Exclusions List applicable to FY 1988 can
be obtained from the National Technical Information Service (NTIS) of
the Department of Commerce. It is available in hard copy for $133.00
plus shipping and handling. A request for the FY 1988 CC Exclusions
List (which should include the identification accession number (PB) 88-
133970) should be made to the following address: National Technical
Information Service, United States Department of Commerce, 5285 Port
Royal Road, Springfield, VA 2216l; or by calling (800) 553-6847.
Users should be aware of the fact that all revisions to the CC
Exclusions List (FYs 1989, 1990, 1991, 1992, 1993, 1994, 1995, 1996,
1997, 1998, 1999, 2000, 2002, and 2003) and those in Tables 6G and 6H
of the final rule for FY 2004 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, 2003. (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 20.0, is available for $225.00,
which includes $15.00 for shipping and handling. Version 21.0 of this
manual, which includes the final FY 2003 DRG changes, is available for
$225.00. These manuals may be obtained by writing 3M/HIS at the
following address: 100 Barnes Road, Wallingford, CT 06492; or by
calling (203) 949-0303. Please specify the revision or revisions
requested.
12. Review of Procedure Codes in DRGs 468, 476, and 477
Each year, we review cases assigned to DRG 468 (Extensive O.R.
Procedure Unrelated to Principal Diagnosis), DRG 476 (Prostatic O.R.
Procedure Unrelated to Principal Diagnosis), and DRG 477 (Nonextensive
O.R. Procedure Unrelated to Principal Diagnosis) to determine whether
it would be appropriate to change the procedures assigned among these
DRGs.
DRGs 468, 476, and 477 are reserved for those cases in which none
of the O.R. procedures performed are related to the principal
diagnosis. These DRGs are intended to capture atypical cases, that is,
those cases not occurring with sufficient frequency to represent a
distinct, recognizable clinical group. DRG 476 is assigned to those
discharges in which one or more of the following prostatic procedures
are performed and are unrelated to the principal diagnosis:
[sbull] 60.0, Incision of prostate
[sbull] 60.12, Open biopsy of prostate
[sbull] 60.15, Biopsy of periprostatic tissue
[sbull] 60.18, Other diagnostic procedures on prostate and
periprostatic tissue
[sbull] 60.21, Transurethral prostatectomy
[sbull] 60.29, Other transurethral prostatectomy
[sbull] 60.61, Local excision of lesion of prostate
[sbull] 60.69, Prostatectomy, not elsewhere classified
[sbull] 60.81, Incision of periprostatic tissue
[sbull] 60.82, Excision of periprostatic tissue
[sbull] 60.93, Repair of prostate
[sbull] 60.94, Control of (postoperative) hemorrhage of prostate
[sbull] 60.95, Transurethral balloon dilation of the prostatic
urethra
[sbull] 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).
In the August 1, 2002 final rule (67 FR 49999), we did not move any
procedures from DRG 477. However, we did move procedures codes from DRG
468 and placed them in more clinically coherent DRGs.
a. Moving Procedure Codes from DRG 468 or DRG 477 to MDCs. We
annually conduct a review of procedures
[[Page 27169]]
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 are not proposing to move
any procedures from DRG 477 to one of the surgical DRGs.
However, we have identified a necessary proposed change under DRG
468 relating to code 50.29 (Other destruction of lesion of liver). We
were contacted by a hospital about the fact that code 50.29 is not
currently included in MDC 6 (Diseases and Disorders of the Digestive
System). The hospital pointed out that it is not uncommon for patients
to have procedures performed on the liver when they are admitted for a
condition that is classified in MDC 6. For example, DRGs 170 and 171
(Other Digestive System O.R. Procedures With and Without CC,
respectively) in MDC 6 currently include liver procedures such as
biopsy of the liver. The hospital disagreed with the assignment of code
50.29 to DRG 468 when performed on a patient with a principal diagnosis
in MDC 6. We believe that the commenter is correct and are proposing to
assign code 50.29 to DRGs 170 and 171 in MDC 6.
b. Reassignment of Procedures among DRGs 468, 476, and 477. We also
annually review the list of ICD-9-CM procedures that, when in
combination with their principal diagnosis code, result in assignment
to DRGs 468, 476, and 477, to ascertain if any of those procedures
should be reassigned from one of these DRGs to another of these DRGs
based on average charges and length of stay. We look at the data for
trends such as shifts in treatment practice or reporting practice that
would make the resulting DRG assignment illogical. If we find these
shifts, we would propose moving cases to keep the DRGs clinically
similar or to provide payment for the cases in a similar manner.
Generally, we move only those procedures for which we have an adequate
number of discharges to analyze the data. Based on our review this
year, we are not proposing to move any procedures from DRG 468 to DRGs
476 or 477, from DRG 476 to DRGs 468 or 477, or from DRG 477 to DRGs
468 or 476.
c. Adding Diagnosis or Procedure Codes to MDCs. Based on our review
this year, we are not proposing to add any diagnosis codes to MDCs.
However, we have identified several procedures that we propose to
move from DRG 468 and add to DRGs 476 and 477 because the procedures
are nonextensive:
[sbull] 38.21, Biopsy of blood vessel
[sbull] 77.42, Biopsy of scapula, clavicle and thorax [ribs and
sternum]
[sbull] 77.43, Biopsy of radius and ulna
[sbull] 77.44, Biopsy of carpals and metacarpals
[sbull] 77.45, Biopsy of femur
[sbull] 77.46, Biopsy of patella
[sbull] 77.47, Biopsy of tibia and fibula
[sbull] 77.48, Biopsy of tarsals and metatarsals
[sbull] 77.49, Biopsy of other bones
[sbull] 92.27, Implantation or insertion of radioactive elements
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 $23.00 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.
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), 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 2004 at a public meeting held on December 6, 2002,
and finalized the coding changes after consideration of comments
received at the meetings and in writing by January 10, 2003. Those
coding changes are announced later in this section of the preamble.
Copies of the Committee procedure minutes of the 2002 meetings can be
obtained from the CMS home page at: http://www.cms.gov/paymentsystems/icd9/. The diagnosis minutes are found at: http://www.cdc.gov/nchs/icd9.htm. Paper copies of these minutes are no longer available and the
mailing list has been discontinued.
The first of the 2003 public meetings was held on April 3, 2003. In
the September 7, 2001 final rule implementing the IPPS new technology
add-on payments (66 FR 46906), we indicated we would attempt to include
all proposals discussed and approved at the April meeting as part of
the code revisions effective the following October. Because this
proposed rule is being published after the April meeting, we are able
to include all new codes that were approved subsequent to that meeting
in Table 6F of the Addendum to this proposed rule, including the DRG
assignments.
For a report of procedure topics discussed at the April 2003
meeting, see the Summary Report at: http://www.cms.hhs.gov/paymentsystems/icd9/. For a report of the diagnosis topics discussed at
the April 2003 meeting, see the Summary Report at: http:/www.cdc.gov/
nchs/icd9.htm.
[[Page 27170]]
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 2404, 3311 Toledo
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 Mangement, Hospital
and Ambulatory 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, 2003. 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 Addendum to this
proposed rule. As we stated above, the code numbers and their titles
were presented for public comment at the ICD-9-CM Coordination and
Maintenance Committee meetings. Both oral and written comments were
considered before the codes were approved. In this proposed rule, we
are only soliciting comments on the proposed DRG classification of
these new codes.
For codes that have been replaced by new or expanded codes, the
corresponding new or expanded diagnosis codes are included in Table 6A.
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, 2003. Table 6D contains invalid
procedure codes. Revisions to diagnosis code titles are in Table 6E
(Revised Diagnosis Code Titles), which also includes the DRG
assignments for these revised codes. Table 6F includes a revised
procedure code title for FY 2003.
The Department of Health and Human Services has been actively
working on the development of new coding systems to replace the ICD-9-
CM. For example, the ICD-10-CM (for diagnoses) and the ICD-10-PCS (for
procedures) were developed to replace ICD-9-CM. These efforts have
become increasingly important because of the many problems with the
ICD-9-CM, which was implemented 24 years ago.
Implementing ICD-10-PCS as a national standard was discussed at the
December 6, 2002, ICD-9-CM Coordination and Maintenance Committee
meeting. A complete report of the meeting, including examples of
letters supporting and opposing ICD-10-PCS, can be found at the CMS web
site: www.cms.hhs.gov/paymentsystems/icd9/. Also, the Secretary has
asked the NCVHS to recommend whether or not the country should replace
ICD-9-CM as a national coding standard with ICD-10-CM and ICD-10-PCS. A
complete report on the activities of this committee can be found 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 proposed rule, we considered a number of other DRG-
related issues. Below is a summary of the issues that were addressed.
a. Cochlear Implants. Cochlear implants were first covered by
Medicare in 1986 and were assigned to DRG 49 (Major Head and Neck
Procedures) in MDC 3 (Diseases and Disorders of the Ear, Nose, Mouth,
and Throat). This is the highest weighted surgical DRG in MDC 3.
However, commenters have contended that this DRG is clinically and
economically inappropriate and have requested a specific DRG for
cochlear implants. The commenters contend that, like heart assist
systems (we created a new DRG last year, DRG 525 (Heart Assist System
Implant) in MDC 5), cochlear implants are low incidence procedures with
disproportionately high costs compared to other procedures within DRG
49.
As we stated in the FY 2003 final rule in our discussion regarding
the creation of DRG 525 (67 FR 49989), we found 185 heart assist system
cases in DRG 104 (Cardiac Valve and Other Major Cardiothoracic
Procedures with Cardiac Catheterization) and 90 cases in DRG 105
(Cardiac Valve and Other Major Cardiothoracic Procedures without
Cardiac Catheterization). The average charges for these cases were
approximately $36,000 and $85,000, higher than the average charges for
cases in DRGS 104 and 105, respectively, but they represented only a
small fraction of all cases in these DRGs (1.3 percent and 0.5 percent,
respectively). Therefore, despite the drastically higher average
charges for heart assist systems, the relative volume was insufficient
to affect the DRG weight to any great degree.
In our analysis of the FY 2002 MedPAR file, we found 134 cochlear
implant cases out of 1,637 cases assigned to DRG 49, which represent
more than 8 percent of the total cases in DRG 49. Compared to the
situation with the heart assist system implant cases in DRGs 104 and
105, cochlear implants do have a greater effect on the relative weight
for DRG 49. Also, while average charges for cochlear implant cases are
significantly more than other cases in DRG 49 (average charges for
cochlear implant cases were $51,549 compared to $25,052 for noncochlear
implant cases), this difference is much less than the $36,000 and
$85,000 differences for heart assist systems cited above.
Although we are concerned about the disparity between the average
costs and payments for cochlear implant patients, we also have concerns
about establishing a separate DRG for these cases. Doing so could
create an incentive for some of these procedures to be shifted from
outpatient settings, where most are currently performed. Even among
current cochlear implant cases, our analysis found the average length
of stay for Medicare patients receiving this procedure in the inpatient
setting was just over 1 day, indicating minimal inpatient care is
necessary for these cases. It is unclear whether a shift toward more
inpatient stays would be appropriate.
We also are concerned whether the volume of cochlear implant cases
across all hospitals performing this procedure warrants establishing a
new DRG. The DRG relative weights reflect an average cost per case,
with the costs of some procedures above the DRG mean costs and some
below the mean. It is expected that hospitals will offset losses for
certain procedures with payment gains for other procedures, while
responding to incentives to maintain efficient operations. An excessive
proliferation of new DRGs for specific technologies would fundamentally
alter this averaging concept.
Accordingly, for the reasons cited above, we are not proposing to
change the DRG assignment of cochlear implants at this time. However,
we encourage public comments as to whether a new DRG for cochlear
implants (or some other solution) is warranted.
b. Burn Patients on Mechanical Ventilation. Concerns have been
raised by hospitals treating burn patients that the current DRG payment
for burn patients on mechanical ventilation is not adequate. The DRG
assignment for these cases depends on whether the hospital performed
the tracheostomy, or the tracheostomy was performed prior to transfer
to the hospital. If the hospital does not actually perform the
tracheostomy, the case is assigned to
[[Page 27171]]
one of the burn DRGs in MDC 22 (Burns). If the hospital performs a
tracheostomy, the case is assigned to DRG 482 (Tracheostomy for Face,
Mouth, and Neck Diagnoses) or DRG 483 (Tracheostomy with Mechanical
Ventilation 96 + Hours, Except Face, Mouth and Neck Diagnoses).
In the August 1, 2002 final rule, we modified DRGs 482 and 483 to
recognize code 96.72 (Continuous mechanical ventilation for 96
consecutive hours or more) for the first time in the DRG assignment (67
FR 49996). We noted that many patients assigned to DRG 483 did not have
code 96.72 recorded. We believed this was due, in part, to the limited
number of procedure codes (six) that can be submitted on the current
billing form, and the fact that code 96.72 did not affect the DRG
assignment (prior to FY 2003). We stated that we would give future
consideration to further modifying DRGs 482 and 483 based on the
presence of code 96.72. We anticipate that cases of patients receiving
96 or more hours of continuous mechanical ventilation are more
expensive than other tracheostomy patients. Once code 96.72 is reported
more frequently, we will be better able to assess the need for future
revisions to DRGs 482 and 483.
To assess the payment for burn patients on mechanical ventilation
when the hospital did not perform the tracheostomy, we analyzed data on
cases reporting both code 96.72 and diagnosis code V44.0 (Tracheostomy
status). We had hoped that these cases would show patients on long-term
ventilation who were admitted to the hospital with a tracheostomy in
place. Our data did not include any cases reported in any of the burn
DRGs with codes 96.72 and V44.0. We then analyzed data on the frequency
of cases reporting code 96.72 along with diagnosis code V46.1
(Respirator dependence). We found only 5 of these cases in the burn
DRGs. With so few cases reporting code 96.72, it is difficult for us to
determine the effect of long-term ventilation on reimbursement for burn
cases.
All hospitals, including those that treat burn patients, are
encouraged to increase the reporting of code 96.72 for patients who are
on continuous mechanical ventilation for 96 or more hours. With better
data, we would be able to determine how best to make any future DRG
modification for all patients on long-term mechanical ventilation.
c. Multiple Level Spinal Fusion. We received a comment recommending
the establishment of new DRGs that would differentiate between the
number of levels of vertebrae involved in a spinal fusion procedure.
The commenter noted that the ICD-9-CM Coordination and Maintenance
Committee discussed adding a new series of codes to identify multiple
levels of spinal fusions at its December 6, 2002 meeting.
The following codes were approved by the Committee, effective for
October 1, 2003, and are listed in Table 6B in the Addendum to this
proposed rule:
[sbull] 81.62, Fusion or refusion of 2-3 vertebrae
[sbull] 81.63, Fusion or refusion of 4-8 vertebrae
[sbull] 81.64, Fusion or refusion of 9 or more vertebrae
The commenter conducted an analysis to support redefining the
spinal fusion DRGs using these new ICD-9-CM codes. Using the CMS FY
2001 Standard Analytical File data for physicians and hospitals as the
basis for its analysis, the commenter linked a 5-percent sample of
hospital spinal fusion cases with the corresponding physician claims.
Because there were no ICD-9-CM codes to identify multiple level fusions
in 2001, multiple level fusions were identified using Current
Procedural Terminology (CPT) codes on the physician claims.
The analysis found that increasing the levels fused from 1 to 2
levels to 3 or more levels increased the mean standardized charges by
38 percent for lumbar/thoracic fusions, and by 47 percent for cervical
fusions. The commenter then recommended redefining the spinal fusion
DRGs to differentiate between 1 to 2 level spinal fusions and
multilevel spinal fusions.
The following current spinal fusion DRGs separate cases based on
whether or not a CC is present: DRG 497 (Spinal Fusion Except Cervical
With CC) and DRG 498 (Spinal Fusion Except Cervical Without CC); and
DRG 519 (Cervical Spinal Fusion With CC) and DRG 520 (Cervical Spinal
Fusion Without CC). The difference in charges associated with the
current CC-split is only slightly greater than the difference
attributable to the number of levels fused as found by the commenter's
analysis. Therefore, at this time, we are not proposing to redefine
these DRGs to differentiate on the basis of the number of levels fused.
We note that adopting the commenter's recommendation would
necessitate adjusting the DRG relative weights using non-MedPAR data,
because Medicare claims data with the new ICD-9-CM codes will not be
available until the FY 2003 MedPAR file. Although we considered this
possibility, we believe the more prudent course, given that the current
DRG structure actually appears to differentiate appropriately among
these cases, is to wait until sufficient data with the new multilevel
spinal fusion codes are available before making a final determination
on whether multilevel spinal fusions should be incorporated into the
DRG structure.
d. Heart Assist System Implant. During the comment period for the
FY 2003 IPPS proposed rule on which the FY 2003 IPPS final rule was
based, we received a suggestion that we develop a new heart transplant
DRG entitled ``Heart Transplant with Left Ventricular Assist Device
(LVAD).'' The commenter stated that, because 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. Cases in which heart
transplantation occurs during the hospitalization are assigned to DRG
103 (Heart Transplant). Therefore, the costs of LVAD cases are included
in the DRG relative weight for DRG 103. However, we noted that we would
continue to monitor these types of cases.
When we reviewed the FY 2002 MedPAR data, we identified only 21
cases in DRG 103 that listed a procedure code that would indicate the
use of an LVAD. We do not believe this is a sufficient number of cases
to support creation of an additional DRG. Therefore, we are not
proposing a change to the structure of either DRG 103 or DRG 525 at
this time.
e. Drug-Eluting Stents. In the August 1, 2002 final rule, we
created two new temporary DRGs to reflect cases involving the insertion
of a drug-eluting coronary artery stent as signified by the presence of
code 36.07 (Insertion of drug-eluting coronary artery stent): DRG 526
(Percutaneous Cardiovascular Procedure With Drug-Eluting Stent With
AMI); and DRG 527 (Percutaneous Cardiovascular Procedure With Drug-
Eluting Stent Without AMI). 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.
In the absence of MedPAR data reflecting the use of drug-eluting
stents, it was necessary to undertake several calculations to establish
the FY 2003 DRG relative weights for these two new DRGs. First, based
on prices 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
[[Page 27172]]
between nondrug-eluting and drug-eluting 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, we
estimate that the net incremental charge for cases that would receive
drug-eluting stents is $3,996.
In order to determine accurately the DRG relative weights for these
two new DRGs relative to all other DRGs, we also must estimate the
volume of cases likely to occur. We used the manufacturer's estimate
that as many as 43 percent of current stent patients will receive drug-
eluting stents during FY 2003 to calculate the FY 2003 DRG relative
weights, although we prorated this percentage since the new DRGs did
not become active until April 1, 2003. Even though the DRG will become
active on April 1, 2003, we expect that hospitals did not use this
technology before FDA approval. (We intend to identify and review any
cases with the code 36.07 that occurred prior to FDA approval.)
Therefore, no payments are expected to have been made under these DRGs
for cases occurring before FDA approval.
In determining the FY 2004 proposed DRG relative weights for DRGs
526 and 527, we assumed that 43 percent of coronary stent cases (those
with code 36.06 (Insertion of nondrug-eluting coronary artery stent))
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 are proposing to maintain DRGs 526 and 527 for FY 2004, and to
adopt the same methodology to establish the relative weights as we used
for FY 2003. The FDA issued a decision on April 24, 2003 approving
drug-eluting stents. For the final rule, we will use the best available
data at that time to establish the FY 2004 relative weights for DRGs
526 and 527.
f. Artificial Anal Sphincter. The ICD-9-CM Coordination and
Maintenance Committee created two new codes to describe procedures
involving an artificial anal sphincter for use for discharges occurring
on or after October 1, 2002. One code (49.75, Implantation or revision
of artificial anal sphincter) is used to identify cases involving
implantation or revision of an artificial anal sphincter. The second
code (49.76, Removal of artificial anal sphincter) is used to identify
cases involving the removal of the device. In Table 6B of the August 1,
2002 IPPS final rule (67 FR 50242), we assigned both codes to one of
four MDCs based on principal diagnosis, and to one of six DRGs within
those MDCs as follows: MDC 6, DRG 157 (Anal and Stomal Procedures With
CC) and DRG 158 (Anal and Stomal Procedures Without CC); MDC 9
(Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast),
DRG 267 (Perianal and Pilonidal Procedures); MDC 21 (Injuries,
Poisonings, and Toxic Effect of Drugs), DRG 442 (Other O.R. Procedures
for Injuries With CC) and DRG 443 (Other O.R. Procedures for Injuries
Without CC); and MDC 24 (Multiple Significant Trauma), DRG 486 (Other
O.R. Procedures for Multiple Significant Trauma).
We have received a request that we review these DRG assignments.
According to the requester, the artificial anal sphincter procedures
are expensive and the payment does not adequately cover a hospital's
costs in the most likely occurring DRGs 157 and 158. The requester
submitted data showing cases involving artificial anal sphincters with
average charges of $44,000, and suggested that we assign codes 49.75
and 49.76 in MDC 6 to DRG 170 (Other Digestive System O.R. Procedures
With CC) and DRG 171) (Other Digestive System O.R. Procedures Without
CC) because DRG 170 and DRG 171 are higher weighted than DRGs 157 and
158.
At this time, we are not proposing to assign these cases to DRGs
170 and 171. Although we recognize the data submitted by the commenter
appear to show this procedure is associated with above average costs in
the DRGs to which these cases are assigned, we believe the current
assignment is the most clinically appropriate at this time. As noted
above, the procedure codes to identify the implantation, revision, or
removal of these devices were effective beginning on October 1, 2002.
Therefore, we propose to monitor the costs of these cases using actual
Medicare cases with these codes included from the FY 2003 MedPAR that
will be used for the FY 2004 DRG relative weights.
C. Recalibration of DRG Weights
We are proposing to use the same basic methodology for the FY 2004
recalibration as we did for FY 2003 (August 1, 2002 IPPS final rule (67
FR 50008). That is, we are proposing to recalibrate the DRG weights
based on charge data for Medicare discharges using the most current
charge information available (the FY 2002 MedPAR file).
The MedPAR file is based on fully coded diagnostic and procedure
data for all Medicare inpatient hospital bills. FY 2002 MedPAR data
include discharges occurring between October 1, 2001 and September 30,
2002, based on bills received by CMS through December 31, 2002, from
all hospitals subject to the IPPS and short-term acute care hospitals
in Maryland (which is under a waiver from the IPPS under section
1814(b)(3) of the Act). The FY 2002 MedPAR file includes data for
approximately 11,404,829 Medicare discharges. Discharges for Medicare
beneficiaries enrolled in a Medicare+Choice managed care plan are
excluded from this analysis. The data include hospitals that
subsequently became CAHs, although no data are included for hospitals
after the point they are certified as CAHs.
The proposed methodology used to calculate the DRG relative weights
from the FY 2002 MedPAR file is as follows:
[sbull] To the extent possible, all the claims were regrouped using
the DRG classification revisions discussed in section II.B. of this
preamble.
[sbull] 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.
[sbull] 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.
[sbull] Statistical outliers were eliminated by removing all cases
that are beyond 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.
[sbull] 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.
[sbull] The transplant cases that were used to establish the
relative weight for heart and heart-lung, liver, and lung transplants
(DRGs 103, 480, and 495) were limited to those Medicare-approved
transplant centers that have cases in the FY 2000 MedPAR file.
(Medicare coverage for heart, heart-lung, liver, and lung transplants
is limited to
[[Page 27173]]
those facilities that have received approval from CMS as transplant
centers.)
[sbull] Organ acquisition costs for kidney, heart, heart-lung,
liver, lung, pancreas, and intestinal (or multivisceral organs)
transplants continue to be paid on a reasonable cost basis. Because
these acquisition costs are paid separately from the prospective
payment rate, it is necessary to subtract the acquisition charges from
the total charges on each transplant bill that showed acquisition
charges before computing the average charge for the DRG and before
eliminating statistical outliers.
When we recalibrated the DRG weights for previous years, we set a
threshold of 10 cases as the minimum number of cases required to
compute a reasonable weight. We used that same case threshold in
recalibrating the proposed DRG weights for FY 2004. Using the FY 2002
MedPAR data set, there are 42 DRGs that contain fewer than 10 cases. We
computed the weights for these low-volume DRGs by adjusting the
proposed FY 2003 weights of these DRGs by the percentage change in the
average weight of the cases in the other DRGs.
The proposed new weights are normalized by an adjustment factor
(1.45510) 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 IPPS.
As noted below in section IV.A.2., we are proposing to expand the
transfer policy applicable to postacute care transfers from 10 DRGs
currently to an additional 19 DRGs, beginning in FY 2004. Because we
count a transfer case as a fraction of a case as described above in the
recalibration process, any expansion of the postacute care transfer
policy to 19 additional DRGs would affect the proposed relative weights
for those DRGs. Therefore, we calculated the proposed FY 2004
normalization factor comparing the case-mix using the proposed FY 2004
DRG relative weights in which we treated postacute care transfer cases
in the 19 DRGs proposed to be added to the postacute transfer policy
for FY 2004 as a fraction of a case with the case-mix using the FY 2003
DRG relative weights without treating cases in these 19 additional DRGs
as transfer cases.
Section 1886(d)(4)(C)(iii) of the Act requires that, beginning with
FY 1991, reclassification and recalibration changes be made in a manner
that assures that the aggregate payments are neither greater than nor
less than the aggregate payments that would have been made without the
changes. Although normalization is intended to achieve this effect,
equating the average case weight after recalibration to the average
case weight before recalibration does not necessarily achieve budget
neutrality with respect to aggregate payments to hospitals because
payments to hospitals are affected by factors other than average case
weight. Therefore, as we have done in past years and as discussed in
section II.A.4.a. of the Addendum to this proposed rule, we are
proposing to make a budget neutrality adjustment to ensure that the
requirement of section 1886(d)(4)(C)(iii) of the Act is met.
D. Proposed LTC-DRG Reclassifications and Relative Weights for LTCHs
for FY 2004
1. Background
In the March 7, 2003 LTCH PPS proposed rule (68 FR 11234), we
proposed to change the LTCH PPS annual payment rate update cycle to be
effective July 1 through June 30 instead of October 1 through September
30. In addition, since the patient classification system utilized under
the LTCH PPS is based directly on the DRGs used under the IPPS for
acute care hospitals, in that same proposed rule, we proposed that the
annual update of the long-term care diagnosis-related group (LTC-DRG)
classifications and relative weights would continue to remain linked to
the annual reclassification and recalibration of the CMS-DRGs under the
IPPS.
The annual update to the IPPS DRGs is based on the annual revisions
to the ICD-9-CM codes and is effective each October 1. In the health
care industry, annual changes to the ICD-9-CM codes are effective for
discharges occurring on or after October 1 each year. The use of the
ICD-9-CM coding system is also compliant with the requirements of the
Health Insurance Portability and Accountability Act (HIPAA), Pub. L.
104-191, under 45 CFR Parts 160 and 162. Therefore, the manual and
electronic versions of the GROUPER software, which are based on the
ICD-9-CM codes, are also revised annually and effective for discharges
occurring on or after October 1 each year. Because the LTC-DRGs are
based on the patient classification system used under the IPPS (CMS-
DRGs), which is updated annually and effective for discharges occurring
on or after October 1 through September 30 each year, in the March 7,
2003 LTCH PPS proposed rule (68 FR 11234), we proposed to continue to
update the LTC-DRG classifications and relative weights to be effective
for discharges occurring on or after October 1 through September 30
each year.
As we explained in the March 7, 2003 LTCH PPS proposed rule (68 FR
11234), the FY 2004 DRGs and relative weights used under the IPPS had
not yet been proposed, and we were unable to propose updated LTC-DRGs
and relative weights at that time. Therefore, since the LTC-DRG
classifications and relative weights would continue to be based on the
annual updates to the IPPS DRGs, we proposed that proposed revisions to
the LTC-DRG classifications and relative weights would be presented for
public comment in the IPPS proposed rule and finalized in the IPPS
final rule, to be effective October 1, 2003 through September 30, 2004.
For FY 2003, version 20.0 of the DRG GROUPER is being utilized
under both the IPPS and the LTCH PPS. The LTC-DRG classifications and
relative weights are shown in Table 3 of the Addendum to the August 30,
2002 for FY 2003 final rule (67 FR 56076-56084) and in Table 3 of the
Addendum to the March 7, 2003 LTCH PPS proposed rule (68 FR 11285
through 11292). Below we discuss the proposed LTC-DRGs and relative
weights for FY 2004 based on the proposed changes to the hospital IPPS
DRGs (GROUPER version 21.0) discussed in section II. of this preamble.
2. Proposed Changes in the LTC-DRG Classifications
a. Background. Section 123 of Pub. L. 106-113 specifically requires
that the PPS for LTCHs be a per discharge system with a DRG-based
patient classification system reflecting the differences in patient
resources and costs in LTCHs while maintaining budget neutrality.
Section 307(b)(1) of Pub. Law 106-554 modified the requirements of
section 123 of Pub. L. 106-113 by specifically requiring that the
Secretary examine ``the feasibility and the impact of basing payment
under such a system [the LTCH PPS] on the use of existing (or refined)
hospital diagnosis-related groups (DRGs) that have been modified to
account for different resource use of long-term care hospital patients
as well as the use of the most recently available hospital discharge
data.''
In accordance with section 307(b)(1) of Pub. L. 106-554 and Sec.
412.515 of our existing regulations, the LTCH PPS uses information from
LTCH patient records to classify patient cases into distinct LTC-DRGs
based on clinical characteristics and expected resource needs. The LTC-
DRGs used as the patient classification component of the LTCH PPS
correspond to the DRGs
[[Page 27174]]
under the IPPS for acute care hospitals. Thus, in this proposed rule,
we are proposing to use the proposed IPPS version 21.0 GROUPER for FY
2004 to process LTCH PPS claims. The proposed changes to the IPPS DRG
classification system for FY 2004 (Grouper 21.0) are discussed in
section II.B. of this preamble.
Under the LTCH PPS, we determine relative weights for each of the
IPPS DRGs to account for the difference in resource use by patients
exhibiting the case complexity and multiple medical problems
characteristic of LTCHs. In a departure from the IPPS, as we discussed
in the August 30, 2002 final rule (67 FR 55985), we use low volume LTC-
DRGs (less than 25 LTCH cases) in determining the LTC-DRG weights,
since LTCHs do not typically treat the full range of diagnoses as do
acute care hospitals. In order to deal with the large number of low
volume LTC-DRGs (DRGs with fewer than 25 cases), we group those low
volume LTC-DRGs into 5 quintiles based on average charge per discharge.
(A listing of the composition of low volume quintiles for the FY 2003
LTC-DRGs (based on FY 2001 MedPAR data) appears in the August 30, 2002
final rule at 67 FR 55986-55988). We also adjusted for cases in which
the stay at the LTCH is five-sixths of the geometric average length of
stay; that is, short-stay outlier cases (Sec. 412.529). (A detailed
discussion of the application of the Lewin Group model that was used to
develop the LTC-DRGs appears in the August 30, 2002 final rule at 67 FR
55978).
b. Patient Classifications into DRGs. Generally, under the LTCH
PPS, Medicare payment is made at a predetermined specific rate for each
discharge; that is, payment varies by the LTC-DRG to which a
beneficiary's stay is assigned. Similar to case classification for
acute care hospitals under the IPPS (see section II.B. of this
preamble), cases are classified into LTC-DRGs for payment under the
LTCH PPS 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
ICD-9-CM.
As discussed above in section II.B. of this preamble, the DRGs are
organized into 25 Major Diagnostic Categories (MDCs), most of which are
based on a particular organ system of the body; the remainder involve
multiple organ systems (such as MDC 22, Burns). Accordingly, the
principal diagnosis determines MDC assignment. Within most MDCs, cases
are then divided into surgical DRGs and medical DRGs. Some surgical and
medical DRGs are further differentiated based on the presence or
absence of CCs. (See section II.B. of this preamble for further
discussion of surgical DRGs and medical DRGs.)
Because the assignment of a case to a particular LTC-DRG will help
determine the amount that will be paid for the case, it is important
that the coding is accurate. As is the case under the IPPS,
classifications and terminology used in the LTCH PPS are consistent
with the ICD-9-CM and the Uniform Hospital Discharge Data Set (UHDDS),
as recommended to the Secretary by the National Committee on Vital and
Health Statistics (``Uniform Hospital Discharge Data: Minimum Data Set,
National Center for Health Statistics, April 1980'') and as revised in
1984 by the Health Information Policy Council (HIPC) of the U.S.
Department of Health and Human Services. We wish to point out again
that the ICD-9-CM coding terminology and the definitions of principal
and other diagnoses of the UHDDS are consistent with the requirements
of the Administrative Simplification Act of 1996 of the HIPAA (45 CFR
Parts 160 and 162).
As we stated in the August 30, 2002 LTCH PPS final rule (67 FR
55981), the emphasis on the need for proper coding cannot be
overstated. Inappropriate coding of cases can adversely affect the
uniformity of cases in each LTC-DRG and produce inappropriate weighting
factors at recalibration and result in inappropriate payments under the
LTCH PPS. LTCHs are to follow the same coding guidelines used by the
acute care hospitals to ensure accuracy and consistency in coding
practices. There will be only one LTC-DRG assigned per long-term care
hospitalization; it will be assigned at the discharge. Therefore, it is
mandatory that the coders continue to report the same principal
diagnosis on all claims and include all diagnostic codes that coexist
at the time of admission, that are subsequently developed, or that
affect the treatment received. Similarly, all procedures performed
during that stay are to be reported on each claim. (For further
information on the use of ICD-9-CM codes under the LTCH PPS, see the
August 30, 2002 LTCH PPS final rule (67 FR 55979-55983).)
Upon the discharge of the patient from a LTCH, the LTCH must assign
appropriate diagnosis and procedure codes from the ICD-9-CM. As of
October 16, 2002, a LTCH that was required to comply with the HIPAA
Administrative Simplification Standards and that had not obtained an
extension in compliance with the Administrative Compliance Act (Pub. L.
107-105) is obligated to comply with the standards at 45 CFR 162.1002
and 45 CFR 162.1102. Completed claim forms are to be submitted to the
LTCH's Medicare fiscal intermediary.
Medicare fiscal intermediaries enter the clinical and demographic
information into their claims processing systems and subject this
information to a series of automated screening processes called the
Medicare Code Editor (MCE). These screens are designed to identify
cases that require further review before assignment into a DRG can be
made. (For more information on types of cases selected for further
development, see the August 30, 2002 LTCH PPS final rule (67 FR
55979).)
After screening through the MCE, each LTCH claim will be classified
into the appropriate LTC-DRG by the Medicare LTCH GROUPER. The LTCH
GROUPER is specialized computer software based on the same GROUPER used
under the IPPS. After the LTC-DRG is assigned, the Medicare fiscal
intermediary determines the prospective payment by using the Medicare
PRICER program, which accounts for LTCH hospital-specific adjustments.
As provided for under the IPPS, we provide an opportunity for the LTCH
to review the LTC-DRG assignments made by the fiscal intermediary and
to submit additional information within a specified timeframe (Sec.
412.513(c)).
The GROUPER is used both to classify past cases in order to measure
relative hospital resource consumption to establish the DRG weights and
to classify current cases for purposes of determining payment. The
records for all Medicare hospital inpatient discharges are maintained
in the MedPAR file. The data in this file are used to evaluate possible
DRG classification changes and to recalibrate the DRG weights during
our annual update (as discussed in section II. of this preamble). The
LTC-DRG weights are based on data for the population of LTCH
discharges, reflecting the fact that LTCH patients represent a
different patient mix than patients in short-term acute care hospitals.
3. Development of the Proposed FY 2004 LTC-DRG Relative Weights
a. General Overview of Development of the LTC-DRG Relative Weights.
As we stated in the August 30, 2002 LTCH PPS final rule (67 FR 55984),
one of the primary goals for the implementation of the LTCH IPPS is to
pay each LTCH an appropriate amount for the efficient delivery of care
to Medicare patients.
[[Page 27175]]
The system must be able to account adequately for each LTCH's case-mix
in order to ensure both fair distribution of Medicare payments and
access to adequate care for those Medicare patients whose care is more
costly. To accomplish these goals, we adjust the LTCH PPS standard
Federal prospective payment system rate by the LTC-DRG relative weights
in determining payment to LTCHs for each case.
Under the LTCH PPS, relative weights for each LTC-DRG are a primary
element used to account for the variations in cost per discharge and
resource utilization among the payment groups (Sec. 412.515). To
ensure that Medicare patients classified to each LTC-DRG have access to
an appropriate level of services and to encourage efficiency, we
calculate a relative weight for each LTC-DRG that represents the
resources needed by an average inpatient LTCH case in that LTC-DRG. For
example, cases in a LTC-DRG with a relative weight of 2 will, on
average, cost twice as much as cases in a LTC-DRG with a weight of 1.
b. Data. To calculate the proposed LTC-DRG relative weights for FY
2004 in this proposed rule, we obtained total Medicare allowable
charges from FY 2002 Medicare hospital bill data from the December 2002
update of the MedPAR file, and we used the proposed Version 21.0 of the
CMS GROUPER used under the acute care hospital inpatient IPPS as
discussed above in section II.B. of this preamble. Consistent with the
methodology under the hospital IPPS, we are proposing to recalculate
the FY 2004 LTC-DRG relative weights based on the best available data
for the final rule.
As we discussed in further detail in the August 30, 2002 LTCH PPS
final rule (67 FR 55984), based on comments regarding the data used in
the development of the LTCH prospective payment system, we have
excluded the data from LTCHs that are all-inclusive rate providers and
LTCHs that are reimbursed in accordance with demonstration projects
authorized under section 402(a) of Public Law 90-248 (42 U.S.C. 1395b-
1) or section 222(a) of Public Law 92-603 (42 U.S.C. 1395b-1).
Therefore, in the development of the proposed FY 2004 LTC-DRG relative
weights we have excluded the data of the 22 all-inclusive rate
providers and the 3 LTCHs that are paid in accordance with
demonstration projects.
In addition, as we discussed in the August 30, 2002 LTCH PPS final
rule (67 FR 55989), a data problem regarding the proposed FY 2003 LTC-
DRG relative weight values that were determined using MedPAR (claims)
data for FYs 2000 and 2001 was brought to our attention. Following
notification of this problem, we researched the commenter's claims and
determined that, given the long stays at LTCHs, some providers had
submitted multiple bills for payment under the TEFRA reimbursement
system for the same stay. Based upon our research, we became aware of
the following situation: In certain LTCHs, hospital personnel
apparently reported a different principal diagnosis on each bill since,
under the TEFRA system, payment was not dependent upon principal
diagnosis as it is under a DRG-based system. These claims from the
MedPAR file were run through the LTCH GROUPER and used in determining
the proposed FY 2003 relative weights for each LTC-DRG.
Since this issue was brought to our attention and we discovered
that only data from the final bills were being extracted for the MedPAR
file, it was possible that the original MedPAR file was not receiving
the correct principal diagnosis. Therefore, in the August 30, 2002
final rule (67 FR 55989), we addressed the problem by identifying all
LTCH cases in the FY 2001 MedPAR file for which multiple bills were
submitted. For each of these cases, beginning with the first bill and
moving forward consecutively through subsequent bills for that stay, we
recorded the first unique diagnosis codes up to 10 and the first unique
procedure codes up to 10. We then used these codes to appropriately
group each LTCH case to a LTC-DRG for FY 2003.
As we noted above, we are proposing to use LTCH claims data from
the FY 2002 MedPAR file for the determination of the proposed FY 2004
LTC-DRG relative weights. Since at the time (FY 2002) LTCHs were still
reimbursed under the TEFRA reasonable cost-based system, some LTCHs
also had submitted multiple bills for Medicare payment for the same
stay. Thus, in certain LTCHs, hospital personnel were apparently still
reporting a different principal diagnosis on each bill since, under the
TEFRA system in FY 2002, payment was not dependent upon principal
diagnosis as it is under a DRG-based system. Therefore, we are
proposing to follow the same methodology outlined above to determine
the appropriate diagnosis and procedure codes for those multiple bill
LTCH cases in the FY 2002 MedPAR files, and we are proposing to use
these codes to group each LTCH case to a proposed LTC-DRG for FY 2004.
Since the LTCH PPS was implemented for cost reporting periods beginning
on or after October 1, 2002 (FY 2003), we believe that this problem
will be self-correcting as LTCHs submit more completely coded data in
the future.
c. Hospital-Specific Relative Value Methodology. As we discussed in
the August 30, 2002 LTCH PPS final rule (67 FR 55985), by nature LTCHs
often specialize in certain areas, such as ventilator-dependent
patients and rehabilitation and wound care. Some case types (DRGs) may
be treated, to a large extent, in hospitals that have, from a
perspective of charges, relatively high (or low) charges. Such
nonarbitrary distribution of cases with relatively high (or low)
charges in specific LTC-DRGs has the potential to inappropriately
distort the measure of average charges. To account for the fact that
cases may not be randomly distributed across LTCHs, as explained in
that same final rule (67 FR 55985), we use a hospital-specific relative
value method to calculate the proposed LTC-DRG relative weights instead
of the methodology used to determine the proposed DRG relative weights
under the hospital IPPS described above in section II.C. of this
preamble. We believe this method will remove this hospital-specific
source of bias in measuring LTCH average charges. Specifically, we
reduce the impact of the variation in charges across providers on any
particular LTC-DRG relative weight by converting each LTCH's charge for
a case to a relative value based on that LTCH's average charge.
Under the hospital-specific relative value method, as we explained
in the August 30, 2002 LTCH PPS final rule (67 FR 55985), we
standardize charges for each LTCH by converting its charges for each
case to hospital-specific relative charge values and then adjusting
those values for the LTCH's case-mix. The adjustment for case-mix is
needed to rescale the hospital-specific relative charge values (which,
by definition, averages 1.0 for each LTCH). The average relative weight
for a LTCH is its case-mix, so it is reasonable to scale each LTCH's
average relative charge value by its case-mix. In this way, each LTCH's
relative charge value is adjusted by its case-mix to an average that
reflects the complexity of the cases it treats relative to the
complexity of the cases treated by all other LTCHs (the average case-
mix of all LTCHs).
In accordance with the methodology established in the August 30,
2002 LTCH PPS final rule (67 FR 55985), we standardize charges for each
case by first dividing the adjusted charge for the case (adjusted for
short-stay outliers under Sec. 412.529 as described in section II.D.4.
(step 3) of this preamble) by the average adjusted charge for all cases
at the LTCH in which the case was treated.
[[Page 27176]]
Short-stay outliers under Sec. 412.529 are cases with a length of stay
that is less than or equal to five-sixths the average length of stay of
the LTC-DRG. The average adjusted charge reflects the average intensity
of the health care services delivered by a particular LTCH and the
average cost level of that LTCH. The resulting ratio is multiplied by
that LTCH's case-mix index to determine the standardized charge for the
case.
Multiplying by the LTCH's case-mix index accounts for the fact that
the same relative charges are given greater weight in a LTCH with
higher average costs than they would at a LTCH with low average costs
which is needed to adjust each LTCH's relative charge value to reflect
its case-mix relative to the average case-mix for all LTCHs. Because we
standardize charges in this manner, we count charges for a Medicare
patient at a LTCH with high average charges as less resource intensive
than they would be at a LTCH with low average charges. For example, a
$10,000 charge for a case in a LTCH with an average adjusted charge of
$17,500 reflects a higher level of relative resource use than a $10,000
charge for a case in a LTCH with the same case-mix, but an average
adjusted charge of $35,000. We believe that the adjusted charge of an
individual case more accurately reflects actual resource use for an
individual LTCH because the variation in charges due to systematic
differences in the markup of charges among LTCHs is taken into account.
d. Low Volume LTC-DRGs. In order to account for LTC-DRGs with low
volume (that is, with fewer than 25 LTCH cases), in accordance with the
methodology we established in the August 30, 2002 LTCH PPS final rule
(67 FR 55985), we group those low volume LTC-DRGs into one of five
categories (quintiles) based on average charges, for the purposes of
determining relative weights. For this proposed rule, using LTCH cases
from the December 2002 update of the FY 2002 MedPAR file, we identified
163 proposed LTC-DRGs that contained between 1 and 24 cases. This list
of proposed LTC-DRGs was then divided into one of the five proposed low
volume quintiles, each containing a minimum of 32 proposed LTC-DRGs
(163/5 = 32 with 3 proposed LTC-DRGs as the remainder). For FY 2004, we
are proposing to make an assignment to a specific low volume quintile
by sorting the 163 low volume proposed LTC-DRGs in ascending order by
average charge. Since the number of proposed LTC-DRGs with less than 25
LTCH cases is not evenly divisible by five, the average charge of the
low volume proposed LTC-DRG was used to determine which proposed low
volume quintile received the additional proposed LTC-DRG. After sorting
the 163 low volume proposed LTC-DRGs in ascending order, we are
proposing that the first fifth (32) of low volume proposed LTC-DRGs
with the lowest average charge would be grouped into Quintile 1. Since
the average charge of the 33rd proposed LTC-DRG in the sorted list is
closer to the previous proposed LTC-DRG's average charge (assigned to
proposed Quintile 1) than to the average charge of the 34th proposed
LTC-DRG on the sorted list (to be assigned to proposed Quintile 2), we
are proposing to place it into proposed Quintile 1. The highest average
charge cases would then be grouped into proposed Quintile 5. This
process would be repeated through the remaining low volume proposed
LTC-DRGs so that 3 proposed low volume quintiles would contain 33
proposed LTC-DRGs and 2 proposed low volume quintiles would contain 32
proposed LTC-DRGs.
In order to determine the proposed relative weights for the
proposed LTC-DRGs with low volume for FY 2004, in accordance with the
methodology established in the August 30, 2002 LTCH PPS final rule (67
FR 55985), we would use the five proposed low volume quintiles
described above. The proposed composition of each of the five low
volume quintiles shown below in Table 1 would be used in determining
the proposed LTC-DRG relative weights for FY 2004. We would determine a
proposed relative weight and (geometric) average length of stay for
each of the five proposed low volume quintiles using the formula that
we are proposing to apply to the regular proposed LTC-DRGs (25 or more
cases), as described below in section II.D.4. of this preamble. We are
proposing to assign the same proposed relative weight and average
length of stay to each of the proposed LTC-DRGs that make up that
proposed low volume quintile. We note that as this system is dynamic,
it is possible that the number and specific type of LTC-DRGs with a low
volume of LTCH cases will vary in the future. We use the best available
claims data in the MedPAR file to identify low volume LTC-DRGs and to
calculate the relative weights based on our methodology.
Table 1.--Proposed Composition of Low Volume Quintiles
------------------------------------------------------------------------
Proposed LTC-DRG Description
------------------------------------------------------------------------
Proposed Quintile 1
------------------------------------------------------------------------
044............................... ACUTE MAJOR EYE INFECTIONS
047............................... OTHER DISORDERS OF THE EYE AGE 17 W/O CC
065............................... DYSEQUILIBRIUM
066............................... EPISTAXIS
069............................... OTITIS MEDIA & URI AGE 17
W/O CC
072............................... NASAL TRAUMA & DEFORMITY
128............................... DEEP VEIN THROMBOPHLEBITIS
149............................... MAJOR SMALL & LARGE BOWEL PROCEDURES
W/O CC
178............................... UNCOMPLICATED PEPTIC ULCER W/O CC
192............................... PANCREAS, LIVER & SHUNT PROCEDURES W/
O CC
262............................... BREAST BIOPSY & LOCAL EXCISION FOR
NON-MALIGNANCY
273............................... MAJOR SKIN DISORDERS W/O CC
276............................... NON-MALIGNANT BREAST DISORDERS
305............................... KIDNEY,URETER & MAJOR BLADDER PROC
FOR NON-NEOPL W/O CC
311............................... TRANSURETHRAL PROCEDURES W/O CC
319............................... KIDNEY & URINARY TRACT NEOPLASMS W/O
CC
328............................... URETHRAL STRICTURE AGE 17
W CC
339............................... TESTES PROCEDURES, NON-MALIGNANCY
AGE 17
342............................... CIRCUMCISION AGE 17
348............................... BENIGN PROSTATIC HYPERTROPHY W CC
349............................... BENIGN PROSTATIC HYPERTROPHY W/O CC
[[Page 27177]]
376............................... POSTPARTUM & POST ABORTION DIAGNOSES
W/O O.R. PROCEDURE
385............................... NEONATES, DIED OR TRANSFERRED TO
ANOTHER ACUTE CARE FACILITY
399............................... RETICULOENDOTHELIAL & IMMUNITY
DISORDERS W/O CC
420............................... FEVER OF UNKNOWN ORIGIN AGE 17 W/O CC
428............................... DISORDERS OF PERSONALITY & IMPULSE
CONTROL
431............................... CHILDHOOD MENTAL DISORDERS
432............................... OTHER MENTAL DISORDER DIAGNOSES
455............................... OTHER INJURY, POISONING & TOXIC
EFFECT DIAG W/O CC
465............................... AFTERCARE W HISTORY OF MALIGNANCY AS
SECONDARY DIAGNOSIS
509............................... FULL THICKNESS BURN W/O SKIN GRFT OR
INH INJ W/O CC OR SIG TRAUMA
511............................... NON-EXTENSIVE BURNS W/O CC OR
SIGNIFICANT TRAUMA
540............................... LYMPHOMA AND LEUKEMIA WITH MAJOR
O.R. PROCEDURE WITHOUT CC
-----------------------------------
Proposed Quintile 2
------------------------------------------------------------------------
021............................... VIRAL MENINGITIS
022............................... HYPERTENSIVE ENCEPHALOPATHY
031**............................. CONCUSSION AGE 17 W CC
046............................... OTHER DISORDERS OF THE EYE AGE 17 W CC
053............................... SINUS & MASTOID PROCEDURES AGE 17
084............................... MAJOR CHEST TRAUMA W/O CC
177............................... UNCOMPLICATED PEPTIC ULCER W CC
193............................... BILIARY TRACT PROC EXCEPT ONLY
CHOLECYST W OR W/O C.D.E. W CC
194*.............................. BILIARY TRACT PROC EXCEPT ONLY
CHOLECYST W OR W/O C.D.E. W/O CC
200............................... HEPATOBILIARY DIAGNOSTIC PROCEDURE
FOR NON-MALIGNANCY
206............................... DISORDERS OF LIVER EXCEPT MALIG,
CIRR, ALC HEPA W/O CC
208............................... DISORDERS OF THE BILIARY TRACT W/O
CC
211............................... HIP & FEMUR PROCEDURES EXCEPT MAJOR
JOINT AGE 17 W/O CC
232............................... ARTHROSCOPY
234............................... OTHER MUSCULOSKELET SYS & CONN TISS
O.R. PROC W/O CC
237............................... SPRAINS, STRAINS, & DISLOCATIONS OF
HIP, PELVIS & THIGH
275............................... MALIGNANT BREAST DISORDERS W/O CC
299............................... INBORN ERRORS OF METABOLISM
309............................... MINOR BLADDER PROCEDURES W/O CC
323............................... URINARY STONES W CC, &/OR ESW
LITHOTRIPSY
324............................... URINARY STONES W/O CC
341............................... PENIS PROCEDURES
344............................... OTHER MALE REPRODUCTIVE SYSTEM O.R.
PROCEDURES FOR MALIGNANCY
367............................... MALIGNANCY, FEMALE REPRODUCTIVE
SYSTEM W/O CC
414............................... OTHER MYELOPROLIF DIS OR POORLY DIFF
NEOPL DIAG W/O CC
421............................... VIRAL ILLNESS AGE 17
454............................... OTHER INJURY, POISONING & TOXIC
EFFECT DIAG W CC
473............................... ACUTE LEUKEMIA W/O MAJOR O.R.
PROCEDURE AGE 17
497**............................. SPINAL FUSION W CC
502............................... KNEE PROCEDURES W PDX OF INFECTION W/
O CC
506............................... FULL THICKNESS BURN W SKIN GRAFT OR
INHAL INJ W CC OR SIG TRAUMA
507*.............................. FULL THICKNESS BURN W SKIN GRFT OR
INHAL INJ W/O CC OR SIG TRAUMA
508............................... FULL THICKNESS BURN W/O SKIN GRFT OR
INHAL INJ W CC OR SIG TRAUMA
510............................... NON-EXTENSIVE BURNS W CC OR
SIGNIFICANT TRAUMA
529............................... VENTRICULAR SHUNT PROCEDURES WITH CC
-----------------------------------
Proposed Quintile 3
------------------------------------------------------------------------
031*.............................. CONCUSSION AGE 17 W CC
032............................... CONCUSSION AGE 17 W/O CC
063............................... OTHER EAR, NOSE, MOUTH & THROAT O.R.
PROCEDURES
083............................... MAJOR CHEST TRAUMA W CC
117............................... CARDIAC PACEMAKER REVISION EXCEPT
DEVICE REPLACEMENT
119............................... VEIN LIGATION & STRIPPING
158............................... ANAL & STOMAL PROCEDURES W/O CC
194**............................. BILIARY TRACT PROC EXCEPT ONLY
CHOLECYST W OR W/O C.D.E. W/O CC
197............................... CHOLECYSTECTOMY EXCEPT BY
LAPAROSCOPE W/O C.D.E. W CC
218............................... LOWER EXTREM & HUMER PROC EXCEPT
HIP, FOOT, FEMUR AGE 17
W CC
223............................... MAJOR SHOULDER/ELBOW PROC, OR OTHER
UPPER EXTREMITY PROC W CC
228............................... MAJOR THUMB OR JOINT PROC, OR OTH
HAND OR WRIST PROC W CC
257............................... TOTAL MASTECTOMY FOR MALIGNANCY W CC
293............................... OTHER ENDOCRINE, NUTRIT & METAB O.R.
PROC W/O CC
295............................... DIABETES AGE 0-35
317............................... ADMIT FOR RENAL DIALYSIS
345............................... OTHER MALE REPRODUCTIVE SYSTEM O.R.
PROC EXCEPT FOR MALIGNANCY
347***............................ MALIGNANCY, MALE REPRODUCTIVE
SYSTEM, W/O CC
352............................... OTHER MALE REPRODUCTIVE SYSTEM
DIAGNOSES
[[Page 27178]]
369............................... MENSTRUAL & OTHER FEMALE
REPRODUCTIVE SYSTEM DISORDERS
402............................... LYMPHOMA & NON- ACUTE LEUKEMIA W
OTHER O.R. PROC W/O CC
408............................... MYELOPROLIF DISORD OR POORLY DIFF
NEOPL W OTHER O.R.PROC
410............................... CHEMOTHERAPY W/O ACUTE LEUKEMIA AS
SECONDARY DIAGNOSIS
411............................... HISTORY OF MALIGNANCY W/O ENDOSCOPY
419............................... FEVER OF UNKNOWN ORIGIN AGE 17 W CC
443............................... OTHER O.R. PROCEDURES FOR INJURIES W/
O CC
447............................... ALLERGIC REACTIONS AGE 17
449............................... POISONING & TOXIC EFFECTS OF DRUGS
AGE 17 W CC
450............................... POISONING & TOXIC EFFECTS OF DRUGS
AGE 17 W/O CC
497*.............................. SPINAL FUSION W CC
498*.............................. SPINAL FUSION W/O CC
503............................... KNEE PROCEDURES W/O PDX OF INFECTION
505............................... EXTENSIVE 3RD DEGREE BURNS W/O SKIN
GRAFT
507**............................. FULL THICKNESS BURN W SKIN GRFT OR
INHAL INJ W/O CC OR SIG TRAUMA
518............................... PERCUTANEOUS CARDIVASCULAR PROC W/O
CORONARY ARTERY STENT OR AMI
-----------------------------------
Proposed Quintile 4
------------------------------------------------------------------------
008............................... PERIPH & CRANIAL NERVE & OTHER NERV
SYST PROC W/O CC
061............................... MYRINGOTOMY W TUBE INSERTION AGE 17
095***............................ PNEUMOTHORAX W/O CC
124............................... CIRCULATORY DISORDERS EXCEPT AMI, W
CARD CATH & COMPLEX DIAG
125............................... CIRCULATORY DISORDERS EXCEPT AMI, W
CARD CATH W/O COMPLEX DIAG
150............................... PERITONEAL ADHESIOLYSIS W CC
152............................... MINOR SMALL & LARGE BOWEL PROCEDURES
W CC
157............................... ANAL & STOMAL PROCEDURES W CC
161............................... INGUINAL & FEMORAL HERNIA PROCEDURES
AGE 17 W CC
191............................... PANCREAS, LIVER & SHUNT PROCEDURES W
CC
195............................... CHOLECYSTECTOMY W C.D.E. W CC
210............................... HIP & FEMUR PROCEDURES EXCEPT MAJOR
JOINT AGE 17 W CC
226............................... SOFT TISSUE PROCEDURES W CC
227............................... SOFT TISSUE PROCEDURES W/O CC
230............................... LOCAL EXCISION & REMOVAL OF INT FIX
DEVICES OF HIP & FEMUR
268............................... SKIN, SUBCUTANEOUS TISSUE & BREAST
PLASTIC PROCEDURES
306............................... PROSTATECTOMY W CC
308............................... MINOR BLADDER PROCEDURES W CC
310............................... TRANSURETHRAL PROCEDURES W CC
312............................... URETHRAL PROCEDURES, AGE 17 W CC
360............................... VAGINA, CERVIX & VULVA PROCEDURES
394............................... OTHER O.R. PROCEDURES OF THE BLOOD
AND BLOOD FORMING ORGANS
427............................... NEUROSES EXCEPT DEPRESSIVE
479***............................ OTHER VASCULAR PROCEDURES W/O CC
486............................... OTHER O.R. PROCEDURES FOR MULTIPLE
SIGNIFICANT TRAUMA
493............................... LAPAROSCOPIC CHOLECYSTECTOMY W/O
C.D.E. W CC
494*.............................. LAPAROSCOPIC CHOLECYSTECTOMY W/O
C.D.E. W/O CC
498**............................. SPINAL FUSION W/O CC
500............................... BACK & NECK PROCEDURES EXCEPT SPINAL
FUSION W/O CC
517............................... PERCUTANEOUS CARDIVASCULAR PROC W
NON-DRUG ELUTING STENT W/O AMI
519............................... CERVICAL SPINAL FUSION W CC
532............................... SPINAL PROCEDURES WITHOUT CC
538............................... LOCAL EXCISION AND REMOVAL OF
INTERNAL FIXATION DEVICES EXCEPT
HIP AND FEMUR WITHOUT CC
-----------------------------------
Proposed Quintile 5
------------------------------------------------------------------------
001............................... CRANIOTOMY AGE 17 W CC
055............................... MISCELLANEOUS EAR, NOSE, MOUTH &
THROAT PROCEDURES
075............................... MAJOR CHEST PROCEDURES
077............................... OTHER RESP SYSTEM O.R. PROCEDURES W/
O CC
108............................... OTHER CARDIOTHORACIC PROCEDURES
110............................... MAJOR CARDIOVASCULAR PROCEDURES W CC
115............................... PRM CARD PACEM IMPL W AMI,HRT FAIL
OR SHK,OR AICD LEAD OR GNRTR P
116............................... OTH PERM CARD PACEMAK IMPL OR PTCA W
CORONARY ARTERY STENT IMPLNT
118............................... CARDIAC PACEMAKER DEVICE REPLACEMENT
154............................... STOMACH, ESOPHAGEAL & DUODENAL
PROCEDURES AGE 17 W CC
168............................... MOUTH PROCEDURES W CC
171***............................ OTHER DIGESTIVE SYSTEM O.R.
PROCEDURES W/O CC
201............................... OTHER HEPATOBILIARY OR PANCREAS O.R.
PROCEDURES
209............................... MAJOR JOINT & LIMB REATTACHMENT
PROCEDURES OF LOWER EXTREMITY
216............................... BIOPSIES OF MUSCULOSKELETAL SYSTEM &
CONNECTIVE TISSUE
261............................... BREAST PROC FOR NON-MALIGNANCY
EXCEPT BIOPSY & LOCAL EXCISION
[[Page 27179]]
266***............................ SKIN GRAFT &/OR DEBRID EXCEPT FOR
SKIN ULCER OR CELLULITIS W/O CC
288............................... O.R. PROCEDURES FOR OBESITY
304............................... KIDNEY,URETER & MAJOR BLADDER PROC
FOR NON-NEOPL W CC
365............................... OTHER FEMALE REPRODUCTIVE SYSTEM
O.R. PROCEDURES
401............................... LYMPHOMA & NON-ACUTE LEUKEMIA W
OTHER O.R. PROC W CC
406............................... MYELOPROLIF DISORD OR POORLY DIFF
NEOPL W MAJ O.R.PROC W CC
412............................... HISTORY OF MALIGNANCY W ENDOSCOPY
441............................... HAND PROCEDURES FOR INJURIES
471............................... BILATERAL OR MULTIPLE MAJOR JOINT
PROCS OF LOWER EXTREMITY
482............................... TRACHEOSTOMY FOR FACE,MOUTH & NECK
DIAGNOSES
488............................... HIV W EXTENSIVE O.R. PROCEDURE
494**............................. LAPAROSCOPIC CHOLECYSTECTOMY W/O
C.D.E. W/O CC
499............................... BACK & NECK PROCEDURES EXCEPT SPINAL
FUSION W CC
501............................... KNEE PROCEDURES W PDX OF INFECTION W
CC
515............................... CARDIAC DEFIBRILATOR IMPLANT W/O
CARDIAC CATH
534............................... EXTRACRANIAL VASCULAR PROCEDURES
WITHOUT CC
536............................... CARDIAC DEFIB IMPLANT WITH CARDIAC
CATH WITHOUT AMI/HF/SHOCK
------------------------------------------------------------------------
* One of the original 163 low volume proposed LTC-DRGs initially
assigned to a different proposed low volume quintile; reassigned to
this proposed low volume quintile in addressing nonmonotonicity (see
step 5 below).
** One of the original 163 low volume proposed LTC-DRGs initially
assigned to this proposed low volume quintile; reassigned to a
different proposed low volume quintile in addressing nonmonotonicity
(see step 5 below).
*** One of the original 163 low volume proposed LTC-DRGs initially
assigned to this proposed low volume quintile; removed from the
proposed low volume quintiles in addressing nonmonotonicity (see step
5 below).
4. Steps for Determining the Proposed FY 2004 LTC-DRG Relative Weights
As we noted previously, the proposed FY 2004 LTC-DRG relative
weights are determined in accordance with the methodology established
in the August 30, 2002 LTCH PPS final rule (67 FR 55989-55991). In
summary, LTCH cases must be grouped in the appropriate proposed LTC-
DRG, while taking into account the low volume proposed LTC-DRGs as
described above, before the proposed FY 2004 LTC-DRG relative weights
can be determined. After grouping the cases in the appropriate proposed
LTC-DRG, we are proposing to calculate the proposed relative weights
for FY 2004 in this proposed rule by first removing statistical
outliers and cases with a length of stay of 7 days or less. Next, we
are proposing to adjust the number of cases in each proposed LTC-DRG
for the effect of short-stay outlier cases under Sec. 412.529. The
short-stay adjusted discharges and corresponding charges would be used
to calculate ``relative adjusted weights'' in each proposed LTC-DRG
using the hospital-specific relative value method described above.
Below we discuss in detail the steps for calculating the proposed
FY 2004 LTC-DRG relative weights, in accordance with the methodology
established in the August 30, 2002 LTCH PPS final rule (67 FR 55989-
55991).
Step 1--Remove statistical outliers. The first step in the
calculation of the proposed FY 2004 LTC-DRG relative weights is to
remove statistical outlier cases. We define statistical outliers as
cases that are outside of 3.0 standard deviations from the mean of the
log distribution of both charges per case and the charges per day for
each proposed LTC-DRG. These statistical outliers would be removed
prior to calculating the proposed relative weights. We believe that
they may represent aberrations in the data that distort the measure of
average resource use. Including those LTCH cases in the calculation of
the proposed relative weights could result in an inaccurate proposed
relative weight that does not truly reflect relative resource use among
the proposed LTC-DRGs.
Step 2--Remove cases with a length of stay of 7 days or less. The
proposed FY 2004 LTC-DRG relative weights should reflect the average of
resources used on representative cases of a specific type. Generally,
cases with a length of stay 7 days or less do not belong in a LTCH,
since such stays do not fully receive or benefit from treatment that is
typical in a LTCH stay and full resources are often not used in the
earlier stages of admission to a LTCH. If we were to include stays of 7
days or less in the computation of the proposed FY 2004 LTC-DRG
relative weights, the value of many proposed relative weights would
decrease and, therefore, payments would decrease to a level that may no
longer be appropriate.
We do not believe that it would be appropriate to compromise the
integrity of the payment determination for those LTCH cases that
actually benefit from and receive a full course of treatment at a LTCH,
in order to include data from these very short-stays. Thus, in
determining the proposed FY 2004 LTC-DRG relative weights, we remove
LTCH cases with a length of stay of 7 days or less.
Step 3--Adjust charges for the effects of short-stay outliers. The
third step in the calculation of the proposed FY 2004 LTC-DRG relative
weights is to adjust each LTCH's charges per discharge for short-stay
outlier cases (that is, a patient with a length of stay that is less
than or equal to five-sixths the average length of stay of the LTC-DRG
as described in the August 30, 2002 LTCH PPS final rule (67 FR 55977).
We make this adjustment by counting a short-stay outlier as a
fraction of a discharge based on the ratio of the length of stay of the
case to the average length of stay for the proposed LTC-DRG for
nonshort-stay outlier cases. This has the effect of proportionately
reducing the impact of the lower charges for the short-stay outlier
cases in calculating the average charge for the proposed LTC-DRG. This
process produces the same result as if the actual charges per discharge
of a short-stay outlier case were adjusted to what they would have been
had the patient's length of stay been equal to the average length of
stay of the proposed LTC-DRG.
As we explained in the August 30, 2002 LTCH PPS final rule (67 FR
55990), counting short-stay outlier cases as full discharges with no
adjustment in determining the proposed LTC-DRG relative weights would
lower the proposed LTC-DRG relative weight for affected proposed LTC-
DRGs because the relatively lower charges of the short-
[[Page 27180]]
stay outlier cases would bring down the average charge for all cases
within a proposed LTC-DRG. This would result in an ``underpayment'' to
nonshort-stay outlier cases and an ``overpayment'' to short-stay
outlier cases. Therefore, in this proposed rule, in accordance with the
methodology established in the August 30, 2002 LTCH PPS final rule (67
FR 55990), we adjust for short-stay outlier cases under Sec. 412.529
in this manner since it would result in more appropriate payments for
all LTCH cases.
Step 4--Calculate the proposed FY 2004 LTC-DRG relative weights on
an iterative basis. The process of calculating the LTC-DRG relative
weights using the hospital specific relative value methodology is
iterative. First, for each LTCH case, we calculate a hospital-specific
relative charge value by dividing the short-stay outlier adjusted
charge per discharge (see step 3) of the LTCH case (after removing the
statistical outliers (see step 1)) and LTCH cases with a length of stay
of 7 days or less (see step 2) by the average charge per discharge for
the LTCH in which the case occurred. The resulting ratio is then
multiplied by the LTCH's case-mix index to produce an adjusted
hospital-specific relative charge value for the case. An initial case-
mix index value of 1.0 is used for each LTCH.
For each proposed LTC-DRG, the proposed FY 2004 LTC-DRG relative
weight is calculated by dividing the average of the adjusted hospital-
specific relative charge values (from above) for the proposed LTC-DRG
by the overall average hospital-specific relative charge value across
all cases for all LTCHs. Using these recalculated proposed LTC-DRG
relative weights, each LTCH's average proposed relative weight for all
of its cases (case-mix) is calculated by dividing the sum of all the
LTCH's proposed LTC-DRG relative weights by its total number of cases.
The LTCHs' hospital-specific relative charge values above are
multiplied by these hospital specific case-mix indexes. These hospital-
specific case-mix adjusted relative charge values are then used to
calculate a new set of proposed LTC-DRG relative weights across all
LTCHs. In this proposed rule, this iterative process is continued until
there is convergence between the weights produced at adjacent steps,
for example, when the maximum difference is less than 0.0001.
Step 5--Adjust the proposed FY 2004 LTC-DRG relative weights to
account for nonmonotonically increasing relative weights. As explained
in section II.B. of this preamble, the proposed FY 2004 CMS DRGs, upon
which the proposed FY 2004 LTC-DRGs are based, contain ``pairs'' that
are differentiated based on the presence or absence of CCs. The
proposed LTC-DRGs with CCs are defined by certain secondary diagnoses
not related to or inherently a part of the disease process identified
by the principal diagnosis, but the presence of additional diagnoses
does not automatically generate a CC. As we discussed in the August 30,
2002 LTCH PPS final rule (67 FR 55990), the value of monotonically
increasing relative weights rises as the resource use increases (for
example, from uncomplicated to more complicated). The presence of CCs
in a proposed LTC-DRG means that cases classified into a ``without CC''
proposed LTC-DRG are expected to have lower resource use (and lower
costs). In other words, resource use (and costs) are expected to
decrease across ``with CC''/``without CC'' pairs of proposed LTC-DRGs.
For a case to be assigned to a proposed LTC-DRG with CCs, as we
explained in the August 30, 2002 LTCH PPS final rule (67 FR 55990),
more coded information is called for (that is, at least one relevant
secondary diagnosis), than for a case to be assigned to a proposed LTC-
DRG ``without CCs'' (which is based on only one principal diagnosis and
no relevant secondary diagnoses). Currently, the LTCH claims data
include both accurately coded cases without complications and cases
that have complications (and cost more) but were not coded completely.
Both types of cases are grouped to a proposed LTC-DRG ``without CCs''
since only one principal diagnosis was coded. Since LTCHs were
previously paid under cost-based reimbursement, which is not based on
patient diagnoses, LTCHs' coding for these cases may not have been as
detailed as possible.
Thus, in developing the FY 2003 LTC-DRG relative weights for the
LTCH PPS based on FY 2001 claims data, as we explained in the August
30, 2002 LTCH PPS final rule (67 FR 55990), we found on occasion that
the data suggested that cases classified to the LTC-DRG ``with CCs'' of
a ``with CC''/``without CC'' pair had a lower average charge than the
corresponding LTC-DRG ``without CCs.'' Similarly, based on FY 2002
claims data, we also found on occasion that the data suggested that
cases classified to the proposed LTC-DRG ``with CCs'' of a ``with CC''/
``without CC'' pair would have a lower average charge than the
corresponding proposed LTC-DRG ``without CCs'' for FY 2004.
We believe this anomaly may be due to coding that may not have
fully reflected all comorbidities that were present. Specifically,
LTCHs may have failed to code relevant secondary diagnoses, which
resulted in cases that actually had CCs being classified into a
``without CC'' LTC-DRG. It would not be appropriate to pay a lower
amount for the ``with CC'' LTC-DRG. Therefore, in this proposed rule,
in accordance with the methodology established in that same final rule
(67 FR 55990-55991), we grouped both the cases ``with CCs'' and
``without CCs'' together for the purpose of calculating the proposed FY
2004 LTC-DRG relative weights. We continue to employ this methodology
to account for nonmonotonically increasing relative weights until we
have adequate data to calculate appropriate separate weights for these
anomalous LTC-DRG pairs. We expect that, as was the case when we first
implemented the IPPS, this problem will be self-correcting, as LTCHs
submit more completely coded data in the future.
As we discussed in the August 30, 2002 LTCH PPS final rule (67 FR
55990), there are three types of ``with CC'' and ``without CC'' pairs
that were nonmonotonic, that is, where the ``without CC'' proposed LTC-
DRG would have a higher average charge than the ``with CC'' proposed
LTC-DRG. For this proposed rule, using the LTCH cases in the December
2002 update of the FY 2002 MedPAR file, we identified two of the types
of nonmonotonic LTC-DRG pairs.
The first category of nonmonotonically increasing relative weights
for proposed FY 2004 LTC-DRG pairs ``with and without CCs'' contains no
pairs of proposed LTC-DRGs in which both the proposed LTC-DRG ``with
CCs'' and the proposed LTC-DRG ``without CCs'' had 25 or more LTCH
cases and, therefore, would not fall into one of the 5 proposed low
volume quintiles. For that type of nonmonotonic LTC-DRG pair, in
accordance with the methodology established in the August 30, 2002 LTCH
PPS final rule (67 FR 55990-55991), we would combine the LTCH cases and
compute a new proposed relative weight based on the case-weighted
average of the combined LTCH cases of the proposed LTC-DRGs. The case-
weighted average charge is determined by dividing the total charges for
all LTCH cases by the total number of LTCH cases for the combined
proposed LTC-DRG. This new proposed relative weight would then be
assigned to both of the proposed LTC-DRGs in the pair. However, as
there are no pairs that fall into this category, in this proposed rule,
we are proposing that, for FY 2004, there would be zero proposed LTC-
DRGs in this category.
[[Page 27181]]
The second category of nonmonotonically increasing relative weights
for proposed LTC-DRG pairs with and without CCs consists of 5 pairs of
proposed LTC-DRGs that has fewer than 25 cases, and each proposed LTC-
DRG would be grouped to different proposed low volume quintiles in
which the ``without CC'' proposed LTC-DRG would be in a higher-weighted
proposed low volume quintile than the ``with CC'' proposed LTC-DRG. For
those pairs, in accordance with the methodology established in the
August 30, 2002 LTCH PPS final rule (67 FR 55990-55991), we combine the
LTCH cases and determine the case-weighted average charge for all LTCH
cases. The case-weighted average charge is determined by dividing the
total charges for all LTCH cases by the total number of LTCH cases for
the combined proposed LTC-DRG. Based on the case-weighted average LTCH
charge, we determine which proposed low volume quintile the ``combined
proposed LTC-DRG'' would be grouped. Both proposed LTC-DRGs in the pair
are then grouped into the same proposed low volume quintile, and thus
would have the same proposed relative weight. For the FY 2004, in this
proposed rule, we are proposing that the following proposed LTC-DRGs
would be in this category: Proposed LTC-DRGs 31 and 32 (proposed low
volume quintile 3); proposed LTC-DRGs 193 and 194 (proposed low volume
quintile 2); proposed LTC-DRGs 493 and 494 (proposed low volume
quintile 4); proposed LTC-DRGs 497 and 498 (proposed low volume
quintile 3); and proposed LTC-DRGs 506 and 507 (proposed low volume
quintile 2).
The third category of nonmonotonically increasing relative weights
for proposed LTC-DRG pairs with and without CCs consists of 5 pairs of
proposed LTC-DRGs where one of the proposed LTC-DRGs has fewer than 25
LTCH cases and is grouped to a proposed low volume quintile and the
other proposed LTC-DRG has 25 or more LTCH cases and has its own
proposed LTC-DRG relative weight, and the proposed LTC-DRG ``without
CCs'' has the higher proposed relative weight. In accordance with the
methodology established in the August 30, 2002 LTCH PPS final rule (67
FR 55990 and 55991), we remove the proposed low volume LTC-DRG from the
proposed low volume quintile and combine it with the other proposed
LTC-DRG for the computation of a new proposed relative weight for each
of these proposed LTC-DRGs. This new proposed relative weight is
assigned to both proposed LTC-DRGs, so they each have the same proposed
relative weight. For FY 2004, in this proposed rule, we are proposing
the following proposed LTC-DRGs would be in this category: Proposed
LTC-DRGs 94 and 95; proposed LTC-DRGs 170 and 171; proposed LTC-DRGs
265 and 266; proposed LTC-DRGs 346 and 347; and proposed LTC-DRGs 478
and 479.
Step 6--Determine a proposed FY 2004 LTC-DRG relative weight for
LTC-DRGs with no LTCH cases. As we stated above, we determine the
proposed relative weight for each proposed LTC-DRG using charges
reported in the December 2002 update of the FY 2002 MedPAR file. Of the
518 proposed LTC-DRGs for FY 2004, we identified 164 proposed LTC-DRGs
for which there were no LTCH cases in the database. That is, based on
data from the FY 2002 MedPAR file used in this proposed rule, no
patients who would have been classified to those proposed LTC-DRGs were
treated in LTCHs during FY 2002 and, therefore, no charge data were
reported for those proposed LTC-DRGs. Thus, in the process of
determining the proposed LTC-DRG relative weights, we are unable to
determine proposed weights for these 164 proposed LTC-DRGs using the
methodology described in steps 1 through 5 above. However, since
patients with a number of the diagnoses under these proposed LTC-DRGs
may be treated at LTCHs beginning in FY 2004, in accordance with the
methodology established in the August 30, 2002 LTCH PPS final rule (67
FR 55991), we assign proposed relative weights to each of the 164 ``no
volume'' proposed LTC-DRGs based on clinical similarity and relative
costliness to one of the remaining 354 (518-164 = 354) proposed LTC-
DRGs for which we are able to determine proposed relative weights,
based on FY 2002 claims data.
As there are currently no LTCH cases in these ``no volume''
proposed LTC-DRGs, in accordance with the methodology established in
the August 30, 2002 LTCH PPS final rule (67 FR 55991), we determine
proposed relative weights for the 164 proposed LTC-DRGs with no LTCH
cases in the FY 2002 MedPAR file used in this proposed rule by grouping
them to the appropriate proposed low volume quintile. This methodology
is consistent with our methodology used in determining proposed
relative weights to account for the proposed low volume LTC-DRGs
described above.
As we described in the August 30, 2002 LTCH PPS final rule (67 FR
55991), our methodology for determining proposed relative weights for
the ``no volume'' proposed LTC-DRGs is as follows: First, we crosswalk
the no volume proposed LTC-DRGs by matching them to other similar
proposed LTC-DRGs for which there were LTCH cases in the FY 2002 MedPAR
file based on clinical similarity and intensity of use of resources as
determined by care provided during the period of time surrounding
surgery, surgical approach (if applicable), length of time of surgical
procedure, post-operative care, and length of stay. We assign the
proposed relative weight for the applicable proposed low volume
quintile to the no volume proposed LTC-DRG if the proposed LTC-DRG to
which it is crosswalked is grouped to one of the proposed low volume
quintiles. If the proposed LTC-DRG to which the no volume proposed LTC-
DRG is crosswalked is not one of the proposed LTC-DRGs to be grouped to
one of the proposed low volume quintiles, we compare the proposed
relative weight of the proposed LTC-DRG to which the no volume proposed
LTC-DRG is crosswalked to the proposed relative weights of each of the
five proposed quintiles and we assign the no volume proposed LTC-DRG
the proposed relative weight of the proposed low volume quintile with
the closest weight. For this proposed rule, a list of the no volume
proposed FY 2004 LTC-DRGs and the proposed FY 2004 LTC-DRG to which it
is crosswalked in order to determine the appropriate proposed low
volume quintile for the assignment of a proposed relative weight for FY
2004 is shown below in Table 2.
Table 2.--Proposed No Volume LTC-DRG Crosswalk and Proposed Quintile
Assignment for FY 2004
------------------------------------------------------------------------
Cross walked Low volume
LTC-DRG Description LTC-DRG quintile assigned
------------------------------------------------------------------------
2............. CRANIOTOMY AGE 17 W/O CC.
3............. CRANIOTOMY AGE 0-17. 1 Quintile 5.
[[Page 27182]]
6............. CARPAL TUNNEL 251 Quintile 1.
RELEASE.
26............ SEIZURE & HEADACHE 25 Quintile 2.
AGE 0-17.
30............ TRAUMATIC STUPOR & 29 Quintile 3.
COMA, COMA <1 HR
AGE 0-17.
33............ CONCUSSION AGE 0-17. 25 Quintile 2.
36............ RETINAL PROCEDURES.. 47 Quintile 1.
37............ ORBITAL PROCEDURES.. 47 Quintile 1.
38............ PRIMARY IRIS 47 Quintile 1.
PROCEDURES.
39............ LENS PROCEDURES WITH 47 Quintile 1.
OR WITHOUT
VITRECTOMY.
40............ EXTRAOCULAR 47 Quintile 1.
PROCEDURES EXCEPT
ORBIT AGE 17.
41............ EXTRAOCULAR 47 Quintile 1.
PROCEDURES EXCEPT
ORBIT AGE 0-17.
42............ INTRAOCULAR 47 Quintile 1.
PROCEDURES EXCEPT
RETINA, IRIS & LENS.
43............ HYPHEMA............. 47 Quintile 1.
45............ NEUROLOGICAL EYE 46 Quintile 2.
DISORDERS.
48............ OTHER DISORDERS OF 47 Quintile 1.
THE EYE AGE 0-17.
49............ MAJOR HEAD & NECK 64 Quintile 4.
PROCEDURES.
50............ SIALOADENECTOMY..... 63 Quintile 3.
51............ SALIVARY GLAND 63 Quintile 3.
PROCEDURES EXCEPT
SIALOADENECTOMY.
52............ CLEFT LIP & PALATE 63 Quintile 3.
REPAIR.
54............ SINUS & MASTOID 63 Quintile 3.
PROCEDURES AGE 0-17.
56............ RHINOPLASTY......... 72 Quintile 1.
57............ T&A PROC, EXCEPT 63 Quintile 3.
TONSILLECTOMY &/OR
ADENOIDECTOMY ONLY,
AGE 17.
58............ T&A PROC, EXCEPT 63 Quintile 3.
TONSILLECTOMY &/OR
ADENOIDECTOMY ONLY,
AGE 0-17.
59............ TONSILLECTOMY &/OR 63 Quintile 3.
ADENOIDECTOMY ONLY,
AGE 17.
60............ TONSILLECTOMY &/OR 63 Quintile 3.
ADENOIDECTOMY ONLY,
AGE 0-17.
62............ MYRINGOTOMY W TUBE 63 Quintile 3.
INSERTION AGE 0-17.
67............ EPIGLOTTITIS........ 63 Quintile 3.
70............ OTITIS MEDIA & URI 69 Quintile 1.
AGE 0-17.
71............ LARYNGOTRACHEITIS... 97 Quintile 2.
74............ OTHER EAR, NOSE, 69 Quintile 1.
MOUTH & THROAT
DIAGNOSES AGE 0-17.
81............ RESPIRATORY 69 Quintile 1.
INFECTIONS &
INFLAMMATIONS AGE 0-
17.
91............ SIMPLE PNEUMONIA & 90 Quintile 2.
PLEURISY AGE 0-17.
98............ BRONCHITIS & ASTHMA 97 Quintile 2.
AGE 0-17.
104........... CARDIAC VALVE & 110 Quintile 5.
OTHER MAJOR
CARDIOTHORACIC PROC
W CARDIAC CATH.
105........... CARDIAC VALVE & 110 Quintile 5.
OTHER MAJOR
CARDIOTHORACIC PROC
W/O CARDIAC CATH.
106........... CORONARY BYPASS W 110 Quintile 5.
PTCA.
107........... CORONARY BYPASS W 110 Quintile 5.
CARDIAC CATH.
109........... CORONARY BYPASS W/O 110 Quintile 5.
PTCA OR CARDIAC
CATH.
111........... MAJOR CARDIOVASCULAR 110 Quintile 5.
PROCEDURES W/O CC.
137........... CARDIAC CONGENITAL & 136 Quintile 2.
VALVULAR DISORDERS
AGE 0-17.
146........... RECTAL RESECTION W 148 Quintile 5.
CC.
147........... RECTAL RESECTION W/O 148 Quintile 5.
CC.
151........... PERITONEAL 150 Quintile 4.
ADHESIOLYSIS W/O CC.
153........... MINOR SMALL & LARGE 152 Quintile 4.
BOWEL PROCEDURES W/
O CC.
155........... STOMACH, ESOPHAGEAL 171 Quintile 5.
& DUODENAL
PROCEDURES AGE 17 W/O CC.
156........... STOMACH, ESOPHAGEAL 171 Quintile 5.
& DUODENAL
PROCEDURES AGE 0-17.
159........... HERNIA PROCEDURES 161 Quintile 4.
EXCEPT INGUINAL &
FEMORAL AGE 17 W CC.
160........... HERNIA PROCEDURES 161 Quintile 4.
EXCEPT INGUINAL &
FEMORAL AGE 17 W/O CC.
162........... INGUINAL & FEMORAL 178 Quintile 1.
HERNIA PROCEDURES
AGE 17 W/
O CC.
163........... HERNIA PROCEDURES 178 Quintile 1.
AGE 0-17.
164........... APPENDECTOMY W 148 Quintile 5.
COMPLICATED
PRINCIPAL DIAG W CC.
165........... APPENDECTOMY W 149 Quintile 1.
COMPLICATED
PRINCIPAL DIAG W/O
CC.
166........... APPENDECTOMY W/O 148 Quintile 5.
COMPLICATED
PRINCIPAL DIAG W CC.
167........... APPENDECTOMY W/O 149 Quintile 1.
COMPLICATED
PRINCIPAL DIAG W/O
CC.
169........... MOUTH PROCEDURES W/O 72 Quintile 1.
CC.
184........... ESOPHAGITIS, 183 Quintile 2.
GASTROENT & MISC
DIGEST DISORDERS
AGE 0-17.
186........... DENTAL ORAL DIS 185 Quintile 2.
EXCEPT EXTRACTIONS
& RESTORATIONS, AGE
0-17.
187........... DENTAL EXTRACTIONS & 185 Quintile 2.
RESTORATIONS.
190........... OTHER DIGESTIVE 189 Quintile 2.
SYSTEM DIAGNOSES
AGE 0-17.
196........... CHOLECYSTECTOMY W 197 Quintile 3.
C.D.E. W/O CC.
198........... CHOLECYSTECTOMY 197 Quintile 3.
EXCEPT BY
LAPAROSCOPE W/O
C.D.E. W/O CC.
199........... HEPATOBILIARY 200 Quintile 2.
DIAGNOSTIC
PROCEDURE FOR
MALIGNANCY.
212........... HIP & FEMUR 211 Quintile 2.
PROCEDURES EXCEPT
MAJOR JOINT AGE 0-
17.
219........... LOWER EXTREM & HUMER 218 Quintile 3.
PROC EXCEPT HIP,
FOOT, FEMUR AGE 17 W/O CC.
220........... LOWER EXTREM & HUMER 218 Quintile 3.
PROC EXCEPT HIP,
FOOT, FEMUR AGE 0-
17.
224........... SHOULDER, ELBOW OR 234 Quintile 2.
FOREARM PROC, EXC
MAJOR JOINT PROC, W/
O CC.
229........... HAND OR WRIST PROC, 234 Quintile 2.
EXCEPT MAJOR JOINT
PROC, W/O CC.
252........... FX, SPRN, STRN & 234 Quintile 2.
DISL OF FOREARM,
HAND, FOOT AGE 0-17.
255........... FX, SPRN, STRN & 234 Quintile 2.
DISL OF UPARM,
LOWLEG EX FOOT AGE
0-17.
258........... TOTAL MASTECTOMY FOR 257 Quintile 3.
MALIGNANCY W/O CC.
[[Page 27183]]
259........... SUBTOTAL MASTECTOMY 257 Quintile 3.
FOR MALIGNANCY W CC.
260........... SUBTOTAL MASTECTOMY 257 Quintile 3.
FOR MALIGNANCY W/O
CC.
267........... PERIANAL & PILONIDAL 158 Quintile 1.
PROCEDURES.
279........... CELLULITIS AGE 0-17. 78 Quintile 1.
282........... TRAUMA TO THE SKIN, 281 Quintile 2.
SUBCUT TISS &
BREAST AGE 0-17.
286........... ADRENAL & PITUITARY 292 Quintile 4.
PROCEDURES.
289........... PARATHYROID 293 Quintile 3.
PROCEDURES.
290........... THYROID PROCEDURES.. 293 Quintile 3.
291........... THYROGLOSSAL 293 Quintile 3.
PROCEDURES.
298........... NUTRITIONAL & MISC 297 Quintile 2.
METABOLIC DISORDERS
AGE 0-17.
303........... KIDNEY,URETER & 304 Quintile 5.
MAJOR BLADDER
PROCEDURES FOR
NEOPLASM.
307........... PROSTATECTOMY W/O CC 306 Quintile 4.
313........... URETHRAL PROCEDURES, 311 Quintile 1.
AGE 17 W/
O CC.
314........... URETHRAL PROCEDURES, 311 Quintile 1.
AGE 0-17.
322........... KIDNEY & URINARY 326 Quintile 2.
TRACT INFECTIONS
AGE 0-17.
327........... KIDNEY & URINARY 326 Quintile 2.
TRACT SIGNS &
SYMPTOMS AGE 0-17.
329........... URETHRAL STRICTURE 328 Quintile 1.
AGE 17 W/
O CC.
330........... URETHRAL STRICTURE 328 Quintile 1.
AGE 0-17.
333........... OTHER KIDNEY & 332 Quintile 1.
URINARY TRACT
DIAGNOSES AGE 0-17.
334........... MAJOR MALE PELVIC 345 Quintile 3.
PROCEDURES W CC.
335........... MAJOR MALE PELVIC 345 Quintile 3.
PROCEDURES W/O CC.
336........... TRANSURETHRAL 341 Quintile 2.
PROSTATECTOMY W CC.
337........... TRANSURETHRAL 341 Quintile 2.
PROSTATECTOMY W/O
CC.
338........... TESTES PROCEDURES, 339 Quintile 1.
FOR MALIGNANCY.
340........... TESTES PROCEDURES, 339 Quintile 1.
NON-MALIGNANCY AGE
0-17.
343........... CIRCUMCISION AGE 0- 339 Quintile 1.
17.
351........... STERILIZATION, MALE. 339 Quintile 1.
353........... PELVIC EVISCERATION, 365 Quintile 5.
RADICAL
HYSTERECTOMY &
RADICAL VULVECTOMY.
354........... UTERINE,ADNEXA PROC 365 Quintile 5.
FOR NON-OVARIAN/
ADNEXAL MALIG W CC.
355........... UTERINE,ADNEXA PROC 365 Quintile 5.
FOR NON-OVARIAN/
ADNEXAL MALIG W/O
CC.
356........... FEMALE REPRODUCTIVE 360 Quintile 4.
SYSTEM
RECONSTRUCTIVE
PROCEDURES.
357........... UTERINE & ADNEXA 360 Quintile 4.
PROC FOR OVARIAN OR
ADNEXAL MALIGNANCY.
358........... UTERINE & ADNEXA 360 Quintile 4.
PROC FOR NON-
MALIGNANCY W CC.
359........... UTERINE & ADNEXA 360 Quintile 4.
PROC FOR NON-
MALIGNANCY W/O CC.
361........... LAPAROSCOPY & 149 Quintile 1.
INCISIONAL TUBAL
INTERRUPTION.
362........... ENDOSCOPIC TUBAL 149 Quintile 1.
INTERRUPTION.
363........... D&C, CONIZATION & 367 Quintile 2.
RADIO-IMPLANT, FOR
MALIGNANCY.
364........... D&C, CONIZATION 367 Quintile 2.
EXCEPT FOR
MALIGNANCY.
370........... CESAREAN SECTION W 369 Quintile 3.
CC.
371........... CESAREAN SECTION W/O 367 Quintile 2.
CC.
372........... VAGINAL DELIVERY W 367 Quintile 2.
COMPLICATING
DIAGNOSES.
373........... VAGINAL DELIVERY W/O 367 Quintile 2.
COMPLICATING
DIAGNOSES.
374........... VAGINAL DELIVERY W 367 Quintile 2.
STERILIZATION &/OR
D&C.
375........... VAGINAL DELIVERY W 367 Quintile 2.
O.R. PROC EXCEPT
STERIL &/OR D&C.
377........... POSTPARTUM & POST 367 Quintile 2.
ABORTION DIAGNOSES
W O.R. PROCEDURE.
378........... ECTOPIC PREGNANCY... 369 Quintile 3.
379........... THREATENED ABORTION. 376 Quintile 1.
380........... ABORTION W/O D&C.... 376 Quintile 1.
381........... ABORTION W D&C, 376 Quintile 1.
ASPIRATION
CURETTAGE OR
HYSTEROTOMY.
382........... FALSE LABOR......... 376 Quintile 1.
383........... OTHER ANTEPARTUM 376 Quintile 1.
DIAGNOSES W MEDICAL
COMPLICATIONS.
384........... OTHER ANTEPARTUM 376 Quintile 1.
DIAGNOSES W/O
MEDICAL
COMPLICATIONS.
386........... EXTREME IMMATURITY.. 367 Quintile 2.
387........... PREMATURITY W MAJOR 367 Quintile 2.
PROBLEMS.
388........... PREMATURITY W/O 367 Quintile 2.
MAJOR PROBLEMS.
389........... FULL TERM NEONATE W 367 Quintile 2.
MAJOR PROBLEMS.
390........... NEONATE W OTHER 367 Quintile 2.
SIGNIFICANT
PROBLEMS.
391........... NORMAL NEWBORN...... 376 Quintile 1.
392........... SPLENECTOMY AGE 17.
393........... SPLENECTOMY AGE 0-17 194 Quintile 2.
396........... RED BLOOD CELL 399 Quintile 1.
DISORDERS AGE 0-17.
405........... ACUTE LEUKEMIA W/O 404 Quintile 2.
MAJOR O.R.
PROCEDURE AGE 0-17.
407........... MYELOPROLIF DISORD 408 Quintile 3.
OR POORLY DIFF
NEOPL W MAJ O.R.
PROC W/O CC.
417........... SEPTICEMIA AGE 0-17. 416 Quintile 3.
422........... VIRAL ILLNESS & 420 Quintile 1.
FEVER OF UNKNOWN
ORIGIN AGE 0-17.
446........... TRAUMATIC INJURY AGE 445 Quintile 2.
0-17.
448........... ALLERGIC REACTIONS 455 Quintile 1.
AGE 0-17.
451........... POISONING & TOXIC 455 Quintile 1.
EFFECTS OF DRUGS
AGE 0-17.
481........... BONE MARROW 394 Quintile 1.
TRANSPLANT.
[[Page 27184]]
484........... CRANIOTOMY FOR 1 Quintile 5.
MULTIPLE
SIGNIFICANT TRAUMA.
485........... LIMB REATTACHMENT, 209 Quintile 5.
HIP AND FEMUR PROC
FOR MULTIPLE
SIGNIFICANT TR.
491........... MAJOR JOINT & LIMB 209 Quintile 5.
REATTACHMENT
PROCEDURES OF UPPER
EXTREMITY.
492........... CHEMOTHERAPY W ACUTE 410 Quintile 3.
LEUKEMIA AS
SECONDARY DIAGNOSIS.
496........... COMBINED ANTERIOR/ 210 Quintile 4.
POSTERIOR SPINAL
FUSION.
504........... EXTENSIVE 3RD DEGREE 468 Quintile 5.
BURNS W SKIN GRAFT.
516........... PERCUTANEOUS 578 Quintile 3.
CARDIVASCULAR
PROCEDURE W AMI.
520........... CERVICAL SPINAL 498 Quintile 3.
FUSION W/O CC.
525........... HEART ASSIST SYSTEM 468 Quintile 5.
IMPLANT.
526........... PERCUTANEOUS 517 Quintile 4.
CARVIOVASCULAR PROC
W DRUG-ELUTING
STENT W AMI.
527........... PERCUTANEOUS 517 Quintile 4.
CARVIOVASCULAR PROC
W DRUG-ELUTING
STENT W/O AMI.
528........... INTRACRANIAL 1 Quintile 5.
VASCLUAR PROCEDURES
WITH PDX HEMORRHAGE.
530........... VENTRICULAR SHUNT 529 Quintile 2.
PROCEDURES WITHOUT
CC.
531........... SPINAL PROCEDURES 519 Quintile 4.
WITH CC.
533........... EXTRACRANIAL 534 Quintile 5.
VASCULAR PROCEDURES
WITH CC.
535........... CARDIAC DEFIB 515 Quintile 5.
IMPLANT WITH
CARDIAC CATH WITH
AMI/HF/SHOCK.
537........... LOCAL EXCISION AND 253 Quintile 2.
REMOVAL OF INTERNAL
FIXATION DEVICES
EXCEPT HIP AND
FEMUR WITH CC.
539........... LYMPHOMA AND 401 Quintile 5.
LEUKEMIA WITH MAJOR
O.R. PROCEDURE WITH
CC.
------------------------------------------------------------------------
To illustrate this methodology, which was established in the August
30, 2002 LTCH PPS final rule (67 FR 55991), for determining the
proposed relative weights for the 164 proposed LTC-DRGs with no LTCH
cases, we are providing the following examples, which refer to the no
volume proposed LTC-DRGs crosswalk information for FY 2004 provided
above in Table 2:
Example 1: There were no cases in the FY 2002 MedPAR file used
for this proposed rule for proposed LTC-DRG 163 (Hernia Procedures
Age 0-17). Since the procedure is similar in resource use and the
length and complexity of the procedures and the length of stay are
similar, we determined that proposed LTC-DRG 178 (Uncomplicated
Peptic Ulcer Without CC), which is assigned to proposed low volume
quintile 1 for the purpose of determining the proposed FY 2004
relative weights, would display similar clinical and resource use.
Therefore, we are proposing to assign the same proposed relative
weight of LTC-DRG 178 of 0.5711 (proposed Quintile 1) for FY 2004
(Table 11 in the Addendum to this proposed rule) to proposed LTC-DRG
163.
Example 2: There were no LTCH cases in the FY 2002 MedPAR file
used in this proposed rule for proposed LTC-DRG 91 (Simple Pneumonia
and Pleurisy Age 0-17). Since the severity of illness in patients
with bronchitis and asthma is similar in patients regardless of age,
we determined that proposed LTC-DRG 90 (Simple Pneumonia and
Pleurisy Age 17 Without CC) would display similar
clinical and resource use characteristics and have a similar length
of stay to proposed LTC-DRG 91. There were over 25 cases in proposed
LTC-DRG 90. Therefore, it would not be assigned to a proposed low
volume quintile for the purpose of determining the proposed LTC-DRG
relative weights. However, under our established methodology,
proposed LTC-DRG 91, with no LTCH cases, would need to be grouped to
a proposed low volume quintile. We identified that the proposed low
volume quintile with the closest weight to proposed LTC-DRG 90
(0.7429; see Table 11 in the Addendum to this proposed rule) would
be proposed low volume quintile 2 (0.7347; see Table 11 in the
Addendum to this proposed rule). Therefore, we are proposing to
assign proposed LTC-DRG 91 a proposed relative weight of 0.7347 for
FY 2004.
Furthermore, in accordance with the methodology established in the
August 30, 2002 final rule (67 FR 55991), we are proposing LTC-DRG
relative weights of 0.0000 for heart, kidney, liver, lung, pancreas,
and simultaneous pancreas/kidney transplants (proposed LTC-DRGs 103,
302, 480, 495, 512, and 513, respectively) for FY 2004 because Medicare
will only cover these procedures if they are performed at a hospital
that has been certified for the specific procedures by Medicare and
presently no LTCH has been so certified.
Based on our research, as we discussed in that same final rule (67
FR 55995), we found that most LTCHs only perform minor surgeries, such
as minor small and large bowel procedures, to the extent any surgeries
are performed at all. Given the extensive criteria that must be met to
become certified as a transplant center for Medicare, we believe it is
unlikely that any LTCHs would become certified as a transplant center.
In fact, in the nearly 20 years since the implementation of the IPPS,
there has never been a LTCH that even expressed an interest in becoming
a transplant center.
However, if in the future a LTCH applies for certification as a
Medicare-approved transplant center, we believe that the application
and approval procedure would allow sufficient time for us to propose
appropriate weights for the LTC-DRGs affected. At the present time, we
would only include these six transplant proposed LTC-DRGs in the
GROUPER program for administrative purposes. Since we use the same
GROUPER program for LTCHs as is used under the acute care hospital
IPPS, removing these LTC-DRGs would be administratively burdensome.
Again, we note that as this system is dynamic, it is entirely
possible that the number of proposed LTC-DRGs with a zero volume of
LTCH cases based on the system will vary in the future. We used the
best most recent available claims data in the MedPAR file to identify
zero volume proposed LTC-DRGs and to determine the relative weights in
this final rule.
Table 11 in the Addendum to this proposed rule lists the proposed
LTC-DRGs and their respective proposed relative weights, geometric mean
length of stay, and five-sixths of the geometric mean length of stay
(to assist in the determination of short-stay outlier payments under
Sec. 412.529) for FY 2004.
E. Add-On Payments for New Services and Technologies
1. Background
Sections 1886(d)(5)(K) and (L) of the Act establish a process of
identifying and ensuring adequate payment for new medical services and
technologies under the IPPS. Section 1886(d)(5)(K)(ii)(I) of
[[Page 27185]]
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 under this
subsection 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.
Section 412.87(b)(1) of our existing regulations provides that a
new technology will 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 (see the September
7, 2001 final rule (66 FR 46902)). Section 412.87(b)(3) provides that,
to receive special payment treatment, new technologies meeting this
clinical definition must be demonstrated to be inadequately paid
otherwise under the DRG system. 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). Table 10 in the Addendum to this
proposed rule lists the proposed qualifying criteria by DRG, based on
the discharge data that we are using to calculate the proposed FY 2004
DRG weights. The thresholds that will be published in the final rule
for FY 2004 will be used to evaluate applicants for new technology add-
on payments during FY 2005.
In addition to the clinical and cost criteria, we established that,
in order to qualify for the new technology add-on payments, 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 2002 are used to calculate the
proposed FY 2004 DRG weights in this proposed rule.
Technology may be considered ``new'' for purposes of this provision
within 2 or 3 years after the point at which data begin to become
available reflecting the costs of the technology. After we have
recalibrated the DRGs to reflect the costs of an otherwise new
technology, the special add-on payment for new technology will cease
(Sec. 412.87(b)(2)). For example, an approved new technology that
received FDA approval in October 2002 would be eligible to receive add-
on payments as a new technology at least until FY 2005 (discharges
occurring before October 1, 2004), when data reflecting the costs of
the technology would be used to recalibrate the DRG weights. Because
the FY 2005 DRG weights will be calculated using FY 2003 MedPAR data,
the costs of such a new technology would likely be reflected in the FY
2005 DRG weights.
Similar to the timetable for applying for new technology add-on
payments during FY 2004, we are proposing that applicants for FY 2005
must submit a formal request, including a full 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, along with a significant sample of
data to demonstrate the technology meets the high-cost threshold, no
later than early October 2003. We are proposing that a complete
database must be submitted no later than mid-December 2003. Complete
application information is available at our Web site at: http://www.cms.hhs.gov/providers /hipps/default.asp. To allow interested
parties to identify the technologies under review before the
publication of the annual proposed rule, the Web site also lists the
tracking forms completed by each applicant.
The new technology add-on payment policy provides additional
payments for cases with high costs involving eligible 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 pays 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 is limited to the DRG payment plus 50
percent of the estimated costs of the new technology.
The report language accompanying section 533 of Public Law 106-554
indicated Congressional intent that the Secretary implement the new
mechanism on a budget neutral basis (H.R. Conf. Rep. No. 106-1033,
106th Cong., 2nd 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 would
discuss in the annual proposed and final rules those technologies that
were considered under this provision; our determination as to whether a
particular technology meets our criteria to be considered new; 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 the 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 add-on
payments for new technology under the provisions of sections
1886(d)(5)(K) and (L) of the Act 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
[[Page 27186]]
reduced amount. Although the marginal payment rate for individual
technologies would be reduced, this reduction would be offset by large
overall payments to hospitals for new technologies under this
provision.
2. FY 2004 Status of Technology Approved for FY 2003 Add-On Payments:
Drotrecogin Alfa (Activated)--Xigris[reg]
In the August 1, 2002 IPPS final rule, we stated that cases
involving the administration of Xigris[reg] (a biotechnology product
that is a recombinant version of naturally occurring Activated Protein
C (APC)) as identified by the presence of code 00.11 (Infusion of
drotrecogin alfa (activated)) are eligible for additional payments of
up to $3,400 (50 percent of the average cost of the drug)'' (67 FR
50013). (The August 1, 2002 final rule contains a detailed discussion
of this technology.) Although Xigris[reg] was approved by the FDA in
November 2001, it did not qualify for add-on payments until discharges
on or after October 1, 2002. Consequently, FY 2002 discharges (between
October 1, 2001 and September 30, 2002) may not reflect full
utilization of the technology due to the absence of the add-on payment.
Therefore, for FY 2004, we are proposing to continue to make add-on
payments for cases involving the administration of Xigris[reg] as
identified by the presence of code 00.11. Based on preliminary analysis
of the incidence of Xigris[reg] in the first quarter FY 2003 MedPAR
file, we are proposing to revise downward our estimate of total add-on
payments for Xigris[reg]. For FY 2003, we estimated that total add-on
payments would be approximately $74.8 million (22,000 Medicare patients
who would be eligible for a $3,400 add-on payment). For FY 2004, we are
estimating the total add-on payments would be approximately $50 million
(based on 14,000 Medicare patients who would be eligible for a $3,400
add-on payment). We are proposing that this additional payment would be
included in the DRG reclassification and recalibration budget
neutrality factor, which is applied to the standardized amounts and the
hospital-specific amounts. However, we will reevaluate our assumptions
regarding this estimate based on preliminary claims data from the FY
2003 MedPAR file before the publication of the FY 2004 IPPS final rule.
3. FY 2004 Applicants for New Technology Add-On Payments
We received two applications for new technologies to be designated
eligible for inpatient add-on payments for new technology for FY 2004.
A discussion of these applications and our determinations on these
applications appears below.
a. Bone Morphogenetic Proteins (BMPs) for Spinal Fusions. An
application was submitted by Medtronic Sofamor Danek for the
InFUSETM Bone Graft/LT-CAGE[reg]'' Lumbar Tapered Fusion
Device for approval as a new technology eligible for add-on payments. A
similar application was submitted last year but was denied because,
based on the available data, the technology did not exceed the one
standard deviation threshold above the average charges for the DRGs to
which the technology is assigned.
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 procedure is done in
place of the more traditional use of autogenous iliac crest bone graft.
For a more detailed discussion about InFUSETM Bone Graft/LT-
CAGE[reg] Lumbar Tapered Fusion, see the August 1, 2002 IPPS final rule
(67 FR 50016).
On July 2, 2002, the FDA approved InFUSETM Bone Graft/
LT-CAGE[reg] for spinal fusion procedures in skeletally mature patients
at one level. Therefore, based on the FDA's approval, multilevel use of
this technology would be off-label. In the August 1, 2002 IPPS final
rule (67 FR 50017), we stated this technology would meet the cost
threshold only if the added costs of multilevel fusions were taken into
account. Because the FDA had not approved this technology for
multilevel fusions, and the applicant had not submitted data to
demonstrate this technology is a substantial clinical improvement for
multilevel fusions (the clinical trial upon which the application was
based was a single-level fusion trial), we could not issue a
substantial clinical improvement determination for multilevel fusions
and, consequently, did not consider the costs associated with
multilevel fusions in our analysis of whether this technology met the
cost threshold. Therefore, because the average charges for this new
technology, when used for single-level spinal fusions, did not exceed
the threshold to qualify for new technology add-on payment of $37,815,
we denied this application for add-on payments for FY 2003. For similar
reasons, we did not consider data on the charges for multilevel fusions
in our analysis of whether this technology meets the cost threshold for
FY 2004.
In its application for add-on payments for FY 2004, Medtronic used
data from CMS' FY 2001 Standard Analytical File for physicians and
hospitals. The analysis linked a 5-percent sample of hospital spinal
fusions cases with the corresponding physician claims. Because there
were no ICD-9-M codes to identify multilevel fusions in 2001,
multilevel fusions were identified using CPT codes on the physician
claims. Average charges were taken from actual cases used in clinical
trials.
After grouping these cases into one, two, and three or more levels
fused in DRGs 497 and 498 (Spinal Fusion Except Cervical With and
Without CC, respectively), the applicant then calculated average
charges assuming the use of the InFUSETM Bone Graft/LT-
CAGE[reg] for these cases. For DRG 497, the estimated single-level
fusion average charge was $41,321; for DRG 498, the estimated single-
level fusion average charge was $37,200. Because these DRGs are not
currently split for different numbers of fusion levels involved,
Medtronic has calculated its own standard deviation of average charges
to determine the threshold for these DRGs using the 5-percent sample
data. For DRG 497, the threshold (calculated by Medtronic) was $45,646,
which is greater than the estimated average charge of $41,321 for
single-level fusions noted above. For DRG 498, the threshold
(calculated by Medtronic) was $36,935, which is less than the average
charges for single-level fusions in this DRG as noted above.
However, we note the thresholds to qualify for the new technology
add-on payments for FY 2003 published in Table 10 of the August 1, 2002
IPPS final rule for DRGs 497 and 498 were $58,040 and $41,923,
respectively. These thresholds were computed based on all cases
assigned to these DRGs, and do not differentiate between the number of
spinal levels fused. Because we are not proposing to redefine these
DRGs to differentiate cases on the basis of the number of levels of the
spine fused in the manner suggested by the applicant's analysis, the
thresholds published in last year's final rule are applicable for a new
technology to qualify for add-on payments in these DRGs for FY 2004.
Therefore, because the averages calculated by the applicant for single-
level fusions do not exceed the published thresholds, we are proposing
not to approve this technology on the basis of this analysis.
The applicant also submitted data from actual cases involving the
InFUSETM Bone Graft/LT-CAGE[reg] with single level fusions
only. The data submitted included 31 claims from 4
[[Page 27187]]
hospitals (only one Medicare patient was included in the sample). All
31 cases were from DRG 498. The average standardized charge for these
cases was $47,172. Based on these data, the average standardized charge
exceeds the threshold for DRG 498. However, we note that this limited
sample excludes any cases from DRG 497.
We note that, effective for discharges occurring on or after
October 1, 2002, ICD-9-CM codes 84.51 (Insertion of interbody spinal
fusion device) and 84.52 (Insertion of recombinant bone morphogenetic
protein) are effective to identify cases involving this technology.
Therefore, in an effort to resolve the difficulties in obtaining
sufficient data upon which to determine whether this technology exceeds
the applicable threshold, we intend to review available MedPAR data for
the first several months of FY 2003 to identify these cases and
calculate their average standardized charges to compare with the
thresholds. We anticipate some of these cases will involve multilevel
spinal fusions, and it will be necessary to identify those cases in
order to remove them from the calculation of the average charges.
If the technology meets the cost threshold based on the MedPAR
data, we will evaluate whether it qualifies as a substantial clinical
improvement. According to the applicant:
``InFUSETM Bone Graft is more appropriate to use and has
been proven more effective in its use than autogenous iliac crest bone
graft, when either is placed in the LT-CageTM Lumbar Tapered
Fusion Device for anterior lumbar interbody fusion. Use of
InFUSETM Bone Graft instead of autogenous iliac crest bone
graft:
[sbull] Obviates iliac crest bone graft donor site morbidity.
[sbull] Reduces operative time, blood loss and hospitalization.
[sbull] Results in greater fusion success.
[sbull] We found that the Oswestry Low Back Pain Disability score
and SF-36 Physical Component and Pain Index score were consistently 10
percent better in the InFUSETM Bone Graft group than the
autogenous iliac bone graft group.
[sbull] Enables earlier return to work.''
Among the issues we will consider are: Does avoiding the
complications associated with the iliac crest bone harvesting procedure
constitute a substantial clinical improvement; and, with the increased
rate of osteoarthritis and osteoporosis in the Medicare population, is
there evidence that the technology represents a substantial clinical
improvement in spinal fusions among this population? We are
particularly interested in data on the results of aged Medicare
patients who have been treated with BMP, and any basic biology bench
data on the results of using BMP in osteoporotic bones.
b. GLIADEL[reg] Wafer. Glioblastoma Multiforme (GBM) is the most
common and most aggressive of the primary brain tumors. Standard care
for patients diagnosed with GBM is surgical resection and radiation.
According to the manufacturer (Guilford Pharmaceuticals), the
GLIADEL[reg] Wafer is indicated for use as an adjunct to surgery to
prolong survival in patients with recurrent GBM. Implanted directly
into the cavity that is created when a brain tumor is surgically
removed, GLIADEL[reg] delivers chemotherapy directly to the site where
tumors are most likely to recur.
The FDA approved GLIADEL[reg] Wafer on September 23, 1996, for use
as an adjunct to surgery to prolong survival in patients with recurrent
GBM for whom surgical resection is indicated. In announcing its
approval, the FDA indicated that GLIADEL[reg] was approved:
`` * * * based on the results of a multi-center placebo controlled
study in 222 patients who had recurrent malignant glioma after initial
treatment with surgery and radiation therapy. Following surgery to
remove the tumor, half of the patients were treated with GLIADEL[reg]
implants and half with placebo. In patients with glioblastoma
multiforme, the 6-month survival rate increased from 36 percent with
placebo to 56 percent with GLIADEL[reg]. Median survival increased from
20 weeks with placebo to 28 weeks with GLIADEL[reg]. In patients with
pathologic diagnoses other than glioblastoma multiforme, GLIADEL[reg]
had no effect on survival.''
Guilford Pharmaceuticals has requested that GLIADEL[reg] still be
considered new because, until a new ICD-9-CM code (00.10 Implementation
of Chemotherapeutic Agent) was established on October 1, 2002, it was
not possible to identify specifically these cases in the MedPAR data.
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 GLIADEL[reg] are currently reflected in the DRG
weights (despite the absence of a specific code), GLIADEL[reg] does not
meet our criterion that a medical service or technology be ``new''.
That is, FY 2002 MedPAR data used to calculate the proposed DRG weights
for FY 2004 include cases where GLIADEL[reg] was administered (and the
corresponding charges of these cases, include charges associated with
GLIADEL[reg]). On February 26, 2003, the FDA approved GLIADEL[reg] for
use in newly diagnosed patients with high-grade malignant glioma as an
adjunct to surgery and radiation. However, our understanding is that
many newly diagnosed patients were already receiving this therapy. To
the extent this is true, the charges associated with this use of
GLIADEL[reg] are also reflected in the DRG relative weights.
According to Guilford's application, the current average wholesale
price of GLIADEL[reg] is $10,985. Guilford submitted charge data for 23
Medicare patients at 7 hospitals from FY 2000. The charges were then
standardized and adjusted for inflation using the hospital market
basket inflation factor (from 2000 to 2003) in order to determine an
inflated average standardized charge of $33,002. Guilford points out
that this charge narrowly misses the DRG 2 threshold published in Table
10 of the August 1, 2002 IPPS final rule of $34,673. However, we note
that, according to the manufacturer, as many as 60 percent of current
GLIADEL[reg] cases may be assigned to DRG 1 based on the presence of
CCs. Based on this assumption, the qualifying threshold for
GLIADEL[reg] would be $54,312 (60 percent of the DRG 1 threshold of
$67,404, and 40 percent of the DRG 2 threshold of $34,673).
As mentioned above in section II.B.3.a. of this proposed rule, we
examined the definitions of DRGs 1 and 2 to determine whether they
could be improved, and we are proposing to create a new DRG for
patients with an intracranial vascular procedure and an intracranial
hemorrhage and two new DRGs for patients with only a vascular shunt
procedure (splitting on the presence or absence of a CC). We also
compared the data submitted in the application on the charges for
GLIADEL[reg] cases with the charges of other procedures in DRGs 1 and
2. We found that, although the $33,002 average standardized charge
reported is just below the qualifying threshold in DRG 2, it is
actually well below the mean average standardized charge for DRG 1
($42,092). As noted previously, as many as 60 percent of current
GLIADEL[reg] cases may be assigned to DRG 1 based on the presence of
CCs. Therefore, we do not believe that any change to the DRG assignment
of cases receiving GLIADEL[reg] is warranted at this time. However, we
will continue to monitor our data to determine whether a change is
warranted in the future.
4. Review of the High-Cost Threshold
The current cost threshold for a new technology to qualify for add-
on
[[Page 27188]]
payments is that the average standardized charges of cases involving
the new technology must be demonstrated to exceed one standard
deviation beyond the mean standardized charges of the DRG to which the
new technology will be assigned. When we established this threshold in
the September 7, 2001 final rule, we expressed our belief that it is
important to establish a threshold that recognizes the variability in
costs per case within DRGs and maintains the fundamental financial
incentives of the IPPS (66 FR 46917).
In its comments on this approach, MedPAC supported the one standard
deviation threshold. However, others, particularly representatives of
the manufacturers of new technology, have argued this threshold is too
high, and that virtually no new technology would qualify for the
special payment provision.
We are concerned that establishing higher payments for a great
number of new technologies may be inflationary because the add-on
payments reduce the efficiency incentives hospitals face when new
technologies must otherwise be financed out of current payments for
similar cases. Traditionally, new technologies were required to compete
with existing treatment methods on clinical and cost criteria. Add-on
payments are intended to give new technologies a competitive boost
relative to existing treatment methods with the goal of encouraging
faster and more widespread adoption of new technologies.
Much of the current variation around the mean within any particular
DRG is due to the range of procedures contained within each DRG.
Generally, some of these procedures will be more expensive than the
mean and some will be less expensive. The threshold should be set high
enough to ensure that it identifies truly high-cost technologies. If
the threshold were set too low (for example, at $2,500, as some have
suggested), additional technologies may qualify merely by association
with a procedure only slightly more costly than the mean for the DRG.
For example, consider a DRG with five different procedures and mean
charges of $15,000. The mean charges for each procedure are distributed
around $15,000, as illustrated in the following table. A qualifying
threshold of $2,500 would result in any new technology that is only
used for the fifth procedure automatically qualifying for new
technology add-on payments (unless the new technology had the unlikely
effect of lowering the mean cost for cases with this procedure by at
least $2,500). This is because the average charge of $20,000 for cases
in this procedure already exceeds the mean charges for the DRG plus
$2,500.
------------------------------------------------------------------------
Procedure Mean charge
------------------------------------------------------------------------
1....................................................... $10,000
2....................................................... 12,000
3....................................................... 15,000
4....................................................... 17,000
5....................................................... 20,000
------------------------------------------------------------------------
At the same time, we recognize that the very limited number of
applications that have been submitted the past 2 years (five for FY
2003; two for FY 2004) may indicate that only a very small number of
the new technologies that come onto the market every year are costly
enough even to apply for new technology add-on payments. Therefore, for
FY 2005 and subsequent Fiscal Years, we are proposing to reduce the
threshold to 75 percent of one standard deviation beyond the geometric
mean standardized charge for all cases in the DRG to which the new
medical service or technology is assigned (proposed Sec.
412.87(b)(3)).
Based on our analysis of the thresholds for FY 2004, this proposed
change would reduce the average threshold across all DRGs to qualify
for the add-on payments from approximately $9,900 above the mean
standardized charges for each DRG to approximately $7,400. This
reduction would maintain the averaging principles of the IPPS while
easing the requirement somewhat to allow more technologies to qualify.
Furthermore, the situation illustrated above, where a technology
qualifies on the basis of its association with a high cost procedure,
is much less likely to occur as a result of this reduction than if the
threshold were reduced dramatically.
5. Technical Changes
Subpart H of part 412 describes payments to hospitals under IPPS.
We have become aware of references to the calculation of IPPS payments
in this subpart that inadvertently omit references to new technology
add-on payments. For example, Sec. 412.112(c) describes the basis for
per case payments. This section refers to outlier payments under
subpart F, but was not revised to reflect the implementation of the new
technology add-on payments. Therefore, we are proposing to amend Sec.
412.112(c) to add a new paragraph (d) to include a reference to
additional payments for new medical services or technologies under
subpart F.
Section 412.116(e) currently states that payments for outlier cases
are not made on an interim basis. That is, for hospitals receiving
payments under a biweekly, lump-sum payment methodology, outlier
payments are not included in the calculation of the lump-sum payment
amounts. Rather, outlier payments are calculated on a case-by-case
basis. Similarly, due to the unique nature of the new technology add-on
payments, we are proposing that they would also be calculated on a
case-by-case basis rather than included in the calculation of interim
payment amounts. Therefore, we are proposing to revise Sec. 412.116(e)
to include this policy.
III. Proposed Changes to the Hospital Wage Index
A. Background
Section 1886(d)(3)(E) of the Act requires that, as part of the
methodology for determining prospective payments to hospitals, the
Secretary must adjust the standardized amounts ``for area differences
in hospital wage levels by a factor (established by the Secretary)
reflecting the relative hospital wage level in the geographic area of
the hospital compared to the national average hospital wage level.'' In
accordance with the broad discretion conferred under the Act, we
currently define hospital labor market areas based on the definitions
of Metropolitan Statistical Areas (MSAs), Primary MSAs (PMSAs), and New
England County Metropolitan Areas (NECMAs) issued by the Office of
Management and Budget (OMB). OMB also designates Consolidated MSAs
(CMSAs). A CMSA is a metropolitan area with a population of one million
or more, comprising two or more PMSAs (identified by their separate
economic and social character). For purposes of the hospital wage
index, we use the PMSAs rather than CMSAs since they allow a more
precise breakdown of labor costs. If a metropolitan area is not
designated as part of a PMSA, we use the applicable MSA. Rural areas
are areas outside a designated MSA, PMSA, or NECMA. For purposes of the
wage index, we combine all of the rural counties in a State to
calculate a rural wage index for that State.
We note that, effective April 1, 1990, the term Metropolitan Area
(MA) replaced the term MSA (which had been used since June 30, 1983) to
describe the set of metropolitan areas consisting of MSAs, PMSAs, and
CMSAs. The terminology was changed by OMB in the March 30, 1990 Federal
Register to distinguish between the individual metropolitan areas known
as MSAs and the set of all metropolitan areas (MSAs, PMSAs, and CMSAs)
(55 FR 12154). For
[[Page 27189]]
purposes of the IPPS, 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 IPPS.
In a December 27, 2000 notice published in the Federal Register (65
FR 82228), the Office of Management and Budget (OMB) issued its revised
standards for defining MSAs. In that notice, OMB indicated that it
plans to announce in calendar year 2003 new definitions of ``Core Based
Statistical Areas'' (CBSAs) based on the new standards and the Census
2000 data. The new standards establish two categories of CBSAs: (1)
Metropolitan Statistical Areas (50,000 or more), and (2) Micropolitan
Statistical Areas (10,000 to 49,999). After these new CBSAs are
announced, we will evaluate the new area designations and their
possible effects on the Medicare hospital wage index. Therefore, the
earliest these new CBSA definitions would be used is the FY 2005 wage
index.
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 1886(d)(3)(E) of the Act also provides 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 April 4, 2003 Federal Register (68 FR 16516), we
published a notice of intent to collect calendar year 2002 data from
hospitals. There is a 60-day public comment period on that notice.
After considering and responding to the comments we receive, we plan to
send the surveys to all IPPS hospitals (and hospitals in Maryland that
are under a waiver from the IPPS) through the fiscal intermediaries. We
intend to collect these data to be incorporated in the FY 2005 wage
index after notice and opportunity for public comment.
B. Proposed FY 2004 Wage Index Update
The proposed FY 2004 wage index values (effective for hospital
discharges occurring on or after October 1, 2003 and before October 1,
2004) in section V. of the Addendum to this proposed rule are based on
the data collected from the Medicare cost reports submitted by
hospitals for cost reporting periods beginning in FY 2000 (the FY 2003
wage index was based on FY 1999 wage data).
The proposed FY 2004 wage index includes the following categories
of data associated with costs paid under the IPPS (as well as
outpatient costs), which were also included in the FY 2003 wage index:
[sbull] Salaries and hours from short-term, acute care hospitals.
[sbull] Home office costs and hours.
[sbull] Certain contract labor costs and hours.
[sbull] Wage-related costs.
Consistent with the wage index methodology for FY 2003, the
proposed wage index for FY 2004 also excludes the direct and overhead
salaries and hours for services not subject to IPPS payment, such as
SNF services, home health services, costs related to GME (teaching
physicians and residents) and certified registered nurse anesthetists
(CRNAs), and other subprovider components that are not paid under the
IPPS.
C. FY 2004 Wage Index Proposals
1. Elimination of Wage Costs Associated With Rural Health Clinics and
Federally Qualified Health Centers
In the FY 2001 IPPS final rule, we discussed removing from the wage
index the salaries, hours, and wage-related costs of hospital-based
rural health clinics (RHCs) and Federally qualified health centers
(FQHCs) because Medicare pays for these costs outside of the IPPS (65
FR 47074). We noted that because RHC and FQHC costs were not separately
reported on Worksheet S-3 of the Medicare cost report, we could not
exclude these costs from the prior wage indexes. We further noted that
we would evaluate the exclusion of RHC and FQHC wage data in developing
the FY 2004 wage index. We now have revised Worksheet S-3 so that it
allows for the separate reporting of RHC and FQHC wage costs and hours
beginning with FY 2000. Therefore, as we now have the ability to
exclude these costs from the wage index, beginning with the FY 2004
wage index, we are proposing to exclude the wage costs and hours data
for RHCs and FQHCs from the hospital wage index calculation. An
analysis of the effects of this change is included in the Appendix A of
this proposed rule.
2. Paid Hours
It has been the longstanding policy of CMS to calculate the wage
index using paid hours rather than hours worked (58 FR 46299). This
policy reflects our belief that paid hours more appropriately reflect a
hospital's total wage costs, which include amounts paid for actual time
worked and for covered leave periods (for example, annual, sick, and
holiday leave). Therefore, the inclusion of paid lunch hours in the
wage index is consistent with our inclusion of other paid nonworking
hours.
Several hospitals have requested that we exclude paid lunch or meal
break hours from the wage index calculation. At these hospitals, the
typical workday is 7\1/2\ working hours, plus a \1/2\ hour paid meal
break, for a total of 8 paid hours. These hospitals, some of which are
municipal-owned and required by their overarching union contracts to
provide paid lunch hours, believe they are disadvantaged by wage index
policy that requires paid lunch hours to be included in calculating the
wage index.
The hospitals argue that their practice of paying employees for
meal breaks is not substantially different, in practice, from other
hospitals whose employees do not receive paid lunch hours but who are
on call during their lunch periods. These hospitals further argue that
this policy causes them, in some cases due to union contracts beyond
the hospital's control, to be the only hospitals with this category of
nonproductive hours included in the wage index.
We are soliciting comments on our policy that paid lunch hours
should be excluded from the wage index. Specifically, we would like a
broader understanding of the issue of whether some hospitals may, in
fact, be truly disadvantaged by this policy through no fault of their
own. Any change in our policy would not be implemented until, at the
earliest, the FY 2005 wage index.
[[Page 27190]]
Some hospitals and associations have also recommended that we
exclude the paid hours associated with military and jury duty leave
from the wage index calculation. They state that, unlike other paid
leave categories for which workers are usually paid at their full
hourly rates (for example, annual, sick, and holiday), hospitals
typically pay employees on military or jury duty only a fraction of
their normal pay. The amount that the hospital pays is intended to only
supplement the earnings that the employee receives from the government,
so that, while performing military or civic duties, the employee can
continue to be paid the same salary level as if he or she were still
working at the hospital.
The hospitals and associations believe that including the lower pay
rates associated with employees' military and jury duty leave unfairly
decreases a hospital's average hourly wage and, therefore, its wage
index value. Therefore, we are proposing to exclude from the wage index
the paid hours associated with military and jury duty leave, beginning
with the FY 2005 wage index. The associated salaries would continue to
be reported on Worksheet S-3, Part II, Line 1 of the Medicare cost
report.
D. Verification of Wage Data From the Medicare Cost Reports
The data for the proposed FY 2004 wage index were obtained from
Worksheet S-3, Parts II and III of the FY 2000 Medicare cost reports.
The data file used to construct the proposed wage index includes FY
2000 data submitted to us as of February 18, 2003. As in past years, we
performed an intensive review of the wage data, mostly through the use
of edits designed to identify aberrant data.
We asked our fiscal intermediaries to revise or verify data
elements that resulted in specific edit failures. Some unresolved data
elements are included in the calculation of the proposed FY 2004 wage
index, pending their resolution before calculation of the final FY 2004
wage index. We instructed the intermediaries to complete their
verification of questionable data elements and to transmit any changes
to the wage data no later than April 4, 2003. We believe all unresolved
data elements will be resolved by the date the final rule is issued.
The revised data will be reflected in the final rule.
Also, as part of our editing process, we removed data for 110
hospitals that failed edits. We identified 72 hospitals with incomplete
or inaccurate data resulting in zero or negative, or otherwise
aberrant, average hourly wages. Therefore, wage data from these
hospitals were removed from the calculation. We have notified the
fiscal intermediaries of these hospitals and will continue to work with
the fiscal intermediaries to correct these data whenever possible. As a
result, the proposed FY 2004 wage index is calculated based on FY 2000
wage data for 4,593 hospitals.
In constructing the proposed FY 2004 wage index, we include the
wage data for facilities that were IPPS hospitals in FY 2000, even for
those facilities that have terminated their participation in the
program as hospitals or have since been designated as a critical access
hospital (CAH), as long as those data do not fail any of our edits for
reasonableness. We believe that including the wage data for these
hospitals is, in general, appropriate to reflect the economic
conditions in the various labor market areas during the relevant past
period.
However, we received correspondence suggesting that the wage data
for hospitals that have subsequently been redesignated as CAHs should
be removed from the wage index calculation because CAHs are unique
compared to other short-term, acute care hospitals. CAHs are limited to
only 15 acute care beds. An additional 10 beds may be designated as
swing-beds, but only 15 beds can be used at one time to serve acute
care patients. CAHs tend to be located in isolated, rural areas. We
solicit comment on whether we should exclude wage data from such
hospitals from the wage index calculation. However, we have included
the data for CAHs in the proposed FY 2004 wage index if the CAH was
paid under the IPPS during FY 2000.
E. Computation of the Proposed FY 2004 Wage Index
The method used to compute the proposed FY 2004 wage index follows:
Step 1--As noted above, we based the proposed FY 2004 wage index on
wage data reported on the FY 2000 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, 1999 and before October 1, 2000. In addition, we
included data from some hospitals that had cost reporting periods
beginning before October 1999 and reported a cost reporting period
covering all of FY 2000. 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 2000 data. We note that, if a hospital
had more than one cost reporting period beginning during FY 2000 (for
example, a hospital had two short cost reporting periods beginning on
or after October 1, 1999 and before October 1, 2000), we included wage
data from only one of the cost reporting periods, the longer, 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 later period in the wage index calculation. We have removed
the wage data of CAHs, after the effective date of the CAH designation,
from the calculation of the proposed wage index.
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, 5 and 5.01, 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 IPPS). 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
[[Page 27191]]
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, 1999 through
April 15, 2001 for private industry hospital workers from the Bureau of
Labor Statistics' Compensation and Working Conditions. We use the ECI
because it reflects the price increase associated with total
compensation (salaries plus fringes) rather than just the increase in
salaries. In addition, the ECI includes managers as well as other
hospital workers. This methodology to compute the monthly update
factors uses actual quarterly ECI data and assures that the update
factors match the actual quarterly and annual percent changes. The
factors used to adjust the hospital's data were based on the midpoint
of the cost reporting period, as indicated below.
Midpoint of Cost Reporting Period
------------------------------------------------------------------------
Adjustment
After Before factor
------------------------------------------------------------------------
10/14/1999.............................. 11/15/1999 1.06794
11/14/1999.............................. 12/15/1999 1.06447
12/14/1999.............................. 01/15/2000 1.06083
01/14/2000.............................. 02/15/2000 1.05713
02/14/2000.............................. 03/15/2000 1.05335
03/14/2000.............................. 04/15/2000 1.04954
04/14/2000.............................. 05/15/2000 1.04571
05/14/2000.............................. 06/15/2000 1.04186
06/14/2000.............................. 07/15/2000 1.03786
07/14/2000.............................. 08/15/2000 1.03356
08/14/2000.............................. 09/15/2000 1.02898
09/14/2000.............................. 10/15/2000 1.02425
10/14/2000.............................. 11/15/2000 1.01953
11/14/2000.............................. 12/15/2000 1.01482
12/14/2000.............................. 01/15/2001 1.01004
01/14/2001.............................. 02/15/2001 1.00509
02/14/2001.............................. 03/15/2001 1.00000
03/14/2001.............................. 04/15/2001 0.99491
------------------------------------------------------------------------
For example, the midpoint of a cost reporting period beginning
January 1, 2000 and ending December 31, 2000 is June 30, 2000. An
adjustment factor of 1.03786 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 2000 and covered a
period of less than 360 days or more than 370 days, we annualized the
data to reflect a 1-year cost report. Annualization is accomplished by
dividing the data by the number of days in the cost report and then
multiplying the results by 365.
Step 6--Each hospital was assigned to its appropriate urban or
rural labor market area before any reclassifications under section
1886(d)(8)(B) or section 1886(d)(10) of the Act. Within each urban or
rural labor market area, we added the total adjusted salaries plus
wage-related costs obtained in Step 5 for all hospitals in that area to
determine the total adjusted salaries plus wage-related costs for the
labor market area.
Step 7--We divided the total adjusted salaries plus wage-related
costs obtained under both methods in Step 6 by the sum of the
corresponding total hours (from Step 4) for all hospitals in each labor
market area to determine an average hourly wage for the area.
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 $24.5439.
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
$11.5431 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.
[[Page 27192]]
Step 11--Section 4410 of Pub. L. 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 2004,
this change affects 141 hospitals in 44 MSAs. The MSAs affected by this
provision are identified by a footnote in Table 4A in the Addendum of
this proposed rule.
F. Proposed 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 IPPS.
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
Sec. Sec. 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 Pub. L. 106-554 provides that 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. The implementing regulations
for this provision are at Sec. 412.235.
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 (1) If the rural county would otherwise be considered
part of an urban area under the standards published in the Federal
Register for designating MSAs (and for designating NECMAs), and (2) 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 meet these criteria are
deemed urban for purposes of the standardized amounts and for purposes
of assigning the wage index.
Revised MSA standards were published in the December 27, 2000
Federal Register (65 FR 82228). We are working with the Census Bureau
to compile a list of hospitals that meet the new standards based on the
2000 census data; however, that work is not yet complete. Therefore,
for purposes of calculating the proposed wage indexes in this proposed
rule, we used the list of qualifying hospitals based on the 1990 MSA
standards.
However, if the updated list of hospitals meeting the new standards
based on the 2000 census data is available in time, we will incorporate
it in the final rule to be published by August 1, 2003. To the extent
hospitals otherwise reclassified by the MGCRB for FY 2004 are adversely
affected by their inclusion on or exclusion from the new list, we will
address this in the final rule. Among the options we may consider in
the final rule to address situations where hospitals may be adversely
affected are: Assigning adversely affected hospitals the highest
applicable wage index; or extending the opportunity for adversely
affected hospitals to withdraw from a reclassification by the MGCRB for
FY 2004.
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,\3\ the wage index values
were determined by considering the following:
---------------------------------------------------------------------------
\3\ Although section 1886(d)(8)(C)(iv)(I) of the Act also
provides that the wage index for an urban area may not decrease as a
result of redesignated hospitals if the urban area wage index is
below the wage index for rural areas in the State in which the urban
area is located, this was effectively made moot by section 4410 of
Public Law 105-33, which provides that 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.
Also, section 1886(d)(8)(C)(iv)(II) of the Act provides that an
urban area's wage index may not decrease as a result of redesignated
hospitals if the urban area is located in a State that is composed
of a single urban area.
---------------------------------------------------------------------------
[sbull] 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.
[sbull] 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.
[sbull] 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 (otherwise, redesignated rural hospitals
are excluded from the calculation of the rural wage index).
[sbull] The wage index value for a redesignated rural hospital
cannot be reduced below the wage index value for the rural areas of the
State in which the hospital is located.
If including the wage data for the redesignated hospitals increases
the wage index value for the urban area to which the hospitals are
redesignated, both the area and the redesignated hospitals receive the
combined wage index value. Otherwise, the hospitals located in the
urban area receive a wage index excluding the wage data of hospitals
redesignated into the area.
The wage data for a reclassified urban hospital is included in both
the wage index calculation of the area to which
[[Page 27193]]
the hospital is reclassified (subject to the rules described above) and
the wage index calculation of the urban area where the hospital is
physically located.
The proposed wage index values for FY 2004 are shown in Tables 4A,
4B, 4C, and 4F in the Addendum to this proposed rule. Hospitals that
are redesignated should use the wage index values shown in Table 4C.
Areas in Table 4C may have more than one wage index value because the
wage index value for a redesignated urban or rural hospital cannot be
reduced below the wage index value for the rural areas of the State in
which the hospital is located, and those areas have hospitals from more
than one State reclassified into them.
Tables 3A and 3B in the Addendum of this proposed rule list the 3-
year average hourly wage for each labor market area before the
redesignation of hospitals, based on FYs 1998, 1999, and 2000 cost
reporting periods. Table 3A lists these data for urban areas and Table
3B lists these data for rural areas. In addition, Table 2 in the
Addendum to this proposed rule includes the adjusted average hourly
wage for each hospital from the FY 1998 and FY 1999 cost reporting
periods, as well as the FY 2000 period used to calculate the proposed
FY 2004 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.
At the time this proposed wage index was constructed, the MGCRB had
completed its review of FY 2004 reclassification requests. We have
included in this proposed rule Table 9, which shows hospitals that have
been reclassified under either section 1886(d)(8) or section
1886(d)(10)(D) of the Act. This table includes hospitals reclassified
for FY 2004 by the MGCRB (73 for wage index, 66 for the standardized
amount, and 33 for both the wage index and the standardized amount), as
well as hospitals that were reclassified for the wage index in either
FY 2002 (476) or FY 2003 (56) and are, therefore, in either the second
or third year of their 3-year reclassification. This table also
includes hospitals located in urban areas that have been designated
rural in accordance with section 1886(d)(8)(E) of the Act (14). In
addition, it includes rural hospitals redesignated to an urban area
under section 1886(d)(8)(B) of the Act for purposes of the standardized
amount and the wage index (42).
Under Sec. 412.273, hospitals that have been reclassified by the
MGCRB are permitted to withdraw their applications within 45 days of
the publication of this proposed rule in the Federal Register.
Similarly, hospitals may terminate an existing 3-year reclassification
within 45 days of the publication of this proposed rule. The request
for withdrawal of an application for reclassification or termination of
an existing 3-year reclassification that would be effective in FY 2003
must be received by the MGCRB within 45 days of the publication of this
proposed rule. If a hospital elects to withdraw its wage index
application after the MGCRB has issued its decision but prior to the
above date, it may later 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 (Sec. 412.273(b)(2)(i)).
The request to cancel a prior withdrawal must be made in writing to the
MGCRB no later than the deadline for submitting reclassification
applications for the following fiscal year (Sec. 412.273(d)). For
further information about withdrawing, terminating, or canceling a
previous withdrawal or termination of a 3-year reclassification for
wage index purposes, we refer the reader to Sec. 412.273, as well as
the August 1, 2002 IPPS final rule (67 FR 50065) and the August 1, 2001
IPPS final rule (66 FR 39887).
Any changes to the wage index that result from withdrawals of
requests for reclassification, wage index corrections, appeals, and the
Administrator's review process will be incorporated into the wage index
values published in the final rule following this proposed rule.
Therefore, the final wage indexes will likely be different from those
published in this proposed rule, and, in some cases, they may be quite
different. Although, as described above, the statute provides that a
reclassified rural hospital may not have a lower wage index after
reclassification than before, there is no similar protection for urban
hospitals. Therefore, hospitals should carefully evaluate the impacts
of their reclassifications prior to the deadline for withdrawing from
an approved reclassification.
Applications and other information about MGCRB reclassifications
may be obtained via the CMS internet Web site at http://cms.hhs.gov/providers/prrb/mgcinfo.asp, or by calling the MGCRB at (410) 786-1174.
The mailing address of the MGCRB is: 2520 Lord Baltimore Drive, Suite
L, Baltimore, MD 21244-2670.
As noted previously, OMB plans to announce new definitions of CBSAs
by the middle of this year, and the earliest these new CBSA definitions
would be used for the wage index is FY 2005. Applications for
reclassification by the MGCRB for FY 2005 will be due by September 2,
2003. However, by that time, we will not have completed our analysis of
the new CBSAs. Therefore, hospitals submitting applications for
reclassification by the MGCRB for FY 2005 should base those
applications on the current MSAs. We will assess the implications of
the new CBSAs on hospitals' reclassification requests in the FY 2005
proposed rule.
G. Requests for Wage Data Corrections
The preliminary wage data file was made available on January 10,
2003 (and subsequently on February 4, 2003), through the Internet on
CMS's Web site at http://www.cms.hhs.gov/providers/hipps/default.asp.
In a memorandum dated December 31, 2002, we instructed all Medicare
fiscal intermediaries to inform the IPPS hospitals they service of the
availability of the wage data file and the process and timeframe for
requesting revisions (including the specific deadlines listed below).
We also instructed the fiscal intermediaries to advise hospitals that
these data are made available directly through their representative
hospital organizations.
If a hospital wished to request a change to its data as shown in
that wage data file, the hospital was to submit corrections along with
complete, detailed supporting documentation to its intermediary by
February 17, 2003 (this deadline was initially announced as February
10, 2003, but was changed due to the need to repost some of the data).
Hospitals were notified of this deadline and of all other possible
deadlines and requirements, including the requirement to review and
verify their data as posted on the preliminary wage data file on the
Internet, through the December 31, 2002 memorandum referenced above.
After reviewing requested changes submitted by hospitals, fiscal
intermediaries transmitted any revised cost reports to CMS and
forwarded a copy of the revised Worksheet S-3, Parts II and III to the
hospitals by April 4, 2003. In addition, fiscal intermediaries were to
notify hospitals of the changes or the reasons that changes were not
accepted. These deadlines are necessary to allow sufficient time to
review and process the data so that the final wage index
[[Page 27194]]
calculation can be completed for the development of the final FY 2004
prospective payment rates to be published by August 1, 2003.
If a hospital disagreed with the fiscal intermediary's resolution
of a policy issue (for example, whether a general category of cost is
allowable in the wage data), the hospital could have contacted CMS in
an effort to resolve the issue. We note that the April 4, 2003 deadline
also applied to these requests. Requests were required to be sent to
CMS at the address below (with a copy to the hospital's fiscal
intermediary). The request must have fully documented all attempts by
the hospital to resolve the dispute through the process described
above, including copies of relevant correspondence between the hospital
and the fiscal intermediary. During review, we do not consider issues
such as the adequacy of a hospital's supporting documentation, as we
believe that fiscal intermediaries are generally in the best position
to make evaluations regarding the appropriateness of these types of
issues (which should have been resolved earlier in the process).
Hospitals should also examine Table 2 in the Addendum to this
proposed rule to verify their data. Table 2 contains each hospital's
adjusted average hourly wage used to construct the wage index values
for the past 3 years, including the FY 2000 data used to construct the
proposed FY 2004 wage index. We note that the hospital average hourly
wages shown in Table 2 only reflect changes made to a hospital's data
and transmitted to CMS prior to February 18, 2003.
We will release a final wage data file in May 2003 to hospital
associations and the public on the Internet at http://www.cms.hhs.gov/providers/hipps/default.asp. The May 2003 public use file will be made
available solely for the limited purpose of identifying any potential
errors made by CMS or the fiscal intermediary in the entry of the final
wage data that result from the correction process described above
(revisions submitted to CMS by the fiscal intermediaries by April 4,
2003). If, after reviewing the May 2003 final file, a hospital believes
that its wage data are incorrect due to a fiscal intermediary or CMS
error in the entry or tabulation of the final wage data, it should send
a letter to both its fiscal intermediary and CMS that outlines why the
hospital believes an error exists and provide all supporting
information, including relevant dates (for example, when it first
became aware of the error).
CMS and the fiscal intermediaries must receive these requests no
later than June 6, 2003. Requests mailed to CMS should be sent to:
Centers for Medicare & Medicaid Services, Center for Medicare
Management, Attention: Wage Index Team, Division of Acute Care, C4-07-
05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
Each request also must be sent to the hospital's fiscal
intermediary. The intermediary will review requests upon receipt and
contact CMS immediately to discuss its findings.
At this point in the process, that is, after the release of the May
2003 wage index file, changes to the hospital wage data will only be
made in those very limited situations involving an error by the
intermediary or CMS that the hospital could not have known about before
its review of the final wage data file. Specifically, neither the
intermediary nor CMS will approve the following types of requests:
[sbull] Requests for wage data corrections that were submitted too
late to be included in the data transmitted to CMS by fiscal
intermediaries on or before April 4, 2003.
[sbull] Requests for correction of errors that were not, but could
have been, identified during the hospital's review of the January 2003
wage data file.
[sbull] 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 6, 2003) will be incorporated into the final wage index in the
final rule to be published by August 1, 2003, and to be effective
October 1, 2003.
We have created the process described above to resolve all
substantive wage data correction disputes before we finalize the wage
data for the FY 2004 payment rates. Accordingly, hospitals that did not
meet the procedural deadlines set forth above will not be afforded a
later opportunity to submit wage data corrections or to dispute the
intermediary's decision with respect to requested changes.
Specifically, our policy is that hospitals that do not meet the
procedural deadlines set forth above will not be permitted to challenge
later, before the Provider Reimbursement Review Board, the failure of
CMS to make a requested data revision (See W. A. Foote Memorial
Hospital v. Shalala, No. 99-CV-75202-DT (E.D. Mich. 2001)).
Again, we believe the wage data correction process described above
provides hospitals with sufficient opportunity to bring errors in their
wage data to the fiscal intermediaries' attention. Moreover, because
hospitals will have access to the final wage data by early May 2003,
they will have the opportunity to detect any data entry or tabulation
errors made by the fiscal intermediary or CMS before the development
and publication of the FY 2004 wage index by August 1, 2003, and the
implementation of the FY 2004 wage index on October 1, 2003. If
hospitals avail themselves of this opportunity, the wage index
implemented on October 1 should be accurate. Nevertheless, in the event
that errors are identified after that date, we retain the right to make
midyear changes to the wage index under very limited circumstances.
Specifically, in accordance with Sec. 412.63(x)(2) of our existing
regulations, we make midyear corrections to the wage index for an area
only if a hospital can show that the intermediary or CMS made an error
in tabulating its data. 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 earlier, 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
publication of the FY 2004 wage index. As indicated earlier, since a
hospital will have the opportunity to verify its data, and the fiscal
intermediary will notify the hospital of any changes, we do not expect
that midyear corrections will 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.
H. Modification of the Process and Timetable for Updating the Wage
Index
Although the wage data correction process described in section
III.G. of this preamble has proven successful in the past for ensuring
that the wage data used each year to calculate the wage indexes are
generally reliable and accurate, we continue to be concerned about the
growing volume of wage data revisions initiated by hospitals after the
release of the first public use file in February. This issue has been
discussed previously in the FY 1998 IPPS proposed rule (62 FR 29918)
and in the FY 2002 IPPS proposed rule (66 FR 22682). In each
discussion, we describe the increasing number of revisions to wage data
between the proposed rule and the final rule.
Currently, the fiscal intermediaries are required to conduct
initial desk reviews on or before November 15 in advance of the
preparation of the preliminary wage data public use file in early
January (see Program
[[Page 27195]]
Memorandum A-02-94, October 4, 2002). Furthermore, they are required to
address items that fall outside the established thresholds. This may
involve further review of the supplementary documentation or contacting
the hospital for additional documentation. In addition, fiscal
intermediaries are required to notify State hospital associations
regarding hospitals that fail to respond to issues raised during the
desk review. These actions are to be completed in advance of sending
the data to CMS to prepare the preliminary wage data public use file in
early January. However, as we have indicated in prior Federal
Registers, as much as 30 percent of hospitals subsequently request
revisions to their data after the preliminary wage data file is made
available.
This high volume of revisions results in an additional workload for
the fiscal intermediaries. In particular, much of a fiscal
intermediary's efforts prior to submitting the data to prepare the
preliminary public use file may be in vain if the hospital subsequently
revises all of its data prior to the early February deadline (which is
the hospital's right at that point). Therefore, we are proposing to
modify the process to release the preliminary wage data file prior to
requiring the fiscal intermediaries to conduct their initial desk
reviews on the data. This unaudited data would be available on the
Internet by early October rather than early January. Hospitals would
review this file to ensure it contains their correct data as submitted
on their cost reports and request any changes by early November. At
that time, the fiscal intermediaries would review the revision requests
and conduct desk reviews of the data including all approved changes.
Under this proposed revised timetable, the fiscal intermediaries
would notify the hospitals in early February of any changes to the wage
data as a result of the desk reviews and the resolution of the
hospitals' early November change requests. The fiscal intermediaries
would also submit the revisions to CMS in early February. Hospitals
would then have until early March to submit requests to the fiscal
intermediaries for reconsideration of adjustments made by the fiscal
intermediaries as a result of the desk review. Other than requesting
reconsideration of desk review adjustments, hospitals would not be able
to submit new requests for additional changes that were not submitted
by early November. By early April, the fiscal intermediaries would
notify all hospitals of their decisions regarding the hospitals'
requests to reconsider desk review adjustments and submit all of the
revised wage data to CMS. From this point (early April) until the
publication of the final rule, the process would be identical to the
current timetable. Similar to the current timetable, hospitals would
also have the opportunity in early April to request CMS consideration
of policy disputes.
We believe that the proposed revision of the schedule would improve
the quality of the wage index by initiating hospitals' review of their
data sooner and allowing the fiscal intermediaries to focus their
reviews on the final data submitted by hospitals to be included in the
wage index. In addition, we would receive the revised data in time to
incorporate them into the wage indexes published in the proposed rule,
resulting in fewer changes from the proposed rule to the final rule.
This will improve the ability of hospitals to assess whether they
should request a withdrawal from a MGCRB reclassification. Because the
decision of whether to withdraw a wage index reclassification must be
made prior to publication of the final rule, this proposed schedule
should decrease the likelihood that the final wage index will be
dramatically different from the proposed wage index.
The following table illustrates the proposed timetable that would
be applicable for the development of the FY 2005 wage index:
------------------------------------------------------------------------
Steps in wage index development
Timeframe process
------------------------------------------------------------------------
Early October..................... Preliminary and unaudited wage data
file published as a public use file
(PUF) on CMS Web site.
Early November.................... Deadline for hospitals to send
requests for revisions to the
fiscal intermediaries.
Early February.................... Fiscal intermediaries review
revisions and desk review wage
data; notify hospitals of changes
and resolution of revision
requests; and submit preliminary
revised data to CMS.
Early March....................... Deadline for hospitals to request
wage data reconsideration of desk
review adjustments and provide
adequate documentation to support
the request.
Early April....................... Deadline for the fiscal
intermediaries to submit additional
revisions resulting from the
hospitals' reconsideration
requests. This is also the deadline
for hospitals to request CMS
intervention in cases where the
hospital disagrees with the fiscal
intermediary's policy
interpretations.
Early May *....................... Release of final wage data PUF on
CMS Web site.
Early June *...................... Deadline for hospitals to submit
correction requests, to both CMS
and their fiscal intermediary, for
errors due to the mishandling of
the final wage data by CMS or the
fiscal intermediary.
August 1 *........................ Publication of the final rule.
October 1 *....................... Effective date of updated wage
index.
------------------------------------------------------------------------
* Indicates no change from prior years.
IV. Other Decisions and Proposed Changes to the IPPS for Operating
Costs and GME Costs
A. Transfer Payment Policy (Sec. 412.4)
Existing regulations at Sec. 412.4(a) define discharges under the
IPPS 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.
The per diem rate paid to a transferring hospital is calculated by
dividing the full DRG payment by the geometric mean length of stay for
the DRG. Based on an analysis that showed that the first day of
hospitalization is the most expensive (60 FR 45804), our policy
provides for payment that is double the per diem amount for the first
day (Sec. 412.4(f)(1)). Transfer cases are also eligible for outlier
payments. The outlier threshold for transfer cases is equal to the
fixed-loss outlier threshold for nontransfer cases, divided by the
geometric mean length of stay for the DRG, multiplied by the length of
stay for the case, plus one day.
[[Page 27196]]
1. Transfers to Another Acute Care Hospital (Sec. 412.4(b))
Medicare adopted its IPPS transfer policy because, if we were to
pay the full DRG payment regardless of whether a patient is transferred
or discharged, there would be a strong incentive for hospitals to
transfer patients to another IPPS hospital early in their stay in order
to minimize costs while still receiving the full DRG payment. The
transfer policy adjusts the payments to approximate the reduced costs
of transfer cases.
Currently, when a patient chooses to depart from a hospital against
the medical opinion of treating physicians, the case is treated as a
left against medical advice (LAMA) discharge and coded as discharge
status ``07-Left Against Medical Advice (LAMA)'' on the inpatient
billing claim form. Because, by definition, LAMA discharges are assumed
not to involve the active participation of the hospital administration,
our policy has been to treat LAMA cases as discharges. This policy
applies even if the patient is admitted to another hospital on the date
of the LAMA discharge. Consequently, we currently make a full DRG
payment for any discharge coded as a LAMA case.
However, we are concerned that some hospitals may be incorrectly
coding transfers as LAMA cases. The Office of Inspector General (OIG)
issued a report in March 2002 (A-06-99-00045), asserting that of the
approximately 60,000 LAMA discharges annually, 1,500 patients were
subsequently admitted to another IPPS hospital the same day. The OIG
performed a detailed review of the medical records at selected
hospitals and found evidence that the hospitals actively participated
in transferring the patients to a different IPPS hospital, yet the
hospital coded the claim as a LAMA. OIG cited several examples of these
cases:
``In the first example, the transferring hospital did not have an
inpatient room available for the patient, who had been in the emergency
room for 24 hours. The medical record showed that the treating
physician contacted another PPS hospital to determine whether the
hospital could accept the patient. Specifically, the medical record
stated: `Upon request of the patient, [hospital name] was contacted
since there is a good possibility of transferring patient to [name of
hospital]. At present, he has been in emergency room for 24 hours
waiting for a bed.' ''
In this example, despite the overt participation of the physician
in securing the admission to the other IPPS hospital and the fact that
the transferring hospital did not have an inpatient room available for
the patient, the claim was submitted as a LAMA discharge, rather than
as a transfer to another IPPS hospital.
``In the second example, the patient was brought to the first
hospital by ambulance. Subsequently, the patient's family indicated
that they wanted a neurologist at another hospital to render the
treatment needed by the patient. The attending physician contacted the
neurologist in order to determine if the neurologist would accept,
admit, and treat the patient. The medical record contained ample
evidence of knowledge and participation of the transferring hospital,
and the discharge should have been reported as a PPS transfer.
Specifically, the medical record stated: `Patient's family wanted to
sign the patient out against medical advice and take her to [name of
hospital]. The physician spoke with the neurologist at [name of
hospital], who agreed to accept the patient. The patient's family
signed the patient discharged against medical advice. All the risks of
self-discharge were explained.' ''
In this case, although the medical record indicated the patient
wanted to leave against medical advice, there is also evidence that the
patient's attending physician at the hospital participated in the
transfer to another IPPS hospital. While we do not wish to discourage
such participation and cooperation in cases where a transfer occurs,
this situation would seem almost indistinguishable from other transfer
situations. For instance, we have long recognized situations where
patients are transferred from a rural hospital to an urban hospital for
a surgical procedure, then back to the rural hospital to complete the
recuperative care, as appropriate transfer situations as long as the
transfers are medically appropriate. In such a case, the rural hospital
would receive a payment under the transfer policy for the first portion
of the stay, the urban hospital would also receive payment under the
transfer policy for the care it provided, and the rural hospital would
receive a full DRG payment as the discharging hospital for the
recuperative care it provided upon the patient's return from the urban
hospital. In such situations, each portion of the stay may be assigned
a different DRG.
Therefore, we are proposing to expand our definition of a transfer
under Sec. 412.4(b) to include all patients who are admitted to
another IPPS hospital on the same day that the patient is discharged
from an IPPS hospital, unless the first (transferring) hospital can
demonstrate that the patient's treatment was completed at the time of
discharge from that hospital. In other words, unless the same-day
readmission is to treat a condition that is unrelated to the condition
treated during the original admission (for example, the beneficiary is
in a car accident later that day), any situation where the beneficiary
is admitted to another IPPS hospital on the same date that he or she is
discharged from an IPPS hospital would be considered a transfer, even
if the patient left against medical advice from the first hospital.
Although we considered proposing a policy that would be based on
whether the hospital actively participated in the transfer, and
exempting from the transfer definition cases where the hospital had
absolutely no knowledge that the patient intended to go to another
hospital, we are not proposing such a policy for two reasons. First, it
would be difficult to administer equitably a policy that required a
determination as to whether the hospital or the physician had knowledge
of the patient's intentions. Such a policy would require fiscal
intermediaries to make a difficult judgment call in many cases. Second,
if we were to base the determination of whether a case is a transfer on
the level of involvement of the hospital and the physician caring for
the patient, we would be creating a financial disincentive to hospitals
for ensuring an efficient and cooperative transfer once a decision has
been made by the patient or the patient's family to leave the hospital.
We recognize that, in some cases, a hospital cannot know the
patient will go to another hospital. However, we note the claims
processing system can identify cases coded as discharges where the date
of discharge matches the admission date at another hospital. In these
cases, the fiscal intermediary will notify the hospital of the need to
submit an adjustment claim. However, if the hospital can present
documentation showing that the patient's care associated with the
admission to the hospital was completed before discharge, consistent
with our current policy, the transfer policy will not be applied.
2. Technical Correction
Section 412.4(b)(2) defines a discharge from one inpatient area of
the hospital to another area of the hospital as a transfer. Although
this situation may be viewed as an intrahospital transfer, it does not
implicate the transfer policy under the IPPS. Therefore, to avoid
confusion and to be
[[Page 27197]]
consistent with the proposed changes to Sec. 412.4(b) described at
section IV.A.3. of this preamble, we are proposing to delete existing
Sec. 412.4(b)(2) from the definition of a transfer.
3. Expanding the Postacute Care Transfer Policy to Additional DRGs
(Sec. Sec. 412.4(c) and (d))
Under section 1886(d)(5)(J) of the Act, 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:
[sbull] 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.)
[sbull] A SNF (as defined at section 1819(a) of the Act).
[sbull] 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 IPPS 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).
Section 1886(d)(5)(J) of the Act 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:
[sbull] DRG 14 (Intracranial Hemorrhage and Stroke with Infarction
(formerly ``Specific Cerebrovascular Disorders Except Transient
Ischemic Attack''));
[sbull] DRG 113 (Amputation for Circulatory System Disorders Except
Upper Limb and Toe);
[sbull] DRG 209 (Major Joint Limb Reattachment Procedures of Lower
Extremity);
[sbull] DRG 210 (Hip and Femur Procedures Except Major Joint
Procedures Age 17 With CC);
[sbull] DRG 211 (Hip and Femur Procedures Except Major Joint
Procedures Age 17 Without CC);
[sbull] DRG 236 (Fractures of Hip and Pelvis);
[sbull] DRG 263 (Skin Graft and/or Debridement for Skin Ulcer or
Cellulitis With CC);
[sbull] DRG 264 (Skin Graft and/or Debridement for Skin Ulcer or
Cellulitis Without CC);
[sbull] DRG 429 (Organic Disturbances and Mental Retardation); and
[sbull] DRG 483 (Tracheostomy With Mechanical Ventiliation 96+
Hours or Principal Diagnosis Except Face, Mouth, and Neck Diagnoses
(formerly ``Tracheostomy Except for Face, Mouth, and Neck
Diagnoses'')).
Similar to the 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 before 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 single per diem (rather
than double 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.''
Section 1886(d)(5)(J)(iv) of the Act authorizes the Secretary to
expand the postacute transfer policy beyond 10 DRGs. In the May 9, 2002
IPPS proposed rule, we discussed the possibility of expanding this
policy to either all DRGs or a subset of additional DRGs (we identified
13 additional DRGs in that proposed rule) (67 FR 31455). However, as
discussed further in the August 1, 2002 final rule (65 FR 50048), we
did not expand the postacute transfer provision to additional DRGs for
FY 2003. The commenters on the options in the May 9, 2002 proposed rule
raised many issues regarding the impact of expanding this policy that
we needed to consider further 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. We indicated
that we would continue to conduct research to assess whether further
expansion of this policy may be warranted and, if so, how to design any
such refinements.
Many commenters on the May 9, 2002 proposed rule 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 an
inappropriate incentive for hospitals to keep patients longer.
Commenters also expressed concern that the expansion of the
transfer provision violates the fundamental principle of the IPPS. The
DRG system is based on payments that will, on average, be adequate.
These commenters argued that expansion of the postacute care transfer
policy would give the IPPS 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).
We agree that the transfer policy should not hamper the provision
of effective patient care, and any future expansion must consider both
the need to reduce payments to reflect cost-shifting due to reductions
in length of stay attributable to early transfers to postacute care and
the need to ensure that payments, on average, remain adequate to ensure
effective patient care. Therefore, we have assessed the extent to which
the current postacute transfer policy balances these objectives.
The table below displays the results of our analysis. We first
examined whether the 10 DRGs included in the policy continue to exhibit
a relatively high percentage of cases transferred to postacute care
settings, particularly
[[Page 27198]]
among cases with lengths of stay shorter than the geometric mean for
the DRG (these cases would be affected by the reduced payments for
transfers). The table shows that these DRGs continue to contain high
percentages of cases transferred to postacute care settings similar to
those we reported in the FY 1999 final rule (63 FR 40975). These
results would appear to demonstrate that the postacute transfer policy
has not greatly altered hospitals' treatment patterns for these cases.
This similarity in treatment patterns is further evidenced by the
fact that, for 6 of the 10 DRGs, the geometric mean length of stay has
continued to decline in the 5 years since the policy was implemented.
Accordingly, hospitals have continued to transfer many patients in
these DRGs before the mean length of stay, despite the transfer policy.
As we stated in the July 31, 1998 final rule, the transfer provision
adjusts payments to hospitals to reflect the reduced lengths of stay
arising from the shift of patient care from the acute care setting to
the postacute setting (63 FR 40977). This policy does not require a
change in physician clinical decisionmaking nor in the manner in which
physicians and hospitals practice medicine: it simply addresses the
appropriate level of payments once those decisions have been made.
With respect to whether this policy alters the fundamental
averaging principles of the IPPS, we believe the current policy, which
targets specific DRGs where evidence shows hospitals have aggressively
moved care to postacute care settings, does not alter the averaging
principles of the system. In fact, it could be said to enhance those
principles because 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 methodology
ensures the DRG weight calculation is consistent with the payment
policy for transfer cases. The last column of the table below indicates
that all but three of these DRGs have experienced increases in DRG
weights since the policy was implemented. By reducing the contribution
of transfer cases to the calculation of the DRG average charge, the
relative weights (the result of dividing the DRG average charge by the
national average charge per case) are higher than they would otherwise
be. This is because transfers, particularly short-stay transfers, have
lower total charges, on average.
----------------------------------------------------------------------------------------------------------------
Percent of
all cases Percent of Percent Percent Percent
All transferred all cases change in change in change in
DRG DRG title transfer to transferred mean length mean length DRG
cases postacute prior to of stay FYs of stay FYs relative
care mean length 92-98 98-03 weight FYs
setting of stay 98-03
----------------------------------------------------------------------------------------------------------------
14............ Intracranial 143,649 48.88 11.74 -29.17 -5.88 8.53
Hemorrhage and
Stroke with
Infarction.
113........... Amputation for 24,470 66.57 30.12 -32.17 7.22 9.21
Circulatory
System Disorders
Except Upper Limb
and Toe.
209........... Major Joint and 244,969 66.66 19.76 -47.52 -15.09 -8.09
Limb Reattachment
Procedures of
Lower Extremity.
210........... Hip and Femur 87,253 76.26 35.67 -42.98 -6.15 0.1
Procedures Except
Major Joint Age
17
With CC.
211........... Hip and Femur 20,239 72.38 15.89 -44.44 -8.00 1.39
Procedures Except
Major Joint Age
17
Without CC.
236........... Fractures of Hip 26,583 69.86 11.20 -34.85 -6.98 -1.43
and Pelvis.
263........... Skin Graft and/or 13,158 62.00 31.35 -41.45 4.49 9.36
Debridement for
Skin Ulcer or
Cellulitis with
CC.
264........... Skin Graft and/or 1,759 49.97 18.81 -37.21 1.85 5.36
Debridement for
Skin Ulcer or
Cellulitis
Without CC.
429........... Organic 30,349 53.25 15.22 -28.95 -12.96 -5.27
Disturbances and
Mental
Retardation.
483........... Tracheostomy With 21,818 52.93 27.34 -15.29 2.37 1.38
Mechanical
Ventilation 96 +
Hours or
Principal
Diagnosis Except
Face, Mouth, and
Neck Diagnoses.
----------------------------------------------------------------------------------------------------------------
After determining the current 10 DRG postacute care transfer policy
appears to be appropriately balancing the objectives to reduce payments
to reflect cost-shifting due to reductions in length of stay
attributable to early postacute care transfers and to ensure that
payments, on average, remain adequate to ensure effective patient care,
we once again undertook the analysis to identify additional DRGs to
which the policy may be expanded. However, it should be noted that, at
this time, we have decided not to expand the policy to all DRGs.
Although we still believe expanding the postacute care transfer policy
to all DRGs might be the most equitable approach because a policy that
is limited to certain DRGs may result in disparate payment treatment
across hospitals, at this time, we believe an incremental expansion is
appropriate. That is, we believe further analysis is necessary to
assess whether it would be appropriate to apply a reduced payment for
postacute care transfers across all DRGs. In particular, it is
important to attempt to distinguish between DRGs where the care is
increasingly being shifted to postacute care sites versus DRGs where
some patients have always been discharged to postacute care early in
the stay. For the latter DRGs, it may not be appropriate to reduce
payment for these DRGs if the base payment already reflects a similar
postacute care utilization rate (for example, in these cases there
would be no cost shifting).
As described below, we have identified an additional 19 DRGs, based
on declining mean lengths of stay and high percentages of postacute
transfers, for which an expansion of the current policy appears
warranted.
MedPAC has also conducted analysis on the current postacute care
transfer policy. Most recently, in its March 2003 Report to Congress,
MedPAC recommended adding 13 additional DRGs to the 10 DRGs covered
under the current policy (page 46). The 13 DRGs were the same DRGs
included in one of our proposals to expand the postacute care transfer
policy in last year's IPPS proposed rule. MedPAC did not recommend
expanding the policy to include all DRGs at this time, noting
[[Page 27199]]
that this expansion might reduce payments to some hospitals by as much
as 4 percent. Rather, it suggested evaluating the impact of a limited
expansion before extending the policy to more DRGs.
MedPAC's report cites several reasons for expanding the postacute
care transfer policy beyond the current 10 DRGs. First, it notes the
continuing shifts in services from the acute care setting to the
postacute care setting. Second, the report points to different
postacute care utilization for different hospitals, particularly based
on geographic location. Third, the report states: ``the expanded
transfer policy provides a better set of incentives to protect
beneficiaries from potential premature discharge to postacute care.''
Fourth, MedPAC notes that the policy improves payment equity across
hospitals by: Reducing payments to hospitals that transfer patients to
postacute care while making full payments to hospitals that provide all
of the acute inpatient services in an acute care setting; and
maintaining more accurate DRG weights that reflect the true resource
utilization required to provide the full course of acute inpatient
care, as distinguished from the partial services provided to patients
who are transferred to postacute care.
Since the publication of last year's rule, we have conducted an
extensive analysis to identify the best method by which to expand the
postacute care transfer policy. Similar to the analysis used to
identify the current 10 DRGs, we are proposing to identify DRGs with
high postacute care transfer rates and at least 14,000 transfer cases.
However, rather than ranking DRGs on the basis of the percentage of all
postacute care transfers, we are proposing to rank DRGs on the basis of
the percentage of postacute care transfers occurring before the DRG
geometric mean length of stay. This is because only transfers that
occur before the geometric mean length of stay, minus one day due to
the policy that hospitals receive double the per diem for the first
day, are impacted by the transfer policy. In order to focus on those
DRGs where this policy would have the most impact, we are proposing to
include only DRGs where at least 10 percent of all cases that were
transferred to postacute care before the geometric mean length of stay.
The next proposed criterion is to identify DRGs with at least a 7-
percent decline in length of stay over the past 5 years (from FY 1998
to FY 2003). This criterion would focus on those DRGs for which
hospitals have been most aggressively discharging patients sooner into
postacute care settings. Finally, we are proposing to include only DRGs
with a geometric mean length of stay of at least 3 days because the
full payment is reached on the second day for a DRG with a 3-day length
of stay.
Using these criteria, we have identified 19 additional DRGs to
include in the postacute care transfer policy. However, some of the 13
DRGs proposed last year (and included in MedPAC's proposed expansion)
are not included in this proposed rule. For example, DRGs 79 and 80
(Respiratory Infections and Inflammations Age 17 With and
Without CC, respectively) were included in last year's proposed
expansion but are not included in this proposed rule for FY 2004. DRGs
79 and 80 are excluded from this proposed rule because they did not
exhibit a decline in length of stay of at least 7 percent over the past
5 years.
We note that 7 of these 19 DRGs are paired DRGs (that is, they
contain a CC and no-CC split). Because these DRGs are paired DRGs (that
is, the only difference in the cases assigned to DRG 130, for example,
as opposed to DRG 131 is that the patient has a complicating or
comorbid condition), we are proposing to include both DRGs under this
expanded policy. If we were to include only DRG 130 in the transfer
policy, there would be an incentive for hospitals not to include any
code that would identify a complicating or comorbid condition, so that
a transfer case would be assigned to DRG 131 instead of DRG 130.
Using the selection criteria described above, we identified the
following 19 DRGs that we are proposing to include under the postacute
care transfer policy (in addition to the 10 DRGs already subject to the
policy).
----------------------------------------------------------------------------------------------------------------
Percent of
all cases Percent of Percent Percent
All transferred cases change in change in
DRG DRG title transfer to transferred mean length mean length
cases postacute prior to of stay FYs of stay FYs
care mean length 1992-1998 1998-2003
setting of stay
----------------------------------------------------------------------------------------------------------------
12.................. Degenerative Nervous 39,034 54.13 13.10 -21.74 -12.00
System Disorders.
24.................. Seizure and Headache Age 19,239 35.67 11.63 -20.75 -7.69
17 With CC.
25.................. Seizure and Headache Age 4,738 19.15 2.15 -14.29 -10.71
17 Without CC.
89.................. Simple Pneumonia and 175,441 34.86 11.37 -18.31 -11.11
Pleurisy Age
17 With CC.
90.................. Simple Pneumonia and 9,544 20.86 2.82 -20.37 -15.00
Pleurisy Age 17 Without CC.
121................. Circulatory Disorders 79,242 52.52 20.46 -21.95 -11.67
With AMI and Major
Complication, Discharged
Alive.
122................. Circulatory Disorders 33,028 48.91 24.09 -26.67 -23.08
With AMI Without Major
Complications Discharged
Alive.
130................. Peripheral Vascular 31,106 37.78 14.27 -13.11 -11.76
Disorders With CC.
131................. Peripheral Vascular 5,723 23.08 5.42 -4.44 -19.51
Disorders Without CC.
239................. Pathological Fractures 23,188 53.54 21.96 -22.67 -7.55
and Musculoskeletal and
Connective Tissue
Malignancy.
243................. Medical Back Problems.... 36,772 41.49 13.61 -14.00 -7.50
277................. Cellulitis Age 17 With CC.
278................. Cellulitis Age 17 Without CC.
296................. Nutritional and 104,216 40.05 11.88 -21.67 -9.30
Miscellaneous Metabolic
Disorders Age 17 With CC.
297................. Nutritional and 12,649 28.03 2.17 -17.50 -10.00
Miscellaneous Metabolic
Disorders Age 17 Without CC.
320................. Kidney and Urinary Tract 77,669 44.64 12.40 -23.88 -8.51
Infectious Age 17 With CC.
321................. Kidney and Urinary Tract 8,610 29.90 5.67 -20.41 -13.89
Infections Age 17 Without CC.
462................. Rehabilitation........... 147,211 56.59 22.69 -22.54 -11.43
468................. Extensive O.R. Procedure 24,783 44.51 18.53 -20.30 -7.07
Unrelated to Principal
Diagnosis.
----------------------------------------------------------------------------------------------------------------
[[Page 27200]]
We are proposing to revise Sec. 412.4(d) to incorporate these
additional 19 DRGs as qualifying DRGs for transfer payments and to make
a conforming change to Sec. 412.4(c).
We also examined whether any of these DRGs would qualify for the
alternative payment methodology of 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
specified in existing regulations under Sec. 412.4(f). To identify the
DRGs that might qualify, the average charges for all cases with a
length of stay of 1 day were compared to the average charges of all
cases in a particular DRG. To qualify for the alternative methodology,
the average charges of 1-day discharge cases must be at least 50
percent of the average charges for all cases in the DRG.
Based on this analysis, we determined that 5 out of the 19 DRGs
would qualify for this payment method (DRGs 25, 122, 131, 297, and
321). However, the fact that the average charges of 1-day stays equal
at least 50 percent of the average charges for all cases in these DRGs
is due to the very short lengths of stay for these DRGs. Therefore, we
do not believe that it is necessary to include them in the alternative
payment methodology. For example, for a DRG with a 3-day geometric mean
length of stay, full DRG payment will be met on the second day of the
stay, regardless of which payment methodology is used. Therefore, we
are proposing that none of the 19 additional DRGs that we are proposing
to add to the postacute care transfer policy would be paid under the
alternative payment methodology.
We also have analyzed the 10 DRGs that are currently subject to the
postacute care transfer policy. Of the three DRGs that are receiving
payments under the special payment (transfers after 1 day incur charges
equal to at least 50 percent of the average charges for all cases).
Unlike the five DRGs that would otherwise meet this criterion, the
geometric mean lengths of stay of both DRG 209 and 211 are over 4 days.
In addition, DRG 210 is currently paid under the special payment
methodology, but our current analysis indicates average charges for one
day stays are less than 50 percent of the average charges for all cases
in the DRG. Nonetheless, DRG 210 is a paired with DRG 211, which meets
the criteria. Therefore, we are proposing DRG 210 will continue to be
paid under the special payment methodology. Similar to our rationale
for including both paired DRGs when one qualifies for inclusion in the
postacute care transfer policy, we are including both DRGs in this pair
under the special payment methodology. Accordingly, we are proposing
that only DRGs 209, 210, and 211 that are currently paid under the
alternative transfer payment methodology would continue to be paid
under this methodology.
Finally, we note that the OIG has prepared several reports that
examined hospitals' compliance with proper coding of patients'
discharge status as transferred under our guidelines, and has found
substantial noncompliance leading to excessive payments.\4\
Specifically, the OIG found hospitals submitting claims indicating the
patient had been discharged when, in fact, the patient was transferred
to a postacute care setting. As we indicated in the May 8, 1998 Federal
Register (63 FR 25593), hospitals found to be intentionally engaging in
such practices may be investigated for fraudulent or abusive billing
practices. We intend to work with the OIG to develop the most
appropriate response to ensure all hospitals become compliant with our
guidelines.
---------------------------------------------------------------------------
\4\ The OIG report identification numbers are: A-04-00-02162, A-
04-00-01220 and A-04-01210. A fourth report is expected out soon.
---------------------------------------------------------------------------
B. Rural Referral Centers (Sec. 412.96)
Under the authority of section 1886(d)(5)(C)(i) of the Act, the
regulations at Sec. 412.96 set forth the criteria that a hospital must
meet in order to qualify under the IPPS 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 are 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.
Rural referral centers with a disproportionate share percentage of
at least 30 percent are not subject to the 5.25 percent cap on DSH
payments that is applicable to other rural hospitals (with the
exception of rural hospitals with 500 or more beds). Rural referral
centers are not subject to the proximity criteria when applying for
geographic reclassification, and they do not have to meet the
requirement that a hospital's average hourly wage must exceed 106
percent of the average hourly wage of the labor market area where the
hospital is located.
As discussed in Federal Register documents at 62 FR 45999 and 63 FR
26325, 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. Effective
October 1, 2000, if a hospital located in what is now an urban area was
ever a rural referral center, it is reinstated to rural referral center
status (65 FR 47089). Otherwise, a hospital seeking rural referral
center status must satisfy the applicable criteria.
One of the criteria under which a hospital may qualify as a rural
referral center is to have 275 or more beds available for use (Sec.
412.96(b)(1)(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)).
(See also the September 30, 1988 Federal Register (53 FR 38513).) With
respect to the two mandatory prerequisites, a hospital may be
classified as a rural referral center if--
[sbull] 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
[sbull] 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, as specified in section 1886(d)(5)(C)(i) of the
Act.)
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 2004 includes all urban hospitals nationwide,
and the proposed regional values for FY 2004 are the
[[Page 27201]]
median values of urban hospitals within each census region, excluding
those hospitals with approved teaching programs (that is, those
hospitals receiving indirect medical education payments as provided in
Sec. 412.105). These proposed values are based on discharges occurring
during FY 2002 (October 1, 2001 through September 30, 2002) and include
bills posted to CMS' records through December 2002.
We are proposing that, in addition to meeting other criteria, if
they are to qualify for initial rural referral center status for cost
reporting periods beginning on or after October 1, 2003, rural
hospitals with fewer than 275 beds must have a case-mix index value for
FY 2002 that is at least--
[sbull] 1.3374; or
[sbull] The median case-mix index value (not transfer-adjusted) 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 proposed median case-mix index values by region are set forth
in the following table:
------------------------------------------------------------------------
Case-mix index
Region value
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)................. 1.2252
2. Middle Atlantic (PA, NJ, NY)......................... 1.2270
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV).. 1.3157
4. East North Central (IL, IN, MI, OH, WI).............. 1.2485
5. East South Central (AL, KY, MS, TN).................. 1.2511
6. West North Central (IA, KS, MN, MO, NE, ND, SD)...... 1.1841
7. West South Central (AR, LA, OK, TX).................. 1.2733
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)............ 1.3511
9. Pacific (AK, CA, HI, OR, WA)......................... 1.2834
------------------------------------------------------------------------
The preceding numbers will be revised in the final rule to the
extent required to reflect the updated FY 2002 MedPAR file, which will
contain data from additional bills received through March 31, 2002.
Hospitals seeking to qualify as rural referral centers or those
wishing to know how their case-mix index value compares to the criteria
should obtain hospital-specific case-mix index values (not transfer-
adjusted) 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 2002 (that
is, October 1, 2001 through September 30, 2002).
Therefore, we are proposing that, in addition to meeting other
criteria, a hospital, if it is to qualify for initial rural referral
center status for cost reporting periods beginning on or after October
1, 2003, must have as the number of discharges for its cost reporting
period that began during FY 2002 a figure that is at least--
[sbull] 5,000 (3,000 for an osteopathic hospital); or
[sbull] The median number of discharges for urban hospitals in the
census region in which the hospital is located, as indicated in the
following table:
------------------------------------------------------------------------
Number of
Region discharges
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)................. 7,476
2. Middle Atlantic (PA, NJ, NY)......................... 8,906
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV).. 9,497
4. East North Central (IL, IN, MI, OH, WI).............. 8,439
5. East South Central (AL, KY, MS, TN).................. 6,894
6. West North Central (IA, KS, MN, MO, NE, ND, SD)...... 3,991
7. West South Central (AR, LA, OK, TX).................. 7,629
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)............ 8,908
9. Pacific (AK, CA, HI, OR, WA)......................... 7,021
------------------------------------------------------------------------
These numbers will be revised in the final rule based on the latest
available cost report data.
C. Indirect Medical Education (IME) Adjustment (Sec. 412.105) and
Disproportionate Share Hospital (DSH) Adjustment (Sec. 412.105)
1. Available Beds and Patient Days: Background (Sec. 412.105(b) and
Sec. 412.106(a)(1)(ii))
Section 1886(d)(5)(B) of the Act provides that subsection (d)
hospitals that have residents in approved graduate medical education
(GME) programs receive an additional payment for each discharge of
Medicare beneficiaries to reflect the higher indirect patient care
costs of teaching hospitals relative to nonteaching hospitals. The
existing regulations regarding the calculation of this additional
payment, known as the indirect medical education (IME) adjustment, are
located at Sec. 412.105. The additional payment is based on the IME
adjustment factor, calculated using
[[Page 27202]]
hospitals' ratios of residents to beds. The determination of the number
of beds, based on available bed days, is specified at Sec. 412.105(b).
This determination of the number of available beds is also applicable
for other purposes, including the level of the disproportionate share
hospital (DSH) adjustment payments under Sec. 412.106(a)(l)(i).
Section 1886(d)(5)(F) of the Act specifies two methods for a
hospital to qualify for the Medicare DSH adjustment. The primary
method, which is the subject of a provision in this proposed rule, is
for a hospital to qualify based on a complex statutory formula under
which payment adjustments are based on the level of the DSH patient
percentage. The first computation includes the number of patient days
that are furnished to patients who were entitled to both Medicare Part
A and Supplemental Security Income (SSI) benefits. This number is
divided by the total number of patient days that are associated with
patients entitled to benefits under Medicare Part A. The second
computation includes hospital patient days that are furnished to
patients who, for those days, were eligible for Medicaid but were not
entitled to benefits under Medicare Part A. This number is divided by
the number of total hospital inpatient days in the same period.
Hospitals whose DSH patient percentage exceeds 15 percent are
eligible for a DSH payment adjustment (prior to April 1, 2001, the
qualifying DSH patient percentage varied, in part, by the number of
beds (66 FR 39882)). The DSH payment adjustment may vary based on the
DSH patient percentage and the type of hospital: the statute provides
for different adjustments for urban hospitals with 100 or more beds and
rural hospitals with 500 or more beds, hospitals that qualify as rural
referral centers or SCHs, and other hospitals.
We are combining our discussion of proposed changes to the policies
for counting beds and patient days, in relation to the calculations at
Sec. Sec. 412.105(b) and 412.106(a)(1)(ii) because the underlying
concepts are similar, and we believe they should generally be
interpreted in a consistent manner for both purposes. Specifically, we
are proposing to clarify that beds and patient days that are counted
for these purposes should be limited to beds or patient days in
hospital units or wards that would be directly included in determining
the allowable costs of inpatient hospital care payable under the IPPS
on the Medicare cost reports. As a preliminary matter, beds and patient
days associated with these beds that are located in units or wards that
are excluded from the IPPS (for example, psychiatric or rehabilitation
units), and thus from the determination of allowable costs of inpatient
hospital care under the IPPS on the Medicare cost report, are not to be
counted for purposes of Sec. Sec. 412.105(b) and 412.106(a)(1)(ii).
The remainder of this discussion pertains to beds and patient days
associated with these beds that are located in units or wards that are
not excluded from the IPPS and for which costs are included in
determining the allowable costs of inpatient hospital care under the
IPPS on the Medicare cost report. For example, neonatal intensive care
unit beds are included in the determination of available beds because
the costs and patient days associated with these beds are directly
included in the determination of the allowable costs of inpatient
hospital care under the IPPS. In contrast, beds and patient days
associated with these beds that are located in excluded distinct-part
psychiatric or rehabilitation units would not be counted for purposes
of Sec. Sec. 412.105(b) and 412.106(a)(1)(ii) under any circumstances,
because the costs associated with those units or wards are excluded
from the determination of the costs of allowable inpatient care under
IPPS.
This policy has been upheld in the past by various courts. (See,
for example, Little Co. of Mary Hospital and Health Care Centers v.
Shalala, 165 F.3d 1162 (7th Cir. 1999; Grant Medical Center v. Shalala,
905 F. Supp. 460 (S.D. Ohio 1995); Sioux Valley Hospital v. Shalala,
No. 93-3741SD, 1994 U.S. App. LEXIS 17759 (8th Cir. July 20, 1996)
(unpublished table decision); Amisub v. Shalala, No. 94-1883 (TFH)
(D.D.C. December 4, 1995) (mem.).) In these cases, the courts agreed
with the Secretary's position distinguishing between the treatment of
neonatal intensive care unit beds and well-baby nursery beds based on
the longstanding policy of CMS that neonatal intensive care unit days
are considered intensive care days (part of inpatient routine care)
rather than nursery days.
Our policies on counting beds are applied consistently for both IME
and DSH although the incentives for hospitals can be different for IME
and DSH. For purposes of IME, teaching hospitals have an incentive to
minimize their number of available beds in order to increase the
resident-to-bed ratio and maximize the IME adjustment. On the other
hand, for DSH purposes, urban hospitals with under 100 beds and rural
hospitals with under 500 beds may have an incentive to increase their
bed count in order to qualify for the higher DSH payments for urban
hospitals with over 100 beds (or rural hospitals with over 500 beds).
However, some courts have applied our current rules in a manner
that is inconsistent with our current policy and that would result in
inconsistent treatment of beds, patient days, and costs. For example,
in Clark Regional Medical Center v. United States Department of Health
& Human Services, 314 F.3d 241 (6th Cir. 2002), the court upheld the
district court's ruling that all bed types not specifically excluded
from the definition of available bed days in the regulations must be
included in the count of available bed days. Similarly, in a recent
decision in the Ninth Circuit Court of Appeals Alhambra v. Thompson,
259 F.3d 1071 (Ninth Cir. 2001), the court ruled that days attributable
to groups of beds that are not separately certified as distinct part
beds (that is, nonacute care beds in which care provided is at a level
below the level of routine inpatient acute care) but are adjacent to or
in an acute care ``area'' are included in the ``areas of the hospital
that are subject to the prospective payment system'' and should be
counted in calculating the Medicare DSH patient percentage.
These courts considered subregulatory guidance (program
instructions) in formulating their decisions. Although this proposed
rule would clarify the underlying principles for our bed and patient
days counting policies and would amend the relevant regulations to be
consistent with these clarifications, we recognize the need to revise
some of our program instructions to make them fully consistent with
these clarifications and will act to do so as soon as possible.
While some of the topics discussed below pertain only to counting
available beds (unoccupied beds) and some only to counting patient days
(section 1115 waiver days, dual-eligible days, and Medicare+Choice
days), several important topics are applicable to both bed-counting and
day-counting policies (nonacute care beds and days, observation beds
and days, and swing-beds and days). Therefore, for ease of discussion,
we have combined all topics pertaining to counting available beds and
patient days together in the following discussion.
2. Unoccupied Beds
The current policy for counting hospital beds for IME and DSH is
specified at Sec. 412.105(b). That count is based on total available
bed days during
[[Page 27203]]
the hospital's cost reporting period, divided by the number of days in
the cost reporting period. The regulations specify certain types of
beds to be excluded from this count (for example, beds or bassinets in
the healthy newborn nursery, custodial care beds, and beds in excluded
distinct part hospital units).
Further instructions for counting beds are detailed in section
2405.3, Part I, of the Medicare Provider Reimbursement Manual (PRM).
That section states that a bed must be permanently maintained for
lodging inpatients and it must be available for use and housed in
patient rooms or wards. Thus, beds in a completely or partially closed
wing of the facility are considered available only if the hospital can
put the beds into use when they are needed.
Currently, if a bed can be staffed for inpatient care either by
nurses on staff or from a nurse registry within 24 to 48 hours, the
unoccupied bed is determined available.\5\ In most cases, it is a
straightforward matter to determine whether unoccupied beds can be
staffed within this timeframe because they are located in a unit that
is otherwise staffed and occupied (an unoccupied bed is available for
patient care but it is not occupied by a patient on a particular day).
The determination is not as simple in situations where a room in an
otherwise occupied unit has been altered for other purposes, such as
for a staff lounge or for storage.
---------------------------------------------------------------------------
\5\ This policy was first articulated in correspondence to the
Blue Cross and Blue Shield Association (BCBSA) on November 2, 1988,
and published in BCBSA's Administrative Bulletin 1841,
88.01, on November 18, 1988.
---------------------------------------------------------------------------
Section 2405.3 of the PRM states that beds in unoccupied rooms or
wards are to be excluded from the bed count if the associated costs are
excluded from depreciable plant assets because the area is not
available for patient use. However, issues continue to arise with
regard to how to treat entire units or even entire floors that are
unoccupied over a period of time. For example, in one recent Provider
Reimbursement Review Board (PRRB) decision, the hospital acknowledged
that an entire floor was temporarily unoccupied for approximately 2
years. Rooms on the floor were used for office space, storage and
outpatient services. The PRRB ruled that current rules allowed these
beds to be counted. Specifically, the PRRB found the beds could
reasonably be made ready for inpatient use within 24 to 48 hours, the
rooms were counted on the hospital's cost report as depreciable plant
assets available for patient care, and the hospital could adequately
provide patient care in the beds using staff nurses or nurses from a
nurse registry. Upon review, the Administrator also ultimately upheld
this decision based on existing policies and instructions.
We do not believe that an accurate bed count should include beds
that are essentially hypothetical in nature; for example, when the beds
are on a floor that is not used for inpatient care throughout the
entire cost reporting period (and, indeed, may have been used for other
purposes). Followed to the extreme, a hospital could count every bed in
its facility, even if it had no intention of ever using a bed for
inpatient care, as long as it would be theoretically possible to place
an inpatient in the bed. We do not believe such a result would
accurately reflect a hospital's inpatient bed capacity. Even though
some teaching hospitals have an incentive to minimize the bed count for
payment purposes, some DSH hospitals have an incentive to maximize the
bed count for the same reason. Our current policy is intended to
reflect a hospital's bed count as accurately as possible, achieving a
balance between capturing short-term shifts in occupancy and long-term
changes in capacity. Therefore, we believe further clarification and
refinement of our policies relating to counting available beds is
necessary.
In the FY 2003 IPPS proposed rule published on May 9, 2002 (67 FR
31462), we proposed that, if a hospital's reported bed count results in
an occupancy rate (average daily census of patients divided by the
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. However, at the time the FY 2003 IPPS final rule
was published on August 1, 2002 (67 FR 50060), we decided not to
proceed with the proposed changes as final and to reconsider the issue
as part of a future comprehensive analysis of our bed and patient day
counting policies.
In this proposed rule, rather than establish a minimum standard
occupancy rate, we are proposing to determine whether beds in a unit
are available based upon whether the unit was used to provide patient
care of a level generally payable under the IPPS (``IPPS level of
care'') at any time during the 3 preceding months. If any of the beds
in the unit were used to provide an IPPS level of care at any time
during the preceding 3 months, all of the beds in the unit are counted
for purposes of determining available bed days during the current
month. If no patient care of a type generally payable under the IPPS
was provided in that unit during the 3 preceding months, the beds in
the unit are to be excluded from the determination of available bed
days during the current month (proposed Sec. Sec. 412.105(b)(2) and
412.106(a)(1)(ii)(C)).
For example, our policy as to how to count beds during minor
renovations of units, wards, or individual rooms has been that unless
the space costs are treated as nonallowable, the beds would be counted.
Under the policy we are proposing, beds in an otherwise unoccupied unit
that are occupied (for purposes of providing IPPS-level care) at any
time during the 3 preceding months would be counted as available for
the current month. This would apply even if the rooms were undergoing
renovation during a portion of that 3-month period.
We believe a unit or ward can be defined as a group of rooms
staffed by nurses assigned to a single nursing station. In most cases,
the patients treated within a single unit or ward will receive a
similar level of care (that is, acute, intensive, rehabilitation,
psychiatric, or skilled nursing). However, we encourage comments on the
most useful definition of a unit or ward.
We believe this proposed policy would provide a clear standard for
both hospitals and fiscal intermediaries to use to determine whether
otherwise unoccupied beds should be counted. We note that if the
required time period for excluding the unoccupied beds were to be set
too low, hospitals could potentially manipulate their available bed
count by not admitting any patients to a unit during low occupancy
periods, thereby distorting the measure of hospital size. We believe 3
months, one quarter of a hospital's fiscal year, represents a
reasonable standard for determining that a unit is not being used to
provide patient care and may be excluded from the hospital's available
bed count.
It is also necessary to consider our policy with respect to
individual beds within rooms located in an otherwise occupied unit when
those beds are used for alternative purposes. For example, section
2405.3 of the PRM states that beds used for the following are excluded
from the definition (of a bed): Postanesthesia or postoperative
recovery rooms, outpatient areas, emergency rooms, ancillary
departments nurses' and other staff residences, and other such areas as
are regularly maintained and utilized for only a portion of the stay of
patients or for purposes other than inpatient lodging. In some
situations, beds used for these excluded
[[Page 27204]]
purposes may be intermingled with acute care inpatient beds.
Beds being used to provide specific categories of nonacute
services, such as outpatient services in an observation bed or skilled
nursing services in a swing-bed, are excluded from the count. As
discussed later, this flows from our policy that the bed days are
treated consistently with the assignment of the costs on the Medicare
cost report of the services provided in the bed.
In the case of individual rooms in an otherwise occupied unit that
are altered to be used for other uses besides inpatient care, we are
proposing the bed(s) should be counted if a patient could be admitted
to the room within 24 hours (proposed Sec. 412.105(b)(3)). This would
apply even if the bed(s) were not currently located in the room, as
long as a bed could be physically placed in the room and made available
within 24 hours. We are proposing that it would no longer be necessary
for the hospital to determine whether a bed could be staffed within 24
to 48 hours. For example, in the case of a room that has been altered
for use as a staff lounge, if the room could be made available to house
a patient merely by replacing the lounge furniture with a patient bed,
the bed should be counted as available.
Under this proposal, other than when an inpatient room is used to
provide observation services, labor/delivery room services, or skilled
nursing services in a swing-bed (all discussed later in this proposed
rule), the alternative purpose of the room is only relevant if it
impacts whether the room could be made available for patient occupancy
within 24 hours. If the hospital was fully occupied (no other room was
available), and the room still was not put into service when needed,
that would provide evidence that the room could not be made available
and beds in the room should be excluded from the bed count.
Therefore, we are proposing to amend Sec. 412.105(b) to indicate
that the bed days in a unit that is unoccupied by patients receiving
IPPS-level care for the 3 preceding months are to be excluded from the
available bed day count for the current month. We are further proposing
the beds in a unit that was occupied for IPPS-level care during the 3
preceding months should be counted unless they could not be made
available for patient occupancy within 24 hours, or they are used to
provide outpatient observation services or swing-bed skilled nursing
care.
3. Nonacute Care Beds and Days
As noted above, these policies are consistent with the reporting of
the days, costs, and beds that are used to calculate the costs of
hospital inpatient care in individual cost centers on the Medicare cost
report. Furthermore, since the IME and DSH adjustments are part of the
IPPS, we read the statute to apply only to inpatient beds and days.
Under the existing provisions of Sec. 412.105(b), the regulations
specifically exclude beds or bassinets in the healthy newborn nursery,
custodial care beds, or beds in excluded distinct part hospital units
as types of beds excluded from the count of available beds.
Existing regulations at Sec. 412.106(a)(1)(ii) state that the
number of patient days used in the DSH percentage calculation includes
only those days attributable to areas of the hospital that are subject
to the IPPS and excludes all others. This regulation was added after
being proposed in the March 22, 1988 Federal Register (53 FR 9339), and
made final in the September 30, 1988 Federal Register (53 FR 38479). At
that time, we indicated that, ``based on a reading of the language in
section 1886(d)(5)(F) of the Act, which implements the disproportionate
share provision, we are in fact required to consider only those
inpatient days to which the prospective payment system applies in
determining a prospective payment hospital's eligibility for a
disproportionate share adjustment.'' Using this reasoning, we stated
that the DSH patient percentage calculation should only include patient
days associated with the types of services paid under the IPPS.
As noted previously, a recent decision in the Ninth Circuit Court
of Appeals (Alhambra v. Thompson) ruled that days attributable to
groups of beds that are not separately certified as distinct part beds
(that is, nonacute care beds in which care provided is at a level below
the level of routine inpatient acute care), but are adjacent to or in
an acute care ``area,'' are included in the ``areas of the hospital
that are subject to the prospective payment system'' and should be
counted in calculating the Medicare DSH patient percentage.
In light of the Ninth Circuit decision that our rules were not
sufficiently clear to permit exclusion of bed days based on the area
where the care is provided, we are proposing to revise our regulations
to be more specific. Therefore, in this proposed rule, we are proposing
to clarify that beds and patient days are excluded from the
calculations at Sec. 412.105(b) and Sec. 412.106(a)(1)(ii) if the
nature of the care provided in the unit or ward is inconsistent with
what is typically furnished to acute care patients, regardless of
whether these units or wards are separately certified or are located in
the same general area of the hospital as a unit or ward used to provide
an acute level of care. Although the intensity of care may vary within
a particular unit, such that some patients may be acute patients while
others are nonacute, we understand that a patient-by-patient review of
whether the care received would be paid under the IPPS would be unduly
burdensome. Therefore, we believe it is more practical to permit the
application of this principle based upon the location at which the
services were furnished.
In particular, we are proposing to revise our regulations to
clarify that the beds and patient days attributable to a nonacute care
unit or ward should not be included in the calculations at Sec.
412.105(b) and Sec. 412.106(a)(1)(ii), even if the unit is not
separately certified by Medicare as a distinct-part unit and even if
the unit or ward is within the same general location of the hospital as
areas that are subject to the IPPS.
Exceptions to this policy are outpatient observation and swing-bed
days, which are excluded from the count of available bed days even if
the care is provided in an acute care unit. Our policies pertaining to
these beds are discussed further below. Another exception is healthy
newborn nursery days. The costs, days, and beds of a healthy newborn
nursery are excluded from inpatient calculations for Medicare purposes.
Meanwhile, for the purpose of computing the Medicaid patient share
computation of the DSH patient percentages, these days are included
both as Medicaid patient days and as total patient days. Nursery costs
are not directly included in calculating Medicare hospital inpatient
care costs because Medicare does not generally cover services for
infants. However, Medicaid does offer extensive coverage to infants,
and nursery costs would be directly included in calculating Medicaid
hospital inpatient care costs. Therefore, these costs, days, and beds
are excluded for Medicare purposes, but included for determining the
Medicaid DSH percentage. (This policy was previously communicated
through a memorandum to CMS Regional Offices on February 27, 1997.)
Generally, as discussed previously, if the nature of the care
provided in the unit or ward is consistent with what is typically
furnished to acute care patients, and, therefore, would be
characteristic of services paid under the IPPS, the patient days, beds,
and costs of that unit or ward would be classified as inpatient acute
care (except for observation bed days and swing bed days, as discussed
later in this
[[Page 27205]]
preamble). Conversely, if the intensity and type of care provided in
the unit or ward are not typical of a service that would be paid under
the IPPS (for example, nonacute care), we are proposing that the beds
and patient days attributable to a nonacute care unit or ward should
not be included in the calculations of beds and patient days at Sec.
412.105(b) and Sec. 412.106(a)(1)(ii).
This proposed policy is not intended to focus on the level or type
of care provided to individual patients in a unit, but rather on the
level and type of care provided in the unit as a whole. For example,
the bed days for a patient participating in an experimental procedure
that is not covered under the IPPS should be counted as long as the
patient is treated in a unit of the hospital that generally provides
acute inpatient care normally payable under the IPPS. The expectation
is that a patient located in an acute care unit or ward of the hospital
is receiving a level of care that is consistent with what would be
payable under the IPPS.
There are instances where services that are provided in units
excluded from the IPPS (such as rehabilitation and psychiatric
distinct-part units) are consistent with the level of care that would
qualify for payment under the IPPS. However, Sec. Sec. 412.105(b) and
412.106(a)(1)(ii) specifically exclude the beds and patient days
associated with these excluded units. That exclusion is because the
costs of care provided in these units are paid outside the IPPS, even
though some of the care provided is of a type that would be payable
under the IPPS if the care was provided in an IPPS unit.
We are proposing to revise Sec. 412.105(b) to clarify that beds in
units or wards established or used to provide a level of care that is
not consistent with what would be payable under the IPPS cannot be
counted (proposed paragraph (b)(1)). We also are proposing to revise
the DSH regulations at Sec. 412.106(a)(1)(ii) to clarify that the
number of patient days includes only those attributable to patients
that receive care in units or wards that furnish a level of care that
would generally be payable under the IPPS (proposed paragraph
(a)(1)(ii)(C)).
We note these proposed revisions are clarifications of our
regulations to reflect our longstanding interpretation of the statutory
intent, especially relating to the calculation of the Medicare DSH
patient percentage.
4. Observation Beds and Swing-Beds
Observation services are those services furnished by a hospital on
the hospital's premises that include use of a bed and periodic
monitoring by a hospital's nursing or other staff in order to evaluate
an outpatient's condition or to determine the need for a possible
admission to the hospital as an inpatient. When a hospital places a
patient under observation but has not formally admitted him or her as
an inpatient, the patient initially is treated as an outpatient.
Consequently, the observation bed days are not recognized under the
IPPS as part of the inpatient operating costs of the hospital.
Observation services may be provided in a distinct observation bed
area, but they may also be provided in a routine inpatient care area.
In either case, our policy is the bed days attributable to beds used
for observation services are excluded from the counts of available bed
days and patient days at Sec. Sec. 412.105(b) and 412.106(a)(1)(ii).
This policy was clarified in a memorandum that was sent to all CMS
Regional Offices (for distribution to fiscal intermediaries) dated
February 27, 1997, which stated that if a hospital provides observation
services in beds that are generally used to provide hospital inpatient
services, the equivalent days that those beds are used for observation
services should be excluded from the count of available bed day count
(even if the patient is ultimately admitted as an acute inpatient).
A swing-bed is a bed otherwise available for use to provide acute
inpatient care that is also occasionally used to provide SNF care. The
criteria to qualify as a swing-bed hospital are located under Sec.
482.66, and for a swing-bed CAH under Sec. 485.645. Under Sec.
413.114(a)(1), payment for posthospital SNF care furnished in swing-
beds is in accordance with the provisions of the prospective payment
system for SNF care (effective for services furnished in cost reporting
periods beginning on and after July 1, 2002). Similar to observation
beds and patient days, swing-beds and patient days are excluded from
the counts of available bed days and patient days at Sec. Sec.
412.105(b) and 412.106(a)(1)(ii) when the swing-bed is used to furnish
SNF care.\6\
---------------------------------------------------------------------------
\6\ Ibid.
---------------------------------------------------------------------------
Observation beds and swing-beds are both special, frequently
temporary, alternative uses of acute inpatient care beds. That is, only
the days an acute inpatient care unit bed is used to provide outpatient
observation services are to be deducted from the available bed count
under Sec. 412.105(b). Otherwise, the bed is considered available for
acute care services (as long as it otherwise meets the criteria to be
considered available). This same policy applies for swing-beds. The
policies to exclude observation bed days and swing-bed days stem from
the fact that these bed days are not payable under the IPPS (unless the
patient is ultimately admitted, in the case of observation bed days).
Some hospitals have contested our policy excluding swing-beds and
patient days and observation beds and patient days under existing
Sec. Sec. 412.105(b) and 412.106(a)(1)(ii). For example, in Clark
Regional Medical Center v. United States Department of Health & Human
Services, 314 F.3d 241 (6th Cir. 2002), the court upheld the district
court's ruling that all bed types not specifically excluded from the
definition of available bed days in the regulations must be included in
the count of available bed days. The hospitals involved in this
decision wanted to include observation and swing-bed days in their bed
count calculation in order to qualify for higher DSH payments as 100
bed hospitals. The Court found that ``the listing of beds to be
excluded from the count restricts the class of excluded beds only to
those specifically listed.'' Because observation beds and swing-beds
are not currently specifically mentioned in Sec. 412.105(b) as being
excluded from the bed count, the Court ruled that these beds must be
included in the count.
The list of the types of beds excluded from the count under
existing Sec. 412.105(b) was never intended to be an exhaustive list
of all of the types of beds to be excluded from the bed count under
this provision. In fact, over the years, specific bed types have been
added to the list as clarifications of the types of beds to be
excluded, not as new exclusions (see the September 1, 1994 Federal
Register (59 FR 45373) and September 1, 1995 Federal Register (60 FR
45810), where we clarified exclusions under our policy that were not
previously separately identified in the regulation text).
Courts also have recently found that observation and swing-bed days
are included under the `plain meaning' of Sec. 412.106(a)(1)(ii),
which reads: ``The number of patient days includes only those days
attributable to areas of the hospital that are subject to the
prospective payment system and excludes all others.'' However, the
preamble language when this provision was promulgated clarified its
meaning (53 FR 38480):
[sbull] ``Although previously the Medicare regulations did not
specifically define the inpatient days for use in the computation of a
hospital's disproportionate share patient percentage, we believe that,
based on a
[[Page 27206]]
reading of the language in section 1886(d)(5)(F) of the Act, which
implements the disproportionate share provision, we are in fact
required to consider only those inpatient days to which the prospective
payment system applies in determining a prospective payment hospital's
eligibility for a disproportionate share adjustment.''
Our policy excluding outpatient observation and swing-bed days is
consistent with this regulatory interpretation of days to be counted
under Sec. 412.106(a)(1)(ii). That is, the services provided in these
beds are not payable under the IPPS (unless the patient is admitted, in
the case of observation bed days).
As outlined previously, our consistent and longstanding policy,
which has been reviewed and upheld previously by several courts,
including the United States District Court for the District of
Columbia, is based on the principle of counting beds in the same manner
as the patient days and costs are treated. Our policy to exclude
observation and swing-bed days under the regulations at Sec.
412.105(b) and Sec. 412.106(a)(1)(ii) stems from this policy.
However, we are proposing to amend our policy with respect to
observation bed days of patients who ultimately are admitted. As noted
previously, our current policy is that these bed days are excluded from
the available bed day and the patient day counts. This policy was
communicated in a memorandum to all CMS Regional Offices on February
27, 1997. Specifically, we are proposing that, if a patient is admitted
as an acute inpatient subsequent to receiving outpatient observation
services, because the charges of the observation ancillary services the
patient receives are currently treated as inpatient charges on the cost
report, in order to be consistent with our policy to treat the costs
and patient days consistently, we will begin to include the patient bed
days associated with the observation services in the inpatient bed day
count.
In order to avoid any potential future misunderstandings about our
policies regarding the exclusion of observation and swing-bed days
under the regulations at Sec. 412.105(b) and Sec. 412.106(a)(1)(ii),
we are proposing to revise our regulations to specify our policy that
observation and swing-bed bed days are to be excluded from the counts
of both available beds and patient days, unless a patient treated in an
observation bed is ultimately admitted, in which case the beds and days
would be included in those counts.
5. Labor, Delivery, Recovery, and Postpartum Beds and Days
Prior to December 1991, Medicare's policy on counting days for
maternity patients required an inpatient day to be counted for an
admitted maternity patient in the labor/delivery room at the census
taking hour. This is consistent with Medicare policy for counting days
for admitted patients in any other ancillary department at the census-
taking hour. However, based on decisions adverse to the government
regarding this policy in a number of Federal courts of appeal,
including the United States Court of Appeals for the District of
Columbia Circuit, the policy regarding the counting of inpatient days
for maternity patients was revised.
Therefore, our current policy regarding the treatment of labor and
delivery bed days was initially described in Section 2205.2 of the PRM.
Section 2205.2. of the PRM states that a maternity inpatient in the
labor/delivery room at midnight is not included in the census of
inpatient routine care if the patient has not occupied an inpatient
routine bed at some time since admission. For example, if a Medicaid
patient is in the labor room at the census and has not yet occupied a
routine bed, the bed day is not counted as a routine bed day of care in
Medicaid or total days and, therefore, is not included in the counts
under existing Sec. Sec. 412.105(b) and 412.106(a)(1)(ii). If the
patient is in the labor room at the census but had first occupied a
routine bed, a routine bed day is counted, in Medicaid and total days,
for DSH purposes and for apportioning the cost of routine care on the
cost report (consistent with our longstanding policy to treat days,
costs, and beds similarly).
Increasingly, hospitals are redesigning their maternity areas from
separate labor and delivery rooms apart from the postpartum rooms, to
single labor, delivery room, and postpartum (LDRP) rooms. In order to
appropriately track the days and costs of LDRP rooms, it is necessary
to apportion them between the labor and delivery ancillary cost center
and the routine adults and pediatrics cost center. This is done by
determining the proportion of the patient's stay in the LDRP room that
the patient was receiving ancillary services (labor and delivery) as
opposed to routine adult and pediatric services (recovery and
postpartum).
An example of this would be if 25 percent of the patient's time in
the LDRP room was for labor/delivery services and 75 percent for
routine care, over the course of a 4-day stay in the LDRP room. In that
case, 75 percent of the time the patient spent in the LDRP room is
applied to the total bed days and costs (resulting in 3 routine adults
and pediatrics bed days for this patient, 75 percent of 4 total days).
The resulting days (or portion of days) are included in total days and
in Medicaid days for all purposes. For purposes of determining hospital
bed count, the time when the beds are unoccupied should be counted as
available bed days using an average percentage (for example, 75 percent
adults and pediatrics and 25 percent ancillary) based on all patients.
In other words, 75 percent of the days the bed is unoccupied would be
counted in the available bed count.
We realize that it may be burdensome for a hospital to determine
for each patient in this type of room the amount of time spent in
labor/delivery and the amount of time spent receiving routine care.
Alternatively, the hospital could calculate an average percentage of
time patients receive ancillary services, as opposed to routine
inpatient care during a typical month, to apply the rest of the year.
6. Days Associated with Demonstration Projects Under Section 1115 of
the Act
Some States extend medical benefits to a given population that
could not have been made eligible for Medicaid under a State plan
amendment under section 1902(r)(2) or section 1931(b) of the Act, under
a demonstration under a section 1115(a)(2) demonstration project (also
referred to as a section 1115 waiver). These populations are specific,
finite populations identifiable in the award letters and special terms
and conditions for the demonstrations.
On January 20, 2000, we issued an interim final rule with comment
period (65 FR 3136), followed by a final rule issued on August 1, 2000
(65 FR 47086 through 47087), to allow hospitals to include the patient
days of all populations that receive benefits under a section 1115
demonstration project in calculating the Medicare DSH adjustment.
Previously, hospitals were to include only those days for populations
under the section 1115 demonstration project who were, or could have
been made, eligible under a State plan. Patient days of those expansion
waiver groups who could not be made eligible for medical assistance
under the State plan were not to be included for determining Medicaid
patient days in calculating the Medicare DSH patient percentage. Under
the January 20, 2000 interim final rule with comment period (65 FR
3137), hospitals could include in the numerator of the Medicaid
fraction those patient days for individuals who receive benefits under
[[Page 27207]]
a section 1115 expansion waiver demonstration project (effective with
discharges occurring on or after January 20, 2000).
In the January 20, 2000 interim final rule with comment period, we
explained that including the section 1115 expansion populations ``in
the Medicare DSH calculation is fully consistent with the Congressional
goals of the Medicare DSH adjustment to recognize the higher costs to
hospitals of treating low-income individuals covered under Medicaid.''
Since that revision, we have become aware that there are certain
section 1115 demonstration projects that serve expansion populations
with benefit packages so limited that the benefits are not similar to
the medical assistance available under a Medicaid State plan. These
section 1115 demonstration projects extend coverage only for specific
services and do not include inpatient care in the hospital. Because of
the limited nature of the coverage offered, the population involved may
have a significantly higher income than traditional Medicaid
beneficiaries.
In allowing hospitals to include patient days related to section
1115 expansion waiver populations, our intention was to include patient
days of section 1115 expansion waiver populations who receive benefits
under the demonstration project that are similar to those available to
traditional Medicaid beneficiaries, including inpatient benefits.
Because of the differences between expansion populations in these
limited benefit demonstrations and traditional Medicaid beneficiaries,
we are proposing that the Medicare DSH calculation should exclude from
treatment as Medicaid patient days those patient days attributable to
limited benefit section 1115 expansion waiver populations (proposed
Sec. 412.106(b)(4)(i)).
For example, a State may extend a family planning benefit to an
individual for 2 years after she has received the 60-day postpartum
benefit under Medicaid, or a State may choose to provide a family
planning benefit to all individuals below a certain income level,
regardless of having previously received the Medicaid postpartum
benefit. This is a limited, temporary benefit that is generally
administered in a clinic setting (see section 1905(a)(4)(C) of the
Act). Also, a number of States are developing demonstrations that are
limited to providing beneficiaries an outpatient prescription drug
benefit. Generally, these limited benefits under a demonstration
project do not include inpatient benefits. If a hospital were to
include the days attributable to patients receiving benefits under such
a limited benefit, the hospital would be able to receive higher DSH
payments, perhaps substantially, for patients who may otherwise be
insured for inpatient care. For example, these limited demonstrations
provide benefits that may be needed to supplement private insurance
coverage for individuals who do not have incomes low enough to qualify
for Medicaid under the State plan. We do not believe such patients
should be counted in the DSH patient percentage as eligible for title
XIX.
As we have noted previously, at the time the Congress enacted the
Medicare DSH adjustment provision, there were no approved section 1115
demonstration projects involving expansion populations and the statute
does not address the treatment of these days. Although we did not
initially include patient days for individuals who receive extended
benefits only under a section 1115 demonstration project, we
nevertheless expanded our policy in the January 20, 2000 revision to
these rules to include such patient days. We now believe that this
reading is warranted only to the extent that those individuals receive
inpatient benefits under the section 1115 demonstration project.
Therefore, we are proposing to revise Sec. 412.106(b)(4)(i) to
clarify that patients must be eligible for medical assistance inpatient
hospital benefits under an approved State Medicaid plan (or similar
benefits, including inpatient hospital benefits, under a section 1115
demonstration project) in order for their hospital inpatient days to be
counted as Medicaid days in the calculation of a hospital's DSH patient
percentage. Under this proposed clarification, hospital inpatient days
attributed to patients who do not receive coverage for inpatient
hospital benefits either under the approved State plan or through a
section 1115 demonstration would not be counted in the calculation of
Medicaid days for purposes of determining a hospital's DSH patient
percentage.
Under this reading, in the examples given above, the days
associated with a hospital inpatient who receives coverage of
prescription drugs or family planning services on an outpatient basis,
but no inpatient hospital coverage, through either a Medicaid State
plan or a section 1115 demonstration, would not be counted as Medicaid
days for purposes of determining the DSH patient percentage.
This proposed revision would address an unintended potential
consequence of our interpretation that hospitals may include in the DSH
calculation patient days associated with section 1115 demonstration
populations (65 FR 3136). As discussed above, that interpretation was
based on our finding that individuals receiving a comprehensive benefit
package under a section 1115 demonstration project could appropriately
be included in the numerator of the Medicaid fraction even though the
statute does not require such an inclusion, but did not address
individuals who were receiving limited benefit packages under a section
1115 demonstration project.
7. Dual-Eligible Patient Days
As described above, the DSH patient percentage is equal to the sum
of the percentage of Medicare inpatient days attributable to patients
entitled to both Medicare Part A and SSI benefits, and the percentage
of total inpatient days attributable to patients eligible for Medicaid
but not entitled to Medicare Part A benefits. If a patient is a
Medicare beneficiary who is also eligible for Medicaid, the patient is
considered dual-eligible and the patient days are included in the
Medicare fraction of the DSH patient percentage but not the Medicaid
fraction. This is consistent with the language of section
1886(d)(5)(F)(vi)(II) of the Act, which specifies that patients
entitled to benefits under Part A are excluded from the Medicaid
fraction.
This policy currently applies even after the patient's Medicare
coverage is exhausted. In other words, if a dual-eligible patient is
admitted without any Medicare Part A coverage remaining, or the patient
exhausts Medicare Part A coverage while an inpatient, his or her
patient days are counted in the Medicare fraction before and after
Medicare coverage is exhausted. This is consistent with our inclusion
of Medicaid patient days even after the patient's Medicaid coverage is
exhausted.
We are proposing to change our policy, to begin to count in the
Medicaid fraction of the DSH patient percentage the patient days of
dual-eligible Medicare beneficiaries whose Medicare coverage has
expired. We note the statute referenced above stipulates that patient
days attributable to patients entitled to benefits under Medicare Part
A are to be excluded from the Medicaid fraction, while the statute
specifies the Medicaid fraction is to include patients who are eligible
for Medicaid.
As noted above, our current policy regarding dual-eligible patient
days is that they are counted in the Medicare fraction and excluded
from the
[[Page 27208]]
Medicaid fraction, even if the patient's Medicare Part A coverage has
been exhausted. We believe this interpretation is consistent with the
statutory intent of section 1886(d)(5)(F)(vi)(II) of the Act. However,
we recognize there are other plausible interpretations. In addition, on
a more practical level, we recognize it is often difficult for fiscal
intermediaries to differentiate the days for dual-eligible patients
whose Part A coverage has been exhausted. The degree of difficulty
depends on the data provided by the States, which may vary from one
State to the next. Some States identify all dual-eligible beneficiaries
in their lists of Medicaid patient days provided to the hospitals,
while in other States the fiscal intermediary must identify patient
days attributable to dual-eligible beneficiaries by matching Medicare
Part A bills with the list of Medicaid patients provided by the State.
The latter case is problematic when Medicare Part A coverage is
exhausted because no Medicare Part A bill may be submitted for these
patients. Thus, the fiscal intermediary has no data by which to readily
verify any adjustment for these cases in the Medicaid data provided by
the hospital. Currently, the fiscal intermediaries are reliant on the
hospitals to identify the days attributable to dual-eligible
beneficiaries so these days can be excluded from the Medicaid patient
days count.
Therefore, in order to facilitate consistent handling of these days
across all hospitals, we are proposing that the days of patients who
have exhausted their Medicare Part A coverage will no longer be
included in the Medicare fraction. Instead, we are proposing these days
should be included in the Medicaid fraction of the DSH calculation. (We
note that not all SSI recipients are Medicaid eligible. Therefore, it
will not be automatic that the patient days of SSI recipients will be
counted in the Medicaid fraction when their Part a coverage expires.)
Under this proposed change, before a hospital could count patient
days attributable to dual-eligible beneficiaries in the Medicaid
fraction, the hospital must submit documentation to the fiscal
intermediary that justifies including the days in the Medicaid fraction
after the Medicare Part A benefits have been exhausted. That is, if the
State provides data on all the days associated with all dual-eligible
patients treated at a hospital, regardless of whether the beneficiary
had Medicare Part A coverage, the hospital is responsible for providing
documentation showing which days should be included in the Medicaid
fraction because Medicare Part A coverage was exhausted.
8. Medicare+Choice (M+C) Days
Under Sec. 422.1, an M+C plan ``means health benefits coverage
offered under a policy or contract by an M+C organization that includes
a specific set of health benefits offered at a uniform premium and
uniform level of cost-sharing to all Medicare beneficiaries residing in
the service area of the M+C plan.'' Generally, each M+C plan must
provide coverage of all services that are covered by Medicare Part A
and Part B (or just Part B if the M+C plan enrollee is only entitled to
Part B).
We have received questions whether patients enrolled in an M+C Plan
should be counted in the Medicare fraction or the Medicaid fraction of
the DSH patient percentage calculation. The question stems from whether
M+C plan enrollees are entitled to benefits under Medicare Part A since
M+C plans are administered through Medicare Part C.
We note that, under Sec. 422.50, an individual is eligible to
elect an M+C plan if he or she is entitled to Medicare Part A and
enrolled in Part B. However, once a beneficiary has elected to join an
M+C plan, that beneficiary's benefits are no longer administered under
Part A.
Therefore, we are proposing to clarify that once a beneficiary
elects Medicare Part C, those patient days attributable to the
beneficiary should not be included in the Medicare fraction of the DSH
patient percentage. These patient days should be included in the count
of total patient days in the Medicaid fraction (the denominator), and
the patient's days for the M+C beneficiary who is also eligible for
Medicaid would be included in the numerator of the Medicaid fraction.
D. Medicare Geographic Classification Review Board (MGCRB)
Reclassification Process (Sec. 412.230)
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 (Sec. Sec. 412.230 et seq.) set
forth criteria and conditions for redesignations for purposes of the
wage index or the average standardized amount, or both, 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.
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 years of hourly wage data from the most recently
published data for the hospital when evaluating a hospital's request
for reclassification. The regulations at Sec. 412.230(e)(2)(ii)
stipulate that the wage data are taken from the CMS hospital wage
survey used to construct the wage index in effect for prospective
payment purposes. To evaluate applications for wage index
reclassifications for FY 2004, the MGCRB used the 3-year average hourly
wages published in Table 2 of the August 1, 2002 IPPS final rule (67 FR
50135). These average hourly wages are taken from data used to
calculate the wage indexes for FY 2001, FY 2002, and FY 2003, based on
cost reporting periods beginning during FY 1997, FY 1998, and FY 1999,
respectively.
Last year, we received a comment suggesting that we allow for the
correction of inaccurate data from prior years as part of a hospital's
bid for geographic reclassification (67 FR 50027). The commenter
suggested that not to allow corrections to the data results in
inequities in the calculation in the average hourly wage for purposes
of reclassification. In the August 1, 2002 IPPS final rule, we
responded:
``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
[[Page 27209]]
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.''
Since responding to this comment in the FY 2003 IPPS final rule, we
have become aware of a situation in which a hospital does not meet the
criteria to reclassify because its wage data were erroneous in prior
years, and these data are now being used to evaluate its
reclassification application. In addition, in this situation, the
hospital's wage index was subject to the rural floor because the
hospital was located in an urban area with an actual wage index below
the statewide rural wage index for the State, and it was for a time
period preceding the requirement for using 3 years of data. Therefore,
the hospital contends, it had no incentive to ensure its wage data were
completely accurate. (However, we would point out that hospitals are
required to certify that their cost reports submitted to CMS are
complete and accurate. Furthermore, inaccurate or incomplete reporting
may have other payment implications beyond the wage index.)
While we continue to have all of the concerns we expressed in last
year's final rule, we now more fully understand this particular
hospital's situation. Although we do have administrative authority to
establish a policy allowing corrections for this particular set of
circumstances, we are concerned about establishing a precedent that
could reduce the importance of ensuring that the final wage data
published in the annual IPPS final rule are complete and accurate. As
we indicated in our response last year, we are concerned this could
lead to less accuracy and stability in the wage indexes from year to
year.
However, we are soliciting comments on whether it may be
appropriate to establish a policy whereby, for the limited purpose of
qualifying for reclassification based on data from years preceding the
establishment of the 3-year requirement (that is, cost reporting years
beginning before FY 2000), a hospital in an urban area that was subject
to the rural floor for the period during which the wage data the
hospital wishes to revise were used to calculate the wage index, a
hospital may request that its wage data be revised.
E. Costs of Approved Nursing and Allied Health Education Activities
(Sec. 413.85)
1. Background
Medicare has historically paid providers for the share of the costs
that providers incur in connection with approved educational
activities. The activities may be divided into the following three
general categories to which different payment policies apply:
[sbull] Approved graduate medical education (GME) programs in
medicine, osteopathy, dentistry, and podiatry. Medicare makes direct
and indirect medical education payments to hospitals for residents
training in these programs. Existing policy on direct GME payment is
found at 42 CFR 413.86, and for indirect GME payment at 42 CFR 412.105.
[sbull] Approved nursing and allied health education programs
operated by the provider. The costs of these programs are excluded from
the definition of inpatient hospital operating costs and are not
included in the calculation of payment rates for hospitals paid under
the IPPS or in the calculation of payments to hospitals and hospital
units excluded from the IPPS that are subject to the rate-of-increase
ceiling. These costs are separately identified and ``passed through''
(that is, paid separately on a reasonable cost basis). Existing
regulations on nursing and allied health education program costs are
located at 42 CFR 413.85.
[sbull] All other costs that can be categorized as educational
programs and activities are considered to be part of normal operating
costs and are included in the per discharge amount for hospitals
subject to the IPPS, or are included as reasonable costs that are
subject to the rate-of-increase limits for hospitals and hospital units
excluded from the IPPS.
In this section, we are proposing to clarify our policy governing
payments to hospitals for provider-operated nursing and allied health
education programs. Under the regulations at Sec. 413.85 (``Cost of
approved nursing and allied health educational activities''), Medicare
makes reasonable cost payment to hospitals for provider-operated
nursing and allied health education programs. A program is considered
to be provider-operated if the hospital meets the criteria specified in
Sec. 413.85(f), which means the hospital directly incurs the training
costs, controls the curriculum and the administration of the program,
employs the teaching staff, and provides and controls both clinical
training and classroom instruction (where applicable) of a nursing or
allied health education program.
In the January 12, 2001 Federal Register (66 FR 3358), we published
a final rule that clarified the policy for payments for approved
nursing and allied health education activities in response to section
6205(b)(2) of the Omnibus Budget Reconciliation Act of 1989 (Pub. L.
101-239) and sections 4004(b)(1) and (2) of the Omnibus Budget
Reconciliation Act of 1990 (Pub. L. 101-508).
Section 6205(b)(2) of Public Law 101-239 directed the Secretary to
publish regulations clarifying the rules governing allowable costs of
approved educational activities. The Secretary was directed to publish
regulations to specify the conditions under which those costs are
eligible for pass-through, including the requirement that there be a
relationship between the approved nursing or allied health education
program and the hospital. Section 4004(b)(1) of Public Law 101-508
provides an exception to the requirement that programs be provider-
operated to receive pass-through payments. The section provides that,
effective for cost reporting periods beginning on or after October 1,
1990, if certain conditions are met, the costs incurred by a hospital
(or by an educational institution related to the hospital by common
ownership or control) for clinical training (as defined by the
Secretary) conducted on the premises of the hospital under an approved
nursing or allied health education program that is not operated by the
hospital are treated as pass-through costs and paid on the basis of
reasonable cost. Section 4004(b)(2) of Public Law 101-508 sets forth
the conditions that a hospital must meet to receive payment on a
reasonable cost basis under section 4004(b)(1).
2. Continuing Education Issue for Nursing and Allied Health Education
Since publication of the January 12, 2001 final rule on nursing and
allied health education, we have encountered questions concerning the
substantive difference between provider-operated continuing education
programs for nursing and allied health education (which would not be
reimbursable under Medicare on a reasonable cost basis) and provider-
operated approved programs that are eligible to receive Medicare
reasonable cost payment. In that final rule, we stated that Medicare
would generally provide reasonable cost payment for ``programs of long
duration designed to develop trained practitioners in a nursing or
allied health discipline, such as professional nursing or occupational
therapy. This is contrasted with a continuing education program of a
month to a year in duration in which a practitioner, such as a
registered nurse, receives training in a specialized skill such as
enterostomal therapy. While such training is undoubtedly valuable in
enabling the nurse to treat patients with special needs and in
improving the level of
[[Page 27210]]
patient care in a provider, the nurse, upon completion of the program,
continues to function as a registered nurse, albeit one with special
skills. Further distinction can be drawn between this situation and one
in which a registered nurse undergoes years of training to become a
CRNA. For these reasons, the costs of continuing education training
programs are not classified as costs of approved educational activities
that are passed-through and paid on a reasonable cost basis. Rather,
they are classified as normal operating costs covered by the
prospective payment rate or, for providers excluded from the IPPS, as
costs subject to the target rate-of-increase limits'' (66 FR 3370).
Accordingly, upon publication of the final rule, we revised Sec.
413.85(h)(3) to include continuing education programs in the same
category as ``educational seminars and workshops that increase the
quality of medical care or operating efficiency of the provider.''
Costs associated with continuing education programs, as stated above,
are recognized as normal operating costs and are paid in accordance
with applicable principles.
We received an inquiry requesting further clarification on what is
meant by continuing education. It is our belief that provider-operated
programs that do not lead to any specific certification in a specialty
would be classified as continuing education. By certification, we do
not mean certification in a specific skill, such as when an individual
is certified to use a specific piece of machinery or perform a specific
procedure. Rather, we believe certification would mean the ability to
perform in the specialty as a whole.
Although, in the past, we believe we have allowed hospitals to be
paid for operating a pharmacy ``residency'' program, it has come to our
attention that those programs do not meet the criteria for approval as
a certified program. Once individuals have finished their undergraduate
degree in pharmacy, there are some individuals who go on to participate
in 1-year hospital-operated postundergraduate programs. It is our
understanding that many individuals complete the 1-year
postundergraduate program practice pharmacy inside the hospital
setting. However, we also understand that there are pharmacists who do
not complete the 1-year postundergraduate program, but have received
the undergraduate degree in pharmacy, who also practice pharmacy inside
the hospital setting. Because pharmacy students need not complete the
1-year residency program to be eligible to practice pharmacy in the
hospital setting, the 1-year programs that presently are operated by
hospitals would be considered continuing education, and therefore,
would be ineligible for pass-through reasonable cost payment.
We understand that all individuals who wish to be nurses practicing
in a hospital must either complete a 4-year degree program in a
university setting, a 2-year associate degree in a community or junior
college setting, or a diploma program traditionally offered in a
hospital setting. Since participants that complete a provider-operated
diploma nursing program could not practice as nurses without that
training, the diploma nursing programs are not continuing education
programs and, therefore, may be eligible for pass-through treatment.
Because of the apparent confusion concerning continuing education
programs in the nursing and allied health reasonable cost context, we
are proposing to revise Sec. 413.85(h)(3) to state that educational
seminars, workshops, and continuing education programs in which the
employees participate that enhance the quality of medical care or
operating efficiency of the provider and, effective October 1, 2003, do
not lead to certification required to practice or begin employment in a
nursing or allied health specialty, would be treated as educational
activities that are part of normal operating costs. We also are
proposing to add a conforming definition of ``certification'' for
purposes of nursing and allied health education under Sec. 413.85(c)
to mean ``the ability to practice or begin employment in a specialty as
a whole.''
3. Programs Operated by Wholly Owned Subsidiary Educational
Institutions of Hospitals
Another matter that has come to CMS' attention since publication of
the January 12, 2001 final rule (66 FR 3363) on nursing and allied
health education concerns the preamble language of the rule, which
states:
``Concerning those hospitals that have established their own
educational institution to meet accrediting standards, we believe that,
in some cases, these providers can be eligible to receive payment for
the classroom and clinical training of students in approved programs.
If the provider demonstrates that the educational institution it has
established is wholly within the provider's control and ownership and
that the provider continues to incur the costs of both the classroom
and clinical training portions of the program, the costs would continue
to be paid on a reasonable cost basis. An independent college would not
meet these criteria.
``An example of a program that could be considered provider-
operated would be one in which the hospital is the sole corporate
member of the college, elects the board of trustees, has board members
in common, employs the faculty and pays the salaries, controls the
administration of the program and the curriculum, and provides the site
for the clinical and classroom training on the premises of the
hospital. We believe that, in these situations, the community has not
undertaken to finance the training of health professionals; the
provider has merely restructured its provider-operated program to meet
certain State or accrediting requirements. In most cases, providers
have aligned themselves with already established educational
institutions. We note that a program operated by an educational
institution that is related to the provider through common ownership or
control would not be considered to meet the criteria for provider
operated.'' (66 FR 3363)
We have received a question from a hospital that pertains to the
cited preamble language in the narrow circumstance where the hospital
previously received Medicare reasonable cost payment for direct
operation of nursing or allied health education programs and then
established its own wholly owned subsidiary college to operate the
programs, in order to meet accreditation standards. The hospital has
continued to receive Medicare payments after the hospital moved
operation of the programs to the wholly owned subsidiary college. The
hospital believes that, based on the cited preamble language regarding
wholly owned subsidiary colleges and the lack of prior specific
guidance on this particular organizational structure (as well as its
continued receipt of pass-through payments) and because the hospital
continues to pay all of the costs of the nursing and allied health
education programs, the hospital is still the direct operator of the
programs and should continue to receive pass-through treatment.
However, we believe that once the hospital moved the direct operation
of its nursing and allied health education programs to the college, the
programs no longer met our provider-operated criteria at Sec.
413.85(f). At the very least, it appears that the hospital did not hire
the faculty for the program(s) and did not have direct control of the
curriculum of the program(s) after operation was transferred to the
wholly owned subsidiary college. As we stated in the
[[Page 27211]]
preamble language quoted above: ``a program operated by an educational
institution that is related to the provider through common ownership or
control would not be considered to meet the criteria for provider
operated'' (66 FR 3363).
However, we understand that some hospitals, including this
hospital, may have interpreted the preamble language that stated, ``if
the provider demonstrates that the educational institution it has
established is wholly within the provider's control and ownership and
that the provider continues to incur the costs of both the classroom
and clinical training portions of the program, the costs would continue
to be paid on a reasonable cost basis'' (Ibid.), to mean that hospitals
that establish wholly owned subsidiary colleges or educational
institutions would continue to receive Medicare reasonable cost payment
if the hospitals incur the costs of the classroom instruction and
clinical training. We are proposing to clarify that transferring
operation of previously provider-operated programs to educational
institutions, even if the institutions are wholly owned by the
hospital, does not necessarily mean that the programs continue to meet
our provider-operated criteria under Sec. 413.85(f). In order to
remain provider operated, the hospital must have direct control of the
program; the hospital itself must employ the teaching staff, have
direct control of the program curriculum, and meet other requirements,
as stated at Sec. 413.85(f).
While we are proposing to clarify that merely operating programs
through a wholly owned subsidiary college does not constitute direct
operation of nursing or allied health education programs unless the
hospital itself meets the requirements of the regulations at Sec.
413.85(f), we believe it would be unfair to recoup Medicare payments
that have already been made to hospitals that meet this very narrow
fact pattern. Therefore, we are proposing that Medicare would not
recoup reasonable cost payment from hospitals that have received pass-
through payments for portions of cost reporting periods occurring on or
before October 1, 2003 (the effective date of finalizing this proposed
rule) for the nursing or allied health education program(s) where the
program(s) had originally been operated by the hospital, and then
operation of the program(s) had been transferred by the hospital to a
wholly owned subsidiary educational institution in order to meet
accreditation standards prior to October 1, 2003, and where the
hospital had continuously incurred the costs of both the classroom and
clinical training portions of the programs at the educational
institution.
In addition, we are proposing that, for portions of cost reporting
periods occurring on or after October 1, 2003, such a hospital would
continue to receive reasonable cost payments for the clinical training
costs incurred by the hospital for the program(s) described above that
were previously provider operated. However, we are further proposing
that, with respect to classroom costs, only those classroom costs
incurred by the hospital for the courses that were paid by Medicare on
a reasonable cost basis and included in the hospital's provider-
operated program(s) could continue to be reimbursed on a reasonable
cost basis. That is, Medicare would pay on a reasonable cost basis for
the classroom costs associated with the courses provided as part of the
nursing and allied health education programs (for example, the courses
relating to the theory and practice of the particular nursing and
allied health discipline(s)) that were offered by the hospital when the
hospital was the direct operator of the program(s).
We believe this proposed policy is appropriate since continued
pass-through payment will allow these hospitals to maintain equal
footing with other hospitals that receive pass-through payments and
have maintained their provider-operated programs. In addition, it would
not be equitable to discontinue longstanding Medicare pass-through
payment to these hospitals (in fact, reasonable cost payment to at
least one of these hospitals for nonprovider-operated programs preceded
the publication of the January 12, 2001 final rule on nursing and
allied health education payments by many years) that restructured
operation of their nursing and allied health education program(s) as
wholly owned subsidiaries in order to meet accreditation standards
while relying on their understanding of CMS' prior expressions of
provider-operated requirements and the recent preamble language. If
these providers were now forced to restructure in order to meet the
requirements of Sec. 413.85(f), they would not be able to maintain
their accreditation.
We note that Congress has specifically expressed its intent that
providers that have restructured their programs to be operated by a
wholly owned subsidiary educational institution in order to meet
accreditation standards should continue to receive Medicare reasonable
cost payment. In the conference report accompanying the Consolidated
Appropriations Resolution for FY 2003, Congress stated:
``The conferees are particularly concerned about nursing and allied
health educational programs that cannot meet the regulations set forth
at 42 CFR 413.85(f) solely as a result of regional educational
accrediting criteria. Given the shortage of nursing and allied health
professionals, the conferees support the payment of costs on a
reasonable cost basis for a hospital that has historically been the
operator of nursing and allied health education programs(s) that
qualified for Medicare payments under 42 CFR 413.85, but, solely in
order to meet educational standards, subsequently relinquishes some
control over the program(s) to an educational institution, which meets
regional accrediting standards; is wholly owned by the provider; and is
supported by the hospital, that is, the hospital is incurring the costs
of both the classroom and clinical training of the program.'' (H.R.
Rep. No. 108-10, 108th Cong., 1st Sess., 1115 (2003).)
However, the proposed policy does not allow these hospitals to be
paid for additional classroom costs for courses that were not paid on a
reasonable cost basis to the hospitals in conjunction with their
provider-operated programs (for example, additional classes needed to
meet degree requirements). We believe that to allow pass-through
payment for those additional costs would provide these hospitals with
an unfair advantage over other hospitals with provider-operated
programs.
We note that any hospital that chooses to restructure its programs
to be operated by a wholly owned subsidiary educational institution on
or after the effective date of this proposal when finalized (October 1,
2003) would not be eligible for pass-through payments under this
proposed provision unless the hospital continues to meet the
requirements of Sec. 413.85(f). We believe it is appropriate to limit
the proposed payments to hospitals that restructured before this
proposed rule is made final because our policy with respect to programs
by a wholly owned subsidiary of a hospital will have been clarified in
that final rule.
We are proposing to revise Sec. 413.85 by adding new paragraphs
(d)(1)(iii) and (g)(3) to reflect this proposed payment policy.
F. 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
[[Page 27212]]
(GME). The payments are based in part on the number of residents
trained by the hospital. Section 1886(h)(4)(F) of the Act caps the
number of allopathic and osteopathic residents that hospitals may count
for direct GME.
Section 1886(h) of the Act, as added by section 9202 of the
Consolidated Omnibus Budget 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 added 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.
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. Prohibition Against Counting Residents Where Other Entities First
Incur the Training Costs
a. General Background on Methodology for Determining FTE Resident
Count. As we explain earlier in this preamble, Medicare makes both
direct and indirect GME payments to hospitals for the training of
residents. Direct GME payments are reimbursed in accordance with
section 1886(h) of the Act, based generally on hospital-specific PRAs,
the number of FTE residents a hospital trains, and the hospital's
Medicare patient share. The indirect costs of GME are reimbursed in
accordance with section 1886(d)(5)(B) of the Act, based generally on
the ratio of the hospital's FTE residents to the number of hospital
beds. It is well-established that the calculation of both direct GME
and IME payments is affected by the number of FTE residents that a
hospital is allowed to count; generally, the greater the number of FTE
residents a hospital counts, the greater the amount of Medicare direct
GME and IME payments the hospital will receive. In an attempt to end
the implicit incentive for hospitals to increase the number of FTE
residents, Congress instituted a cap on the number of allopathic and
osteopathic residents a hospital is allowed to count for direct GME and
IME purposes under the provisions of section 1886(h)(4)(F) (direct GME)
and section 1886(d)(5)(B)(v) (IME) of the Act. Dental and podiatric
residents were not included in this statutorily mandated cap.
With respect to reimbursement of direct GME costs, since July 1,
1987, hospitals have been allowed to count the time residents spend
training in sites that are not part of the hospital (referred to as
``nonprovider'' or ``nonhospital sites'') under certain conditions.
Section 1886(h)(4)(E) of the Act requires that the Secretary's rules
concerning computation of FTE residents for purposes of separate
reimbursement of direct GME costs ``provide that only time spent in
activities relating to patient care shall be counted and that all the
time so spent by a resident under an approved medical residency
training program shall be counted towards the determination of full-
time equivalency, without regard to the setting in which the activities
are performed, if the hospital incurs all, or substantially all, of the
costs for the training program in that setting.'' (Section
1886(h)(4)(E) of the Act, as added by section of 9314 of the Omnibus
Budget Reconciliation Act of 1986, Pub. L. 99-509.)
Regulations on time spent by residents training in nonhospital
sites for purposes of direct GME payment were first implemented in the
September 29, 1989 final rule (54 FR 40286). We stated in that rule
(under Sec. 413.86(f)(3)) that a hospital may count the time residents
spend in nonprovider settings for purposes of direct GME payment if the
residents spend their time in patient care activities and there is a
written agreement between the hospital and the nonprovider entity
stating that the hospital will incur all or substantially all of the
costs of the program. The regulations at that time defined ``all or
substantially all'' of the costs to include the residents' compensation
for the time spent at the nonprovider setting.
Prior to October 1, 1997, for IME payment purposes, hospitals could
only count the time residents spend training in areas subject to the
IPPS and outpatient areas of the hospital. Section 4621(b)(2) of the
Balanced Budget Act of 1997 (Pub. L. 105-33) revised section
1886(d)(5)(B) of the Act to allow providers to count time residents
spend training in nonprovider sites for IME purposes, effective for
discharges occurring on or after October 1, 1997. Specifically, section
1886(d)(5)(B)(iv) of the Act was amended to provide that ``all the time
spent by an intern or resident in patient care activities under an
approved medical residency program at an entity in a non-hospital
setting shall be counted towards the determination of full-time
equivalency if the hospital incurs all, or substantially all, of the
costs for the training program in that setting.''
In the regulations at Sec. Sec. 412.105(f)(1)(ii)(C) and
413.86(f)(4) (as issued in the July 31, 1998 Federal Register), we
specify the requirements a hospital must meet in order to include a
resident training in a nonhospital site in its FTE count for Medicare
reimbursement for portions of cost reporting periods occurring on or
after January 1, 1999 for both direct GME and for IME payments. The
regulations at Sec. 413.86(b) redefine ``all or substantially all of
the costs for the training program in the nonhospital setting'' as the
residents' salaries and fringe benefits (including travel and lodging
where applicable), and the portion of the cost of teaching physicians'
salaries and fringe benefits attributable to direct GME. A written
agreement between the hospital and the nonhospital site is required
before the hospital may begin to count residents training at the
nonhospital site; the agreement must provide that the hospital will
incur the costs of the resident's salary and fringe benefits while the
resident is training in the nonhospital site. The hospital must also
provide reasonable compensation to the nonhospital site for supervisory
teaching activities, and the written agreement must specify that
compensation amount.
b. Inappropriate Counting of FTE Residents. As we stated above,
dental residents, along with podiatric residents, are excepted from the
statutory cap on the count of FTE residents for both direct GME and IME
payment purposes. We have become aware of a practice pertaining to the
counting of FTE residents at a nonhospital site, particularly dental
residents, that we see as inappropriate under Medicare policy. Most
often, the situation involves dental schools that, for a number of
years, have been training dental residents in programs at the dental
schools of universities affiliated with teaching hospitals, and the
schools have been directly incurring the costs of the dental residents
training at the dental schools (for example, the teaching faculty
costs, the resident salary costs, the office space costs, and
[[Page 27213]]
any overhead expenses of the programs). We also understand that there
are dental clinics at these dental schools that treat patients (that
is, are involved in ``patient care activities'').
As a result of the provisions that Congress added to allow
hospitals to count FTE residents and receive IME payment, as well as
direct GME payment, if the hospital incurs ``all or substantially all''
the costs of training residents in nonhospital settings, a significant
number of dental schools are shifting the resident training costs of
the dental programs from the schools to the hospital, and thus to the
Medicare program, when the hospitals count the FTE dental residents
training in these dental schools (that is, ``nonhospital sites'') under
the regulations at Sec. 413.86(f)(4). Furthermore, in the case of
training dentists at dental school clinics, as a result of this cost-
shifting and because dental residents are excepted from the cap,
hospitals are receiving significant amounts of Medicare direct GME and
IME payments when they have incurred relatively small costs of the
residents training in a dental school.
The following actual situations are illustrative of the
inappropriate application of Medicare direct GME and IME policy that we
have found:
[sbull] An academic medical center hospital associated with a
university has been training allopathic residents for at least 20
years. Prior to 1999, the university s affiliated dental school had
always incurred the costs of dental residency programs at the dental
school. Beginning with the hospital's cost report for its fiscal year
ending in 1999, for the first time ever, the hospital has requested
direct GME and IME payment for an additional 67 FTE residents because
the hospital claims it has begun to incur ``all or substantially all''
of the costs of the dental residents training in the university's
affiliated dental school, in accordance with the regulations at Sec.
413.86(f)(4).
[sbull] A university dental school in one State has been incurring
the costs of dental residency programs at its dental school for several
years. Beginning in FY 1999, a teaching hospital in a neighboring State
decided to begin incurring ``all or substantially all'' of the costs of
the dental residents training in the dental clinics in the program
(which is located in a different State from the hospital) in order to
receive Medicare direct GME and IME payment for an additional 60 FTE
residents.
[sbull] In another situation, a teaching hospital on the East Coast
of the United States has requested direct GME and IME payment for an
additional 60 FTE dental residents, some of whom are training in dental
programs at nonhospital sites located in Hawaii, New Mexico, and the
Netherlands, because it has begun to incur ``all or substantially all''
of the costs of dental residents training in those remote ``nonhospital
sites''. Prior to 1999, the costs for these dental programs were funded
by nonhospital sources.
We note that such inappropriate cost-shifting practices are by no
means limited to the dental school context. Indeed, we understand that
there are some hospitals with resident counts below their direct GME
and IME FTE resident caps that have recently (as of October 1, 1997,
when it became possible to receive significant IME payments under the
amendment made by Pub. L. 105-33) started to incur ``all or
substantially all'' of the costs of residents who had been training at
sites outside of the hospital without any financial assistance from the
hospital, in order for the hospital to count those FTE residents and
receive Medicare direct GME and IME payments for the additional
residents. The actual costs of the programs that are being shifted from
nonhospital entities to hospitals are relatively small, compared to the
direct GME and IME payments that hospitals receive as a result of
incurring ``all or substantially all'' of the training costs.
[sbull] In another example, an academic medical center hospital in
one State asked Medicare to allow it to count an additional 10 FTEs for
both direct GME and IME payment, beginning with its fiscal year ending
1999 cost report, because the hospital claims it is incurring all or
substantially all of the costs of training osteopathic family practice
residents in a walk-in clinic. The osteopathic family practice
residency program had previously been sponsored by this clinic for
several years and the residents do not participate in any training at
the hospital.
c. Congressional Intent. Congress has delegated broad authority to
the Secretary to implement a policy on the count of FTE residents for
purposes of calculating direct GME and IME payments. For IME payment,
section 1886(d)(5)(B) of the Act simply states that ``the Secretary
shall provide for an additional payment amount'' which includes ``the
ratio of the hospital's full-time equivalent interns and residents to
beds.'' The methodology to compute the count of FTE residents for IME
is not established in the statute. Similarly, for direct GME, section
1886(h)(4)(A) of the Act states that ``the Secretary shall establish
rules consistent with this paragraph for the computation of the number
of full-time equivalent residents in an approved medical residency
training program.''
Although not in the context of the general rules for counting FTE
residents, Congress similarly acknowledged its intent to defer to the
Secretary with respect to the rules for implementing ``limits'' or caps
on the number of FTE residents hospitals may count for purposes of
direct GME and IME payment. The conference agreement that accompanied
Pub. L. 105-33, which established a cap on the number of allopathic and
osteopathic residents a hospital may count, states--
``[T]he Conferees recognize that such limits raise complex issues,
and provide for specific authority for the Secretary to promulgate
regulations to address the implementation of this provision. The
Conferees believe that rulemaking by the Secretary would allow careful
but timely consideration of this matter, and that the record of the
Secretary's rulemaking would be valuable when Congress revisits this
provision.'' (H.R. Conf. Rep. No. 105-217, 105th Cong., 1st Sess., 821
(1997).
The absence of statutory specificity on determining FTE counts in
these situations and the declared Congressional delegations of
authority to the Secretary on the subject are clear indications that
Congress has given the Secretary broad discretion to promulgate
reasonable regulations in order to implement the policy on the counting
of residents for direct GME and IME payments.
When Congress enacted the nonhospital site provisions for both
direct GME and IME, Congress intended to address application of the FTE
count policy to situations where the training site had been the
hospital. The intent was to create incentives for hospitals to move
resident training from the hospital to nonhospital settings. We believe
that Congress did not intend for hospitals to be able to add to their
FTE counts residents that had historically trained outside the hospital
in other settings. Training in those nonhospital settings had
historically occurred without Congress offering any financial incentive
to hospitals to move the training out of the hospital.
This Congressional intent is evident in the legislative history of
both the direct GME and the IME provisions on nonhospital settings.
First, legislative history associated with passage of the direct GME
provision (as part of Pub. L. 99-509) indicates that Congress intended
to broaden the scope of settings in which a hospital could train its
residents and still receive separate direct GME cost reimbursement, and
to
[[Page 27214]]
provide incentives to hospitals for training residents in primary care
programs. The Conference committee report indicates that ``[s]ince it
is difficult to find sufficient other sources of funding [than
hospitals and Medicare] for the costs of such training, [that is,
training in freestanding primary care settings such as family practice
clinics or ambulatory surgery centers] assignments to these settings
are discouraged. It is the Committee's view that training in these
settings is desirable, because of the growing trend to treat more
patients out of the inpatient hospital setting and because of the
encouragement it gives to primary care.'' (Emphasis added.) (H.R. Rep.
No. 99-727, 99th Cong., 1st Sess., 70 (1986).)
Thus, from the start of the policy allowing payment for training in
nonprovider sites, we believe Congress intended to create a monetary
incentive for hospitals to rotate residents from the hospital to the
nonhospital settings. We believe Congress did not intend for hospitals
to be paid for residents who had previously been training at
nonhospital sites without hospital funding.
Further, in the Conference committee report accompanying the
provision of Pub. L. 105-33 on IME payment for training in nonhospital
settings, Congress stated that ``[t]he conference agreement includes
new permission for hospitals to rotate residents through nonhospital
settings, without reduction in indirect medical education funds.''
(Emphasis added.) (H.R. Conf. Rep. No. 105-217, 105th Cong., 1st Sess.,
817 (1997).)
We note that, prior to enactment of Pub. L. 105-33, if a hospital
rotated a resident to train at a nonhospital site, the hospital could
not count the time the resident spent at the nonhospital site for
purposes of Medicare IME payments. As a result, the lack of IME
payments acted as a disincentive and discouraged hospitals from
rotating residents out of the hospital. Therefore, Congress authorized
hospitals to count residents in nonhospital sites for IME purposes as a
specific incentive to encourage hospitals to rotate their residents to
nonhospital sites (and not to encourage hospitals to incur the costs of
a program at a nonhospital site that had already been funded by other
sources). This legislative intent becomes more apparent when the nature
of the Medicare IME payment is considered. The Medicare IME payment is
inherently a payment that reflects the increased operating costs of
treating inpatients as a result of the hospital having a residency
program. For example, as explained in the September 29, 1989 final rule
(54 FR 40286), the indirect costs of medical education might include
added costs resulting from an increased number of tests ordered by
residents as compared to the number of tests normally ordered by more
experienced physicians.
The IME payment is an adjustment that is made for each Medicare
discharge from the areas subject to the IPPS in a teaching hospital.
The authorization by Congress for IME payments relating to nonhospital
services while residents are training at nonhospital sites would be
absurd if not viewed as an incentive to transfer existing residency
training from the hospital to the nonhospital setting. We do not
believe Congress intended to permit such IME payments to be allowable
to the hospital that is incurring ``all or substantially all the
costs'' of residents training in nonhospital sites except in the
situation where the hospital rotated residents from the hospital to the
nonhospital settings. The illustrative situations described above in
which nonhospital sites, such as dental schools, are shifting the costs
of existing programs to the hospitals are not consistent with the
intent of Congress to encourage hospitals to rotate residents from the
hospital setting to nonhospital sites.
Thus, we believe Congress intended both cited provisions of the Act
on counting residents in nonhospital sites for purposes of direct GME
and IME payments to be limited to situations in which hospitals rotate
residents from the hospital to the nonhospital settings, and not
situations in which nonhospital sites transfer the costs of an existing
program at a nonhospital site to the hospital.
d. Medicare Principles on Redistribution of Costs and Community
Support. It is longstanding Medicare policy that if the community has
undertaken to bear the costs of medical education, these costs are not
to be assumed by the Medicare program. In addition, medical education
costs that have been incurred by an educational institution may not be
redistributed to the Medicare program. Indeed, these concepts,
community support and redistribution of costs, have been a part of
Medicare GME payment policy since the inception of the Medicare
program. Both the House and Senate Committee reports accompanying Pub.
L. 89-97 (the authorizing Medicare statute) indicate that Congress
intended Medicare to share in the costs of medical education only in
situations in which the community has not stepped in to incur them:
``Many hospitals engage in substantial education activities,
including the training of medical students, internship and residency
programs, the training of nurses and the training of various
paramedical personnel. Educational activities enhance the quality of
care in an institution and it is intended, until the community
undertakes to bear such education costs in some other way, that a part
of the net cost of such activities * * * should be considered as an
element in the cost of patient care, to be borne to an appropriate
extent by the hospital insurance program. (Emphasis added.) (S. Rep.
No. 404, 89th Cong., 1st Sess., 36 (1965); H.R. Rep. No. 213, 89th
Cong., 1st Sess., 32 (1965).)
The principle behind the congressional committee report language
for Pub. L. 89-97 that Medicare would share in the costs of educational
activities until communities bore them in some other way has guided
Medicare policy on educational activities from the inception of the
Medicare program. The principles of community support and
redistribution of costs associated with payment for GME have been
continually reiterated in various regulations, manual provisions, and
implementing instructions to fiscal intermediaries. As recently as the
final rule published in the Federal Register on January 12, 2001, we
stated:
``We note that the proposed revisions in the proposed rule
inadvertently did not include community support as the basis for an
offset from the allowed cost of a GME or nursing and allied health
program. In this final rule, we restate our longstanding policy that
Medicare will share in the costs of educational activities of providers
where communities have not assumed responsibility for financing these
programs. Medicare's policy is to offset from otherwise allowable
education costs, community funding for these activities.'' (66 FR 3368)
We note the instructions that CMS (then HCFA) gave to its Regional
Offices in the 1990 audit instructions for purposes of calculating the
direct GME base period PRA specifically addressed redistribution of
costs and community support in the GME context:
``Where costs for services related to medical education activities
have historically been borne by the university, it is assumed the
community has undertaken to support these activities, and subsequent
allocation of these costs to a hospital constitutes a redistribution of
costs from an educational institution to a patient care institution. In
such a situation, these costs are not allowable under the Medicare
program. (See 42 CFR
[[Page 27215]]
413.85(c) and HCFA Pub. L. 15-1, Sec. 406). For example, if in the
past the hospital did not identify and claim costs attributable to the
time teaching physicians spent supervising I&Rs [interns and residents]
working at the hospital, it is assumed that these costs were borne by
the university. Therefore, the hospital may not claim these costs in
subsequent cost reports.'' (Instructions for Implementing Program
Payments for Graduate Medical Education to ARAs for Medicare, Director
of Office of Financial Operations of the Health Care Financing
Administration, BPO-F12, February 12, 1990.)
Furthermore, the regulation at Sec. 413.85(c) that was originally
issued in the Federal Register on September 30, 1986 (51 FR 34793)
(which was further refined, but conceptually left unchanged, as of
March 12, 2001) addressed the Congressional intent not to increase
program costs, as well. That paragraph (c) stated:
``Educational Activities. Many providers engage in education
activities including training programs for nurses, medical students,
interns and residents, and various paramedical specialties * * * .
Although the intent of the program is to share in the support of
educational activities customarily or traditionally carried on by
providers in conjunction with operations, it is not intended that this
program should participate in increased costs resulting from
redistribution of costs from educational institutions or units to
patient care institutions or units.''
The Secretary of Health and Human Services interpreted this
provision to deny reimbursement of educational costs that were borne in
prior years by a hospital's affiliated medical school. The U.S. Supreme
Court affirmed the Secretary's interpretation of the redistribution of
costs regulation in Thomas Jefferson University v. Shalala (``Thomas
Jefferson''), 512 U.S. 504 (1994). The Court found of Sec. 413.85(c)
that:
``The regulation provides, in unambiguous terms, that the `costs'
of these educational activities will not be reimbursed when they are
the result of a `redistribution,' or shift, of costs of an
`educational' facility to a `patient care' facility.'' (Emphasis
added.) (Thomas Jefferson, 512 U.S. at 514). Thus, the Supreme Court in
Thomas Jefferson held that it is well within the Secretary's discretion
to interpret the language at Sec. 413.85(c), which was specifically
derived from the legislative history of the original enacting Medicare
legislation quoted above, to impose a substantive limitation on medical
education payment.
The Supreme Court's opinion in Thomas Jefferson lends substantial
support and credibility to CMS' longstanding policy on community
support and redistribution of costs in the GME context.
e. Application of Redistribution of Costs and Community Support
Principles. As we have described above, we have discovered an
inappropriate application of Medicare direct GME and IME payment
policies relating to the counting of FTE residents in nonhospital
settings. As stated previously, we believe that: (1) Congress has given
the Secretary broad discretion to implement policy on FTE resident
counts; (2) Congress intended that the nonhospital site policy for both
direct GME and IME would encourage hospitals to move resident training
from the hospital to nonhospital settings, not to enable nonhospital
sites to shift the costs of already established residency programs in
the nonhospital site to the hospital; and (3) since the inception of
the Medicare program, CMS' policy has been consistent with the intent
of Congress that Medicare would only share in the costs of medical
education until the community assumes the costs. The Supreme Court has
specifically found that CMS' implementation of the redistribution of
costs and community support principles is ``reasonable.'' (Thomas
Jefferson, 512 U.S. at 514.)
Accordingly, we are proposing that residents training at
nonhospital sites may be counted in a hospital's FTE resident count
only where the principles of redistribution of costs and community
support are not violated. We are proposing this policy at this time to
address the inappropriate practice of nonhospital sites shifting costs
to hospitals solely to allow the hospitals to count residents training
in the nonhospital sites. However, we believe the concepts of
redistribution of costs and community support are equally relevant to
the counting of FTEs residents by a hospital in general.
We note again that the Medicare program has a long tradition of
applying redistribution of costs and community support principles to
medical education payments. As we have stated above, both the House and
Senate Committee reports accompanying Pub. L. 89-97 (the 1965
authorizing Medicare statute) indicate that Congress intended Medicare
to share in the costs of medical education only where the community has
not stepped in to incur them.
We believe it is appropriate to employ the principles of
redistribution of costs and community support to specifically address
the inappropriate scenarios described above whereby hospitals attempt
to inflate their FTE resident counts by assuming payment of training
costs for residents in nonhospital sites that were previously funded by
a nonhospital entity. Therefore, we are proposing to specify the
application of the redistribution of costs and community support
principles by adopting the definitions (with some modification to
reflect the methodology for counting FTE residents applicable to GME)
of ``community support'' and ``redistribution of costs'' at Sec.
413.85(c), which relate to nursing and health education program costs,
for use at Sec. 413.86(b), which relates to GME. In addition, we are
proposing a general rule at proposed Sec. 413.86(i) on the application
of community support and redistribution of costs principles to the
counting of FTE residents for GME. We are proposing to (1) make the
provisions under Sec. 413.86(f) relating to determining the number of
FTE residents subject to the provisions of the proposed Sec.
413.86(i); (2) add a proposed Sec. 413.86(f)(4) in order to clarify
that the principles of redistribution of costs and community support
are applicable to the counting of FTE residents, including when the
residents are training in nonhospital settings; and (3) making the
provisions of the proposed Sec. 413.86(i) specifically applicable to
determining the number of FTE residents under Sec. 413.86(g)(4)
through (6) and (g)(12).
The general rule at proposed Sec. 413.86(i) contains two
provisions. Proposed Sec. 413.86(i)(1) states the principles of
community support and redistribution of costs: In relation to community
support, we are proposing that if the community has undertaken to bear
the costs of medical education through community support, the training
costs of residents that are paid through community support are not
considered GME costs to the hospital for purposes of Medicare payment.
In relation to redistribution of costs, we are proposing that the costs
of training residents that constitute a redistribution of costs from an
educational institution to the hospital are not considered GME costs to
the hospital for purposes of Medicare payment.
In applying the redistribution of costs and community support
principles, we are proposing under Sec. 413.86(i)(2) to state that a
hospital must continuously incur direct GME costs of residents training
in a particular program at a training site since the date the residents
first began training in that site in order for the hospital to count
the FTE residents in accordance with the
[[Page 27216]]
provisions of paragraphs (f) and (g)(4) through (g)(6), and (g)(12) of
Sec. 413.86.
We note that our reasons for specifically referencing the
applicability of the principles of community support and redistribution
of costs at Sec. 413.86(f)(4), the paragraph concerning counting
residents training in nonhospital settings for direct GME purposes, are
twofold. First, although we are already making the proposed Sec.
413.86(i) applicable to Sec. 413.86(f), which would make the
principles applicable to each paragraph under Sec. 413.86(f), in
consideration of the inappropriate applications we have identified of
the GME FTE-counting policy with respect to counting residents in
nonhospital sites, we believe it is appropriate to also specifically
address the applicability of the redistribution of costs and community
support principles to Sec. 413.86(f)(4). In addition, we note that the
proposed reference at Sec. 413.86(f)(4) has implications for IME
payment as well, as explained below.
Under existing Sec. 412.105(f)(1)(ii)(C), the rule for the
counting of FTE residents training in nonhospital settings for IME
payment, there is a specific reference indicating that the criteria set
forth in Sec. 413.86(f)(4) must be met in order for a hospital to
count the FTE residents training in nonhospital settings for purposes
of IME payments. Thus, if under proposed Sec. 413.86(f)(4)(iv) (the
paragraph making redistribution of costs and community support
principles applicable) a hospital is not permitted to count the FTE
residents training in a nonhospital site because of redistribution of
costs or community support, the hospital would not be permitted to
count the FTE residents for purposes of IME payment as well, because
the IME regulation at Sec. 412.105(f)(1)(ii)(C) requires the criteria
under Sec. 413.86(f)(4) to be met.
As we have stated above, payment for IME is based on the concept
that, as a direct result of the hospital's resident training program,
the costs the hospital incurs for patient care are increased. When
Congress included section 1886(d)(5)(B)(iv) of the Act as part of
Public Law 105-33, the statute expanded the circumstances under which
IME payments to a hospital could be made by allowing the hospital to
count the number of residents training outside the hospital setting
under certain conditions. Even though it is clear that those residents
training outside the hospital cannot have any impact on patient care
costs to the hospital, Congress nevertheless allowed the hospital to
receive IME payments when the hospital counts FTE residents training in
a nonhospital setting in accordance with section 1886(d)(5)(B)(iv) of
the Act, where those residents would otherwise have trained in the
hospital setting. As we have stated, Congress created an incentive (or
removed a disincentive) with the provisions of Public Law 105-33 for
hospitals to rotate residents to nonhospital settings by allowing
hospitals to continue to receive IME payment as if the residents
continued to train in the hospital setting. If there is a
redistribution of costs or community support, we believe IME payment to
the hospital would be contrary to Congressional intent to encourage the
hospital to rotate residents from the hospital to the nonhospital site.
In addition, when Congress included section 1886(d)(5)(B)(iv) of
the Act as part of Public Law 105-33, the statutory authority for IME
payment was premised on the hospital incurring the direct GME costs of
the residents: ``all the time spent by an intern or resident in patient
care activities under an approved medical residency program at an
entity in a nonhospital setting shall be counted towards the
determination of full-time equivalency if the hospital incurs all, or
substantially all, of the costs for the training program in that
setting.'' (Emphasis added.) (Section 4621(b)(2) of Public Law 105-33;
section 1886(d)(5)(B)(iv) of the Act.) We believe Congress intended the
hospital to incur direct GME costs of the program in the nonhospital
site in order to count the FTE residents training in nonhospital
settings for purposes of IME payment. Thus, in the situation where a
hospital incurred direct GME costs but there was redistribution of
costs or community support, a disallowance of direct GME payments as
well as a disallowance of IME payments is appropriate.
Although we are stating generally that the principles of community
support and redistribution of cost have applied since the inception of
Medicare to graduate medical education payment, as we have stated
above, we have identified relatively recent inappropriate application
of the nonhospital site policy for counting FTE residents. Therefore,
we believe it is appropriate to propose to identify January 1, 1999, as
the date our fiscal intermediaries should use to determine whether a
hospital or another entity has been incurring the costs of training in
a particular program at a training setting for purposes of determining
whether there has been a redistribution of costs or community support.
We are proposing that January 1, 1999 be used as the date the fiscal
intermediaries should use for determinations, since it may be difficult
for our fiscal intermediaries to obtain from hospitals contemporaneous
documentation that the hospitals have appropriately been incurring the
direct GME costs in earlier fiscal years. We believe the January 1,
1999 date should simplify confirmation by our fiscal intermediaries and
hospitals of whether the hospital or another entity had been incurring
the costs of the program in particular training settings and whether
redistribution of costs or community support had occurred. We have
chosen the January 1, 1999 date because of administrative convenience
and feasibility, so that necessary data are both valid and available,
and in recognition of the fact that our fiscal intermediaries must
prioritize their limited audit resources. While we are not requiring
our fiscal intermediaries to determine whether a hospital had been
incurring the training costs of a program prior to the January 1, 1999
date, if the fiscal intermediaries determine that there is a
redistribution of costs or community support exists with respect to
certain residents prior to January 1, 1999, a disallowance of direct
GME and IME payments with respect to those FTE residents would
certainly be required.
Since calculation of a hospital's FTE resident count is dependent
upon whether the hospital incurred the training costs, we are proposing
to require each teaching hospital and its fiscal intermediary to
determine which entity had been incurring the training costs at least
since January 1, 1999. For example, if a nonhospital entity, such as a
school of medicine or dentistry, had incurred the costs of training the
residents anytime on or after January 1, 1999, and a hospital
subsequently begins to incur direct GME costs of training those FTE
residents, the hospital would not qualify to count those FTE residents
for purposes of direct GME and IME payments.
We note that the proposal states that a hospital must have been
continuously incurring the costs of the training since the date the
residents first began training in that program. Accordingly, if a
hospital had at one time incurred the costs of training residents in a
particular program, whether at the hospital or in a nonhospital
setting, but a nonhospital institution later assumed the costs of
training in that setting, even if the hospital assumed payment for the
training costs again, the hospital could not then count those residents
for purposes of direct GME and IME payments.
We note that if a hospital incurs the direct GME costs, whether
training takes
[[Page 27217]]
place inside the hospital or in a nonhospital setting, in a new
residency program, the hospital may be eligible to count the FTE
residents as specified by the regulations under Sec. 413.86(g)(6).
Consistent with the policy on redistribution of costs and community
support discussed above, if a hospital incurs the direct GME costs of
additional FTE residents training in an existing program in a hospital
setting where the costs of the existing program had been incurred by a
nonhospital entity and the hospital has continuously funded the
additional residents in the existing program in the hospital setting
since the date the residents first began training there, the
redistribution of costs or community support principles would not
prohibit the hospital from counting the additional FTE residents for
purposes of direct GME and IME payments.
We note that, under existing policy, to count residents in a
nonhospital setting, a hospital is required to incur for ``all or
substantially all of the costs of the program'' in that setting. In
other words, a hospital is required to assume financial responsibility
for the full complement of residents training in a nonhospital site in
a particular program in order to count any FTE residents training there
for purposes of IME payment. A hospital cannot count any FTE residents
if it incurs ``all or substantially all of the costs'' for only a
portion of the FTE residents in that program training setting. This
policy is derived from the language of the IME and direct GME
provisions of the statute on counting residents in nonhospital
settings; both sections 1886(d)(5)(B)(iv) and 1886(h)(4)(E) of the Act
state that the hospital must incur ``all, or substantially all, of the
costs for the training program in that setting.'' (Emphasis added.) In
contrast, as explained earlier, it is permissible under the proposed
policy on the application of the redistribution of costs and community
support principles for the hospital to count FTE residents where the
hospital incurs direct GME costs of FTE residents that are added to an
existing program, even though the hospital may not count the existing
FTE residents due to the application of the redistribution of costs or
community support rules. In the nonhospital setting, as a result of the
interaction of these two separate FTE counting requirements--(1) that
the hospital must not violate the redistribution of costs and the
community support principles in order to count the resident FTEs in the
nonhospital settings, and (2) that the hospital must incur ``all or
substantially all'' of the costs for the training program in that
setting--a hospital would be prohibited from counting FTE residents
added to an existing program at a nonhospital site unless the hospital
incurs all or substantially all of the costs of training all of the
residents in that program at that setting. That is, even if the
hospital incurs all or substantially of the costs for all of the
training program at the nonhospital site, the hospital would only be
able to count the additional FTE residents who were not excluded by
application of the redistribution of costs or community support
principles.
For example, training in a general dentistry program with 10 FTE
residents has taken place at a school of dentistry for 20 years. The
school of dentistry has been incurring the training costs of the
general dentistry residents since the inception of the program.
Beginning in 2003, the school of dentistry has decided to add an
additional 5 FTE residents to the program, and Hospital A decides to
incur ``all or substantially all'' the costs of those 5 additional FTE
residents only. Applying the policy concerning redistribution of costs
and community support in combination with the policy on incurring all
or substantially all of the costs, the hospital could not count the
additional 5 FTE residents in the dental school since it is not paying
for all or substantially all of the costs of the program. Even if the
hospital were to incur all or substantially all of the costs for the
training program for all 15 FTE residents, the hospital could not count
the 10 FTEs that were part of the existing general dentistry program
because of the redistribution of costs and community support
principles; it would be a redistribution of costs for the hospital to
begin to incur direct GME costs of the 10 FTE residents when the dental
school had previously been incurring those costs.
We note that such a result does not occur when a new program is
established in the nonhospital site. If, from the outset of the
program, the hospital incurs direct GME costs and also incurs ``all or
substantially all'' of the costs for the training program for all the
new residents training at the site, there would be no redistribution of
costs or community support, and the hospital could count all of those
residents in the new program in its FTE count (subject, of course, to
the hospital's 1996 FTE resident cap).
We also note that the interaction of the two provisions discussed
above--redistribution of costs and community support, and ``all or
substantially all''--does not occur when counting FTE residents
training inside the hospital, since a hospital is not required to incur
``all or substantially all'' of the costs for the training program
inside the hospital.
Furthermore, if one hospital had incurred the direct GME costs of
training residents in a particular program in a nonhospital site from
one point in time, for example, 1995 through 1999, and then another
hospital consecutively incurs the costs from 2000 and thereafter, the
second hospital may be eligible to receive direct GME and IME payments
for training the FTE residents from the point in time where the second
hospital incurred the direct GME costs, and the redistribution and
community support exclusions would not apply. The second hospital may
be eligible to receive Medicare direct GME and IME payments because the
costs were incurred previously by a hospital, and not either the
community or the university. Therefore, there was neither community
support nor redistribution of costs.
The following are some examples to clarify how these proposed
policies would be implemented:
Example 1
Since 1995, 10 FTE residents in an internal medicine program have
been training in the Community Clinic. In accordance with the current
provisions of Sec. 413.86(f), Hospital A has incurred all or
substantially all of the costs of training the 10 FTE residents since
1995. Assuming the current provisions of the regulations at Sec. Sec.
412.105(f)(1)(ii)(C) and 413.86(f)(3) and (f)(4) are met, Hospital A
may continue to receive IME and direct GME payments for 10 FTE
residents because Hospital A had incurred direct GME costs continuously
(as evidenced by contemporaneous documentation since January 1, 1999),
as specified in our proposed regulation.
Beginning July 1, 2004, in addition to continuing to incur all or
substantially all of the costs of the first 10 FTE internal medicine
residents training in the nonhospital site, Hospital A also incurs all
or substantially all of the costs of training an additional 3 FTE
internal medicine residents at that site. Accordingly, beginning July
1, 2004, Hospital A may count all 13 FTE residents training in the
Community Clinic for purposes of direct GME and IME payments, assuming
Hospital A does not exceed its FTE cap for IME and direct GME.
Example 2
Since 1995, 2.25 dental FTE residents in a dental school program
were training in a dental clinic at the dental school. While the 2.25
FTEs were training at the
[[Page 27218]]
clinic, the dental school paid for all of the costs of the dental
program. Prior to July 1, 2000, Hospital A signed a written agreement
with the clinic to incur all or substantially all of the costs of
training the 2.25 FTE residents, from July 1, 2000 and onward. Thus,
beginning with July 1, 2000, the dental school no longer incurred the
costs of the program at this nonhospital site. In this scenario (even
if Hospital A inappropriately received direct GME and IME payments for
the 2.25 FTEs since July 1, 2000), Hospital A may not receive direct
GME or IME payment for the 2.25 FTE residents training in the clinic
because there would have been a redistribution of costs associated with
training these 2.25 FTE residents from the dental school to the
hospital.
Example 3
Since 1995, 2.25 FTE residents in a family practice program were
training in a physicians' group practice. While the 2.25 FTEs were
training at the physicians' practice, a school of medicine paid for the
costs of the family practice residency program. Prior to July 1, 2000,
Hospital A signed a written agreement with the physicians' practice to
send 1 additional family practice FTE resident to the physicians'
practice and to incur all or substantially all of the costs of training
the original 2.25 FTE residents and the 1 additional FTE, from July 1,
2000 and onward. Thus, beginning with July 1, 2000, the school of
medicine no longer incurred the costs of the program at this
nonhospital site. Hospital A may not count the 2.25 FTE residents that
had been training since 1995 in that physicians' practice for purposes
of direct GME and IME payments because the training costs were shifted
from the school of medicine to the hospital. However, Hospital A may
count the 1 FTE resident the hospital began to rotate for training in
the physicians' practice because there was no cost-shifting for that
resident and Hospital A incurred ``all or substantially all'' of the
costs of the entire family practice program in the physicians' office
setting.
Example 4
Residents in a surgery program have been rotating from a hospital
to two nonhospital clinics, Clinic A and Clinic B, since 1996. The
training of the surgery residents in Clinic A has been supported by a
nonhospital institution since 1996, while the hospital has incurred all
or substantially all of the costs of the surgery residents in Clinic B
since 1996. The hospital cannot count the surgery FTE residents
training in Clinic A, even if it begins to pay for all of the costs of
the program at that site, since a nonhospital institution had supported
the training in Clinic A since 1996 (in other words, the redistribution
of costs and community support principles would prohibit the hospital
from counting these FTE residents). However, if the hospital continues
to incur all or substantially all of the costs of the surgery residents
in Clinic B, the hospital may count the FTE residents training in
Clinic B for purposes of direct GME and IME payments because there
would be no cost-shifting to the hospital for these residents and the
hospital would incur all or substantially all of the costs for the
training program in that setting.
3. Rural Track FTE Limitation for Purposes of Direct GME and IME
for Urban Hospitals that Establish Separately Accredited Approved
Medical Programs in a Rural Area (Sec. Sec. 412.105(f)(1)(x) and
413.86(g)(12)) a. Change in the Amount of Rural Training Time Required
for an Urban Hospital to Qualify for an Increase in the Rural Track FTE
Limitation. To encourage the training of physicians in rural areas,
section 407(c) of Pub. L. 106-113 amended sections 1886(d)(5)(B) and
1886(h)(4)(H) of the Act to add a provision that, in the case of an
urban hospital that establishes separately accredited approved medical
residency training programs (or rural tracks) in a rural area or has an
accredited training program with an integrated rural track, an
adjustment shall be made to the urban hospital's cap on the number of
residents. For direct GME, the amendment applies to payments to
hospitals for cost reporting periods beginning on or after April 1,
2000; for IME, the amendment applies to discharges occurring on or
after April l, 2000.
Section 407(c) of Pub. L. 106-113 did not define a ``rural track''
or an ``integrated rural track,'' nor are these terms defined elsewhere
in the Act or in any applicable regulations.
Currently, there are a number of accredited 3-year primary care
residency programs in which residents train for 1 year of the program
at an urban hospital and are then rotated for training for the other 2
years of the 3-year program to a rural facility(ies). These separately
accredited ``rural track'' programs are recognized by the Accreditation
Council of Graduate Medical Education (ACGME) as ``1-2'' rural track
programs. As far as CMS is able to determine, ACGME is the only
accrediting body to ``separately accredit'' rural track residency
programs, a requirement specified in Pub. L. 106-113.
We implemented the rural track program provisions of section
1886(d)(5)(B) and 1886(h)(4)(H) of the Act to address these ``1-2''
programs and to account for other programs that are not specifically
``1-2'' programs but that include rural training components. As stated
above, since there is no existing definition of ``rural track'' or
``integrated rural track,'' we define at Sec. 413.86(b) a ``rural
track'' and an ``integrated rural track'' as an approved medical
residency training program established by an urban hospital in which
residents train for a portion of the program at the urban hospital and
then rotate for a portion of the program to a rural hospital(s) or to a
rural nonhospital site(s). We have previously noted that the terms
``rural track'' and ``integrated rural track,'' for purposes of this
definition, are synonymous.
To implement these provisions, we revised Sec. 413.86 to add
paragraph (g)(11) (since redesignated as (g)(12)), and Sec. 412.105 to
add paragraph (f)(1)(x) to specify that, for direct GME, for cost
reporting periods beginning on or after April 1, 2000, or, for IME, for
discharges occurring on or after April 1, 2000, an urban hospital that
establishes a new residency program, or has an existing residency
program, with a rural track (or an integrated rural track) may, under
certain circumstances, include in its FTE count residents in those
rural tracks, in addition to the residents subject to the FTE cap at
Sec. 413.86(g)(4). (See the August 1, 2000 interim final rule with
comment period (65 FR 47033) and the August 1, 2001 IPPS final rule (66
FR 39902)). These regulations specify that an urban hospital may count
the residents in the rural track in excess of the hospital's FTE cap up
to a ``rural track FTE limitation'' for that hospital. We defined this
rural track FTE limitation at Sec. 413.86(b) as the maximum number of
residents (as specified in Sec. 413.86(g)(12)) training in a rural
track residency program that an urban hospital may include in its FTE
count, in addition to the number of FTE residents already included in
the hospital's FTE cap.
Generally, the rural track policy is divided into two categories:
rural track programs in which residents are rotated to a rural area for
at least two-thirds of the duration of the program; and rural track
programs in which residents are rotated to a rural area for less than
two-thirds of the duration of the program. Currently, family practice
is the only specialty that has separately accredited rural track
programs. As previously noted, to account for other specialties that
have program lengths greater than
[[Page 27219]]
or less than 3 years, or that are not ``1-2'' programs, but may
establish separately accredited rural track residency programs that are
longer than 3 years, our regulations specify that residents must train
in the rural area for ``two-thirds of the duration of the program,''
rather than ``2 out of 3 program years,'' in order for the urban
hospital to count FTEs in the rural track (up to the rural track FTE
limitation) in addition to the residents included in the hospital's FTE
limitation. Thus, for example, under current policy, if a surgery
program, which is a 5-year program, were to establish a separately
accredited rural track, the urban hospital must rotate the surgery
residents to the rural area for at least two-thirds of the duration of
the 5-year program in order to qualify to count those FTEs in excess of
the hospital's FTE cap, as provided in Sec. 413.86(g)(12) and Sec.
412.105(f)(1)(x).
Accordingly, our policy for determining whether an urban hospital
qualifies for an adjustment to the FTE cap for training residents in
rural areas is dependent upon the proportion of time the residents
spend training in the rural areas. If the time spent training in rural
areas (either at a rural hospital or a rural nonhospital site)
constitutes at least two-thirds of the duration of the program, then
the urban hospital may include the time the residents train at that
urban hospital in determining GME payments. However, if the urban
hospital rotates residents to rural areas for a period of time that is
less than two-thirds of the duration of the program, although the rural
hospital may count the time the residents train at the rural hospital
if the program is new, the urban hospital may not include the time the
residents train at the urban hospital for GME payment purposes (unless
it can do so within the hospital's FTE cap).
When we first implemented this policy on rural tracks, it was
consistent with our understanding of how the ACGME accredits rural
track ``1-2'' programs, in which residents train for 1 year of the
program at an urban hospital and are then rotated for training years 2
and 3 to a rural facility. We believed that the ACGME did not
separately accredit an approved program as a rural track program unless
it met this ``1-2'' condition; that is, the residents were spending
one-third of program training in the urban area and two-thirds of the
program training in the rural area. However, we have recently learned
that there are a few rural track programs that are separately
accredited by the ACGME as ``1-2'' rural track programs, but the
residents in these programs are not training in rural areas for at
least two-thirds of the duration of the program. We understand that in
certain instances in which the case-mix of the rural facilities might
not be sufficiently broad to provide the residents with an acceptable
range of training opportunities, the ACGME allows the residents in
program years 2 and 3 to return to the urban hospital for some training
in both years. However, because the training in years 2 and 3 is
predominantly occurring at the rural locations, the ACGME still
separately accredits the urban and rural portions as a ``1-2'' program.
The existing regulations at Sec. Sec. 412.105(f)(1)(x) and
413.86(g)(12) specify two main criteria for an urban hospital to count
the time spent by residents training in a rural track while at the
urban hospital in excess of the hospital's FTE limitation: (1) The
program must be separately accredited by the ACGME; and (2) the time
spent training in rural areas (either at a rural hospital or a rural
nonhospital site) must constitute at least two-thirds of the duration
of the program.
We believe that an urban hospital that operates a program that is
separately accredited by the ACGME as a ``1-2'' program, but in which
residents train in rural areas for more than half but less than two-
thirds of the duration of the program, should still be allowed to count
those FTE residents for GME payment purposes. Therefore, to be
consistent with the ACGME accreditation practices, we are proposing to
revise our regulations. Proposed Sec. 413.86(g)(12) would still
address our policy that an urban hospital qualifies for an adjustment
to the FTE cap for training in rural areas based upon the proportion of
time the residents spend training in the rural areas. However, instead
of using a ``two-thirds'' model to specify the amount of time residents
are training in the rural areas, as the framework exists under current
policy, the proposal would use, at Sec. Sec. 413.86(g)(12)(i) through
(iv), a ``one-half of the time'' model to specify the amount of time
residents are training in rural areas. This proposal would address the
limited cases where ACGME separately accredits programs as ``1-2''
rural tracks but residents in those programs train in the rural areas
less than two-thirds of the time, although greater than one-half of the
time. Specifically, we are proposing at Sec. 413.86(g)(12) to state:
[sbull] If an urban hospital rotates residents to a separately
accredited rural track program at a rural hospital(s) for two-thirds of
the duration of the program for cost reporting periods beginning on or
after April 1, 2000 and before October 1, 2003, or for more than one-
half of the duration of the program for cost reporting periods
beginning on or after October 1, 2003, the urban hospital may include
those residents in its FTE count for the time the rural track residents
spend at the urban hospital.
[sbull] If an urban hospital rotates residents to a separately
accredited rural track program at a rural nonhospital site(s) for two-
thirds of the duration of the program for cost reporting periods
beginning on or after April 1, 2000, and before October 1, 2003, or for
more than one-half of the duration of the program for cost reporting
periods beginning on or after October 1, 2003, the urban hospital may
include those residents in its FTE count, subject to the requirements
under Sec. 413.86(f)(4).
[sbull] If an urban hospital rotates residents in the rural track
program to a rural hospital(s) for less than two-thirds of the duration
of the program for cost reporting periods beginning on or after April
1, 2002, and before October 1, 2003, or for one-half or less than one-
half of the duration of the program for cost reporting periods
beginning on or after October 1, 2003, the rural hospital may not
include those residents it its FTE count (if the rural track is not a
new program under Sec. 413.86(g)(6)(iii), or if the rural hospital's
FTE count exceeds that hospital's FTE cap), nor may the urban hospital
include those residents when calculating its rural track FTE
limitation.
[sbull] If an urban hospital rotates residents in the rural track
program to a rural nonhospital site(s) for a period of time that is
less than two-thirds of the duration of the program for cost reporting
periods beginning on or after April 1, 2002, and before October 1,
2003, or for one-half or less than one-half of the duration of the
program for cost reporting periods beginning on or after October 1,
2003, the urban hospital may include those residents in its FTE count,
subject to the requirements under Sec. 413.86(f)(4).
We also are proposing to make a conforming change to Sec.
412.105(f)(1)(x) to make these proposed provisions applicable to IME
payments for discharges occurring on or after October 1, 2003.
We believe this proposal produces a more equitable result than the
existing policy; the proposal encompasses what we believe to be all
situations in which the ACGME separately accredits rural track programs
and in which residents in the programs spend a majority of the time
training in rural settings, fulfilling the intent of Congress for
Medicare to
[[Page 27220]]
provide GME payments for significant rural residency training.
b. Inclusion of Rural Track FTE Residents in the Rolling Average
Calculation. Section 1886(h)(4)(G) of the Act, as added by section 4623
of Public Law 105-33, provides that, for a hospital's first cost
reporting period beginning on or after October 1, 1997, the hospital's
FTE resident count for direct GME payment purposes equals the average
of the actual FTE resident count for that cost reporting period and the
preceding cost reporting period. Section 1886(h)(4)(G) of the Act
requires that, for cost reporting periods beginning on or after October
1, 1998, a hospital's FTE resident count for direct GME payment
purposes equals the average of the actual FTE resident count for the
cost reporting period and the preceding two cost reporting periods
(that is, a 3-year rolling average). This provision phases in over a 3-
year period any reduction in direct GME payments to hospitals that
results from a reduction in the number of FTE residents below the
number allowed by the FTE cap. We first implemented this provision in
the August 29, 1997 final rule with comment period (62 FR 46004) and
revised Sec. 413.86(g)(5) accordingly. Because hospitals may have two
PRAs, one for residents in primary care and obstetrics and gynecology
(the ``primary care PRA''), and a lower PRA for nonprimary care
residents, we revised our policy for computing the rolling average for
direct GME payment purposes (not for IME) in the August 1, 2001 final
rule (66 FR 39893) to create two separate rolling averages, one for
primary care and obstetrics and gynecology residents (the ``primary
care rolling average''), and one for nonprimary care residents.
Effective for cost reporting periods beginning on or after October 1,
2001, direct GME payments are calculated based on the sum of: (1) The
product of the primary care PRA and the primary care rolling average;
and (2) the product of the nonprimary care PRA and the nonprimary care
FTE rolling average. (This sum is then multiplied by the Medicare
patient load to determine Medicare direct GME payments).
Section 407(c) of Public Law 106-113, which amended sections
1886(d)(5)(B) and 1886(h)(4)(H) of the Act to create the rural track
provision, provided that, in the case of an urban hospital that
establishes a separately accredited rural track, ``* * * the Secretary
shall adjust the limitation under subparagraph (F) in an appropriate
manner insofar as it applies to such programs in such rural areas in
order to encourage the training of physicians in rural areas''
(emphasis added). Subparagraph (F) of the Act is the provision that
establishes a cap on the number of allopathic and osteopathic FTE
residents that may be counted at each hospital for Medicare direct GME
payment purposes. Thus, the provision authorizes the Secretary to allow
for an increase to an urban hospital's FTE cap on allopathic and
osteopathic residents in certain instances when an urban hospital
establishes a rural track program. Although the rural track provision
effectively allows an increase to the urban hospital's FTE cap by
adjusting the FTE limitation under subparagraph (F), the statute makes
no reference to subparagraph (G), the provision concerning the rolling
average count of residents. That is, the statute does not provide for
an exclusion from the rolling average for the urban hospital for those
FTE residents training in a rural track.
Since we implemented this rural track provision in the August 1,
2000 interim final rule with comment period (65 FR 47033), we have
interpreted this provision to mean that, except for new rural track
programs begun by urban teaching hospitals that are establishing an FTE
cap for the first time under Sec. 413.86(g)(6)(i), when an urban
hospital establishes a new rural track program or expands an existing
rural track program, FTE residents in the rural track that are counted
by the urban hospital are included in the hospital's rolling average
calculation immediately. Although we have not specified in the
regulations that rural track FTE residents counted by an urban hospital
are included in the hospital's rolling average FTE resident count, this
has been our policy. The Medicare cost report, Form CMS-2552-96 (line
3.05 on Worksheet E, Part A, for IME payments, and on line 3.02 on
Worksheet E-3, Part IV, for direct GME payments), reflects this policy.
Accordingly, FTE residents in a rural track program are to be included
in the urban hospital's rolling average count for IME and direct GME
for cost reporting periods beginning on or after April 1, 2000.
We are proposing to revise the regulations at Sec. 413.86(g)(5) to
add a new paragraph (vii) to clarify that, subject to regulations at
Sec. 413.86(g)(12), except for new rural track programs begun by urban
hospitals that are first establishing an FTE cap under Sec.
413.86(g)(6)(i), when an urban hospital with an existing FTE cap
establishes a new program with a rural track (or an integrated rural
track), or expands an existing rural track (or an integrated rural
track) program, the FTE residents in that program that are counted by
the urban hospital are included in the urban hospital's rolling average
FTE resident count immediately. We also are proposing to revise
Sec. Sec. 413.86(g)(12)(i)(A), (g)(12)(ii)(B), and (g)(12)(iv)(A) to
indicate that for the first 3 years of the rural track's existence, the
rural track FTE limitation for each urban hospital will be the actual
number of FTE residents, subject to the rolling average, training in
the rural track at the urban hospital.
4. Technical Change Relating to Affiliated Groups and Affiliation
Agreements
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 give hospitals flexibility in
structuring rotations within a combined cap when they share a
resident's 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). We further
clarified our policy concerning affiliation agreements in the August 1,
2002 final rule (67 FR 50069).
We are aware that there has been some confusion at times among
members of the provider community when using the term ``affiliation
agreement,'' since the term is used in contexts other than for Medicare
GME payment purposes. For example, an ``affiliation agreement'' is a
term historically used in the academic community that generally relates
to agreements made between hospitals and medical schools or among
sponsors of medical residency education programs. To help prevent
further confusion, we are proposing to change the term in the
regulations to ``Medicare GME affiliation agreement.'' We believe this
will help to distinguish these agreements used for purposes of GME
payments from agreements used for other purposes in the provider
community. We are proposing to revise the regulations at Sec.
413.86(b) to state ``Medicare GME affiliated group,'' and ``Medicare
GME affiliation agreement,'' and we are making similar revisions to
Sec. 413.86(g)(4)(iv), (g)(7)(i) through (v), and Sec.
412.105(f)(1)(vi) for IME payment purposes.
[[Page 27221]]
G. Notification of Updates to the Reasonable Compensation Equivalent
(RCE) Limits (Sec. 415.70)
1. Background
Under the Medicare program, payment for services furnished by a
physician is made under either the Hospital Insurance Program (Part A)
or the Supplementary Medical Insurance Program (Part B), depending on
the type of services furnished. In accordance with section 1848 of the
Act, physicians' charges for medical or surgical services to individual
Medicare patients generally are covered under Part B on a fee-for-
service basis under the Medicare physician fee schedule. The
compensation that physicians receive from or through a provider for
services that benefit patients generally (for example, administrative
services, committee work, teaching, and supervision) can be covered
under Part A or Part B, depending on the provider's setting.
As required by section 1887(a)(2)(B) of the Act, allowable
compensation for services furnished by physicians to providers that are
paid by Medicare on a reasonable cost basis is subject to reasonable
compensation equivalent (RCE) limits. Under these limits, payment is
determined based on the lower of the actual cost of the services to the
provider (that is, any form of compensation to the physician) or a
reasonable compensation equivalent. For purposes of applying the RCE
limits, physician compensation costs means monetary payments, fringe
benefits, deferred compensation and any other items of value (excluding
office space or billing and collection services) that a provider or
other organization furnishes a physician in return for the physician's
services.
The RCE limits do not apply to the costs of physician compensation
that are attributable to furnishing inpatient hospital services paid
for under the IPPS or GME costs. In addition, RCE limits do not apply
to the costs CAHs incur in compensating physicians for services.
Furthermore, compensation that a physician receives for activities that
may not be paid for under either Part A or Part B are not considered in
applying the RCE limits.
The limits apply equally to all physician services to providers
that are payable on a reasonable cost basis under Medicare. If a
physician receives any compensation from a provider for his or her
physician services to the provider (that is, those services that
benefit patients generally), payment to those affected providers for
the costs of such compensation is subject to the RCE limits. The RCE
limits are not applied to payment for services that are identifiable
medical or surgical services to individual patients and paid for under
the physician fee schedule, even if the physician agrees to accept
compensation (for example, from a hospital) for those services.
(However, payments to teaching hospitals that have elected to be paid
for these services on a reasonable cost basis in accordance with
section 1861(b)(7) of the Act are subject to the limits.)
Section 415.70(b) of the regulations specifies the methodology for
determining annual RCE limits, considering average physician incomes by
specialty and type of location, to the extent possible using the best
available data. On October 31, 1997, the revised RCE limits update
methodology was published in the Federal Register (62 FR 59075). For
cost reporting periods beginning on or after January 1, 1998, updates
to the RCE limits are calculated using the Medicare Economic Index
(MEI). The inflation factor used to develop the initial RCE limits and,
subsequently, to update those limits to reflect increases in net
physician compensation was the Consumer Price Index for All Urban
Consumers (CPI-U). In 1998, we revised the RCE limits update
methodology by replacing the CPI-U with the physician fee schedule's
inflation factor (the MEI), to achieve a measure of consistency in the
methodologies employed to determine reasonable payments to physicians
for direct medical and surgical services furnished to individual
patients and reasonable compensation levels for physicians' services
that benefit provider patients generally.
2. Publication of the Updated RCE Limits
We intend to publish updated payment limits on the amount of
allowable compensation for services furnished by physicians to
providers in the FY 2004 IPPS final rule. These revised limits will be
mere updates that will be calculated by applying the most recent
economic index data. We are not proposing any change in the
methodology. Therefore, in accordance with Sec. 415.70(f), we are
allowed to publish the revised RCE limits in a final rule without prior
publication of a proposed rule for public comment. Furthermore, we
believe that publication of the revised RCE limits in a proposed rule
with opportunity for public comment is unnecessary, and we find good
cause to waive the procedure.
V. PPS for Capital-Related Costs
In this proposed rule, we are not proposing any changes in the
policies governing the determination of the payment rates for capital-
related costs for short-term acute care hospitals under the IPPS.
However, for the readers' benefit, in this section of this proposed
rule, we are providing a summary of the statutory basis for the PPS for
hospital capital-related costs, the methodology used to determine
capital-related payments to hospitals, and a brief description of the
payment policies under the PPS for capital-related costs for new
hospitals, extraordinary circumstances, and exception (regular and
special) payments. (Refer to the August 1, 2001 IPPS final rule (66 FR
39910) for a more detailed discussion 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 regular and
special exceptions payments.)
Section 1886(g) of the Act requires the Secretary to pay for the
capital-related costs of inpatient hospital services ``in accordance
with a PPS established by the Secretary.'' Under the statute, the
Secretary has broad authority in establishing and implementing the PPS
for capital related costs. We initially implemented the capital PPS in
the August 30, 1991 IPPS 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 PPS for hospital
inpatient capital-related costs. Beginning in FY 2002, capital PPS
payments are based solely on the Federal rate for the vast majority of
hospitals. The basic methodology for determining capital prospective
payments based on the Federal rate is set forth in Sec. 412.312. For
the purpose of calculating payments for each discharge, the standard
Federal rate is adjusted as follows:
(Standard Federal Rate) x (DRG Weight) x (Geographic Adjustment Factor
(GAF)) x (Large Urban Add-on, if applicable) x (COLA Adjustment for
hospitals located in Alaska and Hawaii) x (1 + DSH Adjustment Factor +
IME Adjustment Factor, if applicable)
[[Page 27222]]
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.
During the 10-year transition period, a new hospital (as defined at
412.300(b)) was exempt from the capital PPS for its first 2 years of
operation and was paid 85 percent of its reasonable costs during that
period. Originally, this provision was effective only through the
transition period and, therefore, ended with cost reporting periods
beginning in FY 2002. As we discussed in the August 1, 2002 final rule
(67 FR 50101), 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. Therefore, we believe that the rationale for this policy
applies to new hospitals after the transition period as well, and in
that same final rule, we established regulations under Sec.
412.304(c)(2) that provide the same special payment to new hospitals
for cost reporting periods beginning on or after October 1, 2002.
Therefore, a new hospital, defined under Sec. 412.300(b), is paid 85
percent of its allowable Medicare inpatient hospital capital-related
costs through its first 2 years of operation unless the new hospital
elects to receive fully prospective payment based on 100 percent of the
Federal rate. (For more detailed information regarding this policy, see
the August 1, 2002 IPPS final rule (67 FR 50101).)
Regulations at Sec. 412.348(f) provide 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. This policy was established for
hospitals during the 10-year transition period, but we established
regulations at Sec. 412.312(e) to specify that payment for
extraordinary circumstances is also made for cost reporting periods
after the transition period (that is, cost reporting periods beginning
on or after October 1, 2001). (For more detailed information regarding
this policy, refer to the August 1, 2002 Federal Register (67 FR
50102).)
During the transition period, under Sec. Sec. 412.348(b) through
(e), eligible hospitals could receive regular exception payments. These
exception payments guaranteed a hospital a minimum payment of a
percentage of its Medicare allowable capital-related costs depending on
the class of hospital (Sec. 412.348(c)). However, after the end of the
transition period, eligible hospitals can receive additional payments
under the special exceptions provisions at Sec. 412.348(g), which
guarantees an eligible hospital a minimum payment of 70 percent of its
Medicare allowable capital-related costs. Special exceptions payments
may be made only for the 10 years after the cost reporting year in
which the hospital completes its qualifying project, which can be no
later than the hospital's cost reporting period beginning before
October 1, 2001. Thus, an eligible hospital may receive special
exceptions payments for up to 10 years beyond the end of the capital
PPS transition period. Hospitals eligible for special exceptions
payments were required to submit documentation to the intermediary
indicating the completion date of their project. (For more detailed
information regarding the special exceptions policy under Sec.
412.348(g), refer to the August 1, 2001 IPPS final rule (66 FR 39911
through 39914) and the August 1, 2002 IPPS final rule (67 FR 50102).)
VI. Proposed Changes for Hospitals and Hospital Units Excluded from the
IPPS
A. Payments to Excluded Hospitals and Hospital Units (Sec. Sec.
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
Pub. L. 105-33) established caps on the target amounts for certain
existing hospitals and hospital units excluded from the IPPS 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 LTCHs.
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 Sec. Sec. 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 would be computed using the hospital's or unit's target
amount from the previous cost reporting period updated by the rate-of-
increase specified in Sec. 413.40(c)(3)(viii) of the regulations 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 paid 100 percent of the
Federal rate. Effective for cost reporting periods beginning on or
after October 1, 2002, LTCHs also are no longer paid on a reasonable
cost basis but are paid under a DRG-based PPS. As part of this process
for LTCHs, we established a 5-year transition period from reasonable
cost-based reimbursement to a fully Federal PPS. However, a LTCH,
subject to the blend methodology, may elect to be paid based on a 100
percent of the Federal prospective rate. (Sections VII.A.3. and 4. of
this preamble contain for a more detailed discussion of the IRF PPS and
the LTCH PPS.)
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 LTCHs. 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 IPPS on
or after October 1, 1997.
The amount of payment for a ``new'' psychiatric hospital or unit
would be determined as follows:
[sbull] 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.
[sbull] Under existing Sec. 413.40(c)(4)(v), for cost reporting
periods following the hospital's or unit's first two 12-month cost
reporting periods, the target amount is equal to the amount determined
under section 1886(b)(7)(A)(i) of the Act for the third period, updated
by the applicable hospital market basket increase percentage.
[[Page 27223]]
The proposed amounts included in the following table reflect the
updated 110 percent of the national median target amounts of new
excluded psychiatric hospitals and units for cost reporting periods
beginning during FY 2004. These figures are updated with the most
recent data available to reflect the projected market basket increase
percentage of 3.5 percent. This projected percentage change in the
market basket reflects the average change in the price of goods and
services purchased by hospitals to furnish inpatient hospital services
(as projected by the Office of the Actuary of CMS based on its
historical experience with the IPPS). For a new provider, the labor-
related share of the target amount is multiplied by the appropriate
geographic area wage index, without regard to IPPS 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 2004 FY 2004
proposed proposed
Class of excluded hospital or unit labor- nonlabor-
related related
share share
------------------------------------------------------------------------
Psychiatric................................. $7,301 $2,902
------------------------------------------------------------------------
Effective for cost reporting periods beginning on or after October
1, 2002, this payment limitation is no longer applicable to new LTCHs
because they are paid 100 percent of the Federal rate. Under the LTCH
PPS, a new LTCH is defined as a provider of inpatient hospital services
that meets the qualifying criteria for LTCHs specified under Sec.
412.23(e)(1) and (e)(2) and whose first cost reporting period as a LTCH
begins on or after October 1, 2002 (Sec. 412.23(e)(4)). (We note that
this definition of new LTCHs should not be confused with those LTCHs
first paid under the TEFRA payment system for discharges occurring on
or after October 1, 1997, and before October 1, 2002.) New LTCHs are
paid based on 100 percent of the fully Federal prospective rate (they
may not participate in the 5-year transition from cost-based
reimbursement to prospective payment). In contrast, those ``new'' LTCHs
that meet the definition of ``new'' under Sec. 413.40(f)(2)(ii) and
that have their first cost reporting periods beginning on or after
October 1, 1997, and before October 1, 2002, may be paid under the LTCH
PPS transition methodology. Since those hospitals by definition would
have been considered new before October 1, 2002, they would have been
subject to the updated payment limitation on new hospitals that was
published in the FY 2003 IPPS final rule (67 FR 50103). Under existing
regulations at Sec. 413.40(f)(2)(ii), the ``new'' hospital would be
subject to the same cap in its second cost reporting period; this cap
would not be updated for the new hospital's second cost reporting year.
Thus, because the same cap is to be used for the new LTCH's first two
cost reporting periods, it is no longer necessary to publish an updated
cap for new LTCHs.
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 because they are paid 100 percent of
the Federal prospective rate under the IRF PPS. Therefore, it is also
no longer necessary to update the payment limitation for new
rehabilitation hospitals or units.
3. Implementation of a PPS for IRFs
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 PPS 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 PPS 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 PPS 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 PPS for inpatient rehabilitation
facilities, effective for cost reporting periods beginning on or after
January 1, 2002. Under the IRF PPS, for cost reporting periods
beginning on or after January 1, 2002, and before October 1, 2002,
payment consisted 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, payments
are based entirely on the Federal prospective payment rate determined
under the IRF PPS.
4. Implementation of a PPS for LTCHs
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
established a per discharge, DRG-based PPS for LTCHs as described in
section 1886(d)(1)(B)(iv) of the Act for cost reporting periods
beginning on or after October 1, 2002, in a final rule issued on August
30, 2002 (67 FR 55954). The LTCH PPS uses information from LTCH
hospital patient records to classify patients into distinct LTC-DRGs
based on clinical characteristics and expected resource needs. Separate
payments are calculated for each LTC-DRG with additional adjustments
applied.
As part of the implementation of the system, we established a 5-
year transition period from reasonable cost-based reimbursement to the
fully Federal prospective rate. A blend of the reasonable cost-based
reimbursement percentage and the prospective payment Federal rate
percentage would be used to determine a LTCH's total payment under the
LTCH PPS during the transition period. Certain LTCHs may elect to be
paid based on 100 percent of the Federal prospective rate. All LTCHs
will be paid under the fully Federal prospective rate for cost
reporting periods beginning on or after October 1, 2006.
B. Payment for Services Furnished at Hospitals-Within-Hospitals and
Satellite Facilities
Existing regulations at Sec. 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. Moreover, existing
Sec. 412.22(f) provides for the grandfathering of hospitals-within-
hospitals that were in existence on or before September 30, 1995.
Sections 412.22(h) and 412.25(e), relating to satellites of
hospitals and hospital units, respectively, excluded from the IPPS,
define a satellite facility as a part of a hospital or 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. Sections 412.22(h)(3) and
412.25(e)(3) provide for the grandfathering of excluded hospitals and
units that were structured as satellite facilities on September 30,
1999, to the extent they operate under
[[Page 27224]]
the same terms and conditions in effect on that date.
In providing for the grandfathering of satellite facilities of
hospitals and hospital units, we believed it was appropriate to require
that the satellite facilities operate under the same terms and
conditions that were in effect on September 30, 1999. There are
similarities between the definition of the two types of satellite
facilities and the definition of hospitals-within-hospitals (that is,
hospitals-within-hospitals and satellite facilities are both physically
located in acute care hospitals that are paid for their inpatient
services on a prospective payment basis). Also, satellite facilities of
both excluded hospitals and hospital units and hospitals-within-
hospitals provide inpatient hospital services that are paid at a higher
rate than would apply if the facilities were treated by Medicare as
part of an acute care hospital.
We are proposing to revise Sec. 412.22(f) to specify that,
effective with cost reporting periods beginning on or after October 1,
2003, a hospital operating as a hospital-within-a-hospital on or before
September 30, 1995, is exempt from the criteria in Sec. 412.22(e)(1)
through (e)(5) only if the hospital-within-a-hospital continues to
operate under the same terms and conditions in effect as of September
30, 1995. The intent of the ``grandfathering'' provision was to ensure
that hospitals that had been in existence prior to the effective date
of our hospital-within-hospital requirements should not be adversely
affected by those requirements. To the extent hospitals were already
operating as hospitals-within-hospitals without meeting those
requirements, we believe it is appropriate to limit the
``grandfathering'' provision to those hospitals that continue to
operate in the same manner as they had operated prior to the effective
date of those rules. However, if a hospital changes the way it operates
(for example, adds more beds) subsequent to the effective date of the
new rules, it should no longer receive the benefit of the
``grandfathering'' provision.
Under Sec. 412.22(e), we specify the criteria that a hospital-
within-a-hospital is required to meet in order to be excluded from the
IPPS. One of these criteria, under Sec. 412.22(e)(5)(i), requires that
a hospital-within-a-hospital is able to perform basic hospital
functions (for example, medical record services and nursing services)
that are presently included in the Medicare hospital conditions of
participation under Part 482 of the Medicare regulations. These
requirements were first included in Part 412 in response to hospitals
organizing themselves as what is referred to as the hospital-within-a-
hospital model. Thus, to avoid recognizing nominal hospitals, while
allowing hospitals adequate flexibility and opportunity for legitimate
networking and sharing of services, we included, by reference, certain
hospital conditions of participation as additional criteria in part 412
for hospitals-within-hospitals that request exclusion from the IPPS.
(Further discussion can be found in a final rule published in the
Federal Register on September 1, 1994 (59 FR 45389).) Modifications to
the conditions of participation have been made since the publication of
that September 1, 1994 final rule. Thus, we need to update the
references to the conditions of participation in Sec. 412.22(e)(5)(i)
to make them consistent with existing provisions under the basic
hospital conditions of participation. Therefore, we are proposing to
amend Sec. 412.22(e)(5)(i) to add references to Sec. 482.43
(discharge planning) and Sec. 482.45 (organ, tissue, and eye
procurement) as basic hospital functions that a hospital-within-a-
hospital would also be required to meet.
C. Clarification of Classification Requirements for LTCHs
Under Sec. 412.23(e)(2), to qualify to be excluded from the IPPS
as a LTCH and to be paid under the LTCH PPS, a hospital must have an
average Medicare length of stay of greater than 25 days (which includes
all covered and noncovered days of stay for Medicare patients) as
calculated under the criteria of Sec. 412.23(e)(3). In calculating
this average Medicare inpatient length of stay, data from the
hospital's most recently filed cost report are used to make this
determination. However, if the hospital has not yet filed a cost report
or if there is an indication that the most recently filed cost report
does not accurately reflect the hospital's current Medicare average
length of stay, data from the most recent 6-month period are used.
Our interpretation of Sec. 412.23(e)(3)(ii) and (e)(3)(iii) was to
allow hospitals that submit data for purposes of exclusion from the
IPPS to use a period of at least 5 months of the most recent data from
the preceding 6-month period. This longstanding policy interpretation
was necessary in order to comply with the time requirement in Sec.
412.22(d) that specifies that, for purposes of the IPPS, status is
determined at the beginning of each cost reporting period and is
effective for the entire cost reporting period. Therefore, we are
proposing to revise Sec. Sec. 412.23(e)(3)(ii) and (iii) to reflect
our longstanding interpretation of the regulations.
D. Criteria for Payment on a Reasonable Cost Basis for Clinical
Diagnostic Laboratory Services Performed by CAHs
Section 1820 of the Act provides for the establishment of Medicare
Rural Hospital Flexibility Programs, under which individual States may
designate certain facilities as critical access hospitals (CAHs).
Facilities that are so designated and meet the CAH conditions of
participation in 42 CFR part 485, subpart F, will be certified as CAHs
by CMS. Section 1834(g) of the Act states that the amount of payment
for outpatient services furnished by a CAH will be the reasonable costs
of the CAH in providing these services.
Regulations implementing section 1834(g) of the Act are set forth
at Sec. 413.70. These regulations state, in paragraph (b)(2)(iii),
that payment to a CAH for outpatient clinical diagnostic laboratory
tests will be made on a reasonable cost basis only if the individuals
for whom the tests are performed are outpatients of the CAH, as defined
in 42 CFR 410.2, at the time the specimens are collected. The
regulations also state that clinical diagnostic laboratory tests for
persons who are not patients of the CAH at the time the specimens are
collected will be paid for in accordance with the provisions of
sections 1833(a)(1)(D) and 1833(a)(2)(D) of the Act. These provisions,
which also are the basis for payment for clinical diagnostic laboratory
tests performed by independent laboratories and by hospitals on
specimens drawn at other locations, set payment at the least of: (1)
Charges determined under the fee schedule as set forth in section
1833(h)(1) or section 1834(d)(1) of the Act; (2) the limitation amount
for that test determined under section 1833(h)(4)(B) of the Act; or (3)
a negotiated rate established under section 1833(h)(6) of the Act.
Payments determined under this methodology are typically referred to as
``fee schedule payments,'' and are so described here both for ease of
reference and to differentiate them from payments determined on a
reasonable cost basis.
The definition of an ``outpatient'' in 42 CFR 410.2 states that an
outpatient means a person who has not been admitted as an inpatient but
who is registered on hospital or CAH records as an outpatient and
receives services (rather than supplies alone) directly from the
hospital or CAH.
Recently, we have received numerous questions about how Medicare
pays for laboratory services that a CAH may furnish to Medicare
beneficiaries in various settings other than the CAH.
[[Page 27225]]
Specifically, the questioners have asked whether a CAH may obtain
reasonable cost payment for such services to individuals in other
locations by sending a CAH employee into the setting and registering
the individual as a CAH patient while the blood is drawn or other
specimen collection is accomplished. The settings that have been
referred to most frequently are: (1) A rural health clinic (RHC),
especially one that is provider-based with respect to the CAH; (2) the
individual's home; and (3) a SNF.
We have considered these suggestions and understand the position
taken by those who believe that nominal compliance with the
requirements for outpatient status should be enough to warrant
reasonable cost payment for clinical diagnostic laboratory tests for
individuals at locations outside the CAH. However, we do not agree that
providing reasonable cost payment under these circumstances would be
appropriate. On the contrary, we believe that extending reasonable cost
payment for services furnished to individuals who are not at the CAH
when the specimen is drawn would duplicate existing coverage, create
confusion for beneficiaries and others by blurring the distinction
between CAHs and other providers, such as SNFs and HHAs, and increase
the costs of care to Medicare patients without enhancing either the
quality or the availability of that care.
To clarify our policies in this area and avoid possible
misunderstandings about the scope of the CAH benefit, we are proposing
to revise Sec. 413.70(b)(2)(iii) to state that payment to a CAH for
outpatient clinical diagnostic laboratory tests will be made on a
reasonable cost basis only if the individuals for whom the tests are
performed are outpatients of the CAH, as defined in 42 CFR 410.2, ``and
are physically present in the CAH'' at the time the specimens are
collected. (We note that, in some cases, the CAH outpatients from whom
specimens are collected at the CAH may include individuals referred to
the CAH from RHCs or other facilities to receive the tests.) We are
proposing to further revise this paragraph to state that clinical
diagnostic laboratory tests for individuals who do not meet these
criteria but meet other applicable requirements will be paid for only
in accordance with the provisions of sections 1833(a)(1)(D) and
1833(a)(2)(D) of the Act, that is, payment will be made only on a fee
schedule basis. By making the second proposed change, we wish to
emphasize that this proposal does not mean that no payment would be
made for clinical diagnostic laboratory tests performed by CAHs that do
not meet the revised criteria. On the contrary, such tests would be
paid, but on a fee schedule basis. We believe these clarifications are
appropriate, as the CAH is not providing CAH services but is acting as
an independent laboratory in providing these clinical diagnostic
laboratory tests.
E. Technical Change
On July 30, 1999, we published in the Federal Register a final rule
(64 FR 41532) that set forth criteria for a satellite facility of a
hospital or hospital unit to be excluded from the IPPS under Sec.
412.25. Section 412.25(e)(3) of the regulations specifies that any unit
structured as a satellite facility on September 30, 1999, and excluded
from the IPPS on that date, is grandfathered as an excluded hospital to
the extent that the unit continues operating under the same terms and
conditions, including the number of beds and square footage considered
to be part of the unit, in effect on September 30, 1999, except as we
specified in Sec. 412.25(e)(4). When we specified the exception for
the number of beds and square footage requirement under Sec.
412.25(e)(4), we inadvertently referred to paragraph (e)(4) as being an
exception to paragraph (h)(3). We should have specified that it was an
exception to paragraph (e)(3). We are proposing to correct this
reference.
VII. MedPAC Recommendations
We are required by section 1886(e)(4)(B) of the Act to respond to
MedPAC's IPPS recommendations in our annual proposed rule. We have
reviewed MedPAC's March 1, 2003 ``Report to the Congress: Medicare
Payment Policy'' and have given it careful consideration in conjunction
with the proposals set forth in this document. For further information
relating specifically to the MedPAC report or to obtain a copy of the
report, contact MedPAC at (202) 653-7220, or visit MedPAC's Web site
at: http://www.medpac.gov.
MedPAC's Recommendation 2A-6 concerning the update factor for
inpatient hospital operating costs and for hospitals and distinct-part
hospital units excluded from the IPPS is discussed in Appendix C to
this proposed rule. MedPAC's other recommendations relating to payments
for Medicare inpatient hospital services focused mainly on the
expansion of DRGs subject to the postacute care transfer policy, a
reevaluation of the labor-related share of the market basket used in
determining the hospital wage index, an increase in the DSH adjustment,
and payments to rural hospitals. These recommendations and our
responses are set forth below:
Recommendation 2A-1: The Secretary should add 13 DRGs to the
postacute transfer policy in FY 2004 and then evaluate the effects on
hospitals and beneficiaries before proposing further expansions.
Response: We are proposing to expand the postacute care transfer
policy to 19 additional DRGs for FY 2004. A thorough discussion of this
proposal, including a summary of MedPAC's analysis, can be found at
section IV.A.3. of this preamble.
Recommendation 2A-2: The Congress should enact a low-volume
adjustment to the rates used in the inpatient PPS. This adjustment
should apply only to hospitals that are more than 15 miles from another
facility offering acute inpatient care.
Response: MedPAC's analysis ``revealed that hospitals with a small
volume of total discharges have higher costs per discharge than larger
facilities, after controlling for the other cost-related factors
recognized in the payment system.'' Although there are special payment
protections for some rural hospitals such as CAHs, SCHs, and MDHs,
MedPAC believes these provisions do not sufficiently target hospitals
with low discharge volume.
This recommendation, which MedPAC estimates would increase Medicare
payments to hospitals by less than $50 million in FY 2004, and others
requiring Congressional action, should be considered in the context of
larger discussions within Congress and between Congress and the
Administration regarding Medicare reform and payment refinements.
Therefore, we are not responding specifically to MedPAC's
recommendation regarding a low-volume adjustment to the IPPS payments
at this time.
Recommendation 2A-3: The Secretary should reevaluate the labor
share used in the wage index system that geographically adjusts rates
in the inpatient PPS, with any resulting change phased in over 2 years.
Response: CMS defines the labor-related share to include costs that
are likely related to, influenced by, or vary with local labor markets,
even if they could be purchased in a national market. Since the
implementation of the IPPS, the labor-related share has been determined
by adding together the cost weights from categories in the hospital
market basket that are influenced by local labor markets. When the
hospital market basket weights are updated or rebased, the labor-
related share is updated. The estimate of the labor-
[[Page 27226]]
related share using the most recently revised and rebased hospital
market basket (1997-based) is 72.495 percent. This was the labor-
related share proposed in the FY 2003 proposed rule.
In the August 1, 2002 IPPS final rule, we elected to continue to
use 71.066 percent as the labor-related share applicable to the
standardized amounts (67 FR 50041). At that time, we indicated that we
would conduct further analysis to determine the most appropriate
methodology for the labor-related share.
We are not proposing to use the updated labor-related share at this
time because we have not yet completed our research into the
appropriateness of this measure. Specifically, we are currently
reviewing the labor-related share in two ways. First, we are updating
the regression analysis that was done when the IPPS was originally
developed, with the expectation that it would help give an alternative
indication of the labor-related share. Second, we are reevaluating the
methodology we currently use for determining the labor-related share
using the hospital market basket.
Our regression analysis attempts to explain the variation in
operating cost per case for a given year using many different
explanatory variables, such as case-mix, DSH status, and ownership
type. We described this methodology and some of our initial results in
the May 9, 2002 Federal Register (67 FR 31447-31479). When included in
the regression, the area wage index produces a coefficient that can be
interpreted as the proportion of operating costs that vary with the
geographic location of the hospital. The latest results on 1997 data
produced a coefficient for the area wage index of 0.621, which can be
interpreted as a labor share of 62.1 percent and is very close to the
results reached by other groups. However, using the same specification
produced coefficients of 76.7 percent for rural hospitals and 47.6
percent for urban hospitals, a disparity that cannot be supported
either by theory or existing cost data. For example, the proportion of
costs accounted for by wages, benefits, and contract labor is 60.8
percent for urban hospitals and 62.3 percent for rural hospitals, a
spread much smaller than the regressions indicate. In addition, when
the regressions were run separately by case-mix quartile and with
hospital-specific wage variation (as opposed to using the area wage
index), the findings were both difficult to explain and inconsistent
with the underlying cost data. Thus, we believe at this point that the
regression results are not robust enough to support changing the
current labor-related share measurement.
A second approach was to reevaluate our methodology for determining
the labor-related share using the hospital market basket. We have
researched various alternative data sources for further breaking down
the cost categories in the market basket and have begun to evaluate
alternative methodologies. While each of these alternatives has
strengths and weaknesses, it is not clear at this point that any one
alternative is superior to the current methodology. We want to continue
researching these alternatives, in part, because changing from the
current methodology would impact the labor-related shares for SNFs,
HHAs, and all of the excluded hospital payment systems, since they use
a similar methodology. Our research plan includes consulting with
experts on these issues, including MedPAC, to evaluate the various
alternative approaches to determining the labor-related share. We plan
to invite public comments on any proposed change to the labor-related
share.
In conclusion, we are proposing to continue using the 71.066
percent labor-related share that was calculated from the 1992-based
market basket until we have completed our research.
Recommendation 2A-4: The Congress should raise the inpatient base
rate for hospitals in rural and other urban areas to the level of the
rate for those in large urban areas, phased in over 2 years.
Response: This recommendation, which MedPAC estimates would
increase Medicare payments to hospitals by between $200 and $600
million in FY 2004, and others requiring Congressional action, should
be considered in the context of larger discussions within Congress and
between Congress and the Administration regarding Medicare reform and
payment refinements. Therefore, we are not responding specifically to
MedPAC's recommendation regarding raising the base rate for hospitals
in rural and other urban areas at this time.
Recommendation 2A-5: The Congress should raise the cap on the
disproportionate share add-on a hospital can receive in the inpatient
PPS from 5.25 percent to 10 percent, phased in over 2 years.
Response: This recommendation, which MedPAC estimates would
increase Medicare payments to hospitals by between $50 and $200 million
in FY 2004, and others requiring Congressional action, should be
considered in the context of larger discussions within Congress and
between Congress and the Administration regarding Medicare reform and
payment refinements. Therefore, we are not responding specifically to
MedPAC's recommendation regarding raising the maximum DSH adjustments
at this time.
VIII. Other Required Information
A. Requests for Data From the Public
In order to respond promptly to public requests for data related to
the prospective payment system, we have established a process under
which commenters can gain access to raw data on an expedited basis.
Generally, the data are available in computer tape or cartridge format;
however, some files are available on diskette as well as on the
Internet at http://www.hcfa.gov/stats/pufiles.htm. Data files and the
cost for each file, if applicable, are listed below. Anyone wishing to
purchase data tapes, cartridges, or diskettes should submit a written
request along with a company check or money order (payable to CMS-PUF)
to cover the cost to the following address: Centers for Medicare &
Medicaid Services, Public Use Files, Accounting Division, PO Box 7520,
Baltimore, MD 21207-0520, (410) 786-3691. Files on the Internet may be
downloaded without charge.
1. CMS Wage Data
This file contains the hospital hours and salaries for FY 2000 used
to create the proposed FY 2004 prospective payment system wage index.
The file will be available by the beginning of February for the NPRM
and the beginning of May for the final rule.
------------------------------------------------------------------------
Wage data PPS fiscal
Processing year year year
------------------------------------------------------------------------
2003.......................................... 2000 2004
2002.......................................... 1999 2003
2001.......................................... 1998 2002
2000.......................................... 1997 2001
1999.......................................... 1996 2000
1998.......................................... 1995 1999
1997.......................................... 1994 1998
1996.......................................... 1993 1997
1995.......................................... 1992 1996
1994.......................................... 1991 1995
1993.......................................... 1990 1994
1992.......................................... 1989 1993
1991.......................................... 1988 1992
------------------------------------------------------------------------
These files support the following:
[sbull] NPRM published in the Federal Register.
[sbull] Final Rule published in the Federal Register.
Media: Diskette/most recent year on the Internet.
File Cost: $165.00 per year.
Periods Available: FY 2004 PPS Update.
[[Page 27227]]
2. CMS Hospital Wages Indices (Formerly: Urban and Rural Wage Index
Values Only)
This file contains a history of all wage indices since October 1,
1983.
Media: Diskette/most recent year on the Internet.
File Cost: $165.00 per year.
Periods Available: FY 2004 PPS Update.
3. PPS SSA/FIPS MSA State and County Crosswalk
This file contains a crosswalk of State and county codes used by
the Social Security Administration (SSA) and the Federal Information
Processing Standards (FIPS), county name, and a historical list of
Metropolitan Statistical Area (MSA).
Media: Diskette/Internet.
File Cost: $165.00 per year.
Periods Available: FY 2004 PPS Update.
4. Reclassified Hospitals New Wage Index (Formerly: Reclassified
Hospitals by Provider Only)
This file contains a list of hospitals that were reclassified for
the purpose of assigning a new wage index. Two versions of these files
are created each year. They support the following:
[sbull] NPRM published in the Federal Register.
[sbull] Final Rule published in the Federal Register.
Media: Diskette/Internet.
File Cost: $165.00 per year.
Periods Available: FY 2004 PPS Update.
5. PPS-IV to PPS-XII Minimum Data Set
The Minimum Data Set contains cost, statistical, financial, and
other information from Medicare hospital cost reports. The data set
includes only the most current cost report (as submitted, final
settled, or reopened) submitted for a Medicare participating hospital
by the Medicare fiscal intermediary to CMS. This data set is updated at
the end of each calendar quarter and is available on the last day of
the following month.
Media: Tape/Cartridge.
File Cost: $770.00 per year.
------------------------------------------------------------------------
Periods
beginning and before
on or after
------------------------------------------------------------------------
PPS-IV........................................ 10/01/86 10/01/87
PPS-V......................................... 1010/01/87 10/01/88
PPS-VI........................................ 1010/01/88 10/01/89
PPS-VII....................................... 1010/01/89 10/01/90
PPS-VIII...................................... 1010/01/90 10/01/91
PPS-IX........................................ 1010/01/91 10/01/92
PPS-X......................................... 1010/01/92 10/01/93
PPS-XI........................................ 1010/01/93 10/01/94
PPS-XII....................................... 1010/01/94 10/01/95
------------------------------------------------------------------------
(Note: The PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, and
PPS-XVIII Minimum Data Sets are part of the PPS-XIII, PPS-XIV, PPS-
XV, PPS-XVI, PPS-XVII, and PPS-XVIII Hospital Data Set Files (refer
to item 9 below).)
6. PPS-IX to PPS-XII Capital Data Set
The Capital Data Set contains selected data for capital-related
costs, interest expense and related information and complete balance
sheet data from the Medicare hospital cost report. The data set
includes only the most current cost report (as submitted, final settled
or reopened) submitted for a Medicare certified hospital by the
Medicare fiscal intermediary to CMS. This data set is updated at the
end of each calendar quarter and is available on the last day of the
following month.
Media: Tape/Cartridge.
File Cost: $770.00 per year.
------------------------------------------------------------------------
Periods
beginning and before
on or after
------------------------------------------------------------------------
PPS-IX........................................ 10/01/91 10/01/92
PPS-X......................................... 10/01/92 10/01/93
PPS-XI........................................ 10/01/93 10/01/94
PPS-XII....................................... 10/01/94 10/01/95
------------------------------------------------------------------------
(Note: The PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, and
PPS-XVIII Capital Data Sets are part of the PPS-XIII, PPS-XIV, PPS-
XV, PPS-XVI, PPS-XVII, and PPS-XVIII Hospital Data Set Files (refer
to item 9 below).)
7. PPS-XIII to PPS-XVIII Hospital Data Set
The file contains cost, statistical, financial, and other data from
the Medicare Hospital Cost Report. The data set includes only the most
current cost report (as submitted, final settled, or reopened)
submitted for a Medicare-certified hospital by the Medicare fiscal
intermediary to CMS. The data set is updated at the end of each
calendar quarter and is available on the last day of the following
month.
Media: Diskette/Internet.
File Cost: $2,500.00.
------------------------------------------------------------------------
Periods
beginning and before
on or after
------------------------------------------------------------------------
PPS-XIII...................................... 10/01/95 10/01/96
PPS-XIV....................................... 10/01/96 10/01/97
PPS-XV........................................ 10/01/97 10/01/98
PPS-XVI....................................... 10/01/98 10/01/99
PPS-XVII...................................... 10/01/99 10/01/00
PPS-XVIII..................................... 10/01/00 10/01/01
------------------------------------------------------------------------
8. Provider-Specific File
This file is a component of the PRICER program used in the fiscal
intermediary's system to compute DRG payments for individual bills. The
file contains records for all prospective payment system eligible
hospitals, including hospitals in waiver States, and data elements used
in the prospective payment system recalibration processes and related
activities. Beginning with December 1988, the individual records were
enlarged to include pass-through per diems and other elements.
Media: Diskette/Internet.
File Cost: $265.00.
Periods Available: FY 2004 PPS Update.
9. CMS Medicare Case-Mix Index File
This file contains the Medicare case-mix index by provider number
as published in each year's update of the Medicare hospital inpatient
prospective payment system. The case-mix index is a measure of the
costliness of cases treated by a hospital relative to the cost of the
national average of all Medicare hospital cases, using DRG weights as a
measure of relative costliness of cases. Two versions of this file are
created each year. They support the following:
[sbull] NPRM published in the Federal Register.
[sbull] Final rule published in the Federal Register.
Media: Diskette/most recent year on Internet.
Price: $165.00 per year/per file.
Periods Available: FY 1985 through FY 2004.
10. DRG Relative Weights (Formerly Table 5 DRG)
This file contains a listing of DRGs, DRG narrative description,
relative weights, and geometric and arithmetic mean lengths of stay as
published in the Federal Register. The hard copy image has been copied
to diskette. There are two versions of this file as published in the
Federal Register:
[sbull] NPRM.
[sbull] Final rule.
Media: Diskette/Internet.
File Cost: $165.00.
Periods Available: FY 2004 PPS Update.
11. PPS Payment Impact File
This file contains data used to estimate payments under Medicare's
hospital inpatient prospective payment systems for operating and
capital-related costs. The data are taken from various sources,
including the Provider-Specific File, Minimum Data Sets, and prior
impact files. The data set is abstracted
[[Page 27228]]
from an internal file used for the impact analysis of the changes to
the prospective payment systems published in the Federal Register. This
file is available for release 1 month after the proposed and final
rules are published in the Federal Register.
Media: Diskette/Internet.
File Cost: $165.00.
Periods Available: FY 2004 PPS Update.
12. AOR/BOR Tables
This file contains data used to develop the DRG relative weights.
It contains mean, maximum, minimum, standard deviation, and coefficient
of variation statistics by DRG for length of stay and standardized
charges. The BOR tables are ``Before Outliers Removed'' and the AOR is
``After Outliers Removed.'' (Outliers refers to statistical outliers,
not payment outliers.)
Two versions of this file are created each year. They support the
following:
[sbull] NPRM published in the Federal Register.
[sbull] Final rule published in the Federal Register.
Media: Diskette/Internet.
File Cost: $165.00.
Periods Available: FY 2004 PPS Update.
13. Prospective Payment System (PPS) Standardizing File
This file contains information that standardizes the charges used
to calculate relative weights to determine payments under the
prospective payment system. Variables include wage index, cost-of-
living adjustment (COLA), case-mix index, disproportionate share, and
the Metropolitan Statistical Area (MSA). The file supports the
following:
[sbull] NPRM published in the Federal Register.
[sbull] Final rule published in the Federal Register.
Media: Internet.
File Cost: No charge.
Periods Available: FY 2004 PPS Update.
For further information concerning these data tapes, contact the
CMS Public Use Files Hotline at (410) 786-3691.
Commenters interested in obtaining or discussing any other data
used in constructing this rule should contact Stephen Phillips at (410)
786-4548.
B. Collection of Information Requirements
This document does not impose information collection and
recordkeeping requirements. Consequently, it need not be reviewed by
the Office of Management and Budget under the authority of the
Paperwork Reduction Act of 1995.
List of Subjects
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.
For the reasons stated in the preamble of this proposed rule, the
Centers for Medicare & Medicaid Services proposes to amend 42 CFR
chapter IV as follows:
PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL
SERVICES
1. The authority citation for part 412 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
2. Section 412.4 is amended by--
A. Revising paragraphs (b), (c), and (d).
B. In paragraph (f)(1), revising the reference ``paragraph (b)(1)
or (c)'' to read ``paragraph (b) or (c)''.
The revisions read as follows:
Sec. 412.4 Discharges and transfers.
* * * * *
(b) Acute care transfers. A discharge of a hospital inpatient is
considered to be a transfer for purposes of payment under this part if
the patient is readmitted the same day (unless the readmission is
unrelated to the initial discharge) to another hospital that is--
(1) Paid under the prospective payment system described in subparts
A through M of this part; or
(2) Excluded from being paid under the prospective payment system
described in subparts A through M of this part because of participation
in an approved statewide cost control program as described in subpart C
of part 403 of this chapter.
(c) Postacute care transfers. A discharge of a hospital inpatient
is considered to be a transfer for purposes of this part when the
patient's discharge is assigned, as described in Sec. 412.60(c), to
one of the qualifying diagnosis-related groups (DRGs) listed in
paragraph (d) of this section and the discharge is made under any of
the following circumstances:
(1) To a hospital or distinct part hospital unit excluded from the
prospective payment system described in subparts A through M of this
part under subpart B of this part.
(2) To a skilled nursing facility.
(3) To home under a written plan of care for the provision of home
health services from a home health agency and those services begin
within 3 days after the date of discharge.
(d) Qualifying DRGs. For purposes of paragraph (c) of this section,
the qualifying DRGs are:
(1) For discharges occurring on or after October 1, 1998, DRGs 14,
113, 209, 210, 211, 236, 263, 264, 429, and 483.
(2) For discharges occurring on or after October 1, 2003, the DRGs
listed in paragraph (d)(1) of this section and DRGs 12, 24, 25, 89, 90,
121, 122, 130, 131, 239, 243, 277, 278, 296, 297, 320, 321, 462, and
468.
* * * * *
3. Section 412.22 is amended by:
A. Republishing the introductory text of paragraph (e)(5) and
revising the first sentence of paragraph (e)(5)(i).
B. Revising paragraph (f).
The revisions read as follows:
Sec. 412.22 Excluded hospitals and hospital units: General rules.
* * * * *
(e) * * *
(5) Performance of basic hospital functions. The hospital meets one
of the following criteria:
(i) The hospital performs the basic functions specified in
Sec. Sec. 482.21 through 482.27, 482.30, 482.42, 482.43, and 482.45 of
this chapter through the use of employees or under contracts or other
agreements with entities other than the hospital occupying space in the
same building or on the same campus, or a third entity that controls
both hospitals. * * *
(f) Application for certain hospitals. If a hospital was excluded
from the prospective payment systems under the provisions of this
section on or before September 30, 1995, and at that time occupied
space in a building also used by another hospital, or in one or more
buildings located on the same campus as buildings used by another
hospital, the criteria in paragraph (e) of this section do not apply to
the hospital. However, effective for cost reporting periods beginning
on or after October 1, 2003, those hospitals-within-hospitals must
continue to operate under the same terms and conditions, including the
number of beds and square footage considered, for purposes of Medicare
participation and payment, in effect on September 30, 1995.
* * * * *
4. Section 412.23 is amended by revising paragraphs (e)(3)(ii) and
(e)(3)(iii) to read as follows:
[[Page 27229]]
Sec. 412.23 Excluded hospitals: Classifications.
* * * * *
(e) Long-term care hospitals. * * *
(3) Calculation of average length of stay. * * *
(ii) If a change in the hospital's Medicare average length of stay
is indicated, the calculation is made by the same method for the period
of at least 5 months of the immediately preceding 6-month period.
(iii) If a hospital has undergone a change of ownership (as
described in Sec. 489.18 of this chapter) at the start of a cost
reporting period or at any time within the period of at least 5 months
of the preceding 6-month period, the hospital may be excluded from the
prospective payment system as a long-term care hospital for a cost
reporting period if, for the period of at least 5 months of the 6
months immediately preceding the start of the period (including time
before the change of ownership), the hospital has the required Medicare
average length of stay, continuously operated as a hospital, and
continuously participated as a hospital in Medicare.
* * * * *
Sec. 412.25 [Amended]
5. In Sec. 412.25(e)(4), introductory text, the reference
``paragraph (h)(3) of this section'' is revised to read ``paragraph
(e)(3) of this section''.
6. Section 412.87 is amended by revising paragraph (b)(3) to read
as follows:
Sec. 412.87 Additional payment for new medical services and
technologies: General provisions.
* * * * *
(b) Eligibility criteria. * * *
(3) The DRG prospective payment rate otherwise applicable to
discharges involving the medical service or technology is determined to
be inadequate, based on application of a threshold amount to estimated
charges incurred with respect to such discharges. To determine whether
the payment would be adequate, CMS will determine whether the charges
of the cases involving a new medical service or technology will exceed
a threshold amount set at 75 percent of one standard deviation beyond
the geometric mean standardized charge for all cases in the DRG to
which the new medical service or technology is assigned (or the case-
weighted average of all relevant DRGs if the new medical service or
technology occurs in many different DRGs). Standardized charges reflect
the actual charges of a case adjusted by the prospective payment system
payment factors applicable to an individual hospital, such as the wage
index, the indirect medical education adjustment factor, and the
disproportionate share adjustment factor.
7. Section 412.105 is amended by--
A. In paragraph (a)(1), introductory text, revising the phrase
``paragraph (f) of this section'' to read ``paragraphs (f) and (h) of
this section''.
B. In paragraph (a)(1)(i), revising the phrase ``affiliated
groups'' to read ``Medicare GME affiliated groups''.
C. Revising paragraph (b).
D. Adding a sentence at the end of paragraph (f)(1)(v).
E. In paragraph (f)(1)(vi), revising the phrase ``affiliated
group'' to read ``Medicare GME affiliated group''.
F. Revising paragraph (f)(1)(x).
The revisions and additions read as follows:
Sec. 412.105 Special treatment: Hospitals that incur indirect costs
for graduate medical education programs.
* * * * *
(b) Determination of number of beds. For purposes of this section,
the number of beds in a hospital is determined by counting the number
of available bed days during the cost reporting period and dividing
that number by the number of days in the cost reporting period. This
count excludes bed days associated with--
(1) Beds in any other units or wards where the level of care
provided would not be payable under the acute care hospital inpatient
prospective payment system;
(2) Beds in units unoccupied for the previous 3 months;
(3) Beds that could not be made available for inpatient occupancy
within 24 hours.
(4) Beds in excluded distinct part hospital units;
(5) Beds otherwise countable under this section used for outpatient
observation services (unless the patient is subsequently admitted for
acute inpatient care), skilled nursing swing-bed services, or ancillary
labor/delivery services;
(6) Beds or bassinets in the healthy newborn nursery; and
(7) Custodial care beds;
* * * * *
(f) Determining the total number of full-time equivalent residents
for cost reporting periods beginning on or after July 1, 1991. (1) * *
*
(v) * * * Subject to the provisions of paragraph (f)(1)(x) of this
section, effective for cost reporting periods beginning on or after
April 1, 2000, FTE residents in a rural track program are included in
the urban hospital's rolling average calculation described in this
paragraph (f)(1)(v).
* * * * *
(x) An urban hospital that establishes a new residency program (as
defined in Sec. 413.86(g)(13) of this subchapter), or has an existing
residency program, with a rural track (or an integrated rural track)
may include in its FTE count residents in those rural tracks in
accordance with the applicable provisions of Sec. 413.86(g)(12) of
this subchapter effective for discharges occurring on or after April 1,
2002 and before October 1, 2003, and the applicable provisions of Sec.
413.86(g)(12) of this subchapter effective for discharges occurring on
or after October 1, 2003.
* * * * *
7. Section 412.106 is amended by revising paragraphs (a)(1)(ii) and
(b)(4)(i) to read as follows:
Sec. 412.106 Special treatment: Hospitals that serve a
disproportionate share of low-income patients.
(a) General considerations. (1) * * *
(ii) For purposes of this section, the number of patient days in a
hospital includes only those days attributable to units or wards of the
hospital providing acute care services generally payable under the
prospective payment system and excludes patient days associated with--
(A) Beds in excluded distinct part hospital units;
(B) Beds otherwise countable under this section used for outpatient
observation services (unless the patient is subsequently admitted for
acute inpatient care), skilled nursing swing-bed services, or ancillary
labor/delivery services; and
(C) Beds in any other units or wards where the level of care
provided would not be payable under the acute care hospital inpatient
prospective payment system.
* * * * *
(b) Determination of a hospital's disproportionate payment
percentage. * * *
(4) Second computation. * * *
(i) For purposes of this computation, a patient is deemed eligible
for Medicaid on a given day only if the patient is eligible for
inpatient hospital services under an approved State Medicaid plan or
under a waiver authorized under section 1115(a)(2) of the Act on that
day, regardless of whether particular items or services were covered or
paid under the State plan or the authorized waiver.
* * * * *
[[Page 27230]]
8. In Sec. 412.112, the introductory text is republished and a new
paragraph (d) is added to read as follows:
Sec. 412.112 Payments determined on a per case basis.
A hospital is paid the following amounts on a per case basis.
* * * * *
(d) Additional payments for new medical services and technologies
determined under subpart F of this part.
9. Section 412.116 is amended by revising paragraph (e) to read as
follows:
Sec. 412.116 Method of payment.
* * * * *
(e) Outlier payment and additional payments for new medical
services and technologies. Payments for outlier cases and additional
payments for new medical services and technologies (described in
subpart F of this part) are not made on an interim basis. These
payments are made based on submitted bills and represent final payment.
* * * * *
PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR
END-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED
PAYMENT RATES FOR SKILLED NURSING FACILITIES
1. The authority citation for part 413 is revised to read as
follows:
Authority: Secs. 1102, 1812(d), 1814(b), 1815, 1833(a), (i), and
(n), 1871, 1881, 1883, and 1886 of the Social Security Act (42
U.S.C. 1302, 1395d(d), 1395f(b), 1395g, 1395l(a), (i), and (n),
1395hh, 1395rr, 1395tt, and 1395ww).
2. Section 413.70 is amended by revising paragraph (b)(2)(iii),
introductory text, to read as follows:
Sec. 413.70 Payment for services of a CAH.
* * * * *
(b) Payment for outpatient services furnished by CAH. * * *
(2) Reasonable costs for facility services. * * *
(iii) Payment for outpatient clinical diagnostic laboratory tests
is not subject to the Medicare Part B deductible and coinsurance
amounts. Payment to a CAH for clinical diagnostic laboratory tests will
be made on a reasonable cost basis under this section only if the
individuals are outpatients of the CAH, as defined in Sec. 410.2 of
this chapter, and are physically present in the CAH, at the time the
specimens are collected. Clinical diagnostic laboratory tests performed
for persons who are not physically present in the CAH when the
specimens are collected will be made in accordance with the provisions
of sections 1833(a)(1)(D) and 1833(a)(2)(D) of the Social Security Act.
* * * * *
3. Section 413.85 is amended by--
A. Adding under paragraph (c) a definition of ``Certification'' in
alphabetical order.
B. Republishing the introductory text of paragraph (d)(1) and
adding a new paragraph (d)(1)(iii).
C. Adding a new paragraph (g)(3).
D. Republishing the introductory text of paragraph (h) and revising
paragraph (h)(3).
The addition and revision read as follows.
Sec. 413.85 Cost of approved nursing and allied health education
activities.
* * * * *
(c) Definitions. * * *
Certification means the ability to practice or begin employment in
a specialty as a whole.
* * * * *
(d) General payment rules. (1) Payment for a provider's net cost of
nursing and allied health education activities is determined on a
reasonable cost basis, subject to the following conditions and
limitations:
* * * * *
(iii) The costs of certain nonprovider-operated programs at wholly
owned subsidiary educational institutions are reimbursable on a
reasonable cost basis if the provisions of paragraph (g)(3) of this
section are met.
* * * * *
(g) Payments for certain nonprovider-operated programs. * * *
(3) Special rule: Payment for certain nonprovider-operated programs
at wholly owned subsidiary educational institutions.
(i) Effective for portions of cost reporting periods occurring on
or after October 1, 2003, a provider that incurs costs for a nursing or
allied health education program(s) where those program(s) had
originally been provider-operated according to the criteria at
paragraph (f) of this section, and then operation of the program(s) was
transferred to a wholly owned subsidiary educational institution in
order to meet accreditation standards prior to October 1, 2003, and
where the provider has continuously incurred the costs of both the
classroom and clinical training portions of the program(s) at the
educational institution, may receive reasonable cost payment for such a
program(s) according to the specifications under paragraphs (g)(3)(ii)
and (g)(3)(iii) of this section.
(ii) Payment for the incurred costs of educational activities
identified in paragraph (g)(3)(i) of this section will be made on a
reasonable cost basis if a provider, as described in paragraph
(g)(3)(i) of this section, received Medicare reasonable cost payment
for those nursing and allied health education program(s) both prior and
subsequent to the date the provider transferred operation of the
program(s) to its wholly owned subsidiary educational institution (and
ceased to be a provider-operated program(s) according to the criteria
under paragraph (f) of this section).
(iii) The provider that meets the requirements in paragraphs
(g)(3)(i) and (g)(3)(ii) of this section will be eligible to receive
payment under this paragraph for: (A) the clinical training costs
incurred for the program(s) as described in paragraph (g)(3)(i) of this
section; and (B) classroom costs, but only those costs incurred by the
provider for the courses that were included in the programs described
in paragraph (g)(3)(i) of this section.
(h) Activities treated as normal operating costs. The costs of the
following educational activities incurred by a provider but not
operated by that provider are recognized only as normal operating costs
and paid in accordance with the reimbursement principles specified in
part 412 of this subchapter. They include:
* * * * *
(3) Educational seminars, workshops, and continuing education
programs in which the employees participate that enhance the quality of
medical care or operating efficiency of the provider and, effective
October 1, 2003, do not lead to certification required to practice or
begin employment in a nursing or allied health specialty.
* * * * *
4. Section 413.86 is amended by--
A. Under paragraph (b)--
(1) Removing the definitions of ``Affiliated group'' and
``Affiliation agreement''.
(2) Adding definitions of ``Community support'', ``Medicare GME
affiliated agreement'', ``Medicare GME affiliated group'', and
``Redistribution of costs'' in alphabetical order.
(3) Under the definition of ``Rural track FTE limitation'',
revising the phrase ``paragraph (g)(11)'' to read ``paragraph
(g)(12)''.
B. Revising the introductory text of paragraph (f).
C. Adding a new paragraph (f)(4)(iv).
D. In paragraph (g)(1)(i), revising the reference ``paragraphs
(g)(1)(ii) and (g)(1)(iii)'' to read ``paragraphs (g)(1)(ii) through
(g)(1)(iv)''.
[[Page 27231]]
E. Revising the introductory text of paragraph (g)(4).
F. Revising paragraph (g)(4)(iv).
G. Revising the introductory text of paragraph (g)(5).
H. Adding a new paragraph (g)(5)(vii).
I. Revising paragraphs (g)(6)(i)(D) and (g)(6)(i)(E).
J. Revising paragraph (g)(7).
K. Revising the introductory text of paragraph(g)(12).
L. Revising paragraph (g)(12)(i).
M. Revising paragraph (g)(12)(ii), introductory text.
N. Revising paragraph (g)(12)(ii)(A).
O. Revising paragraph (g)(12)(ii)(B)(1)(i).
P. Revising paragraph (g)(12)(iii).
Q. Revising paragraph (g)(12)(iv), introductory text.
R. Revising paragraph (g)(12)(iv)(A).
S. Revising paragraph (g)(12)(iv)(B)(1).
T. Redesignating paragraphs (i) and (j) as paragraphs (j) and (k),
respectively, and adding a new paragraph (i).
The additions and revisions read as follows:
Sec. 413.86 Direct graduate medical education payments.
* * * * *
(b) Definitions. * * *
Community support means funding that is provided by the community
and generally includes all non-Medicare sources of funding (other than
payments made for furnishing services to individual patients),
including State and local government appropriations. Community support
does not include grants, gifts, and endowments of the kind that are not
to be offset in accordance with section 1134 of the Act.
* * * * *
Medicare GME 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 a contiguous area and meet the rotation requirements
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 Medicare GME affiliation agreements beginning July 1,
2003, meet the rotation requirement in paragraph (g)(7)(ii) of this
section.
Medicare GME affiliation agreement means a written, signed, and
dated agreement by responsible representatives of each respective
hospital in a Medicare GME affiliated group, as defined in this
section, that specifies--
(1) The term of the Medicare GME affiliation 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 Medicare GME affiliation;
(3) The total adjustment to each hospital's FTE caps in each year
that the Medicare GME 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 hospital's FTE counts
resulting from the FTE resident's (or residents') participation in a
shared rotational arrangement at each hospital participating in the
Medicare GME affiliated group for each year the Medicare GME
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 members.
* * * * *
Redistribution of costs means an attempt by a hospital to increase
the amount it is allowed to receive from Medicare under this section by
counting FTE residents that were in medical residency programs where
the costs of the programs had previously been incurred by the
educational institution.
* * * * *
(f) Determining the total number of FTE residents. Subject to the
weighting factors in paragraphs (g) and (h) of this section, and
subject to the provisions of paragraph (i) of this section, the count
of FTE residents is determined as follows:
* * * * *
(4) * * *
(iv) The hospital is subject to the principles of community support
and redistribution of costs as specified in the provisions of paragraph
(i) of this section.
(g) Determining the weighted number of FTE residents.
* * * * *
(4) Subject to the provisions of paragraph (i) of this section, for
purposes of determining direct graduate medical education payment--
* * * * *
(iv) Hospitals that are part of the same Medicare GME 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.
* * * * *
(5) Subject to the provisions of paragraph (i) of this section, for
purposes of determining direct graduate medical education payment--
* * * * *
(vii) Subject to the provisions under paragraph (g)(12) of this
section, effective for cost reporting periods beginning on or after
April 1, 2000, FTE residents in a rural track program at an urban
hospital are included in the urban hospital's rolling average
calculation described in paragraph (g)(5) of this section.
* * * * *
(6) * * *
(i) * * *
(D) An urban hospital that qualifies for an adjustment to its FTE
cap under paragraph (g)(6)(i) of this section is not permitted to be
part of a Medicare GME affiliated group for purposes of establishing an
aggregate FTE cap.
(E) A rural hospital that qualifies for an adjustment to its FTE
cap under paragraph (g)(6)(i) of this section is permitted to be part
of a Medicare GME affiliated group for purposes of establishing an
aggregate FTE cap.
* * * * *
(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 a Medicare GME affiliated group (as
defined under paragraph (b) of this section). Under this provision--
(i) Each hospital in the Medicare GME affiliated group must submit
the Medicare GME 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 Medicare GME affiliation
agreement will be in effect.
[[Page 27232]]
(ii) Each hospital in the Medicare GME affiliated group must have a
shared rotational arrangement, as defined in paragraph (b) of this
section, with at least one other hospital within the Medicare GME
affiliated group, and all of the hospitals within the Medicare GME
affiliated group must be connected by a series of such shared
rotational arrangements.
(iii) During the shared rotational arrangements under an Medicare
GME affiliation agreement, as defined in paragraph (b) of this section,
more than one of the hospitals in the Medicare GME 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 Medicare GME affiliated hospitals' aggregate FTE cap for each
Medicare GME affiliation agreement must not exceed zero.
(v) If the Medicare GME affiliation agreement terminates for any
reason, the FTE cap of each hospital in the Medicare GME 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.
* * * * *
(12) Subject to the provisions of (i) of this section, an urban
hospital that establishes a new residency program, or has an existing
residency program, with a rural track (or an integrated rural track)
may include in its FTE count residents in those rural tracks, in
addition to the residents subject to its FTE cap specified under
paragraph (g)(4) of this section. An urban hospital with a rural track
residency program may count residents in those rural tracks up to a
rural track FTE limitation if the hospital complies with the conditions
specified in paragraphs (g)(12)(i) through (g)(12)(vi) of this section.
(i) If an urban hospital rotates residents to a separately
accredited rural track program at a rural hospital(s) for two-thirds of
the duration of the program for cost reporting periods beginning on or
after April 1, 2000 and before October 1, 2003, or for more than one-
half of the duration of the program for cost reporting periods
beginning on or after October 1, 2003, the urban hospital may include
those residents in its FTE count for the time the rural track residents
spend at the urban hospital. The urban hospital may include in its FTE
count those residents in the rural track training at the urban
hospital, not to exceed its rural track FTE limitation, determined as
follows:
(A) For the first 3 years of the rural track's existence, the rural
track FTE limitation for each urban hospital will be the actual number
of FTE residents, subject to the rolling average at paragraph
(g)(5)(vii) of this section, training in the rural track at the urban
hospital.
(B) Beginning with the fourth year of the rural track's existence,
the rural track FTE limitation is equal to the product of the highest
number of residents, in any program year, who during the third year of
the rural track's existence are training in the rural track at the
urban hospital or the rural hospital(s) and are designated at the
beginning of their training to be rotated to the rural hospital(s) for
at least two-thirds of the duration of the program for cost reporting
periods beginning on or after April l, 2000 and before October 1, 2002,
or for more than one-half of the duration of the program effective for
cost reporting periods beginning on or after October 1, 2003, and the
number of years those residents are training at the urban hospital.
(ii) If an urban hospital rotates residents to a separately
accredited rural track program at a rural nonhospital site(s) for two-
thirds of the duration of the program for cost reporting periods
beginning on or after April 1, 2000 and before October 1, 2003, or for
more than one-half of the duration of the program for cost reporting
periods beginning on or after October 1, 2003, the urban hospital may
include those residents in its FTE count, subject to the requirements
under paragraph (f)(4) of this section. The urban hospital may include
in its FTE count those residents in the rural track, not to exceed its
rural track FTE limitation, determined as follows:
(A) For the first 3 years of the rural track's existence, the rural
track FTE limitation for each urban hospital will be the actual number
of FTE residents, subject to the rolling average specified in paragraph
(g)(5)(vii) of this section, training in the rural track at the urban
hospital and the rural nonhospital site(s).
(B) * * *
(1) * * *
(i) The urban hospital and are designated at the beginning of their
training to be rotated to a rural nonhospital site(s) for at least two-
thirds of the duration of the program for cost reporting periods
beginning on or after April 1, 2000 and before October 1, 2003, or for
more than one-half of the duration of the program for cost reporting
periods beginning on or after October 1, 2003; and
* * * * *
(iii) If an urban hospital rotates residents in the rural track
program to a rural hospital(s) for less than two-thirds of the duration
of the program for cost reporting periods beginning on or after April
1, 2000 and before October 1, 2003, or for one-half or less than one-
half of the duration of the program for cost reporting periods
beginning on or after October 1, 2003, the rural hospital may not
include those residents in its FTE count (if the rural track is not a
new program under paragraph (g)(6)(iii) of this section, or if the
rural hospital's FTE count exceeds that hospital's FTE cap), nor may
the urban hospital include those residents when calculating its rural
track FTE limitation.
(iv) If an urban hospital rotates residents in the rural track
program to a rural nonhospital site(s) for period of time is less than
two-thirds of the duration of the program for cost reporting periods
beginning on or after April 1, 2000 and before October 1, 2003, or for
one-half or less than one-half of the duration of the program for cost
reporting periods beginning on or after October 1, 2003, the urban
hospital may include those residents in its FTE count, subject to the
requirements under paragraph (f)(4) of this section. The urban hospital
may include in its FTE count those residents in the rural track, not to
exceed its rural track limitation, determined as follows:
(A) For the first 3 years of the rural track's existence, the rural
track FTE limitation for the urban hospital will be the actual number
of FTE residents, subject to the rolling average specified in paragraph
(g)(5)(vii) of this section, training in the rural track at the rural
nonhospital site(s).
(B) * * *
(1) The highest number of residents in any program year who, during
the third year of the rural track's existence, are training in the
rural track at the rural nonhospital site(s) or are designated at the
beginning of their training to be rotated to the rural nonhospital
site(s) for a period that is less than two-thirds of the duration of
the program for cost reporting periods beginning on or after April 1,
2002, and before October 1, 2003, or for one-half or less than one-half
of the duration of the program for cost reporting periods beginning on
or after October 1, 2003; and
* * * * *
(i) Application of community support and redistribution of costs in
determining FTE resident counts.
(1) For purposes of determining direct graduate medical education
payments, the following principles apply:
[[Page 27233]]
(i) Community support. If the community has undertaken to bear the
costs of medical education through community support, the costs are not
considered graduate medical education costs to the hospital for
purposes of Medicare payment.
(ii) Redistribution of costs. The costs of training residents that
constitute a redistribution of costs from an educational institution to
the hospital are not considered graduate medical education costs to the
hospital for purposes of Medicare payment.
(2) Application. A hospital must continuously incur the costs of
direct graduate medical education of residents training in a particular
program at a training site since the date the residents first began
training in that program in order for the hospital to count the FTE
residents in accordance with the provisions of paragraphs (f) and
(g)(4) through (g)(6) and (g)(12) of this section.
* * * * *
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance)
Dated: April 22, 2003.
Thomas A. Scully,
Administrator, Centers for Medicare & Medicaid Services
Dated: May 8, 2003.
Tommy G. Thompson,
Secretary.
[Editorial Note: The following Addendum and appendixes will not
appear in the Code of Federal Regulations.]
Addendum--Proposed Schedule of Standardized Amounts Effective with
Discharges Occurring On or After October 1, 2003 and Update Factors and
Rate-of-Increase Percentages Effective With Cost Reporting Periods
Beginning On or After October 1, 2003
I. Summary and Background
In this Addendum, we are setting forth the proposed amounts and
factors for determining prospective payment rates for Medicare
hospital inpatient operating costs and Medicare hospital inpatient
capital-related costs. We are also setting forth proposed rate-of-
increase percentages for updating the target amounts for hospitals
and hospital units excluded from the IPPS.
For discharges occurring on or after October 1, 2003, except for
SCHs, MDHs, and hospitals located in Puerto Rico, each hospital's
payment per discharge under the IPPS will be based on 100 percent of
the Federal national rate, which will be based on the national
adjusted standardized amount. This amount reflects the national
average hospital costs per case from a base year, updated for
inflation.
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 the updated hospital-specific rate based on 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 reflecting base year
average costs per case of Puerto Rico hospitals and 50 percent of a
blended Federal national rate (a discharge-weighted average of the
national large urban and other areas standardized amounts). (See
section II.D.3. of this Addendum for a complete description.)
As discussed below in section II. of this Addendum, we are
proposing to make changes in the determination of the prospective
payment rates for Medicare inpatient operating costs for FY 2004.
The changes, to be applied prospectively effective with discharges
occurring on or after October 1, 2003, affect the calculation of the
Federal rates. In section III. of this Addendum, we discuss our
proposed changes for determining the prospective payment rates for
Medicare inpatient capital-related costs for FY 2004. Section IV. of
this Addendum sets forth our proposed changes for determining the
rate-of-increase limits for hospitals excluded from the IPPS for FY
2004. Section V. of this Addendum sets forth policies on payment for
blood clotting factor administered to hemophilia patients. The
tables to which we refer in the preamble to this proposed rule are
presented in section VI. of this Addendum.
II. Proposed Changes to Prospective Payment Rates for Hospital
Inpatient Operating Costs for FY 2004
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 Sec. Sec. 412.210 and 412.212. Below,
we discuss the factors used for determining the prospective payment
rates.
In summary, the proposed standardized amounts set forth in
Tables 1A and 1C of section VI. of this Addendum reflect--
[sbull] Updates of 3.5 percent for all areas (that is, the full
market basket percentage increase of 3.5 percent);
[sbull] An adjustment to ensure the proposed DRG recalibration
and wage index update and changes, as well as the add-on payments
for new technology, 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;
[sbull] 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 2003 budget neutrality
factor and applying a revised factor;
[sbull] An adjustment to apply the new outlier offset by
removing the FY 2003 outlier offsets and applying a new offset.
A. Calculation of Adjusted Standardized Amounts
1. Standardization of Base-Year Costs or Target Amounts
The national standardized amounts are based on per discharge
averages of adjusted hospital costs from a base period (section
1886(d)(2)(A) of the Act) or, for Puerto Rico, adjusted target
amounts from a base period (section 1886(d)(9)(B)(i) of the Act),
updated and otherwise adjusted in accordance with the provisions of
section 1886(d) of the Act. The preamble to the September 1, 1983
interim final rule (48 FR 39763) contained a detailed explanation of
how base-year cost data (from cost reporting periods ending during
FY 1981) were established in the initial development of standardized
amounts for the IPPS. 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.
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 IPPS, the Secretary estimates from time to time
the proportion of costs that are wages and wage-related costs. Based
on the estimated labor-related share, the standardized amounts are
divided into labor-related and nonlabor-related amounts. As
discussed in section IV. of the preamble to the August 1, 2002 IPPS
final rule, when we revised the market basket in FY 2003, we did not
revise the labor share of the standardized amount (the proportion
adjusted by the wage index). We consider 71.1 percent of costs to be
labor-related for purposes of the IPPS. The average labor share in
Puerto Rico is 71.3 percent.
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.
[[Page 27234]]
Section 402(b) of Pub. L. 108-7 required that, effective for
discharges occurring on or after April 1, 2003, and before October
1, 2003, the Federal rate for all IPPS hospitals would be based on
the large urban standardized amount. However, for discharges
occurring on or after October 1, 2003, the Federal rate will again
be calculated based on separate average standardized amounts for
hospitals in large urban areas and for hospitals in other areas.
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 Pub. L. 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 2004. These areas are identified in
Table 4A of section VI. of this Addendum.
3. Updating the Average Standardized Amounts
In accordance with section 1886(d)(3)(A)(iv) of the Act, we are
proposing to update the large urban areas' and the other areas'
average standardized amounts for FY 2004 by the full estimated
market basket percentage increase for hospitals in all areas, as
specified in section 1886(b)(3)(B)(i)(XIX) of the Act. 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 2004 is 3.5 percent. Thus, for FY 2004, the
update to the average standardized amounts equals 3.5 percent for
hospitals in all areas.
Although the update factors for FY 2004 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 2004 for both
IPPS hospitals and hospitals excluded from the IPPS. Our proposed
recommendation on the update factors (which is required by sections
1886(e)(4)(A) and (e)(5)(A) of the Act) is set forth as Appendix B
of this proposed rule.
4. Other Adjustments to the Average Standardized Amounts
As in the past, we are proposing to adjust the FY 2004
standardized amounts to remove the effects of the FY 2003 geographic
reclassifications and outlier payments before applying the FY 2004
updates. We then apply the new offsets to the standardized amounts
for outliers and geographic reclassifications for FY 2004.
We do not remove the prior years' 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.
Budget neutrality is determined by comparing aggregate IPPS
payments before and after making the changes that are required to be
budget neutral (for example, reclassifying and recalibrating the
DRGs, updating the wage data, and geographic reclassifications). We
include outlier payments in the payment simulations because outliers
may be affected by changes in these payment parameters. Because the
proposed changes to the postacute care transfer policy discussed in
section IV.A. of this preamble are not budget neutral, we included
the effects of expanding this policy to additional DRGs prior to
estimating the payment effects of the DRG and wage data changes.
a. Recalibration of DRG Weights and Updated Wage Index--Budget
Neutrality Adjustment. Section 1886(d)(4)(C)(iii) of the Act
specifies that, beginning in FY 1991, the annual DRG
reclassification and recalibration of the relative weights must be
made in a manner that ensures that aggregate payments to hospitals
are not affected. As discussed in section II. of the preamble, we
normalized the recalibrated DRG weights by an adjustment factor, so
that the average case weight after recalibration is equal to the
average case weight prior to recalibration. However, equating the
average case weight after recalibration to the average case weight
before recalibration does not necessarily achieve budget neutrality
with respect to aggregate payments to hospitals because payments to
hospitals are affected by factors other than average case weight.
Therefore, as we have done in past years, we are proposing to make a
budget neutrality adjustment to ensure that the requirement of
section 1886(d)(4)(C)(iii) of the Act is met.
Section 1886(d)(3)(E) of the Act requires us to update the
hospital wage index on an annual basis beginning October 1, 1993.
This provision also requires us to make any updates or adjustments
to the wage index in a manner that ensures that aggregate payments
to hospitals are not affected by the change in the wage index.
Section 4410 of Pub. L. 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 Pub.
L. 105-33 to be budget neutral. Therefore, we include the effects of
this provision in our calculation of the wage update budget
neutrality factor.
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.E. of this proposed rule, we are
proposing to approve one new technology for add-on payments in FY
2004. We estimate that the proposed total add-on payments for this
new technology would be $50 million for FY 2004.
To comply with the requirement that DRG reclassification and
recalibration of the relative weights be budget neutral, and the
requirement that the updated wage index be budget neutral, we used
FY 2002 discharge data to simulate payments and compared aggregate
payments using the FY 2003 relative weights, wage index, and new
technology add-on payments to aggregate payments using the proposed
FY 2004 relative weights and wage index, plus the proposed
additional add-on payments for new technology. The same methodology
was used for the FY 2003 budget neutrality adjustment.
Based on this comparison, we computed a proposed budget
neutrality adjustment factor equal to 1.003133. We also adjust the
Puerto Rico-specific standardized amounts for the effect of DRG
reclassification and recalibration. We computed a proposed budget
neutrality adjustment factor for Puerto Rico-specific standardized
amounts equal to 1.000627. These budget neutrality adjustment
factors are applied to the standardized amounts without removing the
effects of the FY 2003 budget neutrality adjustments.
In addition, we are proposing to apply these same adjustment
factors to the hospital-specific rates that are effective for cost
reporting periods beginning on or after October 1, 2003. (See the
discussion in the September 4, 1990 final rule (55 FR 36073).)
b. Reclassified Hospitals--Budget Neutrality Adjustment. Section
1886(d)(8)(B) of the Act provides that, effective with discharges
occurring on or after October 1, 1988, certain rural hospitals are
deemed urban. In addition, section 1886(d)(10) of the Act provides
for the reclassification of hospitals based on determinations by the
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 IPPS 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 2002 discharge data to simulate
payments, and compared total IPPS payments prior to any
reclassifications to total IPPS payments after reclassifications.
Based on these simulations, we are proposing to apply an adjustment
factor of 0.991848 to ensure that the effects of reclassification
are budget neutral.
The proposed adjustment factor is applied to the standardized
amounts after removing the effects of the FY 2003 budget neutrality
adjustment factor. We note that the proposed FY 2004 adjustment
reflects proposed FY 2004 wage index and standardized amount
[[Page 27235]]
reclassifications approved by the MGCRB or the Administrator as of
February 28, 2003, and the effects of section 1886(d)(10)(D)(v) of
the Act to extend wage index reclassifications for 3 years. The
effects of any additional reclassification changes that occur as a
result of appeals and reviews of the MGCRB decisions for FY 2004 or
from a hospital's request for the withdrawal of a reclassification
for FY 2004 will be reflected in the final budget neutrality
adjustment required under section 1886(d)(8)(D) of the Act and
published in the IPPS final rule for FY 2004.
c. Outliers. Section 1886(d)(5)(A) of the Act provides for
payments in addition to the basic prospective payments, for
``outlier'' cases, that is, cases involving extraordinarily high
costs. To qualify for outlier payments, a case must have costs above
a fixed-loss cost threshold amount (a dollar amount by which the
costs of a case must exceed payments in order to qualify for outlier
payment). 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 2004 outlier fixed-loss cost threshold. In the August 1,
2002 IPPS final rule (67 FR 50124), we established a threshold for
FY 2003 that was equal to the prospective payment rate for the DRG,
plus any IME and DSH payments and any additional payments for new
technology, plus $33,560. The marginal cost factor (the percent of
costs paid after costs for the case exceed the threshold) was 80
percent.
In the March 5, 2003 Federal Register (67 FR 10420), we
published proposed changes to our outlier policy. We noted recent
analyses indicate that some hospitals have taken advantage of our
existing outlier payment methodology to maximize their outlier
payments. Therefore, we proposed three central changes to our
outlier policy in the March 5, 2003 proposed rule.
The first of the proposed changes was that fiscal intermediaries
would use more up-to-date data when determining the cost-to-charge
ratio for each hospital. Currently, fiscal intermediaries use the
hospital's most recent settled cost report. We proposed to revise
our regulations to specify that fiscal intermediaries would use
either the most recent settled or the most recent tentative settled
cost report, whichever is from the latest reporting period.
The second proposed change was to remove the current requirement
in our regulations specifying that a fiscal intermediary will assign
a hospital the statewide average cost-to-charge ratio when the
hospital has a cost-to-charge ratio that falls below established
thresholds (3 standard deviations below the national geometric mean
cost-to-charge ratio). We proposed that hospitals would receive
their actual cost-to-charge ratios no matter how low their ratios
actually fall.
The third proposal was to add a provision to our regulations to
provide that the outlier payments for some hospitals may become
subject to reconciliation when the hospitals' cost reports are
settled. In addition, outlier payments would be subject to an
adjustment to account for the time value of any outlier overpayments
or underpayments that are ultimately reconciled.
However, as of the time this FY 2004 proposed rule was prepared,
these proposed changes to the outlier policy had not been finalized.
Therefore, the proposed changes have not been factored into the
calculation of the proposed FY 2004 fixed-loss threshold. If these
changes are made final prior to (or as part of) the publication of
the final FY 2004 fixed-loss threshold, they will be reflected in
the analysis used to establish the final FY 2004 threshold.
To calculate the proposed FY 2004 outlier thresholds, we
simulated payments by applying proposed FY 2004 rates and policies
using cases from the FY 2002 MedPAR file. Therefore, in order to
determine the appropriate proposed FY 2003 threshold, it was
necessary to inflate the charges on the MedPAR claims by 2 years,
from FY 2002 to FY 2004.
As discussed in the August 1, 2002 IPPS final rule (67 FR
50124), 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, as had been done in prior years, we used a 2-
year average annual rate of change in charges per case to calculate
the FY 2003 outlier threshold.
We are proposing to continue to use a 2-year average annual rate
of change in charges per case to establish the proposed FY 2004
threshold. The 2-year average annual rate of change in charges per
case from FY 2000 to FY 2001, and from FY 2001 to FY 2002, was
12.8083 percent annually, or 27.3 percent over 2 years.
Using the methodology above for setting the charge inflation
factors for FY 2004, we are proposing to establish a fixed-loss cost
outlier threshold equal to the prospective payment rate for the DRG,
plus any IME and DSH payments, and any add-on payments for new
technology, plus $50,645.
This single threshold would be applicable to qualify for both
operating and capital outlier payments. We also are proposing to
maintain the marginal cost factor for cost outliers at 80 percent.
Again, any final rule subsequent to the March 5, 2003 proposed
rule that implements changes to the outlier payment methodology is
likely to affect how we will calculate the final FY 2004 outlier
threshold. Therefore, the final FY 2004 threshold is likely to be
different from this proposed threshold, as a result of any changes
subsequent to the March 5, 2003 proposed rule. For example, if we
were to implement the proposal to no longer apply the statewide
average cost-to-charge ratio when hospitals' actual ratios fall
below the established threshold (see below), this change would
impact our calculation of the threshold.
ii. Other changes concerning outliers. As stated in the
September 1, 1993 final rule (58 FR 46348), we establish outlier
thresholds that are applicable to both hospital inpatient operating
costs and hospital inpatient capital-related costs. When we modeled
the combined operating and capital outlier payments, we found that
using a common set of thresholds resulted in a higher percentage of
outlier payments for capital-related costs than for operating costs.
We project that the proposed thresholds for FY 2004 would result in
outlier payments equal to 5.1 percent of operating DRG payments and
5.5 percent of capital payments based on the Federal rate.
In accordance with section 1886(d)(3)(B), we reduced the
proposed FY 2004 standardized amounts by the same percentage to
account for the projected proportion of payments paid to outliers.
The proposed outlier adjustment factors to be applied to the
standardized amounts for FY 2004 are as follows:
------------------------------------------------------------------------
Operating
standardized amounts Capital federal rate
------------------------------------------------------------------------
National.................... 0.948981 0.945484
Puerto Rico................. 0.981549 0.984490
------------------------------------------------------------------------
We apply the outlier adjustment factors after removing the
effects of the FY 2003 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. These costs are then combined and compared
with the fixed-loss outlier threshold.
[[Page 27236]]
Once again, although a final rule subsequent to the March 5,
2003 proposed rule on outliers may be published before (or as part
of) the FY 2004 IPPS final rule, we are proposing changes for FY
2004 without taking the proposals contained in the March 5, 2003
proposed rule into account at this time.
For those hospitals for which the fiscal intermediary computes
operating cost-to-charge ratios lower than 0.194 or greater than
1.223, or capital cost-to-charge ratios lower than 0.012 or greater
than 0.163, we are proposing statewide average ratios would be used
to calculate costs to determine whether a hospital qualifies for
outlier payments.\7\ Table 8A in section VI. of this Addendum
contains the proposed statewide average operating cost-to-charge
ratios for urban hospitals and for rural hospitals for which the
fiscal intermediary is unable to compute a hospital-specific cost-
to-charge ratio within the above range. These proposed statewide
average ratios would replace the ratios published in the August 1,
2002 IPPS final rule (67 FR 50263). Table 8B in section VI. of this
Addendum contains the proposed comparable statewide average capital
cost-to-charge ratios. Again, the cost-to-charge ratios in Tables 8A
and 8B would be used during FY 2004 when hospital-specific cost-to-
charge ratios based on the latest settled cost report are either not
available or are outside the range noted above.
---------------------------------------------------------------------------
\7\ This range represents 3.0 standard deviations (plus or
minus) from the mean of the log distribution of cost-to-charge
ratios for all hospitals.
---------------------------------------------------------------------------
iii. FY 2002 and FY 2003 outlier payments. In the August 1, 2002
IPPS final rule (67 FR 50125), we stated that, based on available
data, we estimated that actual FY 2002 outlier payments would be
approximately 6.9 percent of actual total DRG payments. This
estimate was computed based on simulations using the FY 2001 MedPAR
file (discharge data for FY 2001 bills). That is, the estimate of
actual outlier payments did not reflect actual FY 2002 bills but
instead reflected the application of FY 2002 rates and policies to
available FY 2001 bills.
Our current estimate, using available FY 2002 bills, is that
actual outlier payments for FY 2002 were approximately 7.9 percent
of actual total DRG payments. Thus, the data indicate that, for FY
2002, the percentage of actual outlier payments relative to actual
total payments is higher than we projected before FY 2002 (and thus
exceeds the percentage by which we reduced the standardized amounts
for FY 2002). Nevertheless, consistent with the policy and statutory
interpretation we have maintained since the inception of the IPPS,
we do not plan to make retroactive adjustments to outlier payments
to ensure that total outlier payments for FY 2002 are equal to 5.1
percent of total DRG payments.
We currently estimate that actual outlier payments for FY 2003
will be approximately 5.5 percent of actual total DRG payments, 0.4
percentage points higher than the 5.1 percent we projected in
setting outlier policies for FY 2003. This estimate is based on
simulations using the FY 2002 MedPAR file (discharge data for FY
2002 bills). We used these data to calculate an estimate of the
actual outlier percentage for FY 2003 by applying FY 2003 rates and
policies including an outlier threshold of $33,560 to available FY
2002 bills. If changes to the outlier payment methodology are made
effective during FY 2003, these may affect the actual percentage of
FY 2003 outlier payments.
5. FY 2004 Standardized Amounts
The adjusted standardized amounts are divided into labor and
nonlabor portions. Table 1A in section VI. of this Addendum contains
the two national standardized amounts that we are proposing will be
applicable to all hospitals, except hospitals in Puerto Rico. As
described in section II.A.1. of this Addendum, we are not proposing
to revise the labor share of the national standardized amount from
71.1 percent.
The following table illustrates the proposed changes from the FY
2003 national average standardized amounts. The first row in the
table shows the updated (through FY 2003) average standardized
amounts after restoring the FY 2003 offsets for outlier payments and
geographic reclassification budget neutrality. The DRG
reclassification and recalibration and wage index budget neutrality
factor is cumulative. Therefore, the FY 2003 factor is not removed
from the amounts in the table.
----------------------------------------------------------------------------------------------------------------
Large urban Other Areas
----------------------------------------------------------------------------------------------------------------
FY 2003 Base Rate (after removing Labor $3,212.32.................... Labor $3,161.41)
reclassification budget neutrality Nonlabor 1,276.01.................. Nonlabor 1,285.01
and outlier offset).
Proposed FY 2004 Update Factor........ 1.035.............................. 1.035
Proposed FY 2004 DRG Recalibrations 1.003133........................... 1.003133
and Wage Index Budget Neutrality
Factor.
Proposed FY 2004 Reclassification 0.991848........................... 0.991848
Budget Neutrality Factor.
Proposed FY 2004 Outlier Factor....... 0.948997........................... 0.948997
Proposed Rate for FY 2004 (after Labor $3,139.26.................... Labor $3,089.56
multiplying FY 2003 base rate by Nonlabor 1,276.01.................. Nonlabor 1,255.81
above factors).
----------------------------------------------------------------------------------------------------------------
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 of
section VI. of this Addendum. 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 section VI. of this Addendum,
contain the labor-related and nonlabor-related shares that we are
proposing to use to calculate the prospective payment rates for
hospitals located in the 50 States, the District of Columbia, and
Puerto Rico. This section addresses two types of adjustments to the
standardized amounts that are made in determining the proposed
prospective payment rates as described in this Addendum.
1. Adjustment for Area Wage Levels
Sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act require
that we make an adjustment to the labor-related portion of the
national and Puerto Rico prospective payment rates, respectively, to
account for area differences in hospital wage levels. This
adjustment is made by multiplying the labor-related portion of the
adjusted standardized amounts by the appropriate wage index for the
area in which the hospital is located. In section III. of this
preamble, we discuss the data and methodology for the proposed FY
2004 wage index. The proposed FY 2004 wage index is set forth in
Tables 4A, 4B, 4C, and 4F of section VI. 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 2004, we are proposing to adjust the payments for hospitals
in Alaska and Hawaii by multiplying the nonlabor portion of the
standardized amounts by the appropriate adjustment factor contained
in the table below. If the Office of Personnel Management releases
revised cost-of-living adjustment factors before July 1, 2003, we
will publish them in the final rule and use them in determining FY
2004 payments.
[[Page 27237]]
Table of Cost-of-Living Adjustment Factors, Alaska and Hawaii Hospitals
------------------------------------------------------------------------
[cent]
------------------------------------------------------------------------
Alaska--All areas..................................... 1.25
Hawaii:
County of Honolulu.................................. 1.25
County of Hawaii.................................... 1.165
County of Kauai..................................... 1.2325
County of Maui...................................... 1.2375
County of Kalawao................................... 1.2375
------------------------------------------------------------------------
(The above factors are based on data obtained from the U.S. Office
of Personnel Management.)
C. DRG Relative Weights
As discussed in section II. of the preamble, we have developed a
classification system for all hospital discharges, assigning them
into DRGs, and have developed relative weights for each DRG that
reflect the resource utilization of cases in each DRG relative to
Medicare cases in other DRGs. Table 5 of section VI. of this
Addendum contains the relative weights that we are proposing to use
for discharges occurring in FY 2004. These factors have been
recalibrated as explained in section II. of the preamble.
D. Calculation of Proposed Prospective Payment Rates for FY 2004
General Formula for Calculation of Proposed Prospective Payment Rates
for FY 2004
The proposed operating prospective payment rate for all
hospitals paid under the IPPS located outside of Puerto Rico, except
SCHs and MDHs, equals the Federal rate based on the proposed amounts
in Table 1A in section VI. of this Addendum.
The proposed prospective payment rate for SCHs equals the higher
of the proposed applicable Federal rate from Table 1A or the
hospital-specific rate as described below. The proposed prospective
payment rate for MDHs equals the higher of the Federal rate, or the
Federal rate plus 50 percent of the difference between the Federal
rate and the hospital-specific rate as described below. The proposed
prospective payment rate for Puerto Rico equals 50 percent of the
Puerto Rico rate plus 50 percent of the proposed national rate from
Table 1C in section VI. of this Addendum.
1. Federal Rate
For discharges occurring on or after October 1, 2003 and before
October 1, 2004, except for SCHs, MDHs, and hospitals in Puerto
Rico, payment under the IPPS is based exclusively on the Federal
rate.
The Federal rate 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 VI. of this Addendum).
Step 2--Multiply the labor-related portion of the standardized
amount by the applicable wage index for the geographic area in which
the hospital is located or the area to which the hospital is
reclassified (see Tables 4A, 4B, and 4C of section VI. of this
Addendum).
Step 3--For hospitals in Alaska and Hawaii, multiply the
nonlabor-related portion of the standardized amount by the
appropriate cost-of-living adjustment factor.
Step 4--Add the amount from Step 2 and the nonlabor-related
portion of the standardized amount (adjusted, if appropriate, under
Step 3).
Step 5--Multiply the final amount from Step 4 by the relative
weight corresponding to the appropriate DRG (see Table 5 of section
VI. of this Addendum).
The Federal rate as determined in Step 5 may then be further
adjusted if the hospital qualifies for either the IME or DSH
adjustment.
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 the updated hospital-specific rate based on FY
1996 costs per discharge.
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 rates based on either FY 1982 or FY
1987 costs 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 costs per discharge, the FY
1987 costs per discharge or, for SCHs, the FY 1996 costs 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 proposed budget neutrality adjustment factor (that
is, by 1.003133) as discussed in section II.A.4.a. of this Addendum.
The resulting rate would be used in determining the payment rate an
SCH or MDH would receive for its discharges beginning on or after
October 1, 2003.
b. Updating the FY 1982, FY 1987, and FY 1996 Hospital-Specific
Rates for FY 2004. We are proposing to increase the hospital-
specific rates by 3.5 percent (the hospital market basket
percentage) for SCHs and MDHs for FY 2004. Section 1886(b)(3)(C)(iv)
of the Act provides that the update factor applicable to the
hospital-specific rates for SCHs is equal to the update factor
provided under section 1886(b)(3)(B)(iv) of the Act, which, for SCHs
in FY 2004, is the market basket rate of increase. Section
1886(b)(3)(D) of the Act provides that the update factor applicable
to the hospital-specific rates for MDHs also equals the update
factor provided under section 1886(b)(3)(B)(iv) of the Act, which,
for FY 2004, is the market basket rate.
3. General Formula for Calculation of Prospective Payment Rates for
Hospitals Located in Puerto Rico Beginning On or After October 1, 2003
and Before October 1, 2004
a. Puerto Rico Rate. The Puerto Rico prospective payment rate is
determined as follows:
Step 1--Select the appropriate adjusted average standardized
amount considering the large urban or other designation of the
hospital (see Table 1C of section VI. of the Addendum).
Step 2--Multiply the labor-related portion of the standardized
amount by the appropriate Puerto Rico-specific wage index (see Table
4F of section VI. of the Addendum).
Step 3--Add the amount from Step 2 and the nonlabor-related
portion of the standardized amount.
Step 4--Multiply the result in Step 3 by 50 percent.
Step 5--Multiply the amount from Step 4 by the appropriate DRG
relative weight (see Table 5 of section VI. of the Addendum).
b. National Rate. The national prospective payment rate is
determined as follows:
Step 1--Multiply the labor-related portion of the national
average standardized amount (see Table 1C of section VI. of the
Addendum) by the appropriate national wage index (see Tables 4A and
4B of section VI. of the Addendum).
Step 2--Add the amount from Step 1 and the nonlabor-related
portion of the national average standardized amount.
Step 3--Multiply the result in Step 2 by 50 percent.
Step 4--Multiply the amount from Step 3 by the appropriate DRG
relative weight (see Table 5 of section VI. of the Addendum).
The sum of the Puerto Rico rate and the national rate computed
above equals the prospective payment for a given discharge for a
hospital located in Puerto Rico. This rate may then be further
adjusted if the hospital qualifies for either the IME or DSH
adjustment.
III. Proposed Changes to Payment Rates for Acute Care Hospital
Inpatient Capital-Related Costs for FY 2004
The PPS 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 PPS 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 Sec. Sec. 412.308
through 412.352. Below we discuss the factors that we are proposing
to use to determine the capital Federal rate for FY 2004, which
would be effective for discharges occurring on or after October 1,
2003. 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
[[Page 27238]]
Sec. Sec. 412.304(c)(2) and 412.324(b)) 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 IPPS 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. Section 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) exception under Sec. 412.348. Section
412.308(c)(4)(ii) requires that the standard 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 FY 1998, 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 discussed in the August 1, 2002 IPPS final rule (67
FR 50102) and implemented in Sec. 412.308(b)(6)), a small part of
that reduction was 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 during the transition period. As we
explained in the August 1, 2001 IPPS final rule (66 FR 39911),
beginning in FY 2003, an adjustment for regular exception payments
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 exception policy
in FY 2003 and after, we no longer use 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 IPPS final rule
(66 FR 40099).
In accordance with section 1886(d)(9)(A) of the Act, under the
IPPS for acute care hospital 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 PPS 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 Proposed Federal Hospital Inpatient Capital-
Related Prospective Payment Rate Update
In the final IPPS rule published in the Federal Register on
August 1, 2002 (67 FR 50127), we established a Federal rate of
$407.01 for FY 2003. Section 402(b) of Public Law 108-7 requires
that, effective for discharges occurring on or after April 1, 2003,
and before October 1, 2003, the Federal rate for operating costs for
all IPPS hospitals would be based on the large urban standardized
amount. However, for discharges occurring on or after October 1,
2003, the Federal rate will again be calculated based on separate
average standardized amounts for hospitals in large urban areas and
for hospitals in other areas. In addition, a correction notice to
the FY 2003 final IPPS rule issued in the Federal Register on April
25, 2003 (68 FR 22272) contains corrections and revisions to the
wage index and geographic adjustment factor (GAF). In conjunction
with the change to the operating PPS standardized amounts made by
Public Law 108-7 and the wage index and GAF corrections, we have
established a capital PPS standard Federal rate of $406.93 effective
for discharges occurring on or after April 1, 2003 through September
30, 2003. The rates effective for discharges occurring on or after
April 1, 2003 through September 30, 2003, were used in determining
the proposed FY 2004 rates. As a result of the changes that we are
proposing to the factors used to establish the Federal rate that are
explained in this Addendum, the proposed FY 2004 capital standard
Federal rate is $411.72.
In the discussion that follows, we explain the factors that were
used to determine the proposed FY 2004 capital Federal rate. In
particular, we explain why the proposed FY 2004 Federal rate has
increased 1.18 percent compared to the FY 2003 Federal rate
(effective for discharges occurring on or after April 1, 2003
through September 30, 2003). We also estimate aggregate capital
payments will increase by 2.5 percent during this same period. This
increase is primarily due to the increase in the number of hospital
admissions and the increase in case-mix. This increase in capital
payments is slightly less than last year (5.81 percent), mostly due
to the restoration of the 2.1 percent reduction to the capital
Federal rate in FY 2003 (Sec. 412.308(b)(6)).
Total payments to hospitals under the IPPS 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 PPS are estimated to increase in FY 2004 compared
to FY 2003.
1. Proposed 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 several other policy adjustment
factors. Specifically, we have adjusted the projected CIPI rate of
increase as appropriate each year for case-mix index-related
changes, for intensity, and for errors in previous CIPI forecasts.
The proposed update factor for FY 2004 under that framework is 0.7
percent, based on data available at this time. This proposed update
factor is based on a projected 0.7 percent increase in the CIPI, a
0.0 percent adjustment for intensity, a 0.0 percent adjustment for
case-mix, a 0.0 percent adjustment for the FY 2002 DRG
reclassification and recalibration, and a forecast error correction
of 0.0 percent. We explain the basis for the FY 2004 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 IPPS. 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:
[sbull] The average resource use of Medicare patients changes
(``real'' case-mix change);
[sbull] Changes in hospital coding of patient records result in
higher weight DRG assignments ( coding effects ); and
[sbull] 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
[[Page 27239]]
framework for the PPS 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 2002 DRG reclassification and
recalibration as part of our update for FY 2004.) We have adopted
this case-mix index adjustment in the capital update framework as
well.
For FY 2004, 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 2004. Therefore, the net adjustment for
case-mix change in FY 2004 is 0.0 percentage points.
We estimate that FY 2002 DRG reclassification and recalibration
will result in a 0.0 percent change in the case-mix when compared
with the case-mix index that would have resulted if we had not made
the reclassification and recalibration changes to the DRGs.
Therefore, we are making a 0.0 percent adjustment for DRG
reclassification and recalibration in the update for FY 2004 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 0.2 percentage points was calculated for
the FY 2002 update. That is, current historical data indicate that
the forecasted FY 2002 CIPI used in calculating the FY 2002 update
factor (0.7 percent) overstated the actual realized price increases
(0.5 percent) by 0.2 percentage points. This slight overprediction
was mostly due to an underestimation of the interest rate cuts by
the Federal Reserve Board in 2002, which impacted the interest
component of the CIPI. However, since this estimation of the change
in the CIPI is less than 0.25 percentage points, it is not reflected
in the update recommended under this framework. Therefore, we are
making a 0.0 percent adjustment for forecast error in the update for
FY 2004.
Under the capital PPS system framework, we also make an
adjustment for changes in intensity. We calculate this adjustment
using the same methodology and data that are used in the framework
for the operating PPS. 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, for changes in
within-DRG severity, and for expected modification of practice
patterns to remove noncost-effective 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
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.
As we discussed in the May 9, 2002 proposed rule (67 FR 51514),
we have developed a Medicare-specific intensity measure based on a
5-year average. 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.
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. As we
noted above, in accordance with Sec. 412.308(c)(1)(ii), we began
updating the standard Federal capital rate in FY 1996 using an
update framework that takes into account, among other things,
allowable changes in the intensity of hospital services. For FYs
1996 through 2001, we found that case-mix constant intensity was
declining and we established a 0.0 percent adjustment for intensity
in each of those years. For FYs 2001 and 2002, we found that case-
mix constant intensity was increasing and we established a 0.3
percent adjustment and 1.0 percent adjustment for intensity,
respectively.
Using the methodology described above, for FY 2004 we examined
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 for FYs 1998 though 2002. We found that, over this
period and in particular the last 3 years of this period (FYs 2000
through 2002), the charge data appear to be skewed. More
specifically, we found a dramatic increase in hospital charges for
FYs 2000 through 2002 without a corresponding increase in hospital
case-mix index. If hospitals were treating new or different types of
cases, which would result in an appropriate increase in charges per
discharge, then we would expect hospitals' case-mix to increase
proportionally.
The timing of this increase in charge growth is consistent with
the dramatic increase in charges that we discussed in the March 5,
2003 high-cost outlier proposed rule (68 FR 10420 through 14029). As
we discussed in that proposed rule, because hospitals have the
ability to increase their outlier payments through dramatic charge
increases, we proposed several changes in our high-cost outlier
policy at Sec. Sec. 412.84(i) and (m) in order to prevent hospitals
from taking advantage of our current outlier policy.
As discussed above, because our intensity calculation relies
heavily upon charge data and we believe that this charge data may be
inappropriately skewed, we are proposing a 0.0 percent adjustment
for intensity in FY 2004. In past FYs (1996 through 2000) when we
found intensity to be declining, we believed a zero (rather then
negative) intensity adjustment was appropriate. Similarly, we
believe that it is appropriate to propose a zero intensity
adjustment for FY 2004 until we believe that any increase in charges
can be tied to intensity rather then to attempts to maximize outlier
payments.
Above we described the basis of the components used to develop
the proposed 0.7 percent capital update factor for FY 2004 as shown
in the table below.
CMS's Proposed FY 2004 Update Factor to the Capital Federal Rate
------------------------------------------------------------------------
------------------------------------------------------------------------
Capital Input Price Index............................... 0.7
Intensity............................................... 0.0
Case-Mix Adjustment Factors:
Projected Case-Mix Change........................... -1.0
Real Across DRG Change.............................. 1.0
Subtotal................................................ 0.0
Effect of FY 2002 Reclassification and Recalibration.... 0.0
Forecast Error Correction............................... 0.0
[[Page 27240]]
Total Proposed Update................................... 0.7
------------------------------------------------------------------------
b. Comparison of CMS and MedPAC Update Recommendation. In the
past, MedPAC has included update recommendations for capital PPS in
a Report to Congress. In its March 2003 Report to Congress, MedPAC
did not make an update recommendation for capital PPS payments.
However, in that same report, MedPAC made an update recommendation
for hospital inpatient and outpatient services (page 4). MedPAC
stated that hospital inpatient and outpatient services should be
considered together because they are so closely interrelated. Their
recommendation is based on an assessment of whether payments are
adequate to cover the costs of efficient providers, an estimate of
input price inflation (measured by the market basket index), and an
adjustment for technological charges, which is offset by reasonable
expectations in productivity gains.
2. Outlier Payment Adjustment Factor
Section 412.312(c) establishes a unified outlier methodology for
inpatient operating and inpatient capital-related costs. A single
set of thresholds is used to identify outlier cases for both
inpatient operating and inpatient capital-related payments. Section
412.308(c)(2) provides that the standard Federal rate for inpatient
capital-related costs be reduced by an adjustment factor equal to
the estimated proportion of capital-related outlier payments to
total inpatient capital-related PPS 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, 2002 IPPS final rule (67 FR 50129), we
estimated that outlier payments for capital in FY 2003 would equal
5.31 percent of inpatient capital-related payments based on the FY
2003 Federal rate. Accordingly, we applied an outlier adjustment
factor of 0.9469 to the FY 2003 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 would equal 5.45 percent
of inpatient capital-related payments based on the Federal rate in
FY 2004. Therefore, we are proposing an outlier adjustment factor of
0.9455 to the Federal rate. Thus, the projected percentage of
capital outlier payments to total capital standard payments for FY
2004 is higher than the percentage for FY 2003.
The outlier reduction factors are not built permanently into the
rates; that is, they are not applied cumulatively in determining the
Federal rate. Therefore, the net proposed change in the outlier
adjustment to the Federal rate for FY 2004 is 0.9985 (0.9455/
0.9469). The outlier adjustment decreases the proposed FY 2004
Federal rate by 0.15 percent compared with the FY 2003 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 IPPS 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 exception payment adjustment
factor. As we explain in section III.A.4. of this Addendum,
beginning in FY 2003 an adjustment for regular exception payments 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
payment adjustment factor for special exceptions payments.
To determine the proposed factors for FY 2004, we compared
(separately for the national rate and the Puerto Rico rate)
estimated aggregate Federal rate payments based on the FY 2003 DRG
relative weights and the FY 2003 GAF to estimated aggregate Federal
rate payments based on the proposed FY 2004 relative weights and the
proposed FY 2004 GAF. In the August 1, 2002 IPPS final rule (67 FR
50129) for FY 2003, the budget neutrality adjustment factors were
0.9885 for the national rate and 0.9963 for the Puerto Rico rate. As
a result of the revisions to the GAF effective for discharges
occurring on or after April 1, 2003 through September 30, 2003, the
budget neutrality adjustment factor is 0.9983 for the national rate
for discharges occurring on or before April 1, 2003 through
September 30, 2003. The budget neutrality adjustment factor for the
Puerto Rico rate remained unchanged (0.9963). As we noted above, the
rates effective for discharges occurring on or after April 1, 2003
through September 30, 2003 were used in determining the proposed FY
2004 rates. 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 proposing to
apply an incremental budget neutrality adjustment of 1.0034 for FY
2004 to the previous cumulative FY 2003 adjustment (0.9883),
yielding a proposed cumulative adjustment of 0.9929 through FY 2004.
For the Puerto Rico GAF, we are proposing to apply an incremental
budget neutrality adjustment of 1.0002 for FY 2004 to the previous
cumulative FY 2003 adjustment (0.9963), yielding a proposed
cumulative adjustment of 0.9964 through FY 2004. (This is the
rounded result of a calculation performed on unrounded numbers.)
We then compared estimated aggregate Federal rate payments based
on the FY 2003 DRG relative weights and the FY 2003 GAF to estimated
aggregate Federal rate payments based on the proposed FY 2004 DRG
relative weights and the proposed FY 2004 GAF. The proposed
incremental adjustment for DRG classifications and changes in
relative weights is 1.0004 both nationally and for Puerto Rico. The
proposed cumulative adjustments for DRG classifications and changes
in relative weights and for changes in the GAF through FY 2004 are
0.9920 nationally and 0.9968 for Puerto Rico (this is the rounded
result of a calculation performed with unrounded numbers). The
following table summarizes the adjustment factors for each fiscal
year:
[[Page 27241]]
Budget Neutrality Adjustment for DRG Reclassifications and Recalibration and the Geographic Adjustment Factors
--------------------------------------------------------------------------------------------------------------------------------------------------------
National Puerto Rico
-------------------------------------------------------------------------------------------------------------
Incremental adjustment Incremental adjustment
Fiscal year ------------------------------------------- -------------------------------------------
Geographic DRG Cumulative Geographic DRG Cumulative
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\ \3\ 1.00009 \3\ 0.99922 \3\ \3\ 1.00009 \3\ 1.00508
0.99771 0.99780 1.00365 1.00374
2002...................................... \4\ \4\ 0.99668 \4\ 0.99268 \4\ \4\ 0.99668 \4\ 0.99164
0.99666 0.99335 0.98991 0.99662
2003 \5\.................................. 0.99915 0.99662 0.99577 0.98848 1.00809 0.99662 1.00468 0.99628
2003 \6\.................................. \7\ \7\ 0.99662 \7\ 0.98830 \7\ \7\ 0.99662 \7\ 0.99628
0.99896 0.99558 1.00809 1.00468
2004...................................... \8\ \8\ 1.00036 \8\ 0.99202 \8\ \8\ 1.00036 \8\ 0.99679
1.00341 1.00376 1.00015 1.00051
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Factors effective for the first half of FY 2001 (October 2000 through March 2001).
\2\ Factors effective for the second half of FY 2001 (April 2001 through September 2001).
\3\ Incremental factors are applied to FY 2000 cumulative factors.
\4\ Incremental factors are applied to the cumulative factors for the first half of FY 2001.
\5\ Factors effective for the first half of FY 2003 (October 2002 through March 2003).
\6\ Factors effective for the second half of FY 2003 (April 2003 through September 2003).
\7\ Incremental factors are applied to FY 2002 cumulative factors.
\8\ Incremental factors are applied to the cumulative factors for the second half of FY 2003.
The methodology used to determine the proposed recalibration and
geographic (DRG/GAF) budget neutrality adjustment factor for FY 2004
is similar to that used in establishing budget neutrality
adjustments under the PPS for operating costs. One difference is
that, under the operating PPS, 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 PPS, 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.
In the August 1, 2002 IPPS final rule (67 FR 50129), we
calculated a GAF/DRG budget neutrality factor of 0.9957 for FY 2003.
As we noted above, as a result of the revisions to the GAF effective
for discharges occurring on or after April 1, 2003 through September
30, 2003, we calculated a GAF/DRG budget neutrality factor of 0.9956
for discharges occurring on or after April 1, 2003 through September
30, 2003. Furthermore, the rates effective for discharges occurring
on or after April 1, 2003 through September 30, 2003 were used in
determining the proposed FY 2004 rates. For FY 2004, we are
proposing a GAF/DRG budget neutrality factor of 1.00038. The GAF/DRG
budget neutrality factors are built permanently into the rates; that
is, they are applied cumulatively in determining the Federal rate.
This follows from the requirement that estimated aggregate payments
each year be no more or less than they would have been in the
absence of the annual DRG reclassification and recalibration and
changes in the GAF. The proposed incremental change in the
adjustment from FY 2003 to FY 2004 is 1.00038. The proposed
cumulative change in the rate due to this adjustment is 0.9920 (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, FY 2003,
and the proposed incremental factor for FY 2004: 0.9980 x 1.0053
0.9998 x 0.9994 x 0.9987 x 0.9989 x 1.0028 x 0.9985 x 0.9979 x
0.9934 x 0.9956 x 1.00038 = 0.9920).
This proposed factor accounts for DRG reclassifications and
recalibration and for changes in the GAF. It also incorporates the
effects on the GAF of FY 2004 geographic reclassification decisions
made by the MGCRB compared to FY 2003 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 PPS
payments. In estimating the proportion of regular exception payments
to total capital PPS 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 IPPS final rule (66 FR 40099)) to determine the exceptions
payment adjustment factor, which was applied to both the Federal and
hospital-specific rates.
An adjustment for regular exception payments is no longer
necessary in determining the FY 2004 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 IPPS 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 calculating the proposed FY 2004 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 exceptions payments if it meets (1) a project
need requirement as described at Sec. 412.348(g)(2), which, in the
case of certain urban hospitals, includes an excess capacity test as
described at Sec. 412.348(g)(4); (2) an age
[[Page 27242]]
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 IPPS final rule (66 FR
39912 through 39914), in order to determine the estimated proportion
of special exceptions payments to total capital payments, we
attempted to identify the universe of eligible hospitals that may
potentially qualify for special exceptions 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 PPS. In the September 1,
1994 final rule (59 FR 45385), we stated that, based on the June
1994 update of the cost report files in HCRIS, the 75th percentile
for buildings and fixed assets for FY 1992 was 16.4 years. However,
we noted that we would make a final determination of that value on
the basis of more complete cost report information at a later date.
In the August 29, 1997 final rule (62 FR 46012), based on the
December 1996 update of HCRIS and the removal of outliers, we
finalized the 75th percentile for buildings and fixed assets for FY
1992 as 15.4 years. Thus, we eliminated any hospitals from the
potential universe of hospitals that may qualify for special
exception payments if its average age of fixed assets did not exceed
15.4 years.
For the hospitals remaining in the potential universe, we
estimated project-size by using the fixed capital acquisitions shown
on Worksheet A7 from the following HCRIS cost reports updated
through December 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.
XVIII...................................... FY 2001.
------------------------------------------------------------------------
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 2000). (Although some FY 2001 cost reports
are available in HCRIS, only a few hospitals have submitted FY 2001
costs. Consequently, too few cost reports are available to reliably
model FY 2001 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 exception provision 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 PPS payments and costs, and the
cumulative operating margin offset (excluding 75 percent of
operating DSH payments).
Our modeling of special exception payments for FY 2004 produced
the following results:
------------------------------------------------------------------------
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........................................ 1 ...........
PPS XII....................................... 4 ...........
PPS XIII...................................... 5 ...........
PPS XIV....................................... 11 ...........
PPS XV........................................ 15 ...........
PPS XVI....................................... 24 0.0002
PPS XVII...................................... 27 0.0005
PPS XVIII..................................... N/A N/A
------------------------------------------------------------------------
We note that hospitals still have one more cost reporting period
(PPS XVIII) to complete their projects in order to be eligible for
special exceptions payments, and, therefore, we estimate that about
30 hospitals could qualify for special exceptions payments. Thus, we
project that special exception payments as a fraction of capital
payments to all hospitals to be approximately 0.0005.
Because special exceptions are budget neutral, we are proposing
to offset the Federal capital rate by 0.05 percent for special
exceptions payments for FY 2004. Therefore, the proposed exceptions
adjustment factor would equal 0.9995 (1 - 0.0005) to account for
special exceptions payments in FY 2004. Furthermore, we are
proposing to estimate the exceptions payment adjustment factor for
special exceptions payments in FY 2004 in the final rule based on
updated data.
In the August 1, 2002 IPPS final rule (67 FR 50131) for FY 2003,
we estimated that total (special) exceptions payments would equal
0.30 percent of aggregate payments based on the Federal rate.
Therefore, we applied an exceptions reduction factor of 0.9970 (1 -
0.0030) in determining the FY 2003 Federal rate. As we stated, we
estimate that exceptions payments in FY 2004 would equal 0.05
percent of aggregate payments based on the proposed FY 2004 Federal
rate. Therefore, we are proposing to apply an exceptions payment
adjustment factor of 0.9995 (1 - 0.0005) to the proposed Federal
rate for FY 2004. The proposed exceptions adjustment factor for FY
2004 is 0.25 percent higher than the factor for FY 2003 published in
the August 1, 2002 IPPS final rule (67 FR 50131). This increase is
primarily due to a refined analysis of more recent data.
The exceptions reduction factors are not built permanently into
the rates; that is, the factors are not applied cumulatively in
determining the Federal rate. Therefore, the proposed net change in
the exceptions adjustment factor used in determining the proposed FY
2004 Federal rate is 0.9995/0.9970, or 1.0025.
5. Proposed Standard Capital Federal Rate for FY 2004
In the August 1, 2002 IPPS final rule (67 FR 50131) we
established a capital Federal rate of $407.01 for FY 2003. As we
noted above, as a result of the revisions to the GAF effective for
discharges occurring on or after April 1, 2003 through September 30,
2003, we have established a capital Federal rate of $406.93 for
discharges occurring on or after April 1, 2003 through September 30,
2003. The rates effective for discharges occurring on or after April
1, 2003 through September 30, 2003, were used in determining the
proposed FY 2004 rates. In this proposed rule, we are proposing a
capital Federal rate of $411.72 for FY 2004. The proposed Federal
rate for FY 2004 was calculated as follows:
[sbull] The proposed FY 2004 update factor is 1.0070; that is,
the update is 0.70 percent.
[sbull] The proposed FY 2004 budget neutrality adjustment factor
that is applied to the standard Federal payment rate for changes in
the DRG relative weights and in the GAF is 1.0038.
[sbull] The proposed FY 2004 outlier adjustment factor is
0.9455.
[sbull] The proposed FY 2004 (special) exceptions payment
adjustment factor is 0.9995.
Since the proposed Federal rate has already been adjusted for
differences in case-mix, wages, cost-of-living, indirect medical
education costs, and payments to hospitals serving a
disproportionate share of low-income patients, we are proposing to
make no additional adjustments in the standard Federal rate for
these factors, other than the
[[Page 27243]]
budget neutrality factor for changes in the DRG relative weights and
the GAF.
We are providing a chart that shows how each of the proposed
factors and adjustments for FY 2004 affected the computation of the
proposed FY 2004 Federal rate in comparison to the FY 2003 Federal
rate. The proposed FY 2004 update factor has the effect of
increasing the Federal rate by 0.70 percent compared to the FY 2003
Federal rate, while the proposed GAF/DRG budget neutrality factor
has the effect of increasing the Federal rate by 0.38 percent. The
proposed FY 2004 outlier adjustment factor has the effect of
decreasing the Federal rate by 0.15 percent compared to the FY 2003
Federal rate. The proposed FY 2004 exceptions payment adjustment
factor has the effect of increasing the Federal rate by 0.25 percent
compared to the exceptions payment adjustment factor for FY 2003.
The combined effect of all the proposed changes is to increase the
Federal rate by 1.18 percent compared to the FY 2003 Federal rate.
Comparison of Factors and Adjustments: FY 2003 Federal Rate and Proposed
FY 2004 Federal Rate
------------------------------------------------------------------------
Proposed Percent
FY 2003 FY 2004 Change change
------------------------------------------------------------------------
Update factor \1\........... 1.0110 1.0070 1.0070 0.70
GAF/DRG Adjustment Factor 0.9957 1.0038 1.0038 0.38
\1\........................
Outlier Adjustment Factor 0.9469 0.9455 0.9985 -0.15
\2\........................
Exceptions Adjustment Factor 0.9970 0.9995 1.0025 0.25
\2\........................
Federal Rate................ $406.93 $411.72 1.0118 1.18
------------------------------------------------------------------------
\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 2003 to FY 2004 resulting from the application of the
proposed 1.0038 GAF/DRG budget neutrality factor for FY 2004 is
1.0038.
\2\ The outlier reduction factor and the exceptions adjustment 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 proposed FY 2004
outlier adjustment factor is 0.9455/0.9469, or 0.9985.
6. Special Rate for Puerto Rico Hospitals
As explained at the beginning of section II.D. of this Addendum,
hospitals in Puerto Rico are paid based on 50 percent of the Puerto
Rico rate and 50 percent of the Federal rate. The Puerto Rico rate
is derived from the costs of Puerto Rico hospitals only, while the
Federal rate is derived from the costs of all acute care hospitals
participating in the PPS (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 PPS wage index and varies,
depending on the MSA or rural area in which the hospital is located.
We use the Puerto Rico wage index to determine the GAF for the
Puerto Rico part of the capital-blended rate and the national wage
index to determine the GAF for the national part of the blended
rate.
Because we implemented a separate GAF for Puerto Rico in FY
1998, we also apply separate budget neutrality adjustments for the
national GAF and for the Puerto Rico GAF. However, we apply the same
budget neutrality factor for DRG reclassifications and recalibration
nationally and for Puerto Rico. As we stated in section III.A.4. of
this Addendum, for Puerto Rico the proposed GAF budget neutrality
factor is 1.0002, while the proposed DRG adjustment is 1.0004, for a
proposed combined cumulative adjustment of 0.9968.
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. In FY 2003, a small part of that reduction was
restored.
For FY 2003, before application of the GAF, the special rate for
Puerto Rico hospitals was $198.29. With the changes we are proposing
to the factors used to determine the rate, the proposed FY 2004
special rate for Puerto Rico is $201.26.
B. Calculation of Inpatient Capital-Related Prospective Payments
for FY 2004
With the end of the capital PPS 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 2004. The applicable Federal rate was determined
by making adjustments as follows:
[sbull] For outliers, by dividing the standard Federal rate by
the outlier reduction factor for that fiscal year; and
[sbull] 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 2004, 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 proposed outlier thresholds for FY
2004 are in section II.A.4.c. of this Addendum. For FY 2004, 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 $50,645.
An eligible hospital may also qualify for a special exceptions
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 PPS 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 PPS; 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 PPS for their first 2
years of operation and are paid 85 percent of their reasonable costs
during that period. Effective with the third year of operation
through the remainder of the transition period, under Sec.
412.324(b) we paid the hospital under the appropriate transition
methodology. If the hold-harmless methodology was applicable, the
hold-harmless payment for assets in use during the base period would
extend for 8 years, even if the hold-harmless payments extend beyond
the normal transition period. As discussed in section VI.B. of the
preamble of this proposed rule, under Sec. 412.304(c)(2), for cost
reporting periods beginning on or after October 1, 2002, we pay a
new hospital 85 percent of their reasonable costs during the first 2
years of operation unless it elects
[[Page 27244]]
to receive payment based on 100 percent of the Federal rate.
Effective with the third year of operation, we pay the hospital
based on 100 percent of the capital Federal rate (that is, the same
methodology used to pay all other hospitals subject to the capital
PPS).
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
1997 in the August 1, 2002 final rule (67 FR 50044).
2. Forecast of the CIPI for Federal Fiscal Year 2004
We are forecasting the proposed CIPI to increase 0.7 percent for
FY 2004. This reflects a projected 1.2 percent increase in vintage-
weighted depreciation prices (building and fixed equipment, and
movable equipment) and a 3.4 percent increase in other capital
expense prices in FY 2004, partially offset by a 2.0 percent decline
in vintage-weighted interest rates in FY 2004. The weighted average
of these three factors produces the 0.7 percent increase for the
CIPI as a whole.
IV. Proposed Changes to Payment Rates for Excluded Hospitals and
Hospital Units: Rate-of-Increase Percentages
As discussed in section VI. of the preamble of this proposed
rule, 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 existing psychiatric hospitals and units,
rehabilitation hospitals and units, and long-term care hospitals
excluded from the IPPS are no longer subject to limits on a
hospital-specific target amount (expressed in terms of the inpatient
operating cost per discharge) that are set for each hospital, based
on the hospital's own historical cost experience trended forward by
the applicable rate-of-increase percentages (update factors).
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 are paid under the IRF PPS.
Effective for cost reporting periods beginning on or after October
1, 2002, LTCHs also are no longer paid on a reasonable cost basis
but are paid under a DRG-based PPS. As part of the payment process
for LTCHs, we established a 5-year transition period from reasonable
cost-based reimbursement to a fully Federal PPS. However, a LTCH,
subject to the blend methodology, may elect to be paid based on a
100 percent of the Federal prospective rate.
In accordance with existing Sec. 413.40(c)(4)(ii) and (d)(1)(i)
and (ii), where applicable, excluded hospitals and units that
continue to be paid on a reasonable cost basis will have payments
based on their Medicare inpatient operating costs, not to exceed the
ceiling (as defined in Sec. 413.40(a)(3)).
Section 1886(b)(7) of the Act had established a payment
limitation for new hospitals and units excluded from the IPPS. While
both rehabilitation hospitals and units and LTCHs are now paid under
a PPS, psychiatric hospitals and units continue to be subject to the
payment limitation. 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).
The amount of payment for a ``new'' psychiatric hospital or unit
would be determined as follows:
[sbull] Under existing Sec. 413.40(f)(2)(ii), for cost
reporting periods beginning on or after October 1, 1997, the amount
of payment for a new hospital or unit that was not paid as an
excluded hospital or unit before October 1, 1997, is the lower of:
(1) The hospital's net inpatient operating costs per case; or (2)
110 percent of the national median of the target amounts for the
same class of excluded hospitals and units, adjusted for differences
in wage levels and updated to the first cost reporting period in
which the hospital receives payment. The second cost reporting
period is subject to the same target amount applied to the first
cost reporting period.
[sbull] In the case of a hospital that received payments under
Sec. 413.40(f)(2)(ii) as a newly created hospital or unit, to
determine the hospital's or unit's target amount for the hospital's
or unit's third 12-month cost reporting period, the payment amount
determined under Sec. 413.40(f)(2)(ii)(A) for the preceding cost
reporting period is updated to the third cost reporting period.
The proposed amounts included in the following table reflect the
updated 110 percent of the national median target amounts of new
excluded psychiatric hospitals and units for cost reporting periods
beginning during FY 2004. These figures are updated with the most
recent data available to reflect the projected market basket
increase percentage of 3.5 percent. This projected percentage change
in the market basket reflects the average change in the price of
goods and services purchased by hospitals to furnish inpatient
hospital services (as projected by CMS's Office of the Actuary based
on its historical experience with the IPPS). For a new provider, the
labor-related share of the target amount is multiplied by the
appropriate geographic area wage index, without regard to IPPS
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 2004 FY 2004
proposed proposed
Class of excluded hospital or unit labor- nonlabor-
related related
share share
------------------------------------------------------------------------
Psychiatric................................. $7,301 $2,902
------------------------------------------------------------------------
Effective for cost reporting periods beginning on or after
October 1, 2002, this payment limitation is no longer applicable to
new LTCHs since they will be paid 100 percent of the Federal rate. A
new LTCH is a provider of inpatient hospital services that meets the
qualifying criteria for LTCHs specified under Sec. 412.23(e)(1) and
(e)(2) and whose first cost reporting period as a LTCH begins on or
after October 1, 2002 (Sec. 412.23(e)(4)). Under the LTCH PPS, new
LTCHs are paid based on 100 percent of the fully Federal prospective
rate (they may not participate in the 5-year transition from cost-
based reimbursement to prospective payment). In contrast, those
``new'' LTCHs that meet the definition of ``new'' under Sec.
413.40(f)(2)(ii) and that have their first cost reporting periods
beginning on or after October 1, 1997, and before October 1, 2002,
may be paid under the LTCH PPS transition methodology. Since those
hospitals by definition would have been considered new before
October 1, 2002, they would have been subject to the updated payment
limitation on new hospitals that was published in the FY 2003 IPPS
final rule (67 FR 50103). Under existing regulations at Sec.
413.40(f)(2)(ii), the ``new'' hospital would be subject to the same
cap in its second cost reporting period; this cap would not be
updated for the new hospital's second cost reporting year. Thus,
since the same cap is to be used for the ``new'' LTCH's first two
cost reporting periods, it is no longer necessary to publish an
updated cap.
V. Payment for Blood Clotting Factor Administered to Hemophilia
Inpatients
In December 2002, the Department implemented a policy that
established the Single Drug Pricer (SDP) to correct identified
discrepancies, further the legislative goal of establishing a
uniform payment allowance as a reflection of the average wholesale
price (AWP), and otherwise apply the existing stature and regulation
more accurately and efficiently (CMS Program Memorandum AB-02-174,
December 3, 2002, which can be accessed at: http:/www.cms.hhs.gov/manuals). Under the SDP, CMS will establish prices centrally,
thereby resulting in greater consistency in drug pricing nationally.
The SDP instruction applies to blood clotting factors furnished to
hospital inpatients. The payment allowance for the single national
drug price for each Medicare covered drug is based on 95 percent of
the AWP, except for drugs billed to durable medical equipment
regional carriers (DMERCs) and hospital outpatient drugs billed to
fiscal intermediaries. We are publishing this notice here because we
previously have addressed the add-on payment for the costs of
administering blood clotting factor in the IPPS annual rule (see the
August 1, 2000 IPPS final rule (65 FR 47116).
[[Page 27245]]
On a quarterly basis, CMS will furnish three SDP files to all
fiscal intermediaries. Each fiscal intermediary must accept the SDP
files and process claims for any drug identified on the files on the
basis of the price shown on the applicable file. Previously, the
fiscal intermediary performed annual update calculations based on
the most recent AWP data available to the carrier. The fiscal
intermediary should use the SDP to price the blood clotting factors.
VI. Tables
This section contains the tables referred to throughout the
preamble to this proposed rule and in this Addendum. For purposes of
this proposed rule, and to avoid confusion, we have retained the
designations of Tables 1 through 5 that were first used in the
September 1, 1983 initial prospective payment final rule (48 FR 39844).
Tables 1A, 1C, 1D, 2, 3A, 3B, 4A, 4B, 4C, 4F, 4G, 4H, 5, 6A, 6B, 6C,
6D, 6E, 6F, 6G, 6H, 7A, 7B, 8A, 8B, 9, 10, and 11 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 2002
(1998 Wage Data), 2003 (1999 Wage Data), and 2004 (2000 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 from the CC Exclusions List
Table 7A--Medicare Prospective Payment System Selected Percentile
Lengths of Stay FY 2002 MedPAR Update December 2002 GROUPER V20.0
Table 7B--Medicare Prospective Payment System Selected Percentile
Lengths of Stay FY 2002 MedPAR Update December 2002 GROUPER V21.0
Table 8A--Statewide Average Operating Cost-to-Charge Ratios for Urban
and Rural Hospitals (Case Weighted) March 2003
Table 8B--Statewide Average Capital Cost-to-Charge Ratios (Case
Weighted) March 2003
Table 9--Hospital Reclassifications and Redesignations by Individual
Hospital--FY 2004
Table 10--Mean and Standard Deviations by Diagnosis-Related Groups
(DRGs)--FY 2004
Table 11--Proposed LTC-DRGs Relative Weights and Geometric and Five-
Sixths of the Average Length of Stay-FY 2004
Table 1A.--National Adjusted Operating Standardized Amounts, Labor/
nonlabor
------------------------------------------------------------------------
Large urban areas Other areas
------------------------------------------------------------------------
Labor-related Nonlabor-related Labor-related Nonlabor-related
------------------------------------------------------------------------
$3,139.26 $1,276.01 $3,089.56 $1,255.81
------------------------------------------------------------------------
Table 1C.--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/nonlabor
----------------------------------------------------------------------------------------------------------------
Large urban areas Other areas
---------------------------------------------------------------
Labor Nonlabor Labor Nonlabor
----------------------------------------------------------------------------------------------------------------
National........................................ $3,112.84 $1,265.27 $3,112.84 $1,267.03
Puerto Rico..................................... 1,516.86 610.57 1,492.84 600.90
----------------------------------------------------------------------------------------------------------------
Table 1D.--Capital Standard Federal Payment Rate
------------------------------------------------------------------------
Rate
------------------------------------------------------------------------
National................................................ $411.72
Puerto Rico............................................. $201.26
------------------------------------------------------------------------
* Denotes wage data not available for the provider for that year.
** Based on the sum of the salaries and hours computed for Federal FYs
2002, 2003, and 2004.
[[Page 27246]]
Table 2.--Hospital Average Hourly Wage for Federal Fiscal Years 2002 (1998 Wage Data), 2003 (Wage Data), and
2004 (2000 Wage Data) Wage Indexes and 3-Year Average of Hospital Average Hourly Wages
----------------------------------------------------------------------------------------------------------------
Average Average Average Average
Provider No. hourly wage hourly wage hourly wage hourly** wage
FY 2002 FY 2003 FY 2004 (3 yrs)
----------------------------------------------------------------------------------------------------------------
010001.......................................... 17.4467 17.9841 19.3989 18.2929
010004.......................................... 19.0010 20.1613 19.9457 19.7003
010005.......................................... 18.6554 19.9733 18.3970 19.0198
010006.......................................... 17.6115 18.3931 19.0976 18.4162
010007.......................................... 15.6788 16.0781 17.5462 16.4299
010008.......................................... 17.4728 19.0182 19.6573 18.7416
010009.......................................... 18.4979 19.7272 20.3130 19.5087
010010.......................................... 16.4664 17.7348 18.5730 17.5867
010011.......................................... 22.4292 24.8922 25.6737 24.2683
010012.......................................... 15.8686 20.3376 20.0896 18.5710
010015.......................................... 19.1178 19.8205 18.8890 19.2826
010016.......................................... 20.2198 20.3175 21.7918 20.8284
010018.......................................... 18.9388 19.5519 19.2071 19.2353
010019.......................................... 17.0856 17.6414 18.6539 17.7694
010021.......................................... 15.1241 25.3335 17.7595 18.4456
010022.......................................... 17.6435 22.1250 22.2266 20.3667
010023.......................................... 16.3209 18.4567 20.0397 18.1965
010024.......................................... 15.9034 17.3746 18.5108 17.2202
010025.......................................... 15.1548 17.4702 18.9839 17.1956
010027.......................................... 16.8595 16.5157 14.0974 15.7259
010029.......................................... 18.3605 19.3393 20.9608 19.6182
010031.......................................... 18.6402 19.2612 21.0176 19.6504
010032.......................................... 15.3590 16.3967 16.4712 16.0937
010033.......................................... 21.2986 21.9828 24.5088 22.5487
010034.......................................... 15.3639 14.9379 14.5106 14.9494
010035.......................................... 15.9439 20.7808 21.6182 19.2869
010036.......................................... 17.7166 18.7158 17.7766 18.0775
010038.......................................... 19.6098 19.6887 18.5873 19.2586
010039.......................................... 20.3406 21.3550 22.9241 21.5758
010040.......................................... 20.0983 20.4486 20.7536 20.4392
010043.......................................... 18.6640 17.3567 19.9012 18.6528
010044.......................................... 24.0265 23.4575 25.8561 24.4502
010045.......................................... 17.0417 18.7569 21.1167 18.8731
010046.......................................... 18.9737 18.8741 19.7870 19.2388
010047.......................................... 15.4190 13.4130 16.1695 14.9341
010049.......................................... 15.5246 16.3349 16.2841 16.0555
010050.......................................... 17.9830 20.3028 20.7398 19.6262
010051.......................................... 11.8108 12.3280 14.2767 12.7951
010052.......................................... 18.0653 19.8289 11.9019 15.6329
010053.......................................... 15.5649 15.4156 17.3238 16.1023
010054.......................................... 19.4955 20.9656 20.6203 20.3735
010055.......................................... 18.8590 19.5667 19.8170 19.4298
010056.......................................... 19.6577 20.5645 21.1104 20.4208
010058.......................................... 16.9715 16.1265 17.7800 16.9302
010059.......................................... 18.8020 19.1270 20.5534 19.4928
010061.......................................... 14.5003 18.5320 16.9028 16.6415
010062.......................................... 12.3259 16.9721 17.1786 15.3820
010064.......................................... 19.5256 20.5650 21.7162 20.5136
010065.......................................... 16.8752 17.0557 17.2698 17.0733
010066.......................................... 13.1559 14.8904 14.8696 14.3351
010068.......................................... 18.6925 23.4322 18.2092 20.2305
010069.......................................... 14.7211 15.4497 16.9839 15.7052
010072.......................................... 16.2339 16.5652 18.8807 17.1920
010073.......................................... 14.1273 13.5594 14.9826 14.2068
010078.......................................... 18.1363 18.5127 20.1447 18.9315
010079.......................................... 17.0648 17.1612 20.7401 18.2252
010081.......................................... 17.2996 * * 17.2996
010083.......................................... 18.0312 18.4282 19.8525 18.7454
010084.......................................... 18.7769 19.8773 21.6522 20.1274
010085.......................................... 19.9023 21.5860 22.5282 21.3942
010086.......................................... 16.5711 16.8886 18.0122 17.1417
010087.......................................... 18.0567 18.7915 18.7253 18.4944
010089.......................................... 17.7800 19.5241 19.5783 18.9652
010090.......................................... 18.9445 19.5635 20.0287 19.5086
010091.......................................... 17.0799 17.1775 17.4672 17.2432
[[Page 27247]]
010092.......................................... 17.8144 18.5478 19.9289 18.7707
010095.......................................... 12.2597 12.3064 12.5243 12.3676
010097.......................................... 12.7286 14.2675 15.1593 14.0568
010098.......................................... 14.0300 15.5763 15.1629 14.9158
010099.......................................... 15.5619 15.9232 16.3307 15.9423
010100.......................................... 17.9430 18.3755 19.8146 18.7658
010101.......................................... 14.4625 18.9525 19.0718 17.2612
010102.......................................... 13.8136 15.7777 16.4636 15.3148
010103.......................................... 17.7242 22.0802 22.5709 20.6405
010104.......................................... 16.8457 21.9457 20.9391 19.7211
010108.......................................... 19.4617 19.1596 20.6337 19.7473
010109.......................................... 14.6752 15.9627 18.2235 16.2157
010110.......................................... 15.8283 15.5817 16.0015 15.8256
010112.......................................... 16.8271 15.6041 17.9243 16.7545
010113.......................................... 16.8936 18.2774 19.1978 18.1229
010114.......................................... 17.0760 19.3772 20.1763 18.8237
010115.......................................... 14.2261 15.3510 15.7873 15.0923
010118.......................................... 17.0834 17.4620 19.4280 17.9013
010119.......................................... 19.3942 19.5163 20.1990 19.7084
010120.......................................... 18.2567 18.9975 19.4369 18.8719
010121.......................................... 14.5262 15.2345 17.1640 15.7079
010123.......................................... 19.2140 * * 19.2141
010124.......................................... 16.7465 * * 16.7465
010125.......................................... 16.0136 16.5117 16.8622 16.4618
010126.......................................... 19.1065 19.5933 19.9845 19.5804
010127.......................................... 18.2786 * * 18.2786
010128.......................................... 14.4322 16.6899 14.7646 15.2637
010129.......................................... 16.1733 16.7609 16.4904 16.4644
010130.......................................... 19.5573 17.4614 18.7190 18.5367
010131.......................................... 20.1883 19.0492 22.3132 20.5855
010134.......................................... 19.9856 18.5179 16.8181 18.4871
010137.......................................... 20.5828 21.3573 28.7410 23.1563
010138.......................................... 14.5254 14.1369 14.2024 14.2898
010139.......................................... 20.4331 20.5708 22.8390 21.2553
010143.......................................... 17.6212 18.9084 20.6578 19.0594
010144.......................................... 18.2040 18.8272 19.1497 18.7345
010145.......................................... 20.5895 20.8157 21.7700 21.0799
010146.......................................... 19.1415 18.3666 21.3384 19.6056
010148.......................................... 15.8349 18.4591 17.6830 17.3825
010149.......................................... 18.0156 19.0199 20.8645 19.3169
010150.......................................... 18.9359 19.4819 21.1878 19.8964
010152.......................................... 18.7677 19.8990 21.1438 19.9058
010155.......................................... 15.0689 13.6136 * 14.4394
010157.......................................... * 17.7372 19.6977 18.7304
010158.......................................... 18.3957 18.6052 18.5464 18.5206
010159.......................................... * 19.3950 * 19.3950
020001.......................................... 28.0394 28.6530 30.1452 28.9867
020002.......................................... 25.1987 28.2759 30.4165 27.8092
020004.......................................... 25.4679 29.2351 27.3516 27.2833
020005.......................................... 29.2378 35.0860 32.7936 32.3866
020006.......................................... 28.1417 33.0843 31.2673 30.7745
020007.......................................... 32.3852 27.7269 27.5708 28.8969
020008.......................................... 30.8691 31.8878 33.4543 32.1364
020009.......................................... 18.4660 18.5594 24.9415 20.3403
020010.......................................... 22.7559 23.7275 20.7928 22.3051
020011.......................................... 28.0658 27.5062 29.6249 28.3773
020012.......................................... 25.5320 26.7586 27.9955 26.7886
020013.......................................... 28.1557 29.5646 30.6424 29.4993
020014.......................................... 24.5875 27.7870 29.6806 27.4656
020017.......................................... 28.0572 28.8752 30.3017 29.1234
020024.......................................... 25.3205 25.5933 28.0930 26.3977
020025.......................................... 20.2583 29.4375 32.8655 26.7102
030001.......................................... 21.7869 22.8996 25.7513 23.3305
[[Page 27248]]
030002.......................................... 21.8375 23.1450 25.6038 23.5516
030003.......................................... 22.6804 23.9849 22.1436 22.9249
030004.......................................... 15.5478 13.8452 15.7742 15.0275
030006.......................................... 20.0273 20.5019 23.0216 21.0706
030007.......................................... 21.5169 22.2473 26.1551 23.4298
030008.......................................... 22.2190 * * 22.2190
030009.......................................... 18.7557 19.1258 19.9131 19.2261
030010.......................................... 19.5123 19.8496 20.7204 20.0003
030011.......................................... 19.4310 19.8141 21.0028 20.0690
030012.......................................... 20.6585 21.1099 24.2366 22.1509
030013.......................................... 20.0535 19.9517 21.9766 20.7166
030014.......................................... 19.7966 20.3017 21.5382 20.5679
030016.......................................... 19.4785 22.2526 24.3380 22.1886
030017.......................................... 21.7938 23.1702 21.8792 22.2509
030018.......................................... 20.8980 21.8067 24.9216 22.5811
030019.......................................... 21.2540 22.0341 23.2973 22.2278
030022.......................................... 19.5794 22.3351 24.9941 22.3479
030023.......................................... 24.1678 25.4626 28.6628 26.2700
030024.......................................... 23.6009 23.7663 26.7641 24.7020
030025.......................................... 11.9894 20.2690 18.7967 16.8149
030027.......................................... 17.6555 18.5500 19.4583 18.5927
030030.......................................... 21.6932 23.1280 25.2425 23.1970
030033.......................................... 20.2820 20.3034 26.4812 22.3008
030034.......................................... 20.8689 19.5578 17.7772 19.3850
030035.......................................... 20.0226 20.5339 * 20.2741
030036.......................................... 21.6371 22.2690 24.9432 23.0233
030037.......................................... 23.7615 23.7325 23.0542 23.5162
030038.......................................... 22.9822 23.4477 25.2632 23.9087
030040.......................................... 19.7636 19.3706 21.2717 20.1331
030041.......................................... 18.8717 18.4750 18.6985 18.6886
030043.......................................... 20.5598 20.5653 20.8619 20.6748
030044.......................................... 17.6575 18.6781 21.9503 19.2464
030047.......................................... 21.4412 22.7385 23.8939 22.7605
030049.......................................... 19.3580 19.7315 * 19.5288
030054.......................................... 15.0657 15.7973 16.8863 15.9671
030055.......................................... 20.2991 20.8373 22.8612 21.3919
030059.......................................... 22.6279 27.3929 * 24.8227
030060.......................................... 18.6313 19.5021 21.7685 19.9508
030061.......................................... 19.9047 21.1013 22.9706 21.3676
030062.......................................... 18.7172 19.2670 21.1639 19.7478
030064.......................................... 20.3837 21.6435 22.8009 21.6120
030065.......................................... 20.7838 22.2846 24.6064 22.6068
030067.......................................... 17.2778 17.6414 18.4004 17.7581
030068.......................................... 17.7208 18.9718 19.7097 18.8803
030069.......................................... 21.0936 23.4902 24.5432 23.0752
030080.......................................... 20.6581 21.2299 22.7867 21.6244
030083.......................................... 23.5229 23.5049 24.3273 23.8162
030085.......................................... 20.8690 21.6542 21.8196 21.4875
030087.......................................... 21.9465 23.1339 25.6344 23.5331
030088.......................................... 20.5340 21.4491 23.5761 21.9185
030089.......................................... 20.9516 22.0850 24.5055 22.5911
030092.......................................... 21.8308 19.6625 20.6577 20.5622
030093.......................................... 20.4314 21.7195 23.2485 21.9062
030094.......................................... 22.8123 21.8049 24.5992 23.0301
030095.......................................... 13.7664 20.5222 * 16.1313
030099.......................................... 18.2263 19.8092 20.3310 19.5882
030100.......................................... 23.7609 23.5868 * 23.6643
030101.......................................... 19.2547 21.1029 23.8414 21.3423
030102.......................................... 18.2413 21.5405 * 19.8425
030103.......................................... * 28.9308 40.8755 33.8153
030104.......................................... * 32.8668 34.6026 33.8315
040001.......................................... 16.9178 16.3882 16.2652 16.4883
040002.......................................... 15.1107 16.1353 18.0776 16.4361
[[Page 27249]]
040003.......................................... 15.5740 15.5186 16.3918 15.8349
040004.......................................... 17.9034 19.0105 19.8567 18.9476
040005.......................................... 11.1318 16.5465 * 13.6054
040007.......................................... 18.6998 22.5319 23.3992 21.2518
040008.......................................... 14.7985 20.2121 * 17.4031
040010.......................................... 19.4913 19.8251 20.4612 19.9398
040011.......................................... 16.0995 17.1337 18.8346 17.5256
040014.......................................... 18.1434 19.3996 22.4970 19.9652
040015.......................................... 15.5207 17.9602 18.8513 17.4824
040016.......................................... 20.2321 19.8087 21.2198 20.4114
040017.......................................... 15.4736 16.5648 17.7545 16.6023
040018.......................................... 18.7463 18.8203 22.2459 19.8242
040019.......................................... 23.4163 21.0465 21.1711 21.7572
040020.......................................... 18.9844 17.6056 18.0130 18.1484
040021.......................................... 19.6835 21.3321 23.3840 21.5035
040022.......................................... 20.8281 19.2393 20.5951 20.1448
040024.......................................... 17.6607 17.1507 17.5750 17.4623
040025.......................................... 13.4705 14.8071 17.6791 15.1660
040026.......................................... 19.7924 21.0143 22.6617 21.1612
040027.......................................... 17.4431 17.7161 19.3388 18.1973
040028.......................................... 13.9946 15.2850 13.9975 14.4367
040029.......................................... 21.1370 22.5094 22.1882 21.9489
040030.......................................... 11.2402 16.5488 * 13.2353
040032.......................................... 13.2872 13.8013 16.2781 14.3506
040035.......................................... 10.9569 11.0611 11.8237 11.2698
040036.......................................... 20.2012 21.1066 21.6742 21.0202
040037.......................................... 14.0941 15.4984 * 14.7246
040039.......................................... 14.7177 15.2811 15.9673 15.3471
040040.......................................... 19.1984 19.6704 * 19.4380
040041.......................................... 16.4624 17.7783 20.4646 18.2091
040042.......................................... 15.2057 16.6875 16.2285 16.0552
040044.......................................... 13.3501 17.1869 18.4270 16.2509
040045.......................................... 16.2469 16.6648 19.5573 17.3603
040047.......................................... 17.5336 18.6295 20.4173 18.8431
040050.......................................... 14.0036 14.2087 15.1428 14.4627
040051.......................................... 16.6039 18.2152 17.6964 17.5006
040053.......................................... 15.0219 14.1508 19.2586 15.8377
040054.......................................... 14.2577 16.5217 16.5573 15.7676
040055.......................................... 18.0414 17.4236 17.1669 17.5528
040058.......................................... 16.4278 19.3124 * 17.6419
040060.......................................... 17.9805 15.4220 19.0007 17.4501
040062.......................................... 17.8902 19.4255 20.6917 19.3314
040064.......................................... 11.5029 13.3479 18.6107 14.1151
040066.......................................... 19.7144 19.5619 21.7766 20.3116
040067.......................................... 14.4741 15.0081 16.0516 15.1736
040069.......................................... 17.0026 18.9754 20.5968 18.8667
040070.......................................... 16.9700 18.6066 20.5214 18.8036
040071.......................................... 17.6144 18.4956 18.7641 18.2815
040072.......................................... 17.4960 21.3320 18.4032 18.9950
040074.......................................... 18.7542 20.8465 22.0800 20.5126
040075.......................................... 14.0975 14.6681 15.7875 14.8313
040076.......................................... 20.5840 21.8010 23.5948 21.9901
040077.......................................... 13.9114 14.7230 16.7832 15.1038
040078.......................................... 18.5821 19.6363 21.4854 19.9519
040080.......................................... 19.3707 22.8153 18.3431 19.9751
040081.......................................... 11.1332 12.4796 13.2797 12.2892
040082.......................................... 15.1331 16.4840 18.1636 16.5196
040084.......................................... 17.7295 18.3410 20.1163 18.7753
040085.......................................... 16.5216 14.1782 15.5811 15.3778
040088.......................................... 17.1624 18.3159 19.8286 18.3979
040090.......................................... 19.0824 16.6619 * 17.8591
040091.......................................... 20.1378 20.2904 20.6688 20.3813
040093.......................................... 13.9741 14.7132 * 14.3380
[[Page 27250]]
040100.......................................... 15.6833 17.0271 17.8889 16.9700
040105.......................................... 14.3896 14.8936 15.4697 14.9508
040106.......................................... 18.1341 19.0936 19.1726 18.8593
040107.......................................... 17.8628 20.6852 17.6695 18.7676
040109.......................................... 16.6278 16.2496 17.1706 16.6926
040114.......................................... 21.1231 21.3826 21.3532 21.2885
040118.......................................... 18.2123 19.6248 21.8065 19.9138
040119.......................................... 16.9407 18.6028 19.9013 18.5380
040124.......................................... 19.2889 * * 19.2889
040126.......................................... 11.6517 16.3391 13.3832 13.6732
040132.......................................... 10.3875 24.6941 29.2337 17.5163
040134.......................................... 19.0185 22.1291 * 20.6229
040135.......................................... 23.0084 * * 23.0082
040136.......................................... * 21.4139 * 21.4138
040137.......................................... * * 24.7813 24.7813
040138.......................................... * * 21.0859 21.0859
050002.......................................... 36.9630 30.2629 30.9729 32.2632
050006.......................................... 18.2061 22.4890 25.4618 22.0352
050007.......................................... 30.8676 31.6270 34.1406 32.1656
050008.......................................... 26.3682 28.2021 32.4067 28.7024
050009.......................................... 28.4734 28.3021 30.2740 29.0378
050013.......................................... 28.0569 27.2552 30.1682 28.4525
050014.......................................... 23.6745 25.1664 27.7646 25.5586
050015.......................................... 27.7731 28.2204 27.5652 27.8552
050016.......................................... 21.2045 22.7014 25.1232 23.0550
050017.......................................... 25.6178 25.7403 28.4165 26.5820
050018.......................................... 15.2903 16.5909 17.9621 16.7254
050022.......................................... 24.5254 26.2574 28.1312 26.3930
050024.......................................... 22.4274 21.5230 25.1016 22.9531
050025.......................................... 24.8245 26.0161 29.8262 26.8932
050026.......................................... 23.1904 23.4651 23.8785 23.5278
050028.......................................... 17.6138 17.9421 18.7866 18.1131
050029.......................................... 24.6839 26.6783 30.2538 27.1782
050030.......................................... 21.5621 21.8639 21.9251 21.7896
050032.......................................... 24.3598 24.4176 24.6284 24.4685
050033.......................................... 32.0179 31.1768 * 31.6954
050036.......................................... 21.8239 24.8017 25.3885 24.0459
050038.......................................... 29.9698 32.1757 36.1619 32.5954
050039.......................................... 22.8288 23.8478 26.8993 24.5711
050040.......................................... 30.2607 30.1153 30.7426 30.3810
050042.......................................... 24.5260 25.4903 27.6765 25.9508
050043.......................................... 33.8255 38.8988 37.3217 36.6008
050045.......................................... 21.1474 21.0356 22.1691 21.4359
050046.......................................... 25.2005 25.3067 25.5490 25.3505
050047.......................................... 29.9580 31.6959 34.4427 32.0849
050051.......................................... 18.7809 17.9266 * 18.3161
050054.......................................... 22.0982 19.2395 21.3495 20.8463
050055.......................................... 29.2730 32.0923 36.1182 32.3322
050056.......................................... 23.8396 24.7994 27.1458 25.3250
050057.......................................... 20.7420 22.2584 24.2758 22.4840
050058.......................................... 23.3009 24.8366 23.2205 23.7636
050060.......................................... 20.5450 21.9971 22.9491 22.0213
050061.......................................... 24.5488 23.9906 25.3042 24.6040
050063.......................................... 25.7593 25.5798 28.6093 26.6450
050065.......................................... 24.6290 27.6677 28.8369 27.0472
050066.......................................... 16.1649 26.3920 * 19.8363
050067.......................................... 25.8857 22.1250 27.8867 24.8006
050068.......................................... 19.3615 19.2325 21.9031 19.5920
050069.......................................... 24.6153 25.8560 27.2744 25.8994
050070.......................................... 34.0721 36.4136 39.5178 36.7625
050071.......................................... 34.4367 36.4834 40.1344 37.0182
050072.......................................... 39.7321 36.1146 39.2188 38.3181
050073.......................................... 32.8555 36.1054 38.6763 35.9238
[[Page 27251]]
050075.......................................... 33.7160 37.8104 40.2265 37.4233
050076.......................................... 33.9752 37.0415 40.8075 37.1398
050077.......................................... 24.1404 25.3481 27.1234 25.5664
050078.......................................... 24.3150 23.0613 23.2913 23.5117
050079.......................................... 30.0167 36.5455 39.6651 35.3854
050082.......................................... 23.7617 23.7718 23.9154 23.8161
050084.......................................... 25.4517 25.1155 25.9728 25.5331
050088.......................................... 24.9641 25.2282 27.1103 25.7384
050089.......................................... 22.8450 23.4120 24.7857 23.6599
050090.......................................... 24.6070 25.4545 27.4193 25.8348
050091.......................................... 23.7713 26.6463 29.2522 26.4442
050092.......................................... 17.1211 17.1883 18.1132 17.4867
050093.......................................... 25.6647 27.2048 29.2642 27.4393
050095.......................................... 30.4847 29.2226 * 29.7245
050096.......................................... 22.7394 22.5034 23.0526 22.7555
050097.......................................... 22.5991 24.2548 24.4129 23.7724
050099.......................................... 25.3722 26.2363 27.1308 26.2772
050100.......................................... 25.2031 23.9877 25.3258 24.8411
050101.......................................... 31.8957 33.1232 32.3802 32.4675
050102.......................................... 24.0014 22.6741 25.5763 24.0204
050103.......................................... 25.4133 23.5946 25.0854 24.6669
050104.......................................... 26.9726 27.3260 26.1592 26.8000
050107.......................................... 22.2019 22.2746 22.6900 22.4227
050108.......................................... 25.1758 25.6983 28.5244 26.4357
050110.......................................... 19.9589 21.3399 21.9296 21.1132
050111.......................................... 20.7897 21.0813 23.7715 21.9292
050112.......................................... 26.8182 29.1268 31.9797 29.3043
050113.......................................... 28.5224 32.4493 32.6932 31.3678
050114.......................................... 26.6757 27.6486 28.1909 27.5327
050115.......................................... 23.0182 24.3748 24.1481 23.8529
050116.......................................... 24.9196 27.0331 28.2924 26.6320
050117.......................................... 22.2123 23.0697 24.7555 23.3917
050118.......................................... 23.7129 24.9094 28.9358 25.8815
050121.......................................... 18.7272 18.8430 24.6584 20.3903
050122.......................................... 26.9546 26.9048 29.1534 27.6723
050124.......................................... 24.5069 23.9379 23.0843 23.8087
050125.......................................... 32.0230 33.3290 35.6572 33.6339
050126.......................................... 24.6752 26.9718 27.7126 26.4996
050127.......................................... 20.9027 20.5928 21.8559 21.1158
050128.......................................... 26.6132 26.2519 28.7668 27.1805
050129.......................................... 24.0108 23.7432 25.2780 24.3452
050131.......................................... 32.5462 33.0980 37.7844 34.4656
050132.......................................... 24.0173 24.1583 28.0265 25.4346
050133.......................................... 23.2093 23.9479 25.1948 24.1576
050135.......................................... 24.7157 23.2750 12.5413 18.0625
050136.......................................... 24.7280 28.0754 31.1484 27.7833
050137.......................................... 32.9192 33.7489 35.0503 33.8818
050138.......................................... 38.1584 40.8912 43.0858 40.6538
050139.......................................... 31.4984 35.1492 33.8749 33.3407
050140.......................................... 32.7609 36.7096 36.1708 35.1295
050144.......................................... 27.4069 29.8983 30.3678 29.2851
050145.......................................... 34.5185 37.5003 37.5722 36.5610
050148.......................................... 20.0971 21.1622 17.3908 19.5271
050149.......................................... 26.8674 25.8880 28.0501 26.8823
050150.......................................... 24.6596 25.9494 26.7728 25.8255
050152.......................................... 33.3305 34.5096 34.5694 34.1486
050153.......................................... 32.3389 33.3333 34.5870 33.4428
050155.......................................... 25.3354 23.2118 21.2069 23.1002
050158.......................................... 28.6071 28.9764 30.6598 29.4328
050159.......................................... 22.5313 26.6139 21.3422 23.0637
050167.......................................... 21.8796 21.9596 23.1879 22.3467
050168.......................................... 25.1937 27.1971 26.4047 26.2183
050169.......................................... 24.8407 24.7737 25.6896 25.1108
[[Page 27252]]
050170.......................................... 24.3654 27.7693 29.4075 26.9505
050172.......................................... 19.6120 22.0400 24.5849 22.0737
050173.......................................... 24.8694 * 27.7070 26.3141
050174.......................................... 30.2775 31.6888 33.5204 31.9008
050175.......................................... 24.7548 26.0146 26.9627 25.9076
050177.......................................... 21.1396 22.5039 23.1575 22.2317
050179.......................................... 23.8868 22.8941 23.0583 23.2574
050180.......................................... 33.3257 34.0900 36.9905 34.8613
050186.......................................... 23.6288 25.0791 27.6638 25.5202
050188.......................................... 28.2364 30.6007 34.1503 31.0517
050189.......................................... 27.4071 28.3295 32.3514 29.2097
050191.......................................... 25.3516 29.4162 28.1689 27.6587
050192.......................................... 14.1996 19.0400 19.5157 17.3616
050193.......................................... 24.9444 25.5294 24.6307 25.0325
050194.......................................... 29.5678 28.5389 28.0291 28.6722
050195.......................................... 36.9068 39.1617 42.1735 39.4471
050196.......................................... 18.2411 19.4304 19.8203 19.1752
050197.......................................... 32.4030 34.6878 25.9224 30.7008
050204.......................................... 22.7099 23.0192 24.9458 23.5600
050205.......................................... 24.1691 24.1275 25.2841 24.5169
050207.......................................... 22.9941 23.7774 25.1863 23.9991
050211.......................................... 31.7280 33.2481 34.3396 33.0898
050213.......................................... 21.4951 * * 21.4951
050214.......................................... 24.0276 21.1480 22.2431 22.4178
050215.......................................... 35.0459 31.6895 34.4745 33.7035
050217.......................................... 20.2042 21.3026 22.2055 21.2565
050219.......................................... 21.2458 21.7637 21.8649 21.6598
050222.......................................... 23.3563 23.0670 24.6959 23.7403
050224.......................................... 23.5101 24.8431 25.1943 24.5595
050225.......................................... 21.6820 22.0981 24.5601 22.7516
050226.......................................... 24.4443 26.1959 26.0826 25.7144
050228.......................................... 34.2596 36.0632 38.6751 36.2629
050230.......................................... 26.6291 26.7963 30.0380 27.8217
050231.......................................... 26.7321 27.4697 27.0320 27.0798
050232.......................................... 24.5245 25.8640 25.3439 25.2423
050234.......................................... 24.6126 25.0104 23.2830 24.1727
050235.......................................... 27.0922 26.0323 27.2838 26.7962
050236.......................................... 25.9458 27.7406 26.9290 26.8640
050238.......................................... 24.5823 25.1796 26.0312 25.2541
050239.......................................... 23.2711 24.9469 27.0911 25.1055
050240.......................................... 26.7620 28.8910 32.8542 29.7204
050241.......................................... 29.8345 * * 29.8345
050242.......................................... 32.0829 33.5646 34.4412 33.3749
050243.......................................... 26.4627 26.0256 28.5626 27.0708
050245.......................................... 23.2716 24.6092 25.7585 24.5579
050248.......................................... 27.6457 28.4413 29.1192 28.4523
050251.......................................... 23.6360 27.9531 24.4552 25.2214
050253.......................................... 16.7540 21.0399 23.9247 20.2377
050254.......................................... 20.1176 22.3414 23.3358 21.9420
050256.......................................... 23.4835 25.1104 26.8618 25.3035
050257.......................................... 17.2596 15.6379 17.4909 16.8191
050260.......................................... 27.4234 30.1623 24.9073 27.2549
050261.......................................... 20.1040 19.4649 21.4693 20.3613
050262.......................................... 29.5550 30.8866 33.0425 31.0973
050264.......................................... 36.0331 33.2270 37.5425 35.5478
050267.......................................... 26.0401 27.8393 26.6558 26.7955
050270.......................................... 25.3757 26.4092 27.9871 26.6878
050272.......................................... 23.0587 23.3443 24.0921 23.5076
050276.......................................... 33.3302 34.0633 34.4832 33.9454
050277.......................................... 26.0822 23.6065 35.6323 28.8604
050278.......................................... 23.9289 24.9699 26.0331 24.9976
050279.......................................... 21.8949 22.2776 23.5145 22.5756
050280.......................................... 25.6651 26.3392 28.4969 26.8343
[[Page 27253]]
050281.......................................... 24.2251 25.2699 25.7832 25.1246
050282.......................................... 25.4428 26.4698 * 25.9126
050283.......................................... 31.7669 32.3270 35.1831 33.1816
050286.......................................... 19.4241 20.6191 19.7351 19.9268
050289.......................................... 30.4750 32.2125 34.9651 32.5458
050290.......................................... 29.6796 31.5000 31.9510 31.0288
050291.......................................... 29.4029 30.9334 28.3451 29.5051
050292.......................................... 20.8410 21.4357 27.6114 23.1188
050293.......................................... 24.1875 17.1935 * 20.0134
050295.......................................... 21.7883 25.4405 25.4332 24.2106
050296.......................................... 28.3906 30.0984 33.5948 30.6658
050298.......................................... 23.2006 22.4000 26.1833 23.8635
050299.......................................... 25.5035 24.6751 26.9870 25.7710
050300.......................................... 25.9228 26.0298 26.6700 26.2233
050301.......................................... 21.1403 24.7987 22.7711 22.8646
050305.......................................... 36.7908 36.6981 38.7597 37.4248
050308.......................................... 28.9284 30.3887 31.6790 30.3648
050309.......................................... 25.3515 25.5221 25.5367 25.4704
050312.......................................... 26.0015 26.0172 28.2557 26.8194
050313.......................................... 25.6827 28.9126 25.0948 26.4529
050315.......................................... 22.7359 22.5906 23.6638 23.0139
050320.......................................... 32.4809 31.6571 31.9686 32.0209
050324.......................................... 25.3694 26.8313 28.4931 27.0063
050325.......................................... 23.6327 22.6353 26.6326 24.1679
050327.......................................... 25.6450 31.1527 33.0549 29.6283
050329.......................................... 21.6984 24.2134 26.6341 24.1720
050331.......................................... 25.0230 25.2110 21.5193 23.7909
050333.......................................... 19.1449 14.1808 15.6929 16.0637
050334.......................................... 34.2557 34.3956 37.2336 35.3386
050335.......................................... 22.9926 22.9335 23.9713 23.3018
050336.......................................... 21.3402 22.0203 * 21.6868
050342.......................................... 20.8255 22.4510 23.0282 22.0864
050348.......................................... 25.1085 29.3364 28.9864 27.7954
050349.......................................... 15.0667 15.4536 15.6042 15.3828
050350.......................................... 26.4161 27.2368 27.2573 26.9829
050351.......................................... 24.8121 25.2436 27.4042 25.8956
050352.......................................... 26.4262 27.7489 32.6772 28.8662
050353.......................................... 23.2699 24.1009 24.8223 24.0722
050355.......................................... 21.0969 41.4710 * 27.5904
050357.......................................... 24.5345 24.3540 25.2126 24.7119
050359.......................................... 21.7548 19.7653 22.9175 21.4664
050360.......................................... 31.7583 33.3592 35.9032 33.7039
050366.......................................... 19.6823 22.0442 23.4696 21.8093
050367.......................................... 30.7328 31.7487 32.6760 31.7233
050369.......................................... 26.2234 26.6627 28.0909 27.0127
050373.......................................... 27.8275 29.9749 30.4697 29.3692
050376.......................................... 28.0990 28.4026 30.3530 28.9347
050377.......................................... 17.0012 11.6463 14.3889 14.7469
050378.......................................... 26.9101 27.8389 30.4937 28.3969
050379.......................................... 18.4278 24.2408 27.5150 22.7721
050380.......................................... 31.9578 31.5962 35.1536 32.9076
050382.......................................... 25.9244 26.3968 26.8949 26.4027
050385.......................................... * 27.1692 * 27.1692
050388.......................................... 22.0122 17.6762 15.6834 18.4348
050390.......................................... 24.2700 25.8556 25.7881 25.2656
050391.......................................... 20.0615 19.0832 20.2887 19.7798
050392.......................................... 22.9430 24.9003 21.8139 23.1475
050393.......................................... 24.1981 25.4028 26.4918 25.4171
050394.......................................... 23.1526 23.1641 25.1869 23.8865
050396.......................................... 25.3729 25.7580 28.4161 26.5200
050397.......................................... 20.6397 23.3212 24.7280 22.8187
050401.......................................... 18.4593 * * 18.4593
050404.......................................... 15.9839 16.4845 20.0233 17.3758
[[Page 27254]]
050406.......................................... 17.8596 21.5282 23.0438 20.5476
050407.......................................... 30.8346 32.0753 33.2894 32.0587
050410.......................................... 19.8508 17.1718 19.8436 18.9151
050411.......................................... 33.1943 33.1718 * 33.1828
050414.......................................... 25.9723 24.5471 26.8815 25.7060
050417.......................................... 23.3005 23.3862 24.4608 23.7300
050419.......................................... 23.4936 25.1449 26.4357 25.0021
050420.......................................... 23.5438 26.4201 26.7537 25.5652
050423.......................................... 21.3552 24.8113 26.5188 24.3189
050424.......................................... 24.0727 25.9378 27.5273 25.9000
050425.......................................... 35.3712 33.7276 37.7347 35.6925
050426.......................................... 29.0120 26.7941 30.9610 28.8680
050427.......................................... 16.4330 31.4154 25.8360 23.8810
050430.......................................... 21.2275 25.2322 31.5171 24.6961
050432.......................................... 24.5630 26.0686 28.2074 26.3472
050433.......................................... 18.9021 17.7980 14.3846 17.2267
050434.......................................... * 24.0017 * 24.0017
050435.......................................... 23.3426 22.5428 22.6561 22.8168
050438.......................................... 23.2583 25.3763 26.5535 25.0490
050440.......................................... 22.5400 25.4767 28.2209 25.3120
050441.......................................... 31.8774 33.4696 36.6680 33.8900
050443.......................................... 17.2875 16.8897 18.0063 17.3814
050444.......................................... 22.4530 22.6469 23.5299 22.8500
050446.......................................... 22.3422 20.3611 20.0104 20.8646
050447.......................................... 18.9851 24.4339 25.7274 23.3050
050448.......................................... 21.7718 22.6612 26.6967 23.5469
050449.......................................... 23.4614 * * 23.4614
050454.......................................... 30.0792 30.3063 34.4813 31.6390
050455.......................................... 19.8577 20.5575 23.8527 21.3319
050456.......................................... 18.1585 17.5846 23.7594 19.3948
050457.......................................... 32.1910 34.2116 37.4570 34.4455
050464.......................................... 25.7710 25.8092 31.4768 27.7900
050468.......................................... 22.2926 22.9771 17.8128 20.5312
050469.......................................... 24.5205 * 25.7995 25.2381
050470.......................................... 16.0805 15.7765 21.2996 17.4624
050471.......................................... 27.1597 29.4705 32.3570 29.6121
050476.......................................... 24.0253 25.9458 25.9711 25.3460
050477.......................................... 27.5819 30.8781 32.1676 30.2255
050478.......................................... 26.3306 28.1829 28.3893 27.6685
050481.......................................... 27.7973 28.5320 29.4912 28.6205
050482.......................................... 16.0114 21.6091 23.0016 19.2164
050485.......................................... 24.6906 25.2723 23.8237 24.5767
050488.......................................... 31.7481 33.8291 37.2438 34.4285
050491.......................................... 27.4600 27.7412 29.2987 28.1988
050492.......................................... 20.5030 23.4977 23.7383 22.6518
050494.......................................... 29.1296 30.2875 30.7725 30.1010
050496.......................................... 34.9704 32.7474 35.7115 34.4409
050497.......................................... 15.4115 * 14.4481 14.9306
050498.......................................... 26.1716 27.6099 28.2196 27.3481
050502.......................................... 25.3701 27.2724 27.9506 26.8641
050503.......................................... 23.3745 25.7668 26.7924 25.3905
050506.......................................... 25.0333 27.1555 30.4731 27.5747
050510.......................................... 33.7481 36.2548 39.6005 36.5514
050512.......................................... 34.4368 36.0785 39.0767 36.6044
050515.......................................... 33.7321 37.3440 36.3131 35.7452
050516.......................................... 26.1969 25.3450 30.0359 27.0104
050517.......................................... 22.0985 23.6067 23.4131 22.9981
050522.......................................... 36.2127 37.0295 38.9158 36.9675
050523.......................................... 31.2522 32.1272 33.8053 32.4311
050526.......................................... 26.4014 26.8814 29.0004 27.4593
050528.......................................... 18.9155 21.1741 23.9177 21.3604
050531.......................................... 21.3948 * 22.7311 22.0660
050534.......................................... 24.0001 24.4038 26.7941 25.0949
[[Page 27255]]
050535.......................................... 26.8511 27.7626 29.7904 28.1965
050537.......................................... 24.0354 26.2342 25.1292 25.1574
050539.......................................... 23.3846 23.7778 24.1196 23.7754
050541.......................................... 36.6149 37.0551 41.1980 38.3379
050542.......................................... 17.7737 21.8129 21.2846 19.9901
050543.......................................... 21.6795 22.4134 24.0333 22.7542
050545.......................................... 31.7280 33.6302 33.4322 32.9305
050546.......................................... 38.8087 39.4266 42.8053 40.3552
050547.......................................... 37.7681 37.7633 40.6483 38.6518
050548.......................................... 29.8516 30.3336 32.3944 30.8485
050549.......................................... 28.9615 30.0948 31.6709 30.2918
050550.......................................... 25.6588 26.5515 29.0938 27.1362
050551.......................................... 24.8084 26.1042 28.6834 26.5676
050552.......................................... 20.3239 20.6068 24.9755 21.7907
050557.......................................... 22.2562 23.8340 25.8401 24.0476
050559.......................................... 24.7866 26.3799 25.3299 25.4887
050561.......................................... 33.4423 34.2065 * 33.8236
050564.......................................... 24.2091 * * 24.2090
050565.......................................... 20.8349 * * 20.8349
050566.......................................... 22.3448 21.7712 24.0648 22.6946
050567.......................................... 25.0787 26.2588 27.8475 26.4308
050568.......................................... 20.5376 21.9313 20.8324 21.0880
050569.......................................... 27.3429 27.3294 27.7955 27.4880
050570.......................................... 25.8619 26.8965 29.9470 27.6972
050571.......................................... 24.0154 26.2226 29.1716 26.5115
050573.......................................... 25.6589 25.9380 27.2328 26.2959
050575.......................................... 20.7090 27.8579 23.1358 23.6994
050577.......................................... 23.5487 25.2861 26.4806 25.0050
050578.......................................... 28.9009 32.0554 31.1695 30.6550
050579.......................................... 29.9348 32.0245 34.9794 32.4397
050580.......................................... 24.6962 22.7522 27.2431 24.7685
050581.......................................... 24.9807 26.0580 28.9696 26.6705
050583.......................................... 25.8800 26.2664 30.0427 27.5806
050584.......................................... 19.5805 24.5294 24.5544 22.7601
050585.......................................... 24.2824 26.4446 26.0595 25.5822
050586.......................................... 23.1850 * * 23.1850
050588.......................................... 24.5472 27.0506 30.5453 27.6351
050589.......................................... 23.8880 23.7918 27.9845 25.1893
050590.......................................... 24.4797 25.1100 27.0535 25.5262
050591.......................................... 25.0209 26.7662 28.6151 26.8393
050592.......................................... 22.1174 23.8267 25.9545 23.8223
050594.......................................... 27.7002 28.7415 30.8029 29.1185
050597.......................................... 23.3280 23.1209 24.5542 23.6763
050598.......................................... 23.9202 25.1622 31.1703 26.7495
050599.......................................... 26.0892 26.3782 27.7684 26.7559
050601.......................................... 29.7417 29.7734 32.3033 30.6813
050603.......................................... 21.7031 24.9032 25.0996 23.8892
050604.......................................... 35.4034 36.4669 42.0018 37.9795
050608.......................................... 18.1664 20.9171 20.7954 19.9529
050609.......................................... 33.5028 34.8949 * 34.1686
050613.......................................... 30.2413 34.9768 * 32.5464
050615.......................................... 27.5682 25.8698 29.4322 27.6985
050616.......................................... 24.9843 25.0016 * 24.9928
050618.......................................... 21.4895 22.3548 * 21.9734
050623.......................................... 27.5832 28.6475 29.9553 28.6716
050624.......................................... 26.4659 22.4030 23.4665 23.9161
050625.......................................... 27.5816 29.3665 29.6612 28.9346
050630.......................................... 24.2120 25.2915 27.7052 25.7731
050633.......................................... 25.4283 27.8165 30.2883 27.9289
050636.......................................... 23.5257 25.0214 23.2573 23.9123
050638.......................................... 18.2159 15.6375 21.0088 18.1465
050641.......................................... 17.1258 17.9379 21.5030 19.2373
050644.......................................... 22.1489 * 28.4054 25.2877
[[Page 27256]]
050662.......................................... 35.0989 38.9592 40.9243 38.2885
050663.......................................... 24.9110 22.7770 22.9161 23.2174
050667.......................................... 27.5045 26.9236 31.4906 28.5908
050668.......................................... 61.7751 57.8627 * 59.6272
050670.......................................... 24.6101 24.1626 * 24.3757
050674.......................................... 32.4807 33.7845 36.8871 34.4747
050676.......................................... 20.2087 16.3948 24.3105 19.1193
050677.......................................... 33.6070 34.0936 * 33.8463
050678.......................................... 22.7756 25.2143 27.1337 25.0885
050680.......................................... 31.4839 31.9166 32.2371 31.8875
050682.......................................... 17.3566 19.8107 23.0983 19.8665
050684.......................................... 23.3697 24.2792 23.7443 23.7986
050685.......................................... 35.1307 30.4194 * 32.6498
050686.......................................... 33.4420 34.8278 * 34.1349
050688.......................................... 31.0648 34.9936 36.5555 34.8315
050689.......................................... 30.9399 34.0571 37.5449 34.4378
050690.......................................... 34.8112 36.7516 41.1385 37.6299
050693.......................................... 25.5662 29.1213 32.6638 29.3244
050694.......................................... 23.5572 25.1964 25.8299 24.8850
050695.......................................... 24.4301 26.2838 27.8742 26.2576
050696.......................................... 28.3291 29.6685 29.9410 29.3284
050697.......................................... 18.2338 24.1116 18.5357 19.9903
050698.......................................... * 24.9559 * 24.9559
050699.......................................... 17.5296 23.4611 26.3932 21.9529
050701.......................................... 24.3055 26.4901 28.4650 26.3518
050704.......................................... 22.7618 25.6565 24.6072 24.3668
050707.......................................... 27.8958 28.2637 27.7366 27.9699
050708.......................................... 24.8647 24.5606 22.1605 23.8703
050709.......................................... 19.4977 21.8770 22.7897 21.4220
050710.......................................... 27.5828 30.5918 33.7204 30.7878
050713.......................................... 16.8538 18.2822 19.0071 18.0075
050714.......................................... 30.1925 30.3290 30.3262 30.2901
050717.......................................... 28.7973 31.5021 33.0719 31.0905
050718.......................................... 18.0940 22.5989 21.7835 21.3483
050719.......................................... 23.0833 * 22.0997 22.4754
050720.......................................... 25.8677 * 26.1941 26.0295
050723.......................................... * 32.0291 33.0797 32.5951
050725.......................................... * * 20.6592 20.6592
050726.......................................... * * 25.8742 25.8742
060001.......................................... 21.1819 21.4562 23.1548 21.9595
060003.......................................... 20.4682 21.9043 23.0807 21.8505
060004.......................................... 21.4496 22.9265 25.0037 23.2681
060006.......................................... 20.0213 21.0003 21.8609 21.0085
060007.......................................... 18.2977 19.3071 22.2747 19.9022
060008.......................................... 18.4590 18.7097 19.8803 19.0217
060009.......................................... 22.7164 23.9272 24.1285 23.6009
060010.......................................... 23.6827 24.2735 25.9341 24.6424
060011.......................................... 22.3458 22.2058 25.4458 23.3434
060012.......................................... 19.4932 21.2980 22.6374 21.1159
060013.......................................... 19.1256 23.5248 23.3954 21.9829
060014.......................................... 24.3210 25.7701 25.9159 25.3595
060015.......................................... 23.2469 23.6015 27.6338 24.8106
060016.......................................... 20.2408 20.2361 22.9300 21.1421
060018.......................................... 21.5083 21.8478 21.0581 21.4599
060020.......................................... 18.8985 19.7348 20.9025 19.8893
060022.......................................... 21.0830 22.8059 19.8819 21.2558
060023.......................................... 21.5475 22.4731 24.3749 22.8346
060024.......................................... 22.9185 24.3658 25.2409 24.2358
060027.......................................... 22.0713 22.1717 25.1480 23.2185
060028.......................................... 23.1792 24.2985 27.3340 24.9108
060029.......................................... 18.2938 19.8498 * 19.0675
060030.......................................... 20.3452 21.2612 22.8309 21.5553
060031.......................................... 22.5067 23.3995 23.8781 23.2637
[[Page 27257]]
060032.......................................... 22.8123 24.7678 25.5628 24.4445
060033.......................................... 16.0760 17.8514 16.7266 16.8791
060034.......................................... 23.2816 24.3652 26.2141 24.6650
060036.......................................... 18.5988 18.6521 18.1954 18.4720
060037.......................................... 15.4513 15.7495 17.1258 16.1605
060038.......................................... 14.3249 16.6525 15.3718 15.5616
060041.......................................... 19.1263 19.5872 20.8745 19.8909
060042.......................................... 20.8597 19.3967 22.5613 20.7473
060043.......................................... 13.4443 15.4073 19.1085 15.9780
060044.......................................... 20.8673 21.3102 25.6112 22.7216
060046.......................................... 22.2699 22.6819 24.0645 23.0457
060047.......................................... 17.1534 17.9173 18.1662 17.7570
060049.......................................... 23.0613 25.9592 25.3425 24.9252
060050.......................................... 19.0832 * 20.4386 19.8467
060052.......................................... 14.8729 16.0543 18.2354 16.3844
060053.......................................... 18.0232 19.4746 22.2894 19.8382
060054.......................................... 20.4160 19.7753 20.9346 20.3624
060056.......................................... 18.1263 21.9586 21.9389 20.8180
060057.......................................... 25.4185 24.6599 24.4012 24.8132
060058.......................................... 13.8539 16.4504 20.3154 16.7670
060060.......................................... 15.6018 19.4418 21.0586 18.5977
060062.......................................... 16.8640 17.1032 19.0995 17.6743
060064.......................................... 22.7797 28.8746 29.1806 26.8320
060065.......................................... 24.5572 24.4554 29.2179 26.0872
060066.......................................... 17.2537 17.5556 14.6820 16.5806
060070.......................................... 18.8960 19.2220 22.6894 20.3042
060071.......................................... 17.4068 17.6452 20.1385 18.3916
060073.......................................... 17.0846 18.4971 16.5027 17.3443
060075.......................................... 23.8724 25.0552 27.2654 25.3696
060076.......................................... 20.3265 22.9426 23.6266 22.3373
060085.......................................... 14.3409 10.9724 15.6918 13.4494
060088.......................................... 13.7174 20.7211 22.9170 18.6644
060090.......................................... 16.3760 16.5321 * 16.4540
060096.......................................... 20.8937 21.9951 20.0869 21.0065
060100.......................................... 23.9305 24.8116 27.4972 25.4548
060103.......................................... 23.5083 24.4962 26.7150 24.9461
060104.......................................... 21.1820 24.4248 26.8237 23.9979
060107.......................................... 21.9221 * * 21.9222
060108.......................................... * 19.1327 19.0011 19.0448
060109.......................................... * 27.3180 * 27.3180
060110.......................................... * * 31.3494 31.3494
070001.......................................... 26.3596 27.7441 29.9592 27.9941
070002.......................................... 26.1768 26.6881 28.1101 26.9593
070003.......................................... 27.5200 28.1721 29.7864 28.5044
070004.......................................... 24.2567 25.4310 25.7207 25.1218
070005.......................................... 26.9151 27.6733 29.8173 28.0976
070006.......................................... 28.6413 33.6291 32.6824 31.8244
070007.......................................... 26.3313 28.0875 29.0734 27.8655
070008.......................................... 24.2971 25.1362 24.3907 24.6106
070009.......................................... 24.1871 24.9408 25.4576 24.8664
070010.......................................... 29.2194 28.3168 30.4192 29.3329
070011.......................................... 23.0883 24.8206 24.9457 24.2870
070012.......................................... 28.8067 37.5917 34.9099 33.4527
070015.......................................... 28.1204 29.2693 30.0614 29.1548
070016.......................................... 24.4633 28.4833 31.2173 27.8518
070017.......................................... 26.0424 27.5515 29.2978 27.4590
070018.......................................... 30.6864 32.6301 33.8654 32.4296
070019.......................................... 24.9249 26.2348 27.9838 26.4038
070020.......................................... 25.9964 26.6203 28.4084 27.0418
070021.......................................... 26.3043 29.4596 30.0915 28.7001
070022.......................................... 26.9111 27.2423 29.2864 27.8032
070024.......................................... 24.8948 26.3544 28.3460 26.5801
070025.......................................... 25.4345 27.3592 28.3017 27.0096
[[Page 27258]]
070027.......................................... 26.8450 25.9279 26.8236 26.5341
070028.......................................... 25.7492 26.7286 28.2078 26.9036
070029.......................................... 23.9682 23.8427 25.8107 24.5347
070030.......................................... 22.1578 * * 22.1578
070031.......................................... 24.1198 25.6347 25.5880 25.0884
070033.......................................... 31.4736 34.1591 35.8504 33.8348
070034.......................................... 29.4916 30.0744 32.4220 30.6177
070035.......................................... 24.1423 24.5996 25.9776 24.8552
070036.......................................... 29.9470 31.2961 32.4920 31.2720
070038.......................................... * 26.3126 * 26.3126
070039.......................................... 22.3356 * 32.6059 29.3416
080001.......................................... 24.8833 26.8887 28.0859 26.6310
080002.......................................... 20.1965 20.9385 23.7309 21.6786
080003.......................................... 23.1275 24.8200 24.8199 24.2173
080004.......................................... 22.9706 21.7344 24.2251 22.9785
080006.......................................... 22.6671 20.9399 20.9757 21.4333
080007.......................................... 21.3746 21.5415 23.4933 22.1686
090001.......................................... 21.5751 23.0365 7.5651 17.9081
090002.......................................... 21.5726 20.6550 23.5159 21.8418
090003.......................................... 23.1268 27.1087 22.7014 24.0752
090004.......................................... 25.5054 25.9717 28.7417 26.8011
090005.......................................... 26.3074 26.8690 28.6142 27.2997
090006.......................................... 22.0957 22.9658 23.7111 22.9438
090007.......................................... 29.2840 24.6668 25.8430 26.6042
090008.......................................... 25.2708 * 19.3212 22.1162
090010.......................................... 23.6616 25.9373 * 24.7397
090011.......................................... 26.6349 27.6038 31.7710 28.7553
100001.......................................... 20.2157 22.0101 21.7561 21.3158
100002.......................................... 21.0222 21.5772 21.6362 21.4258
100004.......................................... 15.4149 16.1638 15.6306 15.7493
100006.......................................... 21.2293 21.6922 23.3307 22.1620
100007.......................................... 22.1590 22.5317 23.9004 22.9055
100008.......................................... 20.8381 21.6416 22.7706 21.7804
100009.......................................... 22.1741 22.6370 23.7460 22.8738
100010.......................................... 23.0637 23.9582 25.5614 24.1330
100012.......................................... 20.4659 22.0244 24.2602 22.3053
100014.......................................... 19.5770 21.9875 21.7566 21.0988
100015.......................................... 18.0654 18.9383 22.1272 19.7135
100017.......................................... 19.8655 20.1417 21.1905 20.4341
100018.......................................... 21.6388 22.6587 24.2154 22.8672
100019.......................................... 23.5462 25.8297 24.2201 24.5270
100020.......................................... 20.7816 21.7421 23.1885 21.9438
100022.......................................... 26.5695 27.4235 27.9072 27.2953
100023.......................................... 19.1787 20.2034 21.8111 20.3897
100024.......................................... 22.1332 22.9872 24.4070 23.2018
100025.......................................... 19.4529 20.1360 21.2568 20.2991
100026.......................................... 20.9461 21.3742 21.7970 21.3789
100027.......................................... 14.7916 20.5889 21.9900 18.2354
100028.......................................... 19.3371 20.3751 21.5305 20.4329
100029.......................................... 20.8950 22.2553 24.6814 22.4835
100030.......................................... 20.5952 19.5604 21.5303 20.5938
100032.......................................... 19.7451 20.6543 21.6415 20.6364
100034.......................................... 19.5282 20.0099 22.2146 20.5533
100035.......................................... 23.8117 21.3519 22.6349 22.5792
100038.......................................... 24.5864 24.9548 25.6018 25.0869
100039.......................................... 21.7861 23.3111 23.8060 22.9806
100040.......................................... 18.6321 19.5154 21.3865 19.8692
100043.......................................... 18.8206 20.7688 21.7738 20.4584
100044.......................................... 22.7236 22.9474 23.9952 23.2248
100045.......................................... 21.0228 22.8096 30.3359 24.4856
100046.......................................... 21.3028 23.2027 24.2746 22.8753
100047.......................................... 20.6068 21.4971 24.3522 22.2329
100048.......................................... 15.7790 17.3663 17.5533 16.9309
[[Page 27259]]
100049.......................................... 19.1025 20.9490 21.8676 20.6412
100050.......................................... 17.9039 17.8960 20.0405 18.6106
100051.......................................... 17.9453 19.3258 19.9713 19.1475
100052.......................................... 18.1780 19.6620 18.6363 18.8133
100053.......................................... 19.6800 21.6634 23.7837 21.6611
100054.......................................... 21.1518 20.9612 21.8613 21.3455
100055.......................................... 18.8760 19.1324 19.6350 19.2002
100056.......................................... 21.8506 23.1737 25.9245 23.6383
100057.......................................... 19.5319 22.3406 24.4271 21.9677
100060.......................................... 23.5997 * * 23.5997
100061.......................................... 22.9176 24.5277 25.7559 24.3953
100062.......................................... 21.4424 21.9054 24.9807 22.7317
100063.......................................... 18.4642 19.2510 21.5620 19.9030
100067.......................................... 18.4851 19.2168 23.6270 20.3382
100068.......................................... 19.8308 19.9648 23.7197 21.3073
100069.......................................... 17.3666 18.5789 19.6037 18.6041
100070.......................................... 20.0381 20.9592 20.4770 20.4616
100071.......................................... 17.7234 20.7461 21.7675 20.3419
100072.......................................... 20.5968 22.0317 21.9184 21.5398
100073.......................................... 22.2812 22.2425 23.5843 22.7262
100075.......................................... 19.4480 20.4604 21.8589 20.5692
100076.......................................... 17.8612 18.4815 19.6444 18.6617
100077.......................................... 19.0640 20.9482 22.2470 20.8144
100078.......................................... 19.2891 16.6003 17.4683 17.7417
100080.......................................... 22.7153 22.9720 22.7056 22.7946
100081.......................................... 15.4253 16.5149 16.4804 16.1357
100084.......................................... 22.7009 24.5682 23.5435 23.6450
100086.......................................... 23.3718 24.3067 25.2375 24.3294
100087.......................................... 23.6562 22.1764 26.2514 24.0027
100088.......................................... 20.5566 20.6667 23.6270 21.6062
100090.......................................... 19.7695 21.0431 22.5894 21.1520
100092.......................................... 20.1760 21.4601 25.4630 22.1148
100093.......................................... 16.8422 18.7153 20.2949 18.6499
100098.......................................... 20.8315 21.1723 20.0639 20.7185
100099.......................................... 15.7591 16.5271 16.1165 16.1278
100102.......................................... 19.7673 19.0193 21.6772 20.1082
100103.......................................... 18.7844 19.1222 20.3633 19.4145
100105.......................................... 21.8268 22.7793 24.5464 23.0784
100106.......................................... 17.4958 21.4342 18.5389 19.1251
100107.......................................... 20.0719 21.7553 23.3789 21.7356
100108.......................................... 20.1125 18.4127 15.1791 17.6124
100109.......................................... 20.8370 20.6007 22.3671 21.2613
100110.......................................... 20.1853 22.8127 24.2271 22.5089
100112.......................................... 15.2128 16.2109 16.9325 16.1723
100113.......................................... 21.3489 23.3380 20.6110 21.7279
100114.......................................... 22.8178 22.5326 25.3699 23.4863
100117.......................................... 20.6962 21.3085 23.2994 21.7923
100118.......................................... 20.7323 21.7067 24.1105 22.1068
100121.......................................... 18.5842 19.9033 23.1100 20.5301
100122.......................................... 19.2643 24.9765 23.6638 22.5106
100124.......................................... 20.4022 20.0867 14.8231 17.8809
100125.......................................... 19.6097 20.3232 22.4185 20.8356
100126.......................................... 19.3103 21.4349 21.7977 20.8062
100127.......................................... 19.2122 20.5153 21.0153 20.2670
100128.......................................... 22.8826 23.5835 24.4104 23.6230
100130.......................................... 20.0947 21.0023 20.2478 20.4482
100131.......................................... 23.1622 24.6184 25.4186 24.4498
100132.......................................... 18.7863 19.5259 21.1446 19.8043
100134.......................................... 15.9733 16.9302 18.3392 17.1001
100135.......................................... 19.1865 19.7675 20.3831 19.7887
100137.......................................... 19.5562 20.9015 * 20.2591
100138.......................................... 14.9539 14.9760 16.4384 15.4793
100139.......................................... 15.2532 15.7378 18.2187 16.3579
[[Page 27260]]
100140.......................................... 19.0584 20.2288 22.6326 20.6848
100142.......................................... 18.4113 17.7250 20.0689 18.7079
100146.......................................... 21.3359 20.8381 * 21.0641
100147.......................................... 15.2348 17.1566 17.2835 16.5550
100150.......................................... 21.5057 25.4269 22.9193 23.1341
100151.......................................... 23.8489 26.6143 26.8564 25.9003
100154.......................................... 20.4068 21.6715 23.0820 21.7335
100156.......................................... 18.4779 20.0348 20.7649 19.8064
100157.......................................... 22.6195 24.2188 23.1045 23.3126
100159.......................................... 10.7818 15.0633 19.3145 15.1520
100160.......................................... 23.3121 22.6942 23.4877 23.1680
100161.......................................... 22.3053 23.3612 24.4326 23.3822
100162.......................................... 20.3110 24.2950 23.8001 22.8069
100165.......................................... 22.6622 * * 22.6623
100166.......................................... 21.2309 22.2419 23.7327 22.3765
100167.......................................... 23.2969 25.7676 26.8139 25.3034
100168.......................................... 20.3167 23.0121 24.6276 22.6616
100169.......................................... 20.3017 21.6397 22.5755 21.5513
100170.......................................... 19.3005 21.2469 * 20.1922
100172.......................................... 14.8826 15.7827 17.6051 16.0261
100173.......................................... 17.1337 18.3828 19.7190 18.4365
100174.......................................... 21.9807 * * 21.9807
100175.......................................... 20.5442 21.2532 21.0474 20.9357
100176.......................................... 24.3089 24.6595 26.8740 25.2920
100177.......................................... 24.4284 25.1037 24.4295 24.6550
100179.......................................... 23.0849 23.9633 22.8536 23.2786
100180.......................................... 21.5388 22.7781 24.7990 23.1132
100181.......................................... 18.9510 17.9048 18.1320 18.3165
100183.......................................... 23.0654 22.2063 24.4575 23.2115
100187.......................................... 20.8535 21.4988 23.4760 21.9203
100189.......................................... 26.5962 27.1295 26.6653 26.7935
100191.......................................... 21.0647 22.0526 24.2299 22.5063
100200.......................................... 23.8729 24.8878 24.8120 24.5400
100204.......................................... 20.2193 21.1922 22.2613 21.2482
100206.......................................... 20.1171 20.3436 * 20.2327
100208.......................................... 20.7029 20.4678 24.1482 21.8277
100209.......................................... 23.3903 22.8236 23.5479 23.2587
100210.......................................... 21.8545 23.0431 26.0933 23.6634
100211.......................................... 20.7516 21.6367 * 21.1977
100212.......................................... 21.1263 21.7239 22.6259 21.8401
100213.......................................... 21.1818 22.0176 24.4995 22.6205
100217.......................................... 22.7335 22.7116 24.0291 23.1695
100220.......................................... 21.8246 24.6233 24.9733 23.7248
100221.......................................... 21.2321 23.2263 * 22.1854
100223.......................................... 20.2233 21.8962 21.1051 21.1071
100224.......................................... 21.8628 22.3567 22.7403 22.3391
100225.......................................... 21.5059 22.4619 23.9971 22.6579
100226.......................................... 21.8808 22.7301 23.8070 22.8491
100228.......................................... 20.8810 24.9691 * 22.9269
100229.......................................... 18.2350 19.7259 21.0039 19.5689
100230.......................................... 22.5650 23.4169 25.0408 23.8884
100231.......................................... 18.7526 21.5712 22.8325 20.8200
100232.......................................... 19.8002 20.1459 21.8906 20.6484
100234.......................................... 21.6360 24.3355 24.0421 23.3485
100236.......................................... 20.6942 21.7886 23.7286 22.0173
100237.......................................... 23.2408 23.2712 26.7664 24.3476
100238.......................................... 20.8252 23.3747 24.6513 22.9237
100239.......................................... 19.4481 23.2242 24.9409 22.4134
100240.......................................... 21.0606 21.3495 23.0650 21.8213
100241.......................................... 17.1063 14.1059 14.6992 15.3546
100242.......................................... 18.6938 19.1097 20.4142 19.4632
100243.......................................... 20.8041 22.4495 23.2812 22.2413
100244.......................................... 20.5352 21.4386 23.4876 21.8968
[[Page 27261]]
100246.......................................... 21.9247 23.5614 26.6552 23.9760
100248.......................................... 21.2988 22.1553 23.7614 22.4427
100249.......................................... 18.1397 18.4932 21.3942 19.2694
100252.......................................... 19.8079 22.0976 22.6481 21.5857
100253.......................................... 22.4778 22.6517 23.4448 22.8823
100254.......................................... 19.5523 20.4410 23.2068 21.2034
100255.......................................... 21.0284 20.7228 22.9793 21.5458
100256.......................................... 21.2786 22.4844 23.7315 22.4906
100258.......................................... 20.0300 22.0790 24.5699 22.2126
100259.......................................... 21.1160 21.4991 24.0960 22.2834
100260.......................................... 24.9183 21.2413 23.4255 23.0969
100262.......................................... 21.0927 22.7137 23.8006 22.3809
100264.......................................... 19.9491 21.7410 22.4616 21.4161
100265.......................................... 18.2291 20.2664 21.0688 19.9095
100266.......................................... 19.3623 20.2821 21.5258 20.4415
100267.......................................... 21.7430 22.8054 23.3558 22.6691
100268.......................................... 24.0538 23.5414 26.0297 24.5763
100269.......................................... 22.5114 26.0271 25.0014 24.5239
100270.......................................... 16.7148 20.8217 16.8468 18.0052
100271.......................................... 20.8695 21.9823 * 21.4488
100275.......................................... 21.4904 23.2920 23.1316 22.6853
100276.......................................... 24.1022 24.8251 25.4557 24.8136
100277.......................................... 19.7241 14.9157 25.2985 18.4223
100279.......................................... 22.5879 23.1776 24.6625 23.4267
100280.......................................... 18.1972 19.0157 * 18.6075
100281.......................................... 23.0142 23.4729 25.3382 24.0569
100282.......................................... 18.4884 20.9256 21.8279 20.4704
100284.......................................... 18.9448 18.5716 22.3046 19.9187
110001.......................................... 20.1150 22.4535 24.0561 22.2069
110002.......................................... 19.5158 20.2149 20.0125 19.9219
110003.......................................... 17.1450 18.2792 19.7061 18.4215
110004.......................................... 19.7733 20.6096 21.8791 20.7777
110005.......................................... 22.4568 21.8105 23.6147 22.7129
110006.......................................... 21.0601 22.0325 23.8762 22.3201
110007.......................................... 25.2523 25.9135 27.8969 26.3641
110008.......................................... 18.5265 20.4972 22.6308 20.7088
110009.......................................... 17.4306 16.6452 16.2944 16.8215
110010.......................................... 23.9104 25.1930 26.6265 25.2350
110011.......................................... 18.9823 20.4028 23.2149 20.8820
110013.......................................... 18.9160 16.7833 19.7781 18.4998
110014.......................................... 18.1787 18.4463 18.7642 18.4629
110015.......................................... 20.9926 21.2600 23.2279 21.9187
110016.......................................... 14.2398 14.7571 18.8371 15.7745
110017.......................................... 22.2537 21.2970 21.8808 21.8184
110018.......................................... 22.1480 23.0577 24.7007 23.3525
110020.......................................... 19.4617 20.9687 22.5988 20.9702
110023.......................................... 22.0546 21.6512 23.6182 22.4827
110024.......................................... 20.7345 21.3945 22.1471 21.4330
110025.......................................... 20.4232 20.2493 29.0965 22.6398
110026.......................................... 16.2484 16.9161 19.3200 17.4907
110027.......................................... 14.7081 19.8976 19.8351 18.0251
110028.......................................... 29.1670 28.1695 25.9474 27.6479
110029.......................................... 21.2150 21.3694 23.0779 21.9337
110030.......................................... 19.6412 20.4656 21.6618 20.6037
110031.......................................... 20.0553 20.9219 22.8695 21.3219
110032.......................................... 18.2014 19.2685 18.0744 18.4929
110033.......................................... 25.6335 23.1939 24.1447 24.2752
110034.......................................... 19.5554 23.0724 22.8541 21.6751
110035.......................................... 22.7950 21.8646 23.4610 22.7096
110036.......................................... 24.9234 22.5481 24.5675 23.9890
110038.......................................... 17.7396 18.4508 20.1710 18.7818
110039.......................................... 20.4998 18.9817 17.0608 18.7776
110040.......................................... 16.8083 17.7798 17.3095 17.2984
[[Page 27262]]
110041.......................................... 20.2755 20.1398 20.8080 20.4113
110042.......................................... 25.2331 25.0535 25.5588 25.2869
110043.......................................... 20.6150 21.2714 22.7589 21.5611
110044.......................................... 17.2087 17.5905 19.2562 17.9982
110045.......................................... 21.3049 22.2424 19.7747 21.0415
110046.......................................... 21.4905 22.8820 21.6201 22.0167
110048.......................................... 15.6113 18.8751 21.9621 18.7056
110049.......................................... 16.8639 17.1396 18.9096 17.6498
110050.......................................... 19.2291 18.9048 22.1089 20.1584
110051.......................................... 17.2292 17.2050 17.6816 17.3795
110054.......................................... 20.0549 20.7825 20.5387 20.4734
110056.......................................... 17.7959 17.9037 21.7607 19.3353
110059.......................................... 16.7990 17.8076 19.9802 18.2059
110061.......................................... 16.3557 17.4601 18.6696 17.5523
110062.......................................... 17.0053 17.9421 18.2038 17.7308
110063.......................................... 18.5071 18.0256 19.4401 18.6913
110064.......................................... 19.1203 18.8742 21.7636 19.8777
110065.......................................... 16.3546 16.9829 19.9032 17.6656
110066.......................................... 22.4189 23.4554 * 22.9140
110069.......................................... 20.9575 21.1513 21.0518 21.0559
110070.......................................... 17.3438 19.6361 20.8793 19.1178
110071.......................................... 18.8321 21.5042 15.2336 18.3234
110072.......................................... 12.7625 13.6626 * 13.1941
110073.......................................... 16.4658 17.9372 15.2711 16.4347
110074.......................................... 22.3769 24.4924 23.6564 23.5407
110075.......................................... 20.1757 20.1604 19.6937 20.0081
110076.......................................... 21.9798 23.6127 24.9264 23.5306
110078.......................................... 24.0893 25.7416 27.7261 25.8462
110079.......................................... 22.1070 22.3641 22.2908 22.2542
110080.......................................... 19.1839 19.4635 * 19.3217
110082.......................................... 24.3140 22.7015 24.0664 23.6678
110083.......................................... 23.1463 22.2609 24.5253 23.3268
110086.......................................... 16.6374 19.0164 18.8751 18.1588
110087.......................................... 22.7069 24.0994 25.7908 24.2653
110089.......................................... 19.3855 19.0453 20.6840 19.7079
110091.......................................... 21.5328 23.7110 25.1996 23.4730
110092.......................................... 16.9725 15.9178 16.9116 16.5923
110093.......................................... 16.9827 * * 16.9827
110094.......................................... 16.9503 16.8890 * 16.9211
110095.......................................... 17.1195 18.9904 20.1024 18.8017
110096.......................................... 17.4157 18.0418 18.5513 18.0235
110097.......................................... 17.4558 17.8454 18.9464 18.0488
110098.......................................... 16.0597 16.7800 17.5567 16.8549
110100.......................................... 19.0764 18.6822 15.1316 17.6555
110101.......................................... 18.8491 13.8787 13.3943 14.8763
110103.......................................... 21.1837 21.5683 * 21.4221
110104.......................................... 15.9431 16.6322 17.9805 16.8523
110105.......................................... 16.7775 18.1306 19.2156 18.0663
110107.......................................... 19.3897 21.2267 21.9213 20.8424
110108.......................................... 25.2161 20.1140 18.4912 20.6647
110109.......................................... 16.4031 16.5977 18.7397 17.2348
110111.......................................... 18.3951 18.4274 22.5840 19.8648
110112.......................................... 19.8986 18.9574 20.5171 19.8164
110113.......................................... 15.9532 16.0942 18.0770 16.7135
110114.......................................... 16.4812 16.8297 17.7019 17.0138
110115.......................................... 22.5049 26.5759 26.3274 24.9969
110118.......................................... 19.7509 17.5714 17.7344 18.2780
110120.......................................... 17.7452 18.4738 20.3099 18.8660
110121.......................................... 19.3643 18.8744 19.5230 19.2555
110122.......................................... 21.1469 20.6070 21.1510 20.9707
110124.......................................... 18.3366 19.4093 19.7005 19.1562
110125.......................................... 18.0090 19.5666 19.8695 19.1558
110127.......................................... 20.3765 16.1107 * 18.2840
[[Page 27263]]
110128.......................................... 18.0835 20.3046 28.4942 21.9309
110129.......................................... 19.0001 20.9442 21.5571 20.5238
110130.......................................... 14.6011 16.6915 17.5272 16.2937
110132.......................................... 16.3943 17.1820 17.2924 16.9658
110134.......................................... 19.8639 19.0305 19.1891 19.3419
110135.......................................... 17.3504 15.6668 18.5125 17.0191
110136.......................................... 16.9629 20.7827 21.1235 19.3927
110140.......................................... 17.7915 * * 17.7915
110141.......................................... 14.4935 13.2710 14.3027 14.0327
110142.......................................... 13.9525 14.1203 16.3359 14.8326
110143.......................................... 22.5926 22.4254 23.5876 22.8713
110144.......................................... 17.5112 17.5678 18.9425 17.9918
110146.......................................... 17.1835 17.8499 17.2250 17.4052
110149.......................................... 32.1975 25.2525 25.3618 27.1829
110150.......................................... 21.2909 22.8322 22.7366 22.3193
110152.......................................... 15.1324 16.3837 16.3352 15.9536
110153.......................................... 20.5068 20.6972 21.5300 20.9068
110154.......................................... 17.3761 16.5286 * 16.9482
110155.......................................... 16.5146 16.4756 16.1785 16.4073
110156.......................................... 16.3876 16.0759 * 16.2355
110161.......................................... 22.2861 24.5776 26.1275 24.4282
110163.......................................... 18.6637 20.1183 21.9411 20.2136
110164.......................................... 21.2160 22.6605 23.7801 22.5540
110165.......................................... 20.8030 22.5604 23.1047 22.2007
110166.......................................... 20.5049 22.3822 23.6665 22.0307
110168.......................................... 21.8058 22.3181 23.3426 22.5338
110169.......................................... 22.6648 23.3750 24.7083 23.5314
110171.......................................... 25.5296 24.5313 32.6386 27.7697
110172.......................................... 23.6803 24.7005 25.2396 24.5635
110174.......................................... 14.6199 * * 14.6199
110177.......................................... 21.2796 22.7831 24.4715 22.8933
110179.......................................... 22.0767 24.3673 26.1423 24.1256
110181.......................................... 12.9798 13.9591 34.9028 19.4061
110183.......................................... 22.5148 24.2899 26.4248 24.4133
110184.......................................... 22.1920 22.2761 24.3379 22.9563
110185.......................................... 17.7925 17.3330 19.1991 18.0592
110186.......................................... 18.3178 19.7172 21.1176 19.7561
110187.......................................... 19.8419 22.8248 23.2571 21.8964
110188.......................................... 23.7032 22.0258 * 22.7714
110189.......................................... 20.8786 19.8454 21.4255 20.7155
110190.......................................... 18.3649 20.7292 20.5708 19.8383
110191.......................................... 21.4033 21.3404 23.8471 22.2253
110192.......................................... 21.0486 22.9684 24.3823 22.8864
110193.......................................... 20.7867 22.1477 25.1779 22.7067
110194.......................................... 14.8115 15.8129 16.8075 15.8165
110195.......................................... 12.7261 10.9444 13.7718 12.4602
110198.......................................... 24.8646 24.8275 28.0634 25.9885
110200.......................................... 17.7744 17.9631 19.4363 18.4074
110201.......................................... 20.9497 21.9313 23.7261 22.1742
110203.......................................... 22.7453 24.2062 23.3838 23.4874
110204.......................................... 30.7342 35.3699 * 32.7584
110205.......................................... 21.3617 20.1405 23.1969 21.5575
110207.......................................... 14.7154 14.6045 14.7077 14.6752
110208.......................................... 15.6161 15.0350 * 15.3251
110209.......................................... 18.6404 20.0629 14.4751 17.7558
110211.......................................... 26.9151 20.1024 * 22.9486
110212.......................................... 14.3790 15.8420 18.7651 16.2466
110215.......................................... 18.1539 21.0263 .5679 20.7523
110216.......................................... 27.1878 * * 27.1877
120001.......................................... 29.0427 29.4126 30.0871 29.5170
120002.......................................... 25.2021 23.5667 24.2715 24.3269
120003.......................................... 23.9115 24.6238 24.4013 24.3140
120004.......................................... 24.8632 26.1398 26.8010 25.9297
[[Page 27264]]
120005.......................................... 24.1662 22.3213 23.0113 23.1311
120006.......................................... 25.8943 26.6302 28.1562 26.8635
120007.......................................... 22.8772 22.7179 27.8497 24.2388
120009.......................................... 16.4485 16.7630 13.9812 15.7613
120010.......................................... 24.1923 24.9089 25.4050 24.8421
120011.......................................... 37.2759 35.2051 30.9308 34.0921
120012.......................................... 21.8507 22.0371 21.8997 21.9292
120014.......................................... 24.1208 25.3557 25.3682 24.9359
120015.......................................... 42.6465 * 24.6284 30.4099
120016.......................................... 45.1899 43.5083 39.1160 42.7373
120018.......................................... 31.1879 * * 31.1877
120019.......................................... 25.5659 23.8535 24.4036 24.5914
120021.......................................... 23.1839 36.8286 23.2759 26.4621
120022.......................................... 19.2614 22.2781 22.4951 21.2033
120024.......................................... 32.2514 21.9657 * 26.7529
120025.......................................... 50.6376 40.1332 40.2485 43.1574
120026.......................................... 25.1314 25.7023 26.3653 25.7684
120027.......................................... 24.4535 23.1434 24.9464 24.1547
120028.......................................... 27.0897 27.5365 29.5070 28.0817
130001.......................................... 17.6306 19.6328 18.4733 18.5954
130002.......................................... 16.9867 18.5746 20.1143 18.6076
130003.......................................... 22.3430 23.0994 23.9403 23.1432
130005.......................................... 21.2386 22.6364 24.4844 22.7104
130006.......................................... 20.4614 21.4640 22.8567 21.6494
130007.......................................... 21.8107 22.0894 22.8475 22.2657
130008.......................................... 13.6018 19.3392 25.7798 18.7207
130009.......................................... 15.9701 20.8748 18.3511 18.2768
130010.......................................... 17.5119 17.7826 * 17.6552
130011.......................................... 20.1147 22.1125 23.1120 21.7785
130012.......................................... 24.9976 24.2451 22.5761 23.9471
130013.......................................... 15.1129 22.6624 23.5316 20.2820
130014.......................................... 19.2107 19.8240 21.6770 20.2852
130015.......................................... 18.5913 16.4136 * 17.4135
130016.......................................... 19.0516 20.1220 20.5728 19.9684
130017.......................................... 19.6875 19.9511 20.3656 20.0262
130018.......................................... 19.8425 20.0563 22.1899 20.7223
130019.......................................... 19.1711 19.5147 20.3983 19.7057
130021.......................................... 15.6155 14.4430 16.8582 15.5456
130022.......................................... 18.9127 19.7814 21.5602 20.1253
130024.......................................... 19.0703 19.9934 22.1611 20.4440
130025.......................................... 16.4627 17.5989 18.7814 17.6827
130026.......................................... 21.8106 23.2093 24.4976 23.1615
130027.......................................... 20.5344 20.6641 22.0107 21.0236
130028.......................................... 20.9674 21.2217 21.1492 21.1146
130029.......................................... 18.7694 22.9243 * 20.4335
130030.......................................... 17.5759 18.5827 * 18.0583
130031.......................................... 16.7766 20.4146 23.5135 19.8631
130034.......................................... 18.9483 20.5802 20.2401 19.9098
130035.......................................... 20.7770 17.2864 * 19.1660
130036.......................................... 13.6362 15.1590 18.5921 15.7605
130037.......................................... 18.6856 19.2108 19.3979 19.1230
130043.......................................... 16.7904 17.6920 18.4636 17.6040
130044.......................................... 13.4513 18.7067 20.5584 17.5508
130045.......................................... 19.0208 17.5152 19.0271 18.5109
130048.......................................... 16.7900 * * 16.7900
130049.......................................... 22.4440 22.0520 23.7212 22.7595
130054.......................................... 17.7085 16.4675 16.8484 16.9601
130056.......................................... 20.9476 28.8008 17.3947 21.1836
130060.......................................... 22.7399 23.2512 24.6773 23.5532
130061.......................................... 14.7394 * * 14.7393
130062.......................................... 19.8157 19.8264 24.0494 21.3157
130063.......................................... 18.8024 18.4797 18.8782 18.7287
140001.......................................... 17.7990 18.1511 20.0247 18.6600
[[Page 27265]]
140002.......................................... 19.9284 20.9959 22.5567 21.1478
140003.......................................... 17.8595 18.0163 * 17.9385
140004.......................................... 17.4574 18.9713 19.3237 18.5860
140005.......................................... 12.3002 12.4144 13.2365 12.6493
140007.......................................... 23.8585 24.9847 25.1836 24.6934
140008.......................................... 22.1111 24.2634 26.3152 24.1972
140010.......................................... 28.5635 28.0863 39.3621 32.1479
140011.......................................... 18.6164 18.4052 19.0903 18.7086
140012.......................................... 21.4374 22.5885 24.4070 22.8406
140013.......................................... 19.6722 20.3147 19.9800 19.9935
140014.......................................... 21.4042 22.2944 25.0616 22.9171
140015.......................................... 17.6805 20.3540 21.4328 19.8233
140016.......................................... 14.4938 15.4454 16.3417 15.3940
140018.......................................... 22.4132 23.4062 24.3285 23.3864
140019.......................................... 16.4254 16.1180 17.4206 16.6387
140024.......................................... 15.3782 16.1032 * 15.7337
140025.......................................... 18.5135 21.7775 18.0748 19.4744
140026.......................................... 18.3220 19.7839 20.4084 19.5156
140027.......................................... 19.2149 20.5980 20.9855 20.2413
140029.......................................... 26.0833 28.5670 25.5253 26.6612
140030.......................................... 23.1760 25.3715 26.5229 25.0851
140031.......................................... 17.6067 16.9650 17.7449 17.4509
140032.......................................... 19.0383 19.8033 20.6273 19.8411
140033.......................................... 25.1639 22.8705 23.4279 23.7474
140034.......................................... 19.8792 19.7711 20.9635 20.1903
140035.......................................... 15.5040 17.4514 17.9641 16.9828
140036.......................................... 19.1076 21.2366 18.5788 19.7025
140037.......................................... 14.1083 14.3082 15.5578 14.6732
140038.......................................... 18.4948 19.8197 * 19.1560
140040.......................................... 16.7450 18.0342 19.2160 18.0347
140041.......................................... 18.5952 18.8042 19.2893 18.8908
140042.......................................... 15.8892 16.1157 17.1757 16.3886
140043.......................................... 20.1176 21.7356 23.3751 21.8035
140045.......................................... 17.7799 17.4261 18.9587 18.0683
140046.......................................... 18.6371 20.0859 21.7969 20.2134
140047.......................................... 13.3610 16.6672 17.7090 15.6942
140048.......................................... 23.9545 23.8652 25.9122 24.5813
140049.......................................... 26.9483 26.7160 20.7688 24.9027
140051.......................................... 24.0796 24.7180 24.2472 24.3525
140052.......................................... 17.9571 21.0450 21.6607 20.0955
140053.......................................... 19.9620 20.9768 22.6099 21.1760
140054.......................................... 23.1576 23.9459 35.5659 27.3968
140055.......................................... 14.3603 15.8756 16.4409 15.4892
140058.......................................... 18.6861 19.1199 20.5089 19.4559
140059.......................................... * 18.2593 21.9969 19.9435
140061.......................................... 18.2039 18.4264 22.7791 19.6252
140062.......................................... 28.5304 28.6390 30.7005 29.3149
140063.......................................... 29.1453 29.6998 30.5430 29.8595
140064.......................................... 18.9379 19.6954 20.6505 19.7669
140065.......................................... 25.3336 25.5939 25.8676 25.6079
140066.......................................... 13.6491 15.4818 18.0915 15.5544
140067.......................................... 19.5292 20.7511 21.9579 20.7435
140068.......................................... 21.6188 22.3622 24.1316 22.6861
140069.......................................... 17.3879 17.7785 19.0441 18.0826
140070.......................................... 22.7153 25.2646 25.2960 24.2944
140074.......................................... 21.6052 22.2563 22.8249 22.2227
140075.......................................... 21.6434 21.8472 26.5350 22.9476
140077.......................................... 17.3647 17.3236 18.0487 17.5877
140079.......................................... 23.6928 22.7046 25.7058 24.0319
140080.......................................... 22.1968 22.0682 24.4056 22.8890
140081.......................................... 16.9808 18.1746 * 17.5725
140082.......................................... 29.7262 26.5960 25.0474 26.9608
140083.......................................... 21.0330 20.7704 23.2822 21.6156
[[Page 27266]]
140084.......................................... 22.3467 23.0263 25.4818 23.6135
140086.......................................... 19.1613 19.1815 * 19.1714
140087.......................................... 17.1147 21.4593 * 19.1145
140088.......................................... 25.4176 26.5258 27.7274 26.5193
140089.......................................... 18.3157 19.3230 20.7632 19.4616
140090.......................................... 26.9364 28.0530 35.0300 29.4280
140091.......................................... 21.9322 23.5559 23.7560 23.1453
140093.......................................... 20.1528 20.7564 21.5376 20.7969
140094.......................................... 21.9383 22.8892 23.7841 22.8588
140095.......................................... 24.2859 25.5716 25.4815 25.1248
140097.......................................... 21.1719 21.8418 23.8291 22.4038
140100.......................................... 23.1399 23.8226 27.1868 24.8138
140101.......................................... 21.4211 23.1418 24.6106 23.0966
140102.......................................... 17.5729 18.6328 19.8678 18.6663
140103.......................................... 18.1303 19.1834 21.3727 19.5392
140105.......................................... 22.8944 23.8258 27.3323 24.5505
140107.......................................... 11.8383 11.5827 * 11.7127
140108.......................................... 26.9971 27.9140 * 27.4761
140109.......................................... 14.5498 15.9178 16.4262 15.6166
140110.......................................... 19.2888 20.9631 21.9129 20.7530
140112.......................................... 17.6974 18.1119 19.8563 18.5020
140113.......................................... 19.5584 26.2393 25.2205 23.4083
140114.......................................... 21.0976 23.0383 24.1926 22.8235
140115.......................................... 21.0433 20.4587 25.3410 22.2094
140116.......................................... 23.8993 25.5980 26.8366 25.5062
140117.......................................... 21.4876 22.0889 23.3536 22.3483
140118.......................................... 24.3260 25.3249 26.1627 25.2644
140119.......................................... 27.9145 30.6468 31.3486 29.9292
140120.......................................... 17.9716 17.7667 20.3237 18.6579
140121.......................................... 16.6993 16.2607 17.6019 16.8238
140122.......................................... 26.1270 26.7882 26.7457 26.5545
140124.......................................... 27.9813 30.6820 30.7744 29.7761
140125.......................................... 16.9516 17.8190 19.5359 18.0996
140127.......................................... 20.0489 20.8397 21.3102 20.7463
140128.......................................... 23.1327 23.5481 * 23.3351
140129.......................................... 20.2868 21.6252 21.6495 21.1744
140130.......................................... 23.4298 26.0464 25.7324 25.1138
140132.......................................... 23.3054 23.7046 23.0595 23.3426
140133.......................................... 21.4166 20.1740 21.0993 20.9011
140135.......................................... 17.3985 18.2479 19.3222 18.3661
140137.......................................... 18.6330 20.4807 21.6017 20.2583
140138.......................................... 17.1968 14.5771 14.2313 15.2378
140139.......................................... 11.0397 * 20.2063 14.6320
140140.......................................... 17.6845 18.8185 19.1636 18.5459
140141.......................................... 19.1097 20.2606 20.3707 19.9234
140143.......................................... 19.0810 19.9885 22.0009 20.2373
140144.......................................... 22.2864 24.8854 26.9259 24.6726
140145.......................................... 18.1788 19.4509 20.6142 19.4469
140146.......................................... 19.9704 19.4272 * 19.6862
140147.......................................... 18.8049 17.1013 18.2691 18.0420
140148.......................................... 18.7730 19.7630 21.5777 20.0626
140150.......................................... 24.7976 28.9853 33.5463 28.8474
140151.......................................... 20.0310 20.8820 21.5167 20.8051
140152.......................................... 25.6011 28.3946 28.6284 27.5483
140155.......................................... 20.2778 24.2907 24.4956 22.9401
140158.......................................... 22.7988 23.7428 23.6949 23.4182
140160.......................................... 17.7921 19.8825 20.9016 19.5649
140161.......................................... 20.3799 21.2045 22.2191 21.3060
140162.......................................... 20.3452 21.6901 22.6426 21.5722
140164.......................................... 18.6589 19.8246 19.7774 19.4344
140165.......................................... 14.7223 16.3700 17.0665 16.0112
140166.......................................... 18.3833 19.3672 20.4085 19.3581
140167.......................................... 17.6525 18.8532 19.5959 18.7351
[[Page 27267]]
140168.......................................... 17.7453 18.2896 19.6114 18.5329
140170.......................................... 16.4107 17.6901 17.0666 17.0536
140171.......................................... 15.0237 15.2617 17.3214 15.8617
140172.......................................... 23.6262 24.8587 24.2924 24.2266
140173.......................................... 16.3924 16.0030 32.8692 19.8554
140174.......................................... 35.9320 22.0418 21.7356 24.5213
140176.......................................... 24.5338 26.3468 25.6824 25.5437
140177.......................................... 15.0827 20.3142 20.8526 18.2773
140179.......................................... 21.9859 22.7345 23.9872 22.8894
140180.......................................... 22.7996 22.7508 25.4497 23.6328
140181.......................................... 21.9864 22.6643 23.2767 22.6706
140182.......................................... 28.9515 25.1302 32.1969 28.8546
140184.......................................... 17.2401 17.9169 20.6843 18.6331
140185.......................................... 18.2867 18.8573 20.0931 19.0822
140186.......................................... 23.5034 25.6807 29.0998 26.0890
140187.......................................... 18.3331 19.4049 20.7319 19.4734
140188.......................................... 16.1907 * * 16.1907
140189.......................................... 20.6627 21.1515 22.5875 21.4411
140190.......................................... 17.5263 16.6673 17.9194 17.3611
140191.......................................... 25.2628 27.4166 24.5446 25.6579
140193.......................................... 17.4057 18.5651 20.5958 18.8417
140197.......................................... 19.3774 19.9406 19.2979 19.5430
140199.......................................... 18.0450 18.5409 19.7888 18.7992
140200.......................................... 21.7680 22.4626 24.1358 22.8115
140202.......................................... 23.7955 25.2777 26.2460 25.1620
140203.......................................... 21.0848 24.8870 26.6624 24.2960
140205.......................................... 20.0784 * 25.1010 22.9703
140206.......................................... 22.5109 22.8223 24.8824 23.3989
140207.......................................... 22.3905 25.4539 23.3197 23.6919
140208.......................................... 26.2527 28.3112 27.2009 27.2556
140209.......................................... 20.1557 20.2433 22.0813 20.8567
140210.......................................... 14.8248 15.5345 * 15.2105
140211.......................................... 22.6265 22.8852 25.8603 23.8157
140213.......................................... 24.9892 25.6839 27.4607 26.0827
140215.......................................... 15.2893 18.5502 18.6962 17.4895
140217.......................................... 25.7329 25.9030 24.7146 25.4260
140218.......................................... 14.9851 17.4171 * 16.1590
140220.......................................... 17.8450 19.3915 20.2803 19.2049
140223.......................................... 24.9017 26.2168 27.4355 26.1911
140224.......................................... 32.8292 25.6766 31.4716 29.8171
140228.......................................... 20.1688 21.8627 22.9899 21.6593
140230.......................................... 18.2983 12.3494 * 14.8541
140231.......................................... 24.5019 26.0208 25.5536 25.3988
140233.......................................... 21.2333 24.4419 24.7103 23.5150
140234.......................................... * 19.7266 20.8676 20.3084
140236.......................................... 12.9253 * * 12.9252
140239.......................................... 20.3745 21.6074 23.9213 21.9721
140240.......................................... 24.6949 25.1418 25.0325 24.9609
140242.......................................... 25.2317 26.1850 26.7947 26.1303
140245.......................................... 14.2481 15.1320 15.2537 14.8687
140246.......................................... 11.6267 15.0650 16.1305 14.1116
140250.......................................... 23.6449 25.3410 24.7737 24.5985
140251.......................................... 21.9435 23.5128 24.8256 23.4339
140252.......................................... 25.0220 26.4715 27.4640 26.3370
140253.......................................... 19.5858 18.4567 * 19.0172
140258.......................................... 25.3622 25.0743 27.8202 26.1250
140271.......................................... 12.0079 16.0350 17.5175 14.8913
140275.......................................... 23.8171 22.9656 20.1784 22.2596
140276.......................................... 25.3134 26.1713 25.1140 25.5042
140280.......................................... 18.8300 20.0763 21.7004 20.2210
140281.......................................... 25.2719 26.5197 27.9115 26.6261
140285.......................................... 18.5916 15.7435 * 17.0403
140286.......................................... 26.1290 24.0368 25.9931 25.3447
[[Page 27268]]
140288.......................................... 24.4331 25.8717 26.2186 25.5431
140289.......................................... 18.1747 17.7886 21.3632 19.1491
140290.......................................... 22.8590 26.5055 30.7221 26.7335
140291.......................................... 24.9537 26.8628 26.7900 26.2319
140292.......................................... 21.9950 26.8610 26.0858 25.0061
140294.......................................... 17.7301 19.4218 20.5969 19.2265
140300.......................................... 27.8436 28.9830 30.2598 29.0524
150001.......................................... 24.0620 22.6875 25.4897 24.1367
150002.......................................... 20.7651 20.7353 22.3327 21.2734
150003.......................................... 20.8636 21.4649 21.0944 21.1408
150004.......................................... 21.2449 22.8060 23.5250 22.4800
150005.......................................... 21.6806 22.8149 23.8818 22.8498
150006.......................................... 20.6523 21.8435 23.1779 21.9153
150007.......................................... 20.6635 21.2811 22.1098 21.3541
150008.......................................... 21.8457 23.0208 23.8916 22.9022
150009.......................................... 19.0030 19.5869 19.1857 19.2602
150010.......................................... 20.5570 21.2466 22.5445 21.4807
150011.......................................... 18.3275 19.9096 22.1760 20.1162
150012.......................................... 22.1402 21.7903 23.1644 22.3790
150013.......................................... 16.9327 17.5531 19.8564 18.1751
150014.......................................... 21.5168 22.8402 24.3754 22.8817
150015.......................................... 21.9037 24.2370 21.1839 22.3970
150017.......................................... 19.5339 20.6758 22.7670 21.0275
150018.......................................... 21.0496 22.8922 24.6138 22.9251
150019.......................................... 17.8585 19.8341 17.7411 18.4067
150020.......................................... 16.6600 15.9405 18.4688 17.0524
150021.......................................... 21.5944 23.3800 24.3658 23.1607
150022.......................................... 17.9222 18.7751 22.2973 19.8109
150023.......................................... 19.3412 20.3015 20.7199 20.0985
150024.......................................... 19.2295 19.8368 21.5661 20.1308
150025.......................................... 20.2750 * * 20.2750
150026.......................................... 22.4978 21.9448 23.2169 22.5611
150027.......................................... 18.0335 19.4238 21.5325 19.7090
150029.......................................... 23.2454 24.8939 25.2067 24.4325
150030.......................................... 19.2406 20.7256 22.2537 20.7871
150031.......................................... 18.3463 21.3494 18.3291 19.2245
150033.......................................... 22.6741 23.0756 24.1718 23.2965
150034.......................................... 23.1533 23.3718 22.8812 23.1378
150035.......................................... 21.2374 22.3779 23.5468 22.3841
150036.......................................... 21.4567 22.1464 22.4098 21.9941
150037.......................................... 24.4611 22.3699 26.4359 24.3457
150038.......................................... 22.0572 20.3454 21.6608 21.3217
150039.......................................... 19.6215 16.0227 19.2708 18.1689
150042.......................................... 20.2221 18.0185 23.6783 20.4220
150043.......................................... 20.1741 20.6301 20.8562 20.5460
150044.......................................... 19.1309 19.8951 20.7412 19.9259
150045.......................................... 18.1670 20.6406 22.9339 20.5458
150046.......................................... 18.2543 19.4146 20.3453 19.3721
150047.......................................... 22.0145 21.9824 24.8712 22.8866
150048.......................................... 19.1648 21.1441 22.5181 20.9965
150049.......................................... 18.6451 21.6309 18.4989 19.5784
150050.......................................... 17.7354 18.0411 18.0624 17.9423
150051.......................................... 19.7257 20.6895 22.0106 20.8739
150052.......................................... 17.3750 18.8345 19.1070 18.4211
150053.......................................... 18.8632 18.3493 19.4966 18.9082
150054.......................................... 18.3916 19.3424 * 18.8632
150056.......................................... 21.5774 23.0603 24.5540 23.0525
150057.......................................... 16.9736 17.4044 28.0884 20.1891
150058.......................................... 22.1409 23.0273 24.9479 23.3727
150059.......................................... 22.7360 23.1398 24.5716 23.4998
150060.......................................... 18.6159 19.5011 19.8990 19.3356
150061.......................................... 19.7968 19.4014 17.5585 18.7895
150062.......................................... 20.8274 21.2608 22.9214 21.6432
[[Page 27269]]
150063.......................................... 22.6525 24.8587 28.5326 25.3429
150064.......................................... 20.3865 20.6232 21.2512 20.7527
150065.......................................... 21.2153 21.4572 23.0636 21.9337
150066.......................................... 19.5313 19.6845 20.7240 20.0045
150067.......................................... 18.8862 20.5000 21.4374 20.3431
150069.......................................... 23.3969 23.5510 23.8869 23.5811
150070.......................................... 18.0827 18.9332 20.7413 19.2893
150071.......................................... 13.5111 16.4179 19.4530 16.5251
150072.......................................... 15.0765 18.5813 18.5447 17.3134
150073.......................................... * 19.8034 14.8287 16.6860
150074.......................................... 20.2305 21.3500 22.9598 21.5274
150075.......................................... 16.7532 17.2267 20.0897 17.8847
150076.......................................... 22.6424 23.3724 25.4519 23.8726
150078.......................................... 19.9668 20.2068 20.1260 20.1068
150079.......................................... 18.2051 18.3668 19.3860 18.6860
150082.......................................... 17.8381 19.6881 20.7334 19.4332
150084.......................................... 24.3107 24.9529 27.8354 25.7663
150086.......................................... 18.3838 19.7763 21.5815 19.9584
150088.......................................... 20.3366 22.3055 22.2627 21.6628
150089.......................................... 22.1725 21.5664 21.4993 21.7481
150090.......................................... 21.0945 21.9803 24.7940 22.5227
150091.......................................... 22.4640 26.5235 26.4248 25.0867
150092.......................................... 16.9179 18.2592 16.7372 17.2915
150094.......................................... 17.5244 16.8351 19.5004 18.0298
150095.......................................... 19.2749 22.3214 23.5231 21.7410
150096.......................................... 20.8204 * 19.7975 20.2623
150097.......................................... 19.7751 21.1462 22.3593 21.2002
150098.......................................... 15.2829 16.4763 17.8106 16.4972
150100.......................................... 19.8066 18.7289 21.2980 19.8754
150101.......................................... 20.6209 21.2025 26.1272 22.4675
150102.......................................... 23.7180 20.8818 21.3313 21.8627
150103.......................................... 18.7036 19.3653 17.9684 18.6804
150104.......................................... 20.0765 21.3141 21.0799 20.8409
150105.......................................... 22.4412 21.6975 23.9540 22.7002
150106.......................................... 16.8714 18.7088 19.1976 18.3084
150109.......................................... 19.9066 21.7870 23.4642 21.7343
150110.......................................... 21.9336 * * 21.9336
150111.......................................... 19.2355 24.1559 * 21.5147
150112.......................................... 20.5253 22.1939 23.5151 22.0747
150113.......................................... 19.6603 20.5871 21.2412 20.5276
150114.......................................... 17.9877 18.3097 * 18.1462
150115.......................................... 18.4844 18.1308 21.5042 19.3163
150122.......................................... 17.7867 20.7540 22.2752 20.2587
150123.......................................... 14.0508 16.2898 15.5997 15.3438
150124.......................................... 15.9487 16.2104 17.9062 16.6729
150125.......................................... 21.3311 22.0299 23.1015 22.1704
150126.......................................... 20.6857 24.0000 24.1917 22.8979
150127.......................................... 17.0052 18.0532 * 17.5279
150128.......................................... 19.5576 20.4742 20.9869 20.3528
150129.......................................... 28.6211 29.9888 34.3166 30.8814
150130.......................................... 18.4846 18.3852 18.5578 18.4750
150132.......................................... 20.9443 21.2747 22.2707 21.4967
150133.......................................... 18.4250 20.0320 21.8167 20.0930
150134.......................................... 19.3632 20.2764 20.7680 20.1127
150136.......................................... 21.8097 22.9091 25.8467 23.5584
150146.......................................... 19.0204 * 25.1827 22.2199
150148.......................................... * * 26.2190 26.2188
160001.......................................... 19.0085 20.1699 22.8425 20.6574
160002.......................................... 16.6003 17.6600 19.9607 18.0502
160003.......................................... 16.2208 17.5429 17.5050 17.1062
160005.......................................... 17.9405 19.3348 20.3313 19.1990
160007.......................................... 15.1738 14.9137 * 15.0384
160008.......................................... 16.6193 16.7863 17.9463 17.1044
[[Page 27270]]
160009.......................................... 17.9886 19.0664 20.5800 19.2128
160012.......................................... 16.7112 17.9236 17.2718 17.2909
160013.......................................... 18.6304 20.3023 21.0541 20.0165
160014.......................................... 16.7146 18.7253 18.3097 17.9036
160016.......................................... 19.9747 21.6050 21.8400 21.1711
160018.......................................... 15.6141 16.0793 16.8377 16.1872
160020.......................................... 15.5384 15.7960 16.6092 15.9961
160021.......................................... 16.7617 16.7920 17.2152 16.9236
160023.......................................... 15.0099 15.3854 16.9777 15.7718
160024.......................................... 19.4764 20.5622 22.1034 20.6927
160026.......................................... 19.5260 20.4567 22.8967 20.9474
160027.......................................... 16.9417 18.2081 18.9985 18.0413
160028.......................................... 21.0000 22.9000 25.4337 23.0923
160029.......................................... 21.3457 22.2106 23.6148 22.4178
160030.......................................... 19.6182 21.6899 23.3687 21.5386
160031.......................................... 16.1267 16.8957 17.8994 16.9687
160032.......................................... 18.3168 19.2464 20.5024 19.3173
160033.......................................... 18.8859 20.1916 21.8778 20.2846
160034.......................................... 16.5957 17.3644 19.0684 17.6441
160035.......................................... 16.3991 17.0165 * 16.6797
160036.......................................... 17.4558 20.2598 * 18.9565
160037.......................................... 19.5045 19.5067 20.6425 19.8844
160039.......................................... 17.8647 19.1998 19.8851 19.0101
160040.......................................... 18.0667 19.6339 20.0567 19.2064
160041.......................................... 17.4435 18.7943 * 18.1971
160043.......................................... 14.8564 16.7841 15.5765 15.7233
160044.......................................... 17.8323 19.5552 19.0956 18.8738
160045.......................................... 20.0611 21.4757 22.1285 21.2575
160046.......................................... 16.2737 16.8665 * 16.5694
160047.......................................... 19.0787 20.4259 22.0610 20.5906
160048.......................................... 15.6856 17.2709 17.7273 16.8247
160049.......................................... 15.5673 15.3233 20.5531 16.9039
160050.......................................... 17.7878 21.1184 21.6247 20.1164
160051.......................................... 16.4261 15.8213 14.0556 15.4076
160052.......................................... 21.7647 22.1933 22.2409 22.0595
160054.......................................... 16.1981 16.5258 15.9074 16.2107
160055.......................................... 15.1674 17.6177 14.5971 15.6313
160056.......................................... 17.0172 17.9534 19.6493 18.1612
160057.......................................... 19.1378 19.6802 20.8345 19.9113
160058.......................................... 22.1061 22.2812 23.5663 22.6513
160060.......................................... 17.2825 17.7489 18.1102 17.6991
160061.......................................... 17.0938 17.2064 18.0413 17.4625
160062.......................................... 17.4388 18.8163 22.6687 19.5483
160063.......................................... 16.3583 17.3771 17.9229 17.2470
160064.......................................... 22.2131 25.2962 23.8367 23.7172
160065.......................................... 17.1043 17.0609 * 17.0808
160066.......................................... 17.9971 19.3202 20.4609 19.2300
160067.......................................... 16.7833 17.6602 19.9422 17.9572
160068.......................................... 19.0572 20.5995 23.4967 21.0271
160069.......................................... 19.1640 20.5989 21.7197 20.4818
160070.......................................... 18.4588 17.7855 20.3683 18.7886
160072.......................................... 14.4141 15.3384 15.6894 15.1633
160073.......................................... 11.4997 15.5946 16.2186 14.2046
160074.......................................... 17.9513 18.4624 22.2989 19.4707
160075.......................................... 18.4613 20.7842 21.9161 20.2495
160076.......................................... 17.8824 19.1590 20.1603 19.0456
160077.......................................... 13.6658 15.0468 16.8030 15.1869
160079.......................................... 18.6333 20.5010 21.6562 20.2670
160080.......................................... 19.4925 19.6680 21.1713 20.1081
160081.......................................... 17.4466 19.1442 20.4415 18.9934
160082.......................................... 19.5322 20.7306 21.3139 20.5262
160083.......................................... 19.7542 21.3221 23.1417 21.3360
160085.......................................... 21.2557 19.1929 * 20.1491
[[Page 27271]]
160086.......................................... 17.5308 19.0477 19.8991 18.7925
160088.......................................... 22.3655 23.8098 25.3429 23.8526
160089.......................................... 17.3449 18.3526 19.9688 18.5909
160090.......................................... 17.9614 18.4210 19.6767 18.6779
160091.......................................... 14.2573 14.8904 16.1660 15.1176
160092.......................................... 17.0633 17.9251 20.4731 18.4608
160093.......................................... 18.5675 19.5732 22.8552 20.0542
160094.......................................... 17.6094 18.7835 20.3433 18.9270
160095.......................................... 15.2722 16.4927 * 15.8700
160097.......................................... 16.6790 17.7860 17.7992 17.4211
160098.......................................... 16.8670 16.8997 17.9906 17.2476
160099.......................................... 15.0880 16.0710 17.5828 16.2056
160101.......................................... 18.9788 19.6314 22.1741 20.2613
160102.......................................... 20.1161 14.4837 * 17.0012
160103.......................................... 18.2741 19.6168 22.4647 20.1210
160104.......................................... 17.4829 21.0060 23.2738 20.6777
160106.......................................... 17.3474 19.4385 19.8906 18.8668
160107.......................................... 18.0097 18.8936 19.5110 18.7905
160108.......................................... 16.7779 17.7577 19.6390 18.0443
160109.......................................... 17.9873 18.2938 18.5126 18.2742
160110.......................................... 20.6215 20.9959 21.9299 21.2145
160111.......................................... 14.9965 15.1104 16.7625 15.6341
160112.......................................... 17.2450 19.6950 20.4038 19.1223
160113.......................................... 15.4834 14.9449 16.7574 15.7259
160114.......................................... 16.5006 18.0532 19.1743 17.9155
160115.......................................... 16.5654 16.9991 17.6815 17.0701
160116.......................................... 16.6993 18.4261 19.6923 18.2708
160117.......................................... 18.7615 20.1682 22.3228 20.3906
160118.......................................... 19.4472 17.1480 16.9466 17.7185
160120.......................................... 15.6789 15.0577 15.9432 15.5897
160122.......................................... 18.1469 18.8469 21.2843 19.4799
160124.......................................... 19.1600 19.9144 21.2279 20.1448
160126.......................................... 19.4903 17.8643 20.0149 19.0751
160129.......................................... 17.2112 18.0113 18.1304 17.7899
160130.......................................... 15.6666 16.2628 17.4584 16.4856
160131.......................................... 16.0424 16.5397 18.0499 16.8700
160134.......................................... 15.3012 14.6396 17.0092 15.5453
160135.......................................... 18.7711 18.3973 18.7512 18.6539
160138.......................................... 17.1491 18.3957 17.8475 17.7631
160140.......................................... 18.5630 19.6155 22.1666 20.1522
160142.......................................... 18.1467 17.2792 * 17.6980
160143.......................................... 17.4497 18.1287 19.0623 18.2106
160145.......................................... 16.9092 17.8887 18.4032 17.7185
160146.......................................... 17.7010 19.0576 20.6638 19.0955
160147.......................................... 19.4041 21.6062 22.7993 21.2446
160151.......................................... 17.2177 18.3398 * 17.7679
160152.......................................... 15.9500 17.0750 17.9285 16.9659
160153.......................................... 21.2085 22.7004 23.5212 22.4610
170001.......................................... 17.9218 18.5120 19.8150 18.7852
170004.......................................... 16.1442 17.2262 18.6048 17.3314
170006.......................................... 17.5982 19.1982 19.4488 18.7531
170008.......................................... 16.8412 17.7061 18.2351 17.6303
170009.......................................... 23.1349 25.0508 25.8246 24.6993
170010.......................................... 19.4584 19.5990 20.6294 19.9051
170012.......................................... 18.4432 20.2412 21.6824 20.1902
170013.......................................... 19.4667 20.1852 21.4954 20.4080
170014.......................................... 18.4931 19.6044 21.3084 19.7344
170015.......................................... 17.1302 17.2443 18.0485 17.4844
170016.......................................... 20.0675 22.1023 22.5856 21.5884
170017.......................................... 19.5994 19.7908 21.8586 20.4248
170018.......................................... 15.3237 14.8794 16.9170 15.7229
170019.......................................... 16.9362 17.4699 18.7916 17.7083
170020.......................................... 18.1325 19.1418 20.6658 19.3514
[[Page 27272]]
170022.......................................... 19.1888 20.3269 21.1947 20.2097
170023.......................................... 19.2441 19.6533 21.6273 20.2090
170024.......................................... 14.3604 15.0081 16.1196 15.1666
170025.......................................... 18.7182 19.1720 19.2124 19.0231
170026.......................................... 14.8974 16.9094 17.0837 16.3226
170027.......................................... 17.8690 18.4466 20.7776 19.0432
170030.......................................... 15.9282 12.9413 14.4544 14.3349
170031.......................................... 14.2151 16.4660 16.5916 15.7181
170032.......................................... 16.3449 15.2207 16.1164 15.8915
170033.......................................... 19.1952 20.4533 20.0065 19.9072
170034.......................................... 16.9586 17.8239 18.1073 17.6353
170035.......................................... 17.0945 19.8334 * 18.4676
170038.......................................... 13.8582 15.2505 17.0172 15.4188
170039.......................................... 17.0774 18.5780 18.4473 18.0348
170040.......................................... 21.0617 23.1014 24.5234 22.7728
170041.......................................... 12.4488 9.9263 13.9710 11.9108
170044.......................................... 17.3254 * * 17.3256
170045.......................................... 25.8331 20.5454 18.4142 21.3297
170049.......................................... 20.7921 21.2917 22.9404 21.7361
170051.......................................... 16.4851 16.9003 16.8455 16.7442
170052.......................................... 15.2283 16.0948 15.8809 15.7508
170053.......................................... 14.6133 14.3628 14.5886 14.5203
170054.......................................... 14.6354 15.2814 18.5239 16.1318
170055.......................................... 18.2607 18.1783 * 18.2208
170056.......................................... 18.3550 19.7369 17.1872 18.5237
170058.......................................... 19.5415 20.1090 23.0649 20.9522
170060.......................................... 18.9853 17.5290 17.9830 18.1586
170061.......................................... 15.0258 15.6412 16.6852 15.7398
170063.......................................... 14.1185 13.7611 17.2821 14.6657
170066.......................................... 16.2891 16.8009 18.3113 17.1768
170067.......................................... 14.9921 20.7945 * 17.6559
170068.......................................... 17.0022 19.2629 20.5512 18.8725
170070.......................................... 14.0627 14.8348 15.0540 14.6220
170072.......................................... 12.7709 * * 12.7710
170073.......................................... 17.7056 17.7586 17.4493 17.6284
170074.......................................... 17.3699 17.6543 18.5169 17.8689
170075.......................................... 13.6816 14.4939 15.6809 14.6514
170076.......................................... 14.6109 14.9392 16.0998 15.2083
170077.......................................... 13.9104 14.1376 14.6378 14.2439
170079.......................................... 11.5902 16.7227 * 13.7740
170080.......................................... 14.8293 13.6794 15.0079 14.4977
170081.......................................... 14.6823 15.0840 15.7141 15.0936
170082.......................................... 13.7462 14.8154 15.9973 14.8264
170084.......................................... 13.0519 13.6517 14.5770 13.7521
170085.......................................... 17.5422 21.8907 17.2585 18.9901
170086.......................................... 19.7182 20.7298 21.7451 20.7316
170088.......................................... 13.4860 * * 13.4860
170089.......................................... 15.4860 20.2263 16.2599 17.5460
170090.......................................... 10.9444 23.6837 16.3550 15.3916
170093.......................................... 14.0276 14.7803 14.9660 14.5908
170094.......................................... 21.2035 21.2484 20.1253 20.9151
170095.......................................... 15.3532 16.1078 16.8686 16.1165
170097.......................................... 17.7540 18.6023 18.9865 18.4524
170098.......................................... 16.6210 17.3480 18.5181 17.4543
170099.......................................... 14.3370 16.5247 15.8118 15.5495
170101.......................................... 18.0143 17.3381 17.9291 17.7556
170102.......................................... 14.2447 14.4499 14.6874 14.4627
170103.......................................... 17.9530 18.6172 20.1264 18.9371
170104.......................................... 21.0049 22.0671 22.6619 21.9115
170105.......................................... 16.7403 18.2788 18.3824 17.8166
170106.......................................... 17.7467 * * 17.7468
170109.......................................... 16.9782 18.3483 20.4661 18.7139
170110.......................................... 18.5731 21.0637 16.5883 18.8196
[[Page 27273]]
170112.......................................... 15.4049 15.8097 17.8740 16.3357
170113.......................................... 14.6486 16.4938 19.9957 16.7158
170114.......................................... 16.2645 13.9726 17.4687 15.7793
170115.......................................... 12.9216 13.0253 13.6173 13.1746
170116.......................................... 18.1830 19.4278 20.8800 19.4962
170117.......................................... 16.8237 16.8301 17.5794 17.0795
170119.......................................... 15.2708 15.1982 13.9828 14.8083
170120.......................................... 17.4917 18.2832 18.7576 18.1504
170122.......................................... 21.1769 21.4588 22.2681 21.6171
170123.......................................... 23.6534 25.2122 25.0073 24.6043
170124.......................................... 15.0596 16.3925 14.2191 15.2518
170126.......................................... 13.5736 14.5527 15.4213 14.4901
170128.......................................... 14.1676 17.6259 13.9704 14.9984
170133.......................................... 18.8119 19.9778 20.0593 19.6138
170134.......................................... 14.6799 15.1932 15.4176 15.0931
170137.......................................... 19.3118 19.3344 21.4394 20.0379
170139.......................................... 14.3001 14.8157 16.9180 15.1918
170142.......................................... 17.7134 19.0547 19.6251 18.8022
170143.......................................... 16.0415 16.3258 18.0308 16.8248
170144.......................................... 20.4392 20.8488 23.9179 21.2803
170145.......................................... 19.0142 20.1494 20.5099 19.8990
170146.......................................... 21.7919 25.2520 27.0312 24.7198
170147.......................................... 17.6717 18.4634 18.2480 18.1292
170148.......................................... 19.1942 24.4828 26.3491 22.6386
170150.......................................... 15.9072 14.9718 16.3723 15.7462
170151.......................................... 14.3668 14.5002 15.7242 14.8570
170152.......................................... 15.6423 16.0930 17.6328 16.4532
170160.......................................... 14.4732 17.0629 * 15.6980
170164.......................................... 17.4072 17.0791 18.4142 17.6451
170166.......................................... 12.7507 16.5113 17.8131 15.5313
170171.......................................... 13.1792 14.7051 14.7251 14.2074
170175.......................................... 20.1907 20.8671 22.2203 21.0292
170176.......................................... 23.5043 23.5743 25.5404 24.2059
170180.......................................... 8.6352 * 25.0933 14.1579
170182.......................................... 21.3454 21.9797 23.2115 22.1999
170183.......................................... 19.5182 16.6577 19.6919 18.5350
170185.......................................... * 26.8136 26.5542 26.6930
170186.......................................... * 33.2457 28.4462 30.5174
170187.......................................... * * 20.8289 20.8289
170188.......................................... * * 25.2504 25.2504
170189.......................................... * * 28.1999 28.1996
180001.......................................... 20.4885 20.8169 22.2674 21.1866
180002.......................................... 17.5798 19.8195 20.0075 19.1094
180004.......................................... 17.7149 18.0494 19.8552 18.5287
180005.......................................... 22.4634 23.4941 22.6704 22.8061
180006.......................................... 10.3400 11.2872 14.4066 11.8905
180007.......................................... 17.9491 18.6823 21.3545 19.3281
180009.......................................... 21.0608 21.7746 22.4450 21.7873
180010.......................................... 19.6311 19.4210 21.8916 20.3621
180011.......................................... 19.0526 22.6798 19.2490 20.3535
180012.......................................... 19.0646 19.6614 19.9227 19.5547
180013.......................................... 19.7418 20.0950 21.0512 20.3043
180014.......................................... 21.3361 23.0067 * 22.1047
180016.......................................... 21.1458 19.7242 20.5203 20.4674
180017.......................................... 15.6583 16.7649 18.0329 16.8060
180018.......................................... 15.4892 18.1529 17.5670 17.0578
180019.......................................... 17.8285 19.5953 20.8416 19.3979
180020.......................................... 18.0111 19.4391 20.5659 19.3119
180021.......................................... 17.0618 16.5376 17.6330 17.0802
180023.......................................... 17.4717 19.0574 20.8869 19.1283
180024.......................................... 16.5040 19.6313 22.3922 19.4653
180025.......................................... 15.4180 17.1875 18.3306 16.9977
180026.......................................... 15.0118 13.9959 15.5354 14.8403
[[Page 27274]]
180027.......................................... 17.5286 19.6928 20.5017 19.2757
180028.......................................... 15.7005 26.2220 19.7853 19.6547
180029.......................................... 17.7248 20.0841 19.9084 19.2475
180030.......................................... 17.9543 17.5043 19.5826 18.3704
180031.......................................... 13.1848 17.1003 11.7847 13.7078
180032.......................................... 17.2784 17.2362 17.6939 17.3857
180033.......................................... 15.4131 17.0498 14.8047 15.7339
180034.......................................... 16.3991 17.0349 16.4944 16.6481
180035.......................................... 21.3666 22.4651 23.3685 22.4188
180036.......................................... 20.1860 20.6951 22.2389 21.0630
180037.......................................... 21.2184 21.0177 22.7893 21.7251
180038.......................................... 18.5923 19.3837 20.6888 19.5760
180040.......................................... 21.2229 22.2270 23.1648 22.2239
180041.......................................... 16.3699 17.5950 19.1325 17.6429
180042.......................................... 17.1519 15.5660 17.5774 16.7135
180043.......................................... 14.6526 17.2414 20.7367 17.3094
180044.......................................... 19.4984 21.1057 21.8163 20.8254
180045.......................................... 20.8455 20.7498 22.1027 21.2441
180046.......................................... 21.2080 21.6955 23.1139 22.0204
180047.......................................... 18.6938 17.8625 17.8574 18.1198
180048.......................................... 17.7816 18.3151 18.8537 18.3242
180049.......................................... 16.5459 17.8418 18.5188 17.6210
180050.......................................... 17.1493 19.4992 18.9891 18.5564
180051.......................................... 17.5441 18.3028 18.6730 18.1921
180053.......................................... 15.8994 17.3167 17.6239 16.9255
180054.......................................... 20.0946 17.4354 19.1340 18.8876
180055.......................................... 15.8422 16.6072 17.8704 16.7352
180056.......................................... 17.5881 18.7038 19.4072 18.5962
180058.......................................... 14.5355 14.8840 17.6126 15.5719
180059.......................................... 14.7032 17.2542 17.7683 16.4865
180063.......................................... 12.4448 14.7338 15.5077 14.2770
180064.......................................... 15.5066 16.3894 21.1067 17.5598
180065.......................................... 11.1934 11.0966 9.9166 10.8002
180066.......................................... 19.8956 20.7907 21.1883 20.6121
180067.......................................... 20.1712 20.2762 21.5671 20.6602
180069.......................................... 16.2916 19.0836 19.5693 18.2811
180070.......................................... 15.9362 15.4643 16.9892 16.1274
180072.......................................... 17.2347 17.0576 17.5411 17.2563
180078.......................................... 21.7116 23.7765 23.4616 23.0019
180079.......................................... 15.9048 18.1683 18.0472 17.3416
180080.......................................... 16.6428 17.6735 18.8793 17.7518
180087.......................................... 15.6089 16.2378 16.4726 16.1124
180088.......................................... 22.1774 22.8908 22.9130 22.7063
180092.......................................... 18.3597 18.8964 19.6790 18.9885
180093.......................................... 17.8492 17.7592 18.8469 18.1473
180094.......................................... 13.6233 14.3306 15.7641 14.5357
180095.......................................... 13.9050 15.4478 15.9881 15.0485
180099.......................................... 13.2991 14.0464 14.0115 13.7738
180101.......................................... * 21.0704 21.7454 21.4083
180102.......................................... 18.5240 18.8169 20.1259 19.1237
180103.......................................... 20.3490 20.9598 21.3867 20.8948
180104.......................................... 19.3922 20.2731 21.3866 20.3724
180105.......................................... 16.6997 18.2976 18.3521 17.7554
180106.......................................... 15.2895 15.5278 15.4937 15.4371
180108.......................................... 14.4740 14.8720 16.7327 15.3846
180115.......................................... 16.9096 18.0951 19.2396 18.0795
180116.......................................... 18.6077 19.2389 20.5453 19.4231
180117.......................................... 23.0192 20.7961 17.8273 20.4194
180118.......................................... 16.9250 17.9017 18.3618 17.7402
180120.......................................... 15.3115 16.4226 20.4507 17.0636
180121.......................................... 20.0494 16.9570 16.9881 17.9386
180122.......................................... 18.1930 18.7549 26.1085 21.0314
180123.......................................... 21.1067 21.5962 * 21.3452
[[Page 27275]]
180124.......................................... 18.8487 19.7138 20.5265 19.6910
180125.......................................... 14.9314 22.6609 18.2048 17.7710
180126.......................................... 14.3551 14.8501 14.5644 14.5905
180127.......................................... 17.6365 18.0498 19.9846 18.6169
180128.......................................... 18.2817 18.7194 19.8756 18.9809
180129.......................................... 22.3536 15.6637 14.1861 16.9914
180130.......................................... 20.6450 21.9413 23.4841 22.0517
180132.......................................... 19.5884 19.8393 19.9358 19.7903
180133.......................................... 21.7800 23.2679 * 22.4729
180134.......................................... 14.5387 16.5901 * 15.5000
180138.......................................... 20.2102 19.8524 22.8363 20.9918
180139.......................................... 20.5350 20.3816 20.6987 20.5422
180140.......................................... 15.2719 14.6466 16.9631 15.5822
180141.......................................... 23.8930 20.3404 22.5552 22.1339
180142.......................................... 20.7510 * * 20.7510
180143.......................................... * 21.3197 19.7662 20.5610
190001.......................................... 18.1514 18.8583 20.4946 19.2128
190002.......................................... 19.8834 20.6057 21.0138 20.5155
190003.......................................... 19.9121 19.5115 20.7504 20.0615
190004.......................................... 18.3620 19.6755 20.5272 19.5326
190005.......................................... 17.5161 19.0994 19.8177 18.7716
190006.......................................... 17.5911 17.7333 18.7928 18.0215
190007.......................................... 14.4720 16.3633 17.9392 16.3508
190008.......................................... 19.2456 22.4797 20.3099 20.6400
190009.......................................... 15.9731 16.0395 17.5144 16.4753
190010.......................................... 16.5020 17.7616 18.1797 17.4941
190011.......................................... 15.6351 15.7319 15.4699 15.6120
190013.......................................... 15.5019 16.7770 * 16.1202
190014.......................................... 17.8015 18.6929 * 18.2302
190015.......................................... 18.9896 19.7673 20.5905 19.7878
190017.......................................... 17.5381 19.8449 18.3528 18.5693
190018.......................................... 11.1898 13.1355 18.6199 13.8655
190019.......................................... 18.3788 18.7344 20.8052 19.3372
190020.......................................... 17.6840 18.7252 18.5659 18.3279
190025.......................................... 16.8686 18.1892 19.9177 18.2844
190026.......................................... 18.5015 19.0130 19.9178 19.1653
190027.......................................... 17.4761 18.4070 19.5358 18.4507
190029.......................................... 19.1967 18.7344 18.1118 18.6759
190034.......................................... 18.0754 19.2007 * 18.6247
190036.......................................... 20.0300 21.2960 23.3903 21.5497
190037.......................................... 19.9878 14.1323 15.6062 16.9453
190039.......................................... 19.0376 18.7625 20.4160 19.3991
190040.......................................... 21.7376 23.1819 22.9262 22.6065
190041.......................................... 17.9535 19.5511 21.9983 19.8665
190043.......................................... 15.5618 15.5645 15.7333 15.6215
190044.......................................... 17.4471 17.6788 17.7460 17.6341
190045.......................................... 21.2853 22.0065 22.8709 22.1191
190046.......................................... 20.4458 20.2414 21.1659 20.6024
190048.......................................... 16.8136 16.6848 18.1698 17.2383
190049.......................................... 17.7417 18.5902 19.3768 18.5593
190050.......................................... 16.2854 16.9053 18.6663 17.3158
190053.......................................... 13.0080 13.4768 13.8037 13.4554
190054.......................................... 18.9059 17.7269 19.9370 18.8703
190059.......................................... 15.8373 17.8651 18.3334 17.3742
190060.......................................... 17.8443 19.9121 20.2207 19.3688
190064.......................................... 18.2466 19.7215 21.0488 19.7211
190065.......................................... 18.3091 18.3280 20.3583 19.0184
190071.......................................... 16.4138 16.3822 17.8444 16.8680
190077.......................................... 16.5536 16.8829 17.0480 16.8252
190078.......................................... 16.9383 19.5879 19.8607 18.8295
190079.......................................... 17.9403 18.8187 * 18.3869
190081.......................................... 14.9707 14.7919 11.4756 13.7796
190083.......................................... 18.4951 16.2970 18.4954 17.7997
[[Page 27276]]
190086.......................................... 16.5074 17.6237 18.2005 17.4309
190088.......................................... 19.9362 20.4725 18.6738 19.7186
190089.......................................... 15.0395 15.2055 15.5151 15.2626
190090.......................................... 16.2351 19.8201 19.0519 18.4143
190095.......................................... 17.3258 17.3637 16.9519 17.2138
190098.......................................... 21.0847 21.4328 20.7537 21.0874
190099.......................................... 19.0635 19.0545 23.1606 20.4338
190102.......................................... 20.7870 21.1614 22.0190 21.3440
190103.......................................... 14.4158 15.6415 * 15.0851
190106.......................................... 18.5908 19.9117 20.3114 19.6058
190109.......................................... 15.8187 16.3641 16.6515 16.2945
190110.......................................... 15.7313 15.2652 16.5007 15.8208
190111.......................................... 20.6508 21.3622 24.4380 22.2154
190112.......................................... 22.0741 24.2806 * 23.0835
190113.......................................... * 19.0411 * 19.0411
190114.......................................... 13.9209 13.5044 13.6101 13.6758
190115.......................................... 22.7583 24.0098 25.4983 24.0285
190116.......................................... 17.3757 18.3223 * 17.8596
190118.......................................... 16.3776 17.8543 17.5060 17.2223
190120.......................................... 17.2309 17.6708 18.5094 17.7933
190122.......................................... 15.3742 16.7189 17.7811 16.6133
190124.......................................... 20.1206 22.8245 21.9308 21.6225
190125.......................................... 19.8298 20.1401 21.5692 20.4994
190128.......................................... 20.8770 21.5869 23.8786 22.1716
190130.......................................... 14.0379 14.5586 15.2678 14.6311
190131.......................................... 18.8958 19.7483 21.3154 20.0242
190133.......................................... 15.1393 15.7834 13.4062 14.7514
190134.......................................... 12.4507 * * 12.4507
190135.......................................... 21.3454 23.0213 24.5472 22.9404
190136.......................................... 15.1662 15.6286 16.7852 15.8135
190140.......................................... 14.6829 14.8738 15.4029 14.9883
190142.......................................... 16.2280 19.0464 22.5765 19.3164
190144.......................................... 18.4405 18.3513 21.3838 19.3822
190145.......................................... 16.2505 16.4402 17.4407 16.7345
190146.......................................... 21.9607 20.9312 22.1502 21.6747
190147.......................................... 14.7202 15.2732 16.3596 15.4387
190148.......................................... 15.5338 19.4518 19.3245 17.9652
190149.......................................... 16.4722 16.5153 18.4197 17.1004
190151.......................................... 15.5210 16.2783 17.3402 16.3739
190152.......................................... 22.0319 22.7142 25.1136 23.3179
190156.......................................... 16.0442 17.6573 18.0528 17.2654
190158.......................................... 20.4078 21.6307 23.2361 21.7367
190160.......................................... 18.4662 19.3139 19.8734 19.2722
190161.......................................... 15.9280 15.7807 27.3615 18.5292
190162.......................................... 20.1962 20.9645 20.7350 20.6423
190164.......................................... 18.2379 19.0473 * 18.6694
190167.......................................... 17.7611 15.5795 * 16.5290
190170.......................................... 14.5222 16.2045 * 15.4153
190173.......................................... 23.0934 * * 23.0934
190175.......................................... 20.4580 23.0144 22.7574 22.0818
190176.......................................... 22.2316 21.7051 24.3432 22.8033
190177.......................................... 19.7794 20.3679 22.3318 20.8422
190178.......................................... 12.0372 * * 12.0373
190182.......................................... 20.7102 23.1997 23.6016 22.4491
190183.......................................... 16.0752 16.7402 17.1805 16.6637
190184.......................................... 19.8436 18.6583 20.6096 19.6762
190185.......................................... 20.5852 20.7351 29.7870 23.2575
190186.......................................... 17.4078 16.7272 18.4556 17.5015
190190.......................................... 15.8985 13.7951 16.2819 15.2413
190191.......................................... 19.6911 19.7218 21.9141 20.4097
190196.......................................... 18.6138 19.1961 20.7601 19.5709
190197.......................................... 20.2082 20.9871 21.6908 21.0235
190199.......................................... 15.3522 17.8288 11.3015 14.1164
[[Page 27277]]
190200.......................................... 21.6852 22.3510 24.2525 22.7566
190201.......................................... 19.7421 21.7185 21.1903 20.9110
190202.......................................... * 22.4701 22.4062 22.4391
190203.......................................... 21.7931 23.0636 24.9518 23.3496
190204.......................................... 20.5784 22.9134 26.1231 23.1780
190205.......................................... 19.3737 18.8750 20.2374 19.4986
190206.......................................... 21.3307 21.7867 24.2892 22.5212
190207.......................................... 19.0216 20.7024 19.7316 19.8068
190208.......................................... 16.9641 17.6834 23.0838 18.5667
190218.......................................... 19.2992 20.7290 21.6207 20.5593
190231.......................................... 17.7247 * * 17.7247
190236.......................................... 21.1982 22.5796 24.4661 22.8193
190238.......................................... 20.6799 * * 20.6799
190239.......................................... 19.7601 * * 19.7601
190240.......................................... 14.3579 16.0658 15.4026 15.3226
190242.......................................... * * 12.2209 12.2209
200001.......................................... 18.2513 19.7903 21.3664 19.8121
200002.......................................... 22.3035 22.3145 24.7102 23.1322
200003.......................................... 18.4141 18.5779 20.1431 19.0655
200006.......................................... 21.0922 18.9818 * 20.0361
200007.......................................... 18.1681 19.0387 21.3451 19.4241
200008.......................................... 21.5556 23.2883 25.6369 23.5650
200009.......................................... 21.4763 23.3090 24.6974 23.1816
200012.......................................... 19.1047 20.5141 21.7931 20.4820
200013.......................................... 17.9378 20.3793 22.9359 20.4733
200016.......................................... 17.1187 16.2939 20.9892 18.0074
200018.......................................... 17.8675 19.8848 21.2548 19.6846
200019.......................................... 19.9245 21.1893 22.7794 21.2976
200020.......................................... 22.3355 24.7433 27.0790 24.8621
200021.......................................... 20.7361 22.0144 24.9384 22.6378
200023.......................................... 20.2063 * * 20.2063
200024.......................................... 20.8336 21.0633 22.7515 21.5341
200025.......................................... 20.4165 21.4247 22.8869 21.5952
200026.......................................... 17.9021 18.1459 19.7172 18.5708
200027.......................................... 19.4220 20.2100 20.8262 20.1773
200028.......................................... 18.8763 19.8886 22.2117 20.3329
200031.......................................... 16.1641 17.7875 18.5637 17.4852
200032.......................................... 19.4613 20.9148 22.1885 20.9008
200033.......................................... 22.4685 23.6298 25.1723 23.7287
200034.......................................... 20.4941 21.8266 23.5414 22.0096
200037.......................................... 20.3015 19.5004 22.5582 20.7085
200038.......................................... 21.2632 22.9220 23.7816 22.6253
200039.......................................... 20.1508 21.5695 22.1873 21.3042
200040.......................................... 18.9580 20.7744 21.8525 20.5333
200041.......................................... 18.8131 20.2986 21.3816 20.1961
200043.......................................... 19.4295 20.0280 * 19.7244
200050.......................................... 20.2014 23.0314 23.6076 22.2752
200051.......................................... 22.0712 * * 22.0712
200052.......................................... 17.6271 18.9290 19.5066 18.7096
200055.......................................... 18.5983 19.4998 19.8009 19.2948
200062.......................................... 18.4279 18.0949 18.3225 18.2799
200063.......................................... 21.2121 22.5265 26.3887 23.2533
200066.......................................... 17.0570 18.4281 19.4759 18.3382
210001.......................................... 18.6617 21.5280 22.6614 20.9120
210002.......................................... 23.5132 26.5907 25.6975 24.9889
210003.......................................... 26.0447 22.3090 23.0790 23.7255
210004.......................................... 24.9760 27.2278 28.8679 27.0643
210005.......................................... 21.3829 22.5304 24.7185 22.9229
210006.......................................... 19.3682 20.8607 24.1987 21.4594
210007.......................................... 23.8840 23.4582 27.5104 24.9372
210008.......................................... 21.2895 21.0767 24.6569 22.4641
210009.......................................... 20.7479 20.8476 23.4889 21.7419
210010.......................................... 19.5908 20.4097 23.0440 21.0277
[[Page 27278]]
210011.......................................... 21.4043 20.4017 22.1443 21.2906
210012.......................................... 21.3977 24.8430 25.2892 23.7249
210013.......................................... 19.4505 23.1649 23.0151 21.9197
210015.......................................... 18.7448 23.9651 23.8419 22.0261
210016.......................................... 26.5193 24.7441 27.2302 26.1373
210017.......................................... 18.5079 18.2963 19.5294 18.7753
210018.......................................... 22.8553 23.6442 25.3112 23.9214
210019.......................................... 20.6025 21.5429 23.5259 21.9407
210022.......................................... 24.5744 25.6728 27.6680 25.9838
210023.......................................... 22.9989 24.4815 26.7837 24.7914
210024.......................................... 24.4280 24.7858 24.8939 24.7076
210025.......................................... 21.2769 21.4910 22.8882 21.8653
210026.......................................... 13.8668 20.7986 * 16.5220
210027.......................................... 17.1060 16.2219 19.1886 17.4744
210028.......................................... 19.4157 20.4027 22.4054 20.7783
210029.......................................... 25.4939 24.7605 26.2082 25.5405
210030.......................................... 20.9574 21.9547 20.7801 21.2193
210032.......................................... 20.1955 20.0825 20.3407 20.2132
210033.......................................... 23.7588 22.8303 25.0300 23.8986
210034.......................................... 19.4144 22.6812 22.8827 21.5075
210035.......................................... 20.8317 21.6662 21.6973 21.4040
210037.......................................... 20.5528 21.1659 23.5536 21.8146
210038.......................................... 24.9762 25.9701 26.5696 25.8902
210039.......................................... 21.3559 23.3583 23.5618 22.7399
210040.......................................... 23.4252 23.7067 25.4729 24.1964
210043.......................................... 22.4000 22.9504 20.9824 22.0358
210044.......................................... 23.0917 22.9540 23.8101 23.2851
210045.......................................... 12.1467 13.5654 11.8350 12.5334
210048.......................................... 24.6921 24.9381 24.4328 24.6715
210049.......................................... 19.3022 21.1056 23.4786 21.4119
210051.......................................... 23.6476 24.8949 25.7103 24.7772
210054.......................................... 23.2730 25.1694 27.3551 25.2404
210055.......................................... 26.5272 23.8025 27.4218 25.8633
210056.......................................... 22.9593 22.6958 23.5291 23.0845
210057.......................................... 26.0076 25.6142 27.4175 26.3518
210058.......................................... 16.3191 17.4250 22.0351 18.6822
210059.......................................... 25.6052 * * 25.6053
210060.......................................... 26.5846 26.4566 25.8377 26.3021
210061.......................................... 16.1931 20.8975 22.5454 20.0819
220001.......................................... 22.9064 23.4091 25.8030 24.0472
220002.......................................... 24.5840 25.4158 26.3348 25.4205
220003.......................................... 17.9319 17.6069 18.8150 18.0852
220006.......................................... 22.6337 23.8920 25.9967 24.1779
220008.......................................... 22.0796 24.2393 25.6647 24.0447
220010.......................................... 22.0067 23.4009 24.5021 23.3133
220011.......................................... 29.5290 20.6390 29.7597 26.1454
220012.......................................... 31.2303 31.1041 31.8043 31.3960
220015.......................................... 23.1893 24.1348 25.0272 24.1474
220016.......................................... 23.0951 24.6149 25.5598 24.3980
220017.......................................... 25.1568 25.9000 26.0635 25.6650
220019.......................................... 19.8551 19.9268 21.6620 20.5000
220020.......................................... 22.4295 22.5375 23.2840 22.7668
220024.......................................... 21.9316 23.8620 24.1071 23.3004
220025.......................................... 22.8593 22.0003 23.2374 22.6994
220028.......................................... 21.0630 24.1251 31.4858 25.0402
220029.......................................... 25.6560 25.7660 27.4792 26.3128
220030.......................................... 18.7429 18.9012 20.0816 19.2486
220031.......................................... 29.3091 28.3832 30.8324 29.5603
220033.......................................... 20.3609 21.8156 25.2942 22.4280
220035.......................................... 23.1892 25.7456 26.7656 25.1903
220036.......................................... 24.4091 25.5771 26.1128 25.3339
220038.......................................... 22.3162 22.9821 24.2072 23.1581
220041.......................................... 27.5034 28.6790 29.4322 28.5477
[[Page 27279]]
220042.......................................... 26.0473 28.4675 * 27.2387
220046.......................................... 23.3149 24.1931 26.1955 24.5514
220049.......................................... 27.2689 25.4358 26.7406 26.4572
220050.......................................... 22.5265 23.3330 23.8005 23.2263
220051.......................................... 21.7357 22.4826 22.2965 22.1608
220052.......................................... 23.5225 25.4091 26.3043 25.1274
220057.......................................... 25.8064 26.2945 * 26.0375
220058.......................................... 26.8345 21.6814 22.4816 23.6744
220060.......................................... 28.0794 28.3950 29.6290 28.7209
220062.......................................... 20.2254 22.5567 22.6598 21.8448
220063.......................................... 20.8079 21.8365 23.3704 22.0573
220064.......................................... 22.7497 24.0982 * 23.3816
220065.......................................... 20.1424 21.5657 22.4143 21.3853
220066.......................................... 23.4477 24.5463 23.4622 23.8055
220067.......................................... 27.5405 28.2685 26.9915 27.5793
220070.......................................... 20.9128 23.9850 26.2697 24.8446
220071.......................................... 27.4151 27.7679 27.7773 27.6608
220073.......................................... 26.1328 27.4778 29.7863 27.7808
220074.......................................... 24.3057 25.3331 26.4210 25.3967
220075.......................................... 22.5329 24.6982 25.7813 24.3463
220076.......................................... 23.2795 24.1224 24.8040 24.0785
220077.......................................... 26.1545 27.1503 26.7165 26.6753
220079.......................................... 22.0769 25.7305 * 23.1834
220080.......................................... 22.1971 22.9911 24.6008 23.2916
220081.......................................... 29.6682 31.1326 33.3649 31.4663
220082.......................................... 22.1453 23.2818 23.9542 23.1292
220083.......................................... 22.5815 27.2605 28.3533 25.8389
220084.......................................... 25.3761 26.0395 26.8596 26.1410
220086.......................................... 26.7778 28.7324 31.9999 29.0552
220088.......................................... 23.4258 25.0671 25.0645 24.5354
220089.......................................... 25.4106 25.3521 28.9252 26.5987
220090.......................................... 23.3049 26.0265 26.0654 25.2015
220092.......................................... 24.7905 29.4173 * 26.0747
220095.......................................... 21.7851 22.6828 23.7629 22.7845
220098.......................................... 23.1547 24.7180 26.2287 24.7066
220100.......................................... 27.5841 26.8001 25.8127 26.6900
220101.......................................... 27.0711 28.0856 26.9992 27.3742
220104.......................................... 28.7258 * * 28.7258
220105.......................................... 21.9185 25.5692 24.4095 24.0741
220106.......................................... 25.9277 27.6812 * 26.8476
220108.......................................... 23.4975 24.5939 26.0166 24.7052
220110.......................................... 29.1648 30.6173 33.9228 31.2432
220111.......................................... 24.7510 26.7573 26.9565 26.1374
220116.......................................... 32.0049 28.5716 30.9871 30.4812
220119.......................................... 23.8785 24.6344 25.5111 24.6718
220123.......................................... 32.4678 29.6084 32.1805 31.3951
220126.......................................... 23.6045 23.8123 36.1591 27.2823
220133.......................................... 29.3911 29.8366 27.4183 28.8616
220135.......................................... 28.3648 29.6837 31.2687 29.8642
220154.......................................... 21.1563 23.3590 25.5654 23.5365
220163.......................................... 29.2299 29.3552 27.8718 28.5798
220171.......................................... 24.9261 27.3487 25.9496 26.1526
230001.......................................... 20.0438 23.3051 22.0875 21.7854
230002.......................................... 23.0439 24.3115 23.7972 23.6903
230003.......................................... 21.2215 21.6493 22.6120 21.8276
230004.......................................... 20.5005 22.4538 22.3271 21.7397
230005.......................................... 17.0943 20.5596 20.2186 19.1829
230006.......................................... 20.4978 20.6985 21.9442 21.0676
230013.......................................... 22.2211 20.0954 20.4633 20.9362
230015.......................................... 20.6464 21.9499 21.6344 21.3826
230017.......................................... 22.9755 25.7900 26.1609 24.9780
230019.......................................... 23.6674 23.8779 24.7356 24.1224
230020.......................................... 21.8526 28.8869 25.8265 25.0793
[[Page 27280]]
230021.......................................... 19.8256 20.9145 21.9537 20.8777
230022.......................................... 21.9129 21.8808 22.2179 22.0038
230024.......................................... 24.9664 26.2155 24.1272 25.0227
230027.......................................... 19.6393 22.5114 22.1018 21.3775
230029.......................................... 22.1782 24.9754 24.9385 23.9465
230030.......................................... 18.6406 19.2441 19.2145 19.0453
230031.......................................... 19.9465 19.4676 22.1874 20.5558
230032.......................................... 24.8930 22.8436 23.5011 23.7370
230034.......................................... 19.4366 17.9276 19.0026 18.7604
230035.......................................... 17.7490 20.5906 18.0735 18.7098
230036.......................................... 23.8398 25.1507 25.9801 25.0254
230037.......................................... 23.2751 22.7382 24.7183 23.5739
230038.......................................... 21.9692 20.9389 23.2065 22.0318
230040.......................................... 20.7841 20.2451 21.8062 20.9418
230041.......................................... 21.7364 23.2870 24.2297 23.0470
230042.......................................... 21.3870 20.7745 22.5003 21.5609
230046.......................................... 25.3206 26.1787 27.7076 26.3640
230047.......................................... 22.3595 23.7178 24.3622 23.4689
230053.......................................... 26.8917 23.5702 25.3705 25.3321
230054.......................................... 20.8014 22.2105 18.9493 20.6840
230055.......................................... 20.8492 20.8930 20.9350 20.8938
230056.......................................... 17.8091 17.3516 19.4126 18.2031
230058.......................................... 21.0303 21.6619 22.4579 21.7287
230059.......................................... 20.7092 20.6540 20.6854 20.6835
230060.......................................... 19.8987 20.5120 22.7605 21.0950
230062.......................................... 18.8039 18.2283 * 18.4950
230065.......................................... 22.7416 23.3414 26.3217 24.0577
230066.......................................... 23.0475 23.2790 23.4679 23.2643
230069.......................................... 24.2470 25.0212 26.4859 25.2413
230070.......................................... 21.5666 21.2476 22.8588 21.8801
230071.......................................... 23.1337 23.6398 23.6674 23.4732
230072.......................................... 20.4456 22.6533 22.8090 21.9640
230075.......................................... 22.5866 22.3632 22.4692 22.4739
230076.......................................... 24.7010 26.9662 * 25.7305
230077.......................................... 20.2823 22.6781 23.6116 22.2277
230078.......................................... 17.9868 19.1638 20.5427 19.2537
230080.......................................... 20.2104 19.1810 20.4095 19.9313
230081.......................................... 19.0199 20.0464 20.4289 19.7958
230082.......................................... 19.0419 18.2165 21.0552 19.3344
230085.......................................... 23.4996 24.5765 24.2802 24.1339
230086.......................................... 20.1730 20.1461 25.1139 21.7587
230087.......................................... 19.9700 20.6619 22.2688 20.9389
230089.......................................... 22.6994 23.1023 23.3847 23.0660
230092.......................................... 20.7738 22.3437 22.3122 21.8236
230093.......................................... 20.6314 21.0274 25.0356 22.3197
230095.......................................... 17.6444 18.0582 19.1810 18.3175
230096.......................................... 22.7785 24.3004 26.5685 24.5818
230097.......................................... 21.1254 22.5006 22.9902 22.2246
230099.......................................... 21.7513 22.3422 23.5490 22.5510
230100.......................................... 17.3842 18.2477 19.8016 18.4668
230101.......................................... 20.5315 22.5159 22.3310 21.7559
230103.......................................... 11.3429 18.5254 19.4434 16.3738
230104.......................................... 24.1238 25.5606 27.7635 25.8605
230105.......................................... 22.6098 23.0086 23.9851 23.2114
230106.......................................... 21.6825 22.9909 23.1961 22.6494
230107.......................................... 17.1386 18.9985 * 18.1307
230108.......................................... 20.3437 21.4592 19.9763 20.6173
230110.......................................... 19.7262 21.0925 21.8501 20.8760
230115.......................................... 19.6281 21.0361 * 20.3009
230116.......................................... 14.5692 15.6064 20.1283 16.4365
230117.......................................... 25.6797 25.5154 28.1220 26.4781
230118.......................................... 20.6797 20.2770 23.2432 21.3687
230119.......................................... 22.6555 23.9898 24.7999 23.8287
[[Page 27281]]
230120.......................................... 20.3306 20.6105 22.7243 21.0521
230121.......................................... 21.3342 21.4615 24.6973 22.4295
230124.......................................... 18.9981 20.9641 22.0096 20.6756
230128.......................................... 24.0724 24.4952 * 24.2953
230130.......................................... 22.1775 23.5123 23.7854 23.1764
230132.......................................... 26.1946 27.3637 29.0292 27.5003
230133.......................................... 17.1058 19.0770 20.2461 18.8268
230135.......................................... 20.5637 18.4193 19.8290 19.6840
230141.......................................... 22.4570 24.4560 23.9885 23.6151
230142.......................................... 23.5621 25.0282 22.9036 23.7956
230143.......................................... 16.7948 18.2700 19.5446 18.1583
230144.......................................... 23.4237 23.3295 23.6959 23.4486
230145.......................................... 19.2638 17.9811 15.8192 17.6120
230146.......................................... 21.2260 22.3838 21.3539 21.6475
230147.......................................... 23.2755 26.5260 * 24.7445
230149.......................................... 18.8005 19.9577 20.8933 19.8319
230151.......................................... 23.3967 24.3705 25.6421 24.4652
230153.......................................... 18.7403 20.0098 22.8443 20.5744
230154.......................................... 15.4362 16.7152 15.9001 16.0188
230155.......................................... 20.5409 20.7546 18.0743 19.8594
230156.......................................... 25.6228 27.2254 28.0692 26.9451
230157.......................................... 17.3571 * * 17.3571
230162.......................................... 21.7148 22.7984 * 22.2573
230165.......................................... 23.8881 24.7959 25.9534 24.8621
230167.......................................... 22.9745 24.1344 24.7967 23.9623
230169.......................................... 24.3874 28.1039 24.9264 25.7012
230171.......................................... 17.1282 16.1129 19.9097 17.6776
230172.......................................... 21.4675 22.1709 23.0023 22.2346
230174.......................................... 22.7304 23.5025 24.5090 23.5983
230175.......................................... * 14.4932 22.5965 17.8784
230176.......................................... 23.8204 24.9032 24.7466 24.4760
230178.......................................... 17.3030 17.3428 18.1397 17.5917
230180.......................................... 18.5744 19.6062 20.9131 19.7352
230184.......................................... 19.7717 20.6406 21.3426 20.5906
230186.......................................... 15.7837 19.1289 21.2156 18.3800
230188.......................................... 16.2975 16.8687 18.3241 17.0936
230189.......................................... 17.9218 19.1990 22.7783 19.9127
230190.......................................... 26.4687 24.4643 26.8284 25.9306
230191.......................................... 18.4861 20.6633 * 19.5216
230193.......................................... 19.8287 21.5358 22.8917 21.3669
230195.......................................... 22.9228 23.4647 25.3285 23.9218
230197.......................................... 24.0854 25.5312 26.9776 25.4753
230199.......................................... 20.6580 22.4592 23.5942 22.1770
230201.......................................... 18.0787 18.2486 * 18.1632
230204.......................................... 23.4966 24.5127 24.4095 24.1113
230205.......................................... 15.9314 18.1551 * 17.0325
230207.......................................... 21.2483 20.9059 22.2848 21.4738
230208.......................................... 16.7454 17.8118 19.0898 17.9011
230211.......................................... 21.8581 21.1245 * 21.4701
230212.......................................... 24.2611 24.6420 26.4825 25.1164
230213.......................................... 15.5469 17.1062 18.7123 17.1022
230216.......................................... 21.0710 22.2137 23.4216 22.2323
230217.......................................... 22.2698 24.1455 24.3649 23.6068
230219.......................................... 20.0442 18.1277 20.5935 19.6048
230222.......................................... 21.9711 23.2545 24.2148 23.1524
230223.......................................... 22.6887 25.2666 28.5549 25.4631
230227.......................................... 22.3155 25.8826 27.7510 25.3402
230230.......................................... 22.3097 22.1703 22.0423 22.1610
230235.......................................... 17.7197 17.5940 19.2540 18.1724
230236.......................................... 25.9676 25.3251 25.4791 25.5829
230239.......................................... 17.8168 18.9790 19.8370 18.8918
230241.......................................... 20.7297 21.8472 22.8539 21.9059
230244.......................................... 22.2697 23.1175 23.1234 22.8331
[[Page 27282]]
230253.......................................... 21.0433 22.7706 24.9784 22.9234
230254.......................................... 22.6335 23.3714 24.2594 23.4070
230257.......................................... 21.3880 23.1794 24.8070 22.9716
230259.......................................... 22.3969 23.1768 24.5001 23.3910
230264.......................................... 17.4864 18.6598 18.2571 18.1056
230269.......................................... 24.0992 24.3772 24.9596 24.4951
230270.......................................... 22.5985 25.2665 22.9002 23.5673
230273.......................................... 22.8715 24.1278 25.8466 24.2438
230275.......................................... 20.8985 32.0037 29.4179 26.3638
230276.......................................... 25.8709 22.3313 25.4127 24.3279
230277.......................................... 23.9771 24.3351 25.3381 24.5552
230279.......................................... 17.8074 18.3256 21.2467 19.1913
230280.......................................... 18.3497 * * 18.3498
230283.......................................... 22.5082 * 25.0038 23.8515
230286.......................................... * 47.5925 * 47.5929
230287.......................................... * 22.5420 * 22.5420
230288.......................................... * * 30.5931 30.5929
240001.......................................... 25.6936 26.6372 28.2239 26.9164
240002.......................................... 23.2307 24.2214 24.3916 23.9674
240004.......................................... 24.4030 25.6238 26.8197 25.6037
240005.......................................... 20.3193 20.2389 22.7873 21.0896
240006.......................................... 23.0715 25.7288 29.5789 26.1049
240007.......................................... 19.0850 20.7189 21.4367 20.4240
240008.......................................... 23.3783 22.7437 26.3213 24.1118
240009.......................................... 17.1187 17.4518 * 17.2880
240010.......................................... 25.4752 28.3796 29.0956 27.7014
240011.......................................... 21.5875 22.5188 24.0365 22.7468
240013.......................................... 21.7544 25.1560 27.2049 24.6443
240014.......................................... 24.2610 25.2306 26.5144 25.3969
240016.......................................... 22.2011 23.3772 25.2629 23.6323
240017.......................................... 18.9272 19.3431 21.6243 19.9559
240018.......................................... 18.4268 23.6092 27.3634 22.7452
240019.......................................... 23.1477 24.0613 25.1331 24.1004
240020.......................................... 20.8849 20.6819 24.7719 22.0019
240021.......................................... 20.1457 19.0469 23.9570 20.9424
240022.......................................... 21.3234 23.0394 23.4702 22.5966
240023.......................................... 22.8224 22.3002 24.4609 23.2632
240025.......................................... 20.0308 20.7672 21.2597 20.6915
240027.......................................... 16.7758 18.3837 18.3340 17.8317
240028.......................................... 25.1934 * * 25.1933
240029.......................................... 20.0164 23.0440 21.2343 21.3892
240030.......................................... 20.1653 20.9799 22.0200 21.0838
240031.......................................... 19.3983 21.7620 23.4390 21.5566
240036.......................................... 22.1721 22.5436 23.3926 22.7261
240037.......................................... 20.1195 21.4275 21.8392 21.1496
240038.......................................... 24.3957 26.4513 29.0330 26.6099
240040.......................................... 23.1352 22.8191 21.3870 22.2562
240041.......................................... 21.8655 21.9054 22.8511 22.2064
240043.......................................... 16.9859 18.0186 19.5532 18.2400
240044.......................................... 20.3339 22.5750 22.7043 21.8646
240045.......................................... 24.1557 24.2936 25.9223 24.7977
240047.......................................... 23.8098 25.3233 29.6184 26.0294
240050.......................................... 21.6499 23.1109 24.7589 23.1788
240051.......................................... 22.5855 23.2612 25.5603 23.8542
240052.......................................... * 22.3485 23.5899 22.9828
240053.......................................... 23.8693 24.4191 26.6015 24.9787
240056.......................................... 23.7139 24.8549 28.5169 25.8728
240057.......................................... 24.8686 25.3984 27.7600 26.0180
240058.......................................... 18.4009 19.0506 19.6784 19.0102
240059.......................................... 23.7808 25.3847 27.0517 25.4242
240061.......................................... 25.9951 27.9151 28.6098 27.5450
240063.......................................... 24.4031 25.8594 26.7645 25.6926
240064.......................................... 22.8578 24.6785 24.9928 24.2158
[[Page 27283]]
240065.......................................... 14.8734 14.4623 15.3825 14.9036
240066.......................................... 24.1143 25.5163 27.4066 25.7241
240069.......................................... 21.7991 23.3373 25.7439 23.6631
240071.......................................... 21.2463 22.6332 24.8036 22.9056
240072.......................................... 20.9529 21.5455 22.9244 21.8214
240073.......................................... 17.3559 17.9013 20.1334 18.4502
240075.......................................... 21.3357 21.9160 24.4084 22.5903
240076.......................................... 22.3280 23.6159 26.8682 24.3772
240077.......................................... 20.3445 22.1509 18.9735 20.4406
240078.......................................... 25.1082 26.2576 27.5066 26.3275
240079.......................................... 18.8345 18.2929 20.6644 19.2023
240080.......................................... 25.5619 26.3071 27.8058 26.5849
240082.......................................... 18.7995 20.2018 21.4727 20.1735
240083.......................................... 21.0317 22.3484 24.4855 22.6030
240084.......................................... 21.7421 23.1951 23.9942 22.9738
240085.......................................... 20.9778 20.7535 17.4712 19.7663
240086.......................................... 18.1401 18.1497 17.7594 18.0222
240087.......................................... 21.3323 21.2116 20.1003 20.8883
240088.......................................... 23.1056 24.6260 25.5587 24.4549
240089.......................................... 21.1989 21.3949 23.4029 21.9959
240090.......................................... 19.2166 21.0856 22.6601 21.1189
240093.......................................... 20.2400 20.7138 22.3968 21.1802
240094.......................................... 22.0247 22.5923 24.4166 23.1169
240096.......................................... 21.0417 20.2992 23.8171 21.7632
240097.......................................... 27.9496 29.7597 31.8726 29.9039
240098.......................................... 24.2296 23.9626 * 24.0891
240099.......................................... 15.4964 18.8139 43.7548 21.0887
240100.......................................... 20.8325 24.1875 24.7500 23.2514
240101.......................................... 19.9837 22.1329 24.3455 22.2487
240102.......................................... 16.3659 15.5114 14.5842 15.5365
240103.......................................... 18.7510 21.0182 20.2325 19.9774
240104.......................................... 23.5351 25.1139 27.5745 25.4425
240106.......................................... 23.5005 23.9677 25.5890 24.4099
240107.......................................... 20.9004 21.2163 24.5581 22.1688
240108.......................................... 18.2427 17.6500 19.2516 18.3839
240109.......................................... 16.3216 15.1369 14.5891 15.2649
240110.......................................... 21.0277 21.7340 22.9718 21.9757
240111.......................................... 17.8617 19.9712 20.0499 19.2908
240112.......................................... 16.6244 17.2437 * 16.9303
240114.......................................... 17.3682 18.3415 21.7910 19.3128
240115.......................................... 23.8675 24.6529 26.8906 25.1535
240116.......................................... 18.3520 17.3460 19.2400 18.3173
240117.......................................... 17.9941 18.6677 19.7047 18.8229
240119.......................................... 21.8289 23.0230 23.4148 22.7820
240121.......................................... 22.2266 22.4858 24.5455 23.1566
240122.......................................... 21.2876 20.7795 23.5331 21.8695
240123.......................................... 18.3941 18.9494 20.0721 19.1239
240124.......................................... 20.4728 21.2023 23.5138 21.7551
240125.......................................... 14.9708 17.3846 * 16.1716
240127.......................................... 17.9724 16.4294 19.3859 17.7982
240128.......................................... 16.3608 17.5611 20.1960 17.9593
240129.......................................... 16.5209 17.7242 20.2001 18.1562
240130.......................................... 16.4271 17.7634 17.8752 17.3622
240132.......................................... 23.1452 24.5633 26.7031 24.8511
240133.......................................... 19.5293 20.8958 23.6068 21.3584
240135.......................................... 15.7015 15.6298 17.8575 16.3349
240137.......................................... 21.5073 21.6644 23.1752 22.1872
240138.......................................... 16.7332 19.1676 17.4235 17.7313
240139.......................................... 20.5496 21.0163 22.4472 21.2707
240141.......................................... 23.1009 23.6498 25.1597 24.0447
240142.......................................... 29.2238 24.0719 25.5197 26.0657
240143.......................................... 20.4266 20.7307 18.9442 20.0050
240144.......................................... 21.4469 23.1661 23.3501 22.6969
[[Page 27284]]
240145.......................................... 19.0689 17.6747 22.6062 19.4589
240146.......................................... 16.5412 17.3275 18.1744 17.4437
240148.......................................... 19.5204 19.5372 * 19.5281
240150.......................................... 20.8331 23.3857 * 21.8697
240152.......................................... 22.4744 24.1818 25.4031 24.1733
240153.......................................... 19.3336 18.6556 20.3880 19.4726
240154.......................................... 21.5052 21.5859 21.3809 21.4857
240155.......................................... 20.9385 23.6944 24.4892 23.0432
240157.......................................... 13.7309 20.0571 16.7563 16.8353
240160.......................................... 15.9014 16.4990 17.3072 16.5799
240161.......................................... 16.8809 18.0542 19.1144 18.0796
240162.......................................... 19.1542 19.3296 20.4807 19.6719
240163.......................................... 20.4760 22.2009 23.0778 21.9095
240166.......................................... 19.4131 19.4496 21.5002 20.1541
240169.......................................... 16.3958 * * 16.3959
240170.......................................... 20.3779 21.5994 22.4313 21.4955
240171.......................................... 18.5172 19.6732 20.5124 19.5729
240172.......................................... 20.8606 20.3699 20.9068 20.7077
240173.......................................... 18.5187 18.3183 20.6286 19.1672
240179.......................................... 20.4004 17.7557 19.8250 19.2836
240184.......................................... 16.8917 17.6979 19.7471 18.1054
240187.......................................... 21.2736 23.2471 24.9027 23.1511
240193.......................................... 18.4664 26.6381 23.6164 23.0709
240196.......................................... 25.3479 26.2793 27.3313 26.3610
240200.......................................... 14.9076 18.7517 18.8396 17.3476
240207.......................................... 25.2814 26.0927 27.4330 26.3128
240210.......................................... 24.5664 25.6060 26.6231 25.6397
240211.......................................... 30.6260 34.7849 32.8805 32.7909
240213.......................................... * * 27.4812 27.4811
250001.......................................... 19.2756 20.2019 20.9338 20.1232
250002.......................................... 18.6938 19.6081 21.6643 20.0536
250003.......................................... 16.7570 18.7331 19.3864 18.3353
250004.......................................... 18.3860 19.2913 20.9295 19.5583
250005.......................................... 12.5834 13.7341 11.3971 12.5195
250006.......................................... 17.5192 19.4531 20.3061 19.0833
250007.......................................... 19.7562 20.9757 21.2226 20.6508
250008.......................................... 15.8506 15.8096 16.4863 16.0657
250009.......................................... 17.7283 18.0463 19.7610 18.4932
250010.......................................... 14.6101 16.0233 17.6204 16.0381
250012.......................................... 16.7579 17.4032 15.6117 16.4987
250015.......................................... 11.7249 16.6522 19.3794 15.3452
250017.......................................... 20.5976 18.8850 19.0435 19.5747
250018.......................................... 13.1687 14.7291 16.8783 14.8458
250019.......................................... 18.0956 19.9070 22.9085 20.3396
250020.......................................... 16.2698 19.6575 19.1877 18.3910
250021.......................................... 10.5844 12.7242 15.8485 12.9174
250023.......................................... 12.3434 13.8210 14.7354 13.5480
250024.......................................... 12.9899 14.8394 12.1862 13.2855
250025.......................................... 20.3625 21.9075 21.2651 21.1983
250027.......................................... 14.5445 15.1790 17.5936 15.6987
250029.......................................... 16.0682 14.8216 14.8043 15.2287
250030.......................................... 26.6173 25.5089 27.2140 26.4270
250031.......................................... 18.3825 19.8779 21.7605 20.4551
250032.......................................... 17.5957 * * 17.5957
250033.......................................... 15.0941 16.9132 * 15.9970
250034.......................................... 17.0399 18.8231 20.3681 18.7749
250035.......................................... 16.8349 18.3861 17.1071 17.4370
250036.......................................... 16.1913 17.6247 17.0469 16.9644
250037.......................................... 12.7156 14.3994 16.6348 14.4707
250038.......................................... 17.7019 18.8434 16.8610 17.7868
250039.......................................... 15.1409 16.4502 16.8729 16.1389
250040.......................................... 18.3364 19.6513 20.8178 19.5733
250042.......................................... 17.6531 18.3858 19.4367 18.4780
[[Page 27285]]
250043.......................................... 16.6500 18.4025 17.7554 17.5544
250044.......................................... 16.7321 19.0321 20.3711 18.6909
250045.......................................... 21.8988 22.7225 25.3236 23.3569
250047.......................................... 14.7461 16.0109 * 15.2694
250048.......................................... 17.6649 19.4976 19.3636 18.8723
250049.......................................... 12.1635 12.8275 13.4396 12.7838
250050.......................................... 15.1159 16.0234 16.6723 15.9407
250051.......................................... 10.4900 10.1212 10.5027 10.3736
250057.......................................... 16.1838 16.6316 19.0571 17.2494
250058.......................................... 15.7197 16.2623 16.3813 16.1275
250059.......................................... 16.6494 17.9507 19.0813 17.8285
250060.......................................... 16.1804 12.6893 14.0155 14.2269
250061.......................................... 11.5108 12.0186 11.4573 11.6591
250063.......................................... 13.3092 15.0894 15.9383 14.6934
250065.......................................... 13.6904 15.0507 16.2010 14.9097
250066.......................................... 16.1742 17.2711 16.1044 16.5014
250067.......................................... 16.8522 18.3773 20.0430 18.4322
250068.......................................... 13.4127 13.2644 16.3759 14.2410
250069.......................................... 16.8980 18.5782 21.2111 18.7309
250071.......................................... 12.3488 13.1934 13.7055 13.0670
250072.......................................... 18.9487 21.0602 20.7704 20.1290
250077.......................................... 13.7404 13.9479 14.0318 13.8984
250078.......................................... 15.9739 17.4118 17.4212 16.9775
250079.......................................... 16.5835 16.1483 21.3505 18.0112
250081.......................................... 19.0358 18.1848 20.1214 19.0803
250082.......................................... 17.1427 17.3096 19.5962 18.0482
250083.......................................... 16.6065 16.3054 19.5217 17.6288
250084.......................................... 20.6429 21.0870 22.4632 21.3407
250085.......................................... 15.4477 16.7377 18.0100 16.7072
250088.......................................... 18.2736 19.3976 20.3019 19.3083
250089.......................................... 14.3027 15.0238 16.0202 15.0666
250093.......................................... 16.1506 16.8647 17.6906 16.8800
250094.......................................... 18.5063 18.9681 19.9288 19.0932
250095.......................................... 17.4217 18.4944 18.6616 18.1868
250096.......................................... 19.0584 19.3630 20.5923 19.6554
250097.......................................... 15.5741 16.3328 18.8398 16.9174
250098.......................................... 18.3874 18.8163 17.9562 18.4324
250099.......................................... 15.1265 15.9867 18.2504 16.5120
250100.......................................... 17.8688 19.7559 18.8877 18.8640
250101.......................................... 17.7194 17.6704 41.5335 17.7745
250102.......................................... 18.9348 19.8487 21.3213 20.0396
250104.......................................... 18.7651 19.0165 20.5035 19.4465
250105.......................................... 15.5133 16.1480 17.0135 16.2367
250107.......................................... 15.0737 16.5635 16.7104 16.0939
250109.......................................... 21.3867 24.5760 16.4965 20.5154
250112.......................................... 16.3640 16.6447 16.8696 16.6208
250117.......................................... 16.9787 15.9335 18.8863 17.1858
250119.......................................... 16.1218 16.5700 17.1373 16.5802
250120.......................................... 16.7182 18.1428 22.3897 18.8266
250122.......................................... 19.2990 19.8033 19.7966 19.6361
250123.......................................... 18.7863 22.1376 22.2184 21.1030
250124.......................................... 13.2490 14.4008 15.3772 14.3481
250125.......................................... 21.2660 21.9366 25.3415 22.8644
250126.......................................... 21.9101 19.0168 20.1117 20.3133
250128.......................................... 16.1418 15.9958 15.8352 15.9898
250131.......................................... 12.4557 11.2470 11.5396 11.7049
250134.......................................... 18.5142 21.4489 22.0310 20.5243
250136.......................................... 21.3497 20.0333 21.9977 21.1329
250138.......................................... 20.4550 19.3446 21.2489 20.3584
250141.......................................... 19.6692 21.6835 19.8982 20.4335
250145.......................................... 11.2120 11.2021 * 11.2080
250146.......................................... 14.7781 15.4061 16.9341 15.6577
250148.......................................... 19.4233 23.1459 * 21.1903
[[Page 27286]]
250149.......................................... 15.2318 15.7537 16.4228 15.8106
250150.......................................... 21.8599 * * 21.8600
250151.......................................... * * 20.4581 20.4581
260001.......................................... 20.1560 20.9620 22.6646 21.2406
260002.......................................... 21.6597 23.4259 24.6812 23.4142
260003.......................................... 15.4482 16.2023 16.5931 16.0798
260004.......................................... 13.7035 15.2735 16.4424 15.0947
260005.......................................... 23.9681 22.5860 24.3624 23.6476
260006.......................................... 20.0994 22.1692 24.1078 22.0536
260008.......................................... 16.8893 18.2114 15.9656 17.1196
260009.......................................... 18.2863 19.0654 20.1679 19.1754
260011.......................................... 19.5059 20.3279 21.1624 20.3470
260012.......................................... 17.1662 17.3810 17.7853 17.4521
260013.......................................... 16.1825 17.3772 18.4857 17.3402
260015.......................................... 17.8817 18.3849 21.7581 19.2237
260017.......................................... 16.9914 17.9796 20.8258 18.6436
260018.......................................... 12.5301 13.6120 14.3278 13.5417
260019.......................................... * 18.3629 * 18.3629
260020.......................................... 20.2241 21.0314 22.4643 21.2460
260021.......................................... 21.6237 23.3527 27.2478 23.9117
260022.......................................... 17.7772 18.7707 20.5417 18.9739
260023.......................................... 17.8649 18.5665 19.2256 18.5565
260024.......................................... 15.7815 15.6095 16.9515 16.1624
260025.......................................... 17.0965 18.2804 19.3535 18.2493
260027.......................................... 22.0362 23.1505 22.9973 22.7247
260029.......................................... 21.1858 20.1832 22.0390 21.1257
260030.......................................... 11.9215 12.8349 12.7803 12.5162
260031.......................................... 19.7249 22.5379 24.3626 22.0014
260032.......................................... 19.6728 20.3847 * 20.0208
260034.......................................... 20.4902 20.5439 21.6108 20.9281
260035.......................................... 13.0071 15.1611 15.0710 14.4258
260036.......................................... 18.8104 20.1242 19.4559 19.4803
260039.......................................... 14.6644 15.9689 13.9705 14.9145
260040.......................................... 18.0140 18.5132 19.7196 18.7876
260042.......................................... 18.7514 20.8821 * 19.9434
260044.......................................... 15.9206 16.7879 18.2413 17.0028
260047.......................................... 19.2247 20.2724 22.4013 20.5664
260048.......................................... 21.0602 22.4800 20.1127 21.0958
260050.......................................... 16.8520 17.8142 20.8510 18.4171
260052.......................................... 18.0914 19.1044 21.1297 19.4548
260053.......................................... 16.5166 17.4110 18.9606 17.6806
260054.......................................... 20.6242 23.0188 * 21.7799
260055.......................................... 15.4214 17.9547 18.8793 17.4012
260057.......................................... 19.7144 16.5704 15.8404 17.4526
260059.......................................... 17.0546 16.2074 17.2807 16.8654
260061.......................................... 15.7112 17.1343 18.7280 17.2320
260062.......................................... 21.3138 22.0091 25.1582 22.8328
260063.......................................... 18.8973 19.7231 21.1284 19.8962
260064.......................................... 17.8033 18.3749 17.5188 17.8922
260065.......................................... 20.0975 20.6671 22.0073 20.9514
260066.......................................... 15.3460 15.3139 * 15.3302
260067.......................................... 15.1837 14.5499 15.0354 14.9154
260068.......................................... 19.4240 20.7947 22.0951 20.7923
260070.......................................... 13.9510 18.7384 11.2251 14.4396
260073.......................................... 15.9182 16.9496 17.9000 16.9733
260074.......................................... 19.8915 20.4033 18.7639 19.6422
260077.......................................... 19.4482 20.5830 21.6257 20.5610
260078.......................................... 14.9463 16.0586 16.9217 15.9818
260079.......................................... 16.1453 16.4816 17.3871 16.6399
260080.......................................... 14.6832 13.1617 13.6815 13.7659
260081.......................................... 20.3053 20.2471 22.4329 21.0085
260082.......................................... 15.9858 18.2853 18.7527 17.6725
260085.......................................... 20.7051 21.5137 22.7394 21.6591
[[Page 27287]]
260086.......................................... 15.2927 16.7579 17.2049 16.4038
260091.......................................... 21.5464 22.0772 23.8702 22.5033
260094.......................................... 18.5395 19.7308 20.0014 19.4593
260095.......................................... 20.7292 21.6999 22.8156 21.7294
260096.......................................... 22.5972 22.8259 23.5009 22.9961
260097.......................................... 19.0632 18.6965 19.6203 19.1454
260100.......................................... 16.6523 16.5439 16.6168 16.6045
260102.......................................... 20.6361 21.2133 24.1041 22.0613
260103.......................................... 19.7146 19.9144 * 19.8156
260104.......................................... 20.3176 21.6624 22.1805 21.4297
260105.......................................... 24.8181 22.8005 24.6572 24.0540
260107.......................................... 20.4269 22.5214 23.1564 21.9109
260108.......................................... 20.0034 20.9029 22.4665 21.1879
260109.......................................... 14.8181 15.9724 16.7734 15.8460
260110.......................................... 18.3227 19.5633 * 18.9410
260113.......................................... 16.2223 16.1346 16.3440 16.2356
260115.......................................... 17.4698 19.3873 20.1706 18.9712
260116.......................................... 14.9812 16.0187 16.9807 15.9921
260119.......................................... 17.2942 18.0725 18.7958 18.0259
260120.......................................... 16.4904 17.6811 18.7651 17.6553
260122.......................................... 16.0931 16.3700 16.1637 16.2077
260123.......................................... 14.6822 15.2926 17.7996 15.9122
260127.......................................... 18.4026 18.1342 19.7946 18.7879
260128.......................................... 12.6414 13.2942 * 12.9660
260131.......................................... 18.4154 18.0395 * 18.2242
260134.......................................... 17.5127 17.1341 18.4511 17.6303
260137.......................................... 19.4697 19.5976 20.7638 19.9765
260138.......................................... 23.2364 23.6502 25.4515 24.0813
260141.......................................... 19.1893 19.0444 21.1469 19.7400
260142.......................................... 17.3084 18.2023 18.6412 18.0732
260143.......................................... 13.9040 15.4688 16.0479 15.1578
260147.......................................... 14.7769 15.8522 16.1172 15.5706
260148.......................................... 11.3524 12.6651 15.1916 13.0421
260158.......................................... 12.7699 13.9790 15.0140 13.9277
260159.......................................... 19.7951 20.9636 22.5169 20.9886
260160.......................................... 16.5792 18.4007 18.8723 17.9546
260162.......................................... 21.4099 20.7331 22.3038 21.5147
260163.......................................... 15.8593 16.8300 18.1311 16.9540
260164.......................................... 15.1211 16.3874 16.9403 16.1072
260166.......................................... 21.1224 22.4071 22.8409 22.1650
260172.......................................... 16.0772 16.4854 17.1504 16.5822
260173.......................................... 14.2090 15.5733 17.0117 15.5933
260175.......................................... 17.5625 18.3632 19.7939 18.5994
260176.......................................... 21.6044 23.2414 25.7802 23.6435
260177.......................................... 21.9014 22.9112 24.0679 23.0194
260178.......................................... 20.2796 20.8189 21.2846 20.7937
260179.......................................... 22.7185 21.4470 23.1610 22.4301
260180.......................................... 18.9881 19.5983 21.4226 19.9994
260183.......................................... 21.3175 23.7057 24.2330 23.0675
260186.......................................... 19.6026 21.0675 21.6620 20.8448
260188.......................................... 22.5060 23.7475 * 23.0915
260189.......................................... 16.4233 * * 16.4232
260190.......................................... 19.3419 21.6994 24.5014 21.8167
260191.......................................... 18.1604 19.6784 20.8030 19.6078
260193.......................................... 20.2577 22.2030 22.9556 21.8741
260195.......................................... 19.7068 * 20.0889 19.9145
260197.......................................... 20.5453 * * 20.5453
260198.......................................... 19.7552 21.7926 25.3390 22.1557
260200.......................................... 20.6888 21.7031 21.9868 21.5369
260207.......................................... * * 18.5247 18.5247
260208.......................................... * * 30.6259 30.6261
270002.......................................... 19.2387 19.0221 19.7588 19.3381
270003.......................................... 22.5019 20.7277 23.0396 22.0300
[[Page 27288]]
270004.......................................... 19.4834 20.1821 21.0202 20.3215
270006.......................................... 17.0715 15.1006 18.2057 16.6954
270007.......................................... 13.8824 15.5780 12.8055 13.9488
270009.......................................... 20.8238 20.7031 21.5655 21.0425
270011.......................................... 21.1653 21.8086 21.4031 21.4583
270012.......................................... 19.7878 20.7913 21.7634 20.7748
270014.......................................... 19.9859 20.4321 20.3456 20.2664
270016.......................................... 18.6149 17.9984 21.0198 19.0996
270017.......................................... 20.0152 22.1046 23.2320 21.7798
270019.......................................... 15.4128 18.5111 19.6625 17.8208
270021.......................................... 16.9457 18.0515 21.1624 18.5631
270023.......................................... 22.7181 22.7162 23.7486 23.1141
270026.......................................... 18.0568 20.1673 19.9669 19.4168
270027.......................................... 17.2091 17.2005 17.4500 17.3066
270028.......................................... 19.1177 19.6212 20.4877 19.7233
270029.......................................... 17.3710 18.2097 17.9731 17.8617
270032.......................................... 18.7811 19.3937 20.1801 19.4478
270033.......................................... 18.4876 20.7060 25.0179 21.1320
270035.......................................... 16.4302 17.9822 19.1036 17.8465
270036.......................................... 16.8552 16.1031 18.8787 17.3089
270039.......................................... 19.6796 20.3800 19.6505 19.8960
270040.......................................... 20.1242 20.1887 20.7239 20.3415
270041.......................................... 25.8153 * * 25.8151
270044.......................................... 17.5137 19.2939 18.6533 18.4293
270048.......................................... 18.0666 17.4506 18.1269 17.8742
270049.......................................... 22.2540 22.0263 22.9524 22.4171
270050.......................................... 19.9356 19.6317 21.0901 20.2259
270051.......................................... 20.1950 20.0386 22.2580 20.8285
270052.......................................... 14.7009 17.1932 13.3673 15.1086
270057.......................................... 20.6714 20.1507 21.9997 20.9799
270058.......................................... 16.1412 18.4780 17.7905 17.3778
270059.......................................... 19.1808 16.9303 17.4365 17.7389
270060.......................................... 20.4148 21.3776 18.3386 20.1127
270063.......................................... 15.1049 16.4553 19.7307 16.9992
270073.......................................... 16.1937 16.6083 15.6319 16.1437
270079.......................................... 16.7048 19.5493 * 18.0578
270080.......................................... 15.0705 16.6010 20.6145 17.2851
270081.......................................... 16.7389 18.0543 15.6834 16.8629
270082.......................................... 23.1245 23.3209 21.0150 22.5579
270083.......................................... 17.8554 16.8420 19.1381 17.8988
270084.......................................... 16.2958 15.7062 19.6105 17.1115
280001.......................................... 18.1831 18.7137 18.9480 18.6168
280003.......................................... 23.0213 23.6058 26.0937 24.2580
280005.......................................... 23.6949 22.8981 23.9753 23.5311
280009.......................................... 20.9643 23.2300 23.8046 22.6996
280010.......................................... 20.0462 22.0137 23.8324 22.0012
280011.......................................... 15.9614 16.2281 * 16.0965
280013.......................................... 22.5163 24.0852 23.4920 23.3630
280014.......................................... 16.8368 16.7109 * 16.7707
280015.......................................... 16.6939 18.0207 19.1420 17.9018
280017.......................................... 13.9939 16.9884 15.8099 15.6454
280018.......................................... 15.4496 16.6439 17.0625 16.3884
280020.......................................... 21.2467 21.9587 23.4658 22.2728
280021.......................................... 17.6345 19.1263 21.5215 19.4605
280022.......................................... 16.8184 15.3785 * 16.0620
280023.......................................... 22.3433 21.5761 19.6265 21.1633
280024.......................................... 15.0380 15.8747 18.1544 16.1976
280025.......................................... 21.4764 22.2214 * 21.8488
280026.......................................... 16.5851 18.7258 * 17.6496
280028.......................................... 18.0793 19.1080 * 18.5723
280029.......................................... 24.4359 17.1351 * 20.5379
280030.......................................... 24.7723 26.3542 26.2806 25.7410
280031.......................................... 9.6321 9.6951 14.3030 11.3451
[[Page 27289]]
280032.......................................... 19.1191 20.5246 21.5150 20.4101
280033.......................................... 17.4745 17.9841 * 17.7291
280035.......................................... 16.6872 18.6089 * 17.5717
280037.......................................... 17.1064 14.8049 * 15.9325
280038.......................................... 18.2503 18.9305 * 18.5950
280039.......................................... 16.1587 17.0153 18.3375 17.1382
280040.......................................... 20.9896 21.5426 23.7407 22.1421
280041.......................................... 16.5503 16.6889 14.4252 15.9446
280042.......................................... 16.6239 16.4684 * 16.5457
280043.......................................... 17.5937 16.8186 * 17.2004
280045.......................................... 15.7630 17.7408 15.2407 16.1990
280046.......................................... 17.3214 17.9752 17.5600 17.6110
280047.......................................... 17.4735 21.3143 19.5815 19.4044
280048.......................................... 15.8100 17.9319 18.6882 17.5211
280049.......................................... 18.4365 19.4589 20.1665 19.3973
280050.......................................... 20.0379 * * 20.0378
280051.......................................... 17.1942 19.6206 * 18.3037
280052.......................................... 14.1201 14.9903 15.4041 14.8495
280054.......................................... 18.7575 19.4049 23.1191 20.4732
280055.......................................... 13.8129 14.2046 15.2426 14.4185
280056.......................................... 15.6135 15.6442 * 15.6285
280057.......................................... 20.0686 21.4754 22.5480 21.4261
280058.......................................... 21.4868 22.8105 17.7506 20.7067
280060.......................................... 20.7022 22.4677 22.7755 21.9926
280061.......................................... 18.6370 20.2066 21.2901 20.0793
280062.......................................... 15.6018 16.1708 17.2218 16.3363
280064.......................................... 16.8330 18.2196 * 17.5260
280065.......................................... 20.7370 21.6999 23.8128 22.1199
280066.......................................... 11.7207 12.2225 10.6969 11.4854
280068.......................................... 10.5987 10.5103 11.6283 10.9064
280070.......................................... 22.6201 18.7211 * 20.3601
280073.......................................... 17.7698 18.3496 * 18.0596
280074.......................................... 17.3143 13.6025 18.6064 16.1704
280075.......................................... 13.2230 13.3154 18.0464 14.6143
280076.......................................... 16.7488 16.1939 18.2504 17.1042
280077.......................................... 20.0148 21.1883 22.7244 21.3192
280079.......................................... 16.6117 17.1519 17.7968 17.1767
280080.......................................... 16.9487 16.1902 * 16.5447
280081.......................................... 20.9606 23.3805 25.2237 23.2090
280082.......................................... 14.6173 15.4420 15.2322 15.0937
280083.......................................... 21.5336 20.8995 * 21.2308
280084.......................................... 13.6536 13.2158 14.3005 13.7432
280085.......................................... 20.4825 20.8532 * 20.6808
280089.......................................... 18.9567 19.9003 20.7438 19.8619
280090.......................................... 15.1274 * * 15.1274
280091.......................................... 16.1866 16.3456 * 16.2669
280092.......................................... 14.7912 13.3032 16.5893 14.8029
280094.......................................... 16.3474 16.9180 18.5068 17.3100
280097.......................................... 13.8223 14.1870 * 14.0071
280098.......................................... 12.5875 12.4995 * 12.5457
280101.......................................... 16.9973 10.5153 * 12.9714
280104.......................................... 16.2167 15.5949 14.8257 15.4728
280105.......................................... 21.0735 23.7103 26.1112 23.6557
280106.......................................... 16.0679 16.3564 * 16.2080
280107.......................................... 14.4679 * * 14.4678
280108.......................................... 17.1961 18.5134 20.9016 18.8959
280109.......................................... 12.4408 * * 12.4408
280110.......................................... 14.2136 13.0278 * 13.5867
280111.......................................... 19.6283 19.7688 20.7398 20.0680
280114.......................................... 17.3076 17.1154 * 17.2096
280115.......................................... 18.1480 18.3464 19.7797 18.7967
280117.......................................... 18.8279 20.3819 20.5464 19.9214
280118.......................................... 18.6524 17.8891 19.3465 18.6584
[[Page 27290]]
280123.......................................... 11.8582 23.6682 24.3539 18.1396
280125.......................................... 16.3944 17.2718 19.7871 17.7870
280126.......................................... * * 35.5895 35.5900
290001.......................................... 22.7450 24.3681 25.9590 24.4242
290002.......................................... 16.5419 16.7948 16.8363 16.7281
290003.......................................... 24.2175 25.4303 27.2718 25.6701
290005.......................................... 21.9814 22.7804 24.6877 23.2224
290006.......................................... 22.4063 22.4832 24.2211 23.1190
290007.......................................... 30.9075 34.9911 33.7208 33.2446
290008.......................................... 24.1255 26.9216 27.0115 25.8955
290009.......................................... 23.9373 24.8816 26.9020 25.2711
290010.......................................... 16.4476 20.8387 25.4598 20.8166
290011.......................................... 21.1234 19.7410 21.7835 20.8924
290012.......................................... 25.0430 25.5647 25.4791 25.3714
290013.......................................... 15.7932 20.2914 21.1487 18.7341
290014.......................................... 18.7829 20.2762 25.6155 21.5373
290015.......................................... 19.4504 20.2336 22.3653 20.5695
290016.......................................... 23.8656 21.8030 17.9615 20.7686
290019.......................................... 22.2045 22.5584 25.1684 23.3359
290020.......................................... 21.2380 19.5039 24.2374 21.4763
290021.......................................... 22.9488 24.1397 26.0430 24.3771
290022.......................................... 25.5011 25.3914 27.5364 26.1224
290027.......................................... 13.3769 13.1463 * 13.2560
290032.......................................... 23.9504 26.9846 27.1791 26.2060
290036.......................................... 12.9074 * * 12.9073
290038.......................................... 27.7030 26.0836 30.0397 27.9572
290039.......................................... 25.5024 26.6283 28.5925 26.9886
290041.......................................... 25.9905 27.7740 28.6294 27.7224
290042.......................................... 18.7527 18.7669 * 18.7611
290043.......................................... 27.9053 * * 27.9053
290045.......................................... * * 26.4843 26.4843
300001.......................................... 23.8567 25.7142 26.8650 25.5285
300003.......................................... 24.1297 25.3252 26.7859 25.4284
300005.......................................... 22.2858 22.3258 22.8163 22.4895
300006.......................................... 18.9745 22.2642 22.0188 21.0625
300007.......................................... 20.6325 21.3633 23.6919 21.9920
300008.......................................... 19.6149 20.9207 23.1085 21.2699
300009.......................................... 20.0938 20.1486 22.7539 20.9686
300010.......................................... 20.2130 21.0316 24.6296 21.8421
300011.......................................... 23.0279 23.8390 25.0979 24.0124
300012.......................................... 24.5619 25.8581 26.1792 25.6027
300013.......................................... 20.1669 20.0269 21.3396 20.4889
300014.......................................... 20.1774 21.6705 23.7144 21.9343
300015.......................................... 19.6627 22.8966 24.4870 22.4848
300016.......................................... 17.8148 15.1311 19.6529 17.5958
300017.......................................... 22.7191 23.9651 26.0604 24.3780
300018.......................................... 21.6385 22.8379 25.7851 23.5726
300019.......................................... 19.6728 20.5801 23.8076 21.3279
300020.......................................... 22.6627 23.0806 24.8189 23.5472
300021.......................................... 19.3101 20.2585 19.0918 19.5659
300022.......................................... 19.1875 20.1209 22.3918 20.6206
300023.......................................... 22.7649 22.1896 24.9992 23.3536
300024.......................................... 21.5842 22.2235 22.4882 22.1265
300028.......................................... 20.0778 21.4207 21.7975 21.0588
300029.......................................... 22.6013 23.8415 24.5772 23.7645
300033.......................................... 17.1632 17.4836 20.4502 18.3308
300034.......................................... 24.4975 25.2355 26.9093 25.5558
310001.......................................... 27.4730 31.1568 29.6344 29.4408
310002.......................................... 27.9728 28.7786 33.9058 30.2896
310003.......................................... 27.5624 29.3522 31.1739 29.3684
310005.......................................... 22.9712 23.9477 25.6120 24.1650
310006.......................................... 22.0894 24.1538 25.9000 24.0238
310008.......................................... 24.7618 26.4989 28.0970 26.4414
[[Page 27291]]
310009.......................................... 21.7094 23.2420 24.6353 23.1866
310010.......................................... 23.1060 24.5471 26.5921 24.8321
310011.......................................... 24.2885 25.4900 26.1586 25.3131
310012.......................................... 26.6772 28.1367 31.1705 28.7006
310013.......................................... 22.5603 23.2424 25.0951 23.6575
310014.......................................... 23.1956 31.0834 29.1931 27.3029
310015.......................................... 27.9684 29.1340 29.3681 28.8346
310016.......................................... 24.5206 26.0738 25.7368 25.3848
310017.......................................... 24.5976 25.1634 25.2577 25.0191
310018.......................................... 22.4779 24.1428 25.9108 24.1664
310019.......................................... 24.9914 28.5952 26.4492 26.6564
310020.......................................... 24.4152 25.0803 25.0147 24.8332
310021.......................................... 25.4393 27.8958 29.2267 27.4313
310022.......................................... 20.8258 23.3412 26.7487 23.5627
310024.......................................... 24.9521 27.0459 26.9499 26.3252
310025.......................................... 24.1812 25.5227 26.8719 25.4915
310026.......................................... 22.1997 23.2895 24.6697 23.2693
310027.......................................... 22.5696 24.4437 22.1935 23.0737
310028.......................................... 23.9428 26.1931 25.7246 25.2908
310029.......................................... 23.6610 24.4290 25.9606 24.6455
310031.......................................... 26.6831 26.7174 29.5581 27.5915
310032.......................................... 24.7404 24.9133 25.7088 25.2148
310034.......................................... 24.1150 24.8567 26.4468 25.1211
310036.......................................... 21.7187 23.0320 * 22.3716
310037.......................................... 28.1289 28.7738 29.9732 28.9646
310038.......................................... 28.4893 28.1756 32.3865 29.6794
310039.......................................... 22.7317 23.6605 24.6045 23.6772
310040.......................................... 26.3573 26.5769 27.2418 26.7140
310041.......................................... 23.5559 23.8857 26.8145 24.8018
310042.......................................... 24.7678 24.9702 26.9695 25.5501
310043.......................................... 21.6128 24.0238 * 22.6515
310044.......................................... 23.1549 23.1489 25.1618 23.8298
310045.......................................... 28.9274 29.4877 31.7376 30.0182
310047.......................................... 26.1921 25.9777 26.0860 26.0841
310048.......................................... 25.2870 23.4189 28.4136 25.6301
310049.......................................... 27.0842 25.6732 26.3666 26.3559
310050.......................................... 24.7988 23.7735 25.3772 24.6345
310051.......................................... 27.5378 28.6248 28.3783 28.1725
310052.......................................... 23.3973 24.9773 26.8158 24.9554
310054.......................................... 27.7376 27.6290 27.2303 27.5237
310057.......................................... 22.2572 22.2630 26.3903 23.6641
310058.......................................... 26.3765 25.3983 25.6526 25.8266
310060.......................................... 20.0997 21.4455 22.1914 21.1757
310061.......................................... 33.9582 23.4283 24.9678 26.7631
310063.......................................... 22.1080 21.2619 22.9871 22.1071
310064.......................................... 25.4822 25.9350 27.8388 26.4138
310067.......................................... 23.9278 24.1943 26.3624 24.7328
310069.......................................... 24.2329 25.3464 25.7690 25.1083
310070.......................................... 28.2220 29.5101 30.1917 29.3042
310072.......................................... 22.5611 24.4480 25.3145 24.0886
310073.......................................... 26.2937 26.7954 28.7528 27.2829
310074.......................................... 22.3588 24.2009 27.6789 24.7835
310075.......................................... 24.4788 23.9771 24.9752 24.4724
310076.......................................... 27.9918 29.6667 32.5424 30.0825
310077.......................................... 26.1251 26.7092 28.7352 27.1831
310078.......................................... 24.0587 24.5862 24.7606 24.4553
310081.......................................... 22.4086 23.3310 24.6557 23.4816
310083.......................................... 24.8204 25.0191 25.2465 25.0205
310084.......................................... 24.6049 25.4946 27.3680 25.8446
310086.......................................... 23.1719 23.4966 25.2725 23.9596
310087.......................................... 21.1215 20.6847 * 20.9048
310088.......................................... 23.1722 23.0610 23.7846 23.3408
310090.......................................... 24.8986 23.6661 25.3640 24.6461
[[Page 27292]]
310091.......................................... 23.2969 24.5357 25.6405 24.4610
310092.......................................... 21.6964 22.9721 23.2226 22.6239
310093.......................................... 23.7251 23.9404 24.6942 24.1032
310096.......................................... 24.5759 26.6588 28.4705 26.4515
310105.......................................... 26.2537 28.1317 28.7333 27.6263
310108.......................................... 23.8308 25.1368 24.4096 24.4558
310110.......................................... 23.2146 23.3461 26.4175 24.4668
310111.......................................... 22.1151 23.3646 26.2496 23.9377
310112.......................................... 24.7914 24.2999 27.8796 25.6804
310113.......................................... 23.1961 24.2708 25.9143 24.5219
310115.......................................... 21.1645 23.5148 24.5413 23.0976
310116.......................................... 23.6366 24.2696 25.1189 24.3065
310118.......................................... 26.1315 26.8760 28.0517 26.9540
310119.......................................... 32.7858 29.1045 33.2731 31.6276
310120.......................................... 23.3200 22.6526 24.7079 23.4981
320001.......................................... 20.6225 21.5564 23.0290 21.8122
320002.......................................... 23.0983 25.5144 26.4847 25.1115
320003.......................................... 16.4642 16.4961 20.7939 17.8265
320004.......................................... 19.6642 21.3681 19.4799 20.2196
320005.......................................... 21.0411 22.4178 22.1677 21.9174
320006.......................................... 20.3863 19.8672 21.1222 20.4529
320009.......................................... 19.3500 20.3783 21.5870 20.3252
320011.......................................... 18.5222 19.1476 20.7713 19.4939
320012.......................................... 17.1764 17.1317 * 17.1558
320013.......................................... 24.5543 25.5403 19.4487 22.2842
320014.......................................... 16.8412 22.9026 19.5032 19.7029
320016.......................................... 18.8519 18.8763 19.9200 19.2582
320017.......................................... 19.4498 20.4390 22.5460 20.8081
320018.......................................... 19.2336 20.3141 20.9400 20.1778
320019.......................................... 26.9637 25.1210 26.6900 26.3394
320021.......................................... 19.1265 20.0089 21.0913 20.0920
320022.......................................... 18.0606 20.9797 20.7919 20.0415
320023.......................................... 17.8419 * * 17.8418
320030.......................................... 18.6859 18.1556 16.8696 17.8853
320031.......................................... 25.1715 18.2244 19.0519 20.5648
320032.......................................... 20.6871 21.4815 21.2528 21.1396
320033.......................................... 21.0621 21.9804 24.2703 22.4984
320035.......................................... 15.0612 17.8058 * 16.5303
320037.......................................... 17.8280 17.6724 19.6466 18.4044
320038.......................................... 22.2664 23.1987 19.2962 21.6253
320046.......................................... 18.9607 19.4732 21.5914 20.0169
320048.......................................... 16.8769 * 31.6800 24.0471
320063.......................................... 17.9089 18.5600 20.4936 18.8302
320065.......................................... 18.6525 22.5428 19.9012 20.1608
320067.......................................... 15.3228 16.8015 17.7799 16.4113
320068.......................................... 18.5103 15.6864 15.7757 16.5793
320069.......................................... 14.4212 15.7350 18.5375 16.2248
320074.......................................... 20.2290 22.3403 28.3085 22.7142
320079.......................................... 19.8555 20.2473 21.9090 20.6661
320083.......................................... * * 25.7539 25.7539
330001.......................................... 27.3996 28.6214 30.7042 28.9537
330002.......................................... 26.9341 27.1811 28.2184 27.4257
330003.......................................... 18.9211 19.3972 20.6509 20.4183
330004.......................................... 20.9501 22.5082 24.3703 22.6203
330005.......................................... 22.1957 22.6137 24.3474 23.0406
330006.......................................... 25.8006 26.2970 28.3904 26.7950
330008.......................................... 19.2341 19.6770 20.6816 19.8702
330009.......................................... 31.3435 30.9087 33.3605 31.8514
330010.......................................... 16.6508 17.8935 19.8211 18.0647
330011.......................................... 18.6748 18.7995 19.8035 19.0860
330013.......................................... 19.6269 19.0995 20.9282 19.8689
330014.......................................... 36.8669 32.4496 31.9524 33.5779
330016.......................................... 16.8016 18.7194 18.1603 17.8636
[[Page 27293]]
330019.......................................... 33.5369 31.5927 31.9042 32.2626
330020.......................................... 1142 16.6952 16.8234 16.1733
330023.......................................... 25.6512 26.6997 29.4353 27.3255
330024.......................................... 37.3316 35.7485 35.3598 36.0893
330025.......................................... 16.8687 17.6169 18.7663 17.7638
330027.......................................... 35.5255 35.1046 34.1273 34.9301
330028.......................................... 29.5294 31.7699 31.2424 30.9471
330029.......................................... 17.0016 19.4377 18.4354 18.2976
330030.......................................... 19.1085 18.0866 28.7083 22.0491
330033.......................................... 17.4444 19.5836 18.4160 18.4656
330034.......................................... 27.7738 38.2451 * 31.2246
330036.......................................... 25.2820 25.5888 27.0970 25.9905
330037.......................................... 16.4866 18.3260 18.3557 17.7256
330038.......................................... 17.3429 16.2997 * 16.8497
330041.......................................... 31.4871 29.5305 34.5461 31.7315
330043.......................................... 27.4661 28.9622 31.7873 29.4079
330044.......................................... 19.5219 19.9808 22.0465 20.8006
330045.......................................... 27.9919 28.5267 30.9046 29.1458
330046.......................................... 35.2703 38.1184 41.6759 38.2919
330047.......................................... 18.5536 19.5561 20.1646 19.4202
330048.......................................... 19.1093 19.6129 * 19.3678
330049.......................................... 20.5731 22.1523 24.0154 22.2469
330053.......................................... 17.8082 17.9161 18.1728 17.9636
330055.......................................... 32.8910 34.2159 34.9709 34.0397
330056.......................................... 30.0945 29.8377 32.0982 30.6226
330057.......................................... 19.3643 20.0995 20.5575 20.0172
330058.......................................... 17.7672 18.1007 19.1379 18.3260
330059.......................................... 34.2426 35.0121 36.4176 35.2563
330061.......................................... 25.4082 26.8580 28.6136 26.9092
330062.......................................... 18.1318 18.4662 20.0222 18.7978
330064.......................................... 33.6447 35.1422 36.0976 34.9476
330065.......................................... 19.9305 20.1615 20.5958 20.2322
330066.......................................... 18.8707 19.3644 20.9990 19.7359
330067.......................................... 22.1065 23.6836 24.8927 23.5465
330072.......................................... 30.4171 30.3737 32.9665 31.2232
330073.......................................... 16.4518 16.5166 18.4162 17.3766
330074.......................................... 17.7308 18.9326 21.5724 19.3819
330075.......................................... 17.6385 19.2938 19.9781 18.9556
330078.......................................... 18.7884 18.0362 20.7304 19.1607
330079.......................................... 18.7622 18.9398 21.1153 19.6188
330080.......................................... 31.4424 34.6880 29.5529 31.9593
330084.......................................... 19.3216 19.0261 19.2135 19.1805
330085.......................................... 20.6203 20.9332 21.8271 21.1349
330086.......................................... 23.6496 26.2979 27.1585 25.5888
330088.......................................... 25.7940 26.7583 29.5181 27.3384
330090.......................................... 19.2112 20.1344 20.9327 20.1124
330091.......................................... 19.7776 21.6004 22.9396 21.4093
330092.......................................... 13.3723 17.2083 17.7246 16.0609
330094.......................................... 18.1582 18.8941 20.7039 19.2157
330095.......................................... 21.1096 21.1809 28.8428 22.1947
330096.......................................... 18.5149 20.0370 21.1648 19.9256
330097.......................................... 16.4433 16.1945 18.5608 17.0345
330100.......................................... 29.0916 28.9956 31.5775 29.8728
330101.......................................... 31.5914 35.3618 37.9069 34.7542
330102.......................................... 19.0058 21.0057 23.5253 21.0029
330103.......................................... 16.8110 17.3511 17.9017 17.3639
330104.......................................... 31.2074 31.9746 * 31.5864
330106.......................................... 35.3775 36.2526 38.4384 36.6836
330107.......................................... 27.7797 28.9225 29.7378 29.5391
330108.......................................... 18.0786 18.5849 20.2536 18.9350
330111.......................................... 15.9321 13.3352 17.7020 15.4904
330114.......................................... 17.0581 19.1162 19.2566 18.4674
330115.......................................... 17.4684 18.5911 18.5544 18.2257
[[Page 27294]]
330116.......................................... 14.9610 16.8567 17.0561 16.2974
330119.......................................... 33.1179 33.5653 34.6591 33.7652
330121.......................................... 16.3385 17.1869 17.9757 17.1336
330122.......................................... 20.2417 23.0384 25.6500 22.9753
330125.......................................... 19.7638 20.5922 21.5769 20.6209
330126.......................................... 23.8957 25.1175 27.5394 25.5273
330127.......................................... 30.7356 40.0112 30.6030 33.9644
330128.......................................... 30.8242 34.3468 33.5504 32.9063
330132.......................................... 14.3673 14.8704 16.0311 15.1074
330133.......................................... 35.3576 37.5192 35.9692 35.9945
330135.......................................... 22.2670 23.5662 25.1802 23.5883
330136.......................................... 20.1043 20.4124 21.2943 20.6129
330140.......................................... 19.3615 21.1841 21.1787 20.5922
330141.......................................... 26.7096 27.5960 29.3037 27.9129
330144.......................................... 16.2517 17.1513 17.3920 16.9610
330148.......................................... 16.2782 16.7251 17.6560 16.8727
330151.......................................... 15.7594 15.2233 16.1354 15.7000
330152.......................................... 30.8314 33.5587 32.9336 32.8160
330153.......................................... 18.1776 19.4417 22.0179 21.5648
330157.......................................... 22.3804 23.1743 23.5522 23.0369
330158.......................................... 27.1228 29.3163 32.3534 29.4900
330159.......................................... 19.4998 20.2753 22.7512 20.8227
330160.......................................... 29.5885 30.7893 32.1266 30.7976
330162.......................................... 27.6010 27.9705 29.4475 28.3208
330163.......................................... 20.7456 21.4143 21.1517 21.0818
330164.......................................... 20.9003 22.0699 23.9635 23.6195
330166.......................................... 15.4420 17.0637 18.4262 17.0093
330167.......................................... 30.2346 32.0541 30.7301 30.9496
330169.......................................... 35.4794 36.3690 36.2725 36.0426
330171.......................................... 24.8035 25.1567 25.9946 25.3030
330175.......................................... 18.3116 18.8701 20.4056 19.1653
330177.......................................... 16.3704 16.6059 19.0005 17.2818
330179.......................................... 13.8953 16.0113 15.0665 14.9370
330180.......................................... 17.9877 19.2670 19.8951 19.0453
330181.......................................... 33.0908 34.6065 36.8062 34.8035
330182.......................................... 33.6531 33.3363 35.0496 34.0319
330183.......................................... 20.6164 20.3520 * 20.4865
330184.......................................... 31.3706 28.4726 31.1286 30.9549
330185.......................................... 26.8612 27.8894 28.8893 27.8982
330188.......................................... 18.8000 20.2849 21.0098 20.0662
330189.......................................... 18.4498 23.5589 19.0726 20.2279
330191.......................................... 19.0348 19.5623 20.8876 19.8341
330193.......................................... 30.2260 32.5496 36.2427 32.8255
330194.......................................... 35.2036 35.6486 38.3174 36.4467
330195.......................................... 34.8966 34.4689 36.4249 35.2744
330196.......................................... 30.5799 28.9488 28.1590 29.2904
330197.......................................... 18.3527 19.2237 20.8386 19.4333
330198.......................................... 24.8590 25.6669 25.3622 25.3000
330199.......................................... 30.5409 28.0374 30.2655 29.6011
330201.......................................... 28.7861 30.0524 29.3745 29.3679
330202.......................................... 31.2575 35.4943 41.7560 36.1208
330203.......................................... 25.0345 25.9211 24.7422 25.2170
330204.......................................... 32.2005 31.1366 32.4850 31.9448
330205.......................................... 22.3490 24.9040 28.7587 25.2768
330208.......................................... 26.6682 27.3170 30.6158 28.1551
330209.......................................... 25.1281 27.0257 27.7071 26.6630
330211.......................................... 19.5405 20.0006 20.8224 20.1312
330212.......................................... 24.7681 24.8554 24.9434 24.8488
330213.......................................... 19.6796 20.1166 20.7889 20.1990
330214.......................................... 32.4292 32.3130 31.1205 31.9124
330215.......................................... 17.9863 19.0726 19.9226 18.9889
330218.......................................... 21.1890 21.4747 20.6012 21.0785
330219.......................................... 23.4310 25.1792 28.6712 25.6596
[[Page 27295]]
330221.......................................... 33.3796 32.5044 34.9345 33.6092
330222.......................................... 18.5571 19.3148 23.5491 20.4196
330223.......................................... 17.8306 19.1604 18.8253 18.6087
330224.......................................... 20.4309 20.5881 22.5695 21.2048
330225.......................................... 27.0379 28.0523 29.1744 28.0410
330226.......................................... 23.1859 21.6368 20.6413 21.6149
330229.......................................... 17.5326 18.2554 18.5590 18.1157
330230.......................................... 29.6283 30.6937 32.5997 30.9389
330231.......................................... 32.7200 32.4163 31.0944 32.0731
330232.......................................... 19.1787 20.0924 21.1277 20.1536
330233.......................................... 44.1265 43.1186 39.5133 42.2764
330234.......................................... 35.0720 35.8327 37.7135 36.1847
330235.......................................... 19.5880 20.1255 21.4643 20.3704
330236.......................................... 31.3463 32.1246 31.8491 31.7633
330238.......................................... 17.3976 17.8867 18.3846 17.8977
330239.......................................... 18.5079 18.9953 19.7561 19.0658
330240.......................................... 30.7321 35.6576 35.8530 33.9196
330241.......................................... 23.8638 24.7545 26.7598 25.1593
330242.......................................... 27.6384 28.3561 30.5172 28.8163
330245.......................................... 18.5161 20.7605 20.3764 19.9316
330246.......................................... 28.1205 29.8777 31.4120 29.6840
330247.......................................... 27.3937 32.5858 25.6063 28.6111
330249.......................................... 17.1320 17.6846 19.1469 18.0226
330250.......................................... 19.9619 20.8742 22.5523 21.1636
330254.......................................... 15.9123 15.7864 * 15.8547
330258.......................................... 31.8910 32.6745 * 32.2903
330259.......................................... 25.9994 26.3620 27.1632 26.5007
330261.......................................... 27.9766 30.0489 30.2305 29.4148
330263.......................................... 18.7378 19.5057 20.0831 19.4473
330264.......................................... 22.8099 24.9714 22.9348 23.5396
330265.......................................... 17.6301 21.1215 18.2547 19.0141
330267.......................................... 24.5939 27.8255 28.9459 27.1596
330268.......................................... 15.9060 16.8358 18.7991 17.2148
330270.......................................... 36.0824 33.0375 35.7375 34.9492
330273.......................................... 26.0565 27.0454 28.8548 27.3093
330275.......................................... 18.7268 * * 18.7268
330276.......................................... 19.0228 19.6572 20.7973 19.8310
330277.......................................... 19.1761 20.7851 21.8865 20.6281
330279.......................................... 20.7107 21.7827 22.2342 21.5603
330285.......................................... 24.0491 24.5388 26.1367 24.9296
330286.......................................... 27.7762 28.0994 31.1802 29.0328
330290.......................................... 30.4706 34.3439 35.5617 33.3907
330293.......................................... 16.9238 17.3180 17.6507 17.2993
330304.......................................... 27.3562 29.2207 30.7428 29.1068
330306.......................................... 29.5937 29.6641 30.4426 29.9146
330307.......................................... 21.7257 23.2838 23.8583 22.9902
330314.......................................... 25.9937 25.5405 26.2954 25.9412
330316.......................................... 27.9543 27.9277 33.7857 29.8270
330327.......................................... 20.3874 20.1705 19.3465 20.0015
330331.......................................... 33.1276 32.3249 34.3554 33.2559
330332.......................................... 25.3689 27.6955 30.5104 28.0245
330333.......................................... * 28.8819 29.7725 29.3003
330336.......................................... 29.8294 27.9163 32.9548 30.2195
330338.......................................... 21.2670 23.6142 25.4319 23.4256
330339.......................................... 20.1028 20.2382 20.8423 20.3907
330340.......................................... 28.4129 28.2732 27.6209 28.0963
330350.......................................... 30.9763 33.5493 35.5656 33.4000
330353.......................................... 34.2431 34.2260 35.6821 34.7146
330357.......................................... 34.1846 36.8598 36.5461 35.8671
330372.......................................... 33.3771 23.5381 28.2490 27.9598
330381.......................................... 31.8602 * * 31.8602
330385.......................................... 33.2246 37.5523 29.0854 33.5264
330386.......................................... 20.4231 21.4363 25.2063 22.3343
[[Page 27296]]
330389.......................................... 37.3749 33.1192 32.2112 34.0979
330390.......................................... 30.8744 31.7344 32.5948 31.7185
330393.......................................... 27.8352 31.9272 32.9411 30.8719
330394.......................................... 18.9343 19.6892 21.1737 19.9249
330395.......................................... 32.7494 33.2318 32.1089 32.8033
330396.......................................... 30.7961 32.8517 30.2150 31.2942
330397.......................................... 32.6068 34.6435 40.0884 35.3787
330398.......................................... 29.2872 * * 29.2871
330399.......................................... 33.3012 32.7149 32.1248 32.6847
330400.......................................... 16.2707 16.8168 16.7483 16.6259
330401.......................................... * * 33.9685 33.9685
340001.......................................... 19.7093 22.0257 21.4870 21.0947
340002.......................................... 20.5253 22.9425 23.8010 22.5969
340003.......................................... 19.5145 19.6545 20.4109 19.8596
340004.......................................... 20.9863 23.0890 23.1514 22.4225
340005.......................................... 16.7176 16.6909 19.9094 17.7865
340006.......................................... 16.5709 16.1379 18.3980 17.0420
340007.......................................... 18.3399 18.3760 19.5204 18.7397
340008.......................................... 20.4157 22.6570 23.7394 22.3196
340009.......................................... 20.9178 20.6155 * 20.8194
340010.......................................... 19.4302 20.6547 21.3024 20.4707
340011.......................................... 14.4798 17.4534 18.1926 16.7010
340012.......................................... 17.5112 19.3651 19.6350 18.7911
340013.......................................... 19.4613 21.5130 21.0066 20.6934
340014.......................................... 27.7888 21.9804 14.6001 20.4859
340015.......................................... 19.4676 20.3493 24.3410 21.2831
340016.......................................... 18.8958 19.4160 20.2859 19.5502
340017.......................................... 20.2775 20.6263 21.5523 20.8419
340018.......................................... 18.1751 16.4611 17.3480 17.2851
340019.......................................... 15.2887 15.9037 16.7102 15.9597
340020.......................................... 18.0897 19.2392 21.3385 19.6156
340021.......................................... 20.5813 22.0220 22.9499 21.8152
340022.......................................... 18.7714 20.6484 19.9078 19.7763
340023.......................................... 19.3146 19.9023 * 19.6217
340024.......................................... 17.9130 19.1430 20.4906 19.1924
340025.......................................... 18.4628 19.1770 20.2864 19.3249
340027.......................................... 19.4548 19.4907 20.8946 19.9262
340028.......................................... 19.9403 20.6496 21.9837 20.9344
340030.......................................... 22.4709 23.9505 27.9759 24.5972
340031.......................................... 14.6370 15.4935 * 15.0325
340032.......................................... 20.7444 22.0245 22.7382 21.8244
340035.......................................... 18.9930 18.5883 16.4821 17.7616
340036.......................................... 17.7619 18.4203 20.8313 18.9871
340037.......................................... 17.5829 18.3655 17.1949 17.6512
340038.......................................... 18.1493 20.3091 13.9936 16.9604
340039.......................................... 21.3711 22.4020 24.8246 22.8823
340040.......................................... 20.7237 21.1397 23.6131 21.8157
340041.......................................... 15.5873 16.3200 15.2995 15.7337
340042.......................................... 17.0034 19.1386 21.0806 19.0573
340044.......................................... 18.0863 18.9562 18.2154 18.4256
340045.......................................... 13.6182 20.2641 17.4067 16.7851
340047.......................................... 20.0744 21.5178 23.3831 21.6665
340049.......................................... 19.5127 17.2986 21.2734 19.3901
340050.......................................... 19.6726 20.6831 20.3262 20.2425
340051.......................................... 19.3627 19.0282 20.3057 19.5812
340052.......................................... 23.2134 26.2243 31.1678 25.9648
340053.......................................... 19.9915 23.2410 25.2543 22.6238
340054.......................................... 15.5090 16.6208 * 15.9979
340055.......................................... 19.4035 20.8253 23.1390 21.1444
340060.......................................... 19.3410 20.8570 19.4707 19.8979
340061.......................................... 22.1175 23.7173 25.1081 23.6221
340063.......................................... 16.7377 26.4132 * 21.1044
340064.......................................... 18.5069 17.6106 19.4523 18.4891
[[Page 27297]]
340065.......................................... 17.3530 23.2606 20.2174 19.9588
340067.......................................... 19.7187 22.4054 22.2565 21.2710
340068.......................................... 17.8065 18.8758 18.9555 18.5436
340069.......................................... 21.6728 22.5995 24.4650 22.9542
340070.......................................... 20.6829 21.3511 22.4458 21.5104
340071.......................................... 18.0767 19.3679 19.8571 19.1466
340072.......................................... 17.7129 18.7920 19.2773 18.5813
340073.......................................... 23.5832 24.0794 26.6829 24.9327
340075.......................................... 20.0081 19.7450 22.9365 20.9263
340080.......................................... 18.2061 * * 18.2061
340084.......................................... 19.0103 19.6087 20.8175 19.7922
340085.......................................... 18.3179 20.3684 21.7019 20.1735
340087.......................................... 18.2255 20.2445 19.7815 19.4322
340088.......................................... 22.2322 22.6462 22.9486 22.6109
340089.......................................... 15.4760 16.1321 16.5968 16.0500
340090.......................................... 18.5287 18.7701 20.3261 19.2336
340091.......................................... 20.3861 21.2665 22.4370 21.4299
340093.......................................... 16.8903 16.5452 17.2910 16.9100
340094.......................................... * 21.0091 * 21.0091
340096.......................................... 19.4696 20.9686 22.1174 20.8605
340097.......................................... 18.2399 20.0302 20.9190 19.7534
340098.......................................... 21.9578 23.4949 24.1099 23.2572
340099.......................................... 15.3752 16.9979 17.3123 16.5041
340101.......................................... 15.6509 20.7841 * 17.9177
340104.......................................... 11.5169 12.1845 12.9949 12.2095
340106.......................................... 18.1211 19.1147 20.1076 19.1527
340107.......................................... 19.3197 20.7601 21.0070 20.3722
340109.......................................... 19.0532 19.3357 19.0067 19.1328
340111.......................................... 16.5976 17.2127 19.4520 17.8152
340112.......................................... 15.5142 16.9592 17.0230 16.4908
340113.......................................... 21.9883 24.4222 24.9180 23.7927
340114.......................................... 20.7261 21.7750 19.5543 20.5793
340115.......................................... 21.7586 24.7924 21.2336 22.4360
340116.......................................... 20.6800 21.6744 23.9643 22.1286
340119.......................................... 19.5827 20.5394 21.2239 20.4881
340120.......................................... 15.8240 16.9847 19.3990 17.3770
340121.......................................... 17.8771 19.0420 19.9862 18.9987
340123.......................................... 18.9078 21.5041 22.2199 20.9298
340124.......................................... 17.4185 17.5411 17.5691 17.5084
340125.......................................... 20.2748 * * 20.2748
340126.......................................... 19.3734 21.2045 21.3106 20.5788
340127.......................................... 19.3842 21.4797 22.0597 21.0110
340129.......................................... 20.6521 21.0773 22.3260 21.4712
340130.......................................... 19.8707 20.5851 22.7449 21.1193
340131.......................................... 21.3849 23.2478 24.1370 22.9644
340132.......................................... 17.5711 17.7110 17.8771 17.7237
340133.......................................... 17.2138 17.5170 22.9471 18.7909
340137.......................................... 31.7702 39.9826 33.5581 34.6438
340138.......................................... * * 27.2610 27.2610
340141.......................................... 21.4986 23.2961 24.1329 23.0207
340142.......................................... 18.0766 18.1824 20.2062 18.8388
340143.......................................... 24.4098 21.9304 22.5250 22.9058
340144.......................................... 22.9183 22.8634 25.4597 23.8048
340145.......................................... 19.9233 21.5958 21.8120 21.1598
340146.......................................... 17.3051 19.1306 20.7252 19.1365
340147.......................................... 20.5520 21.5912 22.3744 21.5004
340148.......................................... 18.9912 20.6790 20.8025 20.1744
340151.......................................... 18.4733 19.0779 19.6254 19.0740
340153.......................................... 20.7533 21.7375 23.7537 22.0653
340155.......................................... 23.1021 25.0965 25.7472 24.6273
340158.......................................... 19.0843 20.0921 21.7830 20.4524
340159.......................................... 19.0338 19.4992 21.2983 19.9832
340160.......................................... 16.7170 17.1963 18.7802 17.6409
[[Page 27298]]
340164.......................................... 21.5769 * * 21.5769
340166.......................................... 20.8270 22.0519 22.7235 21.9492
340168.......................................... 15.6071 15.4250 16.8277 15.9431
340171.......................................... 22.4779 22.7304 25.9865 23.8198
340173.......................................... 21.0898 23.3690 23.7037 22.7805
340176.......................................... * * 26.5277 26.5277
350001.......................................... 16.6551 15.6193 * 16.1279
350002.......................................... 18.3459 19.1931 20.4398 19.3340
350003.......................................... 19.2840 20.0663 21.0585 20.1107
350004.......................................... 23.7016 25.1976 28.3773 25.5370
350005.......................................... 19.9156 20.7467 22.5590 21.0499
350006.......................................... 19.0343 19.1257 19.7577 19.2916
350007.......................................... 13.8824 13.9966 13.0050 13.5839
350008.......................................... 22.3783 23.4052 20.7952 22.2417
350009.......................................... 18.3688 19.3668 20.2558 19.3312
350010.......................................... 16.6272 16.7774 17.2489 16.8799
350011.......................................... 19.1944 20.6809 21.1006 20.1738
350012.......................................... 18.2524 16.0990 17.2775 17.4137
350013.......................................... 17.2596 17.8145 19.3705 18.1038
350014.......................................... 18.0999 18.6786 16.1719 17.7037
350015.......................................... 17.1071 17.5658 18.5437 17.7151
350017.......................................... 17.5124 18.0840 19.1952 18.2584
350018.......................................... 16.4939 16.3210 17.1545 16.6530
350019.......................................... 20.1608 20.6743 21.3589 20.7389
350021.......................................... 17.7123 16.3394 17.6652 17.2178
350023.......................................... 17.4983 18.3253 16.7124 17.5523
350024.......................................... 15.4788 15.7510 17.0685 16.1028
350025.......................................... 15.0469 14.6099 * 14.8289
350027.......................................... 15.5178 17.5882 17.6730 16.8430
350029.......................................... 14.6173 * * 14.6173
350030.......................................... 18.1131 18.7993 18.8822 18.5954
350033.......................................... 16.0870 16.0903 16.4715 16.2067
350034.......................................... 19.6445 * * 19.6446
350035.......................................... 11.7675 12.6496 * 12.2147
350038.......................................... 19.6854 19.5497 18.4963 19.2761
350039.......................................... 16.6278 14.8599 13.8504 15.1678
350041.......................................... 19.1341 23.1150 19.7477 20.6986
350042.......................................... 19.3309 19.3370 20.6599 19.7491
350043.......................................... 16.7433 17.6722 18.8378 17.7606
350044.......................................... 11.0601 10.9690 13.3406 11.6826
350047.......................................... 18.0094 19.9749 14.4742 17.4738
350049.......................................... 18.1993 16.8322 15.3488 16.7860
350050.......................................... 12.2183 25.2747 * 15.7885
350051.......................................... 17.0653 16.9201 13.8030 16.0076
350053.......................................... 15.9160 16.7456 * 16.3628
350055.......................................... 15.7916 16.1691 19.2523 16.9922
350056.......................................... 15.0995 15.7752 16.2553 15.6926
350058.......................................... 16.7034 16.1013 15.0197 15.9830
350060.......................................... 10.3076 10.5325 10.5055 10.4468
350061.......................................... 18.8790 19.6460 18.8494 19.1278
360001.......................................... 19.6655 20.3515 22.2387 20.7565
360002.......................................... 18.2613 19.6145 20.7436 19.4695
360003.......................................... 22.7521 23.2905 24.4144 23.4719
360006.......................................... 22.4436 22.6333 23.8087 22.9695
360007.......................................... 14.8213 15.3656 19.1316 16.2099
360008.......................................... 18.7961 19.8034 21.3795 20.0267
360009.......................................... 18.9935 19.6277 21.6966 20.1251
360010.......................................... 19.1852 20.5934 20.6291 20.1715
360011.......................................... 21.3659 19.5383 21.4293 20.6951
360012.......................................... 20.0525 23.0125 24.3521 22.5181
360013.......................................... 21.3690 22.3407 24.4232 22.7482
360014.......................................... 20.7419 22.9930 22.9372 22.2320
360016.......................................... 21.2505 21.3967 22.8430 21.8319
[[Page 27299]]
360017.......................................... 22.2740 22.7446 23.4603 22.8364
360018.......................................... 24.6686 24.6694 29.9085 26.0220
360019.......................................... 20.6480 21.4708 24.1469 22.0806
360020.......................................... 22.1751 21.6607 21.5085 21.7901
360024.......................................... 20.1352 20.9408 22.5356 21.2300
360025.......................................... 20.2531 20.9266 21.6676 20.9599
360026.......................................... 17.9523 18.6739 20.6765 19.1093
360027.......................................... 21.7650 22.8098 22.6956 22.4249
360028.......................................... 18.7174 * * 18.7174
360029.......................................... 19.2928 19.7466 20.5687 19.8808
360030.......................................... 17.6058 19.0551 20.1051 18.9454
360031.......................................... 21.0687 21.0481 24.3482 22.0734
360032.......................................... 19.8020 19.8367 20.6535 20.1098
360034.......................................... 17.9594 19.4982 21.5621 19.7369
360035.......................................... 21.0674 22.6982 24.0810 22.6341
360036.......................................... 20.9916 21.4486 22.3567 21.6200
360037.......................................... 23.1674 23.7504 32.6245 25.9190
360038.......................................... 19.9415 21.4804 23.4855 21.6060
360039.......................................... 19.0013 19.3703 23.3439 20.4210
360040.......................................... 18.7425 19.9750 21.3307 20.0479
360041.......................................... 19.7968 21.9093 22.1352 21.3781
360042.......................................... 17.1952 19.3774 19.5402 18.6350
360044.......................................... 17.6882 17.8417 19.7212 18.4151
360045.......................................... 22.4018 22.8112 * 22.5916
360046.......................................... 20.4607 21.4292 22.8425 21.5814
360047.......................................... 15.2922 15.8279 17.5885 16.2546
360048.......................................... 22.4890 25.6259 24.5867 24.1178
360049.......................................... 20.8393 * 22.4938 21.5834
360050.......................................... 15.0568 15.6847 16.6112 15.6772
360051.......................................... 20.8757 21.2225 22.7466 21.6280
360052.......................................... 18.7931 19.8037 22.2916 20.3236
360054.......................................... 17.4911 17.5714 19.2884 18.1334
360055.......................................... 21.4112 22.8755 23.5586 22.6117
360056.......................................... 20.6968 23.4405 22.1723 22.1096
360057.......................................... 15.8569 16.0395 16.2876 16.0788
360058.......................................... 19.3306 19.0440 21.0717 19.7901
360059.......................................... 19.9304 23.2129 23.0476 22.0393
360062.......................................... 21.9195 24.4898 24.5746 23.8212
360063.......................................... 17.5108 20.2671 23.7440 20.3480
360064.......................................... 20.0615 20.7659 21.3424 20.7273
360065.......................................... 19.6199 22.3443 22.9727 21.6463
360066.......................................... 22.8175 24.1295 24.6806 23.9204
360067.......................................... 14.2745 17.3734 17.0751 16.1999
360068.......................................... 22.6227 22.6027 23.2680 22.8322
360069.......................................... 14.6597 18.5382 19.3142 17.4363
360070.......................................... 18.8406 19.4700 21.8228 20.0184
360071.......................................... 19.0302 19.6873 21.4478 20.0864
360072.......................................... 19.0166 20.8819 21.3735 20.4642
360074.......................................... 18.5889 19.9947 22.9962 20.5125
360075.......................................... 26.0663 27.6992 23.8492 26.5296
360076.......................................... 20.3317 21.0402 22.5863 21.3489
360077.......................................... 21.5517 22.2964 23.3686 22.4049
360078.......................................... 22.6490 22.7743 22.9324 22.7880
360079.......................................... 21.6644 23.9491 25.3134 23.6069
360080.......................................... 17.6369 18.0392 18.7213 18.1448
360081.......................................... 20.4614 20.7477 22.0134 21.0714
360082.......................................... 20.7610 22.9390 25.2254 23.0000
360084.......................................... 22.0492 22.1699 23.3257 22.5390
360085.......................................... 21.5151 24.8010 24.6618 23.5397
360086.......................................... 19.3701 20.5858 21.6902 20.5374
360087.......................................... 20.7969 21.1621 23.9638 22.0097
360088.......................................... 24.0822 20.5703 21.4608 21.9345
360089.......................................... 18.1941 19.5260 21.0229 19.5818
[[Page 27300]]
360090.......................................... 20.8971 21.2072 22.6236 21.6097
360091.......................................... 21.8447 22.6510 23.5759 22.6962
360092.......................................... 21.5073 20.9588 21.9732 21.4976
360093.......................................... 19.0261 21.0134 21.4911 20.5156
360094.......................................... 20.1227 21.1952 22.7772 21.2684
360095.......................................... 19.8521 21.3505 22.6758 21.2848
360096.......................................... 19.6726 20.9838 22.0673 20.9264
360098.......................................... 19.8178 20.8049 22.2481 20.9247
360099.......................................... 19.6241 20.8801 20.8524 20.4553
360100.......................................... 18.0442 19.9768 21.5911 19.8051
360101.......................................... 20.2635 24.1551 26.2875 23.5545
360102.......................................... 18.5367 * * 18.5367
360106.......................................... 19.1778 18.9779 19.8658 19.3346
360107.......................................... 22.1359 21.9939 23.6880 22.6413
360108.......................................... 20.0681 19.0649 18.1522 19.0815
360109.......................................... 19.9237 17.3564 22.4427 19.7960
360112.......................................... 24.6335 25.7920 25.6581 25.3316
360113.......................................... 20.8154 22.8088 22.3348 21.9843
360114.......................................... 18.7509 19.4212 20.8341 19.6739
360115.......................................... 20.7652 21.0104 22.0789 21.2875
360116.......................................... 18.8319 20.1408 21.3809 20.0857
360118.......................................... 19.9141 21.0235 22.7268 21.2720
360121.......................................... 22.2175 21.9111 22.1403 22.0892
360123.......................................... 20.9792 21.9985 23.1310 22.1195
360125.......................................... 20.5508 21.6675 21.1408 21.0968
360126.......................................... 24.5387 * 22.2409 23.5396
360127.......................................... 16.5559 18.2150 18.7369 17.8642
360128.......................................... 17.0515 17.5557 18.0355 17.5624
360129.......................................... 16.6114 17.2309 17.9151 17.2650
360130.......................................... 18.4539 19.8906 20.1257 19.4067
360131.......................................... 18.4688 20.4123 21.7838 20.2068
360132.......................................... 21.3493 21.0162 23.4179 21.9298
360133.......................................... 20.2857 22.1957 22.0416 21.4704
360134.......................................... 20.9564 21.6081 24.3117 22.2074
360136.......................................... 18.2194 18.5687 19.6063 18.7820
360137.......................................... 22.3648 23.1867 23.7795 23.0881
360140.......................................... 21.2881 18.3463 21.0006 20.1760
360141.......................................... 23.5343 23.5980 25.1442 24.0943
360142.......................................... 18.3188 19.6189 21.2072 19.7570
360143.......................................... 21.0336 20.9158 22.2275 21.3979
360144.......................................... 20.9033 20.9386 24.7973 22.2165
360145.......................................... 20.0513 21.2931 22.4813 21.2645
360147.......................................... 17.6779 18.7258 20.0409 18.8813
360148.......................................... 19.1393 20.3120 21.3211 20.2546
360150.......................................... 22.3620 23.1858 24.8485 23.4439
360151.......................................... 19.2788 20.5594 21.6234 20.4589
360152.......................................... 21.6005 20.9704 22.4839 21.6726
360153.......................................... 16.7399 16.1021 16.5065 16.4436
360154.......................................... 14.3593 14.9606 16.1719 15.1150
360155.......................................... 22.2112 22.3347 23.0020 22.5355
360156.......................................... 18.9095 19.9382 21.2853 20.0637
360159.......................................... 21.5695 22.7992 23.3359 22.5729
360161.......................................... 20.6160 19.6266 21.5045 20.5807
360163.......................................... 21.2689 22.1012 23.1500 22.1757
360165.......................................... 18.2417 19.6205 21.7785 19.8643
360170.......................................... 20.4407 19.7980 21.5572 20.5841
360172.......................................... 19.8909 22.3294 22.6475 21.5601
360174.......................................... 20.5399 20.5874 20.7719 20.6325
360175.......................................... 21.5450 22.0274 22.7887 22.1417
360176.......................................... 16.6228 17.6743 18.3421 17.5257
360177.......................................... 18.9576 19.6992 20.8194 19.8306
360178.......................................... 16.7962 18.0773 18.2393 17.6939
360179.......................................... 20.7069 21.3520 23.2092 21.6660
[[Page 27301]]
360180.......................................... 21.0146 22.9260 25.1489 22.9738
360185.......................................... 19.4858 20.0848 21.0618 20.2316
360186.......................................... 20.7572 18.1254 22.4647 20.3502
360187.......................................... 19.6535 20.8423 21.5915 20.6778
360188.......................................... 18.3057 16.4329 20.9591 18.4288
360189.......................................... 18.5940 19.0481 20.0275 19.2171
360192.......................................... 22.7846 23.9969 24.9995 23.9111
360194.......................................... 17.6140 19.3901 20.3677 19.1372
360195.......................................... 20.5828 21.2801 23.1897 21.7230
360197.......................................... 20.5062 21.6110 23.1378 21.7597
360200.......................................... 17.9623 19.5866 27.5373 19.3013
360203.......................................... 15.9609 17.9698 19.3642 17.7421
360210.......................................... 21.8629 21.5961 25.0811 22.8213
360211.......................................... 20.6081 22.0011 22.4529 21.6965
360212.......................................... 20.6987 21.0632 22.8041 21.5064
360213.......................................... 19.0584 20.5448 20.9996 20.1721
360218.......................................... 18.8204 20.7709 22.8059 20.8145
360230.......................................... 20.8042 21.2417 24.7681 22.2381
360231.......................................... 14.4168 12.7388 13.5004 13.4939
360234.......................................... 20.6131 21.0473 22.1787 21.3387
360236.......................................... 21.4628 20.5683 21.9560 21.3210
360239.......................................... 19.2375 20.9440 21.9631 20.7405
360241.......................................... 25.3741 23.7679 23.4061 24.1565
360245.......................................... 15.9782 16.7956 18.1015 16.9965
360247.......................................... 17.0776 * * 17.0775
360249.......................................... 25.4331 * * 25.4330
360250.......................................... * 50.5106 * 50.5105
360253.......................................... * * 26.8610 26.8610
360254.......................................... * * 30.0791 30.0792
360255.......................................... * * 15.0964 15.0963
370001.......................................... 24.1929 22.0586 25.3182 23.8002
370002.......................................... 15.4333 16.1853 18.9544 16.8753
370004.......................................... 18.5233 22.5027 21.5041 20.8266
370005.......................................... 15.3881 * * 15.3881
370006.......................................... 16.4995 15.7367 15.6334 15.9348
370007.......................................... 15.8312 14.4961 16.7597 15.6795
370008.......................................... 17.5553 18.5253 21.4862 19.1897
370011.......................................... 15.6178 16.1757 17.1458 16.3495
370012.......................................... 12.4942 13.3824 * 12.9251
370013.......................................... 18.9584 19.3237 21.1513 19.8462
370014.......................................... 20.2858 22.7976 21.8473 21.6639
370015.......................................... 20.8765 18.9169 20.3965 20.0611
370016.......................................... 19.1613 20.0888 20.4407 19.8819
370017.......................................... 13.6531 * * 13.6531
370018.......................................... 17.7054 18.7928 20.8357 19.1122
370019.......................................... 14.6216 16.1367 18.1260 16.2132
370020.......................................... 15.1035 15.6057 16.8214 15.8194
370021.......................................... 12.9030 * * 12.9030
370022.......................................... 17.3724 18.2109 20.2432 18.6171
370023.......................................... 17.5148 18.1255 19.3386 18.3281
370025.......................................... 18.4815 19.1013 20.2845 19.2928
370026.......................................... 18.0412 18.6982 21.9141 19.5712
370028.......................................... 21.1292 22.1765 24.3775 22.5815
370029.......................................... 18.2580 19.3285 19.6977 19.1304
370030.......................................... 16.5803 18.4568 18.6541 17.9169
370032.......................................... 18.1538 18.9050 20.0827 19.0803
370033.......................................... 11.3210 15.3857 15.7468 13.9159
370034.......................................... 15.6288 16.2204 16.1541 15.9959
370036.......................................... 12.4070 11.7667 16.5843 13.2363
370037.......................................... 18.9556 20.6493 20.9598 20.1863
370038.......................................... 13.0210 15.4551 16.7597 14.9832
370039.......................................... 19.4498 22.7015 20.3137 20.7707
370040.......................................... 15.5109 16.8127 18.9981 17.0372
[[Page 27302]]
370041.......................................... 16.2316 14.7346 19.0064 16.6382
370042.......................................... 15.2764 15.9005 14.0899 15.1360
370043.......................................... 17.0892 20.0991 20.2929 18.9889
370045.......................................... 11.3560 11.6163 12.6613 11.8767
370047.......................................... 17.8769 18.4743 19.4856 18.6175
370048.......................................... 15.6803 17.0785 15.4768 16.0450
370049.......................................... 19.4868 20.3405 20.4826 20.0887
370051.......................................... 12.5171 11.4943 12.0397 11.9839
370054.......................................... 18.0787 19.2294 20.3788 19.2048
370056.......................................... 18.1432 19.2867 20.4872 19.2536
370057.......................................... 15.1228 16.0301 17.3020 16.1401
370059.......................................... 18.3314 21.3103 20.7160 20.0337
370060.......................................... 19.3051 17.9469 23.1897 20.1750
370063.......................................... 16.7342 * 12.7634 16.0398
370064.......................................... 11.9954 11.6347 11.9044 11.8446
370065.......................................... 18.1349 18.2406 18.3966 18.2581
370071.......................................... 16.4567 * * 16.4568
370072.......................................... 13.6519 12.5765 12.5766 12.8934
370076.......................................... 14.3555 15.4067 19.0231 16.2477
370078.......................................... 19.2412 15.2513 22.0344 18.4513
370079.......................................... 16.9201 17.5915 17.9942 17.4569
370080.......................................... 14.7323 14.3546 16.1445 15.0543
370082.......................................... 15.0669 16.9715 12.6060 14.8254
370083.......................................... 13.1810 15.6824 18.5669 15.6441
370084.......................................... 13.1197 15.6184 16.1277 15.0212
370085.......................................... 48.1271 13.7216 15.8930 17.6461
370086.......................................... 11.1900 * * 11.1900
370089.......................................... 17.2638 17.9243 18.0505 17.7472
370091.......................................... 20.1822 20.8536 23.8502 21.5141
370092.......................................... 15.7678 16.8432 * 16.3152
370093.......................................... 19.7008 22.1966 23.5685 21.8046
370094.......................................... 19.5462 19.5565 20.7290 19.9736
370095.......................................... 13.4202 14.5909 14.3563 14.1246
370097.......................................... 23.2056 19.3793 20.3218 20.7266
370099.......................................... 19.4646 18.1467 20.2001 19.2453
370100.......................................... 18.8274 12.9784 13.0682 14.6358
370103.......................................... 18.2685 23.1347 15.6109 19.0349
370105.......................................... 20.7890 25.1252 22.4493 22.5846
370106.......................................... 20.3651 21.8937 24.0117 22.1004
370108.......................................... 12.7470 14.0190 13.8170 13.5126
370112.......................................... 15.3039 14.3384 16.5964 15.3556
370113.......................................... 17.6107 20.3439 21.4267 19.8197
370114.......................................... 17.8941 17.9757 19.3383 18.4232
370121.......................................... 21.3099 20.5488 20.1393 20.6498
370122.......................................... 15.4375 * * 15.4374
370123.......................................... 19.0313 19.7958 20.5180 19.7729
370125.......................................... 13.9436 14.4664 17.9240 15.3291
370126.......................................... 15.8020 * * 15.8021
370131.......................................... 15.7261 * * 15.7262
370133.......................................... 12.9545 16.1855 17.4258 15.5834
370138.......................................... 17.5551 17.4574 19.0403 18.0470
370139.......................................... 14.9964 16.0898 16.3223 15.8016
370140.......................................... 17.1393 17.4950 20.2255 18.2466
370141.......................................... 20.7798 19.8606 24.0523 21.4638
370146.......................................... 13.0399 13.9900 * 13.5128
370148.......................................... 20.6612 22.6237 22.8526 22.0700
370149.......................................... 17.0929 18.0699 18.2260 17.8047
370153.......................................... 16.4669 16.5267 17.9692 16.9732
370154.......................................... 15.6093 16.6687 17.4760 16.6039
370156.......................................... 14.5696 15.4303 15.9647 15.3521
370158.......................................... 15.6994 16.3637 17.3412 16.4535
370159.......................................... 21.1267 25.5592 * 22.6485
370163.......................................... 20.4217 * * 20.4216
[[Page 27303]]
370165.......................................... 13.0375 12.9569 16.1893 13.8212
370166.......................................... 21.0797 19.4219 21.3003 20.6013
370169.......................................... 12.7138 14.8384 16.5607 14.5408
370176.......................................... 18.9951 19.6537 21.7871 20.1373
370177.......................................... 14.6481 14.1304 14.0279 14.2494
370178.......................................... 11.6200 9.8655 12.9636 11.3085
370179.......................................... 21.3002 23.8404 21.9673 22.2749
370183.......................................... 16.9318 16.6061 * 16.7678
370186.......................................... 15.4533 16.3671 16.3879 16.0737
370190.......................................... 19.3570 20.6398 22.3326 20.7903
370192.......................................... 19.6967 21.8343 24.3832 21.9053
370200.......................................... 22.5299 18.3941 16.7164 18.9908
370201.......................................... * 18.2548 18.9906 18.6571
370202.......................................... * 16.5384 24.0239 20.2030
370203.......................................... * 23.5454 19.8772 21.4569
370204.......................................... * * 17.5518 17.5517
370205.......................................... * * 20.7828 20.7830
370206.......................................... * * 22.3471 22.3471
370207.......................................... * * 26.3745 26.3746
380001.......................................... 26.4822 25.1542 20.9585 23.8121
380002.......................................... 21.9185 23.2479 25.2629 23.4657
380003.......................................... 20.9007 23.8074 24.6377 23.1951
380004.......................................... 23.3609 24.5418 26.7995 24.9862
380005.......................................... 25.0750 24.7476 26.3472 25.4394
380006.......................................... 21.3520 20.5914 24.7492 22.3626
380007.......................................... 32.2678 25.9239 30.0497 29.1804
380008.......................................... 22.3004 21.6133 24.6149 22.8464
380009.......................................... 24.3851 25.1040 25.9993 25.1907
380010.......................................... 22.7276 24.1931 * 23.4887
380011.......................................... 20.3357 20.6759 21.9382 20.9633
380013.......................................... 19.8180 19.9606 24.1491 21.3157
380014.......................................... 25.9828 26.6038 28.4536 27.0598
380017.......................................... 25.3954 21.9236 29.2543 25.5247
380018.......................................... 22.9822 24.8661 27.5171 25.1199
380019.......................................... 20.8176 21.1743 23.9736 22.0144
380020.......................................... 22.9568 23.9978 23.7066 23.5720
380021.......................................... 23.8499 24.4365 28.0334 25.5509
380022.......................................... 24.5974 25.6255 26.4793 25.6210
380023.......................................... 21.3831 23.4328 23.0079 22.7334
380025.......................................... 26.9346 26.9398 28.8525 27.6239
380026.......................................... 20.6972 22.7561 23.8666 22.4738
380027.......................................... 21.5490 22.2573 21.5822 21.7906
380029.......................................... 20.1471 22.0371 24.2939 22.3500
380031.......................................... 20.3396 23.7634 25.2963 23.2221
380033.......................................... 27.1343 26.6899 30.4783 28.1499
380035.......................................... 23.9719 25.6016 26.2434 25.3543
380036.......................................... 27.2157 * * 27.2157
380037.......................................... 22.1774 23.4798 25.0199 23.6781
380038.......................................... 26.7759 28.1436 29.1804 28.0609
380039.......................................... 22.8048 25.7614 26.3917 24.8782
380040.......................................... 22.5477 22.6412 21.5958 22.2243
380042.......................................... 24.4172 21.6793 15.2050 19.3932
380047.......................................... 24.2524 25.2591 26.5017 25.3895
380048.......................................... 18.3005 18.2773 22.0609 19.6514
380050.......................................... 20.3205 22.1089 23.1332 21.8624
380051.......................................... 22.3207 24.4081 26.2384 24.3019
380052.......................................... 18.6299 20.7431 21.2567 20.2520
380056.......................................... 18.4961 20.7895 22.3571 20.6518
380060.......................................... 24.2059 23.0106 27.5270 24.9545
380061.......................................... 22.8781 24.1121 26.4940 24.6176
380062.......................................... 18.2148 26.1370 22.8599 22.5474
380064.......................................... 22.9160 27.0627 * 25.0195
380065.......................................... 22.9608 23.3146 24.8933 23.7620
[[Page 27304]]
380066.......................................... 23.2794 23.1175 23.3581 23.2487
380069.......................................... 20.4882 21.2057 21.8362 21.1860
380070.......................................... 27.7790 29.9706 34.1038 30.4794
380071.......................................... 25.1808 25.9113 27.9055 26.3468
380072.......................................... 19.4346 20.6568 21.9516 20.7086
380075.......................................... 22.4139 23.1910 25.1930 23.7443
380078.......................................... 21.0903 22.6996 25.0805 22.9534
380081.......................................... 20.4082 22.9805 22.1822 21.8754
380082.......................................... 22.9606 23.7927 28.0668 25.0482
380083.......................................... 21.7431 22.4058 26.4379 23.4740
380084.......................................... 27.1689 31.0111 27.9068 28.5032
380087.......................................... 17.0380 21.3119 21.1488 19.9159
380088.......................................... 19.5346 24.8158 21.6317 21.8938
380089.......................................... 25.2908 26.1967 29.6989 27.0928
380090.......................................... 24.9351 30.4223 31.8702 28.9771
380091.......................................... 25.3062 28.7846 31.2807 28.6166
380099.......................................... * * 16.7656 16.7656
390001.......................................... 19.6732 20.3350 21.5154 20.5284
390002.......................................... 19.7833 20.8831 21.8704 20.8537
390003.......................................... 18.1025 18.0436 19.1857 18.4384
390004.......................................... 20.3204 20.0557 21.3475 20.5889
390005.......................................... 16.9472 19.0218 19.0727 18.2821
390006.......................................... 21.1786 21.7867 22.9809 21.9897
390007.......................................... 21.3839 * * 21.3839
390008.......................................... 18.2743 19.5439 19.9417 19.2572
390009.......................................... 20.6241 22.5580 21.8195 21.6732
390010.......................................... 17.3335 18.1275 19.4377 18.3086
390011.......................................... 18.3257 18.2751 18.6548 18.4184
390012.......................................... 21.0610 22.2060 28.5114 23.7778
390013.......................................... 19.6562 20.2186 22.1679 20.7339
390015.......................................... 13.7352 14.3138 15.2697 14.4324
390016.......................................... 17.1133 17.4931 18.1536 17.5840
390017.......................................... 18.6113 18.5869 19.1962 18.7750
390018.......................................... 19.0279 20.0672 19.9117 19.6570
390019.......................................... 17.7258 18.7609 21.2807 19.2350
390022.......................................... 24.8468 25.2980 27.5365 25.9219
390023.......................................... 22.1044 23.9246 25.6750 23.9254
390024.......................................... 25.4606 27.7643 25.9806 26.4580
390025.......................................... 15.5523 14.0077 14.8690 14.8024
390026.......................................... 22.9718 23.6317 23.9225 23.5085
390027.......................................... 29.5940 29.4334 33.2139 30.7948
390028.......................................... 23.6571 22.7820 22.9071 23.1380
390029.......................................... 21.2661 24.4753 * 22.6697
390030.......................................... 18.6887 18.9121 20.0598 19.2297
390031.......................................... 18.8162 19.2040 20.6513 19.5475
390032.......................................... 21.5105 18.5545 20.7764 20.3109
390035.......................................... 22.3591 21.9325 23.2173 22.4923
390036.......................................... 19.7671 20.2103 20.5751 20.1842
390037.......................................... 20.4263 19.9175 20.1665 20.1659
390039.......................................... 17.5300 17.6181 18.4580 17.8792
390040.......................................... 16.6876 17.4451 20.5371 18.2001
390041.......................................... 20.4397 19.6159 21.0074 20.3638
390042.......................................... 22.5775 22.0668 21.8863 22.1699
390043.......................................... 17.4764 17.6739 19.8094 18.3425
390044.......................................... 20.9831 21.3382 22.0362 21.4586
390045.......................................... 19.4677 20.2107 19.8137 19.8315
390046.......................................... 21.7445 21.3960 23.0279 22.0786
390047.......................................... 26.9709 * * 26.9709
390048.......................................... 19.7992 18.9776 20.3523 19.7014
390049.......................................... 22.1586 22.8196 23.9058 22.9608
390050.......................................... 22.2639 24.9156 22.5851 23.1577
390051.......................................... 28.1385 * * 28.1385
390052.......................................... 20.1195 21.2729 22.1380 21.1379
[[Page 27305]]
390054.......................................... 18.4975 19.4686 19.8602 19.2479
390055.......................................... 23.4017 25.7327 22.2112 23.7101
390056.......................................... 19.3901 21.4121 21.4239 20.7360
390057.......................................... 20.2395 21.6693 24.5245 22.1897
390058.......................................... 20.3520 20.7930 22.0113 21.0507
390061.......................................... 23.8722 22.8728 24.3816 23.6939
390062.......................................... 17.3750 17.4710 17.6303 17.4968
390063.......................................... 19.4965 20.1696 21.7120 20.4817
390065.......................................... 20.0473 20.2930 23.1698 21.2264
390066.......................................... 18.9296 19.0132 21.7717 19.8676
390067.......................................... 20.8162 21.9885 23.2161 21.9824
390068.......................................... 19.1109 21.6408 21.8596 20.7014
390070.......................................... 21.8549 22.7909 24.4403 23.0308
390071.......................................... 16.0100 18.9416 17.8117 17.5040
390072.......................................... 16.9232 16.9445 20.6881 18.0993
390073.......................................... 21.2623 22.2703 22.7073 22.0769
390074.......................................... 18.3093 19.7446 21.8456 19.9484
390075.......................................... 18.7695 19.5840 19.8576 19.3638
390076.......................................... 21.3290 19.7719 * 20.5305
390078.......................................... 19.0156 20.6483 21.1894 20.2451
390079.......................................... 18.9269 19.5982 20.0240 19.5384
390080.......................................... 21.4707 22.2449 23.0615 22.2544
390081.......................................... 24.7461 25.6575 27.3952 25.9933
390083.......................................... * 26.1660 * 26.1660
390084.......................................... 20.2529 17.0197 18.3551 18.4310
390086.......................................... 18.3563 19.7645 19.5253 19.2361
390088.......................................... 23.9506 * * 23.9506
390090.......................................... 21.3759 20.5433 21.8543 21.2676
390091.......................................... 18.3770 19.0355 19.7361 19.0422
390093.......................................... 18.4442 20.0135 19.9209 19.4590
390095.......................................... 16.6930 17.9697 18.3939 17.6811
390096.......................................... 22.4382 22.2974 22.6176 22.4533
390097.......................................... 25.2845 24.7853 24.6090 24.8791
390100.......................................... 20.9263 21.1186 22.9484 21.6940
390101.......................................... 18.5039 19.0180 19.7332 19.0899
390102.......................................... 21.5496 19.3111 19.9809 20.2918
390103.......................................... 18.8667 20.4422 26.5769 21.5409
390104.......................................... 16.3255 16.2440 16.5081 16.3661
390106.......................................... 16.8439 17.4747 18.2013 17.4917
390107.......................................... 20.9841 20.6024 21.1104 20.9018
390108.......................................... 21.3142 22.0444 23.6644 22.2895
390109.......................................... 16.5299 17.4540 17.2667 17.0836
390110.......................................... 21.6464 21.6005 23.2166 22.1164
390111.......................................... 33.3971 27.1429 30.5237 30.4448
390112.......................................... 15.0065 14.8634 15.6710 15.1640
390113.......................................... 19.3634 19.9496 20.1160 19.8009
390114.......................................... 20.9533 19.8004 23.0501 21.2575
390115.......................................... 21.4287 22.3545 24.1951 22.7320
390116.......................................... 21.3671 22.6783 24.0492 22.6706
390117.......................................... 18.0769 18.9764 18.3341 18.4618
390118.......................................... 18.9507 17.2668 17.8460 18.0300
390119.......................................... 18.8815 19.3946 20.3034 19.5629
390121.......................................... 19.1315 20.6253 20.8017 20.2031
390122.......................................... 17.7734 15.5438 18.5130 17.2135
390123.......................................... 21.3974 21.8897 23.2750 22.1809
390125.......................................... 17.5446 17.0975 18.2411 17.6363
390127.......................................... 22.4555 22.8787 25.0836 23.5152
390128.......................................... 19.3165 19.9764 21.3668 20.1918
390130.......................................... 18.3695 18.5519 19.4835 18.7830
390131.......................................... 19.2096 19.1931 19.2964 19.2343
390132.......................................... 22.8414 24.1878 24.6889 23.9106
390133.......................................... 24.7561 24.1590 25.1423 24.6873
390135.......................................... 22.1905 22.2501 24.0445 22.8305
[[Page 27306]]
390136.......................................... 20.6286 16.8505 * 18.7490
390137.......................................... 18.5397 19.4769 18.4551 18.8068
390138.......................................... 20.6936 20.7726 21.4705 20.9891
390139.......................................... 23.9757 24.8347 26.3622 25.0742
390142.......................................... 28.8877 28.4680 29.9432 29.1087
390145.......................................... 20.4228 20.4964 20.6603 20.5268
390146.......................................... 18.6505 20.1788 21.3295 20.0284
390147.......................................... 21.2492 21.7600 22.3135 21.7727
390150.......................................... 20.3155 20.8970 20.0261 20.3992
390151.......................................... 22.5206 23.6072 24.8175 23.6886
390152.......................................... 19.4017 20.2581 21.5474 20.4133
390153.......................................... 22.9707 23.9039 25.3415 24.1064
390154.......................................... 16.7052 17.8774 19.1300 17.9859
390156.......................................... 22.6398 24.0034 25.0732 23.9019
390157.......................................... 19.1783 20.2647 20.6933 20.0398
390160.......................................... 19.4463 19.4793 19.3598 19.4262
390162.......................................... 21.9188 21.3379 21.3398 21.5478
390163.......................................... 17.7564 18.1831 18.8585 18.2862
390164.......................................... 24.9750 26.1698 23.0298 24.6107
390166.......................................... 19.7978 19.8899 19.8531 19.8460
390168.......................................... 18.8863 19.6875 20.6777 19.7568
390169.......................................... 22.0547 22.7920 22.7695 22.5431
390170.......................................... 24.7973 * * 24.7973
390173.......................................... 18.6613 18.8265 20.6958 19.3949
390174.......................................... 25.3307 26.3891 28.2662 26.6572
390176.......................................... 20.8368 21.7650 18.0752 20.3817
390178.......................................... 17.0534 17.1142 17.2384 17.1362
390179.......................................... 21.8593 21.5792 24.0501 22.5243
390180.......................................... 26.5541 26.7743 28.3812 27.2876
390181.......................................... 19.3832 18.8681 24.1288 20.6497
390183.......................................... 17.9848 17.4535 21.7091 18.9719
390184.......................................... 20.9349 21.1941 21.1962 21.1056
390185.......................................... 20.3877 20.3301 20.4476 20.3876
390189.......................................... 20.3338 19.6186 20.0387 19.9844
390191.......................................... 17.2270 17.1919 18.5972 17.6639
390192.......................................... 17.6597 16.6469 19.1883 17.8533
390193.......................................... 18.1209 17.3804 18.9764 18.1140
390194.......................................... 21.2689 21.0549 21.5850 21.3104
390195.......................................... 24.1793 24.2891 26.2024 24.9040
390197.......................................... 20.7998 22.1974 22.3472 21.7925
390198.......................................... 15.8833 16.6803 17.3937 16.6375
390199.......................................... 17.3865 17.7782 18.9787 18.0590
390200.......................................... 15.4012 18.2456 19.1728 17.6332
390201.......................................... 20.3533 21.3291 22.6548 21.4708
390203.......................................... 21.4989 22.4685 26.9436 23.7942
390204.......................................... 22.9616 22.7282 23.9673 23.2268
390209.......................................... 18.7059 16.8200 18.4248 17.9405
390211.......................................... 18.4213 19.4552 21.0450 19.6873
390213.......................................... 19.1553 20.1152 19.9614 19.7218
390215.......................................... 21.2032 23.5953 25.2617 23.2887
390217.......................................... 19.9837 19.7578 21.4058 20.3609
390219.......................................... 19.6226 20.1311 20.0594 19.9347
390220.......................................... 17.7916 22.7617 23.3890 21.1672
390222.......................................... 22.1548 22.7491 24.9365 23.2941
390223.......................................... 22.1775 18.9493 20.4623 20.4831
390224.......................................... 13.7518 17.2173 15.4657 15.2280
390225.......................................... 18.7290 19.0364 22.5083 20.0077
390226.......................................... 21.8481 22.8588 26.4195 23.5449
390228.......................................... 19.8180 19.6212 20.1219 19.8582
390231.......................................... 19.4798 21.0757 24.6868 21.6606
390233.......................................... 20.2309 20.5800 21.6259 20.8313
390235.......................................... 21.4200 19.9925 23.7068 21.4467
390236.......................................... 17.8735 19.1427 19.8687 18.9492
[[Page 27307]]
390237.......................................... 22.3011 21.7847 23.2054 22.4279
390238.......................................... 17.1055 18.1956 19.2170 18.1264
390244.......................................... 15.6402 14.2136 * 14.8974
390245.......................................... 24.5076 * * 24.5076
390246.......................................... 25.0556 22.3892 22.0687 23.0374
390247.......................................... 21.2151 * * 21.2151
390249.......................................... 13.1657 14.1062 14.7215 14.0139
390256.......................................... 22.2773 22.3540 22.5794 22.4081
390258.......................................... 22.6852 23.8318 25.0634 23.8724
390260.......................................... 21.5982 * * 21.5982
390262.......................................... * 18.8942 21.3264 20.1664
390263.......................................... 20.3796 20.6348 21.9811 21.0229
390265.......................................... 20.4950 20.4760 20.5948 20.5230
390266.......................................... 17.1966 17.6223 18.2424 17.6964
390267.......................................... 19.2665 20.2424 21.4980 20.3945
390268.......................................... 22.0909 22.2046 23.1124 22.4784
390270.......................................... 19.2074 20.7957 22.3861 20.7770
390278.......................................... 17.7176 18.5776 21.1387 19.0743
390279.......................................... 14.8655 15.8080 16.0509 15.5561
390283.......................................... 22.5490 * * 22.5489
390284.......................................... 34.3904 * * 34.3902
390285.......................................... * 29.1270 30.6458 29.8575
390286.......................................... * 22.9746 25.4619 24.2087
390287.......................................... * 30.3252 32.9709 31.6159
390288.......................................... * 26.9662 28.0958 27.3905
390289.......................................... * 22.8963 25.1658 23.9733
390290.......................................... * 30.5037 31.0967 30.8194
390291.......................................... * 20.0272 21.0057 20.4818
390293.......................................... * 23.5285 * 23.5284
390294.......................................... * * 33.3535 33.3537
390295.......................................... * * 26.8863 26.8862
390296.......................................... * * 25.6979 25.6981
390297.......................................... * * 27.2166 27.2167
400001.......................................... 10.5757 10.7531 11.7572 11.0430
400002.......................................... 13.0494 13.3684 11.6804 12.6379
400003.......................................... 12.4078 11.2726 10.5963 11.4141
400004.......................................... 8.5648 9.0781 11.4479 9.6254
400005.......................................... 7.7432 9.7802 10.5356 9.1053
400006.......................................... 10.1048 10.4988 9.2852 9.9205
400007.......................................... 8.0174 8.1974 8.6022 8.2631
400009.......................................... 8.8650 8.7341 9.4413 9.0139
400010.......................................... 10.8011 9.1359 8.9964 9.6421
400011.......................................... 8.5426 8.6252 8.9111 8.6956
400012.......................................... 8.4728 8.6538 9.0740 8.7216
400013.......................................... 9.2624 9.8197 9.9905 9.7250
400014.......................................... 9.4798 10.2712 11.4580 10.3309
400015.......................................... 14.4076 15.5827 * 14.8835
400016.......................................... 13.3922 13.7001 14.5398 13.8932
400017.......................................... 9.2577 9.9167 10.3892 9.8593
400018.......................................... 10.6208 10.5583 10.8254 10.6669
400019.......................................... 10.8940 12.1251 13.2143 12.0755
400021.......................................... 12.1434 12.7462 13.2358 12.7262
400022.......................................... 12.2199 13.0915 15.2904 13.4548
400024.......................................... 9.2409 9.0826 9.8650 9.4011
400026.......................................... 5.8335 7.4280 5.9207 6.3366
400028.......................................... 9.1794 8.9567 9.5266 9.2275
400032.......................................... 10.0448 10.1898 10.7100 10.3326
400044.......................................... 11.9486 12.8671 9.0275 11.6261
400048.......................................... 15.1405 11.5104 10.8618 12.2444
400061.......................................... 13.0988 10.3664 17.0566 13.1015
400079.......................................... 9.7203 8.7218 8.7218 8.9772
400087.......................................... 9.8534 8.6480 10.5762 9.7829
400094.......................................... 7.9187 9.4600 9.1442 8.8371
[[Page 27308]]
400098.......................................... 9.7791 10.4312 13.5901 11.0612
400102.......................................... 9.9903 8.5290 10.9973 9.8471
400103.......................................... 11.5359 11.8454 11.5797 11.6448
400104.......................................... 10.7292 7.9552 7.1781 8.8476
400105.......................................... 9.0556 10.6028 11.5608 10.1248
400106.......................................... 9.2187 9.8694 10.1240 9.7589
400109.......................................... 11.8760 12.2080 12.8750 12.3225
400110.......................................... 10.5277 10.7228 12.0159 11.1009
400111.......................................... 10.9665 12.3311 12.7701 12.0404
400112.......................................... 10.8694 11.0634 11.8808 11.2717
400113.......................................... 8.3168 9.3000 10.1440 9.3104
400114.......................................... 7.0510 9.9477 9.7444 8.8440
400115.......................................... 8.5487 7.2203 7.0336 7.5134
400117.......................................... 10.8756 11.3351 9.6471 10.6080
400118.......................................... 11.4051 11.4317 12.0855 11.6542
400120.......................................... 10.6584 10.9315 11.8837 11.1482
400121.......................................... 9.8322 8.7584 8.3575 8.9176
400122.......................................... 7.6413 9.1638 9.6644 8.8133
400123.......................................... 10.2367 10.9047 10.4081 10.5188
400124.......................................... 12.2452 12.7323 14.1198 13.0556
400125.......................................... 10.2056 10.5997 10.0698 10.2676
410001.......................................... 23.1738 22.4972 24.0033 23.2235
410004.......................................... 21.0638 23.5408 24.7607 23.1523
410005.......................................... 22.7170 24.0086 24.6202 23.7588
410006.......................................... 23.8700 22.8959 26.1234 24.3211
410007.......................................... 23.1325 24.9846 27.7171 25.1159
410008.......................................... 24.9726 24.4792 25.4183 24.9582
410009.......................................... 24.3895 24.3760 26.1891 24.9832
410010.......................................... 28.4589 29.7315 30.4061 29.5287
410011.......................................... 26.1183 27.4880 29.2039 27.5568
410012.......................................... 24.1695 26.4570 28.1791 26.2184
410013.......................................... 24.8800 25.3688 28.4954 26.2187
420002.......................................... 20.7804 22.6182 25.1067 22.8141
420004.......................................... 20.9588 22.4680 23.4275 22.2200
420005.......................................... 17.9694 17.8202 19.5521 18.4820
420006.......................................... 19.1760 18.7153 22.7896 19.8079
420007.......................................... 18.6456 19.0199 22.0134 19.8792
420009.......................................... 19.9586 21.2566 18.6866 19.8536
420010.......................................... 18.0252 19.3267 19.1545 18.8686
420011.......................................... 18.0970 16.7523 17.3200 17.3563
420014.......................................... 18.0519 19.0455 20.4975 19.1969
420015.......................................... 20.1164 20.8736 22.7776 21.3355
420016.......................................... 15.5485 16.6448 17.0051 16.4309
420018.......................................... 21.8775 20.7779 20.4649 20.9903
420019.......................................... 17.1726 19.0199 19.7118 18.6106
420020.......................................... 20.3193 20.5801 22.1616 21.0728
420023.......................................... 20.4053 20.8600 22.9004 21.4470
420026.......................................... 21.8749 23.3072 23.6914 22.9839
420027.......................................... 19.2594 19.7322 20.7327 19.9443
420030.......................................... 20.6448 22.5159 22.5925 21.9394
420031.......................................... 8.2516 15.3605 16.8518 12.3011
420033.......................................... 23.1303 23.7974 26.0792 24.3733
420036.......................................... 21.3222 19.8285 20.6780 20.5493
420037.......................................... 22.7099 23.5244 25.3863 23.9574
420038.......................................... 18.6568 19.9829 21.6132 20.0798
420039.......................................... 18.3017 18.0055 21.1830 18.9968
420043.......................................... 19.7570 19.6834 21.8816 20.4303
420048.......................................... 18.8070 20.5531 21.9517 20.4950
420049.......................................... 19.4049 20.1765 20.2320 19.9533
420051.......................................... 19.1555 19.8549 20.6629 19.9007
420053.......................................... 18.1657 19.0780 19.9013 19.0557
420054.......................................... 20.2574 20.2275 20.7802 20.4197
420055.......................................... 16.8717 18.6782 19.3056 18.2587
[[Page 27309]]
420056.......................................... 15.1835 16.5491 19.8467 17.1664
420057.......................................... 20.5266 22.1312 17.6727 20.1808
420059.......................................... 17.1483 18.2093 20.2630 18.4420
420061.......................................... 17.3543 17.7047 19.9789 18.3969
420062.......................................... 21.7469 20.9032 17.4888 19.8336
420064.......................................... 16.0794 19.7067 20.9057 19.0582
420065.......................................... 19.9435 19.2150 21.9297 20.4427
420066.......................................... 18.0042 19.5366 20.7713 19.3973
420067.......................................... 19.7824 20.8524 22.8104 21.1856
420068.......................................... 18.5481 20.2580 21.7257 20.1957
420069.......................................... 18.1298 18.9017 17.6788 18.2297
420070.......................................... 17.3876 19.2186 20.1378 18.9286
420071.......................................... 20.3902 20.1897 21.2610 20.6237
420072.......................................... 15.0158 18.2531 16.2578 16.5142
420073.......................................... 19.9986 20.2697 21.4718 20.6373
420074.......................................... 18.0967 18.1839 18.7011 18.3051
420075.......................................... 12.8158 15.0132 15.9890 14.6306
420078.......................................... 21.9082 22.7156 23.9730 22.8546
420079.......................................... 21.0874 21.3177 23.0729 21.8705
420080.......................................... 21.9968 23.2871 26.7489 24.1988
420082.......................................... 21.7210 22.8516 28.0149 24.1640
420083.......................................... 22.6376 24.4499 24.8294 24.0095
420085.......................................... 21.6791 22.0071 23.8540 22.5902
420086.......................................... 20.2878 23.5303 24.5760 22.8222
420087.......................................... 19.8388 20.8217 21.9354 20.8793
420088.......................................... 19.9919 21.8979 23.5174 21.7712
420089.......................................... 20.5360 21.3954 23.3240 21.8074
420091.......................................... 20.3092 21.8367 23.7544 21.8937
420093.......................................... 18.3902 19.1299 21.4678 19.5913
420095.......................................... * 33.4632 * 33.4634
420096.......................................... * 26.4863 * 26.4864
430004.......................................... 19.6344 19.2737 22.2198 20.3430
430005.......................................... 16.4560 17.3400 18.2647 17.3726
430007.......................................... 14.6331 15.1494 17.8017 15.8287
430008.......................................... 18.1323 18.5234 20.0124 18.8898
430010.......................................... 19.8191 16.5750 21.3978 18.9840
430011.......................................... 17.4750 18.3648 19.9835 18.5721
430012.......................................... 17.6997 19.2921 21.2588 19.3790
430013.......................................... 18.4817 18.8978 21.3388 19.5495
430014.......................................... 20.2387 20.9118 22.0285 21.0694
430015.......................................... 18.2875 18.8998 20.5848 19.2456
430016.......................................... 20.8850 22.7585 24.2450 22.6451
430018.......................................... 16.2244 15.9424 17.9850 16.6387
430022.......................................... 14.5118 14.0661 * 14.2905
430023.......................................... 16.2164 16.7850 18.8816 17.1465
430024.......................................... 16.1801 17.4816 18.8359 17.4068
430027.......................................... 20.2591 20.8666 22.1807 21.1128
430028.......................................... 17.1577 18.2829 30.0094 20.4957
430029.......................................... 17.6986 17.4932 18.9463 18.0331
430031.......................................... 12.4660 13.2105 15.2322 13.5804
430033.......................................... 17.3652 18.3978 21.6255 19.2950
430034.......................................... 14.2491 13.8535 13.6064 13.9089
430036.......................................... 15.6258 16.7827 16.5848 16.2916
430037.......................................... 18.1293 18.7009 19.3794 18.7558
430038.......................................... 18.4078 * * 18.4078
430040.......................................... 14.4509 14.7860 15.3612 14.8505
430041.......................................... 14.8816 * * 14.8815
430043.......................................... 14.9949 17.0193 17.9673 16.5225
430044.......................................... 21.0823 * * 21.0824
430047.......................................... 17.9823 17.5377 18.2773 17.9221
430048.......................................... 18.7602 19.0261 20.0608 19.3158
430049.......................................... 15.2237 14.9025 17.0885 15.6759
430051.......................................... 18.8070 18.8697 21.2838 19.6636
[[Page 27310]]
430054.......................................... 14.8003 15.0101 17.8870 15.8667
430056.......................................... 10.3697 14.1914 15.9149 13.1642
430057.......................................... 17.2805 18.8777 18.2939 18.1566
430060.......................................... 10.0176 9.7678 10.6493 10.1353
430064.......................................... 14.2184 13.8666 14.3407 14.1427
430066.......................................... 15.6660 14.5957 18.0501 16.1260
430073.......................................... 15.3776 16.5112 16.4387 16.0995
430076.......................................... 13.9883 15.2453 12.6996 13.8839
430077.......................................... 19.8558 20.4361 21.6786 20.6834
430079.......................................... 14.1815 14.4154 15.4268 14.6345
430089.......................................... 17.9790 17.5100 19.8572 18.4672
430090.......................................... 21.5974 23.5180 25.6873 23.7486
430091.......................................... 18.1567 21.6239 22.2824 21.1724
430092.......................................... 21.3807 19.7644 19.7354 20.2342
430093.......................................... 19.5013 23.3009 23.8820 22.1340
430094.......................................... * * 20.8742 20.8743
440001.......................................... 15.5897 17.2282 18.9833 17.1918
440002.......................................... 20.3740 21.4299 20.7715 20.8573
440003.......................................... 19.3042 20.3756 21.6336 20.4509
440006.......................................... 21.4055 23.1483 24.3132 22.9905
440007.......................................... 14.8959 14.0612 14.1008 14.3331
440008.......................................... 18.8994 20.3303 20.9238 20.0515
440009.......................................... 17.4831 18.4068 19.6564 18.5235
440010.......................................... 16.3283 13.3692 16.7270 15.2992
440011.......................................... 18.3375 19.3165 20.5036 19.4558
440012.......................................... 19.5739 19.8949 21.3573 20.2411
440014.......................................... 16.1143 15.0656 * 15.5948
440015.......................................... 22.0659 21.6106 23.3677 22.3025
440016.......................................... 16.2964 14.6142 20.1504 16.8295
440017.......................................... 20.4563 20.4705 22.3573 21.0640
440018.......................................... 17.4995 18.1620 21.2242 19.0126
440019.......................................... 21.5402 22.8463 24.0149 22.8001
440020.......................................... 17.8879 20.2189 21.1075 19.7440
440023.......................................... 16.7837 15.6603 15.5410 15.9556
440024.......................................... 18.4046 18.4276 19.9751 18.8456
440025.......................................... 16.3140 17.0997 18.9008 17.4832
440026.......................................... 23.2566 25.6490 25.1655 24.7161
440029.......................................... 20.7050 22.2889 24.1379 22.4401
440030.......................................... 16.9925 17.6297 19.9056 18.2332
440031.......................................... 17.0211 17.2555 17.0289 17.1002
440032.......................................... 13.8140 13.9784 14.7683 14.1838
440033.......................................... 13.7328 16.4679 17.2637 15.8189
440034.......................................... 20.0309 21.1672 22.2382 21.1482
440035.......................................... 19.3034 20.4168 21.6338 20.4652
440039.......................................... 21.6536 22.4158 24.8698 22.9682
440040.......................................... 16.9275 17.6781 16.9886 17.1928
440041.......................................... 14.9545 14.6684 15.5784 15.0621
440046.......................................... 19.3229 20.5562 22.1743 20.5985
440047.......................................... 17.8092 18.7469 18.7262 18.4184
440048.......................................... 21.4993 21.6132 22.5431 21.9061
440049.......................................... 18.7967 19.6920 22.1252 20.0483
440050.......................................... 18.2511 19.7915 21.3428 19.8422
440051.......................................... 16.0421 17.7067 19.0165 17.5455
440052.......................................... 19.8075 18.6589 18.1897 18.8402
440053.......................................... 19.6494 21.5253 22.0063 21.0648
440054.......................................... 13.3967 15.2154 15.4208 14.7050
440056.......................................... 16.2742 20.4903 19.1329 18.5350
440057.......................................... 13.7257 14.4363 14.1477 14.1083
440058.......................................... 19.1878 20.7722 21.7512 20.5453
440059.......................................... 19.6018 20.8882 22.4248 21.0016
440060.......................................... 19.7916 20.7628 20.0972 20.2143
440061.......................................... 22.5525 16.9234 19.5458 19.4254
440063.......................................... 19.8371 18.8072 19.7468 19.4529
[[Page 27311]]
440064.......................................... 18.9809 18.2678 19.4020 18.8736
440065.......................................... 18.8296 19.2282 19.9099 19.3487
440067.......................................... 17.2397 18.2973 19.6120 18.4263
440068.......................................... 19.3668 19.5428 20.9188 19.9728
440070.......................................... 14.0437 18.0064 18.3717 16.8031
440071.......................................... 19.7836 * * 19.7836
440072.......................................... 19.1522 20.0691 20.9286 20.0759
440073.......................................... 19.5554 19.6290 20.7181 19.9917
440078.......................................... 16.0188 17.1645 20.0509 17.7858
440081.......................................... 19.3454 17.2905 18.2664 18.2167
440082.......................................... 22.6855 22.5590 26.0944 23.6946
440083.......................................... 13.7423 13.7630 15.7015 14.3937
440084.......................................... 13.7731 13.8085 15.0510 14.2295
440091.......................................... 20.1065 20.1359 22.2894 20.8482
440100.......................................... 14.7113 15.9969 20.1545 16.9936
440102.......................................... 14.5500 16.0783 16.6548 15.7421
440103.......................................... 18.6990 * * 18.6990
440104.......................................... 22.6754 21.7135 21.5501 21.9246
440105.......................................... 17.1172 18.1375 19.2902 18.1888
440109.......................................... 17.7443 17.6399 16.5366 17.2746
440110.......................................... 17.4816 18.4998 19.9718 18.7249
440111.......................................... 23.2254 23.2111 24.9666 23.7976
440114.......................................... 15.0036 18.5327 20.1152 17.9248
440115.......................................... 18.5457 18.7054 18.4721 18.5719
440120.......................................... 16.3115 19.8997 22.4031 19.5197
440125.......................................... 19.4115 20.0599 21.2173 20.2484
440130.......................................... 17.4857 19.0905 20.6364 19.0816
440131.......................................... 16.1214 19.9883 21.0641 18.9957
440132.......................................... 16.8871 17.9186 18.9580 17.9377
440133.......................................... 23.0891 22.2257 22.4872 22.5969
440135.......................................... 22.2005 22.5452 23.8313 22.9298
440137.......................................... 15.0070 15.3530 16.5529 15.6758
440141.......................................... 15.9429 17.6819 19.2607 17.4468
440142.......................................... 16.8855 17.1483 17.7587 17.2159
440143.......................................... 18.2061 18.6844 19.2978 18.7274
440144.......................................... 18.3859 18.8127 19.7938 19.0189
440145.......................................... 18.3948 18.3850 18.1226 18.2932
440147.......................................... 26.1464 25.3766 25.0779 25.5115
440148.......................................... 19.4598 19.3769 20.7693 19.8862
440149.......................................... 18.4281 19.8304 18.1316 18.8060
440150.......................................... 20.3006 21.2942 22.8656 21.5228
440151.......................................... 18.3928 19.8977 20.7681 19.6191
440152.......................................... 22.7664 21.7382 27.2915 23.9903
440153.......................................... 16.5716 18.1781 19.9486 18.2431
440156.......................................... 21.7577 21.9374 23.7799 22.5299
440157.......................................... 18.4249 15.5316 17.6241 17.2522
440159.......................................... 20.9371 21.4914 20.5719 20.9737
440161.......................................... 22.8816 23.6805 26.1354 24.2908
440162.......................................... 15.5534 19.8075 20.3909 18.5104
440166.......................................... 19.2159 19.6632 23.1692 20.6397
440168.......................................... 19.1509 21.1947 21.2114 20.4537
440173.......................................... 19.1812 21.0284 20.8442 20.3754
440174.......................................... 18.0865 19.3966 19.2201 18.8962
440175.......................................... 18.5186 19.9022 22.3331 20.2599
440176.......................................... 19.2208 19.8448 20.4861 19.8829
440180.......................................... 20.2184 20.2057 21.1947 20.5447
440181.......................................... 17.7709 19.0915 19.5055 18.7704
440182.......................................... 19.7094 18.1953 19.3928 19.0713
440183.......................................... 21.3465 22.2401 24.9282 22.9040
440184.......................................... 16.8880 18.6890 21.4484 18.5678
440185.......................................... 21.2188 21.1226 22.2855 21.5992
440186.......................................... 19.7983 20.8600 23.0193 21.1673
440187.......................................... 17.5872 18.3729 19.9478 18.6211
[[Page 27312]]
440189.......................................... 18.5252 22.2555 23.2866 21.3831
440192.......................................... 19.1705 19.1976 21.3228 19.9395
440193.......................................... 18.6999 19.9078 22.0345 20.2055
440194.......................................... 22.4562 21.9609 24.4629 23.0062
440197.......................................... 21.8503 22.5282 24.2661 22.9060
440200.......................................... 19.8078 18.7302 16.7752 18.4446
440203.......................................... 16.2861 16.9819 21.3888 18.3754
440210.......................................... 11.9815 12.7622 * 12.3704
440214.......................................... 28.0285 * * 28.0287
440215.......................................... 22.2928 * * 22.2928
440217.......................................... * 19.2834 23.3544 21.1703
440218.......................................... * * 20.1377 20.1377
440219.......................................... * * 18.2762 18.2762
440220.......................................... * * 22.1222 22.1221
450002.......................................... 21.4836 21.5141 24.0413 22.4014
450004.......................................... 16.7850 15.9452 * 16.4042
450005.......................................... 16.6396 16.6354 21.7110 18.0529
450007.......................................... 19.1910 18.0269 18.3073 18.4788
450008.......................................... 17.6582 19.3745 20.1817 19.0466
450010.......................................... 17.6677 19.8998 20.2928 19.2457
450011.......................................... 20.8102 20.2963 21.6599 20.9101
450014.......................................... 17.5815 19.8846 19.4805 18.9747
450015.......................................... 21.6773 22.9820 23.9140 22.8577
450016.......................................... 18.3456 19.1522 19.9783 19.1667
450018.......................................... 23.2293 21.9921 22.9508 22.6215
450020.......................................... 19.1153 18.4642 18.8688 18.8186
450021.......................................... 23.3630 23.7663 24.3718 23.8437
450023.......................................... 17.6360 19.2808 19.1645 18.7230
450024.......................................... 18.5985 19.5584 20.8938 19.7493
450028.......................................... 19.1658 19.5905 22.7775 20.4223
450029.......................................... 17.7425 19.9505 19.9198 19.2371
450031.......................................... 29.6945 29.6772 21.2734 25.9517
450032.......................................... 14.6530 20.8525 20.6076 18.3640
450033.......................................... 21.0222 21.3766 26.0361 22.7005
450034.......................................... 18.8823 19.5233 21.6149 19.9977
450035.......................................... 20.3599 20.3146 24.1791 21.4800
450037.......................................... 19.9140 19.6532 22.9781 20.8451
450039.......................................... 19.7176 20.4660 21.8243 20.6801
450040.......................................... 19.6370 24.8621 21.3097 22.1542
450042.......................................... 18.8357 20.6041 21.8886 20.4547
450044.......................................... 21.0909 23.4476 23.2984 22.5215
450046.......................................... 17.3631 20.2917 20.9220 20.0845
450047.......................................... 16.9028 15.9525 21.8840 18.0090
450050.......................................... 17.7209 19.1390 19.5171 18.7476
450051.......................................... 21.1008 23.0010 23.1281 22.3573
450052.......................................... 15.5890 20.3702 15.9400 17.2648
450053.......................................... 17.2781 19.3347 15.0735 17.2659
450054.......................................... 19.2431 25.3285 23.2915 22.8358
450055.......................................... 15.8526 16.4789 18.2235 16.8274
450056.......................................... 21.8605 22.5341 24.4197 22.9813
450058.......................................... 18.6172 20.0424 21.9588 20.1476
450059.......................................... 19.8240 21.4873 22.8792 21.4779
450063.......................................... 12.7211 15.1779 * 13.6764
450064.......................................... 19.7682 21.3929 18.6112 19.8410
450065.......................................... 23.3797 23.8471 25.0043 24.0958
450068.......................................... 23.3495 22.5626 23.4435 23.1149
450072.......................................... 18.0307 20.0134 20.3683 19.5324
450073.......................................... 16.5942 23.7700 19.2398 20.0099
450078.......................................... 13.2820 13.9324 15.0471 14.0206
450079.......................................... 20.6483 22.0609 23.9209 22.1935
450080.......................................... 18.6212 19.8414 21.0442 19.7978
450081.......................................... 17.5737 19.0276 19.0461 18.5365
450082.......................................... 16.8677 18.0688 16.6397 17.1813
[[Page 27313]]
450083.......................................... 23.3754 20.7446 22.4764 22.1790
450085.......................................... 20.0085 17.5001 18.0245 18.4510
450087.......................................... 21.9320 23.4141 24.6661 23.4257
450090.......................................... 15.5796 15.6090 15.5556 15.5807
450092.......................................... 17.9520 17.2058 16.0808 17.0569
450094.......................................... 23.2863 25.2158 31.6176 26.5357
450096.......................................... 18.6802 19.4430 20.1138 19.4265
450097.......................................... 19.7187 20.7653 22.2467 21.0001
450098.......................................... 19.0454 19.8469 20.1606 19.7427
450099.......................................... 20.4181 19.3493 21.4482 20.3831
450101.......................................... 17.7928 17.6368 20.1473 18.5186
450102.......................................... 19.8793 21.4361 18.0166 19.5784
450104.......................................... 17.0821 17.8219 19.7126 18.2038
450107.......................................... 24.1094 24.5034 23.1605 23.8913
450108.......................................... 15.2797 17.9596 18.4801 17.3161
450109.......................................... 10.5973 18.1085 16.0510 14.2577
450111.......................................... 21.4908 * * 21.4908
450112.......................................... 18.1026 17.9624 19.7041 18.5605
450113.......................................... 20.8306 20.7782 37.8953 21.1550
450119.......................................... 20.2030 20.1436 20.8840 20.4169
450121.......................................... 21.9198 22.0485 24.6090 22.7993
450123.......................................... 14.1755 17.5051 17.8629 16.2415
450124.......................................... 22.5208 22.9853 24.0333 23.2184
450126.......................................... 21.4789 22.9423 23.9298 22.7661
450128.......................................... 18.1446 18.7067 28.0211 21.3216
450130.......................................... 18.9211 20.2613 19.0153 19.4183
450131.......................................... 17.4168 18.1401 19.7316 18.4406
450132.......................................... 21.8089 20.8908 22.4680 21.7157
450133.......................................... 26.0763 24.5319 25.3928 25.3029
450135.......................................... 20.4068 21.7038 22.3664 21.5213
450137.......................................... 23.4346 22.8653 21.9645 22.7576
450140.......................................... 17.3370 19.6205 18.4142 18.4792
450143.......................................... 15.0871 17.8206 18.4456 17.0500
450144.......................................... 17.4309 21.9135 20.8064 20.0145
450145.......................................... 16.1895 18.0437 16.5468 16.9581
450146.......................................... 15.5030 17.4391 16.6809 16.5128
450147.......................................... 19.0477 20.3019 21.4266 20.2587
450148.......................................... 20.4923 21.4982 19.4973 20.4877
450149.......................................... 21.7219 22.6138 * 22.1667
450150.......................................... 17.8612 17.8804 * 17.8714
450151.......................................... 16.4209 16.3279 18.6100 17.0520
450152.......................................... 17.7265 19.6105 20.0480 19.2518
450153.......................................... 18.6514 20.9651 * 19.6822
450154.......................................... 13.9119 16.8748 16.3479 15.7387
450155.......................................... 13.3456 20.2582 18.4020 17.1145
450157.......................................... 15.3083 16.8569 17.8764 16.7446
450160.......................................... 10.6852 18.7780 20.7517 15.2676
450162.......................................... 21.9218 20.5032 26.0570 22.6007
450163.......................................... 17.8028 19.7675 19.8290 19.0858
450164.......................................... 17.7180 18.7103 22.6906 19.5847
450165.......................................... 17.3283 16.1010 16.4098 16.5904
450166.......................................... 11.0541 12.6627 13.5795 12.4215
450170.......................................... 14.3234 15.8525 13.1142 14.3736
450176.......................................... 17.2576 19.2397 19.1706 18.5577
450177.......................................... 15.2419 16.4503 17.2347 16.3235
450178.......................................... 16.0280 15.8597 19.1186 16.9564
450181.......................................... 18.6936 18.3600 17.8882 18.3181
450184.......................................... 20.0821 22.7744 24.3452 22.4382
450185.......................................... 11.5228 13.2015 14.2950 12.8871
450187.......................................... 18.5053 20.8105 22.3174 20.4825
450188.......................................... 15.1954 16.9800 17.5351 16.6019
450191.......................................... 20.9512 20.5883 23.2261 21.6512
450192.......................................... 21.2497 20.8315 20.1718 20.7147
[[Page 27314]]
450193.......................................... 23.1639 25.1215 25.6437 24.6806
450194.......................................... 20.7745 20.7152 22.1151 21.2200
450196.......................................... 17.8993 21.1226 20.3102 19.7302
450200.......................................... 19.2228 19.6496 20.4656 19.7649
450201.......................................... 17.1463 18.0646 19.2517 18.1592
450203.......................................... 19.3978 19.7978 23.1036 20.7628
450209.......................................... 20.0140 21.3218 23.3963 21.5758
450210.......................................... 16.3470 16.8532 16.7851 16.6843
450211.......................................... 18.8114 18.7305 20.0677 19.2205
450213.......................................... 19.0651 19.3440 21.1280 19.7979
450214.......................................... 20.5070 21.3448 22.4544 21.4482
450217.......................................... 12.7647 13.1840 11.3313 12.4053
450219.......................................... 17.6884 18.5534 21.3693 18.8542
450221.......................................... 15.2120 16.2308 19.6778 16.9127
450222.......................................... 19.8967 23.2779 23.4805 22.2795
450224.......................................... 20.1579 20.1723 19.7665 20.0338
450229.......................................... 16.7853 17.0346 17.9811 17.2535
450231.......................................... 19.1746 20.7709 21.0986 20.3555
450234.......................................... 16.3003 17.9478 21.8295 18.7188
450235.......................................... 16.3115 17.0143 18.4234 17.2758
450236.......................................... 16.4957 18.4551 17.1250 17.3256
450237.......................................... 19.0325 21.6497 21.6752 20.8141
450239.......................................... 17.8401 18.8416 19.3655 18.6917
450241.......................................... 16.4240 16.6046 17.4151 16.8266
450243.......................................... 13.6416 11.2035 17.7821 13.8172
450246.......................................... 16.7959 22.7940 20.7893 19.8488
450249.......................................... 11.7658 10.6467 13.1223 11.8062
450250.......................................... 13.6787 18.3361 12.8229 14.7303
450253.......................................... 13.2177 14.5492 16.6365 14.6878
450258.......................................... 16.7337 17.0724 18.3136 17.3431
450264.......................................... 14.5956 17.2825 13.5346 14.9127
450269.......................................... 12.7717 12.2970 13.4838 12.8458
450270.......................................... 14.4792 13.8881 12.3962 13.5856
450271.......................................... 16.7831 17.9570 18.3659 17.7341
450272.......................................... 18.4344 20.5888 21.3492 20.1697
450276.......................................... 14.0745 14.0779 12.8895 13.6150
450278.......................................... 15.2950 14.3931 15.2944 14.9802
450280.......................................... 22.2936 22.2648 22.3781 22.3117
450283.......................................... 15.1950 15.8224 16.9843 16.1315
450288.......................................... 18.8935 17.4817 17.4214 17.9418
450289.......................................... 20.3460 22.4656 19.9906 20.9466
450292.......................................... 20.5335 21.1511 22.8905 21.4277
450293.......................................... 16.2721 16.4077 17.7673 16.8504
450296.......................................... 22.3430 21.5998 20.4483 21.4253
450299.......................................... * 21.2754 22.9849 22.1397
450303.......................................... 12.8996 14.3353 16.1330 14.3646
450306.......................................... 14.2047 13.6333 15.5980 14.3658
450307.......................................... 17.0691 17.6757 19.6952 18.1345
450309.......................................... 13.3771 16.0363 16.5770 15.2473
450315.......................................... 21.4684 23.8151 26.4677 23.7712
450320.......................................... 20.6596 24.8602 24.7457 23.2764
450321.......................................... 14.7344 17.2289 17.4628 16.2569
450322.......................................... 29.1884 28.9834 17.9071 25.3849
450324.......................................... 19.1692 20.9081 24.0112 21.3590
450327.......................................... 13.3639 11.0983 14.3848 12.7752
450330.......................................... 19.8066 21.0921 22.9948 21.3142
450334.......................................... 13.8392 13.9812 14.2209 14.0138
450337.......................................... 25.5708 * * 25.5709
450340.......................................... * 19.2611 18.7179 18.9746
450341.......................................... * 20.8814 * 20.8814
450346.......................................... 18.9475 19.2769 20.1921 19.5923
450347.......................................... 19.3475 20.1899 21.7603 20.4764
450348.......................................... 13.3585 15.0069 15.3299 14.5667
[[Page 27315]]
450351.......................................... 19.3159 21.2842 21.6640 20.7344
450352.......................................... 20.1871 21.2035 21.8138 21.1211
450353.......................................... 16.0003 17.3274 19.5263 17.5681
450355.......................................... 11.8933 12.8876 13.9234 12.8974
450358.......................................... 23.0206 25.5767 25.9233 24.7613
450362.......................................... 18.1983 18.7687 20.6340 19.2155
450369.......................................... 15.3122 16.0667 16.5636 15.9500
450370.......................................... 16.1369 18.7539 17.0463 17.3593
450371.......................................... 16.0236 17.7591 17.3415 16.8971
450372.......................................... 22.0746 21.4050 23.1343 22.1317
450373.......................................... 17.9554 18.5716 17.7025 18.0874
450374.......................................... 15.1750 15.0146 15.2532 15.1489
450378.......................................... 23.4599 24.4143 25.8048 24.6304
450379.......................................... 22.8756 25.1931 29.0865 25.7747
450381.......................................... 16.7112 16.7237 18.7899 17.5371
450388.......................................... 19.7408 20.7989 22.4439 21.1046
450389.......................................... 18.8448 19.3156 20.7206 19.6586
450393.......................................... 22.4992 21.4405 23.5336 22.4798
450395.......................................... 18.0024 17.5236 18.6664 18.0895
450399.......................................... 15.3491 16.3333 19.1571 16.9654
450400.......................................... 18.6668 19.1345 20.1376 19.3717
450403.......................................... 22.8430 24.7657 24.6273 24.1287
450411.......................................... 15.1121 15.9165 16.9559 15.9781
450417.......................................... 15.3591 15.2713 16.1956 15.6177
450418.......................................... 21.9690 22.2511 25.1306 23.1136
450419.......................................... 23.2551 22.9522 26.4121 24.0600
450422.......................................... 28.0257 28.0395 28.5834 28.2238
450424.......................................... 18.7895 20.7634 22.0682 20.6438
450431.......................................... 22.0361 22.6766 22.7459 22.4890
450438.......................................... 15.4553 21.0474 18.4891 18.0730
450446.......................................... 20.7592 13.8011 14.1684 15.5340
450447.......................................... 18.0377 19.7532 21.0247 19.5725
450451.......................................... 18.2988 18.9519 20.1738 19.1894
450457.......................................... 19.6569 * * 19.6569
450460.......................................... 14.6523 15.9446 17.9487 16.1581
450462.......................................... 22.1144 22.5413 20.6169 21.6907
450464.......................................... 15.5908 15.8121 16.1987 15.8774
450465.......................................... 15.4731 19.3928 19.6579 17.7347
450467.......................................... 17.0004 18.9388 18.0994 17.9285
450469.......................................... 22.1930 22.0389 22.7741 22.3634
450473.......................................... 19.7148 18.3813 18.6003 18.8420
450475.......................................... 16.9269 19.0010 19.7305 18.5518
450484.......................................... 18.9825 19.5505 23.2881 20.6738
450488.......................................... 19.2173 22.0927 22.5650 21.2542
450489.......................................... 16.3584 17.8779 18.5941 17.5105
450497.......................................... 16.2997 15.9654 17.1327 16.4523
450498.......................................... 14.4713 15.9479 19.2985 16.4927
450508.......................................... 19.0991 19.3274 20.8183 19.8005
450514.......................................... 20.0144 20.7064 21.0116 20.6064
450517.......................................... 14.3191 17.6011 14.4247 15.4999
450518.......................................... 21.4873 20.7355 21.1015 21.1171
450523.......................................... 21.0393 23.8270 * 22.4523
450530.......................................... 21.1634 21.8988 23.3005 22.1616
450534.......................................... 20.1520 19.7410 22.7437 20.8137
450535.......................................... 21.0513 21.5449 24.0628 22.1998
450537.......................................... 20.1161 20.8849 22.5972 21.2300
450539.......................................... 18.7559 19.3681 18.9497 19.0285
450544.......................................... 23.6652 22.7282 11.0917 17.7372
450545.......................................... 20.2823 21.0792 23.9646 21.6831
450547.......................................... 18.1524 20.5049 23.1348 20.3331
450551.......................................... 16.6237 16.1437 17.7082 16.8161
450558.......................................... 20.7404 21.3116 21.4201 21.1518
450563.......................................... 22.0708 21.9935 27.5446 23.9001
[[Page 27316]]
450565.......................................... 17.3803 17.8058 17.5372 17.5748
450570.......................................... 19.0336 * * 19.0336
450571.......................................... 18.2784 19.5325 21.1391 19.6109
450573.......................................... 17.3518 17.6157 18.6233 17.8792
450574.......................................... 14.6128 14.8549 16.4851 15.3348
450575.......................................... 22.5621 24.0386 23.4900 23.3951
450578.......................................... 18.0925 17.2863 17.3010 17.5480
450580.......................................... 16.7374 17.8224 18.5657 17.7062
450583.......................................... 14.4411 15.9430 16.2818 15.5666
450584.......................................... 14.6735 14.9237 16.9020 15.4896
450586.......................................... 13.8248 14.7433 14.0478 14.1931
450587.......................................... 18.0219 18.0014 17.6532 17.8908
450591.......................................... 17.7795 18.6714 19.6229 18.7114
450596.......................................... 21.6729 21.9445 24.3714 22.6695
450597.......................................... 17.6179 19.0641 19.5574 18.7397
450603.......................................... 23.5572 23.4924 20.6138 22.5917
450604.......................................... 17.6582 18.7465 19.6304 18.7047
450605.......................................... 19.4580 19.7400 22.0210 20.3694
450609.......................................... 17.0986 14.1776 16.6870 15.9595
450610.......................................... 21.5191 23.5626 24.0548 23.1995
450614.......................................... 16.5754 * 18.5895 17.6527
450615.......................................... 15.2956 15.0621 17.3288 15.9012
450617.......................................... 20.8919 21.5004 22.7025 21.7511
450620.......................................... 16.0987 16.4330 17.1624 16.5652
450623.......................................... 23.1270 25.1122 25.4030 24.5910
450626.......................................... 18.4349 20.5225 17.7454 18.8435
450628.......................................... 18.6093 20.0411 17.8201 18.7790
450630.......................................... 20.9605 23.1840 24.7324 23.0079
450631.......................................... 21.6736 21.8940 22.6786 22.1007
450632.......................................... 13.9147 15.1416 14.8913 14.6301
450633.......................................... 19.4949 * * 19.4949
450634.......................................... 22.9877 23.0470 24.8258 23.7101
450638.......................................... 22.1704 23.8335 26.3653 24.1319
450639.......................................... 21.6421 23.0496 23.3156 22.6779
450641.......................................... 15.7578 15.3652 16.5960 15.8967
450643.......................................... 16.8152 18.9088 20.2000 18.7134
450644.......................................... 22.7721 24.5834 25.8182 24.5287
450646.......................................... 19.1433 23.1240 21.8489 21.2674
450647.......................................... 24.2763 25.0549 26.7193 25.3639
450648.......................................... 15.0305 14.4884 16.9698 15.5262
450649.......................................... 16.6577 16.8505 17.5760 17.0475
450651.......................................... 22.7112 25.4679 26.9228 25.1265
450652.......................................... 17.2445 * * 17.2446
450653.......................................... 19.2349 20.2436 22.7236 20.7352
450654.......................................... 14.5423 15.5858 16.3616 15.4967
450656.......................................... 18.2606 18.5874 20.7824 19.2080
450658.......................................... 17.2630 19.4139 19.2521 18.6539
450659.......................................... 23.0108 22.9344 26.0224 24.0406
450661.......................................... 18.9071 19.5504 20.0716 19.5103
450662.......................................... 19.3152 20.7973 26.1213 22.0200
450665.......................................... 16.1319 14.5158 15.8149 15.5054
450666.......................................... 20.2549 * * 20.2549
450668.......................................... 21.0972 21.2002 24.0081 22.0964
450669.......................................... 21.6746 22.5150 25.0200 23.1112
450670.......................................... 20.2632 19.7696 19.7416 19.8975
450672.......................................... 21.4927 23.2623 25.3111 23.3562
450673.......................................... 13.7005 14.9115 16.8250 15.1732
450674.......................................... 22.2426 21.9624 24.7431 23.0384
450675.......................................... 21.4479 23.3954 24.8661 23.3355
450677.......................................... 20.6556 21.7366 23.2841 21.9181
450678.......................................... 24.1301 25.1841 28.1917 25.8918
450683.......................................... 22.8699 22.1965 24.3566 23.1268
450684.......................................... 21.9962 22.2380 23.8945 22.7570
[[Page 27317]]
450686.......................................... 16.4632 17.4746 17.9181 17.2988
450688.......................................... 20.1831 21.7691 21.7922 21.3124
450690.......................................... 22.4707 27.2399 33.1576 27.0095
450694.......................................... 18.1872 18.5520 21.4785 19.2847
450697.......................................... 19.4949 19.4424 20.8952 19.9640
450698.......................................... 15.4750 16.5111 18.1764 16.7102
450700.......................................... 15.9050 14.2055 17.3457 15.8451
450702.......................................... 21.3739 19.8094 22.2953 21.1028
450704.......................................... 20.7987 18.1835 * 19.2723
450705.......................................... 22.1809 18.7138 19.4435 19.9245
450706.......................................... 22.0884 22.4329 * 22.2641
450709.......................................... 22.1490 22.0123 23.4246 22.5690
450711.......................................... 19.8581 20.8047 23.6594 21.4663
450712.......................................... 15.9298 11.1086 18.4546 14.6487
450713.......................................... 22.6986 23.6189 24.4002 23.6310
450715.......................................... 22.5988 24.8068 14.9630 19.6234
450716.......................................... 20.9074 20.8913 24.8614 22.2839
450717.......................................... 20.6551 22.0243 * 21.3435
450718.......................................... 22.1765 23.0051 23.6180 22.9900
450723.......................................... 20.8213 22.0633 22.8048 21.9009
450724.......................................... 20.3706 23.3799 19.6335 21.4203
450727.......................................... 17.9172 24.6125 16.0843 19.3135
450728.......................................... 19.8879 14.9265 10.3991 14.3301
450730.......................................... 23.0054 24.5952 27.8476 25.3002
450733.......................................... 20.2199 21.9921 23.8143 22.0738
450742.......................................... 21.8392 22.8135 25.1295 23.3180
450743.......................................... 19.6015 20.5017 23.6131 21.3065
450746.......................................... 30.2657 14.6683 11.1672 15.8134
450747.......................................... 20.3914 20.3870 21.5883 20.8604
450749.......................................... 19.1678 18.7138 17.6324 18.4286
450750.......................................... 13.8098 * * 13.8098
450751.......................................... 19.9995 19.8170 25.5869 21.1754
450754.......................................... 16.7145 17.8497 17.9189 17.5560
450755.......................................... 19.8743 20.0667 18.6084 19.5138
450757.......................................... 14.9434 15.6425 17.2683 15.9355
450758.......................................... 19.0221 22.6196 22.8713 21.5676
450760.......................................... 19.2225 20.4209 23.2959 20.7991
450761.......................................... 15.7681 14.6511 15.3222 15.2265
450763.......................................... 18.6092 18.9713 19.8939 19.1937
450766.......................................... 23.3879 25.4057 27.1863 25.3095
450769.......................................... 18.4163 17.9879 18.3030 18.2402
450770.......................................... 19.0183 20.0632 18.7369 19.2440
450771.......................................... 21.8268 21.6946 22.9736 22.1610
450774.......................................... 16.2948 * 21.7906 18.6936
450775.......................................... 21.3504 22.6526 23.5785 22.5291
450776.......................................... 14.1720 13.4263 14.6695 14.0866
450777.......................................... 19.0380 18.3119 21.4240 19.6554
450779.......................................... 21.6642 22.6216 27.8925 23.9052
450780.......................................... 19.0914 20.0824 21.6549 20.3201
450788.......................................... 19.6469 19.9817 21.4368 20.3148
450795.......................................... 22.5753 27.0250 19.1371 22.4874
450796.......................................... 19.2059 26.8539 19.9522 22.5780
450797.......................................... 16.4923 20.2356 18.6839 18.3681
450801.......................................... 17.9548 18.0598 19.7124 18.5711
450802.......................................... 17.1435 18.2460 * 17.6977
450803.......................................... 21.6653 37.0925 23.8343 26.2012
450804.......................................... 19.0893 20.5225 22.7169 20.8248
450806.......................................... * 20.7906 * 20.7906
450807.......................................... 13.4306 18.4410 16.8928 15.8881
450808.......................................... 17.4917 18.1728 18.6555 18.1215
450809.......................................... 19.7899 21.9845 23.1978 21.6113
450811.......................................... 19.9168 21.6115 22.7583 21.5237
450813.......................................... 14.5392 15.3780 21.7208 16.6296
[[Page 27318]]
450815.......................................... 21.2741 * * 21.2742
450819.......................................... 16.5521 * * 16.5521
450820.......................................... 26.8348 24.6542 26.9120 26.1797
450822.......................................... 22.8556 24.8702 26.7821 24.9818
450823.......................................... * 17.9756 13.0130 14.5379
450824.......................................... * 25.7488 * 25.7488
450825.......................................... * 16.0793 18.2159 17.2695
450827.......................................... * 20.1310 29.5838 24.8201
450828.......................................... * 19.2902 20.8735 20.1257
450829.......................................... * 14.7121 14.4463 14.5541
450830.......................................... * * 23.0204 23.0205
450832.......................................... * * 24.8572 24.8572
450833.......................................... * * 18.3195 18.3196
450834.......................................... * * 21.7217 21.7217
450835.......................................... * * 24.2285 24.2285
450837.......................................... * * 31.8430 31.8432
460001.......................................... 22.2735 23.5485 24.8844 23.5856
460003.......................................... 22.6289 22.9549 26.5141 23.9755
460004.......................................... 21.7234 23.1289 24.3409 23.0686
460005.......................................... 22.5252 23.0189 25.0063 23.5075
460006.......................................... 21.0700 22.1648 23.4200 22.2290
460007.......................................... 21.1922 22.0409 23.3603 22.2561
460008.......................................... 19.1153 22.6808 24.8233 22.3133
460009.......................................... 22.5295 23.1933 24.5865 23.4290
460010.......................................... 22.4948 24.0907 25.1240 23.9360
460011.......................................... 19.7674 25.3818 21.2634 21.8917
460013.......................................... 20.1936 21.2360 23.1467 21.5125
460014.......................................... 18.5370 * 22.5784 20.9623
460015.......................................... 21.0470 22.4872 23.1068 22.2481
460016.......................................... 21.9105 19.0910 18.7453 19.8107
460017.......................................... 18.9929 19.0724 20.7789 19.6010
460018.......................................... 17.0063 17.0385 16.7143 16.9128
460019.......................................... 17.8690 19.3442 18.1995 18.4514
460020.......................................... 17.2663 18.1542 15.2162 16.7463
460021.......................................... 21.5174 23.1368 23.8565 22.9024
460022.......................................... 21.3614 20.7539 21.8443 21.3226
460023.......................................... 22.9265 24.1825 25.0874 24.0957
460025.......................................... 17.3494 17.4070 22.3100 18.8099
460026.......................................... 20.2576 21.1759 21.9316 21.1444
460027.......................................... 22.2955 21.4833 22.7488 22.1620
460029.......................................... 20.8366 23.7148 24.4379 23.0146
460030.......................................... 17.1383 18.7655 21.2546 18.9564
460032.......................................... 21.4832 21.0286 21.2715 21.2538
460033.......................................... 19.2664 20.2389 21.7215 20.4433
460035.......................................... 16.1685 15.6979 16.9657 16.2272
460036.......................................... 23.4573 24.2651 23.9909 23.9286
460037.......................................... 17.7399 19.0115 20.0323 18.9515
460039.......................................... 24.4808 24.5134 26.3795 25.1512
460041.......................................... 20.2035 21.6676 23.5132 21.8727
460042.......................................... 19.5662 19.7531 22.0844 20.5371
460043.......................................... 23.2819 25.1366 26.0277 24.8166
460044.......................................... 21.8485 23.6604 24.7139 23.4328
460047.......................................... 22.7524 23.5447 22.8135 23.0271
460049.......................................... 20.8283 21.5241 21.9358 21.5104
460051.......................................... 22.1758 21.8950 22.7540 22.2835
460052.......................................... 19.8961 20.1989 23.1718 21.0691
460053.......................................... * * 23.2273 23.2274
470001.......................................... 21.3817 21.7774 23.5882 22.3065
470003.......................................... 22.0563 23.3612 24.1739 23.1995
470004.......................................... 18.1879 17.3576 18.4943 18.0068
470005.......................................... 23.1808 22.6589 24.9625 23.6347
470006.......................................... 20.2829 21.0835 21.6036 21.0098
470008.......................................... 20.1969 20.3833 20.7659 20.4458
[[Page 27319]]
470010.......................................... 21.0616 22.3913 23.2072 22.2567
470011.......................................... 22.2415 24.1306 24.6034 23.6561
470012.......................................... 18.9444 19.8831 20.5072 19.7941
470015.......................................... 20.2125 21.8204 25.6286 22.6045
470018.......................................... 21.2406 24.8493 21.2904 22.3634
470020.......................................... 21.5688 21.9911 22.0333 21.8520
470023.......................................... 21.7139 22.5334 24.1395 22.7760
470024.......................................... 21.9807 23.2738 22.4659 22.5822
490001.......................................... 20.0570 21.4952 22.1209 21.2627
490002.......................................... 15.7365 16.5198 17.5098 16.5736
490003.......................................... 20.3237 20.7688 20.9782 20.6753
490004.......................................... 19.7074 20.7616 22.7571 21.0703
490005.......................................... 21.3318 23.1708 25.2213 23.2687
490006.......................................... 12.3253 19.8977 13.4277 15.2731
490007.......................................... 19.8938 20.7896 22.2638 20.9786
490009.......................................... 23.7659 24.7602 25.2181 24.6030
490011.......................................... 19.8042 19.8179 19.9733 19.8664
490012.......................................... 15.2965 16.0994 15.8346 15.7118
490013.......................................... 18.2396 18.3901 19.5094 18.7096
490014.......................................... 23.5266 27.8907 * 25.5759
490015.......................................... 20.0667 21.4500 21.2557 20.9648
490017.......................................... 19.3854 19.6594 20.7691 19.9104
490018.......................................... 18.5508 19.8955 22.0810 20.2089
490019.......................................... 21.0124 21.6790 23.3077 22.0282
490020.......................................... 19.3424 20.9212 21.2094 20.4866
490021.......................................... 20.0496 21.2263 22.2537 21.2008
490022.......................................... 22.3380 24.3008 24.5122 23.7681
490023.......................................... 21.5683 22.8400 24.9733 23.1948
490024.......................................... 18.4314 19.7491 21.2619 19.8335
490027.......................................... 16.7556 17.5178 20.3644 18.2452
490030.......................................... 8.6446 * * 8.6446
490031.......................................... 16.0003 17.4262 18.4826 17.3314
490032.......................................... 21.4037 22.2041 23.5691 22.3503
490033.......................................... 19.2908 23.2088 24.4370 22.3633
490037.......................................... 17.0113 17.2117 17.5103 17.2485
490038.......................................... 17.6324 18.6012 18.1405 18.1142
490040.......................................... 24.1266 25.5461 27.0513 25.6394
490041.......................................... 18.7987 17.9942 19.9314 18.8986
490042.......................................... 17.0972 18.1864 19.5127 18.3230
490043.......................................... 22.1068 23.5367 25.4354 23.6479
490044.......................................... 19.7842 18.4845 20.8739 19.7388
490045.......................................... 20.5558 22.5238 24.7131 22.7244
490046.......................................... 19.9102 19.8518 21.9164 20.5668
490047.......................................... 18.7614 20.1660 19.8220 19.5730
490048.......................................... 19.5417 20.9110 22.3255 20.9493
490050.......................................... 23.3668 23.8519 26.1521 24.5290
490052.......................................... 16.4787 18.5693 19.2480 18.1097
490053.......................................... 16.8410 17.7363 18.6541 17.7531
490054.......................................... 19.5780 22.5136 18.7738 20.4647
490057.......................................... 20.3160 21.1871 22.1945 21.2773
490059.......................................... 21.4801 24.1516 23.3895 22.9645
490060.......................................... 18.5917 19.3525 20.6028 19.5408
490063.......................................... 26.1930 28.0906 30.4267 28.2207
490066.......................................... 19.8352 21.5920 22.1034 21.2122
490067.......................................... 17.8487 18.6469 20.4058 18.9938
490069.......................................... 20.7582 18.8335 20.6957 20.1008
490071.......................................... 23.3511 24.1882 25.4677 24.4329
490073.......................................... 26.0957 * 27.6711 26.9865
490075.......................................... 19.2156 20.5801 22.3229 20.7337
490077.......................................... 22.6504 21.9175 22.2643 22.2859
490079.......................................... 17.7016 17.5839 19.2196 18.1709
490084.......................................... 18.0555 18.9679 19.8598 18.9692
490085.......................................... 17.6158 19.4261 20.6383 19.2465
[[Page 27320]]
490088.......................................... 17.9141 19.1924 19.7646 18.9625
490089.......................................... 18.2290 19.7936 21.1522 19.7626
490090.......................................... 17.5799 19.2094 20.3015 19.0319
490091.......................................... 25.0272 23.7493 * 24.4545
490092.......................................... 16.4360 27.1805 23.8364 21.5391
490093.......................................... 17.8275 19.1131 20.7412 19.2089
490094.......................................... 22.3033 20.2020 21.9886 21.4787
490097.......................................... 16.9518 16.6563 17.9929 17.2212
490098.......................................... 16.0488 18.5133 19.7116 18.0649
490099.......................................... 18.3985 19.2604 20.7724 19.4805
490101.......................................... 23.5553 25.7804 28.5200 26.0299
490104.......................................... 40.2529 17.1683 28.0286 24.6486
490105.......................................... 21.4428 28.7831 40.6822 26.6520
490106.......................................... 26.3821 31.8566 31.6541 29.5471
490107.......................................... 22.9283 23.9962 26.5312 24.6073
490108.......................................... 24.1232 24.8596 28.7277 25.7440
490109.......................................... 25.9475 23.0609 28.0978 25.5419
490110.......................................... 18.1561 18.8042 23.6080 20.0833
490111.......................................... 17.8510 19.9552 19.4041 19.0697
490112.......................................... 22.1162 23.2843 23.6028 23.0255
490113.......................................... 23.9043 26.1840 28.0893 26.0992
490114.......................................... 18.0359 18.8920 19.9725 18.9850
490115.......................................... 16.8537 18.4499 19.9150 18.4166
490116.......................................... 17.2040 18.2935 19.7007 18.4196
490117.......................................... 14.7944 17.1723 15.6078 15.8681
490118.......................................... 23.2022 24.2668 25.2230 24.2345
490119.......................................... 18.6046 18.9535 20.0944 19.1567
490120.......................................... 20.5777 20.6828 22.2389 21.1886
490122.......................................... 23.8198 26.6681 27.3509 25.9831
490123.......................................... 19.3056 20.0920 20.9506 20.1282
490124.......................................... 21.3818 23.6526 21.3713 22.1870
490126.......................................... 20.4294 19.0782 20.3266 19.9000
490127.......................................... 16.5993 17.6437 17.8070 17.3281
490129.......................................... 28.6868 * * 28.6863
490130.......................................... 17.6943 18.6406 18.6038 18.3141
490132.......................................... 18.4671 19.1742 19.5850 19.0428
500001.......................................... 24.4829 25.3478 25.8406 25.2431
500002.......................................... 19.8476 22.9942 * 21.4076
500003.......................................... 24.4333 25.1200 27.6238 25.7781
500005.......................................... 24.3870 26.2066 29.9352 26.8369
500007.......................................... 21.9911 24.7889 * 23.2199
500008.......................................... 26.1737 27.2852 28.9380 27.5261
500011.......................................... 24.6554 25.7263 27.6762 26.0196
500012.......................................... 24.2799 24.5450 25.4367 24.7615
500014.......................................... 24.0990 25.0490 27.4189 25.5343
500015.......................................... 24.9923 25.9465 27.4387 26.1498
500016.......................................... 24.9439 25.1227 27.7863 25.9574
500019.......................................... 23.2054 23.5730 25.7691 24.2429
500021.......................................... 27.6490 25.9403 26.4648 26.6119
500023.......................................... 27.1025 32.3079 23.9513 27.3082
500024.......................................... 26.6452 26.2113 27.2884 26.7211
500025.......................................... 24.4825 27.3697 27.6755 26.4578
500026.......................................... 26.9884 26.6108 28.7532 27.4597
500027.......................................... 25.1125 27.7429 28.7063 27.2499
500028.......................................... 18.9556 19.0261 19.9288 19.3024
500029.......................................... 18.5042 19.3130 19.7750 19.2311
500030.......................................... 26.3828 28.5297 29.0458 28.0229
500031.......................................... 23.6099 25.8542 26.0740 25.1801
500033.......................................... 22.5462 23.8994 25.4345 23.9873
500036.......................................... 23.6333 25.1255 25.4753 24.7809
500037.......................................... 21.4059 22.1774 23.3808 22.3148
500039.......................................... 24.0007 25.4225 26.0196 25.1368
500041.......................................... 25.4376 24.7070 24.9005 25.0014
[[Page 27321]]
500043.......................................... 22.0466 24.1745 26.6451 24.4187
500044.......................................... 24.2212 24.7816 27.0880 25.3901
500045.......................................... 24.0526 24.6265 8.0818 14.8642
500048.......................................... 20.3207 20.6333 22.9938 21.3649
500049.......................................... 24.5997 26.5857 25.9142 25.6732
500050.......................................... 22.6563 23.0804 25.0907 23.6590
500051.......................................... 25.9447 26.7628 26.9538 26.5713
500053.......................................... 22.8399 24.2492 25.7217 24.2895
500054.......................................... 23.8089 25.7815 27.1634 25.6068
500055.......................................... 23.8622 23.7988 25.3095 24.3502
500057.......................................... 19.0479 20.5812 21.0357 20.2825
500058.......................................... 24.1106 26.5679 27.2582 26.0406
500059.......................................... 26.6270 25.3528 26.1943 26.0221
500060.......................................... 28.3655 29.6030 32.2049 30.0629
500061.......................................... 20.8624 24.5908 27.5845 24.2316
500062.......................................... 19.0557 19.1685 20.9284 19.6775
500064.......................................... 26.7000 27.5791 29.5696 27.9754
500065.......................................... 23.5671 24.0966 26.5881 24.7506
500068.......................................... 19.2638 20.9278 20.2336 20.1549
500069.......................................... 21.4542 22.4158 24.2983 22.7883
500071.......................................... 19.1428 22.3253 23.2071 21.4408
500072.......................................... 25.2001 25.7734 27.5706 26.2080
500073.......................................... 21.7698 22.5222 21.0414 21.7592
500074.......................................... 19.5981 20.6120 21.9018 20.7646
500077.......................................... 23.9410 24.5695 26.6614 25.0769
500079.......................................... 23.1041 24.7946 27.1775 25.0691
500080.......................................... 18.3883 18.8188 21.1121 19.4633
500084.......................................... 24.4044 25.0556 26.3627 25.3208
500085.......................................... 20.4517 20.7422 21.0707 20.7661
500086.......................................... 22.8829 24.2556 25.9705 24.3779
500088.......................................... 25.2478 26.4212 30.1689 27.0767
500089.......................................... 19.7166 20.3478 21.0601 20.3618
500090.......................................... 20.4429 21.7716 * 21.0547
500092.......................................... 19.2028 20.3058 20.8601 20.1437
500094.......................................... 15.7866 17.6625 * 16.7064
500096.......................................... 23.3564 25.1135 25.9490 24.7500
500097.......................................... 20.8774 21.4423 21.8841 21.3903
500098.......................................... 15.2040 17.8453 17.1392 16.7726
500101.......................................... 15.8000 19.8614 * 17.6277
500102.......................................... 21.8963 23.1307 * 22.5307
500104.......................................... 24.9389 24.7875 26.8007 25.5111
500106.......................................... 19.1465 17.1066 21.5532 19.1127
500107.......................................... 17.9489 17.4641 20.4959 18.5615
500108.......................................... 28.6229 26.1609 27.6367 27.4719
500110.......................................... 22.9775 23.5941 24.8448 23.8174
500118.......................................... 24.8034 24.7875 26.1971 25.2739
500119.......................................... 22.1192 23.9939 25.1576 23.7715
500122.......................................... 23.5264 24.4462 22.2238 23.3778
500123.......................................... 19.6646 21.7133 24.4350 21.6023
500124.......................................... 23.7742 24.6591 26.2994 25.0718
500125.......................................... 14.7910 15.6304 18.4512 16.1340
500129.......................................... 25.4685 25.2082 27.1253 25.9641
500132.......................................... 23.1822 21.9915 22.5293 22.5899
500134.......................................... 17.2430 15.9791 25.9538 18.4162
500139.......................................... 22.3053 23.7993 27.7067 24.5705
500141.......................................... 29.9695 28.1014 28.1441 28.6426
500143.......................................... 18.2570 18.7523 19.0982 18.7216
510001.......................................... 20.0429 20.2514 21.4247 20.5803
510002.......................................... 17.6392 19.1517 21.0299 19.3055
510005.......................................... 13.8621 13.8641 14.7332 14.1611
510006.......................................... 19.9609 19.9760 21.0214 20.3316
510007.......................................... 21.6761 22.9326 23.1306 22.5933
510008.......................................... 19.0513 19.9176 22.7595 20.6320
[[Page 27322]]
510012.......................................... 15.6089 15.8596 16.7710 16.1127
510013.......................................... 19.5798 18.3486 19.7937 19.2416
510015.......................................... 16.7311 17.1595 17.9040 17.2636
510018.......................................... 18.5358 18.3023 19.9490 18.9487
510020.......................................... 14.1211 15.7512 * 14.9242
510022.......................................... 21.5770 21.4336 22.0584 21.7005
510023.......................................... 16.7777 17.6516 17.9267 17.4783
510024.......................................... 18.7461 19.6521 20.7521 19.7179
510026.......................................... 13.7952 14.8785 16.5389 14.9496
510027.......................................... 18.5945 20.5222 19.8205 19.6589
510028.......................................... 19.9208 22.4826 24.6543 22.2359
510029.......................................... 18.4668 18.9000 19.8048 19.0629
510030.......................................... 17.7603 19.2558 19.8220 18.9626
510031.......................................... 18.6341 19.3049 20.5742 19.5716
510033.......................................... 18.4718 19.6900 19.6921 19.3132
510035.......................................... 18.3164 21.8290 * 20.0924
510036.......................................... 13.8786 15.0266 14.0926 14.3186
510038.......................................... 15.5576 15.9821 16.1016 15.8882
510039.......................................... 17.1461 17.4002 17.6190 17.3855
510043.......................................... 13.1308 14.4202 15.5857 14.3831
510046.......................................... 18.5896 18.7424 19.2806 18.8709
510047.......................................... 20.8101 21.2885 22.1953 21.4251
510048.......................................... 17.1647 15.2886 16.3761 16.2789
510050.......................................... 18.4036 18.3964 18.9990 18.5986
510053.......................................... 17.5798 18.1046 18.1054 17.9357
510055.......................................... 24.2133 25.6333 27.7422 25.8187
510058.......................................... 18.4501 18.6025 20.1104 19.0814
510059.......................................... 16.1044 17.3844 18.1544 17.1696
510061.......................................... 14.1968 14.6774 14.8848 14.5883
510062.......................................... 18.1588 19.7202 21.0482 19.6174
510067.......................................... 17.3067 17.8816 18.0113 17.7501
510068.......................................... 23.0452 19.4299 19.9056 20.6790
510070.......................................... 18.7091 18.6226 20.0974 19.1353
510071.......................................... 18.0278 18.8766 19.4029 18.7564
510072.......................................... 15.9257 16.5279 18.4566 16.9820
510077.......................................... 18.2947 20.4521 20.9153 19.8338
510080.......................................... 16.3453 19.7131 21.5661 18.8545
510081.......................................... 11.9701 10.4972 * 11.2092
510082.......................................... 13.5946 16.0014 17.2891 15.5840
510084.......................................... 13.5339 14.9683 16.1904 14.8887
510085.......................................... 18.6227 19.0175 20.6364 19.4471
510086.......................................... 14.2241 16.3413 16.3051 15.6167
510088.......................................... 14.8854 16.2850 16.4373 15.8902
520002.......................................... 19.6755 20.2691 21.9073 20.6570
520003.......................................... 18.7956 18.7507 20.4234 19.3853
520004.......................................... 20.4591 21.1549 22.6309 21.4055
520006.......................................... 21.4884 22.4099 22.0238 21.9690
520007.......................................... 18.4629 18.3959 19.4507 18.7649
520008.......................................... 24.9395 24.4927 26.0931 25.2072
520009.......................................... 21.4638 19.8142 20.5615 20.5741
520010.......................................... 22.3311 25.5623 26.4047 24.7952
520011.......................................... 21.5223 21.6945 22.7880 22.0154
520013.......................................... 20.5944 22.1009 23.1173 21.9777
520014.......................................... 18.0841 19.2760 20.4282 19.2712
520015.......................................... 19.7672 21.0428 22.8094 21.2438
520016.......................................... 18.4320 19.5656 * 18.9788
520017.......................................... 19.4780 21.1409 21.7542 20.8166
520018.......................................... 21.5279 22.1929 22.3315 22.0344
520019.......................................... 20.9164 21.8870 22.6895 21.8682
520021.......................................... 21.9531 22.8484 24.1284 23.0293
520024.......................................... 14.4750 16.4879 17.5368 16.1948
520025.......................................... 20.3838 21.9529 23.3835 21.9488
520026.......................................... 20.8546 22.4779 25.0504 22.8714
[[Page 27323]]
520027.......................................... 21.5868 22.1450 23.6595 22.5109
520028.......................................... 22.5941 22.0333 24.3592 23.0143
520029.......................................... 21.4197 21.5561 22.8724 21.9345
520030.......................................... 21.6311 22.7239 23.9474 22.8336
520031.......................................... 20.9875 21.2809 22.9721 21.7580
520032.......................................... 21.1069 24.1092 22.7220 22.6429
520033.......................................... 20.2520 21.0088 22.2650 21.1839
520034.......................................... 20.4307 21.5275 18.8561 20.0847
520035.......................................... 18.7135 19.8917 20.8563 19.8607
520037.......................................... 21.6017 23.0801 25.0587 23.2977
520038.......................................... 20.6130 21.4208 23.1036 21.7099
520039.......................................... 23.3687 21.1719 22.9348 22.4321
520040.......................................... 21.2023 23.0710 21.5671 21.9307
520041.......................................... 18.4117 18.2997 22.6216 19.7373
520042.......................................... 19.5466 20.6354 21.9935 20.7535
520044.......................................... 19.1877 21.4913 22.7626 21.1506
520045.......................................... 21.2427 21.9812 24.1624 22.4304
520047.......................................... 20.3487 21.0370 22.5686 21.3314
520048.......................................... 19.8926 20.3488 19.3461 19.8547
520049.......................................... 20.1667 21.8271 22.7424 21.6003
520051.......................................... 24.0460 23.4366 25.0827 24.1747
520053.......................................... 18.0851 18.9512 20.8040 19.2839
520054.......................................... 16.8363 16.6278 18.1045 17.2001
520057.......................................... 19.8492 20.6959 20.4601 20.3548
520058.......................................... 21.2500 23.6794 23.2907 22.7126
520059.......................................... 21.5796 22.1618 24.1863 22.6609
520060.......................................... 18.8232 20.3357 21.1271 20.1183
520062.......................................... 19.7038 21.2865 23.7166 21.6639
520063.......................................... 20.5262 21.2774 23.3037 21.7486
520064.......................................... 22.0917 23.8181 21.6302 22.5247
520066.......................................... 24.0087 25.4528 23.9212 24.4126
520068.......................................... 19.6855 20.6112 21.4413 20.5790
520069.......................................... 20.1770 21.7233 32.6484 21.3815
520070.......................................... 19.4261 20.0096 22.0590 20.5199
520071.......................................... 19.9866 22.0066 23.4832 21.8338
520074.......................................... 20.9007 21.6636 21.9124 21.4827
520075.......................................... 20.7301 22.1894 23.7322 22.2613
520076.......................................... 19.5878 20.6155 22.2993 20.8518
520077.......................................... 18.7119 18.1077 * 18.3984
520078.......................................... 21.7545 21.7414 23.0727 22.1680
520083.......................................... 23.5787 24.2401 25.3591 24.3864
520084.......................................... 23.5446 21.8102 24.7909 23.3951
520087.......................................... 20.7821 22.2579 22.8173 21.9819
520088.......................................... 21.8931 22.3921 23.8938 22.6992
520089.......................................... 22.1055 23.2335 24.4411 23.2699
520090.......................................... 20.3645 20.9069 21.9482 21.0730
520091.......................................... 20.9440 22.2218 19.2575 20.7952
520092.......................................... 18.6248 19.7181 21.8662 20.1341
520094.......................................... 20.6179 21.3082 22.3925 21.4517
520095.......................................... 18.6425 21.9177 25.1402 21.7601
520096.......................................... 20.6668 21.6803 21.2295 21.2059
520097.......................................... 20.8016 22.2375 23.6512 22.2609
520098.......................................... 23.4707 25.0055 25.5111 24.6770
520100.......................................... 19.4788 20.5366 21.7072 20.6024
520101.......................................... 19.9875 20.0164 19.5272 19.8623
520102.......................................... 21.0138 22.3640 23.7739 22.4092
520103.......................................... 20.1092 22.2765 23.5984 22.0082
520107.......................................... 21.7907 23.8421 25.0837 23.5365
520109.......................................... 19.7609 20.3208 20.0009 20.0293
520110.......................................... 21.0055 22.3923 23.4435 22.3140
520111.......................................... 17.7673 18.2744 26.9667 20.3598
520112.......................................... 18.9577 17.6226 17.8738 18.0211
520113.......................................... 21.8852 23.1852 24.2508 23.1332
[[Page 27324]]
520114.......................................... 17.8476 18.5767 21.9848 19.3865
520115.......................................... 19.2248 21.4279 23.4674 21.4477
520116.......................................... 20.6922 22.2741 23.9066 22.2707
520117.......................................... 18.3963 19.3653 21.9443 19.9279
520118.......................................... 14.8626 13.9920 * 14.4086
520121.......................................... 20.8492 20.9422 23.1869 21.6934
520122.......................................... 16.9335 16.9905 18.8016 17.5509
520123.......................................... 17.7986 19.8134 21.0426 19.6355
520124.......................................... 17.9205 19.2621 21.1327 19.4570
520130.......................................... 16.6873 18.8845 20.0277 18.5254
520131.......................................... 20.2591 21.0400 22.4994 21.3057
520132.......................................... 18.1630 18.2634 19.5140 18.6382
520134.......................................... 18.8150 19.6881 20.8502 19.7907
520135.......................................... 17.3476 18.1026 18.8254 18.0936
520136.......................................... 20.9050 21.3966 22.9085 21.7252
520138.......................................... 22.5599 23.1498 25.1434 23.6620
520139.......................................... 21.4042 22.8070 23.7727 22.6778
520140.......................................... 22.3671 22.5459 23.5622 22.8201
520142.......................................... 21.9432 21.4120 24.1969 22.4917
520144.......................................... 19.9120 20.5864 22.3985 20.9729
520145.......................................... 18.7958 20.3461 25.0771 20.8014
520146.......................................... 18.2370 18.6337 19.4025 18.7800
520148.......................................... 19.1502 20.5075 22.4299 20.7682
520149.......................................... 12.8928 13.8614 * 13.3481
520151.......................................... 18.7070 19.3362 20.1995 19.4436
520152.......................................... 22.5980 26.2402 21.1817 22.9787
520153.......................................... 17.0863 18.5986 18.7375 18.1335
520154.......................................... 19.5994 21.0486 23.2635 21.3043
520156.......................................... 20.9638 20.7808 23.7157 21.8343
520157.......................................... 19.6008 21.6821 23.1495 21.4552
520159.......................................... 17.7649 21.8783 * 19.8043
520160.......................................... 20.5154 21.5871 22.9475 21.7239
520161.......................................... 20.1102 21.4038 22.1857 21.2456
520170.......................................... 21.9857 23.0867 25.0744 23.3943
520171.......................................... 18.0785 18.1844 11.2340 15.1101
520173.......................................... 20.9209 23.2955 24.4722 22.8643
520177.......................................... 24.0139 25.0908 27.5560 25.5340
520178.......................................... 20.9010 23.1509 22.3193 22.0890
520189.......................................... * 22.0889 23.1658 22.6212
530002.......................................... 21.0560 23.0582 23.8852 22.6216
530003.......................................... 15.9523 17.1646 * 16.5866
530004.......................................... 13.3788 17.4672 * 15.3173
530005.......................................... 15.3255 18.4391 19.2049 17.7470
530006.......................................... 19.1305 20.7661 21.3429 20.4783
530007.......................................... 17.7897 18.5286 22.3309 19.6133
530008.......................................... 19.0113 19.5386 21.8714 20.1106
530009.......................................... 21.7795 23.5839 22.0451 22.4288
530010.......................................... 13.9536 17.8687 21.7124 17.2974
530011.......................................... 19.4606 19.9212 22.5720 20.6678
530012.......................................... 21.1854 22.5084 22.4716 22.0976
530014.......................................... 18.4900 20.0422 21.7314 20.1695
530015.......................................... 23.4040 24.6527 25.3915 24.5334
530016.......................................... 19.3205 20.3647 21.0666 20.2058
530017.......................................... 17.7736 20.9408 19.5631 19.3707
530018.......................................... 19.5986 20.1226 * 19.8663
530019.......................................... 20.1097 18.1492 * 19.0248
530022.......................................... 19.6136 19.7902 21.0631 20.1718
530023.......................................... 20.0677 21.6352 * 20.8681
530025.......................................... 22.0300 22.4816 25.4693 23.3672
530026.......................................... 19.8969 20.9919 21.0733 20.6804
530027.......................................... 25.5067 * * 25.5069
530029.......................................... 19.3361 20.3046 19.9692 19.8988
530031.......................................... 20.1734 23.2766 16.8825 20.2555
[[Page 27325]]
530032.......................................... 20.0132 20.9856 19.4450 20.0811
----------------------------------------------------------------------------------------------------------------
*Denotes wage data not available for the provider for that year.
**Based on the sum of the salaries and hours computed for Federal FYs 2002, 2003, and 2004.
Federal Register / Vol. 68, No. 96 / Monday, May 19, 2003 / Proposed
Rules
[[Page 27325]]
Table 3A.--FY 2004 and 3-Year* Average Hourly Wage for Urban Areas
[*Based on the sum of the Salaries and Hours Computed for Federal Fiscal
Years 2002, 2003, and 2004]
------------------------------------------------------------------------
FY 2004 3-Year
average average
Urban area hourly hourly
wage wage
------------------------------------------------------------------------
Abilene, TX....................................... 18.8450 18.2266
Aguadilla, PR..................................... 10.6399 10.5889
Akron, OH......................................... 22.5797 22.3022
Albany, GA........................................ 26.6004 24.9847
Albany-Schenectady-Troy, NY....................... 21.3352 20.4496
Albuquerque, NM................................... 23.1465 22.1931
Alexandria, LA.................................... 19.8057 18.6706
Allentown-Bethlehem-Easton, PA.................... 23.5026 22.8687
Altoona, PA....................................... 21.7576 21.1859
Amarillo, TX...................................... 22.0107 20.8001
Anchorage, AK..................................... 30.1827 29.0196
Ann Arbor, MI..................................... 27.1674 25.8704
Anniston, AL...................................... 19.9785 19.0507
Appleton-Oshkosh-Neenah, WI....................... 21.7216 21.0819
Arecibo, PR....................................... 10.1377 10.1850
Asheville, NC..................................... 23.8010 22.5969
Athens, GA........................................ 23.7190 23.1681
Atlanta, GA....................................... 24.6106 23.4279
Atlantic-Cape May, NJ............................. 26.6595 25.8131
Auburn-Opelika, AL................................ 20.9608 19.6182
Augusta-Aiken, GA-SC.............................. 23.8679 23.3090
Austin-San Marcos, TX............................. 23.4418 22.4440
Bakersfield, CA................................... 24.2171 22.8241
Baltimore, MD..................................... 24.4226 23.1526
Bangor, ME........................................ 24.4261 22.6849
Barnstable-Yarmouth, MA........................... 31.6457 30.9398
Baton Rouge, LA................................... 20.3139 19.2932
Beaumont-Port Arthur, TX.......................... 20.8687 19.6759
Bellingham, WA.................................... 29.0458 28.0229
Benton Harbor, MI................................. 21.8083 20.8961
Bergen-Passaic, NJ................................ 28.6051 27.6355
Billings, MT...................................... 21.8179 21.2445
Biloxi-Gulfport-Pascagoula, MS.................... 22.3087 20.4967
Binghamton, NY.................................... 20.6972 19.6313
Birmingham, AL.................................... 22.7049 21.2110
Bismarck, ND...................................... 19.6799 18.6613
Bloomington,IN.................................... 22.0106 20.8739
Bloomington-Normal, IL............................ 21.8206 21.0629
Boise City, ID.................................... 22.7551 21.5706
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH.. 27.6581 26.3949
Boulder-Longmont, CO.............................. 24.8370 23.1361
Brazoria, TX...................................... 20.1054 19.4362
Bremerton, WA..................................... 26.0196 25.1368
Brownsville-Harlingen-San Benito, TX.............. 25.1120 21.8429
Bryan-College Station, TX......................... 22.1966 21.2204
Buffalo-Niagara Falls, NY......................... 23.5611 22.1052
Burlington, VT.................................... 23.9756 23.1273
Caguas, PR........................................ 10.2735 10.3098
Canton-Massillon, OH.............................. 22.4034 21.0476
Casper, WY........................................ 22.4716 22.0976
Cedar Rapids, IA.................................. 21.9242 20.8155
Champaign-Urbana, IL.............................. 24.3163 23.2596
Charleston-North Charleston, SC................... 22.8428 21.6027
Charleston, WV.................................... 21.4843 20.9535
Charlotte-Gastonia-Rock Hill, NC-SC............... 23.9685 22.5648
Charlottesville, VA............................... 24.7694 24.2141
Chattanooga, TN-GA................................ 22.0529 21.2905
Cheyenne, WY...................................... 21.7314 20.1695
Chicago, IL....................................... 27.0271 25.7822
Chico-Paradise, CA................................ 25.1160 23.2448
Cincinnati, OH-KY-IN.............................. 23.1946 22.0301
Clarksville-Hopkinsville, TN-KY................... 20.4075 19.5286
Cleveland-Lorain-Elyria, OH....................... 23.8495 22.4215
Colorado Springs, CO.............................. 21.6129 22.1293
Columbia, MO...................................... 21.4630 20.1694
Columbia, SC...................................... 21.9871 21.6143
Columbus, GA-AL................................... 21.3541 19.8797
Columbus, OH...................................... 23.6823 22.5560
Corpus Christi, TX................................ 21.0218 19.9937
Corvallis, OR..................................... 28.4536 27.0598
Cumberland, MD-WV................................. 20.1850 18.9617
Dallas, TX........................................ 23.8893 23.1075
Danville, VA...................................... 22.3229 20.7337
Davenport-Moline-Rock Island, IA-IL............... 21.4787 20.4142
Dayton-Springfield, OH............................ 23.1119 21.7481
Daytona Beach, FL................................. 22.5989 21.2728
Decatur, AL....................................... 21.8004 20.7771
Decatur, IL....................................... 19.7294 18.7678
Denver, CO........................................ 26.4474 24.7190
Des Moines, IA.................................... 22.2079 20.6796
Detroit, MI....................................... 24.7828 24.1254
Dothan, AL........................................ 19.4261 18.7019
Dover, DE......................................... 24.2251 22.9785
Dubuque, IA....................................... 21.9559 20.4460
Duluth-Superior, MN-WI............................ 24.9669 24.0017
Dutchess County, NY............................... 26.9158 25.0907
Eau Claire, WI.................................... 22.3936 21.0371
El Paso, TX....................................... 22.7448 21.6387
Elkhart-Goshen, IN................................ 24.1721 22.8091
Elmira, NY........................................ 20.6973 19.6769
Enid, OK.......................................... 21.1469 19.7375
Erie, PA.......................................... 21.1970 20.4552
Eugene-Springfield, OR............................ 28.3045 26.4658
Evansville, Henderson, IN-KY...................... 20.7198 19.5383
Fargo-Moorhead, ND-MN............................. 23.6839 22.0993
Fayetteville, NC.................................. 21.9837 20.9595
Fayetteville-Springdale-Rogers, AR................ 19.7281 19.1438
Flagstaff, AZ-UT.................................. 28.0003 25.5509
Flint, MI......................................... 26.8246 25.6472
Florence, AL...................................... 19.0755 18.2277
Florence, SC...................................... 21.5072 20.4490
Fort Collins-Loveland, CO......................... 25.0356 23.6228
Fort Lauderdale, FL............................... 25.0241 23.9929
Fort Myers-Cape Coral, FL......................... 24.2424 22.5718
Fort Pierce-Port St. Lucie, FL.................... 24.6789 23.4336
Fort Smith, AR-OK................................. 18.9977 18.4272
Fort Walton Beach, FL............................. 21.9145 21.5304
Fort Wayne, IN.................................... 23.7450 22.1024
Fort Worth-Arlington, TX.......................... 22.7469 21.8925
Fresno, CA........................................ 24.9304 23.6658
Gadsden, AL....................................... 20.3125 19.9081
Gainesville, FL................................... 20.9218 21.6396
Galveston-Texas City, TX.......................... 22.9723 22.5896
Gary, IN.......................................... 23.2237 22.2411
Glens Falls, NY................................... 20.8876 19.5296
[[Page 27326]]
Goldsboro, NC..................................... 21.3024 20.4707
Grand Forks, ND-MN................................ 21.3373 20.7295
Grand Junction, CO................................ 23.7749 22.3911
Grand Rapids-Muskegon-Holland, MI................. 23.0656 22.5364
Great Falls, MT................................... 21.7634 20.7748
Greeley, CO....................................... 23.1548 21.9595
Green Bay, WI..................................... 23.3746 22.0316
Greensboro-Winston-Salem-High Point, NC........... 20.9324 21.2497
Greenville, NC.................................... 23.6131 21.8157
Greenville-Spartanburg-Anderson, SC............... 22.7994 21.5334
Hagerstown, MD.................................... 22.6614 20.9120
Hamilton-Middletown, OH........................... 22.6679 21.7796
Harrisburg-Lebanon-Carlisle, PA................... 22.5260 21.6636
Hartford, CT...................................... 27.9285 26.8084
Hattiesburg, MS................................... 17.9684 17.4987
Hickory-Morganton-Lenoir, NC...................... 22.3095 21.3983
Honolulu, HI...................................... 27.4202 26.5871
Houma, LA......................................... 19.0543 18.7854
Houston, TX....................................... 23.5421 22.6783
Huntington-Ashland, WV-KY-OH...................... 23.6117 22.4903
Huntsville, AL.................................... 22.6733 21.0476
Indianapolis, IN.................................. 24.4154 22.8765
Iowa City, IA..................................... 23.5738 22.6166
Jackson, MI....................................... 22.1953 21.6761
Jackson, MS....................................... 20.6436 19.8499
Jackson, TN....................................... 21.1120 20.9308
Jacksonville, FL.................................. 22.9896 21.8027
Jacksonville, NC.................................. 21.0806 19.0573
Jamestown, NY..................................... 19.1768 18.5426
Janesville-Beloit, WI............................. 22.9321 22.5285
Jersey City, NJ................................... 27.4955 26.1092
Johnson City-Kingsport-Bristol, TN-VA............. 20.5450 19.6615
Johnstown, PA..................................... 20.5535 19.7661
Jonesboro, AR..................................... 18.8016 18.5268
Joplin, MO........................................ 21.4481 20.3222
Kalamazoo-Battlecreek, MI......................... 25.9045 24.7622
Kankakee, IL...................................... 27.1800 24.7161
Kansas City, KS-MO................................ 23.4414 22.4424
Kenosha, WI....................................... 24.1159 22.6827
Killeen-Temple, TX................................ 22.6330 22.0648
Knoxville, TN..................................... 22.0574 20.9173
Kokomo, IN........................................ 22.3466 21.1444
La Crosse, WI-MN.................................. 22.7241 21.7520
Lafayette, LA..................................... 20.3031 19.7004
Lafayette, IN..................................... 22.2163 21.3798
Lake Charles, LA.................................. 20.8032 18.7394
Lakeland-Winter Haven, FL......................... 20.8790 20.9460
Lancaster, PA..................................... 22.8876 21.5784
Lansing-East Lansing, MI.......................... 22.7517 22.3069
Laredo, TX........................................ 19.9917 19.1033
Las Cruces, NM.................................... 20.9400 20.1778
Las Vegas, NV-AZ.................................. 28.1201 26.6705
\1\Lawrence, KS................................... ......... .........
Lawton, OK........................................ 20.4263 19.7110
Lewiston-Auburn, ME............................... 23.0437 21.7003
Lexington, KY..................................... 21.1620 20.2378
Lima, OH.......................................... 23.2114 22.1607
Lincoln, NE....................................... 24.7917 23.5197
Little Rock-North Little Rock, AR................. 21.8575 20.9688
Longview-Marshall, TX............................. 22.4348 20.5074
Los Angeles-Long Beach, CA........................ 28.5648 27.6989
Louisville, KY-IN................................. 22.5165 21.7940
Lubbock, TX....................................... 20.4449 20.4788
Lynchburg, VA..................................... 22.5852 21.4509
Macon, GA......................................... 22.1616 21.1692
Madison, WI....................................... 25.1207 24.1736
Mansfield, OH..................................... 22.2335 20.8233
Mayaguez, PR...................................... 11.7315 11.3138
McAllen-Edinburg-Mission, TX...................... 22.2965 20.2067
Medford-Ashland, OR............................... 26.6156 24.7374
Melbourne-Titusville-Palm Bay, FL................. 24.0574 23.3611
Memphis, TN-AR-MS................................. 22.8875 21.1855
Merced, CA........................................ 23.9422 23.0370
Miami, FL......................................... 24.2692 23.0684
Middlesex-Somerset-Hunterdon, NJ.................. 28.0716 26.5525
Milwaukee-Waukesha, WI............................ 24.2703 23.1731
Minneapolis-St. Paul, MN-WI....................... 27.1544 25.6571
Missoula, MT...................................... 21.5392 21.2648
Mobile, AL........................................ 19.5085 18.7864
Modesto, CA....................................... 27.8424 25.5333
Monmouth-Ocean, NJ................................ 26.9085 25.3164
Monroe, LA........................................ 19.5806 18.9433
Montgomery, AL.................................... 19.2813 17.8049
Muncie, IN........................................ 21.4993 21.7481
Myrtle Beach, SC.................................. 21.9670 20.8646
Naples, FL........................................ 24.2154 22.8672
Nashville, TN..................................... 24.1409 22.7215
Nassau-Suffolk, NY................................ 31.9339 31.1765
New Haven-Bridgeport-Stamford-Waterbury-Danbury, 30.6450 28.9030
CT...............................................
New London-Norwich, CT............................ 28.7588 27.3098
New Orleans, LA................................... 22.5126 21.2103
New York, NY...................................... 34.0359 33.2980
Newark, NJ........................................ 28.0215 26.7812
Newburgh, NY-PA................................... 27.7682 26.3667
Norfolk-Virginia Beach-Newport News, VA-NC........ 21.2530 20.1058
Oakland, CA....................................... 36.9259 35.4131
Ocala, FL......................................... 24.0225 22.3877
Odessa-Midland, TX................................ 23.1872 22.5143
Oklahoma City, OK................................. 22.1744 20.7685
Olympia, WA....................................... 27.0728 25.9774
Omaha, NE-IA...................................... 23.9161 22.9252
Orange County, CA................................. 27.5748 26.3219
Orlando, FL....................................... 23.5921 22.5423
Owensboro, KY..................................... 20.6888 19.5760
Panama City, FL................................... 21.2992 20.7203
Parkersburg-Marietta, WV-OH....................... 19.8623 19.0009
Pensacola, FL..................................... 20.6255 19.7879
Peoria-Pekin, IL.................................. 21.5796 20.4881
Philadelphia, PA-NJ............................... 26.8676 25.3554
Phoenix-Mesa, AZ.................................. 25.0656 23.1490
Pine Bluff, AR.................................... 18.7641 18.2815
Pittsburgh, PA.................................... 21.5682 21.5505
Pittsfield, MA.................................... 25.2831 23.9826
Pocatello, ID..................................... 22.3412 21.7279
Ponce, PR......................................... 11.6867 11.7774
Portland, ME...................................... 24.5068 22.7835
Portland-Vancouver, OR-WA......................... 27.4708 25.7362
Providence-Warwick, RI............................ 27.0592 25.4242
Provo-Orem, UT.................................... 24.6487 23.2777
Pueblo, CO........................................ 21.6891 20.4756
Punta Gorda, FL................................... 23.3618 21.6509
Racine, WI........................................ 21.8176 21.4880
Raleigh-Durham-Chapel Hill, NC.................... 24.7888 23.2945
Rapid City, SD.................................... 21.7579 20.7364
Reading, PA....................................... 22.1933 21.7267
Redding, CA....................................... 28.0292 26.2652
Reno, NV.......................................... 26.3682 24.8415
Richland-Kennewick-Pasco, WA...................... 26.0849 25.7185
Richmond-Petersburg, VA........................... 23.0767 22.2287
Riverside-San Bernardino, CA...................... 27.7914 26.2909
Roanoke, VA....................................... 21.4970 20.0809
Rochester, MN..................................... 28.9664 27.6257
Rochester, NY..................................... 23.4531 22.1985
Rockford, IL...................................... 23.8815 22.2381
Rocky Mount, NC................................... 22.2321 21.3362
Sacramento, CA.................................... 29.2332 27.4459
Saginaw-Bay City-Midland, MI...................... 23.6103 22.4738
St. Cloud, MN..................................... 23.3992 22.6517
\1\ St. Joseph, MO................................ 24.1078 24.1078
St. Louis, MO-IL.................................. 22.2105 20.8148
Salem, OR......................................... 25.8986 24.0695
Salinas, CA....................................... 35.4282 34.0968
Salt Lake City-Ogden, UT.......................... 24.2956 23.1582
San Angelo, TX.................................... 20.3421 19.4654
San Antonio, TX................................... 21.7859 20.4173
San Diego, CA..................................... 27.5034 26.1832
San Francisco, CA................................. 35.2175 33.1623
San Jose, CA...................................... 35.9382 33.4495
San Juan-Bayamon, PR.............................. 12.0353 11.2034
San Luis Obispo-Atascadero-Paso Robles, CA........ 28.1871 26.3232
Santa Barbara-Santa Maria-Lompoc, CA.............. 25.7977 24.7645
[[Page 27327]]
Santa Cruz-Watsonville, CA........................ 31.9363 31.6115
Santa Fe, NM...................................... 26.1125 24.6586
Santa Rosa, CA.................................... 31.5034 30.3104
Sarasota-Bradenton, FL............................ 24.1015 22.8397
Savannah, GA...................................... 23.4542 22.5461
Scranton-Wilkes Barre-Hazleton, PA................ 20.5178 19.9473
Seattle-Bellevue-Everett, WA...................... 28.3651 26.8159
Sharon, PA........................................ 19.1498 18.3866
Sheboygan, WI..................................... 21.3074 20.1274
Sherman-Denison, TX............................... 23.3354 21.9733
Shreveport-Bossier City, LA....................... 22.4424 21.1518
Sioux City, IA-NE................................. 22.2184 20.9019
Sioux Falls, SD................................... 22.9990 21.6460
South Bend, IN.................................... 24.2656 23.1221
Spokane, WA....................................... 26.9242 25.3258
Springfield, IL................................... 22.0988 20.5053
Springfield, MO................................... 20.7882 19.8503
Springfield, MA................................... 25.1820 24.9487
State College, PA................................. 21.5944 20.9171
Steubenville-Weirton, OH-WV....................... 20.7491 20.1726
Stockton-Lodi, CA................................. 25.9615 24.8099
Sumter, SC........................................ 20.1378 18.9286
Syracuse, NY...................................... 23.2731 22.4502
Tacoma, WA........................................ 25.0655 25.4358
Tallahassee, FL................................... 20.9393 19.9194
Tampa-St. Petersburg-Clearwater, FL............... 22.3623 21.0795
Terre Haute, IN................................... 20.5894 19.8434
Texarkana, AR-Texarkana, TX....................... 20.1201 19.1440
Toledo, OH........................................ 23.4422 22.6911
Topeka, KS........................................ 22.1410 21.1325
Trenton, NJ....................................... 25.9088 24.4803
Tucson, AZ........................................ 21.9871 20.8658
Tulsa, OK......................................... 22.4262 20.4923
Tuscaloosa, AL.................................... 20.2222 19.1231
Tyler, TX......................................... 21.5724 21.7219
Utica-Rome, NY.................................... 20.8155 19.7105
Vallejo-Fairfield-Napa, CA........................ 33.0023 31.4386
Ventura, CA....................................... 25.7022 25.3153
Victoria, TX...................................... 19.8941 19.6059
Vineland-Millville-Bridgeton, NJ.................. 25.7088 24.0750
Visalia-Tulare-Porterville, CA.................... 24.2540 22.5528
Waco, TX.......................................... 20.7383 19.2135
Washington, DC-MD-VA-WV........................... 26.2793 25.3284
Waterloo-Cedar Falls, IA.......................... 20.6706 19.0431
Wausau, WI........................................ 23.9474 22.8336
West Palm Beach-Boca Raton, FL.................... 24.0146 22.9860
Wheeling, OH-WV................................... 18.4694 18.0317
Wichita, KS....................................... 22.8265 22.1175
Wichita Falls, TX................................. 20.6347 19.2942
Williamsport, PA.................................. 19.8237 19.6398
Wilmington-Newark, DE-MD.......................... 26.8874 25.7166
Wilmington, NC.................................... 23.5730 22.3755
Yakima, WA........................................ 25.3298 24.5057
Yolo, CA.......................................... 22.7290 22.1106
York, PA.......................................... 22.3891 21.4937
Youngstown-Warren, OH............................. 22.7587 21.9477
Yuba City, CA..................................... 25.1911 24.0864
Yuma, AZ.......................................... 21.9766 20.7166
------------------------------------------------------------------------
\1\ The MSA is empty for FY 2004. The hospital(s) in the MSA received
rural status under section 401 of the Balanced Budget Refinement Act
of 1999 (Pub. L. 106-113). The MSA is assigned the statewide rural
wage index (see Table 4B).
Table 3B.--FY 2004 and 3-Year* Average Hourly Wage for Rural Areas
[*Based on the sum of the Salaries and Hours Computed for Federal Fiscal
Years 2002, 2003, and 2004]
------------------------------------------------------------------------
FY 2004 3-Year
average average
Nonurban area hourly hourly
wage wage
------------------------------------------------------------------------
Alabama........................................... 18.3348 17.4929
Alaska............................................ 29.3667 28.1193
Arizona........................................... 22.1917 20.4444
Arkansas.......................................... 19.0502 17.8283
California........................................ 24.5014 22.9050
Colorado.......................................... 22.3036 20.8977
Connecticut....................................... 29.9411 28.5998
Delaware.......................................... 22.7759 21.8259
Florida........................................... 21.7703 20.5939
Georgia........................................... 20.6405 19.3893
Hawaii............................................ 24.6034 24.3938
Idaho............................................. 22.1883 20.5704
Illinois.......................................... 20.4777 19.1094
Indiana........................................... 21.6124 20.4406
Iowa.............................................. 20.7491 19.3057
Kansas............................................ 19.7860 18.4560
Kentucky.......................................... 19.5747 18.6825
Louisiana......................................... 18.3330 17.5766
Maine............................................. 22.1139 20.6732
Maryland.......................................... 22.5202 21.0708
Massachusetts..................................... 26.6580 26.1016
Michigan.......................................... 21.6556 20.8571
Minnesota......................................... 22.9622 21.3937
Mississippi....................................... 19.2263 17.9212
Missouri.......................................... 19.2927 18.4558
Montana........................................... 21.6718 20.0795
Nebraska.......................................... 21.7533 19.3579
Nevada............................................ 24.0509 22.6017
New Hampshire..................................... 24.8141 23.0661
\1\ New Jersey.................................... ......... .........
New Mexico........................................ 20.3060 20.0956
New York.......................................... 21.0328 19.9757
North Carolina.................................... 20.5716 19.9126
North Dakota...................................... 19.2168 18.1538
Ohio.............................................. 21.6481 20.3023
Oklahoma.......................................... 18.6273 17.6874
Oregon............................................ 24.6521 23.6537
Pennsylvania...................................... 20.7089 19.8599
Puerto Rico....................................... 10.2273 9.9080
\1\ Rhode Island.................................. ......... .........
South Carolina.................................... 20.8645 19.9708
South Dakota...................................... 20.2488 18.5076
Tennessee......................................... 19.5008 18.5022
Texas............................................. 18.9842 18.1045
Utah.............................................. 22.1698 21.3594
Vermont........................................... 22.9948 21.9226
Virginia.......................................... 20.9873 19.7038
Washington........................................ 25.9055 23.9310
West Virginia..................................... 19.7553 18.7353
Wisconsin......................................... 22.6498 21.3482
Wyoming........................................... 22.6090 20.9331
------------------------------------------------------------------------
\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 1Abilene, TX................................... 0.7678 0.8345
Taylor, TX
0060 Aguadilla, PR.................................. 0.4335 0.5642
Aguada, PR
Aguadilla, PR
Moca, PR
0080 Akron, OH...................................... 0.9445 0.9617
Portage, OH
Summit, OH
0120 Albany, GA..................................... 1.0838 1.0567
Dougherty, GA
Lee, GA
0160 Albany-Schenectady-Troy, NY.................... 0.8693 0.9085
Albany, NY
Montgomery, NY
Rensselaer, NY
Saratoga, NY
Schenectady, NY
Schoharie, NY
0200 Albuquerque, NM................................ 0.9431 0.9607
Bernalillo, NM
Sandoval, NM
Valencia, NM
0220 Alexandria, LA................................. 0.8087 0.8647
Rapides, LA
0240 Allentown-Bethlehem-Easton, PA................. 0.9576 0.9708
Carbon, PA
Lehigh, PA
Northampton, PA
0280 Altoona, PA.................................... 0.8886 0.9223
Blair, PA
[[Page 27328]]
0320 Amarillo, TX................................... 0.8968 0.9281
Potter, TX
Randall, TX
0380 Anchorage, AK.................................. 1.2433 1.1608
Anchorage, AK
0440 Ann Arbor, MI.................................. 1.1069 1.0720
Lenawee, MI
Livingston, MI
Washtenaw, MI
0450 Anniston, AL................................... 0.8140 0.8686
Calhoun, AL
0460 \2\ Appleton-Oshkosh-Neenah, WI................ 0.9130 0.9396
Calumet, WI
Outagamie, WI
Winnebago, WI
0470 Arecibo, PR.................................... 0.4130 0.5458
Arecibo, PR
Camuy, PR
Hatillo, PR
0480 Asheville, NC.................................. 0.9697 0.9792
Buncombe, NC
Madison, NC
0500 Athens, GA..................................... 0.9664 0.9769
Clarke, GA
Madison, GA
Oconee, GA
0520 \1\ Atlanta, GA................................ 1.0027 1.0018
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.......................... 1.0862 1.0583
Atlantic, NJ
Cape May, NJ
0580 Auburn-Opelika, AL............................. 0.8540 0.8976
Lee, AL
0600 Augusta-Aiken, GA-SC........................... 0.9725 0.9811
Columbia, GA
McDuffie, GA
Richmond, GA
Aiken, SC
Edgefield, SC
0640 \1\ Austin-San Marcos, TX...................... 0.9551 0.9690
Bastrop, TX
Caldwell, TX
Hays, TX
Travis, TX
Williamson, TX
0680 \2\ Bakersfield, CA............................ 0.9907 0.9936
Kern, CA
0720 \1\ Baltimore, MD.............................. 0.9951 0.9966
Anne Arundel, MD
Baltimore, MD
Baltimore City, MD
Carroll, MD
Harford, MD
Howard, MD
Queen Anne's, MD
0733 Bangor, ME..................................... 0.9750 0.9828
Penobscot, ME
0743 Barnstable-Yarmouth, MA........................ 1.2893 1.1901
Barnstable, MA
0760 Baton Rouge, LA................................ 0.8271 0.8781
Ascension, LA
East Baton Rouge, LA
Livingston, LA
West Baton Rouge, LA
0840 Beaumont-Port Arthur, TX....................... 0.8503 0.8949
Hardin, TX
Jefferson, TX
Orange, TX
0860 Bellingham, WA................................. 1.1834 1.1222
Whatcom, WA
0870 Benton Harbor, MI.............................. 0.8949 0.9268
Berrien, MI
0875 \1\ Bergen-Passaic, NJ......................... 1.1655 1.1106
Bergen, NJ
Passaic, NJ
0880 Billings, MT................................... 0.8889 0.9225
Yellowstone, MT
0920 Biloxi-Gulfport-Pascagoula, MS................. 0.9089 0.9367
Hancock, MS
Harrison, MS
Jackson, MS
0960 \2\ Binghamton, NY............................. 0.8530 0.8968
Broome, NY
Tioga, NY
1000 Birmingham, AL................................. 0.9251 0.9481
Blount, AL
Jefferson, AL
St. Clair, AL
Shelby, AL
1010 Bismarck, ND................................... 0.8101 0.8657
Burleigh, ND
Morton, ND
1020 Bloomington, IN................................ 0.8968 0.9281
Monroe, IN
1040 Bloomington-Normal, IL......................... 0.8954 0.9271
McLean, IL
1080 Boise City, ID................................. 0.9295 0.9512
Ada, ID
Canyon, ID
1123 \1\ Boston-Worcester-Lawrence-Lowell-Brockton, 1.1269 1.0853
MA-NH..............................................
Bristol, MA
Essex, MA
Middlesex, MA
Norfolk, MA
Plymouth, MA
Suffolk, MA
Worcester, MA
Hillsborough, NH
Merrimack, NH
Rockingham, NH
Strafford, NH
1125 Boulder-Longmont, CO........................... 1.0119 1.0081
Boulder, CO
1145 Brazoria, TX................................... 0.8324 0.8819
Brazoria, TX
1150 Bremerton, WA.................................. 1.0601 1.0408
Kitsap, WA
1240 Brownsville-Harlingen-San Benito, TX........... 1.0231 1.0158
Cameron, TX
1260 Bryan-College Station, TX...................... 0.9044 0.9335
Brazos, TX
1280 \1\ Buffalo-Niagara Falls, NY.................. 0.9600 0.9724
Erie, NY
Niagara, NY
1303 Burlington, VT................................. 0.9768 0.9841
Chittenden, VT
Franklin, VT
Grand Isle, VT
1310 Caguas, PR..................................... 0.4229 0.5547
Caguas, PR
Cayey, PR
Cidra, PR
Gurabo, PR
San Lorenzo, PR
1320 Canton-Massillon, OH........................... 0.9128 0.9394
Carroll, OH
Stark, OH
1350 Casper, WY..................................... 0.9239 0.9472
Natrona, WY
1360 Cedar Rapids, IA............................... 0.8933 0.9256
Linn, IA
1400 Champaign-Urbana, IL........................... 0.9907 0.9936
Champaign, IL
1440 Charleston-North Charleston, SC................ 0.9307 0.9520
Berkeley, SC
Charleston, SC
Dorchester, SC
1480 Charleston, WV................................. 0.8753 0.9128
Kanawha, WV
Putnam, WV
1520 \1\ Charlotte-Gastonia-Rock Hill, NC-SC........ 0.9766 0.9839
Cabarrus, NC
Gaston, NC
Lincoln, NC
[[Page 27329]]
Mecklenburg, NC
Rowan, NC
Stanly, NC
Union, NC
York, SC
1540 Charlottesville, VA............................ 1.0092 1.0063
Albemarle, VA
Charlottesville City, VA
Fluvanna, VA
Greene, VA
1560 Chattanooga, TN-GA............................. 0.8985 0.9293
Catoosa, GA
Dade, GA
Walker, GA
Hamilton, TN
Marion, TN
1580 \2\ Cheyenne, WY............................... 0.9137 0.9401
Laramie, WY
1600 \1\ Chicago, IL................................ 1.1012 1.0682
Cook, IL
DeKalb, IL
DuPage, IL
Grundy, IL
Kane, IL
Kendall, IL
Lake, IL
McHenry, IL
Will, IL
1620 Chico-Paradise, CA............................. 1.0147 1.0100
Butte, CA
1640 \1\ Cincinnati, OH-KY-IN....................... 0.9452 0.9621
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................ 0.8410 0.8882
Christian, KY
Montgomery, TN
1680\1\ Cleveland-Lorain-Elyria, OH................. 0.9686 0.9784
Ashtabula, OH
Cuyahoga, OH
Geauga, OH
Lake, OH
Lorain, OH
Medina, OH
1720 \2\ Colorado Springs, CO....................... 0.8897 0.9231
El Paso, CO
1740 Columbia, MO................................... 0.8745 0.9123
Boone, MO
1760 Columbia, SC................................... 0.8958 0.9274
Lexington, SC
Richland, SC
1800 Columbus, GA-AL................................ 0.8700 0.9090
Russell, AL
Chattahoochee, GA
Harris, GA
Muscogee, GA
1840 \1\ Columbus, OH............................... 0.9649 0.9758
Delaware, OH
Fairfield, OH
Franklin, OH
Licking, OH
Madison, OH
Pickaway, OH
1880 Corpus Christi, TX............................. 0.8565 0.8994
Nueces, TX
San Patricio, TX
1890 Corvallis, OR.................................. 1.1593 1.1065
Benton, OR
1900 \2\ Cumberland, MD-WV (MD Hospitals)........... 0.9175 0.9427
Allegany, MD
Mineral, WV
1900 Cumberland, MD-WV (WV Hospitals)............... 0.8224 0.8747
Allegany, MD
Mineral, WV
1920 \1\ Dallas, TX................................. 0.9733 0.9816
Collin, TX
Dallas, TX
Denton, TX
Ellis, TX
Henderson, TX
Hunt, TX
Kaufman, TX
Rockwall, TX
1950 Danville, VA................................... 0.9095 0.9371
Danville City, VA
Pittsylvania, VA
1960 Davenport-Moline-Rock Island, IA-IL............ 0.8727 0.9110
Scott, IA
Henry, IL
Rock Island, IL
2000 Dayton-Springfield, OH......................... 0.9432 0.9607
Clark, OH
Greene, OH
Miami, OH
Montgomery, OH
2020 Daytona Beach, FL.............................. 0.9208 0.9451
Flagler, FL
Volusia, FL
2030 Decatur, AL.................................... 0.8882 0.9220
Lawrence, AL
Morgan, AL
2040 \2\ Decatur, IL................................ 0.8282 0.8789
Macon, IL
2080 \1\ Denver, CO................................. 1.0776 1.0525
Adams, CO
Arapahoe, CO
Broomfield, CO
Denver, CO
Douglas, CO
Jefferson, CO
2120 Des Moines, IA................................. 0.9053 0.9341
Dallas, IA
Polk, IA
Warren, IA
2160 \1\ Detroit, MI................................ 1.0097 1.0066
Lapeer, MI
Macomb, MI
Monroe, MI
Oakland, MI
St. Clair, MI
Wayne, MI
2180 Dothan, AL..................................... 0.7931 0.8532
Dale, AL
Houston, AL
2190 Dover, DE...................................... 0.9870 0.9911
Kent, DE
2200 Dubuque, IA.................................... 0.8946 0.9266
Dubuque, IA
2240 Duluth-Superior, MN-WI......................... 1.0133 1.0091
St. Louis, MN
Douglas, WI
2281 Dutchess County, NY............................ 1.0966 1.0652
Dutchess, NY
2290 Eau Claire, WI................................. 0.9141 0.9403
Chippewa, WI
Eau Claire, WI
2320 El Paso, TX.................................... 0.9267 0.9492
El Paso, TX
2330 Elkhart-Goshen, IN............................. 0.9848 0.9896
Elkhart, IN
2335 \2\ Elmira, NY................................. 0.8530 0.8968
Chemung, NY
2340 Enid, OK....................................... 0.8616 0.9030
Garfield, OK
2360 Erie, PA....................................... 0.8636 0.9045
Erie, PA
2400 Eugene-Springfield, OR......................... 1.1212 1.0815
Lane, OR
2440 \2\ Evansville-Henderson, IN-KY (IN Hospitals). 0.8770 0.9140
Posey, IN
Vanderburgh, IN
Warrick, IN
Henderson, KY
2440 Evansville-Henderson, IN-KY (KY Hospitals)..... 0.8442 0.8905
Posey, IN
Vanderburgh, IN
Warrick, IN
Henderson, KY
2520 Fargo-Moorhead, ND-MN.......................... 0.9650 0.9759
Clay, MN
Cass, ND
2560 Fayetteville, NC............................... 0.8957 0.9273
Cumberland, NC
2580 Fayetteville-Springdale-Rogers, AR............. 0.8038 0.8611
[[Page 27330]]
Benton, AR
Washington, AR
2620 Flagstaff, AZ-UT............................... 1.1283 1.0862
Coconino, AZ
Kane, UT
2640 Flint, MI...................................... 1.0929 1.0627
Genesee, MI
2650 Florence, AL................................... 0.7824 0.8453
Colbert, AL
Lauderdale, AL
2655 Florence, SC................................... 0.8763 0.9135
Florence, SC
2670 Fort Collins-Loveland, CO...................... 1.0201 1.0137
Larimer, CO
2680 \1\ Ft. Lauderdale, FL......................... 1.0534 1.0363
Broward, FL
2700 Fort Myers-Cape Coral, FL...................... 0.9877 0.9916
Lee, FL
2710 Fort Pierce-Port St. Lucie, FL................. 1.0227 1.0155
Martin, FL
St. Lucie, FL
2720 \2\ Fort Smith, AR-OK (AR Hospitals)........... 0.7746 0.8395
Crawford, AR
Sebastian, AR
Sequoyah, OK
2720 Fort Smith, AR-OK (OK Hospitals)............... 0.7740 0.8391
Crawford, AR
Sebastian, AR
Sequoyah, OK
2750 Fort Walton Beach, FL.......................... 0.8929 0.9254
Okaloosa, FL
2760 Fort Wayne, IN................................. 0.9674 0.9776
Adams, IN
Allen, IN
De Kalb, IN
Huntington, IN
Wells, IN
Whitley, IN
2800 \1\ Forth Worth-Arlington, TX.................. 0.9268 0.9493
Hood, TX
Johnson, TX
Parker, TX
Tarrant, TX
2840 Fresno, CA..................................... 1.0157 1.0107
Fresno, CA
Madera, CA
2880 Gadsden, AL.................................... 0.8295 0.8798
Etowah, AL
2900 \2\ Gainesville, FL............................ 0.8782 0.9149
Alachua, FL
2920 Galveston-Texas City, TX....................... 0.9360 0.9557
Galveston, TX
2960 Gary, IN....................................... 0.9462 0.9628
Lake, IN
Porter, IN
2975 \2\ Glens Falls, NY............................ 0.8530 0.8968
Warren, NY
Washington, NY
2980 Goldsboro, NC.................................. 0.8679 0.9075
Wayne, NC
2985 Grand Forks, ND-MN (ND Hospitals).............. 0.9031 0.9326
Polk, MN
Grand Forks, ND
2985 \2\ Grand Forks, ND-MN (MN Hospitals).......... 0.9243 0.9475
Polk, MN
Grand Forks, ND
2995 Grand Junction, CO............................. 0.9940 0.9959
Mesa, CO
3000 \1\ Grand Rapids-Muskegon-Holland, MI.......... 0.9406 0.9589
Allegan, MI
Kent, MI
Muskegon, MI
Ottawa, MI
3040 Great Falls, MT................................ 0.8977 0.9288
Cascade, MT
3060 Greeley, CO.................................... 0.9516 0.9666
Weld, CO
3080 Green Bay, WI.................................. 0.9524 0.9672
Brown, WI
3120 \1\ Greensboro-Winston-Salem-High Point, NC.... 0.8533 0.8971
Alamance, NC
Davidson, NC
Davie, NC
Forsyth, NC
Guilford, NC
Randolph, NC
Stokes, NC
Yadkin, NC
3150 Greenville, NC................................. 0.9621 0.9739
Pitt, NC
3160 Greenville-Spartanburg-Anderson, SC............ 0.9289 0.9507
Anderson, SC
Cherokee, SC
Greenville, SC
Pickens, SC
Spartanburg, SC
3180 Hagerstown, MD................................. 0.9233 0.9468
Washington, MD
3200 Hamilton-Middletown, OH........................ 0.9236 0.9470
Butler, OH
3240 Harrisburg-Lebanon-Carlisle, PA................ 0.9178 0.9430
Cumberland, PA
Dauphin, PA
Lebanon, PA
Perry, PA
3283 \1,2\ Hartford, CT............................. 1.2199 1.1458
Hartford, CT
Litchfield, CT
Middlesex, CT
Tolland, CT
3285 \2\ Hattiesburg, MS............................ 0.7810 0.8443
Forrest, MS
Lamar, MS
3290 Hickory-Morganton-Lenoir, NC................... 0.9090 0.9368
Alexander, NC
Burke, NC
Caldwell, NC
Catawba, NC
3320 Honolulu, HI................................... 1.1176 1.0791
Honolulu, HI
3350 Houma, LA...................................... 0.7763 0.8408
Lafourche, LA
Terrebonne, LA
3360 \1\ Houston, TX................................ 0.9591 0.9718
Chambers, TX
Fort Bend, TX
Harris, TX
Liberty, TX
Montgomery, TX
Waller, TX
3400 Huntington-Ashland, WV-KY-OH................... 0.9620 0.9738
Boyd, KY
Carter, KY
Greenup, KY
Lawrence, OH
Cabell, WV
Wayne, WV
3440 Huntsville, AL................................. 0.9238 0.9472
Limestone, AL
Madison, AL
3480 \1\ Indianapolis, IN........................... 0.9934 0.9955
Boone, IN
Hamilton, IN
Hancock, IN
Hendricks, IN
Johnson, IN
Madison, IN
Marion, IN
Morgan, IN
Shelby, IN
3500 Iowa City, IA.................................. 0.9605 0.9728
Johnson, IA
3520 Jackson, MI.................................... 0.9043 0.9334
Jackson, MI
3560 Jackson, MS.................................... 0.8459 0.8917
Hinds, MS
Madison, MS
Rankin, MS
3580 Jackson, TN.................................... 0.8602 0.9020
Madison, TN
Chester, TN
3600 \1\ Jacksonville, FL........................... 0.9426 0.9603
Clay, FL
Duval, FL
Nassau, FL
St. Johns, FL
3605 Jacksonville, NC............................... 0.8589 0.9011
Onslow, NC
3610 \2\ Jamestown, NY.............................. 0.8530 0.8968
Chautauqua, NY
3620 Janesville-Beloit, WI.......................... 0.9344 0.9546
Rock, WI
3640 Jersey City, NJ................................ 1.1203 1.0809
Hudson, NJ
[[Page 27331]]
3660 Johnson City-Kingsport-Bristol, TN-VA (TN 0.8371 0.8854
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 0.8542 0.8977
Hospitals).........................................
Carter, TN
Hawkins, TN
Sullivan, TN
Unicoi, TN
Washington, TN
Bristol City, VA
Scott, VA
Washington, VA
3680 \2\ Johnstown, PA.............................. 0.8429 0.8896
Cambria, PA
Somerset, PA
3700 \2\ Jonesboro, AR.............................. 0.7755 0.8402
Craighead, AR
3710 Joplin, MO..................................... 0.8739 0.9118
Jasper, MO
Newton, MO
3720 Kalamazoo-Battlecreek, MI...................... 1.0554 1.0376
Calhoun, MI
Kalamazoo, MI
Van Buren, MI
3740 Kankakee, IL................................... 1.1074 1.0724
Kankakee, IL
3760 \1\ Kansas City, KS-MO......................... 0.9551 0.9690
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.................................... 0.9826 0.9881
Kenosha, WI
3810 Killeen-Temple, TX............................. 0.9221 0.9460
Bell, TX
Coryell, TX
3840 Knoxville, TN.................................. 0.8987 0.9295
Anderson, TN
Blount, TN
Knox, TN
Loudon, TN
Sevier, TN
Union, TN
3850 Kokomo, IN..................................... 0.8963 0.9278
Howard, IN
Tipton, IN
3870 La Crosse, WI-MN............................... 0.9259 0.9486
Houston, MN
La Crosse, WI
3880 Lafayette, LA.................................. 0.8271 0.8781
Acadia, LA
Lafayette, LA
St. Landry, LA
St. Martin, LA
3920 Lafayette, IN.................................. 0.9052 0.9341
Clinton, IN
Tippecanoe, IN
3960 Lake Charles, LA............................... 0.8460 0.8918
Calcasieu, LA
3980 \2\ Lakeland-Winter Haven, FL.................. 0.8782 0.9149
Polk, FL
4000 Lancaster, PA.................................. 0.9325 0.9533
Lancaster, PA
4040 Lansing-East Lansing, MI....................... 0.9270 0.9494
Clinton, MI
Eaton, MI
Ingham, MI
4080 Laredo, TX..................................... 0.8145 0.8689
Webb, TX
4100 Las Cruces, NM................................. 0.8532 0.8970
Dona Ana, NM
4120 \1\ Las Vegas, NV-AZ........................... 1.1457 1.0976
Mohave, AZ
Clark, NV
Nye, NV
4150................................................
2Lawrence, KS....................................... 0.7860 0.8480
Douglas, KS
4200 Lawton, OK..................................... 0.8322 0.8818
Comanche, OK
4243 Lewiston-Auburn, ME............................ 0.9389 0.9577
Androscoggin, ME
4280 Lexington, KY.................................. 0.8622 0.9035
Bourbon, KY
Clark, KY
Fayette, KY
Jessamine, KY
Madison, KY
Scott, KY
Woodford, KY
4320 Lima, OH....................................... 0.9457 0.9625
Allen, OH
Auglaize, OH
4360 Lincoln, NE.................................... 1.0101 1.0069
Lancaster, NE
4400 Little Rock-North Little Rock, AR.............. 0.8905 0.9237
Faulkner, AR
Lonoke, AR
Pulaski, AR
Saline, AR
4420 Longview-Marshall, TX.......................... 0.9141 0.9403
Gregg, TX
Harrison, TX
Upshur, TX
4480 \1\ Los Angeles-Long Beach, CA................. 1.1656 1.1106
Los Angeles, CA
4520 \1\ Louisville, KY-IN.......................... 0.9174 0.9427
Clark, IN
Floyd, IN
Harrison, IN
Scott, IN
Bullitt, KY
Jefferson, KY
Oldham, KY
4600 Lubbock, TX.................................... 0.8330 0.8824
Lubbock, TX
4640 Lynchburg, VA.................................. 0.9202 0.9446
Amherst, VA
Bedford, VA
Bedford City, VA
Campbell, VA
Lynchburg City, VA
4680 Macon, GA...................................... 0.9011 0.9312
Bibb, GA
Houston, GA
Jones, GA
Peach, GA
Twiggs, GA
4720 Madison, WI.................................... 1.0235 1.0160
Dane, WI
4800 Mansfield, OH.................................. 0.9059 0.9346
Crawford, OH
Richland, OH
4840 Mayaguez, PR................................... 0.4780 0.6032
Anasco, PR
Cabo Rojo, PR
Hormigueros, PR
Mayaguez, PR
Sabana Grande, PR
San German, PR
4880 McAllen-Edinburg-Mission, TX................... 0.9084 0.9363
Hidalgo, TX
4890 Medford-Ashland, OR............................ 1.0844 1.0571
Jackson, OR
4900 Melbourne-Titusville-Palm Bay, FL.............. 0.9837 0.9888
Brevard, Fl
4920 \1\ Memphis, TN-AR-MS.......................... 0.9325 0.9533
Crittenden, AR
DeSoto, MS
Fayette, TN
Shelby, TN
Tipton, TN
4940 \2\ Merced, CA................................. 0.9907 0.9936
Merced, CA
5000 \1\ Miami, FL.................................. 0.9888 0.9923
Dade, FL
5015 \1\ Middlesex-Somerset-Hunterdon, NJ........... 1.1437 1.0963
Hunterdon, NJ
Middlesex, NJ
Somerset, NJ
5080 \1\ Milwaukee-Waukesha, WI..................... 0.9888 0.9923
Milwaukee, WI
Ozaukee, WI
Washington, WI
[[Page 27332]]
Waukesha, WI
5120 \1\ Minneapolis-St. Paul, MN-WI................ 1.1064 1.0717
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................................... 0.8943 0.9264
Missoula, MT
5160 Mobile, AL..................................... 0.7948 0.8545
Baldwin, AL
Mobile, AL
5170 Modesto, CA.................................... 1.1344 1.0902
Stanislaus, CA
5190 \1\ Monmouth-Ocean, NJ......................... 1.1094 1.0737
Monmouth, NJ
Ocean, NJ
5200 Monroe, LA..................................... 0.7978 0.8567
Ouachita, LA
5240 Montgomery, AL................................. 0.7856 0.8477
Autauga, AL
Elmore, AL
Montgomery, AL
5280 \2\ Muncie, IN................................. 0.8770 0.9140
Delaware, IN
5330 Myrtle Beach, SC............................... 0.8950 0.9268
Horry, SC
5345 Naples, FL..................................... 0.9866 0.9908
Collier, FL
5360 \1\ Nashville, TN.............................. 0.9836 0.9887
Cheatham, TN
Davidson, TN
Dickson, TN
Robertson, TN
Rutherford TN
Sumner, TN
Williamson, TN
Wilson, TN
5380 \1\ Nassau-Suffolk, NY......................... 1.3011 1.1975
Nassau, NY
Suffolk, NY
5483 \1\ New Haven-Bridgeport-Stamford-Waterbury-... 1.2525 1.1667
Danbury, CT
Fairfield, CT
New Haven, CT
5523 \2\ New London-Norwich, CT..................... 1.2199 1.1458
New London, CT
5560 \1\ New Orleans, LA............................ 0.9167 0.9422
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............................... 1.3867 1.2509
Bronx, NY
Kings, NY
New York, NY
Putnam, NY
Queens, NY
Richmond, NY
Rockland, NY
Westchester, NY
5640 \1\ Newark, NJ................................. 1.1417 1.0950
Essex, NJ
Morris, NJ
Sussex, NJ
Union, NJ
Warren, NJ
5660 Newburgh, NY-PA................................ 1.1377 1.0924
Orange, NY
Pike, PA
5720 \1\ Norfolk-Virginia Beach-Newport News, VA-NC. 0.8659 0.9061
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................................ 1.5204 1.3323
Alameda, CA
Contra Costa, CA
5790 Ocala, FL...................................... 0.9788 0.9854
Marion, FL
5800 Odessa-Midland, TX............................. 0.9447 0.9618
Ector, TX
Midland, TX
5880 \1\ Oklahoma City, OK.......................... 0.9027 0.9323
Canadian, OK
Cleveland, OK
Logan, OK
McClain, OK
Oklahoma, OK
Pottawatomie, OK
5910 Olympia, WA.................................... 1.1030 1.0694
Thurston, WA
5920 Omaha, NE-IA................................... 0.9744 0.9824
Pottawattamie, IA
Cass, NE
Douglas, NE
Sarpy, NE
Washington, NE
5945 \1\ Orange County, CA.......................... 1.1235 1.0830
Orange, CA
5960 \1\ Orlando, FL................................ 0.9612 0.9733
Lake, FL
Orange, FL
Osceola, FL
Seminole, FL
5990 Owensboro, KY.................................. 0.8429 0.8896
Daviess, KY
6015 \2\ Panama City, FL............................ 0.8782 0.9149
Bay, FL
6020 Parkersburg-Marietta, WV-OH (WV Hospitals)..... 0.8093 0.8651
Washington, OH
Wood, WV
6020 \2\ Parkersburg-Marietta, WV-OH (OH Hospitals). 0.8756 0.9130
Washington, OH
Wood, WV
6080 \2\ Pensacola, FL.............................. 0.8782 0.9149
Escambia, FL
Santa Rosa, FL
6120 Peoria-Pekin, IL............................... 0.8811 0.9170
Peoria, IL
Tazewell, IL
Woodford, IL
6160 \1\ Philadelphia, PA-NJ........................ 1.0947 1.0639
Burlington, NJ
Camden, NJ
Gloucester, NJ
Salem, NJ
Bucks, PA
Chester, PA
Delaware, PA
Montgomery, PA
Philadelphia, PA
6200 \1\ Phoenix-Mesa, AZ........................... 1.0213 1.0145
Maricopa, AZ
Pinal, AZ
6240 Pine Bluff, AR................................. 0.7753 0.8401
Jefferson, AR
6280 \1\ Pittsburgh, PA............................. 0.8788 0.9153
Allegheny, PA
Beaver, PA
Butler, PA
Fayette, PA
Washington, PA
Westmoreland, PA
6323 \2\ Pittsfield, MA............................. 1.1234 1.0829
Berkshire, MA
6340 Pocatello, ID.................................. 0.9103 0.9377
Bannock, ID
6360 Ponce, PR...................................... 0.4762 0.6017
Guayanilla, PR
Juana Diaz, PR
Penuelas, PR
[[Page 27333]]
Ponce, PR
Villalba, PR
Yauco, PR
6403 Portland, ME................................... 0.9985 0.9990
Cumberland, ME
Sagadahoc, ME
York, ME
6440 \1\ Portland-Vancouver, OR-WA.................. 1.1193 1.0802
Clackamas, OR
Columbia, OR
Multnomah, OR
Washington, OR
Yamhill, OR
Clark, WA
6483 \1\ Providence-Warwick-Pawtucket, RI........... 1.1025 1.0691
Bristol, RI
Kent, RI
Newport, RI
Providence, RI
Washington, RI
6520 Provo-Orem, UT................................. 1.0043 1.0029
Utah, UT
6560 \2\ Pueblo, CO................................. 0.8897 0.9231
Pueblo, CO
6580 Punta Gorda, FL................................ 0.9518 0.9667
Charlotte, FL
6600 \2\ Racine, WI................................. 0.9130 0.9396
Racine, WI
6640 \1\ Raleigh-Durham-Chapel Hill, NC............. 1.0084 1.0057
Chatham, NC
Durham, NC
Franklin, NC
Johnston, NC
Orange, NC
Wake, NC
6660 Rapid City, SD................................. 0.8865 0.9208
Pennington, SD
6680 Reading, PA.................................... 0.9042 0.9334
Berks, PA
6690 Redding, CA.................................... 1.1357 1.0910
Shasta, CA
6720 Reno, NV....................................... 1.0758 1.0513
Washoe, NV
6740 Richland-Kennewick-Pasco, WA................... 1.0639 1.0433
Benton, WA
Franklin, WA
6760 Richmond-Petersburg, VA........................ 0.9402 0.9587
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................ 1.1318 1.0885
Riverside, CA
San Bernardino, CA
6800 Roanoke, VA.................................... 0.8759 0.9133
Botetourt, VA
Roanoke, VA
Roanoke City, VA
Salem City, VA
6820 Rochester, MN.................................. 1.1802 1.1201
Olmsted, MN
6840 \1\Rochester, NY............................... 0.9556 0.9694
Genesee, NY
Livingston, NY
Monroe, NY
Ontario, NY
Orleans, NY
Wayne, NY
6880 Rockford, IL................................... 0.9730 0.9814
Boone, IL
Ogle, IL
Winnebago, IL
6895 Rocky Mount, NC................................ 0.9058 0.9345
Edgecombe, NC
Nash, NC
6920 \1\Sacramento, CA.............................. 1.1911 1.1272
El Dorado, CA
Placer, CA
Sacramento, CA
6960 Saginaw-Bay City-Midland, MI................... 0.9620 0.9738
Bay, MI
Midland, MI
Saginaw, MI
6980 St. Cloud, MN.................................. 0.9723 0.9809
Benton, MN
Stearns, MN
7000 \2\St. Joseph, MO.............................. 0.7793 0.8430
Andrew, MO
Buchanan, MO
7040 \1\St. Louis, MO-IL............................ 0.9049 0.9339
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...................................... 1.0594 1.0403
Marion, OR
Polk, OR
7120 Salinas, CA.................................... 1.4435 1.2858
Monterey, CA
7160 \1\Salt Lake City-Ogden, UT.................... 0.9899 0.9931
Davis, UT
Salt Lake, UT
Weber, UT
7200 San Angelo, TX................................. 0.8288 0.8793
Tom Green, TX
7240 \1\San Antonio, TX............................. 0.8876 0.9216
Bexar, TX
Comal, TX
Guadalupe, TX
Wilson, TX
7320 \1\San Diego, CA............................... 1.1206 1.0811
San Diego, CA
7360 \1\San Francisco, CA........................... 1.4349 1.2805
Marin, CA
San Francisco, CA
San Mateo, CA
7400 \1\San Jose, CA................................ 1.4642 1.2984
Santa Clara, CA
7440 \1\San Juan-Bayamon, PR........................ 0.4904 0.6139
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..... 1.1484 1.0994
San Luis Obispo, CA
7480 Santa Barbara-Santa Maria-Lompoc, CA........... 1.0511 1.0347
Santa Barbara, CA
7485 Santa Cruz-Watsonville, CA..................... 1.3012 1.1976
Santa Cruz, CA
7490 Santa Fe, NM................................... 1.0639 1.0433
Los Alamos, NM
Santa Fe, NM
7500 Santa Rosa, CA................................. 1.2836 1.1865
Sonoma, CA
7510 Sarasota-Bradenton, FL......................... 0.9834 0.9886
[[Page 27334]]
Manatee, FL
Sarasota, FL
7520 Savannah, GA................................... 0.9556 0.9694
Bryan, GA
Chatham, GA
Effingham, GA
7560 \2\Scranton--Wilkes-Barre--Hazleton, PA........ 0.8429 0.8896
Columbia, PA
Lackawanna, PA
Luzerne, PA
Wyoming, PA
7600 \1\Seattle-Bellevue-Everett, WA................ 1.1557 1.1042
Island, WA
King, WA
Snohomish, WA
7610 \2\Sharon, PA.................................. 0.8429 0.8896
Mercer, PA
7620 \2\Sheboygan, WI............................... 0.9130 0.9396
Sheboygan, WI
7640 Sherman-Denison, TX............................ 0.9508 0.9660
Grayson, TX
7680 Shreveport-Bossier City, LA.................... 0.9127 0.9394
Bossier, LA
Caddo, LA
Webster, LA
7720 Sioux City, IA-NE.............................. 0.9052 0.9341
Woodbury, IA
Dakota, NE
7760 Sioux Falls, SD................................ 0.9371 0.9565
Lincoln, SD
Minnehaha, SD
7800 South Bend, IN................................. 0.9887 0.9922
St. Joseph, IN
7840 Spokane, WA.................................... 1.0954 1.0644
Spokane, WA
7880 Springfield, IL................................ 0.9004 0.9307
Menard, IL
Sangamon, IL
7920 Springfield, MO................................ 0.8470 0.8925
Christian, MO
Greene, MO
Webster, MO
8003 \2\Springfield, MA............................. 1.1234 1.0829
Hampden, MA
Hampshire, MA
8050 State College, PA.............................. 0.8798 0.9160
Centre, PA
8080 Steubenville-Weirton, OH-WV.................... 0.8454 0.8914
Jefferson, OH
Brooke, WV
Hancock, WV
8120 Stockton-Lodi, CA.............................. 1.1168 1.0786
San Joaquin, CA
8140 \2\Sumter, SC.................................. 0.8489 0.8939
Sumter, SC
8160 Syracuse, NY................................... 0.9482 0.9642
Cayuga, NY
Madison, NY
Onondaga, NY
Oswego, NY
8200 \2\Tacoma, WA.................................. 1.0242 1.0165
Pierce, WA
8240 \2\Tallahassee, FL............................. 0.8782 0.9149
Gadsden, FL
Leon, FL
8280 \1\Tampa-St. Petersburg-Clearwater, FL......... 0.9111 0.9382
Hernando, FL
Hillsborough, FL
Pasco, FL
Pinellas, FL
8320 \2\Terre Haute, IN............................. 0.8770 0.9140
Clay, IN
Vermillion, IN
Vigo, IN
8360 Texarkana,AR-Texarkana, TX..................... 0.8198 0.8728
Miller, AR
Bowie, TX
8400 Toledo, OH..................................... 0.9551 0.9690
Fulton, OH
Lucas, OH
Wood, OH
8440 Topeka, KS..................................... 0.9021 0.9319
Shawnee, KS
8480 Trenton, NJ.................................... 1.0556 1.0377
Mercer, NJ
8520 Tucson, AZ..................................... 0.8958 0.9274
Pima, AZ
8560 Tulsa, OK...................................... 0.9093 0.9370
Creek, OK
Osage, OK
Rogers, OK
Tulsa, OK
Wagoner, OK
8600 Tuscaloosa, AL................................. 0.8239 0.8758
Tuscaloosa, AL
8640 Tyler, TX...................................... 0.8789 0.9154
Smith, TX
8680 \2\Utica-Rome, NY.............................. 0.8530 0.8968
Herkimer, NY
Oneida, NY
8720 Vallejo-Fairfield-Napa, CA..................... 1.3500 1.2282
Napa, CA
Solano, CA
8735 Ventura, CA.................................... 1.0472 1.0321
Ventura, CA
8750 Victoria, TX................................... 0.8105 0.8660
Victoria, TX
8760 Vineland-Millville-Bridgeton, NJ............... 1.0475 1.0323
Cumberland, NJ
8780 \2\Visalia-Tulare-Porterville, CA.............. 0.9907 0.9936
Tulare, CA
8800 Waco, TX....................................... 0.8449 0.8910
McLennan, TX
8840 \1\Washington, DC-MD-VA-WV..................... 1.0707 1.0479
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....................... 0.8422 0.8890
Black Hawk, IA
8940 Wausau, WI..................................... 0.9806 0.9867
Marathon, WI
8960 \1\West Palm Beach-Boca Raton, FL.............. 0.9784 0.9852
Palm Beach, FL
9000 \2\Wheeling, WV-OH (WV Hospitals).............. 0.8008 0.8589
Belmont, OH
Marshall, WV
Ohio, WV
9000 \2\Wheeling, WV-OH (OH Hospitals).............. 0.8756 0.9130
Belmont, OH
Marshall, WV
Ohio, WV
9040 Wichita, KS.................................... 0.9300 0.9515
Butler, KS
Harvey, KS
Sedgwick, KS
9080 Wichita Falls, TX.............................. 0.8407 0.8880
Archer, TX
Wichita, TX
9140 \2\Williamsport, PA............................ 0.8429 0.8896
Lycoming, PA
9160 Wilmington-Newark, DE-MD....................... 1.0955 1.0645
New Castle, DE
Cecil, MD
9200 Wilmington, NC................................. 0.9604 0.9727
New Hanover, NC
Brunswick, NC
9260 Yakima, WA..................................... 1.0320 1.0218
Yakima, WA
9270 \2\Yolo, CA.................................... 0.9907 0.9936
Yolo, CA
9280 York, PA....................................... 0.9154 0.9413
York, PA
[[Page 27335]]
9320 Youngstown-Warren, OH.......................... 0.9273 0.9496
Columbiana, OH
Mahoning, OH
Trumbull, OH
9340 Yuba City, CA.................................. 1.0264 1.0180
Sutter, CA
Yuba, CA
9360 Yuma, AZ....................................... 0.8954 0.9271
Yuma, AZ
------------------------------------------------------------------------
\1\ Large urban area.
\2\ Hospitals geographically located in the area are assigned the
statewide rural wage index for FY 2004.
Table 4B.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Rural Areas
------------------------------------------------------------------------
Wage
Nonurban area index GAF
------------------------------------------------------------------------
Alabama............................................. 0.7517 0.8225
Alaska.............................................. 1.1958 1.1303
Arizona............................................. 0.8906 0.9237
Arkansas............................................ 0.7746 0.8395
California.......................................... 0.9907 0.9936
Colorado............................................ 0.8897 0.9231
Connecticut......................................... 1.2199 1.1458
Delaware............................................ 0.9669 0.9772
Florida............................................. 0.8782 0.9149
Georgia............................................. 0.8365 0.8849
Hawaii.............................................. 0.9896 0.9929
Idaho............................................... 0.8907 0.9238
Illinois............................................ 0.8282 0.8789
Indiana............................................. 0.8770 0.9140
Iowa................................................ 0.8278 0.8786
Kansas.............................................. 0.7860 0.8480
Kentucky............................................ 0.7924 0.8527
Louisiana........................................... 0.7565 0.8261
Maine............................................... 0.8995 0.9300
Maryland............................................ 0.9175 0.9427
Massachusetts....................................... 1.1234 1.0829
Michigan............................................ 0.8807 0.9167
Minnesota........................................... 0.9243 0.9475
Mississippi......................................... 0.7810 0.8443
Missouri............................................ 0.7793 0.8430
Montana............................................. 0.8530 0.8968
Nebraska............................................ 0.8326 0.8821
Nevada.............................................. 0.9758 0.9834
New Hampshire....................................... 0.9944 0.9962
\1\ New Jersey...................................... ........ ........
New Mexico.......................................... 0.8314 0.8812
New York............................................ 0.8530 0.8968
North Carolina...................................... 0.8355 0.8842
North Dakota........................................ 0.7536 0.8239
Ohio................................................ 0.8756 0.9130
Oklahoma............................................ 0.7577 0.8270
Oregon.............................................. 0.9939 0.9958
Pennsylvania........................................ 0.8429 0.8896
Puerto Rico......................................... 0.4037 0.5373
\1\ Rhode Island.................................... ........ ........
South Carolina...................................... 0.8489 0.8939
South Dakota........................................ 0.8093 0.8651
Tennessee........................................... 0.7945 0.8542
Texas............................................... 0.7673 0.8341
Utah................................................ 0.9034 0.9328
Vermont............................................. 0.9401 0.9586
Virginia............................................ 0.8542 0.8977
Washington.......................................... 1.0242 1.0165
West Virginia....................................... 0.8008 0.8589
Wisconsin........................................... 0.9130 0.9396
Wyoming............................................. 0.9137 0.9401
------------------------------------------------------------------------
\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
------------------------------------------------------------------------
Akron, OH........................................... 0.9445 0.9617
Albany, GA.......................................... 1.0643 1.0436
Albuquerque, NM..................................... 0.9431 0.9607
Alexandria, LA...................................... 0.8087 0.8647
Altoona, PA......................................... 0.8886 0.9223
Amarillo, TX........................................ 0.8814 0.9172
Anchorage, AK....................................... 1.2433 1.1608
Ann Arbor, MI....................................... 1.0859 1.0581
Anniston, AL........................................ 0.8025 0.8601
Asheville, NC....................................... 0.9503 0.9657
Athens, GA.......................................... 0.9437 0.9611
Atlanta, GA......................................... 0.9912 0.9940
Atlantic-Cape May, NJ............................... 1.0597 1.0405
Augusta-Aiken, GA-SC................................ 0.9491 0.9649
Austin-San Marcos, TX............................... 0.9551 0.9690
Bangor, ME.......................................... 0.9750 0.9828
Barnstable-Yarmouth, MA............................. 1.2703 1.1780
Baton Rouge, LA..................................... 0.8271 0.8781
Bellingham, WA...................................... 1.1834 1.1222
Benton Harbor, MI................................... 0.8949 0.9268
Bergen-Passaic, NJ.................................. 1.1655 1.1106
Billings, MT........................................ 0.8889 0.9225
Biloxi-Gulfport-Pascagoula, MS...................... 0.8449 0.8910
Binghamton, NY...................................... 0.8433 0.8898
Birmingham, AL...................................... 0.9251 0.9481
Bismarck, ND........................................ 0.8101 0.8657
Bloomington-Normal, IL.............................. 0.8954 0.9271
Boise City, ID...................................... 0.9295 0.9512
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH.... 1.1269 1.0853
Burlington, VT...................................... 0.9442 0.9614
Caguas, PR.......................................... 0.4229 0.5547
Casper, WY.......................................... 0.9239 0.9472
Champaign-Urbana, IL................................ 0.9385 0.9575
Charleston-North Charleston, SC..................... 0.9307 0.9520
Charleston, WV (WV Hospitals)....................... 0.8510 0.8954
Charleston, WV (OH Hospitals)....................... 0.8756 0.9130
Charlotte-Gastonia-Rock Hill, NC-SC................. 0.9636 0.9749
Charlottesville, VA................................. 0.9946 0.9963
Chattanooga, TN-GA.................................. 0.8985 0.9293
Chicago, IL......................................... 1.0863 1.0583
Cincinnati, OH-KY-IN................................ 0.9452 0.9621
Clarksville-Hopkinsville, TN-KY..................... 0.8410 0.8882
Cleveland-Lorain-Elyria, OH......................... 0.9686 0.9784
Columbia, MO........................................ 0.8607 0.9024
Columbia, SC........................................ 0.8958 0.9274
Columbus, GA-AL..................................... 0.8505 0.8950
Columbus, OH........................................ 0.9649 0.9758
Corpus Christi, TX.................................. 0.8565 0.8994
Corvallis, OR....................................... 1.1316 1.0884
Dallas, TX.......................................... 0.9733 0.9816
Davenport-Moline-Rock Island, IA-IL................. 0.8727 0.9110
Dayton-Springfield, OH.............................. 0.9432 0.9607
Decatur, AL......................................... 0.8633 0.9042
Denver, CO.......................................... 1.0581 1.0394
Des Moines, IA...................................... 0.9053 0.9341
Detroit, MI......................................... 1.0097 1.0066
Dothan, AL.......................................... 0.7931 0.8532
Dover, DE........................................... 0.9669 0.9772
Duluth-Superior, MN-WI.............................. 1.0133 1.0091
Dutchess County, NY................................. 1.0769 1.0520
Eau Claire, WI...................................... 0.9141 0.9403
Elkhart-Goshen, IN.................................. 0.9613 0.9733
Erie, PA............................................ 0.8530 0.8968
Eugene-Springfield, OR.............................. 1.0889 1.0601
Fargo-Moorhead, ND-MN............................... 0.9444 0.9616
Fayetteville, NC.................................... 0.8957 0.9273
Flagstaff, AZ-UT.................................... 1.1086 1.0732
Flint, MI........................................... 1.0929 1.0627
Florence, AL........................................ 0.7824 0.8453
Florence, SC........................................ 0.8763 0.9135
Fort Collins-Loveland, CO........................... 1.0201 1.0137
Ft. Lauderdale, FL.................................. 1.0534 1.0363
Fort Pierce-Port St. Lucie, FL...................... 1.0227 1.0155
Fort Smith, AR-OK................................... 0.7577 0.8270
Fort Walton Beach, FL............................... 0.8700 0.9090
Forth Worth-Arlington, TX........................... 0.9268 0.9493
Gadsden, AL......................................... 0.8295 0.8798
Grand Forks, ND-MN (ND Hospitals)................... 0.9031 0.9326
Grand Forks, ND-MN (MN Hospitals)................... 0.9243 0.9475
Grand Junction, CO.................................. 0.9940 0.9959
Grand Rapids-Muskegon-Holland, MI................... 0.9406 0.9589
Great Falls, MT..................................... 0.8977 0.9288
Greeley, CO......................................... 0.9516 0.9666
Green Bay, WI....................................... 0.9201 0.9446
Greensboro-Winston-Salem-High Point, NC (NC 0.8533 0.8971
Hospitals).........................................
Greensboro-Winston-Salem-High Point, NC (VA 0.8542 0.8977
Hospitals).........................................
Greenville, NC...................................... 0.9621 0.9739
Hamilton-Middletown, OH............................. 0.9236 0.9470
Harrisburg-Lebanon-Carlisle, PA..................... 0.9178 0.9430
[[Page 27336]]
Hartford, CT (MA Hospitals)......................... 1.1234 1.0829
Hartford, CT (NY Hospitals)......................... 1.1211 1.0814
Hattiesburg, MS..................................... 0.7810 0.8443
Hickory-Morganton-Lenoir, NC........................ 0.8987 0.9295
Honolulu, HI........................................ 1.1176 1.0791
Houston, TX......................................... 0.9591 0.9718
Huntington-Ashland, WV-KY-OH........................ 0.9080 0.9360
Huntsville, AL...................................... 0.8954 0.9271
Indianapolis, IN.................................... 0.9934 0.9955
Iowa City, IA....................................... 0.9460 0.9627
Jackson, MS......................................... 0.8459 0.8917
Jackson, TN......................................... 0.8602 0.9020
Jacksonville, FL.................................... 0.9426 0.9603
Johnson City-Kingsport-Bristol, TN-VA (VA Hospitals) 0.8542 0.8977
Johnson City-Kingsport-Bristol, TN-VA (KY Hospitals) 0.8371 0.8854
Jonesboro, AR (AR Hospitals)........................ 0.7755 0.8402
Jonesboro, AR (MO Hospitals)........................ 0.7793 0.8430
Joplin, MO.......................................... 0.8621 0.9034
Kalamazoo-Battlecreek, MI........................... 1.0554 1.0376
Kansas City, KS-MO.................................. 0.9551 0.9690
Knoxville, TN....................................... 0.8987 0.9295
Kokomo, IN.......................................... 0.8963 0.9278
Lafayette, LA....................................... 0.8271 0.8781
Lakeland-Winter Haven, FL........................... 0.8782 0.9149
Las Vegas, NV-AZ.................................... 1.1341 1.0900
Lawton, OK.......................................... 0.8194 0.8725
Lexington, KY....................................... 0.8424 0.8892
Lima, OH............................................ 0.9457 0.9625
Lincoln, NE......................................... 0.9613 0.9733
Little Rock-North Little Rock, AR................... 0.8905 0.9237
Longview-Marshall, TX............................... 0.8969 0.9282
Los Angeles-Long Beach, CA.......................... 1.1656 1.1106
Louisville, KY-IN................................... 0.9056 0.9344
Lubbock, TX......................................... 0.8330 0.8824
Lynchburg, VA....................................... 0.9004 0.9307
Macon, GA........................................... 0.9011 0.9312
Madison, WI......................................... 1.0108 1.0074
Medford-Ashland, OR................................. 1.0494 1.0336
Melbourne-Titusville-Palm Bay, FL................... 0.9837 0.9888
Memphis, TN-AR-MS................................... 0.9010 0.9311
Miami, FL........................................... 0.9888 0.9923
Milwaukee-Waukesha, WI.............................. 0.9760 0.9835
Minneapolis-St. Paul, MN-WI......................... 1.1064 1.0717
Missoula, MT........................................ 0.8943 0.9264
Mobile, AL.......................................... 0.7948 0.8545
Modesto, CA......................................... 1.1183 1.0796
Monmouth-Ocean, NJ.................................. 1.1094 1.0737
Monroe, LA.......................................... 0.7978 0.8567
Montgomery, AL...................................... 0.7856 0.8477
Nashville, TN....................................... 0.9582 0.9712
New Haven-Bridgeport-Stamford-Waterbury-............
Danbury, CT........................................ 1.2525 1.1667
New Orleans, LA..................................... 0.9167 0.9422
New York, NY........................................ 1.3867 1.2509
Newark, NJ.......................................... 1.1417 1.0950
Newburgh, NY-PA..................................... 1.1377 1.0924
Norfolk-Virginia Beach-Newport News, VA-NC.......... 0.8659 0.9061
Oakland, CA......................................... 1.5204 1.3323
Ocala, FL........................................... 0.9646 0.9756
Odessa-Midland, TX.................................. 0.9156 0.9414
Oklahoma City, OK................................... 0.9027 0.9323
Olympia, WA......................................... 1.1030 1.0694
Omaha, NE-IA........................................ 0.9744 0.9824
Orange County, CA................................... 1.1235 1.0830
Orlando, FL......................................... 0.9612 0.9733
Peoria-Pekin, IL.................................... 0.8811 0.9170
Philadelphia, PA-NJ................................. 1.0947 1.0639
Phoenix-Mesa, AZ.................................... 1.0213 1.0145
Pine Bluff, AR...................................... 0.7810 0.8443
Pittsburgh, PA...................................... 0.8788 0.9153
Pittsfield, MA...................................... 0.9861 0.9905
Pocatello, ID (ID Hospitals)........................ 0.9103 0.9377
Pocatello, ID (WY Hospitals)........................ 0.9137 0.9401
Portland, ME........................................ 0.9784 0.9852
Portland-Vancouver, OR-WA........................... 1.1193 1.0802
Provo-Orem, UT...................................... 0.9912 0.9940
Raleigh-Durham-Chapel Hill, NC...................... 0.9756 0.9832
Rapid City, SD...................................... 0.8865 0.9208
Reading, PA......................................... 0.8910 0.9240
Redding, CA......................................... 1.1357 1.0910
Reno, NV............................................ 1.0758 1.0513
Richland-Kennewick-Pasco, WA........................ 1.0639 1.0433
Richmond-Petersburg, VA............................. 0.9402 0.9587
Roanoke, VA......................................... 0.8759 0.9133
Rochester, MN....................................... 1.1802 1.1201
Rockford, IL........................................ 0.9500 0.9655
Sacramento, CA...................................... 1.1911 1.1272
Saginaw-Bay City-Midland, MI........................ 0.9470 0.9634
St. Cloud, MN....................................... 0.9723 0.9809
St. Joseph, MO...................................... 0.9694 0.9789
St. Louis, MO-IL.................................... 0.9049 0.9339
Salinas, CA......................................... 1.4435 1.2858
Salt Lake City-Ogden, UT............................ 0.9899 0.9931
San Antonio, TX..................................... 0.8876 0.9216
Santa Fe, NM........................................ 0.9543 0.9685
Santa Rosa, CA...................................... 1.2836 1.1865
Sarasota-Bradenton, FL.............................. 0.9834 0.9886
Savannah, GA........................................ 0.9556 0.9694
Seattle-Bellevue-Everett, WA........................ 1.1557 1.1042
Sherman-Denison, TX................................. 0.9084 0.9363
Shreveport-Bossier City, LA......................... 0.9127 0.9394
Sioux City, IA-NE................................... 0.8806 0.9166
Sioux Falls, SD..................................... 0.9246 0.9477
South Bend, IN...................................... 0.9780 0.9849
Spokane, WA......................................... 1.0770 1.0521
Springfield, IL..................................... 0.9004 0.9307
Springfield, MO..................................... 0.8269 0.8780
Stockton-Lodi, CA................................... 1.1168 1.0786
Syracuse, NY........................................ 0.9381 0.9572
Tampa-St. Petersburg-Clearwater, FL................. 0.9111 0.9382
Texarkana,AR-Texarkana, TX.......................... 0.8018 0.8596
Toledo, OH.......................................... 0.9551 0.9690
Topeka, KS.......................................... 0.8791 0.9155
Tucson, AZ.......................................... 0.8958 0.9274
Tulsa, OK........................................... 0.8876 0.9216
Tuscaloosa, AL...................................... 0.8134 0.8681
Tyler, TX........................................... 0.8789 0.9154
Vallejo-Fairfield-Napa, CA.......................... 1.3500 1.2282
Victoria, TX........................................ 0.8105 0.8660
Waco, TX............................................ 0.8449 0.8910
Washington, DC-MD-VA-WV............................. 1.0707 1.0479
Waterloo-Cedar Falls, IA............................ 0.8422 0.8890
Wausau, WI.......................................... 0.9806 0.9867
West Palm Beach-Boca Raton, FL...................... 0.9784 0.9852
Wichita, KS......................................... 0.9053 0.9341
Wichita Falls, TX................................... 0.8407 0.8880
Wilmington-Newark, DE-MD............................ 1.0782 1.0529
Wilmington, NC...................................... 0.9402 0.9587
York, PA............................................ 0.9154 0.9413
Youngstown-Warren, OH............................... 0.9273 0.9496
Rural Alabama....................................... 0.7517 0.8225
Rural Florida....................................... 0.8782 0.9149
Rural Illinois...................................... 0.8282 0.8789
Rural Kentucky...................................... 0.7924 0.8527
Rural Louisiana..................................... 0.7565 0.8261
Rural Michigan...................................... 0.8807 0.9167
Rural Minnesota..................................... 0.9243 0.9475
Rural Mississippi................................... 0.7810 0.8443
Rural Missouri...................................... 0.7793 0.8430
Rural Nebraska...................................... 0.8326 0.8821
Rural New Hampshire................................. 0.9944 0.9962
Rural Texas......................................... 0.7673 0.8341
Rural Washington.................................... 1.0242 1.0165
Rural Wyoming....................................... 0.9020 0.9318
------------------------------------------------------------------------
[[Page 27337]]
Table 4F.--Puerto rico Wage Index and Capital Geographic Adjustment Factor (GAF)
----------------------------------------------------------------------------------------------------------------
Wage index--
GAF--
Area Wage index GAF reclassified reclassified
hospitals hospitals
----------------------------------------------------------------------------------------------------------------
Aguadilla, PR............................................. 0.9218 0.9458 ............ ............
Arecibo, PR............................................... 0.8782 0.9149 ............ ............
Caguas, PR................................................ 0.8992 0.9298 0.8992 0.9298
Mayaguez, PR.............................................. 1.0163 1.0111 ............ ............
Ponce, PR................................................. 1.0124 1.0085 ............ ............
San Juan-Bayamon, PR...................................... 1.0426 1.0290 ............ ............
Rural Puerto Rico......................................... 0.8583 0.9007 ............ ............
----------------------------------------------------------------------------------------------------------------
Table 4G.--Pre-reclassified Wage Index for Urban Areas
------------------------------------------------------------------------
Wage
Urban area (constituent counties) index
------------------------------------------------------------------------
0040 Abilene, TX.............................................. 0.7714
Taylor, TX
0060 Aguadilla, PR............................................ 0.4323
Aguada, PR
Aguadilla, PR
Moca, PR
0080 Akron, OH................................................ 0.9175
Portage, OH
Summit, OH
0120 Albany, GA............................................... 1.0809
Dougherty, GA
Lee, GA
0160 Albany-Schenectady-Troy, NY.............................. 0.8669
Albany, NY
Montgomery, NY
Rensselaer, NY
Saratoga, NY
Schenectady, NY
Schoharie, NY
0200 Albuquerque, NM.......................................... 0.9405
Bernalillo, NM
Sandoval, NM
Valencia, NM
0220 Alexandria, LA........................................... 0.8048
Rapides, LA
0240 Allentown-Bethlehem-Easton, PA........................... 0.9550
Carbon, PA
Lehigh, PA
Northampton, PA
0280 Altoona, PA.............................................. 0.8841
Blair, PA
0320 Amarillo, TX............................................. 0.8944
Potter, TX
Randall, TX
0380 Anchorage, AK............................................ 1.2264
Anchorage, AK
0440 Ann Arbor, MI............................................ 1.1039
Lenawee, MI
Livingston, MI
Washtenaw, MI
0450 Anniston, AL............................................. 0.8118
Calhoun, AL
0460 Appleton-Oshkosh-Neenah, WI.............................. 0.9204
Calumet, WI
Outagamie, WI
Winnebago, WI
0470 Arecibo, PR.............................................. 0.4119
Arecibo, PR
Camuy, PR
Hatillo, PR
0480 Asheville, NC............................................ 0.9671
Buncombe, NC
Madison, NC
0500 Athens, GA............................................... 0.9638
Clarke, GA
Madison, GA
Oconee, GA
0520 Atlanta, GA.............................................. 1.0000
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.................................... 1.0833
Atlantic, NJ
Cape May, NJ
0580 Auburn-Opelika, AL....................................... 0.8517
Lee, AL
0600 Augusta-Aiken, GA-SC..................................... 0.9698
Columbia, GA
McDuffie, GA
Richmond, GA
Aiken, SC
Edgefield, SC
0640 Austin-San Marcos, TX.................................... 0.9525
Bastrop, TX
Caldwell, TX
Hays, TX
Travis, TX
Williamson, TX
0680 Bakersfield, CA.......................................... 0.9956
Kern, CA
0720 Baltimore, MD............................................ 0.9924
Anne Arundel, MD
Baltimore, MD
Baltimore City, MD
Carroll, MD
Harford, MD
Howard, MD
Queen Anne's, MD
0733 Bangor, ME...............................................
Penobscot, ME 0.9925
0743 Barnstable-Yarmouth, MA.................................. 1.2859
Barnstable, MA
0760 Baton Rouge, LA.......................................... 0.8254
Ascension, LA
East Baton Rouge, LA
Livingston, LA
West Baton Rouge, LA
0840 Beaumont-Port Arthur, TX................................. 0.8480
Hardin, TX
Jefferson, TX
Orange, TX
0860 Bellingham, WA........................................... 1.1802
Whatcom, WA
0870 Benton Harbor, MI........................................ 0.8862
Berrien, MI
0875 Bergen-Passaic, NJ....................................... 1.1623
Bergen, NJ
Passaic, NJ
0880 Billings, MT............................................. 0.8865
Yellowstone, MT
0920 Biloxi-Gulfport-Pascagoula, MS........................... 0.9065
Hancock, MS
Harrison, MS
Jackson, MS
0960 Binghamton, NY........................................... 0.8546
Broome, NY
Tioga, NY
1000 Birmingham, AL........................................... 0.9226
Blount, AL
Jefferson, AL
St. Clair, AL
Shelby, AL
1010 Bismarck, ND............................................. 0.7997
Burleigh, ND
Morton, ND
1020 Bloomington, IN.......................................... 0.8944
Monroe, IN
1040 Bloomington-Normal, IL................................... 0.8867
McLean, IL
1080 Boise City, ID........................................... 0.9246
Ada, ID
Canyon, ID
1123 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH (NH 1.1239
Hospitals)...................................................
Bristol, MA
Essex, MA
Middlesex, MA
Norfolk, MA
Plymouth, MA
Suffolk, MA
Worcester, MA
Hillsborough, NH
Merrimack, NH
[[Page 27338]]
Rockingham, NH
Strafford, NH
1125 Boulder-Longmont, CO..................................... 1.0092
Boulder, CO
1145 Brazoria, TX............................................. 0.8170
Brazoria, TX
1150 Bremerton, WA............................................ 1.0573
Kitsap, WA
1240 Brownsville-Harlingen-San Benito, TX..................... 1.0204
Cameron, TX
1260 Bryan-College Station, TX................................ 0.9008
Brazos, TX
1280 Buffalo-Niagara Falls, NY................................ 0.9574
Erie, NY
Niagara, NY
1303 Burlington, VT........................................... 0.9742
Chittenden, VT
Franklin, VT
Grand Isle, VT
1310 Caguas, PR............................................... 0.4175
Caguas, PR
Cayey, PR
Cidra, PR
Gurabo, PR
San Lorenzo, PR
1320 Canton-Massillon, OH..................................... 0.9103
Carroll, OH
Stark, OH
1350 Casper, WY............................................... 0.9187
Natrona, WY
1360 Cedar Rapids, IA......................................... 0.8909
Linn, IA
1400 Champaign-Urbana, IL..................................... 0.9881
Champaign, IL
1440 Charleston-North Charleston, SC.......................... 0.9282
Berkeley, SC
Charleston, SC
Dorchester, SC
1480 Charleston, WV........................................... 0.8730
Kanawha, WV
Putnam, WV
1520 Charlotte-Gastonia-Rock Hill, NC-SC...................... 0.9739
Cabarrus, NC
Gaston, NC
Lincoln, NC
Mecklenburg, NC
Rowan, NC
Stanly, NC
Union, NC
York, SC
1540 Charlottesville, VA...................................... 1.0065
Albemarle, VA
Charlottesville City, VA
Fluvanna, VA
Greene, VA
1560 Chattanooga, TN-GA....................................... 0.8961
Catoosa, GA
Dade, GA
Walker, GA
Hamilton, TN
Marion, TN
1580 Cheyenne, WY............................................. 0.9187
Laramie, WY
1600 Chicago, IL.............................................. 1.0982
Cook, IL
DeKalb, IL
DuPage, IL
Grundy, IL
Kane, IL
Kendall, IL
Lake, IL
McHenry, IL
Will, IL
1620 Chico-Paradise, CA....................................... 1.0206
Butte, CA
1640 Cincinnati, OH-KY-IN..................................... 0.9425
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.......................... 0.8292
Christian, KY
Montgomery, TN
1680 Cleveland-Lorain-Elyria, OH.............................. 0.9691
Ashtabula, OH
Cuyahoga, OH
Geauga, OH
Lake, OH
Lorain, OH
Medina, OH
1720 Colorado Springs, CO..................................... 0.9063
El Paso, CO
1740 Columbia, MO............................................. 0.8721
Boone, MO
1760 Columbia, SC............................................. 0.8934
Lexington, SC
Richland, SC
1800 Columbus, GA-AL.......................................... 0.8677
Russell, AL
Chattahoochee, GA
Harris, GA
Muscogee, GA
1840 Columbus, OH............................................. 0.9623
Delaware, OH
Fairfield, OH
Franklin, OH
Licking, OH
Madison, OH
Pickaway, OH
1880 Corpus Christi, TX....................................... 0.8542
Nueces, TX
San Patricio, TX
1890 Corvallis, OR............................................ 1.1562
Benton, OR
1900 Cumberland, MD-WV (WV Hospital).......................... 0.8202
Allegany, MD
Mineral, WV
1920 Dallas, TX............................................... 0.9703
Collin, TX
Dallas, TX
Denton, TX
Ellis, TX
Henderson, TX
Hunt, TX
Kaufman, TX
Rockwall, TX
1950 Danville, VA............................................. 0.9071
Danville City, VA
Pittsylvania, VA
1960 Davenport-Moline-Rock Island, IA-IL...................... 0.8728
Scott, IA
Henry, IL
Rock Island, IL
2000 Dayton-Springfield, OH................................... 0.9391
Clark, OH
Greene, OH
Miami, OH
Montgomery, OH
2020 Daytona Beach, FL........................................ 0.9183
Flagler, FL
Volusia, FL
2030 Decatur, AL.............................................. 0.8858
Lawrence, AL
Morgan, AL
2040 Decatur, IL.............................................. 0.8321
Macon, IL
2080 Denver, CO............................................... 1.0747
Adams, CO
Arapahoe, CO
Broomfield, CO
Denver, CO
Douglas, CO
Jefferson, CO
2120 Des Moines, IA........................................... 0.9024
Dallas, IA
Polk, IA
Warren, IA
2160 Detroit, MI.............................................. 1.0070
Lapeer, MI
Macomb, MI
Monroe, MI
Oakland, MI
St. Clair, MI
Wayne, MI
2180 Dothan, AL............................................... 0.7894
Dale, AL
Houston, AL
2190 Dover, DE................................................ 0.9844
Kent, DE
2200 Dubuque, IA.............................................. 0.8922
Dubuque, IA
2240 Duluth-Superior, MN-WI................................... 1.0145
St. Louis, MN
Douglas, WI
2281 Dutchess County, NY...................................... 1.0937
Dutchess, NY
2290 Eau Claire, WI........................................... 0.9204
Chippewa, WI
Eau Claire, WI
2320 El Paso, TX.............................................. 0.9242
El Paso, TX
2330 Elkhart-Goshen, IN....................................... 0.9822
Elkhart, IN
2335 Elmira, NY............................................... 0.8546
Chemung, NY
2340 Enid, OK................................................. 0.8593
Garfield, OK
2360 Erie, PA................................................. 0.8613
Erie, PA
2400 Eugene-Springfield, OR................................... 1.1501
Lane, OR
2440 Evansville-Henderson, IN-KY (IN Hospitals)............... 0.8782
Posey, IN
Vanderburgh, IN
Warrick, IN
[[Page 27339]]
Henderson, KY
2520 Fargo-Moorhead, ND-MN.................................... 0.9624
Clay, MN
Cass, ND
2560 Fayetteville, NC......................................... 0.8933
Cumberland, NC
2580 Fayetteville-Springdale-Rogers, AR....................... 0.8016
Benton, AR
Washington, AR
2620 Flagstaff, AZ-UT......................................... 1.1378
Coconino, AZ
Kane, UT
2640 Flint, MI................................................ 1.0900
Genesee, MI
2650 Florence, AL............................................. 0.7751
Colbert, AL
Lauderdale, AL
2655 Florence, SC............................................. 0.8739
Florence, SC
2670 Fort Collins-Loveland, CO................................ 1.0173
Larimer, CO
2680 Ft. Lauderdale, FL....................................... 1.0168
Broward, FL
2700 Fort Myers-Cape Coral, FL................................ 0.9851
Lee, FL
2710 Fort Pierce-Port St. Lucie, FL........................... 1.0028
Martin, FL
St. Lucie, FL
2720 Fort Smith, AR-OK........................................ 0.7741
Crawford, AR
Sebastian, AR
Sequoyah, OK
2750 Fort Walton Beach, FL.................................... 0.8905
Okaloosa, FL
2760 Fort Wayne, IN........................................... 0.9649
Adams, IN
Allen, IN
De Kalb, IN
Huntington, IN
Wells, IN
Whitley, IN
2800 Forth Worth-Arlington, TX................................ 0.9243
Hood, TX
Johnson, TX
Parker, TX
Tarrant, TX
2840 Fresno, CA............................................... 1.0130
Fresno, CA
Madera, CA
2880 Gadsden, AL.............................................. 0.8254
Etowah, AL
2900 Gainesville, FL.......................................... 0.8846
Alachua, FL
2920 Galveston-Texas City, TX................................. 0.9335
Galveston, TX
2960 Gary, IN................................................. 0.9437
Lake, IN
Porter, IN
2975 Glens Falls, NY.......................................... 0.8546
Warren, NY
Washington, NY
2980 Goldsboro, NC............................................ 0.8656
Wayne, NC
2985 Grand Forks, ND-MN....................................... 0.8670
Polk, MN
Grand Forks, ND
2995 Grand Junction, CO....................................... 0.9661
Mesa, CO
3000 Grand Rapids-Muskegon-Holland, MI........................ 0.9372
Allegan, MI
Kent, MI
Muskegon, MI
Ottawa, MI
3040 Great Falls, MT.......................................... 0.8843
Cascade, MT
3060 Greeley, CO.............................................. 0.9409
Weld, CO
3080 Green Bay, WI............................................ 0.9498
Brown, WI
3120 Greensboro-Winston-Salem-High Point, NC.................. 0.8506
Alamance, NC
Davidson, NC
Davie, NC
Forsyth, NC
Guilford, NC
Randolph, NC
Stokes, NC
Yadkin, NC
3150 Greenville, NC........................................... 0.9595
Pitt, NC
3160 Greenville-Spartanburg-Anderson, SC...................... 0.9264
Anderson, SC
Cherokee, SC
Greenville, SC
Pickens, SC
Spartanburg, SC
3180 Hagerstown, MD........................................... 0.9208
Washington, MD
3200 Hamilton-Middletown, OH.................................. 0.9211
Butler, OH
3240 Harrisburg-Lebanon-Carlisle, PA.......................... 0.9153
Cumberland, PA
Dauphin, PA
Lebanon, PA
Perry, PA
3283 Hartford, CT............................................. 1.2166
Hartford, CT
Litchfield, CT
Middlesex, CT
Tolland, CT
3285 Hattiesburg, MS.......................................... 0.7812
Forrest, MS
Lamar, MS
3290 Hickory-Morganton-Lenoir, NC............................. 0.9065
Alexander, NC
Burke, NC
Caldwell, NC
Catawba, NC
3320 Honolulu, HI............................................. 1.1142
Honolulu, HI
3350 Houma, LA................................................ 0.7743
Lafourche, LA
Terrebonne, LA
3360 Houston, TX.............................................. 0.9572
Chambers, TX
Fort Bend, TX
Harris, TX
Liberty, TX
Montgomery, TX
Waller, TX
3400 Huntington-Ashland, WV-KY-OH............................. 0.9594
Boyd, KY
Carter, KY
Greenup, KY
Lawrence, OH
Cabell, WV
Wayne, WV
3440 Huntsville, AL........................................... 0.9213
Limestone, AL
Madison, AL
3480 Indianapolis, IN......................................... 0.9921
Boone, IN
Hamilton, IN
Hancock, IN
Hendricks, IN
Johnson, IN
Madison, IN
Marion, IN
Morgan, IN
Shelby, IN
3500 Iowa City, IA............................................ 0.9579
Johnson, IA
3520 Jackson, MI.............................................. 0.9019
Jackson, MI
3560 Jackson, MS.............................................. 0.8388
Hinds, MS
Madison, MS
Rankin, MS
3580 Jackson, TN.............................................. 0.8579
Madison, TN
Chester, TN
3600 Jacksonville, FL......................................... 0.9342
Clay, FL
Duval, FL
Nassau, FL
St. Johns, FL
3605 Jacksonville, NC......................................... 0.8566
Onslow, NC
3610 Jamestown, NY............................................ 0.8546
Chautauqua, NY
3620 Janesville-Beloit, WI.................................... 0.9318
Rock, WI
3640 Jersey City, NJ.......................................... 1.1173
Hudson, NJ
3660 Johnson City-Kingsport-Bristol, TN-VA.................... 0.8348
Carter, TN
Hawkins, TN
Sullivan, TN
Unicoi, TN
Washington, TN
Bristol City, VA
Scott, VA
Washington, VA
3680 Johnstown, PA............................................ 0.8415
Cambria, PA
Somerset, PA
3700 Jonesboro, AR............................................ 0.7741
Craighead, AR
3710 Joplin, MO............................................... 0.8715
Jasper, MO
Newton, MO
3720 Kalamazoo-Battlecreek, MI................................ 1.0526
Calhoun, MI
Kalamazoo, MI
Van Buren, MI
3740 Kankakee, IL............................................. 1.1044
Kankakee, IL
3760 Kansas City, KS-MO....................................... 0.9525
Johnson, KS
Leavenworth, KS
Miami, KS
[[Page 27340]]
Wyandotte, KS
Cass, MO
Clay, MO
Clinton, MO
Jackson, MO
Lafayette, MO
Platte, MO
Ray, MO
3800 Kenosha, WI.............................................. 0.9799
Kenosha, WI
3810 Killeen-Temple, TX....................................... 0.9197
Bell, TX
Coryell, TX
3840 Knoxville, TN............................................ 0.8963
Anderson, TN
Blount, TN
Knox, TN
Loudon, TN
Sevier, TN
Union, TN
3850 Kokomo, IN............................................... 0.9080
Howard, IN
Tipton, IN
3870 La Crosse, WI-MN......................................... 0.9234
Houston, MN
La Crosse, WI
3880 Lafayette, LA............................................ 0.8250
Acadia, LA
Lafayette, LA
St. Landry, LA
St. Martin, LA
3920 Lafayette, IN............................................ 0.9027
Clinton, IN
Tippecanoe, IN
3960 Lake Charles, LA......................................... 0.8453
Calcasieu, LA
3980 Lakeland-Winter Haven, FL................................ 0.8846
Polk, FL
4000 Lancaster, PA............................................ 0.9300
Lancaster, PA
4040 Lansing-East Lansing, MI................................. 0.9245
Clinton, MI
Eaton, MI
Ingham, MI
4080 Laredo, TX............................................... 0.8123
Webb, TX
4100 Las Cruces, NM........................................... 0.8509
Dona Ana, NM
4120 Las Vegas, NV-AZ......................................... 1.1426
Mohave, AZ
Clark, NV
Nye, NV
4150 Lawrence, KS............................................. 0.8712
Douglas, KS
4200 Lawton, OK............................................... 0.8300
Comanche, OK
4243 Lewiston-Auburn, ME...................................... 0.9364
Androscoggin, ME
4280 Lexington, KY............................................ 0.8599
Bourbon, KY
Clark, KY
Fayette, KY
Jessamine, KY
Madison, KY
Scott, KY
Woodford, KY
4320 Lima, OH................................................. 0.9432
Allen, OH
Auglaize, OH
4360 Lincoln, NE.............................................. 1.0074
Lancaster, NE
4400 Little Rock-North Little Rock, AR........................ 0.8882
Faulkner, AR
Lonoke, AR
Pulaski, AR
Saline, AR
4420 Longview-Marshall, TX.................................... 0.9116
Gregg, TX
Harrison, TX
Upshur, TX
4480 Los Angeles-Long Beach, CA............................... 1.1607
Los Angeles, CA
4520 Louisville, KY-IN........................................ 0.9149
Clark, IN
Floyd, IN
Harrison, IN
Scott, IN
Bullitt, KY
Jefferson, KY
Oldham, KY
4600 Lubbock, TX.............................................. 0.8308
Lubbock, TX
4640 Lynchburg, VA............................................ 0.9177
Amherst, VA
Bedford, VA
Bedford City, VA
Campbell, VA
Lynchburg City, VA
4680 Macon, GA................................................ 0.9005
Bibb, GA
Houston, GA
Jones, GA
Peach, GA
Twiggs, GA
4720 Madison, WI.............................................. 1.0208
Dane, WI
4800 Mansfield, OH............................................ 0.9034
Crawford, OH
Richland, OH
4840 Mayaguez, PR............................................. 0.4767
Anasco, PR
Cabo Rojo, PR
Hormigueros, PR
Mayaguez, PR
Sabana Grande, PR
San German, PR
4880 McAllen-Edinburg-Mission, TX............................. 0.9060
Hidalgo, TX
4890 Medford-Ashland, OR...................................... 1.0815
Jackson, OR
4900 Melbourne-Titusville-Palm Bay, FL........................ 0.9775
Brevard, Fl
4920 Memphis, TN-AR-MS........................................ 0.9300
Crittenden, AR
DeSoto, MS
Fayette, TN
Shelby, TN
Tipton, TN
4940 Merced, CA............................................... 0.9956
Merced, CA
5000 Miami, FL................................................ 0.9862
Dade, FL
5015 Middlesex-Somerset-Hunterdon, NJ......................... 1.1407
Hunterdon, NJ
Middlesex, NJ
Somerset, NJ
5080 Milwaukee-Waukesha, WI................................... 0.9862
Milwaukee, WI
Ozaukee, WI
Washington, WI
Waukesha, WI
5120 Minneapolis-St. Paul, MN-WI.............................. 1.1034
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............................................. 0.8806
Missoula, MT
5160 Mobile, AL............................................... 0.7927
Baldwin, AL
Mobile, AL
5170 Modesto, CA.............................................. 1.1313
Stanislaus, CA
5190 Monmouth-Ocean, NJ....................................... 1.0934
Monmouth, NJ
Ocean, NJ
5200 Monroe, LA............................................... 0.7956
Ouachita, LA
5240 Montgomery, AL........................................... 0.7835
Autauga, AL
Elmore, AL
Montgomery, AL
5280 Muncie, IN............................................... 0.8782
Delaware, IN
5330 Myrtle Beach, SC......................................... 0.8926
Horry, SC
5345 Naples, FL............................................... 0.9840
Collier, FL
5360 Nashville, TN............................................ 0.9809
Cheatham, TN
Davidson, TN
Dickson, TN
Robertson, TN
Rutherford TN
Sumner, TN
Williamson, TN
Wilson, TN
5380 Nassau-Suffolk, NY....................................... 1.2976
Nassau, NY
Suffolk, NY
5483 New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT...... 1.2452
Fairfield, CT
New Haven, CT
5523 New London-Norwich, CT................................... 1.2166
New London, CT
5560 New Orleans, LA.......................................... 0.9148
Jefferson, LA
Orleans, LA
Plaquemines, LA
St. Bernard, LA
St. Charles, LA
St. James, LA
St. John The Baptist, LA
[[Page 27341]]
St. Tammany, LA
5600 New York, NY............................................. 1.3830
Bronx, NY
Kings, NY
New York, NY
Putnam, NY
Queens, NY
Richmond, NY
Rockland, NY
Westchester, NY
5640 Newark, NJ............................................... 1.1386
Essex, NJ
Morris, NJ
Sussex, NJ
Union, NJ
Warren, NJ
5660 Newburgh, NY-PA.......................................... 1.1283
Orange, NY
Pike, PA
5720 Norfolk-Virginia Beach-Newport News, VA-NC............... 0.8636
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.............................................. 1.5004
Alameda, CA
Contra Costa, CA
5790 Ocala, FL................................................ 0.9761
Marion, FL
5800 Odessa-Midland, TX....................................... 0.9422
Ector, TX
Midland, TX
5880 Oklahoma City, OK........................................ 0.9010
Canadian, OK
Cleveland, OK
Logan, OK
McClain, OK
Oklahoma, OK
Pottawatomie, OK
5910 Olympia, WA.............................................. 1.1001
Thurston, WA
5920 Omaha, NE-IA............................................. 0.9718
Pottawattamie, IA
Cass, NE
Douglas, NE
Sarpy, NE
Washington, NE
5945 Orange County, CA........................................ 1.1205
Orange, CA
5960 Orlando, FL.............................................. 0.9586
Lake, FL
Orange, FL
Osceola, FL
Seminole, FL
5990 Owensboro, KY............................................ 0.8407
Daviess, KY
6015 Panama City, FL.......................................... 0.8846
Bay, FL
6020 Parkersburg-Marietta, WV-OH.............................. 0.8071
Washington, OH
Wood, WV
6080 Pensacola, FL............................................ 0.8846
Escambia, FL
Santa Rosa, FL
6120 Peoria-Pekin, IL......................................... 0.8769
Peoria, IL
Tazewell, IL
Woodford, IL
6160 Philadelphia, PA-NJ...................................... 1.0917
Burlington, NJ
Camden, NJ
Gloucester, NJ
Salem, NJ
Bucks, PA
Chester, PA
Delaware, PA
Montgomery, PA
Philadelphia, PA
6200 Phoenix-Mesa, AZ......................................... 1.0185
Maricopa, AZ
Pinal, AZ
6240 Pine Bluff, AR........................................... 0.7741
Jefferson, AR
6280 Pittsburgh, PA........................................... 0.8764
Allegheny, PA
Beaver, PA
Butler, PA
Fayette, PA
Washington, PA
Westmoreland, PA
6323 Pittsfield, MA........................................... 1.0832
Berkshire, MA
6340 Pocatello, ID............................................ 0.9078
Bannock, ID
6360 Ponce, PR................................................ 0.4749
Guayanilla, PR
Juana Diaz, PR
Penuelas, PR
Ponce, PR
Villalba, PR
Yauco, PR
6403 Portland, ME............................................. 0.9958
Cumberland, ME
Sagadahoc, ME
York, ME
6440 Portland-Vancouver, OR-WA................................ 1.1162
Clackamas, OR
Columbia, OR
Multnomah, OR
Washington, OR
Yamhill, OR
Clark, WA
6483 Providence-Warwick-Pawtucket, RI......................... 1.0995
Bristol, RI
Kent, RI
Newport, RI
Providence, RI
Washington, RI
6520 Provo-Orem, UT........................................... 1.0016
Utah, UT
6560 Pueblo, CO............................................... 0.9063
Pueblo, CO
6580 Punta Gorda, FL.......................................... 0.9493
Charlotte, FL
6600 Racine, WI............................................... 0.9204
Racine, WI
6640 Raleigh-Durham-Chapel Hill, NC........................... 1.0073
Chatham, NC
Durham, NC
Franklin, NC
Johnston, NC
Orange, NC
Wake, NC
6660 Rapid City, SD........................................... 0.8841
Pennington, SD
6680 Reading, PA.............................................. 0.9018
Berks, PA
6690 Redding, CA.............................................. 1.1389
Shasta, CA
6720 Reno, NV................................................. 1.0714
Washoe, NV
6740 Richland-Kennewick-Pasco, WA............................. 1.0599
Benton, WA
Franklin, WA
6760 Richmond-Petersburg, VA.................................. 0.9377
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............................. 1.1293
Riverside, CA
San Bernardino, CA
6800 Roanoke, VA.............................................. 0.8735
Botetourt, VA
Roanoke, VA
Roanoke City, VA
Salem City, VA
6820 Rochester, MN............................................ 1.1770
Olmsted, MN
6840 Rochester, NY............................................ 0.9530
Genesee, NY
Livingston, NY
Monroe, NY
Ontario, NY
Orleans, NY
Wayne, NY
6880 Rockford, IL............................................. 0.9704
Boone, IL
Ogle, IL
Winnebago, IL
6895 Rocky Mount, NC.......................................... 0.9034
Edgecombe, NC
Nash, NC
6920 Sacramento, CA........................................... 1.1879
El Dorado, CA
Placer, CA
Sacramento, CA
6960 Saginaw-Bay City-Midland, MI............................. 0.9594
Bay, MI
Midland, MI
Saginaw, MI
6980 St. Cloud, MN............................................ 0.9508
[[Page 27342]]
Benton, MN
Stearns, MN
7000 St. Joseph, MO........................................... 0.9796
Andrew, MO
Buchanan, MO
7040 St. Louis, MO-IL......................................... 0.9025
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................................................ 1.0524
Marion, OR
Polk, OR
7120 Salinas, CA.............................................. 1.4396
Monterey, CA
7160 Salt Lake City-Ogden, UT................................. 0.9872
Davis, UT
Salt Lake, UT
Weber, UT
7200 San Angelo, TX........................................... 0.8266
Tom Green, TX
7240 San Antonio, TX.......................................... 0.8852
Bexar, TX
Comal, TX
Guadalupe, TX
Wilson, TX
7320 San Diego, CA............................................ 1.1176
San Diego, CA
7360 San Francisco, CA........................................ 1.4310
Marin, CA
San Francisco, CA
San Mateo, CA
7400 San Jose, CA............................................. 1.4603
Santa Clara, CA
7440 San Juan-Bayamon, PR..................................... 0.4890
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............... 1.1454
San Luis Obispo, CA
7480 Santa Barbara-Santa Maria-Lompoc, CA..................... 1.0483
Santa Barbara, CA
7485 Santa Cruz-Watsonville, CA............................... 1.2977
Santa Cruz, CA
7490 Santa Fe, NM............................................. 1.0611
Los Alamos, NM
Santa Fe, NM
7500 Santa Rosa, CA........................................... 1.2801
Sonoma, CA
7510 Sarasota-Bradenton, FL................................... 0.9793
Manatee, FL
Sarasota, FL
7520 Savannah, GA............................................. 0.9530
Bryan, GA
Chatham, GA
Effingham, GA
7560 Scranton--Wilkes-Barre--Hazleton, PA..................... 0.8415
Columbia, PA
Lackawanna, PA
Luzerne, PA
Wyoming, PA
7600 Seattle-Bellevue-Everett, WA............................. 1.1526
Island, WA
King, WA
Snohomish, WA
7610 Sharon, PA............................................... 0.8415
Mercer, PA
7620 Sheboygan, WI............................................ 0.9204
Sheboygan, WI
7640 Sherman-Denison, TX...................................... 0.9482
Grayson, TX
7680 Shreveport-Bossier City, LA.............................. 0.9119
Bossier, LA
Caddo, LA
Webster, LA
7720 Sioux City, IA-NE........................................ 0.9028
Woodbury, IA
Dakota, NE
7760 Sioux Falls, SD.......................................... 0.9345
Lincoln, SD
Minnehaha, SD
7800 South Bend, IN........................................... 0.9860
St. Joseph, IN
7840 Spokane, WA.............................................. 1.0940
Spokane, WA
7880 Springfield, IL.......................................... 0.8980
Menard, IL
Sangamon, IL
7920 Springfield, MO.......................................... 0.8447
Christian, MO
Greene, MO
Webster, MO
8003 Springfield, MA.......................................... 1.0832
Hampden, MA
Hampshire, MA
8050 State College, PA........................................ 0.8775
Centre, PA
8080 Steubenville-Weirton, OH-WV (WV Hospitals)............... 0.8431
Jefferson, OH
Brooke, WV
Hancock, WV
8120 Stockton-Lodi, CA........................................ 1.0549
San Joaquin, CA
8140 Sumter, SC............................................... 0.8478
Sumter, SC
8160 Syracuse, NY............................................. 0.9457
Cayuga, NY
Madison, NY
Onondaga, NY
Oswego, NY
8200 Tacoma, WA............................................... 1.0526
Pierce, WA
8240 Tallahassee, FL.......................................... 0.8846
Gadsden, FL
Leon, FL
8280 Tampa-St. Petersburg-Clearwater, FL...................... 0.9087
Hernando, FL
Hillsborough, FL
Pasco, FL
Pinellas, FL
8320 Terre Haute, IN.......................................... 0.8782
Clay, IN
Vermillion, IN
Vigo, IN
8360 Texarkana,AR-Texarkana, TX............................... 0.8176
Miller, AR
Bowie, TX
8400 Toledo, OH............................................... 0.9525
Fulton, OH
Lucas, OH
Wood, OH
8440 Topeka, KS............................................... 0.8997
Shawnee, KS
8480 Trenton, NJ.............................................. 1.0528
Mercer, NJ
8520 Tucson, AZ............................................... 0.9017
Pima, AZ
8560 Tulsa, OK................................................ 0.9113
Creek, OK
Osage, OK
Rogers, OK
Tulsa, OK
Wagoner, OK
8600 Tuscaloosa, AL........................................... 0.8217
Tuscaloosa, AL
8640 Tyler, TX................................................ 0.8766
Smith, TX
8680 Utica-Rome, NY........................................... 0.8546
Herkimer, NY
Oneida, NY
8720 Vallejo-Fairfield-Napa, CA............................... 1.3410
Napa, CA
Solano, CA
8735 Ventura, CA.............................................. 1.0444
Ventura, CA
8750 Victoria, TX............................................. 0.8084
Victoria, TX
8760 Vineland-Millville-Bridgeton, NJ......................... 1.0447
Cumberland, NJ
8780 Visalia-Tulare-Porterville, CA........................... 0.9956
Tulare, CA
8800 Waco, TX................................................. 0.8427
McLennan, TX
8840 Washington, DC-MD-VA-WV.................................. 1.0678
District of Columbia, DC
[[Page 27343]]
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................................. 0.8431
Black Hawk, IA
8940 Wausau, WI............................................... 0.9731
Marathon, WI
8960 West Palm Beach-Boca Raton, FL........................... 0.9758
Palm Beach, FL
9000 Wheeling, WV-OH.......................................... 0.8027
Belmont, OH
Marshall, WV
Ohio, WV
9040 Wichita, KS.............................................. 0.9275
Butler, KS
Harvey, KS
Sedgwick, KS
9080 Wichita Falls, TX........................................ 0.8385
Archer, TX
Wichita, TX
9140 Williamsport, PA......................................... 0.8415
Lycoming, PA
9160 Wilmington-Newark, DE-MD................................. 1.0925
New Castle, DE
Cecil, MD
9200 Wilmington, NC........................................... 0.9579
New Hanover, NC
Brunswick, NC
9260 Yakima, WA............................................... 1.0526
Yakima, WA
9270 Yolo, CA................................................. 0.9956
Yolo, CA
9280 York, PA................................................. 0.9098
York, PA
9320 Youngstown-Warren, OH.................................... 0.9248
Columbiana, OH
Mahoning, OH
Trumbull, OH
9340 Yuba City, CA............................................ 1.0236
Sutter, CA
Yuba, CA
9360 Yuma, AZ................................................. 0.9017
Yuma, AZ
------------------------------------------------------------------------
Table 4H.--Pre-reclassified Wage Index for Rural Areas
------------------------------------------------------------------------
Wage
Nonurban area index
------------------------------------------------------------------------
Alabama....................................................... 0.7470
Alaska........................................................ 1.1958
Arizona....................................................... 0.8906
Arkansas...................................................... 0.7746
California.................................................... 0.9907
Colorado...................................................... 0.8897
Connecticut................................................... 1.2199
Delaware...................................................... 0.9280
Florida....................................................... 0.8782
Georgia....................................................... 0.8365
Hawaii........................................................ 0.9896
Idaho......................................................... 0.8907
Illinois...................................................... 0.8282
Indiana....................................................... 0.8770
Iowa.......................................................... 0.8278
Kansas........................................................ 0.7860
Kentucky...................................................... 0.7922
Louisiana..................................................... 0.7478
Maine......................................................... 0.8995
Maryland...................................................... 0.9175
Massachusetts................................................. 1.1234
Michigan...................................................... 0.8807
Minnesota..................................................... 0.9223
Mississippi................................................... 0.7795
Missouri...................................................... 0.7793
Montana....................................................... 0.8530
Nebraska...................................................... 0.8326
Nevada........................................................ 0.9758
New Hampshire................................................. 0.9944
\1\ New Jersey................................................ ........
New Mexico.................................................... 0.8314
New York...................................................... 0.8530
North Carolina................................................ 0.8355
North Dakota.................................................. 0.7536
Ohio.......................................................... 0.8756
Oklahoma...................................................... 0.7577
Oregon........................................................ 0.9939
Pennsylvania.................................................. 0.8429
Puerto Rico................................................... 0.4037
\1\ Rhode Island.............................................. ........
South Carolina................................................ 0.8489
South Dakota.................................................. 0.8093
Tennessee..................................................... 0.7945
Texas......................................................... 0.7673
Utah.......................................................... 0.9034
Vermont....................................................... 0.9278
Virginia...................................................... 0.8542
Washington.................................................... 1.0242
West Virginia................................................. 0.8008
Wisconsin..................................................... 0.9130
Wyoming....................................................... 0.9137
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban.
* Medicare data have been supplemented by data from 19 States for low
volume DRGs.
** DRGs 469 and 470 contain cases that could not be assigned to valid
DRGs.
Note 1: Geometric mean is used only to determine payment for transfer
cases.
Note 2: Arithmetic mean is presented for informational purposes only.
Note 3: Relative weights are based on Medicare patient data and may not
be appropriate for other patients.
[[Page 27343]]
Table 5.--List of Diagnosis-Related Groups (DRGs), Relative Weighting Factors, and Geographic and Arithmetic
Mean Length of Stay (LOS)
----------------------------------------------------------------------------------------------------------------
Relative Geometric Arithmetic
DRG MDC Type DRG title weights mean LOS mean LOS
----------------------------------------------------------------------------------------------------------------
1............... 1 SURG CRANIOTOMY AGE 17 W CC.
2............... 1 SURG CRANIOTOMY AGE 17 W/O CC.
3............... 1 SURG *CRANIOTOMY AGE 0-17....... 1.9545 12.7 12.7
4............... 1 SURG *NO LONGER VALID........... 0.0000 0.0 0.0
5............... 1 SURG *NO LONGER VALID........... 0.0000 0.0 0.0
6............... 1 SURG CARPAL TUNNEL RELEASE...... 0.7987 2.1 3.0
7............... 1 SURG PERIPH & CRANIAL NERVE & 2.6451 6.7 9.9
OTHER NERV SYST PROC W CC.
8............... 1 SURG PERIPH & CRANIAL NERVE & 1.5337 1.9 2.8
OTHER NERV SYST PROC W/O
CC.
9............... 1 MED SPINAL DISORDERS & INJURIES 1.3323 4.7 6.4
10.............. 1 MED NERVOUS SYSTEM NEOPLASMS W 1.2348 4.8 6.5
CC.
11.............. 1 MED NERVOUS SYSTEM NEOPLASMS W/ 0.8498 3.0 4.1
O CC.
12.............. 1 MED DEGENERATIVE NERVOUS SYSTEM 0.9170 4.5 5.9
DISORDERS.
13.............. 1 MED MULTIPLE SCLEROSIS & 0.8129 4.0 5.0
CEREBELLAR ATAXIA.
14.............. 1 MED INTRACRANIAL HEMORRHAGE & 1.2589 4.7 6.1
STROKE W INFARCT.
15.............. 1 MED NONSPECIFIC CVA & 0.9588 3.9 4.9
PRECEREBRAL OCCLUSION W/O
INFARCT.
[[Page 27344]]
16.............. 1 MED NONSPECIFIC CEREBROVASCULAR 1.2518 4.8 6.4
DISORDERS W CC.
17.............. 1 MED NONSPECIFIC CEREBROVASCULAR 0.6939 2.5 3.2
DISORDERS W/O CC.
18.............. 1 MED CRANIAL & PERIPHERAL NERVE 0.9970 4.2 5.5
DISORDERS W CC.
19.............. 1 MED CRANIAL & PERIPHERAL NERVE 0.6971 2.8 3.5
DISORDERS W/O CC.
20.............. 1 MED NERVOUS SYSTEM INFECTION 2.7213 8.0 10.5
EXCEPT VIRAL MENINGITIS.
21.............. 1 MED VIRAL MENINGITIS........... 1.5069 5.0 6.6
22.............. 1 MED HYPERTENSIVE ENCEPHALOPATHY 1.0671 3.9 5.1
23.............. 1 MED NONTRAUMATIC STUPOR & COMA. 0.8187 3.2 4.3
24.............. 1 MED SEIZURE & HEADACHE AGE 17 W CC.
25.............. 1 MED SEIZURE & HEADACHE AGE 17 W/O CC.
26.............. 1 MED SEIZURE & HEADACHE AGE 0-17 1.4637 2.3 4.3
27.............. 1 MED TRAUMATIC STUPOR & COMA, 1.3235 3.2 5.2
COMA 1 HR.
28.............. 1 MED TRAUMATIC STUPOR & COMA, 1.3285 4.4 6.1
COMA <1 HR AGE 17 W CC.
29.............. 1 MED TRAUMATIC STUPOR & COMA, 0.7042 2.7 3.5
COMA <1 HR AGE 17 W/O CC.
30.............. 1 MED *TRAUMATIC STUPOR & COMA, 0.3306 2.0 2.0
COMA <1 HR AGE 0-17.
31.............. 1 MED *CONCUSSION AGE 17 W CC.
32.............. 1 MED CONCUSSION AGE 17 W/O CC.
33.............. 1 MED CONCUSSION AGE 0-17........ 0.2076 1.6 1.6
34.............. 1 MED OTHER DISORDERS OF NERVOUS 0.9863 3.7 5.0
SYSTEM W CC.
35.............. 1 MED OTHER DISORDERS OF NERVOUS 0.6293 2.5 3.1
SYSTEM W/O CC.
36.............. 2 SURG RETINAL PROCEDURES......... 0.6302 1.2 1.5
37.............. 2 SURG ORBITAL PROCEDURES......... 1.0539 2.5 3.8
38.............. 2 SURG PRIMARY IRIS PROCEDURES.... 0.4676 1.9 2.8
39.............. 2 SURG LENS PROCEDURES WITH OR 0.6263 1.5 2.1
WITHOUT VITRECTOMY.
40.............. 2 SURG EXTRAOCULAR PROCEDURES 0.8867 2.6 3.8
EXCEPT ORBIT AGE 17.
41.............. 2 SURG *EXTRAOCULAR PROCEDURES 0.3365 1.6 1.6
EXCEPT ORBIT AGE 0-17.
42.............. 2 SURG INTRAOCULAR PROCEDURES 0.7032 1.9 2.7
EXCEPT RETINA, IRIS & LENS.
43.............. 2 MED HYPHEMA.................... 0.5402 2.4 3.4
44.............. 2 MED ACUTE MAJOR EYE INFECTIONS. 0.6631 4.0 5.1
45.............. 2 MED NEUROLOGICAL EYE DISORDERS. 0.7191 2.5 3.1
46.............. 2 MED OTHER DISORDERS OF THE EYE 0.7876 3.4 4.5
AGE 17 W CC.
47.............. 2 MED OTHER DISORDERS OF THE EYE 0.5275 2.4 3.1
AGE 17 W/O CC.
48.............. 2 MED *OTHER DISORDERS OF THE EYE 0.2964 2.9 2.9
AGE 0-17.
49.............. 3 SURG MAJOR HEAD & NECK 1.7194 3.2 4.5
PROCEDURES.
50.............. 3 SURG SIALOADENECTOMY............ 0.8279 1.5 1.9
51.............. 3 SURG SALIVARY GLAND PROCEDURES 0.8429 1.9 2.8
EXCEPT SIALOADENECTOMY.
52.............. 3 SURG CLEFT LIP & PALATE REPAIR.. 0.7986 1.5 1.8
53.............. 3 SURG SINUS & MASTOID PROCEDURES 1.2474 2.2 3.6
AGE 17.
54.............. 3 SURG *SINUS & MASTOID PROCEDURES 0.4805 3.2 3.2
AGE 0-17.
55.............. 3 SURG MISCELLANEOUS EAR, NOSE, 0.9181 2.0 2.9
MOUTH & THROAT PROCEDURES.
56.............. 3 SURG RHINOPLASTY................ 0.9174 1.9 2.9
57.............. 3 SURG T&A PROC, EXCEPT 1.0980 2.4 3.7
TONSILLECTOMY &/OR
ADENOIDECTOMY ONLY, AGE
17.
58.............. 3 SURG T&A PROC, EXCEPT 0.2728 1.5 1.5
TONSILLECTOMY &/OR
*ADENOIDECTOMY ONLY, AGE 0-
17.
59.............. 3 SURG TONSILLECTOMY &/OR 0.9629 1.9 2.7
ADENOIDECTOMY ONLY, AGE
17.
60.............. 3 SURG *TONSILLECTOMY &/OR 0.2077 1.5 1.5
ADENOIDECTOMY ONLY, AGE 0-
17.
61.............. 3 SURG MYRINGOTOMY W TUBE 1.2166 3.0 5.1
INSERTION AGE 17.
62.............. 3 SURG *MYRINGOTOMY W TUBE 0.2942 1.3 1.3
INSERTION AGE 0-17.
63.............. 3 SURG OTHER EAR, NOSE, MOUTH & 1.3651 3.0 4.4
THROAT O.R. PROCEDURES.
64.............. 3 MED EAR, NOSE, MOUTH & THROAT 1.3020 4.3 6.5
MALIGNANCY.
65.............. 3 MED DYSEQUILIBRIUM............. 0.5691 2.3 2.8
66.............. 3 MED EPISTAXIS.................. 0.5755 2.4 3.1
67.............. 3 MED EPIGLOTTITIS............... 0.7751 2.9 3.7
68.............. 3 MED OTITIS MEDIA & URI AGE 0.6481 3.1 3.9
>17 W CC.
69.............. 3 MED OTITIS MEDIA & URI AGE 0.4951 2.5 3.0
>17 W/O CC.
70.............. 3 MED OTITIS MEDIA & URI AGE 0-17 0.3243 1.9 2.3
71.............. 3 MED LARYNGOTRACHEITIS.......... 0.6908 2.4 3.4
72.............. 3 MED NASAL TRAUMA & DEFORMITY... 0.6909 2.6 3.4
73.............. 3 MED OTHER EAR, NOSE, MOUTH & 0.8128 3.3 4.5
THROAT DIAGNOSES AGE 17.
74.............. 3 MED *OTHER EAR, NOSE, MOUTH & 0.3344 2.1 2.1
THROAT DIAGNOSES AGE 0-17.
75.............. 4 SURG MAJOR CHEST PROCEDURES..... 3.0248 7.7 10.0
76.............. 4 SURG OTHER RESP SYSTEM O.R. 2.7935 8.4 11.1
PROCEDURES W CC.
77.............. 4 SURG OTHER RESP SYSTEM O.R. 1.2268 3.5 4.8
PROCEDURES W/O CC.
78.............. 4 MED PULMONARY EMBOLISM......... 1.2641 5.6 6.6
79.............. 4 MED RESPIRATORY INFECTIONS & 1.5867 6.7 8.5
INFLAMMATIONS AGE 17 W CC.
[[Page 27345]]
80.............. 4 MED RESPIRATORY INFECTIONS & 0.8340 4.3 5.4
INFLAMMATIONS AGE 17 W/O CC.
81.............. 4 MED *RESPIRATORY INFECTIONS & 1.5139 6.1 6.1
INFLAMMATIONS AGE 0-17.
82.............. 4 MED RESPIRATORY NEOPLASMS...... 1.3626 5.1 6.9
83.............. 4 MED MAJOR CHEST TRAUMA W CC.... 0.9511 4.3 5.4
84.............. 4 MED MAJOR CHEST TRAUMA W/O CC.. 0.5304 2.6 3.3
85.............. 4 MED PLEURAL EFFUSION W CC...... 1.1847 4.8 6.3
86.............. 4 MED PLEURAL EFFUSION W/O CC.... 0.6805 2.8 3.6
87.............. 4 MED PULMONARY EDEMA & 1.3301 4.8 6.3
RESPIRATORY FAILURE.
88.............. 4 MED CHRONIC OBSTRUCTIVE 0.8869 4.1 5.1
PULMONARY DISEASE.
89.............. 4 MED SIMPLE PNEUMONIA & PLEURISY 1.0374 4.9 5.9
AGE 17 W CC.
90.............. 4 MED SIMPLE PNEUMONIA & PLEURISY 0.6097 3.4 4.0
AGE 17 W/O CC.
91.............. 4 MED SIMPLE PNEUMONIA & PLEURISY 0.7390 3.1 5.1
AGE 0-17.
92.............. 4 MED INTERSTITIAL LUNG DISEASE W 1.1938 5.0 6.3
CC.
93.............. 4 MED INTERSTITIAL LUNG DISEASE W/ 0.7123 3.3 4.0
O CC.
94.............. 4 MED PNEUMOTHORAX W CC.......... 1.1256 4.7 6.3
95.............. 4 MED PNEUMOTHORAX W/O CC........ 0.6112 3.0 3.8
96.............. 4 MED BRONCHITIS & ASTHMA AGE 17 W CC.
97.............. 4 MED BRONCHITIS & ASTHMA AGE 17 W/O CC.
98.............. 4 MED *BRONCHITIS & ASTHMA AGE 0- 0.9560 3.7 3.7
17.
99.............. 4 MED RESPIRATORY SIGNS & 0.6974 2.4 3.2
SYMPTOMS W CC.
100............. 4 MED RESPIRATORY SIGNS & 0.5185 1.7 2.1
SYMPTOMS W/O CC.
101............. 4 MED OTHER RESPIRATORY SYSTEM 0.8582 3.3 4.4
DIAGNOSES W CC.
102............. 4 MED OTHER RESPIRATORY SYSTEM 0.5363 2.1 2.6
DIAGNOSES W/O CC.
103............. PRE SURG HEART TRANSPLANT........... 18.5203 25.9 42.1
104............. 5 SURG CARDIAC VALVE & OTH MAJOR 7.9220 12.2 14.4
CARDIOTHORACIC PROC W CARD
CATH.
105............. 5 SURG CARDIAC VALVE & OTH MAJOR 5.7134 8.2 9.9
CARDIOTHORACIC PROC W/O
CARD CATH.
106............. 5 SURG CORONARY BYPASS W PTCA..... 7.2710 9.6 11.4
107............. 5 SURG CORONARY BYPASS W CARDIAC 5.3525 9.2 10.5
CATH.
108............. 5 SURG OTHER CARDIOTHORACIC 5.3651 7.3 9.8
PROCEDURES.
109............. 5 SURG CORONARY BYPASS W/O PTCA OR 3.9294 6.7 7.7
CARDIAC CATH.
110............. 5 SURG MAJOR CARDIOVASCULAR 4.0328 6.3 8.9
PROCEDURES W CC.
111............. 5 SURG MAJOR CARDIOVASCULAR 2.4669 3.2 4.1
PROCEDURES W/O CC.
112............. 5 SURG NO LONGER VALID............ 0.0000 0.0 0.0
113............. 5 SURG AMPUTATION FOR CIRC SYSTEM 2.9875 10.4 13.3
DISORDERS EXCEPT UPPER
LIMB & TOE.
114............. 5 SURG UPPER LIMB & TOE AMPUTATION 1.6337 6.4 8.7
FOR CIRC SYSTEM DISORDERS.
115............. 5 SURG PRM CARD PACEM IMPL W AMI/ 3.5189 5.0 7.5
HR/SHOCK OR AICD LEAD OR
GNRTR.
116............. 5 SURG OTHER PERMANENT CARDIAC 2.3407 3.1 4.4
PACEMAKER IMPLANT.
117............. 5 SURG CARDIAC PACEMAKER REVISION 1.3838 2.6 4.3
EXCEPT DEVICE REPLACEMENT.
118............. 5 SURG CARDIAC PACEMAKER DEVICE 1.5967 2.0 2.9
REPLACEMENT.
119............. 5 SURG VEIN LIGATION & STRIPPING.. 1.3679 3.2 5.4
120............. 5 SURG OTHER CIRCULATORY SYSTEM 2.3033 5.6 9.0
O.R. PROCEDURES.
121............. 5 MED CIRCULATORY DISORDERS W AMI 1.6033 5.3 6.6
& MAJOR COMP, DISCHARGED
ALIVE.
122............. 5 MED CIRCULATORY DISORDERS W AMI 1.0202 2.9 3.7
W/O MAJOR COMP, DISCHARGED
ALIVE.
123............. 5 MED CIRCULATORY DISORDERS W 1.5486 2.9 4.8
AMI, EXPIRED.
124............. 5 MED CIRCULATORY DISORDERS 1.4273 3.3 4.4
EXCEPT AMI, W CARD CATH &
COMPLEX DIAG.
125............. 5 MED CIRCULATORY DISORDERS 1.0885 2.2 2.8
EXCEPT AMI, W CARD CATH W/
O COMPLEX DIAG.
126............. 5 MED ACUTE & SUBACUTE 2.5295 9.3 11.8
ENDOCARDITIS.
127............. 5 MED HEART FAILURE & SHOCK...... 1.0072 4.1 5.3
128............. 5 MED DEEP VEIN THROMBOPHLEBITIS. 0.7226 4.6 5.5
129............. 5 MED CARDIAC ARREST, UNEXPLAINED 1.0089 1.7 2.6
130............. 5 MED PERIPHERAL VASCULAR 0.9430 4.5 5.7
DISORDERS W CC.
131............. 5 MED PERIPHERAL VASCULAR 0.5634 3.4 4.1
DISORDERS W/O CC.
132............. 5 MED ATHEROSCLEROSIS W CC....... 0.6364 2.3 2.9
133............. 5 MED ATHEROSCLEROSIS W/O CC..... 0.5502 1.8 2.3
134............. 5 MED HYPERTENSION............... 0.5905 2.5 3.2
135............. 5 MED CARDIAC CONGENITAL & 0.9196 3.4 4.5
VALVULAR DISORDERS AGE 17 W CC.
136............. 5 MED CARDIAC CONGENITAL & 0.5698 2.2 2.7
VALVULAR DISORDERS AGE 17 W/O CC.
[[Page 27346]]
137............. 5 MED *CARDIAC CONGENITAL & 0.8156 3.3 3.3
VALVULAR DISORDERS AGE 0-
17.
138............. 5 MED CARDIAC ARRHYTHMIA & 0.8289 3.1 4.0
CONDUCTION DISORDERS W CC.
139............. 5 MED CARDIAC ARRHYTHMIA & 0.5120 2.0 2.5
CONDUCTION DISORDERS W/O
CC.
140............. 5 MED ANGINA PECTORIS............ 0.5240 2.0 2.5
141............. 5 MED SYNCOPE & COLLAPSE W CC.... 0.7408 2.8 3.6
142............. 5 MED SYNCOPE & COLLAPSE W/O CC.. 0.5706 2.1 2.6
143............. 5 MED CHEST PAIN................. 0.5435 1.7 2.1
144............. 5 MED OTHER CIRCULATORY SYSTEM 1.2176 3.9 5.6
DIAGNOSES W CC.
145............. 5 MED OTHER CIRCULATORY SYSTEM 0.5742 2.0 2.6
DIAGNOSES W/O CC.
146............. 6 SURG RECTAL RESECTION W CC...... 2.7198 8.8 10.3
147............. 6 SURG RECTAL RESECTION W/O CC.... 1.5267 5.6 6.2
148............. 6 SURG MAJOR SMALL & LARGE BOWEL 3.3748 10.1 12.3
PROCEDURES W CC.
149............. 6 SURG MAJOR SMALL & LARGE BOWEL 1.4487 5.8 6.3
PROCEDURES W/O CC.
150............. 6 SURG PERITONEAL ADHESIOLYSIS W 2.8525 9.2 11.3
CC.
151............. 6 SURG PERITONEAL ADHESIOLYSIS W/O 1.2952 4.4 5.6
CC.
152............. 6 SURG MINOR SMALL & LARGE BOWEL 1.8931 6.9 8.4
PROCEDURES W CC.
153............. 6 SURG MINOR SMALL & LARGE BOWEL 1.1262 4.7 5.3
PROCEDURES W/O CC.
154............. 6 SURG STOMACH, ESOPHAGEAL & 3.9961 9.9 13.3
DUODENAL PROCEDURES AGE
17 W CC.
155............. 6 SURG STOMACH, ESOPHAGEAL & 1.2946 3.0 4.1
DUODENAL PROCEDURES AGE
17 W/O CC.
156............. 6 SURG *STOMACH, ESOPHAGEAL & 0.8400 6.0 6.0
DUODENAL PROCEDURES AGE 0-
17.
157............. 6 SURG ANAL & STOMAL PROCEDURES W 1.3070 4.0 5.8
CC.
158............. 6 SURG ANAL & STOMAL PROCEDURES W/ 0.6472 2.0 2.6
O CC.
159............. 6 SURG HERNIA PROCEDURES EXCEPT 1.3654 3.8 5.1
INGUINAL & FEMORAL AGE 17 W CC.
160............. 6 SURG HERNIA PROCEDURES EXCEPT 0.8170 2.2 2.7
INGUINAL & FEMORAL AGE 17 W/O CC.
161............. 6 SURG INGUINAL & FEMORAL HERNIA 1.1598 3.0 4.3
PROCEDURES AGE 17 W CC.
162............. 6 SURG INGUINAL & FEMORAL HERNIA 0.6396 1.6 1.9
PROCEDURES AGE 17 W/O CC.
163............. 6 SURG *HERNIA PROCEDURES AGE 0-17 0.6892 2.1 2.1
164............. 6 SURG APPENDECTOMY W COMPLICATED 2.3154 7.0 8.4
PRINCIPAL DIAG W CC.
165............. 6 SURG APPENDECTOMY W COMPLICATED 1.2218 3.8 4.5
PRINCIPAL DIAG W/O CC.
166............. 6 SURG APPENDECTOMY W/O 1.4244 3.6 4.7
COMPLICATED PRINCIPAL DIAG
W CC.
167............. 6 SURG APPENDECTOMY W/O 0.8841 2.0 2.4
COMPLICATED PRINCIPAL DIAG
W/O CC.
168............. 3 SURG MOUTH PROCEDURES W CC...... 1.3135 3.3 4.9
169............. 3 SURG MOUTH PROCEDURES W/O CC.... 0.7487 1.8 2.4
170............. 6 SURG OTHER DIGESTIVE SYSTEM O.R. 2.8023 7.5 10.9
PROCEDURES W CC.
171............. 6 SURG OTHER DIGESTIVE SYSTEM O.R. 1.1816 3.3 4.3
PROCEDURES W/O CC.
172............. 6 MED DIGESTIVE MALIGNANCY W CC.. 1.3576 5.2 7.0
173............. 6 MED DIGESTIVE MALIGNANCY W/O CC 0.7524 2.8 3.8
174............. 6 MED G.I. HEMORRHAGE W CC....... 0.9942 3.9 4.8
175............. 6 MED G.I. HEMORRHAGE W/O CC..... 0.5541 2.5 2.9
176............. 6 MED COMPLICATED PEPTIC ULCER... 1.0918 4.1 5.2
177............. 6 MED UNCOMPLICATED PEPTIC ULCER 0.9182 3.7 4.6
W CC.
178............. 6 MED UNCOMPLICATED PEPTIC ULCER 0.6879 2.6 3.1
W/O CC.
179............. 6 MED INFLAMMATORY BOWEL DISEASE. 1.0800 4.6 6.0
180............. 6 MED G.I. OBSTRUCTION W CC...... 0.9562 4.2 5.5
181............. 6 MED G.I. OBSTRUCTION W/O CC.... 0.5332 2.8 3.4
182............. 6 MED ESOPHAGITIS, GASTROENT & 0.8153 3.4 4.4
MISC DIGEST DISORDERS AGE
17 W CC.
183............. 6 MED ESOPHAGITIS, GASTROENT & 0.5710 2.3 2.9
MISC DIGEST DISORDERS AGE
17 W/O CC.
184............. 6 MED ESOPHAGITIS, GASTROENT & 0.4874 2.3 3.2
MISC DIGEST DISORDERS AGE
0-17.
185............. 3 MED DENTAL & ORAL DIS EXCEPT 0.8680 3.3 4.7
EXTRACTIONS &
RESTORATIONS, AGE 17.
186............. 3 MED *DENTAL & ORAL DIS EXCEPT 0.3202 2.9 2.9
EXTRACTIONS &
RESTORATIONS, AGE 0-17.
187............. 3 MED DENTAL EXTRACTIONS & 0.7731 3.0 4.0
RESTORATIONS.
188............. 6 MED OTHER DIGESTIVE SYSTEM 1.1000 4.1 5.6
DIAGNOSES AGE 17 W CC.
189............. 6 MED OTHER DIGESTIVE SYSTEM 0.5936 2.4 3.1
DIAGNOSES AGE 17 W/O CC.
190............. 6 MED OTHER DIGESTIVE SYSTEM 0.8080 3.7 5.2
DIAGNOSES AGE 0-17.
191............. 7 SURG PANCREAS, LIVER & SHUNT 4.2734 9.8 13.9
PROCEDURES W CC.
192............. 7 SURG PANCREAS, LIVER & SHUNT 1.7906 4.7 6.2
PROCEDURES W/O CC.
193............. 7 SURG BILIARY TRACT PROC EXCEPT 3.4000 10.4 12.8
ONLY CHOLECYST W OR W/O
C.D.E. W CC.
[[Page 27347]]
194............. 7 SURG BILIARY TRACT PROC EXCEPT 1.5934 5.7 6.8
ONLY CHOLECYST W OR W/O
C.D.E. W/O CC.
195............. 7 SURG CHOLECYSTECTOMY W C.D.E. W 3.0458 8.7 10.6
CC.
196............. 7 SURG CHOLECYSTECTOMY W C.D.E. W/ 1.6025 4.8 5.6
O CC.
197............. 7 SURG CHOLECYSTECTOMY EXCEPT BY 2.5296 7.5 9.2
LAPAROSCOPE W/O C.D.E. W
CC.
198............. 7 SURG CHOLECYSTECTOMY EXCEPT BY 1.1732 3.8 4.4
LAPAROSCOPE W/O C.D.E. W/O
CC.
199............. 7 SURG HEPATOBILIARY DIAGNOSTIC 2.3704 6.9 9.8
PROCEDURE FOR MALIGNANCY.
200............. 7 SURG HEPATOBILIARY DIAGNOSTIC 3.0260 6.7 10.6
PROCEDURE FOR NON-
MALIGNANCY.
201............. 7 SURG OTHER HEPATOBILIARY OR 3.6753 10.2 14.2
PANCREAS O.R. PROCEDURES.
202............. 7 MED CIRRHOSIS & ALCOHOLIC 1.3013 4.8 6.4
HEPATITIS.
203............. 7 MED MALIGNANCY OF HEPATOBILIARY 1.3407 5.0 6.7
SYSTEM OR PANCREAS.
204............. 7 MED DISORDERS OF PANCREAS 1.1582 4.4 5.8
EXCEPT MALIGNANCY.
205............. 7 MED DISORDERS OF LIVER EXCEPT 1.1970 4.6 6.2
MALIG,CIRR,ALC HEPA W CC.
206............. 7 MED DISORDERS OF LIVER EXCEPT 0.7045 2.9 3.8
MALIG,CIRR,ALC HEPA W/O CC.
207............. 7 MED DISORDERS OF THE BILIARY 1.1443 4.0 5.3
TRACT W CC.
208............. 7 MED DISORDERS OF THE BILIARY 0.6540 2.3 2.9
TRACT W/O CC.
209............. 8 SURG MAJOR JOINT & LIMB 2.0199 4.4 4.9
REATTACHMENT PROCEDURES OF
LOWER EXTREMITY.
210............. 8 SURG HIP & FEMUR PROCEDURES 1.8335 6.1 7.0
EXCEPT MAJOR JOINT AGE 17 W CC.
211............. 8 SURG HIP & FEMUR PROCEDURES 1.2446 4.5 4.9
EXCEPT MAJOR JOINT AGE 17 W/O CC.
212............. 8 SURG *HIP & FEMUR PROCEDURES 0.8436 11.1 11.1
EXCEPT MAJOR JOINT AGE 0-
17.
213............. 8 SURG AMPUTATION FOR 1.8736 6.7 9.2
MUSCULOSKELETAL SYSTEM &
CONN TISSUE DISORDERS.
214............. 8 SURG NO LONGER VALID............ 0.0000 0.0 0.0
215............. 8 SURG NO LONGER VALID............ 0.0000 0.0 0.0
216............. 8 SURG BIOPSIES OF MUSCULOSKELETAL 2.0981 5.0 8.0
SYSTEM & CONNECTIVE TISSUE.
217............. 8 SURG WND DEBRID & SKN GRFT 2.9860 9.1 13.5
EXCEPT HAND,FOR MUSCSKELET
& CONN TISS DIS.
218............. 8 SURG LOWER EXTREM & HUMER PROC 1.5612 4.3 5.5
EXCEPT HIP,FOOT,FEMUR AGE
17 W CC.
219............. 8 SURG LOWER EXTREM & HUMER PROC 1.0187 2.7 3.2
EXCEPT HIP,FOOT,FEMUR AGE
17 W/O CC.
220............. 8 SURG *LOWER EXTREM & HUMER PROC 0.5819 5.3 5.3
EXCEPT HIP,FOOT,FEMUR AGE
0-17.
221............. 8 SURG NO LONGER VALID............ 0.0000 0.0 0.0
222............. 8 SURG NO LONGER VALID............ 0.0000 0.0 0.0
223............. 8 SURG MAJOR SHOULDER/ELBOW PROC, 1.0493 2.2 3.0
OR OTHER UPPER EXTREMITY
PROC W CC.
224............. 8 SURG SHOULDER,ELBOW OR FOREARM 0.7841 1.6 1.9
PROC,EXC MAJOR JOINT PROC,
W/O CC.
225............. 8 SURG FOOT PROCEDURES............ 1.1638 3.6 5.3
226............. 8 SURG SOFT TISSUE PROCEDURES W CC 1.5413 4.5 6.5
227............. 8 SURG SOFT TISSUE PROCEDURES W/O 0.8139 2.1 2.6
CC.
228............. 8 SURG MAJOR THUMB OR JOINT 1.1547 2.7 4.2
PROC,OR OTH HAND OR WRIST
PROC W CC.
229............. 8 SURG HAND OR WRIST PROC, EXCEPT 0.6975 1.8 2.3
MAJOR JOINT PROC, W/O CC.
230............. 8 SURG LOCAL EXCISION & REMOVAL OF 1.3026 3.6 5.6
INT FIX DEVICES OF HIP &
FEMUR.
231............. 8 SURG *NO LONGER VALID........... 0.0000 0.0 0.0
232............. 8 SURG ARTHROSCOPY................ 0.9638 1.8 2.7
233............. 8 SURG OTHER MUSCULOSKELET SYS & 1.9896 5.0 7.4
CONN TISS O.R. PROC W CC.
234............. 8 SURG OTHER MUSCULOSKELET SYS & 1.1937 2.2 3.1
CONN TISS O.R. PROC W/O CC.
235............. 8 MED FRACTURES OF FEMUR......... 0.7516 3.8 5.0
236............. 8 MED FRACTURES OF HIP & PELVIS.. 0.7299 3.9 4.8
237............. 8 MED SPRAINS, STRAINS, & 0.5948 2.9 3.7
DISLOCATIONS OF HIP,
PELVIS & THIGH.
238............. 8 MED OSTEOMYELITIS.............. 1.3446 6.5 8.7
239............. 8 MED PATHOLOGICAL FRACTURES & 1.0524 5.1 6.4
MUSCULOSKELETAL & CONN
TISS MALIGNANCY.
240............. 8 MED CONNECTIVE TISSUE DISORDERS 1.3065 4.9 6.7
W CC.
241............. 8 MED CONNECTIVE TISSUE DISORDERS 0.6297 3.0 3.8
W/O CC.
[[Page 27348]]
242............. 8 MED SEPTIC ARTHRITIS........... 1.1573 5.3 7.0
243............. 8 MED MEDICAL BACK PROBLEMS...... 0.7535 3.7 4.7
244............. 8 MED BONE DISEASES & SPECIFIC 0.7092 3.7 4.7
ARTHROPATHIES W CC.
245............. 8 MED BONE DISEASES & SPECIFIC 0.4741 2.6 3.3
ARTHROPATHIES W/O CC.
246............. 8 MED NON-SPECIFIC ARTHROPATHIES. 0.5937 2.9 3.7
247............. 8 MED SIGNS & SYMPTOMS OF 0.5672 2.6 3.3
MUSCULOSKELETAL SYSTEM &
CONN TISSUE.
248............. 8 MED TENDONITIS, MYOSITIS & 0.8503 3.8 4.9
BURSITIS.
249............. 8 MED AFTERCARE, MUSCULOSKELETAL 0.6710 2.5 3.6
SYSTEM & CONNECTIVE TISSUE.
250............. 8 MED FX, SPRN, STRN & DISL OF 0.7034 3.2 4.1
FOREARM, HAND, FOOT AGE
17 W CC.
251............. 8 MED FX, SPRN, STRN & DISL OF 0.4539 2.3 2.8
FOREARM, HAND, FOOT AGE
17 W/O CC.
252............. 8 MED *FX, SPRN, STRN & DISL OF 0.2526 1.8 1.8
FOREARM, HAND, FOOT AGE 0-
17.
253............. 8 MED FX, SPRN, STRN & DISL OF 0.7512 3.7 4.7
UPARM,LOWLEG EX FOOT AGE
17 W CC.
254............. 8 MED FX, SPRN, STRN & DISL OF 0.4417 2.6 3.2
UPARM,LOWLEG EX FOOT AGE
17 W/O CC.
255............. 8 MED *FX, SPRN, STRN & DISL OF 0.2943 2.9 2.9
UPARM,LOWLEG EX FOOT AGE 0-
17.
256............. 8 MED OTHER MUSCULOSKELETAL 0.8116 3.8 5.1
SYSTEM & CONNECTIVE TISSUE
DIAGNOSES.
257............. 9 SURG TOTAL MASTECTOMY FOR 0.8851 2.1 2.6
MALIGNANCY W CC.
258............. 9 SURG TOTAL MASTECTOMY FOR 0.6978 1.6 1.8
MALIGNANCY W/O CC.
259............. 9 SURG SUBTOTAL MASTECTOMY FOR 0.9337 1.8 2.7
MALIGNANCY W CC.
260............. 9 SURG SUBTOTAL MASTECTOMY FOR 0.6794 1.2 1.4
MALIGNANCY W/O CC.
261............. 9 SURG BREAST PROC FOR NON- 0.8947 1.6 2.1
MALIGNANCY EXCEPT BIOPSY &
LOCAL EXCISION.
262............. 9 SURG BREAST BIOPSY & LOCAL 0.9466 2.9 4.3
EXCISION FOR NON-
MALIGNANCY.
263............. 9 SURG SKIN GRAFT &/OR DEBRID FOR 2.1904 9.0 12.2
SKN ULCER OR CELLULITIS W
CC.
264............. 9 SURG SKIN GRAFT &/OR DEBRID FOR 1.0940 5.2 6.8
SKN ULCER OR CELLULITIS W/
O CC.
265............. 9 SURG SKIN GRAFT &/OR DEBRID 1.5921 4.2 6.6
EXCEPT FOR SKIN ULCER OR
CELLULITIS W CC.
266............. 9 SURG SKIN GRAFT &/OR DEBRID 0.8719 2.3 3.2
EXCEPT FOR SKIN ULCER OR
CELLULITIS W/O CC.
267............. 9 SURG PERIANAL & PILONIDAL 0.9515 2.9 4.5
PROCEDURES.
268............. 9 SURG SKIN, SUBCUTANEOUS TISSUE & 1.1516 2.5 3.9
BREAST PLASTIC PROCEDURES.
269............. 9 SURG OTHER SKIN, SUBCUT TISS & 1.7647 6.0 8.6
BREAST PROC W CC.
270............. 9 SURG OTHER SKIN, SUBCUT TISS & 0.8085 2.5 3.6
BREAST PROC W/O CC.
271............. 9 MED SKIN ULCERS................ 1.0219 5.6 7.2
272............. 9 MED MAJOR SKIN DISORDERS W CC.. 1.0084 4.6 6.0
273............. 9 MED MAJOR SKIN DISORDERS W/O CC 0.6167 3.0 3.9
274............. 9 MED MALIGNANT BREAST DISORDERS 1.1449 4.7 6.5
W CC.
275............. 9 MED MALIGNANT BREAST DISORDERS 0.5738 2.4 3.5
W/O CC.
276............. 9 MED NON-MALIGANT BREAST 0.6410 3.5 4.5
DISORDERS.
277............. 9 MED CELLULITIS AGE 17 W CC.
278............. 9 MED CELLULITIS AGE 17 W/O CC.
279............. 9 MED CELLULITIS AGE 0-17........ 0.7687 4.0 5.3
280............. 9 MED TRAUMA TO THE SKIN, SUBCUT 0.7035 3.2 4.1
TISS & BREAST AGE 17 W CC.
281............. 9 MED TRAUMA TO THE SKIN, SUBCUT 0.4810 2.3 2.9
TISS & BREAST AGE 17 W/O CC.
282............. 9 MED *TRAUMA TO THE SKIN, SUBCUT 0.2558 2.2 2.2
TISS & BREAST AGE 0-17.
283............. 9 MED MINOR SKIN DISORDERS W CC.. 0.7271 3.5 4.7
284............. 9 MED MINOR SKIN DISORDERS W/O CC 0.4172 2.3 2.9
285............. 10 SURG AMPUTAT OF LOWER LIMB FOR 2.0611 7.9 10.6
ENDOCRINE,NUTRIT,& METABOL
DISORDERS.
286............. 10 SURG ADRENAL & PITUITARY 2.0223 4.4 5.9
PROCEDURES.
287............. 10 SURG SKIN GRAFTS & WOUND DEBRID 1.8651 7.7 10.3
FOR ENDOC, NUTRIT & METAB
DISORDERS.
288............. 10 SURG O.R. PROCEDURES FOR OBESITY 2.1578 3.9 5.0
289............. 10 SURG PARATHYROID PROCEDURES..... 0.9427 1.8 2.7
290............. 10 SURG THYROID PROCEDURES......... 0.8874 1.7 2.2
291............. 10 SURG THYROGLOSSAL PROCEDURES.... 0.6425 1.4 1.6
292............. 10 SURG OTHER ENDOCRINE, NUTRIT & 2.7077 7.2 10.5
METAB O.R. PROC W CC.
293............. 10 SURG OTHER ENDOCRINE, NUTRIT & 1.3678 3.2 4.7
METAB O.R. PROC W/O CC.
294............. 10 MED DIABETES AGE 35. 0.7632 3.4 4.5
[[Page 27349]]
295............. 10 MED DIABETES AGE 0-35.......... 0.7959 3.0 4.0
296............. 10 MED NUTRITIONAL & MISC 0.8572 4.0 5.1
METABOLIC DISORDERS AGE
17 W CC.
297............. 10 MED NUTRITIONAL & MISC 0.5041 2.7 3.3
METABOLIC DISORDERS AGE
17 W/O CC.
298............. 10 MED NUTRITIONAL & MISC 0.4610 2.4 3.2
METABOLIC DISORDERS AGE 0-
17.
299............. 10 MED INBORN ERRORS OF METABOLISM 0.9381 3.7 5.5
300............. 10 MED ENDOCRINE DISORDERS W CC... 1.0938 4.8 6.2
301............. 10 MED ENDOCRINE DISORDERS W/O CC. 0.6113 2.8 3.6
302............. 11 SURG KIDNEY TRANSPLANT.......... 3.2328 7.2 8.5
303............. 11 SURG KIDNEY,URETER & MAJOR 2.3540 6.4 8.1
BLADDER PROCEDURES FOR
NEOPLASM.
304............. 11 SURG KIDNEY,URETER & MAJOR 2.3813 6.2 8.9
BLADDER PROC FOR NON-NEOPL
W CC.
305............. 11 SURG KIDNEY,URETER & MAJOR 1.1767 2.8 3.6
BLADDER PROC FOR NON-NEOPL
W/O CC.
306............. 11 SURG PROSTATECTOMY W CC......... 1.2134 3.5 5.4
307............. 11 SURG PROSTATECTOMY W/O CC....... 0.6094 1.7 2.1
308............. 11 SURG MINOR BLADDER PROCEDURES W 1.5867 4.0 6.2
CC.
309............. 11 SURG MINOR BLADDER PROCEDURES W/ 0.8931 1.7 2.1
O CC.
310............. 11 SURG TRANSURETHRAL PROCEDURES W 1.1402 2.9 4.4
CC.
311............. 11 SURG TRANSURETHRAL PROCEDURES W/ 0.6203 1.5 1.8
O CC.
312............. 11 SURG URETHRAL PROCEDURES, AGE 1.0784 3.0 4.6
17 W CC.
313............. 11 SURG URETHRAL PROCEDURES, AGE 0.6747 1.7 2.3
17 W/O CC.
314............. 11 SURG *URETHRAL PROCEDURES, AGE 0- 0.4931 2.3 2.3
17.
315............. 11 SURG OTHER KIDNEY & URINARY 2.0680 3.8 7.0
TRACT O.R. PROCEDURES.
316............. 11 MED RENAL FAILURE.............. 1.2907 4.9 6.6
317............. 11 MED ADMIT FOR RENAL DIALYSIS... 0.8488 2.4 3.6
318............. 11 MED KIDNEY & URINARY TRACT 1.1797 4.5 6.1
NEOPLASMS W CC.
319............. 11 MED KIDNEY & URINARY TRACT 0.6754 2.2 2.9
NEOPLASMS W/O CC.
320............. 11 MED KIDNEY & URINARY TRACT 0.8785 4.3 5.4
INFECTIONS AGE 17 W CC.
321............. 11 MED KIDNEY & URINARY TRACT 0.5640 3.1 3.7
INFECTIONS AGE 17 W/O CC.
322............. 11 MED KIDNEY & URINARY TRACT 0.4571 2.7 3.2
INFECTIONS AGE 0-17.
323............. 11 MED URINARY STONES W CC, &/OR 0.8026 2.4 3.2
ESW LITHOTRIPSY.
324............. 11 MED URINARY STONES W/O CC...... 0.4752 1.6 1.9
325............. 11 MED KIDNEY & URINARY TRACT 0.6497 2.9 3.8
SIGNS & SYMPTOMS AGE 17 W CC.
326............. 11 MED KIDNEY & URINARY TRACT 0.4181 2.1 2.6
SIGNS & SYMPTOMS AGE 17 W/O CC.
327............. 11 MED *KIDNEY & URINARY TRACT 0.3688 3.1 3.1
SIGNS & SYMPTOMS AGE 0-17.
328............. 11 MED URETHRAL STRICTURE AGE 17 W CC.
329............. 11 MED URETHRAL STRICTURE AGE 17 W/O CC.
330............. 11 MED *URETHRAL STRICTURE AGE 0- 0.3177 1.6 1.6
17.
331............. 11 MED OTHER KIDNEY & URINARY 1.0546 4.2 5.6
TRACT DIAGNOSES AGE 17 W CC.
332............. 11 MED OTHER KIDNEY & URINARY 0.5949 2.4 3.2
TRACT DIAGNOSES AGE 17 W/O CC.
333............. 11 MED OTHER KIDNEY & URINARY 0.9552 3.7 5.8
TRACT DIAGNOSES AGE 0-17.
334............. 12 SURG MAJOR MALE PELVIC 1.4738 3.9 4.6
PROCEDURES W CC.
335............. 12 SURG MAJOR MALE PELVIC 1.0778 2.8 3.0
PROCEDURES W/O CC.
336............. 12 SURG TRANSURETHRAL PROSTATECTOMY 0.8539 2.6 3.4
W CC.
337............. 12 SURG TRANSURETHRAL PROSTATECTOMY 0.5832 1.8 2.0
W/O CC.
338............. 12 SURG TESTES PROCEDURES, FOR 1.2100 3.5 5.5
MALIGNANCY.
339............. 12 SURG TESTES PROCEDURES, NON- 1.1314 2.9 4.8
MALIGNANCY AGE 17.
340............. 12 SURG *TESTES PROCEDURES, NON- 0.2823 2.4 2.4
MALIGNANCY AGE 0-17.
341............. 12 SURG PENIS PROCEDURES........... 1.2651 2.0 3.2
342............. 12 SURG CIRCUMCISION AGE 17.
343............. 12 SURG *CIRCUMCISION AGE 0-17..... 0.1534 1.7 1.7
344............. 12 SURG OTHER MALE REPRODUCTIVE 1.3244 1.6 2.5
SYSTEM O.R. PROCEDURES FOR
MALIGNANCY.
345............. 12 SURG OTHER MALE REPRODUCTIVE 1.1523 3.0 4.9
SYSTEM O.R. PROC EXCEPT
FOR MALIGNANCY.
346............. 12 MED MALIGNANCY, MALE 1.0133 4.5 5.9
REPRODUCTIVE SYSTEM, W CC.
347............. 12 MED MALIGNANCY, MALE 0.5436 2.2 3.0
REPRODUCTIVE SYSTEM, W/O
CC.
348............. 12 MED BENIGN PROSTATIC 0.7423 3.3 4.4
HYPERTROPHY W CC.
349............. 12 MED BENIGN PROSTATIC 0.4562 2.0 2.5
HYPERTROPHY W/O CC.
350............. 12 MED INFLAMMATION OF THE MALE 0.7298 3.6 4.5
REPRODUCTIVE SYSTEM.
351............. 12 MED *STERILIZATION, MALE....... 0.2354 1.3 1.3
352............. 12 MED OTHER MALE REPRODUCTIVE 0.7076 2.9 4.0
SYSTEM DIAGNOSES.
353............. 13 SURG PELVIC EVISCERATION, 1.8469 5.0 6.6
RADICAL HYSTERECTOMY &
RADICAL VULVECTOMY.
[[Page 27350]]
354............. 13 SURG UTERINE,ADNEXA PROC FOR NON- 1.4796 4.7 5.7
OVARIAN/ADNEXAL MALIG W CC.
355............. 13 SURG UTERINE,ADNEXA PROC FOR NON- 0.8855 3.0 3.2
OVARIAN/ADNEXAL MALIG W/O
CC.
356............. 13 SURG FEMALE REPRODUCTIVE SYSTEM 0.7516 1.8 2.1
RECONSTRUCTIVE PROCEDURES.
357............. 13 SURG UTERINE & ADNEXA PROC FOR 2.2673 6.7 8.4
OVARIAN OR ADNEXAL
MALIGNANCY.
358............. 13 SURG UTERINE & ADNEXA PROC FOR 1.1754 3.4 4.2
NON-MALIGNANCY W CC.
359............. 13 SURG UTERINE & ADNEXA PROC FOR 0.8055 2.3 2.6
NON-MALIGNANCY W/O CC.
360............. 13 SURG VAGINA, CERVIX & VULVA 0.8613 2.2 2.8
PROCEDURES.
361............. 13 SURG LAPAROSCOPY & INCISIONAL 1.0865 2.2 3.2
TUBAL INTERRUPTION.
362............. 13 SURG *ENDOSCOPIC TUBAL 0.3009 1.4 1.4
INTERRUPTION.
363............. 13 SURG D&C, CONIZATION & RADIO- 0.9275 2.6 3.6
IMPLANT, FOR MALIGNANCY.
364............. 13 SURG D&C, CONIZATION EXCEPT FOR 0.8939 2.9 4.1
MALIGNANCY.
365............. 13 SURG OTHER FEMALE REPRODUCTIVE 2.1194 5.3 8.2
SYSTEM O.R. PROCEDURES.
366............. 13 MED MALIGNANCY, FEMALE 1.2567 4.8 6.7
REPRODUCTIVE SYSTEM W CC.
367............. 13 MED MALIGNANCY, FEMALE 0.5496 2.2 3.0
REPRODUCTIVE SYSTEM W/O CC.
368............. 13 MED INFECTIONS, FEMALE 1.1619 5.2 6.7
REPRODUCTIVE SYSTEM.
369............. 13 MED MENSTRUAL & OTHER FEMALE 0.5997 2.4 3.3
REPRODUCTIVE SYSTEM
DISORDERS.
370............. 14 SURG CESAREAN SECTION W CC...... 0.9992 4.2 5.7
371............. 14 SURG CESAREAN SECTION W/O CC.... 0.6267 3.2 3.5
372............. 14 MED VAGINAL DELIVERY W 0.5457 2.7 3.5
COMPLICATING DIAGNOSES.
373............. 14 MED VAGINAL DELIVERY W/O 0.3831 2.0 2.3
COMPLICATING DIAGNOSES.
374............. 14 SURG VAGINAL DELIVERY W 0.7410 2.5 3.0
STERILIZATION &/OR D&C.
375............. 14 SURG *VAGINAL DELIVERY W O.R. 0.5745 4.4 4.4
PROC EXCEPT STERIL &/OR
D&C.
376............. 14 MED POSTPARTUM & POST ABORTION 0.5499 2.6 3.4
DIAGNOSES W/O O.R.
PROCEDURE.
377............. 14 SURG POSTPARTUM & POST ABORTION 1.0123 3.2 4.1
DIAGNOSES W O.R. PROCEDURE.
378............. 14 MED ECTOPIC PREGNANCY.......... 0.7893 2.0 2.6
379............. 14 MED THREATENED ABORTION........ 0.3647 2.0 3.0
380............. 14 MED ABORTION W/O D&C........... 0.4261 1.6 2.0
381............. 14 SURG ABORTION W D&C, ASPIRATION 0.5247 1.5 1.9
CURETTAGE OR HYSTEROTOMY.
382............. 14 MED FALSE LABOR................ 0.2113 1.3 1.7
383............. 14 MED OTHER ANTEPARTUM DIAGNOSES 0.5103 2.7 3.8
W MEDICAL COMPLICATIONS.
384............. 14 MED OTHER ANTEPARTUM DIAGNOSES 0.3463 1.9 2.6
W/O MEDICAL COMPLICATIONS.
385............. 15 MED *NEONATES, DIED OR 1.3709 1.8 1.8
TRANSFERRED TO ANOTHER
ACUTE CARE FACILITY.
386............. 15 MED *EXTREME IMMATURITY OR 4.5207 17.9 17.9
RESPIRATORY DISTRESS
SYNDROME, NEONATE.
387............. 15 MED *PREMATURITY W MAJOR 3.0876 13.3 1 3.3
PROBLEMS.
388............. 15 MED *PREMATURITY W/O MAJOR 1.8630 8.6 8.6
PROBLEMS.
389............. 15 MED FULL TERM NEONATE W MAJOR 1.2020 5.2 6.3
PROBLEMS.
390............. 15 MED *NEONATE W OTHER 1.1225 3.4 3.4
SIGNIFICANT PROBLEMS.
391............. 15 MED *NORMAL NEWBORN............ 0.1520 3.1 3.1
392............. 16 SURG SPLENECTOMY AGE 17.
393............. 16 SURG *SPLENECTOMY AGE 0-17...... 1.3429 9.1 9.1
394............. 16 SURG OTHER O.R. PROCEDURES OF 1.9216 4.7 7.6
THE BLOOD AND BLOOD
FORMING ORGANS.
395............. 16 MED RED BLOOD CELL DISORDERS 0.8159 3.2 4.3
AGE 17.
396............. 16 MED RED BLOOD CELL DISORDERS 0.7409 3.0 4.4
AGE 0-17.
397............. 16 MED COAGULATION DISORDERS...... 1.2575 3.7 5.2
398............. 16 MED RETICULOENDOTHELIAL & 1.2266 4.5 5.9
IMMUNITY DISORDERS W CC.
399............. 16 MED RETICULOENDOTHELIAL & 0.6630 2.8 3.5
IMMUNITY DISORDERS W/O CC.
400............. 17 SURG *NO LONGER VALID........... 0.0000 0.0 0.0
401............. 17 SURG LYMPHOMA & NON-ACUTE 2.8817 8.1 11.6
LEUKEMIA W OTHER O.R. PROC
W CC.
402............. 17 SURG LYMPHOMA & NON-ACUTE 1.1371 2.7 4.0
LEUKEMIA W OTHER O.R. PROC
W/O CC.
403............. 17 MED LYMPHOMA & NON-ACUTE 1.8018 5.8 8.1
LEUKEMIA W CC.
404............. 17 MED LYMPHOMA & NON-ACUTE 0.8609 3.0 4.1
LEUKEMIA W/O CC.
405............. 17 MED *ACUTE LEUKEMIA W/O MAJOR 1.9038 4.9 4.9
O.R. PROCEDURE AGE 0-17.
406............. 17 SURG MYELOPROLIF DISORD OR 2.6845 6.9 9.7
POORLY DIFF NEOPL W MAJ
O.R.PROC W CC.
[[Page 27351]]
407............. 17 SURG MYELOPROLIF DISORD OR 1.2347 3.2 4.1
POORLY DIFF NEOPL W MAJ
O.R.PROC W/O CC.
408............. 17 SURG MYELOPROLIF DISORD OR 2.1935 4.8 8.3
POORLY DIFF NEOPL W OTHER
O.R.PROC.
409............. 17 MED RADIOTHERAPY............... 1.2333 4.6 6.2
410............. 17 MED CHEMOTHERAPY W/O ACUTE 1.0780 3.2 4.1
LEUKEMIA AS SECONDARY
DIAGNOSIS.
411............. 17 MED *HISTORY OF MALIGNANCY W/O 0.3906 4.7 4.7
ENDOSCOPY.
412............. 17 MED HISTORY OF MALIGNANCY W 0.5721 2.5 3.7
ENDOSCOPY.
413............. 17 MED OTHER MYELOPROLIF DIS OR 1.3143 5.3 7.1
POORLY DIFF NEOPL DIAG W
CC.
414............. 17 MED OTHER MYELOPROLIF DIS OR 0.7332 3.2 4.2
POORLY DIFF NEOPL DIAG W/O
CC.
415............. 18 SURG O.R. PROCEDURE FOR 3.5998 10.4 14.4
INFECTIOUS & PARASITIC
DISEASES.
416............. 18 MED SEPTICEMIA AGE 17.
417............. 18 MED SEPTICEMIA AGE 0-17........ 0.9864 4.4 5.8
418............. 18 MED POSTOPERATIVE & POST- 1.0605 4.9 6.3
TRAUMATIC INFECTIONS.
419............. 18 MED FEVER OF UNKNOWN ORIGIN AGE 0.8404 3.6 4.6
17 W CC.
420............. 18 MED FEVER OF UNKNOWN ORIGIN AGE 0.6052 2.8 3.4
17 W/O CC.
421............. 18 MED VIRAL ILLNESS AGE 17.
422............. 18 MED VIRAL ILLNESS & FEVER OF 0.7271 2.5 3.7
UNKNOWN ORIGIN AGE 0-17.
423............. 18 MED OTHER INFECTIOUS & 1.8074 5.9 8.4
PARASITIC DISEASES
DIAGNOSES.
424............. 19 SURG O.R. PROCEDURE W PRINCIPAL 2.3708 8.0 12.9
DIAGNOSES OF MENTAL
ILLNESS.
425............. 19 MED ACUTE ADJUSTMENT REACTION & 0.6723 2.8 3.8
PSYCHOSOCIAL DYSFUNCTION.
426............. 19 MED DEPRESSIVE NEUROSES........ 0.5051 3.2 4.5
427............. 19 MED NEUROSES EXCEPT DEPRESSIVE. 0.5029 3.1 4.4
428............. 19 MED DISORDERS OF PERSONALITY & 0.7222 4.5 7.1
IMPULSE CONTROL.
429............. 19 MED ORGANIC DISTURBANCES & 0.8235 4.5 6.1
MENTAL RETARDATION.
430............. 19 MED PSYCHOSES.................. 0.6750 5.6 7.9
431............. 19 MED CHILDHOOD MENTAL DISORDERS. 0.6551 4.4 6.9
432............. 19 MED OTHER MENTAL DISORDER 0.6453 2.8 4.0
DIAGNOSES.
433............. 20 MED ALCOHOL/DRUG ABUSE OR 0.2876 2.2 3.1
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... 1.7409 5.1 8.1
440............. 21 SURG WOUND DEBRIDEMENTS FOR 1.8767 5.8 9.1
INJURIES.
441............. 21 SURG HAND PROCEDURES FOR 0.9595 2.1 3.1
INJURIES.
442............. 21 SURG OTHER O.R. PROCEDURES FOR 2.4020 5.6 8.6
INJURIES W CC.
443............. 21 SURG OTHER O.R. PROCEDURES FOR 0.9737 2.5 3.4
INJURIES W/O CC.
444............. 21 MED TRAUMATIC INJURY AGE 17 W CC.
445............. 21 MED TRAUMATIC INJURY AGE 17 W/O CC.
446............. 21 MED *TRAUMATIC INJURY AGE 0-17. 0.2951 2.4 2.4
447............. 21 MED ALLERGIC REACTIONS AGE 17.
448............. 21 MED *ALLERGIC REACTIONS AGE 0- 0.0971 2.9 2.9
17.
449............. 21 MED POISONING & TOXIC EFFECTS 0.8275 2.6 3.7
OF DRUGS AGE 17
W CC.
450............. 21 MED POISONING & TOXIC EFFECTS 0.4224 1.6 2.0
OF DRUGS AGE 17
W/O CC.
451............. 21 MED *POISONING & TOXIC EFFECTS 0.2621 2.1 2.1
OF DRUGS AGE 0-17.
452............. 21 MED COMPLICATIONS OF TREATMENT 1.0373 3.5 4.9
W CC.
453............. 21 MED COMPLICATIONS OF TREATMENT 0.5086 2.1 2.8
W/O CC.
454............. 21 MED OTHER INJURY, POISONING & 0.8121 3.0 4.2
TOXIC EFFECT DIAG W CC.
455............. 21 MED OTHER INJURY, POISONING & 0.4690 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 1.1855 2.1 3.6
OTHER CONTACT W HEALTH
SERVICES.
462............. 23 MED REHABILITATION............. 1.0073 9.4 11.3
463............. 23 MED SIGNS & SYMPTOMS W CC...... 0.6795 3.1 4.1
464............. 23 MED SIGNS & SYMPTOMS W/O CC.... 0.4940 2.4 3.0
465............. 23 MED AFTERCARE W HISTORY OF 0.9078 2.0 4.0
MALIGNANCY AS SECONDARY
DIAGNOSIS.
[[Page 27352]]
466............. 23 MED AFTERCARE W/O HISTORY OF 0.7967 2.2 3.9
MALIGNANCY AS SECONDARY
DIAGNOSIS.
467............. 23 MED OTHER FACTORS INFLUENCING 0.4916 1.9 3.0
HEALTH STATUS.
468............. ....... .................... EXTENSIVE O.R. PROCEDURE 3.7934 9.4 13.1
UNRELATED TO PRINCIPAL
DIAGNOSIS.
469............. ....... .................... PRINCIPAL DIAGNOSIS INVALID 0.0000 0.0 0.0
AS DISCHARGE **DIAGNOSIS.
470............. ....... .................... **UNGROUPABLE.............. 0.0000 0.0 0.0
471............. 8 SURG BILATERAL OR MULTIPLE MAJOR 3.0380 4.7 5.4
JOINT PROCS OF LOWER
EXTREMITY.
472............. 22 SURG NO LONGER VALID............ 0.0000 0.0 0.0
473............. 17 MED ACUTE LEUKEMIA W/O MAJOR 3.4644 7.4 12.7
O.R. PROCEDURE AGE 17.
474............. 4 SURG NO LONGER VALID............ 0.0000 0.0 0.0
475............. 4 MED RESPIRATORY SYSTEM 3.5767 8.0 11.3
DIAGNOSIS WITH VENTILATOR
SUPPORT.
476............. ....... SURG PROSTATIC O.R. PROCEDURE 2.2299 8.0 11.1
UNRELATED TO PRINCIPAL
DIAGNOSIS.
477............. ....... SURG NON-EXTENSIVE O.R. 1.8593 5.4 8.2
PROCEDURE UNRELATED TO
PRINCIPAL DIAGNOSIS.
478............. 5 SURG OTHER VASCULAR PROCEDURES W 2.3639 4.9 7.4
CC.
479............. 5 SURG OTHER VASCULAR PROCEDURES W/ 1.4223 2.4 3.2
O CC.
480............. PRE SURG LIVER TRANSPLANT........... 9.6510 14.0 21.1
481............. PRE SURG BONE MARROW TRANSPLANT..... 5.9571 19.1 21.7
482............. PRE SURG TRACHEOSTOMY FOR FACE,MOUTH 3.4598 9.6 12.5
& NECK DIAGNOSES.
483............. PRE SURG TRAC W MECH VENT 96+HRS OR 16.5997 34.1 41.3
PDX EXCEPT FACE,MOUTH &
NECK DX OSES.
484............. 24 SURG CRANIOTOMY FOR MULTIPLE 5.3969 9.9 14.7
SIGNIFICANT TRAUMA.
485............. 24 SURG LIMB REATTACHMENT, HIP AND 3.1535 7.9 9.9
FEMUR PROC FOR MULTIPLE
SIGNIFICANT TRA.
486............. 24 SURG OTHER O.R. PROCEDURES FOR 4.8552 8.8 12.9
MULTIPLE SIGNIFICANT
TRAUMA.
487............. 24 MED OTHER MULTIPLE SIGNIFICANT 1.9609 5.3 7.3
TRAUMA.
488............. 25 SURG HIV W EXTENSIVE O.R. 4.7597 11.7 17.0
PROCEDURE.
489............. 25 MED HIV W MAJOR RELATED 1.8340 6.0 8.6
CONDITION.
490............. 25 MED HIV W OR W/O OTHER RELATED 1.0397 3.9 5.5
CONDITION.
491............. 8 SURG MAJOR JOINT & LIMB 1.7059 2.8 3.4
REATTACHMENT PROCEDURES OF
UPPER EXTREMITY.
492............. 17 MED CHEMOTHERAPY W ACUTE 3.8083 9.3 14.9
LEUKEMIA OR W USE OF HIGH
DOSE CHEMOAGENT.
493............. 7 SURG LAPAROSCOPIC 1.8169 4.4 6.0
CHOLECYSTECTOMY W/O C.D.E.
W CC.
494............. 7 SURG LAPAROSCOPIC 0.9950 2.0 2.5
CHOLECYSTECTOMY W/O C.D.E.
W/O CC.
495............. PRE SURG LUNG TRANSPLANT............ 8.3919 13.5 16.4
496............. 8 SURG COMBINED ANTERIOR/POSTERIOR 5.6730 6.8 8.9
SPINAL FUSION.
497............. 8 SURG SPINAL FUSION EXCEPT 3.3896 5.2 6.3
CERVICAL W CC.
498............. 8 SURG SPINAL FUSION EXCEPT 2.5213 3.6 4.0
CERVICAL W/O CC.
499............. 8 SURG BACK & NECK PROCEDURES 1.4186 3.3 4.5
EXCEPT SPINAL FUSION W CC.
500............. 8 SURG BACK & NECK PROCEDURES 0.9344 2.0 2.4
EXCEPT SPINAL FUSION W/O
CC.
501............. 8 SURG KNEE PROCEDURES W PDX OF 2.6174 8.3 10.7
INFECTION W CC.
502............. 8 SURG KNEE PROCEDURES W PDX OF 1.4062 5.2 6.2
INFECTION W/O CC.
503............. 8 SURG KNEE PROCEDURES W/O PDX OF 1.2152 3.0 3.9
INFECTION.
504............. 22 SURG EXTENSIVE 3RD DEGREE BURNS 11.8123 20.1 27.7
W SKIN GRAFT.
505............. 22 MED EXTENSIVE 3RD DEGREE BURNS 2.0106 2.3 5.7
W/O SKIN GRAFT.
506............. 22 SURG FULL THICKNESS BURN W SKIN 4.0998 12.1 16.9
GRAFT OR INHAL INJ W CC OR
SIG TRAUMA.
507............. 22 SURG FULL THICKNESS BURN W SKIN 1.8145 6.5 9.1
GRFT OR INHAL INJ W/O CC
OR SIG TRAUMA.
508............. 22 MED FULL THICKNESS BURN W/O 1.3754 5.7 8.0
SKIN GRFT OR INHAL INJ W
CC OR SIG TRAUMA.
509............. 22 MED FULL THICKNESS BURN W/O 0.6404 3.0 4.3
SKIN GRFT OR INH INJ W/O
CC OR SIG TRAUMA.
510............. 22 MED NON-EXTENSIVE BURNS W CC OR 1.1762 4.6 6.8
SIGNIFICANT TRAUMA.
511............. 22 MED NON-EXTENSIVE BURNS W/O CC 0.6654 3.1 4.6
OR SIGNIFICANT TRAUMA.
512............. PRE SURG SIMULTANEOUS PANCREAS/ 5.3384 11.1 13.1
KIDNEY TRANSPLANT.
513............. PRE SURG PANCREAS TRANSPLANT........ 6.0851 8.5 9.8
514............. 5 SURG NO LONGER VALID............ 0.0000 0.0 0.0
515............. 5 SURG CARDIAC DEFIBRILLATOR 5.3127 3.0 5.2
IMPLANT W/O CARDIAC CATH.
516............. 5 SURG PERCUTANEOUS CARDIOVASC 2.6723 3.7 4.7
PROC W AMI.
517............. 5 SURG PERC CARDIO PROC W NON-DRUG 2.1245 1.8 2.6
ELUTING STENT W/O AMI.
518............. 5 SURG PERC CARDIO PROC W/O 1.8210 2.2 3.3
CORONARY ARTERY STENT OR
AMI.
[[Page 27353]]
519............. 8 SURG CERVICAL SPINAL FUSION W CC 2.4228 3.2 5.1
520............. 8 SURG CERVICAL SPINAL FUSION W/O 1.5749 1.7 2.1
CC.
521............. 20 MED ALCOHOL/DRUG ABUSE OR 0.7054 4.3 5.8
DEPENDENCE W CC.
522............. 20 MED ALC/DRUG ABUSE OR DEPEND W 0.5151 7.7 9.6
REHABILITATION THERAPY W/O
CC.
523............. 20 MED ALC/DRUG ABUSE OR DEPEND W/ 0.3929 3.3 4.1
O REHABILITATION THERAPY W/
O CC.
524............. 1 MED TRANSIENT ISCHEMIA......... 0.7252 2.7 3.4
525............. 5 SURG HEART ASSIST SYSTEM IMPLANT 11.4482 9.0 17.6
526............. 5 SURG PERCUTNEOUS CARDIOVASULAR 2.9729 3.6 4.5
PROC W DRUG ELUTING STENT
W AMI.
527............. 5 SURG PERCUTNEOUS CARDIOVASULAR 2.4342 1.8 2.6
PROC W DRUG ELUTING STENT
W/O AMI.
528............. 1 SURG INTRACRANIAL VASCULAR PROC 7.0434 14.1 17.2
W PDX HEMORRHAGE.
529............. 1 SURG VENTRICULAR SHUNT 3.1094 6.6 10.6
PROCEDURES W CC.
530............. 1 SURG VENTRICULAR SHUNT 1.2664 2.9 3.9
PROCEDURES W/O CC.
531............. 1 SURG SPINAL PROCEDURES W CC..... 3.0474 6.8 10.0
532............. 1 SURG SPINAL PROCEDURES W/O CC... 1.4487 2.9 4.0
533............. 1 SURG EXTRACRANIAL PROCEDURES W 1.6578 2.7 4.1
CC.
534............. 1 SURG EXTRACRANIAL PROCEDURES W/O 1.0689 1.6 2.0
CC.
535............. 5 SURG CARDIAC DEFIB IMPLANT W 8.1344 8.1 11.0
CARDIAC CATH W AMI/HF/
SHOCK.
536............. 5 SURG CARDIAC DEFIB IMPLANT W 6.2536 3.9 5.8
CARDIAC CATH W/O AMI/HF/
SHOCK.
537............. 8 SURG LOCAL EXCIS & REMOV OF INT 1.8090 4.7 7.0
FIX DEV EXCEPT HIP & FEMUR
W CC.
538............. 8 SURG LOCAL EXCIS & REMOV OF INT 0.9874 2.1 2.9
FIX DEV EXCEPT HIP & FEMUR
W/O CC.
539............. 17 SURG LYMPHOMA & LEUKEMIA W MAJOR 3.3744 7.5 11.2
OR PROCEDURE W CC.
540............. 17 SURG LYMPHOMA & LEUKEMIA W MAJOR 1.2851 2.9 4.1
OR PROCEDURE W/O CC.
----------------------------------------------------------------------------------------------------------------
*Medicare data have been supplemented by data from 19 States for low volume DRGs.
**DRGs 469 and 470 contain cases that could not be assigned to valid DRGs.
Federal Register / Vol. 68, No. 96 / Monday, May 19, 2003 / Proposed
Rules
[[Page 27353]]
Table 6A.--New Diagnosis Codes
----------------------------------------------------------------------------------------------------------------
Diagnosis
code Description CC MDC DRG
----------------------------------------------------------------------------------------------------------------
255.10 Primary aldosteronism........ N 10 300, 301
255.11 Glucocorticoid-remediable N 10 300, 301
aldosteronism.
255.12 Conn's syndrome.............. N 10 300, 301
255.13 Bartter's syndrome........... N 10 300, 301
255.14 Other secondary aldosteronism N 10 300, 301
277.81 Primary carnitine deficiency. N 10 299
277.82 Carnitine deficiency due to N 10 299
inborn errors of metabolism.
277.83 Iatrogenic carnitine N 10 299
deficiency.
277.84 Other secondary carnitine N 10 299
deficiency.
277.89 Other specified disorders of N 10 299
metabolism.
282.41 Sickle-cell thalassemia Y 15 \1\ 387, \1\ 389
without crisis. 16 395, 396
282.42 Sickle-cell thalassemia with Y 15 \1\ 387, \1\ 389
crisis. 16 395, 396
282.49 Other thalassemia............ Y 15 \1\ 387, \1\ 389
16 395, 396
282.64 Sickle-cell/Hb-C disease with Y 16 395, 396
crisis.
282.68 Other sickle-cell disease Y 16 395, 396
without crisis.
289.52 Splenic sequestration........ N 16 398, 399
289.81 Primary hypercoagulable state Y 16 398, 399
289.82 Secondary hypercoagulable Y 16 398, 399
state.
289.89 Other specified diseases of N 16 398, 399
blood and blood-forming
organs.
331.11 Pick's disease............... N 1 12
331.19 Other frontotemporal dementia N 1 12
331.82 Dementia with Lewy bodies.... N 1 12
348.30 Encephalopathy, unspecified.. N 1 16, 17
25 \2\ 489
348.31 Metabolic encephalopathy..... N 1 16, 17
25 \2\ 489
348.39 Other encephalopathy......... N 1 16, 17
25 \2\489
[[Page 27354]]
358.00 Myasthenia gravis without Y 1 12
(acute) exacerbation.
358.01 Myasthenia gravis with Y 1 12
(acute) exacerbation.
414.07 Coronary atherosclerosis, Of N 5 132,133
bypass graft (artery) (vein)
of transplanted heart.
458.21 Hypotension of hemodialysis.. N 5 141, 142
458.29 Other iatrogenic hypotension. N 5 141,142
493.81 Exercise induced bronchospasm N 4 96, 97, 98
493.82 Cough variant asthma......... N 4 96, 97, 98
517.3 Acute chest syndrome......... N 4 92, 93
530.20 Ulcer of esophagus without N 6 176
bleeding.
530.21 Ulcer of esophagus with Y 6 176
bleeding.
530.85 Barrett's esophagus.......... N 6 176
600.00 Hypertrophy (benign) of N 12 348, 349
prostate without urinary
obstruction.
600.01 Hypertrophy (benign) of N 12 348, 349
prostate with urinary
obstruction.
600.10 Nodular prostate without N 12 348, 349
urinary obstruction.
600.11 Nodular prostate with urinary N 12 348, 349
obstruction.
600.20 Benign localized hyperplasia N 12 348, 349
of prostate without urinary
obstruction.
600.21 Benign localized hyperplasia N 12 348, 349
of prostate with urinary
obstruction.
600.90 Hyperplasia of prostate, N 12 348, 349
unspecified, without urinary
obstruction.
600.91 Hyperplasia of prostate, N 12 348, 349
unspecified, with urinary
obstruction.
607.85 Peyronie's disease........... N 12 352
674.50 Peripartum cardiomyopathy, Y 14 469
unspecified as to episode of
care or not applicable.
674.51 Peripartum cardiomyopathy, Y 14 370, 371, 372, 374, 375
delivered, with or without
mention of antepartum
condition.
674.52 Peripartum cardiomyopathy, Y 14 370, 371, 372, 374, 375
delivered, with mention of
postpartum condition.
674.53 Peripartum cardiomyopathy, Y 14 383, 384
antepartum condition or
complication.
674.54 Peripartum cardiomyopathy, Y 14 376, 377
postpartum condition or
complication.
719.7 Difficulty in walking........ N 8 247
728.87 Muscle weakness.............. N 8 247
728.88 Rhabdomyolysis............... Y 8 248
752.81 Scrotal transposition........ N 12 352
752.89 Other specified anomalies of N 12 352
genital organs.
766.21 Post-term infant............. N 15 391
766.22 Prolonged gestation of infant N 15 391
767.11 Epicranial subaponeurotic Y 15 389
hemorrhage (massive).
767.19 Other injuries to scalp...... N 15 391
779.83 Delayed separation of N 15 391
umbilical cord.
780.93 Memory loss.................. N 23 463, 464
780.94 Early satiety................ N 23 463, 464
781.94 Facial weakness.............. N 1 34, 35
785.52 Septic shock................. Y 18 416, 417
788.63 Urgency of urination......... N 11 325, 326, 327
790.21 Impaired fasting glucose..... N 10 296, 297, 298
790.22 Impaired glucose tolerance N 10 296, 297, 298
test (oral).
790.29 Other abnormal glucose....... N 10 296, 297, 298
799.81 Decreased libido............. N 23 467
799.89 Other ill-defined conditions. N 23 467
850.11 Concussion, with loss of Y 1 31, 32, 33
consciousness of 30 minutes 24 487
or less.
850.12 Concussion, with loss of Y 1 31, 32, 33
consciousness from 31 to 59 24 487
minutes.
959.11 Other injury of chest wall... N 21 444, 445, 446
24 487
959.12 Other injury of abdomen...... N 21 444, 445, 446
24 487
959.13 Fracture of corpus cavernosum N 21 444, 445, 446
penis. 24 487
959.14 Other injury of external N 21 444, 445, 446
genitals. 24 487
959.19 Other injury of other sites N 21 444, 445, 446
of trunk. 24 487
996.57 Complication, Due to insulin Y 21 452, 453
pump.
V04.81 Need for prophylactic N 23 467
vaccination and inoculation,
Influenza.
V04.82 Need for prophylactic N 23 467
vaccination and inoculation,
Respiratory synctial virus
(RSV).
V04.89 Need for prophylactic N 23 467
vaccination and inoculation,
Other viral diseases.
V15.87 History of Extracorporeal N 23 467
Membrance Oxygenation (ECMO).
V25.03 Encounter for emergency N 23 467
contraceptive counseling and
prescription.
V43.21 Organ or tissue replaced by Y 5 144, 145
other means, Heart assist
device.
V43.22 Organ or tissue replaced by Y 5 144, 145
other means, Fully
implantable artificial heart.
V45.85 Insulin pump status.......... N 23 467
[[Page 27355]]
V53.90 Fitting and adjustment, N 23 467
Unspecified device.
V53.91 Fitting and adjustment of N 23 467
insulin pump.
V53.99 Fitting and adjustment, Other N 23 467
device.
V54.01 Encounter for removal of N 8 249
internal fixation device.
V54.02 Encounter for lengthening/ N 8 249
adjustment of growth rod.
V54.09 Other aftercare involving N 8 249
internal fixation device.
V58.63 Long-term (current) use of N 23 465, 466
antiplatelet/antithrombotic.
V58.64 Long-term (current) use of N 23 465, 466
nonsteriodal anti-
inflammatories.
V58.65 Long-term (current) use of N 23 465, 466
steroids.
V64.41 Laparoscopic surgical N 23 467
procedure coverted to open
procedure.
V64.42 Thoracoscopic surgical N 23 467
procedure converted to open
procedure.
V64.43 Arthroscopic surgical N 23 467
procedure converted to open
procedure.
V65.11 Pediatric pre-birth visit for N 23 467
expectant mother.
V65.19 Other person consulting on N 23 467
behalf of another person.
V65.46 Encounter for insulin pump N 23 467
training.
----------------------------------------------------------------------------------------------------------------
\1\ Classified as a Major Problem.
\2\ Classified as a Major Related Condition.
Table 6B.--New Procedure Codes
----------------------------------------------------------------------------------------------------------------
Procedure
Code Description OR MDC DRG
----------------------------------------------------------------------------------------------------------------
00.15 High-dose infusion N* 17 492
interleukin-2 (IL-2).
37.51 Heart transplantation........ Y PRE 103
37.52 Implantation of total Y 5 525
replacement heart system.
37.53 Replacement or repair of Y 5 525
thoracic unit of total
replacement heart system.
37.54 Replacement or repair of Y 5 525
other implantable component
of total replacement heart
system.
68.31 Laparoscopic supracervical Y 13 354, 355,357,
hysterectomy (LSH). 358, 359
14 375
68.39 Other subtotal abdominal Y 13 354, 355, 357,
hysterectomy, NOS. 358, 359
14 375
81.62 Fusion or refusion of 2-3 \1\ N
vertebrae.
81.63 Fusion or refusion of 4-8 \1\ N
vertebrae.
81.64 Fusion or refusion of 9 or \1\ N
more vertebrae.
----------------------------------------------------------------------------------------------------------------
*Nonoperating room procedure, but affects DRG.
\1\ Nonoperating room procedure code. The DRG assignment is made based on the specific fusion or refusion (81.00-
81.08, 81.30-81.39, 81.61).
Table 6C.--Invalid Diagnosis Codes
----------------------------------------------------------------------------------------------------------------
Diagnosis
code Description CC MDC DRG
----------------------------------------------------------------------------------------------------------------
255.1 Hyperaldosteronism........... N 10 300, 301
277.8 Other specified disorders of N 10 299
metabolism.
282.4 Thalassemias................. Y 15 \1\1381, \1\389
16 395, 396
289.8 Other specified diseases of N 16 398, 399
blood and blood-forming
organs.
331.1 Pick's disease............... N 1 12
348.3 Encephalopathy, unspecified.. N 1 16, 17
25 \2\489
358.0 Myasthenia gravis............ Y 1 12
458.2 Iatrogenic hypotension....... N 5 141, 142
530.2 Ulcer of esophagus........... N 6 176
600.0 Hypertrophy (benign) of N 12 348, 349
prostate.
600.1 Nodular prostate............. N 12 348, 349
600.2 Benign localized hyperplasia N 12 348, 349
of prostate.
600.9 Hyperplasia of prostate, N 12 348, 349
unspecified.
719.70 Difficulty in walking, site N 8 247
unspecified.
719.75 Difficulty in walking, pelvic N 8 247
region and thigh.
719.76 Difficulty in walking, lower N 8 247
leg.
719.77 Difficulty in walking, ankle N 8 247
and foot.
719.78 Difficulty in walking, other N 8 247
specified sites.
719.79 Difficulty in walking, N 8 247
multiple sites.
752.8 Other specified anomalies of N 12 352
genital organs. 13 358, 359, 369
[[Page 27356]]
766.2 Post term infant, not ``heavy N 15 391
for dates''.
767.1 Injuries to scalp............ N 15 391
790.2 Abnormal glucose tolerance N 10 296, 297, 298
test.
799.8 Other ill-defined conditions. N 23 467
850.1 Concussion, with brief loss Y 1 31, 32, 33
of consciousness. 24 487
959.1 Injury, trunk................ N 21 444, 445, 446
24 487
V04.8 Need for prophylactic N 23 467
vaccination and inoculation
against certain viral
disease, Influenza.
V43.2 Organ or tissue replaced by Y 5 144, 145
other means, Heart.
V53.9 Fitting and adjustment of N 23 467
other device, Other and
unspecified device.
V54.0 Aftercare involving removal N 8 249
of fracture plate or other
internal fixation device.
V64.4 Laparoscopic surgical N 23 467
procedure converted to open
procedure.
V65.1 Person consulting on behalf N 23 467
of another person.
----------------------------------------------------------------------------------------------------------------
\1\ Classified as a ``Major Problem.''
\2\ Classified as a ``Major Related Condition.''
TABLE 6D.--Invalid Procedure Codes
----------------------------------------------------------------------------------------------------------------
Procedure
code Description OR MDC DRG
----------------------------------------------------------------------------------------------------------------
37.5 Heart transplantation........ Y PRE 103
68.3 Subtotal abdominal Y 13 354, 355, 357,
hysterectomy. 358, 359
14 375
----------------------------------------------------------------------------------------------------------------
Table 6E.--Revised Diagnosis Code Titles
----------------------------------------------------------------------------------------------------------------
Diagnosis
code Description CC MDC DRG
----------------------------------------------------------------------------------------------------------------
282.60 Sickle-cell disease, Y 16 395, 396
unspecified.
282.61 Hb-SS disease without crisis. Y 16 395, 396
282.62 Hb-SS disease with crisis.... Y 16 395, 396
282.63 Sickle-cell/Hb-C disease Y 16 395, 396
without crisis.
282.69 Other sickle-cell disease Y 16 395, 396
with crisis.
414.06 Of native coronary artery of N 5 132, 133
transplanted heart.
491.20 Obstructive chronic Y 4 88
bronchitis, without
exacerbation.
491.21 Obstructive chronic Y 4 88
bronchitis, with (acute)
exacerbation.
493.00 Extrinsic asthma, unspecified N 4 96, 97, 98
493.02 Extrinsic asthma, with Y 4 96, 97, 98
(acute) exacerbation.
493.10 Intrinsic asthma, unspecified N 4 96, 97, 98
493.12 Intrinsic asthma, with Y 4 96, 97, 98
(acute) exacerbation.
493.20 Chronic obstructive asthma, Y 4 88
unspecified.
493.22 Chronic obstructive asthma, Y 4 88
with (acute) exacerbation.
493.90 Asthma, unspecified, N 4 96, 97, 98
unspecified.
493.92 Asthma, unspecified, with Y 4 96, 97, 98
(acute) exacerbation.
V06.1 Diphtheria-tetanus-pertussis, N 23 467
combined [DTP] [DtaP].
V06.5 Tetanus-diphtheria [Td][DT].. N 23 467
----------------------------------------------------------------------------------------------------------------
Table 6F.--Revised Procedure Code Titles
----------------------------------------------------------------------------------------------------------------
Procedure
code Description OR MDC DRG
----------------------------------------------------------------------------------------------------------------
37.33 Excision or destruction of Y 5 108
other lesion or tissue of
heart, open approach.
37.34 Excision or destruction of Y 5 516, 517, 518
other lesion or tissue of
heart, other approach.
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
----------------------------------------------------------------------------------------------------------------
[[Page 27357]]
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.]
------------------------------------------------------------------------
------------------------------------------------------------------------
*25060 *2800 28242 2848 28262 28249 28268 2860
35800 28241 28249 2849 28263 28264 *28522 2861
35801 28242 28264 2850 28264 28268 28241 2862
*25061 28249 28268 2851 28268 *28310 28242 2863
35800 28264 *2821 *28249 28269 28241 28249 2864
35801 28268 28241 2800 2830 28242 28264 2865
*25062 *2801 28242 2814 28310 28249 28268 2866
35800 28241 28249 2818 28311 28264 *28529 2867
35801 28242 28264 28241 28319 28268 28241 2869
*25063 28249 28268 28242 2832 *28311 28242 2870
35800 28264 *2822 28249 2839 28241 28249 2871
35801 28268 28241 28260 2840 28242 28264 2872
*25080 *2808 28242 28261 2848 28249 28268 2873
35800 28241 28249 28262 2849 28264 *2858 2874
35801 28242 28264 28263 2850 28268 28241 2875
*25081 28249 28268 28264 2851 *28319 28242 2878
35800 28264 *2823 28268 *28268 28241 28249 2879
35801 28268 28241 28269 2800 28242 28264 2880
*25082 *2809 28242 2830 2814 28249 28268 2881
35800 28241 28249 28310 2818 28264 *2859 28981
35801 28242 28264 28311 28241 28268 28241 28982
*25083 28249 28268 28319 28242 *2832 28242 *28982
35800 28264 *28241 2832 28249 28241 28249 2800
35801 28268 2800 2839 28260 28242 28264 2814
*25090 *2810 2814 2840 28261 28249 28268 2818
35800 28241 2818 2848 28262 28264 *2880 28241
35801 28242 28241 2849 28263 28268 28981 28242
*25091 28249 28242 2850 28264 *2839 28982 28249
35800 28264 28249 2851 28268 28241 *2881 28260
35801 28268 28260 *2825 28269 28242 28981 28261
*25092 *2811 28261 28241 2830 28249 28982 28262
35800 28241 28262 28242 28310 28264 *2882 28263
35801 28242 28263 28249 28311 28268 28981 28264
*25093 28249 28264 28264 28319 *2840 28982 28268
35800 28264 28268 28268 2832 28241 *2883 28269
35801 28268 28269 *28260 2839 28242 28981 2830
*2515 *2812 2830 28241 2840 28249 28982 28310
53021 28241 28310 28242 2848 28264 *2888 28311
*25510 28242 28311 28249 2849 28268 28981 28319
2550 28249 28319 28264 2850 *2848 28982 2832
2580 28264 2832 28268 2851 28241 *2889 2839
2581 28268 2839 *28261 *28269 28242 28981 2840
2588 *2813 2840 28241 28241 28249 28982 2848
2589 28241 2848 28242 28242 28264 *28981 2849
*25511 28242 2849 28249 28249 28268 2800 2850
2550 28249 2850 28264 28264 *2849 2814 2851
2580 28264 2851 28268 28268 28241 2818 2860
2581 28268 *28242 *28262 *2827 28242 28241 2861
2588 *2814 2800 28241 28241 28249 28242 2862
2589 28241 2814 28242 28242 28264 28249 2863
*25512 28242 2818 28249 28249 28268 28260 2864
2550 28249 28241 28264 28264 *2850 28261 2865
2580 28264 28242 28268 28268 28241 28262 2866
2581 28268 28249 *28263 *2828 28242 28263 2867
2588 *2818 28260 28241 28241 28249 28264 2869
2589 28241 28261 28242 28242 28264 28268 2870
*25513 28242 28262 28249 28249 28268 28269 2871
2550 28249 28263 28264 28264 *2851 2830 2872
2580 28264 28264 28268 28268 28241 28310 2873
2581 28268 28268 *28264 *2829 28242 28311 2874
2588 *2819 28269 2800 28241 28249 28319 2875
2589 28241 2830 2814 28242 28264 2832 2878
*25514 28242 28310 2818 28249 28268 2839 2879
2550 28249 28311 28241 28264 *28521 2840 2880
2580 28264 28319 28242 28268 28241 2848 2881
2581 28268 2832 28249 *2830 28242 2849 28981
2588 *2820 2839 28260 28241 28249 2850 28982
2589 28241 2840 28261 28242 28264 2851 *28989
2800 35801 53201 53121 5789 53531 53021 *53451
2814 3581 53210 53131 *5307 53541 *53251 53021
2818 *3581 53211 53140 53021 53551 53021 *53460
28241 35800 53220 53141 *53082 53561 *53260 53021
[[Page 27358]]
28242 35801 53221 53150 53021 53783 53021 *53461
28249 *4560 53231 53151 *53085 53784 *53261 53021
28260 53021 53240 53160 4560 56202 53021 *53470
28261 *49381 53241 53161 53021 56203 *53270 53021
28262 49301 53250 53171 5307 56212 53021 *53471
28263 49302 53251 53191 53082 56213 *53271 53021
28264 49311 53260 53200 53100 5693 53021 *53490
28268 49312 53261 53201 53101 56985 *53290 53021
28269 49320 53271 53210 53110 56986 53021 *53491
2830 49321 53291 53211 53111 5780 *53291 53021
28310 49322 53300 53220 53120 5781 53021 *53501
28311 49391 53301 53221 53121 5789 *53300 53021
28319 49392 53310 53231 53131 *53100 53021 *53511
2832 *49382 53311 53240 53140 53021 *53301 53021
2839 49301 53320 53241 53141 *53101 53021 *53521
2840 49302 53321 53250 53150 53021 *53310 53021
2848 49311 53331 53251 53151 *53110 53021 *53531
2849 49312 53340 53260 53160 53021 *53311 53021
2850 49320 53341 53261 53161 *53111 53021 *53541
2851 49321 53350 53271 53171 53021 *53320 53021
2860 49322 53351 53291 53191 *53120 53021 *53551
2861 49391 53360 53300 53200 53021 *53321 53021
2862 49392 53361 53301 53201 *53121 53021 *53561
2863 *5173 53371 53310 53210 53021 *53330 53021
2864 2800 53391 53311 53211 *53130 53021 *53783
2865 2814 53400 53320 53220 53021 *53331 53021
2866 2818 53401 53321 53221 *53131 53021 *53789
2867 28241 53410 53331 53231 53021 *53340 53021
2869 28242 53411 53340 53240 *53140 53021 *5379
2870 28249 53420 53341 53241 53021 *53341 53021
2871 28260 53421 53350 53250 *53141 53021 *56202
2872 28261 53431 53351 53251 53021 *53350 53021
2873 28262 53440 53360 53260 *53150 53021 *56203
2874 28263 53441 53361 53261 53021 *53351 53021
2875 28264 53450 53371 53271 *53151 53021 *56212
2878 28268 53451 53391 53291 53021 *53360 53021
2879 28269 53460 53400 53300 *53160 53021 *56213
2880 2830 53461 53401 53301 53021 *53361 53021
2881 28310 53471 53410 53310 *53161 53021 *5693
28981 28311 53491 53411 53311 53021 *53370 53021
28982 28319 53501 53420 53320 *53170 53021 *56985
*2899 2832 53511 53421 53321 53021 *53371 53021
28241 2839 53521 53431 53331 *53171 53021 *5780
28242 2840 53531 53440 53340 53021 *53390 53021
28249 2848 53541 53441 53341 *53190 53021 *5781
28264 2849 53551 53450 53350 53021 *53391 53021
28268 2850 53561 53451 53351 *53191 53021 *5789
28981 2851 53783 53460 53360 53021 *53400 53021
28982 *53020 53784 53461 53361 *53200 53021 *60000
*33182 4560 56202 53471 53371 53021 *53401 5960
3314 53021 56203 53491 53391 *53201 53021 5996
*34830 5307 56212 53501 53400 53021 *53410 6010
34982 53082 56213 53511 53401 *53210 53021 6012
*34831 53100 5693 53521 53410 53021 *53411 6013
34982 53101 56985 53531 53411 *53211 53021 6021
*34839 53110 56986 53541 53420 53021 *53420 78820
34982 53111 5780 53551 53421 *53220 53021 78829
*34989 53120 5781 53561 53431 53021 *53421 *60001
35800 53121 5789 53783 53440 *53221 53021 5960
35801 53131 *53021 53784 53441 53021 *53430 5996
*3499 53140 4560 56202 53450 *53230 53021 6010
35800 53141 53021 56203 53451 53021 *53431 6012
35801 53150 5307 56212 53460 *53231 53021 6013
*35800 53151 53082 56213 53461 53021 *53440 6021
35800 53160 53100 5693 53471 *53240 53021 78820
35801 53161 53101 56985 53491 53021 *53441 78829
3581 53171 53110 56986 53501 *53241 53021 *60010
*35801 53191 53111 5780 53511 53021 *53450 5960
35800 53200 53120 5781 53521 *53250 53021 5996
6010 67450 67451 67452 67400 6143 7744 7994
6012 67451 67452 67453 67401 6145 7745 *78099
6013 67452 67453 67454 67402 6150 7747 78552
[[Page 27359]]
6021 67453 67454 *66994 67403 6163 7751 *78550
78820 67454 *66942 67450 67404 6164 7752 78552
78829 *64684 67450 67451 67450 6207 7753 *78551
*60011 67450 67451 67452 67451 *75289 7754 78552
5960 67451 67452 67453 67452 5970 7755 *78552
5996 67452 67453 67454 67453 5994 7756 04082
6010 67453 67454 *67400 67454 6140 7757 78550
6012 67454 *66943 67450 *67454 6143 7760 78551
6013 *64690 67450 67451 67400 6145 7761 78552
6021 67450 67451 67452 67401 6150 7762 78559
78820 67451 67452 67453 67402 6163 7763 *78559
78829 67452 67453 67454 67403 6164 7771 78552
*60020 67453 67454 *67401 67404 6207 7772 *7859
5960 67454 *66944 67450 67450 *7670 7775 78552
5996 *64691 67450 67451 67451 76711 7776 *78863
6010 67450 67451 67452 67452 *76711 7780 78820
6012 67451 67452 67453 67453 76711 7790 78829
6013 67452 67453 67454 67454 *7678 7791 *79981
6021 67453 67454 *67402 *7197 76711 7797 04082
78820 67454 *66980 67450 6960 *7679 *77989 44024
78829 *64693 67450 67451 71100 76711 76711 78001
*60021 67450 67451 67452 71101 *77981 *78091 78003
5960 67451 67452 67453 71102 76711 78552 7801
5996 67452 67453 67454 71103 *77982 *78092 78031
6010 67453 67454 *67403 71104 76711 78552 78039
6012 67454 *66981 67450 71105 *77983 *78093 7817
6013 *64890 67450 67451 71106 76501 04082 7854
6021 67450 67451 67452 71107 76502 44024 78550
78820 67451 67452 67453 71108 76503 78001 78551
78829 67452 67453 67454 71109 76504 78003 78552
*60090 67453 67454 *67404 71160 76505 7801 78559
5960 67454 *66982 67450 71161 76506 78031 7863
5996 *64891 67450 67451 71162 76507 78039 78820
6010 67450 67451 67452 71163 76508 7817 78829
6012 67451 67452 67453 71164 7670 7854 7895
6013 67452 67453 67454 71165 76711 78550 7907
6021 67453 67454 *67450 71166 7685 78551 7911
78820 67454 *66983 67400 71167 769 78552 7913
78829 *64892 67450 67401 71168 7700 78559 7991
*60091 67450 67451 67402 71169 7701 7863 7994
5960 67451 67452 67403 7141 7702 78820 *79989
5996 67452 67453 67404 7142 7703 78829 04082
6010 67453 67454 67450 71430 7704 7895 44024
6012 67454 *66984 67451 71431 7705 7907 78001
6013 *64893 67450 67452 71432 7707 7911 78003
6021 67450 67451 67453 71433 77084 7913 7801
78820 67451 67452 67454 *7280 7710 7991 78031
78829 67452 67453 *67451 72888 7711 7994 78039
*60785 67453 67454 67400 *72811 7713 *78094 7817
5970 67454 *66990 67401 72888 77181 04082 7854
5994 *64894 67450 67402 *72812 77183 44024 78550
*64680 67450 67451 67403 72888 77210 78001 78551
67450 67451 67452 67404 *72813 77211 78003 78552
67451 67452 67453 67450 72888 77212 7801 78559
67452 67453 67454 67451 *72819 77213 78031 7863
67453 67454 *66991 67452 72888 77214 78039 78820
67454 *650 67450 67453 *7282 7722 7817 78829
*64681 67450 67451 67454 72888 7724 7854 7895
67450 67451 67452 *67452 *7283 7725 78550 7907
67451 67452 67453 67400 72888 7730 78551 7911
67452 67453 67454 67401 *72881 7731 78552 7913
67453 67454 *66992 67402 72888 7732 78559 7991
67454 *66940 67450 67403 *72886 7733 7863 7994
*64682 67450 67451 67404 72888 7734 78820 *80000
67450 67451 67452 67450 *72888 7740 78829 85011
67451 67452 67453 67451 72888 7741 7895 85012
67452 67453 67454 67452 *75281 7742 7907 *80001
67453 67454 *66993 67453 5970 77430 7911 85011
67454 *66941 67450 67454 5994 77431 7913 85012
*64683 67450 67451 *67453 6140 77439 7991 *80002
85011 85012 *80063 85011 85012 *80154 85011 85012
85012 *80033 85011 85012 *80124 85011 85012 *80315
[[Page 27360]]
*80003 85011 85012 *80094 85011 85012 *80185 85011
85011 85012 *80064 85011 85012 *80155 85011 85012
85012 *80034 85011 85012 *80125 85011 85012 *80316
*80004 85011 85012 *80095 85011 85012 *80186 85011
85011 85012 *80065 85011 85012 *80156 85011 85012
85012 *80035 85011 85012 *80126 85011 85012 *80319
*80005 85011 85012 *80096 85011 85012 *80189 85011
85011 85012 *80066 85011 85012 *80159 85011 85012
85012 *80036 85011 85012 *80129 85011 85012 *80320
*80006 85011 85012 *80099 85011 85012 *80190 85011
85011 85012 *80069 85011 85012 *80160 85011 85012
85012 *80039 85011 85012 *80130 85011 85012 *80321
*80009 85011 85012 *80100 85011 85012 *80191 85011
85011 85012 *80070 85011 85012 *80161 85011 85012
85012 *80040 85011 85012 *80131 85011 85012 *80322
*80010 85011 85012 *80101 85011 85012 *80192 85011
85011 85012 *80071 85011 85012 *80162 85011 85012
85012 *80041 85011 85012 *80132 85011 85012 *80323
*80011 85011 85012 *80102 85011 85012 *80193 85011
85011 85012 *80072 85011 85012 *80163 85011 85012
85012 *80042 85011 85012 *80133 85011 85012 *80324
*80012 85011 85012 *80103 85011 85012 *80194 85011
85011 85012 *80073 85011 85012 *80164 85011 85012
85012 *80043 85011 85012 *80134 85011 85012 *80325
*80013 85011 85012 *80104 85011 85012 *80195 85011
85011 85012 *80074 85011 85012 *80165 85011 85012
85012 *80044 85011 85012 *80135 85011 85012 *80326
*80014 85011 85012 *80105 85011 85012 *80196 85011
85011 85012 *80075 85011 85012 *80166 85011 85012
85012 *80045 85011 85012 *80136 85011 85012 *80329
*80015 85011 85012 *80106 85011 85012 *80199 85011
85011 85012 *80076 85011 85012 *80169 85011 85012
85012 *80046 85011 85012 *80139 85011 85012 *80330
*80016 85011 85012 *80109 85011 85012 *80300 85011
85011 85012 *80079 85011 85012 *80170 85011 85012
85012 *80049 85011 85012 *80140 85011 85012 *80331
*80019 85011 85012 *80110 85011 85012 *80301 85011
85011 85012 *80080 85011 85012 *80171 85011 85012
85012 *80050 85011 85012 *80141 85011 85012 *80332
*80020 85011 85012 *80111 85011 85012 *80302 85011
85011 85012 *80081 85011 85012 *80172 85011 85012
85012 *80051 85011 85012 *80142 85011 85012 *80333
*80021 85011 85012 *80112 85011 85012 *80303 85011
85011 85012 *80082 85011 85012 *80173 85011 85012
85012 *80052 85011 85012 *80143 85011 85012 *80334
*80022 85011 85012 *80113 85011 85012 *80304 85011
85011 85012 *80083 85011 85012 *80174 85011 85012
85012 *80053 85011 85012 *80144 85011 85012 *80335
*80023 85011 85012 *80114 85011 85012 *80305 85011
85011 85012 *80084 85011 85012 *80175 85011 85012
85012 *80054 85011 85012 *80145 85011 85012 *80336
*80024 85011 85012 *80115 85011 85012 *80306 85011
85011 85012 *80085 85011 85012 *80176 85011 85012
85012 *80055 85011 85012 *80146 85011 85012 *80339
*80025 85011 85012 *80116 85011 85012 *80309 85011
85011 85012 *80086 85011 85012 *80179 85011 85012
85012 *80056 85011 85012 *80149 85011 85012 *80340
*80026 85011 85012 *80119 85011 85012 *80310 85011
85011 85012 *80089 85011 85012 *80180 85011 85012
85012 *80059 85011 85012 *80150 85011 85012 *80341
*80029 85011 85012 *80120 85011 85012 *80311 85011
85011 85012 *80090 85011 85012 *80181 85011 85012
85012 *80060 85011 85012 *80151 85011 85012 *80342
*80030 85011 85012 *80121 85011 85012 *80312 85011
85011 85012 *80091 85011 85012 *80182 85011 85012
85012 *80061 85011 85012 *80152 85011 85012 *80343
*80031 85011 85012 *80122 85011 85012 *80313 85011
85011 85012 *80092 85011 85012 *80183 85011 85012
85012 *80062 85011 85012 *80153 85011 85012 *80344
*80032 85011 85012 *80123 85011 85012 *80314 85011
85011 85012 *80093 85011 85012 *80184 85011 85012
*80345 85011 85012 *80436 85011 85012 80072 80163
[[Page 27361]]
85011 85012 *80406 85011 85012 *80499 80073 80164
85012 *80376 85011 85012 *80469 85011 80074 80165
*80346 85011 85012 *80439 85011 85012 80075 80166
85011 85012 *80409 85011 85012 *8500 80076 80169
85012 *80379 85011 85012 *80470 85011 80079 80170
*80349 85011 85012 *80440 85011 85012 80080 80171
85011 85012 *80410 85011 85012 *85011 80081 80172
85012 *80380 85011 85012 *80471 430 80082 80173
*80350 85011 85012 *80441 85011 431 80083 80174
85011 85012 *80411 85011 85012 4320 80084 80175
85012 *80381 85011 85012 *80472 4321 80085 80176
*80351 85011 85012 *80442 85011 436 80086 80179
85011 85012 *80412 85011 85012 78001 80089 80180
85012 *80382 85011 85012 *80473 78003 80090 80181
*80352 85011 85012 *80443 85011 80000 80091 80182
85011 85012 *80413 85011 85012 80001 80092 80183
85012 *80383 85011 85012 *80474 80002 80093 80184
*80353 85011 85012 *80444 85011 80003 80094 80185
85011 85012 *80414 85011 85012 80004 80095 80186
85012 *80384 85011 85012 *80475 80005 80096 80189
*80354 85011 85012 *80445 85011 80006 80099 80190
85011 85012 *80415 85011 85012 80009 80100 80191
85012 *80385 85011 85012 *80476 80010 80101 80192
*80355 85011 85012 *80446 85011 80011 80102 80193
85011 85012 *80416 85011 85012 80012 80103 80194
85012 *80386 85011 85012 *80479 80013 80104 80195
*80356 85011 85012 *80449 85011 80014 80105 80196
85011 85012 *80419 85011 85012 80015 80106 80199
85012 *80389 85011 85012 *80480 80016 80109 8021
*80359 85011 85012 *80450 85011 80019 80110 80220
85011 85012 *80420 85011 85012 80020 80111 80221
85012 *80390 85011 85012 *80481 80021 80112 80222
*80360 85011 85012 *80451 85011 80022 80113 80223
85011 85012 *80421 85011 85012 80023 80114 80224
85012 *80391 85011 85012 *80482 80024 80115 80225
*80361 85011 85012 *80452 85011 80025 80116 80226
85011 85012 *80422 85011 85012 80026 80119 80227
85012 *80392 85011 85012 *80483 80029 80120 80228
*80362 85011 85012 *80453 85011 80030 80121 80229
85011 85012 *80423 85011 85012 80031 80122 80230
85012 *80393 85011 85012 *80484 80032 80123 80231
*80363 85011 85012 *80454 85011 80033 80124 80232
85011 85012 *80424 85011 85012 80034 80125 80233
85012 *80394 85011 85012 *80485 80035 80126 80234
*80364 85011 85012 *80455 85011 80036 80129 80235
85011 85012 *80425 85011 85012 80039 80130 80236
85012 *80395 85011 85012 *80486 80040 80131 80237
*80365 85011 85012 *80456 85011 80041 80132 80238
85011 85012 *80426 85011 85012 80042 80133 80239
85012 *80396 85011 85012 *80489 80043 80134 8024
*80366 85011 85012 *80459 85011 80044 80135 8025
85011 85012 *80429 85011 85012 80045 80136 8026
85012 *80399 85011 85012 *80490 80046 80139 8027
*80369 85011 85012 *80460 85011 80049 80140 8028
85011 85012 *80430 85011 85012 80050 80141 8029
85012 *80400 85011 85012 *80491 80051 80142 80300
*80370 85011 85012 *80461 85011 80052 80143 80301
85011 85012 *80431 85011 85012 80053 80144 80302
85012 *80401 85011 85012 *80492 80054 80145 80303
*80371 85011 85012 *80462 85011 80055 80146 80304
85011 85012 *80432 85011 85012 80056 80149 80305
85012 *80402 85011 85012 *80493 80059 80150 80306
*80372 85011 85012 *80463 85011 80060 80151 80309
85011 85012 *80433 85011 85012 80061 80152 80310
85012 *80403 85011 85012 *80494 80062 80153 80311
*80373 85011 85012 *80464 85011 80063 80154 80312
85011 85012 *80434 85011 85012 80064 80155 80313
85012 *80404 85011 85012 *80495 80065 80156 80314
*80374 85011 85012 *80465 85011 80066 80159 80315
85011 85012 *80435 85011 85012 80069 80160 80316
85012 *80405 85011 85012 *80496 80070 80161 80319
*80375 85011 85012 *80466 85011 80071 80162 80320
[[Page 27362]]
80321 80412 8502 85184 85315 80056 80149 80305
80322 80413 8503 85185 85316 80059 80150 80306
80323 80414 8504 85186 85319 80060 80151 80309
80324 80415 8505 85189 85400 80061 80152 80310
80325 80416 8509 85190 85401 80062 80153 80311
80326 80419 85100 85191 85402 80063 80154 80312
80329 80420 85101 85192 85403 80064 80155 80313
80330 80421 85102 85193 85404 80065 80156 80314
80331 80422 85103 85194 85405 80066 80159 80315
80332 80423 85104 85195 85406 80069 80160 80316
80333 80424 85105 85196 85409 80070 80161 80319
80334 80425 85106 85199 85410 80071 80162 80320
80335 80426 85109 85200 85411 80072 80163 80321
80336 80429 85110 85201 85412 80073 80164 80322
80339 80430 85111 85202 85413 80074 80165 80323
80340 80431 85112 85203 85414 80075 80166 80324
80341 80432 85113 85204 85415 80076 80169 80325
80342 80433 85114 85205 85416 80079 80170 80326
80343 80434 85115 85206 85419 80080 80171 80329
80344 80435 85116 85209 *85012 80081 80172 80330
80345 80436 85119 85210 430 80082 80173 80331
80346 80439 85120 85211 431 80083 80174 80332
80349 80440 85121 85212 4320 80084 80175 80333
80350 80441 85122 85213 4321 80085 80176 80334
80351 80442 85123 85214 436 80086 80179 80335
80352 80443 85124 85215 78001 80089 80180 80336
80353 80444 85125 85216 78003 80090 80181 80339
80354 80445 85126 85219 80000 80091 80182 80340
80355 80446 85129 85220 80001 80092 80183 80341
80356 80449 85130 85221 80002 80093 80184 80342
80359 80450 85131 85222 80003 80094 80185 80343
80360 80451 85132 85223 80004 80095 80186 80344
80361 80452 85133 85224 80005 80096 80189 80345
80362 80453 85134 85225 80006 80099 80190 80346
80363 80454 85135 85226 80009 80100 80191 80349
80364 80455 85136 85229 80010 80101 80192 80350
80365 80456 85139 85230 80011 80102 80193 80351
80366 80459 85140 85231 80012 80103 80194 80352
80369 80460 85141 85232 80013 80104 80195 80353
80370 80461 85142 85233 80014 80105 80196 80354
80371 80462 85143 85234 80015 80106 80199 80355
80372 80463 85144 85235 80016 80109 8021 80356
80373 80464 85145 85236 80019 80110 80220 80359
80374 80465 85146 85239 80020 80111 80221 80360
80375 80466 85149 85240 80021 80112 80222 80361
80376 80469 85150 85241 80022 80113 80223 80362
80379 80470 85151 85242 80023 80114 80224 80363
80380 80471 85152 85243 80024 80115 80225 80364
80381 80472 85153 85244 80025 80116 80226 80365
80382 80473 85154 85245 80026 80119 80227 80366
80383 80474 85155 85246 80029 80120 80228 80369
80384 80475 85156 85249 80030 80121 80229 80370
80385 80476 85159 85250 80031 80122 80230 80371
80386 80479 85160 85251 80032 80123 80231 80372
80389 80480 85161 85252 80033 80124 80232 80373
80390 80481 85162 85253 80034 80125 80233 80374
80391 80482 85163 85254 80035 80126 80234 80375
80392 80483 85164 85255 80036 80129 80235 80376
80393 80484 85165 85256 80039 80130 80236 80379
80394 80485 85166 85259 80040 80131 80237 80380
80395 80486 85169 85300 80041 80132 80238 80381
80396 80489 85170 85301 80042 80133 80239 80382
80399 80490 85171 85302 80043 80134 8024 80383
80400 80491 85172 85303 80044 80135 8025 80384
80401 80492 85173 85304 80045 80136 8026 80385
80402 80493 85174 85305 80046 80139 8027 80386
80403 80494 85175 85306 80049 80140 8028 80389
80404 80495 85176 85309 80050 80141 8029 80390
80405 80496 85179 85310 80051 80142 80300 80391
80406 80499 85180 85311 80052 80143 80301 80392
80409 8500 85181 85312 80053 80144 80302 80393
80410 85011 85182 85313 80054 80145 80303 80394
[[Page 27363]]
80411 85012 85183 85314 80055 80146 80304 80395
80396 80489 85170 85301 *85111 85011 85012 *85202
80399 80490 85171 85302 85011 85012 *85172 85011
80400 80491 85172 85303 85012 *85142 85011 85012
80401 80492 85173 85304 *85112 85011 85012 *85203
80402 80493 85174 85305 85011 85012 *85173 85011
80403 80494 85175 85306 85012 *85143 85011 85012
80404 80495 85176 85309 *85113 85011 85012 *85204
80405 80496 85179 85310 85011 85012 *85174 85011
80406 80499 85180 85311 85012 *85144 85011 85012
80409 8500 85181 85312 *85114 85011 85012 *85205
80410 85011 85182 85313 85011 85012 *85175 85011
80411 85012 85183 85314 85012 *85145 85011 85012
80412 8502 85184 85315 *85115 85011 85012 *85206
80413 8503 85185 85316 85011 85012 *85176 85011
80414 8504 85186 85319 85012 *85146 85011 85012
80415 8505 85189 85400 *85116 85011 85012 *85209
80416 8509 85190 85401 85011 85012 *85179 85011
80419 85100 85191 85402 85012 *85149 85011 85012
80420 85101 85192 85403 *85119 85011 85012 *85210
80421 85102 85193 85404 85011 85012 *85180 85011
80422 85103 85194 85405 85012 *85150 85011 85012
80423 85104 85195 85406 *85120 85011 85012 *85211
80424 85105 85196 85409 85011 85012 *85181 85011
80425 85106 85199 85410 85012 *85151 85011 85012
80426 85109 85200 85411 *85121 85011 85012 *85212
80429 85110 85201 85412 85011 85012 *85182 85011
80430 85111 85202 85413 85012 *85152 85011 85012
80431 85112 85203 85414 *85122 85011 85012 *85213
80432 85113 85204 85415 85011 85012 *85183 85011
80433 85114 85205 85416 85012 *85153 85011 85012
80434 85115 85206 85419 *85123 85011 85012 *85214
80435 85116 85209 *8502 85011 85012 *85184 85011
80436 85119 85210 85011 85012 *85154 85011 85012
80439 85120 85211 85012 *85124 85011 85012 *85215
80440 85121 85212 *8503 85011 85012 *85185 85011
80441 85122 85213 85011 85012 *85155 85011 85012
80442 85123 85214 85012 *85125 85011 85012 *85216
80443 85124 85215 *8504 85011 85012 *85186 85011
80444 85125 85216 85011 85012 *85156 85011 85012
80445 85126 85219 85012 *85126 85011 85012 *85219
80446 85129 85220 *8505 85011 85012 *85189 85011
80449 85130 85221 85011 85012 *85159 85011 85012
80450 85131 85222 85012 *85129 85011 85012 *85221
80451 85132 85223 *8509 85011 85012 *85190 85011
80452 85133 85224 85011 85012 *85160 85011 85012
80453 85134 85225 85012 *85130 85011 85012 *85222
80454 85135 85226 *85100 85011 85012 *85191 85011
80455 85136 85229 85011 85012 *85161 85011 85012
80456 85139 85230 85012 *85131 85011 85012 *85223
80459 85140 85231 *85101 85011 85012 *85192 85011
80460 85141 85232 85011 85012 *85162 85011 85012
80461 85142 85233 85012 *85132 85011 85012 *85224
80462 85143 85234 *85102 85011 85012 *85193 85011
80463 85144 85235 85011 85012 *85163 85011 85012
80464 85145 85236 85012 *85133 85011 85012 *85225
80465 85146 85239 *85103 85011 85012 *85194 85011
80466 85149 85240 85011 85012 *85164 85011 85012
80469 85150 85241 85012 *85134 85011 85012 *85226
80470 85151 85242 *85104 85011 85012 *85195 85011
80471 85152 85243 85011 85012 *85165 85011 85012
80472 85153 85244 85012 *85135 85011 85012 *85229
80473 85154 85245 *85105 85011 85012 *85196 85011
80474 85155 85246 85011 85012 *85166 85011 85012
80475 85156 85249 85012 *85136 85011 85012 *85230
80476 85159 85250 *85106 85011 85012 *85199 85011
80479 85160 85251 85011 85012 *85169 85011 85012
80480 85161 85252 85012 *85139 85011 85012 *85231
80481 85162 85253 *85109 85011 85012 *85200 85011
80482 85163 85254 85011 85012 *85170 85011 85012
80483 85164 85255 85012 *85140 85011 85012 *85232
80484 85165 85256 *85110 85011 85012 *85201 85011
[[Page 27364]]
80485 85166 85259 85011 85012 *85171 85011 85012
80486 85169 85300 85012 *85141 85011 85012 *85233
85011 85012 *85414 8058 95219 8064 80609 80504
85012 *85304 85011 8059 9522 8065 80610 80505
*85234 85011 85012 80600 9523 80660 80611 80506
85011 85012 *85415 80601 9524 80661 80612 80507
85012 *85305 85011 80602 9528 80662 80613 80508
*85235 85011 85012 80603 9529 80669 80614 80510
85011 85012 *85416 80604 *95912 80670 80615 80511
85012 *85306 85011 80605 80500 80671 80616 80512
*85236 85011 85012 80606 80501 80672 80617 80513
85011 85012 *85419 80607 80502 80679 80618 80514
85012 *85309 85011 80608 80503 8068 80619 80515
*85239 85011 85012 80609 80504 8069 80620 80516
85011 85012 *8738 80610 80505 95200 80621 80517
85012 *85310 85011 80611 80506 95201 80622 80518
*85240 85011 85012 80612 80507 95202 80623 8052
85011 85012 *8739 80613 80508 95203 80624 8053
85012 *85311 85011 80614 80510 95204 80625 8054
*85241 85011 85012 80615 80511 95205 80626 8055
85011 85012 *8798 80616 80512 95206 80627 8056
85012 *85312 85011 80617 80513 95207 80628 8057
*85242 85011 85012 80618 80514 95208 80629 8058
85011 85012 *8799 80619 80515 95209 80630 8059
85012 *85313 85011 80620 80516 95210 80631 80600
*85243 85011 85012 80621 80517 95211 80632 80601
85011 85012 *9050 80622 80518 95212 80633 80602
85012 *85314 85011 80623 8052 95213 80634 80603
*85244 85011 85012 80624 8053 95214 80635 80604
85011 85012 *9251 80625 8054 95215 80636 80605
85012 *85315 85011 80626 8055 95216 80637 80606
*85245 85011 85012 80627 8056 95217 80638 80607
85011 85012 *9252 80628 8057 95218 80639 80608
85012 *85316 85011 80629 8058 95219 8064 80609
*85246 85011 85012 80630 8059 9522 8065 80610
85011 85012 *9290 80631 80600 9523 80660 80611
85012 *85319 85011 80632 80601 9524 80661 80612
*85249 85011 85012 80633 80602 9528 80662 80613
85011 85012 *9299 80634 80603 9529 80669 80614
85012 *85400 85011 80635 80604 *95913 80670 80615
*85250 85011 85012 80636 80605 80500 80671 80616
85011 85012 *9588 80637 80606 80501 80672 80617
85012 *85401 85011 80638 80607 80502 80679 80618
*85251 85011 85012 80639 80608 80503 8068 80619
85011 85012 *95901 8064 80609 80504 8069 80620
85012 *85402 85011 8065 80610 80505 95200 80621
*85252 85011 85012 80660 80611 80506 95201 80622
85011 85012 *95909 80661 80612 80507 95202 80623
85012 *85403 85011 80662 80613 80508 95203 80624
*85253 85011 85012 80669 80614 80510 95204 80625
85011 85012 *95911 80670 80615 80511 95205 80626
85012 *85404 80500 80671 80616 80512 95206 80627
*85254 85011 80501 80672 80617 80513 95207 80628
85011 85012 80502 80679 80618 80514 95208 80629
85012 *85405 80503 8068 80619 80515 95209 80630
*85255 85011 80504 8069 80620 80516 95210 80631
85011 85012 80505 95200 80621 80517 95211 80632
85012 *85406 80506 95201 80622 80518 95212 80633
*85256 85011 80507 95202 80623 8052 95213 80634
85011 85012 80508 95203 80624 8053 95214 80635
85012 *85409 80510 95204 80625 8054 95215 80636
*85259 85011 80511 95205 80626 8055 95216 80637
85011 85012 80512 95206 80627 8056 95217 80638
85012 *85410 80513 95207 80628 8057 95218 80639
*85300 85011 80514 95208 80629 8058 95219 8064
85011 85012 80515 95209 80630 8059 9522 8065
85012 *85411 80516 95210 80631 80600 9523 80660
*85301 85011 80517 95211 80632 80601 9524 80661
85011 85012 80518 95212 80633 80602 9528 80662
5012 *85412 8052 95213 80634 80603 9529 80669
*85302 85011 8053 95214 80635 80604 *95914 80670
85011 85012 8054 95215 80636 80605 80500 80671
[[Page 27365]]
85012 *85413 8055 95216 80637 80606 80501 80672
*85303 85011 8056 95217 80638 80607 80502 80679
85011 85012 8057 95218 80639 80608 80503 8068
8069 80620 *99609 *99671
95200 80621 99657 99657
95201 80622 *9961 *99672
95202 80623 99657 99657
95203 80624 *9962 *99673
95204 80625 99657 99657
95205 80626 *99630 *99674
95206 80627 99657 99657
95207 80628 *99639 *99675
95208 80629 99657 99657
95209 80630 *9964 *99676
95210 80631 99657 99657
95211 80632 *99651 *99677
95212 80633 99657 99657
95213 80634 *99652 *99678
95214 80635 99657 99657
95215 80636 *99653 *99679
95216 80637 99657 99657
95217 80638 *99654 *99680
95218 80639 99657 V4321
95219 8064 *99655 V4322
9522 8065 99657 *99683
9523 80660 *99656 V4321
9524 80661 99657 V4322
9528 80662 *99657 *99687
9529 80669 99655 V4321
*95919 80670 99656 V4322
80500 80671 99657 *99791
80501 80672 99659 99657
80502 80679 99660 *99799
80503 8068 99661 99657
80504 8069 99662 *99881
80505 95200 99663 99657
80506 95201 99664 *99883
80507 95202 99665 99657
80508 95203 99666 *99889
80510 95204 99667 99657
80511 95205 99668 *9989
80512 95206 99669 99657
80513 95207 99670 *V421
80514 95208 99671 V4321
80515 95209 99672 V4322
80516 95210 99673 *V4321
80517 95211 99674 V4321
80518 95212 99675 V4322
8052 95213 99676 *V4322
8053 95214 99677 V4321
8054 95215 99678 V4322
8055 95216 99679
8056 95217 *99659
8057 95218 99657
8058 95219 *99660
8059 9522 99657
80600 9523 *99661
80601 9524 99657
80602 9528 *99662
80603 9529 99657
80604 *9598 *99663
80605 85011 99657
80606 85012 *99664
80607 *9599 99657
80608 85011 *99665
80609 85012 99657
80610 *99600 *99666
80611 99657 99657
80612 *99601 *99667
80613 99657 99657
80614 *99602 *99668
80615 99657 99657
[[Page 27366]]
80616 *99603 *99669
80617 99657 99657
80618 *99604 *99670
80619 99657 99657
------------------------------------------------------------------------
Table 6H.--Deletions From 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.]
------------------------------------------------------------------------
------------------------------------------------------------------------
*25060 28263 28260 53201 6013 71169 6960 8501
3580 28269 28261 53210 6021 7141 71100 *80005
*25061 2830 28262 53211 78820 7142 71101 8501
3580 28310 28263 53220 78829 71430 71102 *80006
*25062 28311 28269 53221 *6001 71431 71103 8501
3580 28319 2830 53231 5960 71432 71104 *80009
*25063 2832 28310 53240 5996 71433 71105 8501
3580 2839 28311 53241 6010 *71976 71106 *80010
*25080 2840 28319 53250 6012 6960 71107 8501
3580 2848 2832 53251 6013 71100 71108 *80011
*25081 2849 2839 53260 6021 71106 71109 8501
3580 2850 2840 53261 78820 71108 71160 *80012
*25082 2851 2848 53271 78829 71109 71161 8501
3580 *2825 2849 53291 *6002 71160 71162 *80013
*25083 2824 2850 53300 5960 71166 71163 8501
3580 *28260 2851 53301 5996 71168 71164 *80014
*25090 2824 2860 53310 6010 71169 71165 8501
3580 *28261 2861 53311 6012 7141 71166 *80015
*25091 2824 2862 53320 6013 7142 71167 8501
3580 *28262 2863 53321 6021 71430 71168 *80016
*25092 2824 2864 53331 78820 71431 71169 8501
3580 *28263 2865 53340 78829 71432 7141 *80019
*25093 2824 2866 53341 *6009 71433 7142 8501
3580 *28269 2867 53350 5960 *71977 71430 *80020
*2551 2824 2869 53351 5996 6960 71431 8501
2550 *2827 2870 53360 6010 71100 71432 *80021
2580 2824 2871 53361 6012 71107 71433 8501
2581 *2828 2872 53371 6013 71108 *7528 *80022
2588 2824 2873 53391 6021 71109 5970 8501
2589 *2829 2874 53400 78820 71160 5994 *80023
*2800 2824 2875 53401 78829 71167 6140 8501
2824 *2830 2878 53410 *71970 71168 6143 *80024
*2801 2824 2879 53411 6960 71169 6145 8501
2824 *28310 2880 53420 71100 7141 6150 *80025
*2808 2824 2881 53421 71101 7142 6163 8501
2824 *28311 *2899 53431 71102 71430 6164 *80026
*2809 2824 2824 53440 71103 71431 6207 8501
2824 *28319 *3483 53441 71104 71432 *7998 *80029
*2810 2824 34982 53450 71105 71433 04082 8501
2824 *2832 *34989 53451 71106 *71978 44024 *80030
*2811 2824 3580 53460 71107 6960 78001 8501
2824 *2839 *3499 53461 71108 71100 78003 *80031
*2812 2824 3580 53471 71109 71101 7801 8501
2824 *2840 *3580 53491 71160 71102 78031 *80032
*2813 2824 3580 53501 71161 71103 78039 8501
2824 *2848 3581 53511 71162 71104 7817 *80033
*2814 2824 *3581 53521 71163 71105 7854 8501
2824 *2849 3580 53531 71164 71106 78550 *80034
*2818 2824 *5302 53541 71165 71107 78551 8501
2824 *2850 4560 53551 71166 71108 78559 *80035
*2819 2824 5307 53561 71167 71109 7863 8501
2824 *2851 53082 53783 71168 71160 78820 *80036
*2820 2824 53100 53784 71169 71161 78829 8501
2824 *28521 53101 56202 7141 71162 7895 *80039
*2821 2824 53110 56203 7142 71163 7907 8501
2824 *28522 53111 56212 71430 71164 7911 *80040
*2822 2824 53120 56213 71431 71165 7913 8501
2824 *28529 53121 5693 71432 71166 7991 *80041
*2823 2824 53131 56985 71433 71167 7994 8501
2824 *2858 53140 56986 *71975 71168 *80000 *80042
*2824 2824 53141 5780 6960 71169 8501 8501
2800 *2859 53150 5781 71100 7141 *80001 *80043
[[Page 27367]]
2814 2824 53151 5789 71105 7142 8501 8501
2818 *2898 53160 *6000 71108 71430 *80002 *80044
2824 2800 53161 5960 71109 71431 8501 8501
28260 2814 53171 5996 71160 71432 *80003 *80045
28261 2818 53191 6010 71165 71433 8501 8501
28262 2824 53200 6012 71168 *71979 *80004 *80046
8501 *80093 8501 *80184 8501 *80375 8501 *80466
*80049 8501 *80140 8501 *80331 8501 *80422 8501
8501 *80094 8501 *80185 8501 *80376 8501 *80469
*80050 8501 *80141 8501 *80332 8501 *80423 8501
8501 *80095 8501 *80186 8501 *80379 8501 *80470
*80051 8501 *80142 8501 *80333 8501 *80424 8501
8501 *80096 8501 *80189 8501 *80380 8501 *80471
*80052 8501 *80143 8501 *80334 8501 *80425 8501
8501 *80099 8501 *80190 8501 *80381 8501 *80472
*80053 8501 *80144 8501 *80335 8501 *80426 8501
8501 *80100 8501 *80191 8501 *80382 8501 *80473
*80054 8501 *80145 8501 *80336 8501 *80429 8501
8501 *80101 8501 *80192 8501 *80383 8501 *80474
*80055 8501 *80146 8501 *80339 8501 *80430 8501
8501 *80102 8501 *80193 8501 *80384 8501 *80475
*80056 8501 *80149 8501 *80340 8501 *80431 8501
8501 *80103 8501 *80194 8501 *80385 8501 *80476
*80059 8501 *80150 8501 *80341 8501 *80432 8501
8501 *80104 8501 *80195 8501 *80386 8501 *80479
*80060 8501 *80151 8501 *80342 8501 *80433 8501
8501 *80105 8501 *80196 8501 *80389 8501 *80480
*80061 8501 *80152 8501 *80343 8501 *80434 8501
8501 *80106 8501 *80199 8501 *80390 8501 *80481
*80062 8501 *80153 8501 *80344 8501 *80435 8501
8501 *80109 8501 *80300 8501 *80391 8501 *80482
*80063 8501 *80154 8501 *80345 8501 *80436 8501
8501 *80110 8501 *80301 8501 *80392 8501 *80483
*80064 8501 *80155 8501 *80346 8501 *80439 8501
8501 *80111 8501 *80302 8501 *80393 8501 *80484
*80065 8501 *80156 8501 *80349 8501 *80440 8501
8501 *80112 8501 *80303 8501 *80394 8501 *80485
*80066 8501 *80159 8501 *80350 8501 *80441 8501
8501 *80113 8501 *80304 8501 *80395 8501 *80486
*80069 8501 *80160 8501 *80351 8501 *80442 8501
8501 *80114 8501 *80305 8501 *80396 8501 *80489
*80070 8501 *80161 8501 *80352 8501 *80443 8501
8501 *80115 8501 *80306 8501 *80399 8501 *80490
*80071 8501 *80162 8501 *80353 8501 *80444 8501
8501 *80116 8501 *80309 8501 *80400 8501 *80491
*80072 8501 *80163 8501 *80354 8501 *80445 8501
8501 *80119 8501 *80310 8501 *80401 8501 *80492
*80073 8501 *80164 8501 *80355 8501 *80446 8501
8501 *80120 8501 *80311 8501 *80402 8501 *80493
*80074 8501 *80165 8501 *80356 8501 *80449 8501
8501 *80121 8501 *80312 8501 *80403 8501 *80494
*80075 8501 *80166 8501 *80359 8501 *80450 8501
8501 *80122 8501 *80313 8501 *80404 8501 *80495
*80076 8501 *80169 8501 *80360 8501 *80451 8501
8501 *80123 8501 *80314 8501 *80405 8501 *80496
*80079 8501 *80170 8501 *80361 8501 *80452 8501
8501 *80124 8501 *80315 8501 *80406 8501 *80499
*80080 8501 *80171 8501 *80362 8501 *80453 8501
8501 *80125 8501 *80316 8501 *80409 8501 *8500
*80081 8501 *80172 8501 *80363 8501 *80454 8501
8501 *80126 8501 *80319 8501 *80410 8501 *8501
*80082 8501 *80173 8501 *80364 8501 *80455 430
8501 *80129 8501 *80320 8501 *80411 8501 431
*80083 8501 *80174 8501 *80365 8501 *80456 4320
8501 *80130 8501 *80321 8501 *80412 8501 4321
*80084 8501 *80175 8501 *80366 8501 *80459 436
8501 *80131 8501 *80322 8501 *80413 8501 78001
*80085 8501 *80176 8501 *80369 8501 *80460 78003
8501 *80132 8501 *80323 8501 *80414 8501 80000
*80086 8501 *80179 8501 *80370 8501 *80461 80001
8501 *80133 8501 *80324 8501 *80415 8501 80002
*80089 8501 *80180 8501 *80371 8501 *80462 80003
[[Page 27368]]
8501 *80134 8501 *80325 8501 *80416 8501 80004
*80090 8501 *80181 8501 *80372 8501 *80463 80005
8501 *80135 8501 *80326 8501 *80419 8501 80006
*80091 8501 *80182 8501 *80373 8501 *80464 80009
8501 *80136 8501 *80329 8501 *80420 8501 80010
*80092 8501 *80183 8501 *80374 8501 *80465 80011
8501 *80139 8501 *80330 8501 *80421 8501 80012
80013 80104 80195 80353 80444 85126 85219 *8509
80014 80105 80196 80354 80445 85129 85220 8501
80015 80106 80199 80355 80446 85130 85221 *85100
80016 80109 8021 80356 80449 85131 85222 8501
80019 80110 80220 80359 80450 85132 85223 *85101
80020 80111 80221 80360 80451 85133 85224 8501
80021 80112 80222 80361 80452 85134 85225 *85102
80022 80113 80223 80362 80453 85135 85226 8501
80023 80114 80224 80363 80454 85136 85229 *85103
80024 80115 80225 80364 80455 85139 85230 8501
80025 80116 80226 80365 80456 85140 85231 *85104
80026 80119 80227 80366 80459 85141 85232 8501
80029 80120 80228 80369 80460 85142 85233 *85105
80030 80121 80229 80370 80461 85143 85234 8501
80031 80122 80230 80371 80462 85144 85235 *85106
80032 80123 80231 80372 80463 85145 85236 8501
80033 80124 80232 80373 80464 85146 85239 *85109
80034 80125 80233 80374 80465 85149 85240 8501
80035 80126 80234 80375 80466 85150 85241 *85110
80036 80129 80235 80376 80469 85151 85242 8501
80039 80130 80236 80379 80470 85152 85243 *85111
80040 80131 80237 80380 80471 85153 85244 8501
80041 80132 80238 80381 80472 85154 85245 *85112
80042 80133 80239 80382 80473 85155 85246 8501
80043 80134 8024 80383 80474 85156 85249 *85113
80044 80135 8025 80384 80475 85159 85250 8501
80045 80136 8026 80385 80476 85160 85251 *85114
80046 80139 8027 80386 80479 85161 85252 8501
80049 80140 8028 80389 80480 85162 85253 *85115
80050 80141 8029 80390 80481 85163 85254 8501
80051 80142 80300 80391 80482 85164 85255 *85116
80052 80143 80301 80392 80483 85165 85256 8501
80053 80144 80302 80393 80484 85166 85259 *85119
80054 80145 80303 80394 80485 85169 85300 8501
80055 80146 80304 80395 80486 85170 85301 *85120
80056 80149 80305 80396 80489 85171 85302 8501
80059 80150 80306 80399 80490 85172 85303 *85121
80060 80151 80309 80400 80491 85173 85304 8501
80061 80152 80310 80401 80492 85174 85305 *85122
80062 80153 80311 80402 80493 85175 85306 8501
80063 80154 80312 80403 80494 85176 85309 *85123
80064 80155 80313 80404 80495 85179 85310 8501
80065 80156 80314 80405 80496 85180 85311 *85124
80066 80159 80315 80406 80499 85181 85312 8501
80069 80160 80316 80409 8500 85182 85313 *85125
80070 80161 80319 80410 8501 85183 85314 8501
80071 80162 80320 80411 8502 85184 85315 *85126
80072 80163 80321 80412 8503 85185 85316 8501
80073 80164 80322 80413 8504 85186 85319 *85129
80074 80165 80323 80414 8505 85189 85400 8501
80075 80166 80324 80415 8509 85190 85401 *85130
80076 80169 80325 80416 85100 85191 85402 8501
80079 80170 80326 80419 85101 85192 85403 *85131
80080 80171 80329 80420 85102 85193 85404 8501
80081 80172 80330 80421 85103 85194 85405 *85132
80082 80173 80331 80422 85104 85195 85406 8501
80083 80174 80332 80423 85105 85196 85409 *85133
80084 80175 80333 80424 85106 85199 85410 8501
80085 80176 80334 80425 85109 85200 85411 *85134
80086 80179 80335 80426 85110 85201 85412 8501
80089 80180 80336 80429 85111 85202 85413 *85135
80090 80181 80339 80430 85112 85203 85414 8501
80091 80182 80340 80431 85113 85204 85415 *85136
80092 80183 80341 80432 85114 85205 85416 8501
80093 80184 80342 80433 85115 85206 85419 *85139
[[Page 27369]]
80094 80185 80343 80434 85116 85209 *8502 8501
80095 80186 80344 80435 85119 85210 8501 *85140
80096 80189 80345 80436 85120 85211 *8503 8501
80099 80190 80346 80439 85121 85212 8501 *85141
80100 80191 80349 80440 85122 85213 *8504 8501
80101 80192 80350 80441 85123 85214 8501 *85142
80102 80193 80351 80442 85124 85215 *8505 8501
80103 80194 80352 80443 85125 85216 8501 *85143
8501 *85190 8501 *85402 8054 95215
*85144 8501 *85236 8501 8055 95216
8501 *85191 8501 *85403 8056 95217
*85145 8501 *85239 8501 8057 95218
8501 *85192 8501 *85404 8058 95219
*85146 8501 *85240 8501 8059 9522
8501 *85193 8501 *85405 80600 9523
*85149 8501 *85241 8501 80601 9524
8501 *85194 8501 *85406 80602 9528
*85150 8501 *85242 8501 80603 9529
8501 *85195 8501 *85409 80604 *9598
*85151 8501 *85243 8501 80605 8501
8501 *85196 8501 *85410 80606 *9599
*85152 8501 *85244 8501 80607 8501
8501 *85199 8501 *85411 80608 *99680
*85153 8501 *85245 8501 80609 V432
8501 *85200 8501 *85412 80610 *99683
*85154 8501 *85246 8501 80611 V432
8501 *85201 8501 *85413 80612 *99687
*85155 8501 *85249 8501 80613 V432
8501 *85202 8501 *85414 80614 *V421
*85156 8501 *85250 8501 80615 V432
8501 *85203 8501 *85415 80616 *V432
*85159 8501 *85251 8501 80617 V432
8501 *85204 8501 *85416 80618
*85160 8501 *85252 8501 80619
8501 *85205 8501 *85419 80620
*85161 8501 *85253 8501 80621
8501 *85206 8501 *8738 80622
*85162 8501 *85254 8501 80623
8501 *85209 8501 *8739 80624
*85163 8501 *85255 8501 80625
8501 *85210 8501 *8798 80626
*85164 8501 *85256 8501 80627
8501 *85211 8501 *8799 80628
*85165 8501 *85259 8501 80629
8501 *85212 8501 *9050 80630
*85166 8501 *85300 8501 80631
8501 *85213 8501 *9251 80632
*85169 8501 *85301 8501 80633
8501 *85214 8501 *9252 80634
*85170 8501 *85302 8501 80635
8501 *85215 8501 *9290 80636
*85171 8501 *85303 8501 80637
8501 *85216 8501 *9299 80638
*85172 8501 *85304 8501 80639
8501 *85219 8501 *9588 8064
*85173 8501 *85305 8501 8065
8501 *85221 8501 *95901 80660
*85174 8501 *85306 8501 80661
8501 *85222 8501 *95909 80662
*85175 8501 *85309 8501 80669
8501 *85223 8501 *9591 80670
*85176 8501 *85310 80500 80671
8501 *85224 8501 80501 80672
*85179 8501 *85311 80502 80679
8501 *85225 8501 80503 8068
*85180 8501 *85312 80504 8069
8501 *85226 8501 80505 95200
*85181 8501 *85313 80506 95201
8501 *85229 8501 80507 95202
*85182 8501 *85314 80508 95203
8501 *85230 8501 80510 95204
*85183 8501 *85315 80511 95205
[[Page 27370]]
8501 *85231 8501 80512 95206
*85184 8501 *85316 80513 95207
8501 *85232 8501 80514 95208
*85185 8501 *85319 80515 95209
8501 *85233 8501 80516 95210
*85186 8501 *85400 80517 95211
8501 *85234 8501 80518 95212
*85189 8501 *85401 8052 95213
8501 *85235 8501 8053 95214
------------------------------------------------------------------------
Table 7A.--Medicare Prospective Payment System Selected Percentile Lengths of Stay [FY 2002 MEDPAR Update December 2002 Grouper V20.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Arithmetic
DRG Number of mean length of 10th 25th 50th 75th 90th
discharges stay Percentile Percentile Percentile Percentile Percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1....................................... 29,262 10.8505 3 5 8 14 22
2....................................... 14,769 5.0718 1 2 4 7 10
3....................................... 3 6.0000 1 1 4 13 13
4....................................... 6,712 7.3524 1 2 5 9 16
5....................................... 95,618 2.9596 1 1 2 3 7
6....................................... 356 3.0197 1 1 2 4 7
7....................................... 14,683 9.8438 2 4 7 12 20
8....................................... 4,106 2.8015 1 1 1 3 7
9....................................... 1,711 6.2402 1 3 5 8 12
10...................................... 18,655 6.3850 2 3 5 8 13
11...................................... 3,291 4.0413 1 2 3 5 8
12...................................... 52,512 5.7513 2 3 4 7 11
13...................................... 7,068 5.0035 2 3 4 6 9
14...................................... 237,027 5.9456 2 3 5 7 11
15...................................... 94,223 4.8529 2 3 4 6 9
16...................................... 9,938 6.3106 2 3 5 8 12
17...................................... 2,744 3.2172 1 2 2 4 6
18...................................... 29,701 5.4868 2 3 4 7 10
19...................................... 8,519 3.5184 1 2 3 5 7
20...................................... 6,207 10.1927 3 5 8 13 20
21...................................... 1,885 6.5963 2 3 5 9 13
22...................................... 2,785 5.1178 2 2 4 6 10
23...................................... 12,583 4.1677 1 2 3 5 8
24...................................... 59,102 4.8803 1 2 4 6 10
25...................................... 27,433 3.1776 1 2 3 4 6
26...................................... 18 4.2778 1 1 2 3 4
27...................................... 4,398 5.1719 1 1 3 7 11
28...................................... 13,919 6.0265 1 3 5 8 12
29...................................... 5,282 3.4924 1 2 3 5 7
30...................................... 2 6.5000 2 2 11 11 11
31...................................... 3,897 4.0429 1 2 3 5 8
32...................................... 1,895 2.4776 1 1 2 3 5
34...................................... 23,811 4.9368 1 2 4 6 9
35...................................... 7,451 3.1094 1 1 3 4 6
36...................................... 2,117 1.5328 1 1 1 1 2
37...................................... 1,382 3.7685 1 1 2 5 8
38...................................... ,97 2.8041 1 1 1 4 5
39...................................... 559 2.1163 1 1 1 2 4
40...................................... 1,549 3.8070 1 1 3 5 7
42...................................... 1,581 2.7381 1 1 1 3 6
43...................................... 94 3.3936 1 1 3 4 6
44...................................... 1,227 4.9935 2 3 4 6 9
45...................................... 2,668 3.1267 1 2 3 4 6
46...................................... 3,482 4.4730 1 2 3 6 8
47...................................... 1,402 3.0927 1 1 2 4 6
49...................................... 2,391 4.4676 1 2 3 6 9
50...................................... 2,429 1.8506 1 1 1 2 3
51...................................... 243 2.8354 1 1 1 3 8
52...................................... 223 1.8161 1 1 1 2 3
53...................................... 2,478 3.6186 1 1 2 4 8
55...................................... 1,481 2.9338 1 1 1 3 7
56...................................... 469 2.8955 1 1 1 3 6
57...................................... 711 3.6709 1 1 2 4 8
58...................................... 1 2.0000 2 2 2 2 2
[[Page 27371]]
59...................................... 116 2.6724 1 1 1 3 6
60...................................... 1 3.0000 3 3 3 3 3
61...................................... 254 5.1535 1 1 3 7 11
62...................................... 2 7.0000 1 1 13 13 13
63...................................... 3,000 4.3860 1 2 3 5 9
64...................................... 3,126 6.4997 1 2 4 8 14
65...................................... 40,407 2.8127 1 1 2 4 5
66...................................... 7,841 3.0778 1 1 2 4 6
67...................................... 385 3.6442 1 2 3 5 7
68...................................... 11,658 3.8813 1 2 3 5 7
69...................................... 3,769 3.0186 1 2 3 4 5
70...................................... 30 2.3333 1 1 2 3 4
71...................................... 80 3.4000 1 1 2 4 6
72...................................... 964 3.4035 1 1 3 4 6
73...................................... 7,697 4.4433 1 2 3 6 9
75...................................... 43,504 9.9907 3 5 7 12 20
76...................................... 44,508 11.1024 3 5 9 14 21
77...................................... 2,458 4.8031 1 2 4 7 10
78...................................... 39,504 6.5709 3 4 6 8 11
79...................................... 169,239 8.4557 3 4 7 11 16
80...................................... 8,077 5.3480 2 3 4 7 10
81...................................... 5 4.4000 1 1 3 8 8
82...................................... 64,299 6.8753 2 3 5 9 14
83...................................... 6,665 5.3655 2 3 4 7 10
84...................................... 1,575 3.2565 1 2 3 4 6
85...................................... 22,398 6.2473 2 3 5 8 12
86...................................... 2,250 3.5364 1 2 3 4 7
87...................................... 61,129 6.3127 1 3 5 8 12
88...................................... 404,045 5.0463 2 3 4 6 9
89...................................... 535,162 5.8340 2 3 5 7 11
90...................................... 48,843 3.9563 2 2 3 5 7
91...................................... 45 5.0444 1 2 3 5 13
92...................................... 15,809 6.2907 2 3 5 8 12
93...................................... 1,778 4.0079 1 2 3 5 7
94...................................... 12,813 6.2387 2 3 5 8 12
95...................................... 1,655 3.8127 1 2 3 5 7
96...................................... 56,893 4.5613 2 2 4 6 8
97...................................... 28,776 3.5275 1 2 3 4 6
98...................................... 9 3.6667 1 1 2 2 5
99...................................... 21,400 3.1554 1 1 2 4 6
100..................................... 8,324 2.1371 1 1 2 3 4
101..................................... 22,329 4.3853 1 2 3 6 9
102..................................... 5,644 2.6487 1 1 2 3 5
103..................................... 484 42.1240 9 12 23 53 92
104..................................... 20,637 14.3306 6 8 12 17 25
105..................................... 29,223 9.8741 4 6 8 11 18
106..................................... 3,498 11.4019 5 7 10 14 20
107..................................... 83,307 10.4339 5 7 9 12 17
108..................................... 6,508 9.7617 2 5 8 12 18
109..................................... 57,450 7.7160 4 5 6 9 13
110..................................... 54,835 8.7534 2 4 7 11 17
111..................................... 9,568 4.0565 1 2 4 6 7
113..................................... 39,734 12.4805 4 6 9 15 24
114..................................... 8,315 8.6592 2 4 7 11 17
115..................................... 19,805 7.4228 1 3 6 10 15
116..................................... 116,294 4.3974 1 2 3 6 9
117..................................... 4,731 4.3075 1 1 2 5 10
118..................................... 8,299 2.8976 1 1 1 4 7
119..................................... 1,237 5.2967 1 1 3 7 13
120..................................... 38,109 9.0051 1 3 6 12 20
121..................................... 164,425 6.2836 2 3 5 8 12
122..................................... 77,231 3.5159 1 2 3 5 7
123..................................... 38,627 4.7915 1 1 3 6 11
124..................................... 135,291 4.3838 1 2 3 6 9
125..................................... 91,946 2.7616 1 1 2 4 5
126..................................... 5,395 11.5218 3 6 9 15 22
127..................................... 676,101 5.2357 2 3 4 7 10
128..................................... 7,187 5.4446 2 3 5 7 9
129..................................... 3,853 2.5951 1 1 1 3 6
[[Page 27372]]
130..................................... 88,911 5.5991 2 3 5 7 10
131..................................... 27,124 4.0330 1 2 4 5 7
132..................................... 142,443 2.8904 1 1 2 4 5
133..................................... 8,694 2.2843 1 1 2 3 4
134..................................... 41,542 3.1609 1 2 2 4 6
135..................................... 7,810 4.4540 1 2 3 5 8
136..................................... 1,185 2.6641 1 1 2 3 5
138..................................... 208,716 3.9930 1 2 3 5 8
139..................................... 87,938 2.4733 1 1 2 3 5
140..................................... 55,735 2.5252 1 1 2 3 5
141..................................... 108,834 3.5704 1 2 3 4 7
142..................................... 52,684 2.5530 1 1 2 3 5
143..................................... 250,177 2.0911 1 1 2 3 4
144..................................... 94,588 5.5436 1 2 4 7 11
145..................................... 7,370 2.5700 1 1 2 3 5
146..................................... 10,785 10.2338 5 6 8 12 17
147..................................... 2,644 6.2266 3 5 6 8 9
148..................................... 134,125 12.2751 5 7 10 15 22
149..................................... 20,205 6.3062 4 5 6 7 9
150..................................... 21,184 11.3235 4 6 9 14 20
151..................................... 5,140 5.5586 2 3 5 7 10
152..................................... 4,578 8.3724 3 5 7 10 15
153..................................... 2,058 5.2546 3 4 5 7 8
154..................................... 28,368 13.2140 3 7 10 17 26
155..................................... 6,618 4.0801 1 2 3 6 8
156..................................... 4 2.5000 1 1 1 3 5
157..................................... 8,301 5.7459 1 2 4 7 12
158..................................... 4,362 2.6016 1 1 2 3 5
159..................................... 18,136 5.1194 1 2 4 7 10
160..................................... 12,203 2.6826 1 1 2 3 5
161..................................... 10,803 4.3270 1 2 3 6 9
162..................................... 6,421 1.9305 1 1 1 2 4
163..................................... 8 3.2500 1 1 2 3 6
164..................................... 5,400 8.3580 3 5 7 10 15
165..................................... 2,335 4.4882 2 3 4 6 7
166..................................... 4,206 4.7263 1 2 4 6 9
167..................................... 4,091 2.4133 1 1 2 3 4
168..................................... 1,425 4.8386 1 2 3 6 10
169..................................... 814 2.4005 1 1 2 3 5
170..................................... 15,682 10.8241 2 4 8 14 22
171..................................... 1,530 4.3333 1 2 4 6 9
172..................................... 31,435 6.9669 2 3 5 9 14
173..................................... 2,482 3.7808 1 2 3 5 8
174..................................... 252,303 4.7834 2 3 4 6 9
175..................................... 34,977 2.9157 1 2 3 4 5
176..................................... 13,498 5.2318 2 3 4 6 10
177..................................... 9,080 4.5719 2 3 4 6 8
178..................................... 3,382 3.1227 1 2 3 4 6
179..................................... 13,193 5.9431 2 3 5 7 11
180..................................... 90,752 5.4251 2 3 4 7 10
181..................................... 27,280 3.3710 1 2 3 4 6
182..................................... 273,118 4.4204 1 2 3 5 8
183..................................... 91,272 2.8962 1 1 2 4 5
184..................................... 69 3.2319 1 1 2 4 6
185..................................... 5,350 4.6680 1 2 3 6 10
186..................................... 6 6.6667 2 3 3 10 10
187..................................... 619 4.0307 1 2 3 6 8
188..................................... 84,099 5.5620 1 2 4 7 11
189..................................... 13,098 3.1005 1 1 2 4 6
190..................................... 75 5.1733 1 2 4 6 11
191..................................... 9,537 13.7975 3 6 10 17 28
192..................................... 1,322 6.2201 1 3 6 8 11
193..................................... 4,822 12.7242 5 7 10 16 23
194..................................... 650 6.7323 2 4 6 8 12
195..................................... 4,019 10.5175 4 6 9 13 19
196..................................... 998 5.6092 2 3 5 7 10
197..................................... 18,313 9.1566 3 5 7 11 17
198..................................... 5,418 4.4118 2 3 4 6 7
199..................................... 1,636 9.7353 2 4 7 13 21
[[Page 27373]]
200..................................... 1,076 10.4898 2 3 7 14 23
201..................................... 2,130 14.1469 3 6 11 18 29
202..................................... 26,756 6.3872 2 3 5 8 13
203..................................... 30,055 6.6816 2 3 5 9 13
204..................................... 65,585 5.7470 2 3 4 7 11
205..................................... 27,481 6.1736 2 3 5 8 12
206..................................... 2,057 3.7832 1 2 3 5 8
207..................................... 32,881 5.1924 1 2 4 7 10
208..................................... 10,188 2.8924 1 1 2 4 5
209..................................... 399,893 4.8600 3 3 4 5 7
210..................................... 122,843 6.8859 3 4 6 8 11
211..................................... 30,096 4.8394 3 4 4 6 7
212..................................... 9 7.0000 1 1 4 5 7
213..................................... 9,950 9.2035 2 4 7 12 18
216..................................... 8,770 7.9789 1 2 6 11 17
217..................................... 17,292 13.3846 3 5 9 16 28
218..................................... 23,796 5.5121 2 3 4 7 10
219..................................... 19,891 3.1961 1 2 3 4 6
220..................................... 1 1.0000 1 1 1 1 1
223..................................... 13,308 3.0326 1 1 2 4 6
224..................................... 11,738 1.9052 1 1 1 2 3
225..................................... 6,481 5.2626 1 2 4 7 11
226..................................... 5,874 6.5259 1 2 4 8 14
227..................................... 4,854 2.6360 1 1 2 3 5
228..................................... 2,534 4.1492 1 1 3 5 9
229..................................... 1,263 2.3286 1 1 2 3 5
230..................................... 2,456 5.5668 1 2 3 7 12
231..................................... 13,312 5.0159 1 1 3 6 11
232..................................... 816 2.7132 1 1 1 2 6
233..................................... 9,940 7.3671 1 3 6 10 15
234..................................... 5,364 3.0626 1 1 2 4 7
235..................................... 5,107 4.8659 1 2 4 6 9
236..................................... 40,182 4.6505 1 3 4 6 8
237..................................... 1,782 3.6599 1 2 3 5 7
238..................................... 8,956 8.6382 3 4 7 10 17
239..................................... 46,252 6.2694 2 3 5 8 12
240..................................... 12,062 6.6231 2 3 5 8 13
241..................................... 3,173 3.7690 1 2 3 5 7
242..................................... 2,597 6.8814 2 3 5 9 14
243..................................... 96,552 4.6506 1 2 4 6 9
244..................................... 14,695 4.6521 1 2 4 6 9
245..................................... 5,861 3.2950 1 2 3 4 6
246..................................... 1,498 3.7216 1 2 3 5 7
247..................................... 20,507 3.3340 1 1 3 4 7
248..................................... 13,931 4.9200 1 3 4 6 9
249..................................... 12,932 3.6170 1 1 2 4 7
250..................................... 3,802 4.1302 1 2 3 5 8
251..................................... 2,375 2.7651 1 1 3 3 5
253..................................... 22,095 4.6939 2 3 4 6 8
254..................................... 10,763 3.1601 1 2 3 4 5
256..................................... 6,698 5.1020 1 2 4 6 10
257..................................... 15,758 2.6395 1 1 2 3 5
258..................................... 15,317 1.8212 1 1 2 2 3
259..................................... 3,517 2.6747 1 1 1 3 6
260..................................... 4,236 1.3973 1 1 1 1 2
261..................................... 1,776 2.0884 1 1 1 2 4
262..................................... 668 4.3204 1 1 3 6 9
263..................................... 23,192 11.4687 3 5 8 14 22
264..................................... 3,869 6.5585 2 3 5 8 13
265..................................... 4,103 6.6074 1 2 4 8 14
266..................................... 2,555 3.2337 1 1 2 4 7
267..................................... 241 4.4606 1 1 3 6 10
268..................................... 920 3.7978 1 1 2 4 8
269..................................... 9,852 8.5323 2 3 7 11 17
270..................................... 2,798 3.5615 1 1 2 5 7
271..................................... 19,436 7.2481 2 4 6 9 14
272..................................... 5,752 6.0176 2 3 5 7 12
273..................................... 1,343 3.9598 1 2 3 5 8
274..................................... 2,305 6.4586 1 3 5 8 13
[[Page 27374]]
275..................................... 230 3.6217 1 1 2 4 7
276..................................... 1,327 4.4574 1 2 4 6 8
277..................................... 100,811 5.7271 2 3 5 7 10
278..................................... 32,531 4.1962 2 2 4 5 7
279..................................... 10 5.3000 2 2 3 7 7
280..................................... 17,882 4.1159 1 2 3 5 8
281..................................... 7,536 2.8879 1 1 2 4 5
283..................................... 6,093 4.6606 1 2 4 6 9
284..................................... 2,029 2.9359 1 1 2 4 6
285..................................... 6,962 10.5315 3 5 8 13 20
286..................................... 2,502 5.8981 2 3 4 7 12
287..................................... 6,287 10.2537 3 5 8 13 20
288..................................... 5,524 4.9716 2 3 4 5 8
289..................................... 6,938 2.7257 1 1 1 2 6
290..................................... 9,964 2.1995 1 1 1 2 4
291..................................... 58 1.6379 1 1 1 2 3
292..................................... 6,534 10.4645 2 4 8 14 21
293..................................... 364 4.7033 1 1 3 6 9
294..................................... 98,755 4.5121 1 2 3 6 9
295..................................... 3,550 3.9721 1 2 3 5 7
296..................................... 280,547 5.0716 1 2 4 6 10
297..................................... 48,715 3.2855 1 2 3 4 6
298..................................... 111 3.1802 1 1 2 4 7
299..................................... 1,276 5.4412 1 2 4 7 11
300..................................... 18,798 6.1364 2 3 5 8 12
301..................................... 3,636 3.5954 1 2 3 4 7
302..................................... 8,722 8.5255 4 5 6 9 15
303..................................... 21,880 8.0372 3 4 6 9 15
304..................................... 12,572 8.8705 2 4 6 11 18
305..................................... 3,047 3.5510 1 2 3 4 7
306..................................... 7,077 5.3740 1 2 3 7 12
307..................................... 2,035 2.0708 1 1 2 2 3
308..................................... 7,299 6.2077 1 2 4 8 14
309..................................... 4,183 2.0995 1 1 1 2 4
310..................................... 24,884 4.3725 1 1 3 6 10
311..................................... 7,495 1.8220 1 1 1 2 3
312..................................... 1,524 4.5623 1 1 3 6 10
313..................................... 555 2.2559 1 1 1 3 5
314..................................... 2 40.5000 1 1 80 80 80
315..................................... 34,134 6.9586 1 1 4 9 16
316..................................... 119,645 6.5348 2 3 5 8 13
317..................................... 2,018 3.6051 1 1 2 4 7
318..................................... 5,782 6.0930 1 3 5 8 12
319..................................... 412 2.9320 1 1 2 4 6
320..................................... 188,165 5.2818 2 3 4 6 10
321..................................... 31,355 3.7221 1 2 3 5 7
322..................................... 50 3.2200 1 2 3 4 5
323..................................... 19,957 3.1681 1 1 2 4 6
324..................................... 7,040 1.9006 1 1 1 2 4
325..................................... 9,310 3.8056 1 2 3 5 7
326..................................... 2,732 2.6190 1 1 2 3 5
327..................................... 7 2.5714 1 1 2 3 4
328..................................... 742 3.7251 1 1 3 5 8
329..................................... 94 2.0851 1 1 1 3 5
331..................................... 51,439 5.5878 1 3 4 7 11
332..................................... 5,006 3.1596 1 1 2 4 6
333..................................... 255 5.7843 1 2 3 7 11
334..................................... 10,536 4.5813 2 3 4 5 8
335..................................... 12,727 3.0264 2 2 3 4 5
336..................................... 35,950 3.3945 1 2 2 4 7
337..................................... 29,532 2.0157 1 1 2 2 3
338..................................... 940 5.4851 1 2 3 7 13
339..................................... 1,481 4.7968 1 1 3 6 11
340..................................... 1 2.0000 2 2 2 2 2
341..................................... 3,580 3.2031 1 1 2 3 7
342..................................... 693 3.1977 1 1 2 4 7
344..................................... 3,580 2.5232 1 1 1 2 5
345..................................... 1,370 4.9051 1 1 3 6 11
346..................................... 4,890 5.8937 2 3 5 8 12
[[Page 27375]]
347..................................... 315 3.0762 1 1 2 4 7
348..................................... 3,401 4.3355 1 2 3 5 8
349..................................... 616 2.5049 1 1 2 3 5
350..................................... 6,748 4.4884 2 2 4 6 8
352..................................... 960 3.9740 1 2 3 5 7
353..................................... 2,600 6.4942 2 3 5 7 12
354..................................... 7,444 5.7016 3 3 4 6 10
355..................................... 5,590 3.1971 2 2 3 4 5
356..................................... 25,990 2.0785 1 1 2 3 3
357..................................... 5,663 8.3744 3 4 6 10 16
358..................................... 21,660 4.1750 2 2 3 5 7
359..................................... 32,036 2.5609 1 2 2 3 4
360..................................... 15,871 2.7521 1 1 2 3 4
361..................................... 346 3.2052 1 1 2 3 8
362..................................... 5 1.4000 1 1 1 2 2
363..................................... 2,527 3.6312 1 2 2 4 8
364..................................... 1,637 4.1307 1 1 3 5 8
365..................................... 1,843 8.1872 1 3 5 10 17
366..................................... 4,581 6.6619 1 3 5 8 14
367..................................... 487 3.0678 1 1 2 4 7
368..................................... 3,572 6.6551 2 3 5 8 13
369..................................... 3,482 3.3090 1 1 2 4 7
370..................................... 1,350 5.7911 2 3 4 5 9
371..................................... 1,691 3.4826 2 3 3 4 5
372..................................... 947 3.4805 2 2 2 3 5
373..................................... 4,145 2.2955 1 2 2 3 3
374..................................... 91 2.9341 1 2 2 3 6
376..................................... 325 3.4123 1 2 2 4 7
377..................................... 48 4.0833 1 2 3 5 8
378..................................... 175 2.5943 1 1 2 3 5
379..................................... 355 3.0028 1 1 2 3 5
380..................................... 99 1.9697 1 1 1 2 3
381..................................... 190 1.9053 1 1 1 2 4
382..................................... 49 1.6939 1 1 1 2 3
383..................................... 2,003 3.7913 1 1 3 4 7
384..................................... 129 2.6279 1 1 2 3 5
385..................................... 3 2.0000 1 1 2 3 3
387..................................... 1 55.0000 55 55 55 55 55
389..................................... 12 6.2500 2 3 5 9 10
390..................................... 20 4.3000 1 2 3 5 7
392..................................... 2,271 9.6874 3 4 7 12 21
393..................................... 1 4.0000 4 4 4 4 4
394..................................... 2,605 7.5965 1 2 5 9 17
395..................................... 108,024 4.3238 1 2 3 5 9
396..................................... 17 4.4118 1 1 3 7 9
397..................................... 19,035 5.1743 1 2 4 6 10
398..................................... 18,162 5.8655 2 3 5 7 11
399..................................... 1,693 3.4826 1 2 3 4 6
400..................................... 6,371 9.0333 1 3 6 12 21
401..................................... 5,845 11.5341 2 5 9 15 23
402..................................... 1,478 3.9831 1 1 3 5 9
403..................................... 31,947 8.1013 2 3 6 10 17
404..................................... 4,350 4.1069 1 2 3 5 8
405..................................... 1 31.0000 31 31 31 31 31
406..................................... 2,444 9.6579 2 4 7 12 20
407..................................... 643 4.0560 1 2 3 5 7
408..................................... 2,134 8.2291 1 2 5 10 20
409..................................... 2,154 6.1565 2 3 4 6 12
410..................................... 28,484 4.0951 1 2 4 5 6
411..................................... 7 2.2857 1 1 2 2 4
412..................................... 16 3.8125 1 1 3 6 7
413..................................... 5,349 7.0501 2 3 5 9 14
414..................................... 633 4.2354 1 2 3 5 8
415..................................... 43,349 14.3233 4 6 11 18 28
416..................................... 192,908 7.4362 2 4 6 9 14
417..................................... 38 5.8421 2 3 5 7 12
418..................................... 25,920 6.2986 2 3 5 8 12
419..................................... 16,446 4.5517 1 2 4 6 9
420..................................... 3,220 3.4202 1 2 3 4 6
[[Page 27376]]
421..................................... 10,745 4.0624 1 2 3 5 8
422..................................... 66 3.6970 1 2 2 4 6
423..................................... 8,116 8.3228 2 3 6 10 17
424..................................... 1,236 12.7929 2 4 9 15 26
425..................................... 16,189 3.7961 1 2 3 5 8
426..................................... 4,589 4.4655 1 2 3 6 9
427..................................... 1,596 4.3784 1 2 3 5 9
428..................................... 796 7.1382 1 2 5 8 14
429..................................... 25,933 6.0111 2 3 4 7 11
430..................................... 65,276 7.8291 2 3 6 10 16
431..................................... 314 6.8248 1 2 4 7 12
432..................................... 451 4.0111 1 2 3 4 7
433..................................... 5,554 3.1300 1 1 2 4 6
439..................................... 1,520 8.1855 1 3 5 9 17
440..................................... 5,771 9.0806 2 3 6 11 19
441..................................... 677 3.1374 1 1 2 4 6
442..................................... 17,571 8.5218 1 3 6 10 18
443..................................... 3,920 3.3663 1 1 3 4 7
444..................................... 5,754 4.2011 1 2 3 5 8
445..................................... 2,546 2.8610 1 1 2 4 5
447..................................... 6,514 2.5091 1 1 2 3 5
448..................................... 1 1.0000 1 1 1 1 1
449..................................... 33,181 3.7059 1 1 3 4 7
450..................................... 7,441 1.9790 1 1 1 2 4
451..................................... 1 1.0000 1 1 1 1 1
452..................................... 25,679 4.9178 1 2 3 6 10
453..................................... 5,687 2.7579 1 1 2 3 5
454..................................... 4,792 4.2398 1 2 3 5 8
455..................................... 1,070 2.4140 1 1 2 3 5
461..................................... 5,216 3.5861 1 1 2 4 8
462..................................... 9,650 10.8636 4 6 9 14 20
463..................................... 27,061 4.0439 1 2 3 5 8
464..................................... 7,232 2.9887 1 1 2 4 6
465..................................... 200 3.9100 1 1 1 3 6
466..................................... 1,737 4.0219 1 1 2 4 7
467..................................... 1,140 3.0035 1 1 2 3 6
468..................................... 52,318 12.7674 3 6 10 16 25
471..................................... 13,363 5.3722 3 3 4 6 8
473..................................... 8,095 12.4119 2 3 7 17 32
475..................................... 109,726 11.1546 2 5 9 15 22
476..................................... 3,657 11.0941 2 5 10 15 21
477..................................... 25,400 8.1660 1 3 6 11 17
478..................................... 108,133 7.3130 1 3 5 9 15
479..................................... 24,052 3.1910 1 1 2 4 7
480..................................... 611 21.0638 6 8 12 22 47
481..................................... 865 21.7584 13 17 20 25 33
482..................................... 5,296 12.5015 4 6 9 15 24
483..................................... 45,427 39.2033 15 22 33 48 70
484..................................... 336 14.5744 2 6 11 21 28
485..................................... 3,220 9.8264 4 5 7 11 19
486..................................... 2,094 12.7612 1 6 10 17 26
487..................................... 3,731 7.1702 1 3 6 9 15
488..................................... 769 16.9129 4 7 13 22 36
489..................................... 13,373 8.5374 2 3 6 10 17
490..................................... 5,462 5.4888 1 2 4 7 11
491..................................... 15,370 3.3853 1 2 3 4 6
492..................................... 3,140 14.9239 3 5 7 25 33
493..................................... 59,615 5.9843 1 3 5 8 11
494..................................... 28,880 2.5293 1 1 2 3 5
495..................................... 192 16.4167 7 9 12 19 31
496..................................... 2,479 8.8709 3 4 6 11 18
497..................................... 22,473 6.3553 3 4 5 7 11
498..................................... 16,070 4.0191 2 3 4 5 6
499..................................... 34,688 4.5204 1 2 3 6 9
500..................................... 49,936 2.4069 1 1 2 3 4
501..................................... 2,608 10.6031 4 5 8 13 20
502..................................... 771 6.1647 3 4 5 7 11
503..................................... 5,970 3.9084 1 2 3 5 7
504..................................... 125 27.6560 7 13 21 37 55
[[Page 27377]]
505..................................... 134 5.6567 1 1 1 5 11
506..................................... 919 16.8836 4 7 13 21 35
507..................................... 341 9.0411 2 4 7 13 19
508..................................... 631 7.8051 2 3 5 10 17
509..................................... 160 4.2688 1 2 3 5 9
510..................................... 1,651 6.7274 1 3 5 8 15
511..................................... 581 4.6076 1 1 3 6 10
512..................................... 481 13.1185 6 8 10 15 23
513..................................... 207 9.7585 5 6 8 10 15
514..................................... 26,570 6.9035 1 2 5 9 15
515..................................... 8,131 5.1646 1 1 3 7 12
516..................................... 84,846 4.6338 2 2 4 5 9
517..................................... 198,743 2.5406 1 1 1 3 5
518..................................... 56,613 3.2508 1 1 2 4 7
519..................................... 8,486 4.8547 1 1 3 6 11
520..................................... 12,687 2.0548 1 1 1 2 4
521..................................... 30,898 5.7395 2 3 4 7 11
522..................................... 6,069 9.5670 4 5 8 12 20
523..................................... 15,456 4.0538 1 2 3 5 7
524..................................... 132,651 3.3690 1 2 3 4 6
525..................................... 571 17.2907 1 4 9 18 37
----------------
11,713,347
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 7B.--Medicare Prospective Payment System Selected Percentile Lengths of Stay--FY 2002 MEDPAR Update December 2002 Grouper V21.0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Arithmetic
DRG Number of mean length of 10th 25th 50th 75th 90th
discharges stay percentile percentile percentile percentile percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1....................................... 23,433 10.5551 3 5 8 14 21
2....................................... 11,715 5.2534 1 3 4 7 10
3....................................... 3 6.0000 1 1 4 13 13
6....................................... 356 3.0197 1 1 2 4 7
7....................................... 14,683 9.8438 2 4 7 12 20
8....................................... 4,106 2.8015 1 1 1 3 7
9....................................... 1,711 6.2402 1 3 5 8 12
10...................................... 18,655 6.3850 2 3 5 8 13
11...................................... 3,291 4.0413 1 2 3 5 8
12...................................... 52,512 5.7513 2 3 4 7 11
13...................................... 7,068 5.0035 2 3 4 6 9
14...................................... 237,027 5.9456 2 3 5 7 11
15...................................... 94,223 4.8529 2 3 4 6 9
16...................................... 9,938 6.3106 2 3 5 8 12
17...................................... 2,744 3.2172 1 2 2 4 6
18...................................... 29,701 5.4868 2 3 4 7 10
19...................................... 8,519 3.5184 1 2 3 5 7
20...................................... 6,207 10.1927 3 5 8 13 20
21...................................... 1,885 6.5963 2 3 5 9 13
22...................................... 2,785 5.1178 2 2 4 6 10
23...................................... 11,270 4.2627 1 2 3 5 8
24...................................... 59,102 4.8803 1 2 4 6 10
25...................................... 27,433 3.1776 1 2 3 4 6
26...................................... 18 4.2778 1 1 2 3 4
27...................................... 4,398 5.1719 1 1 3 7 11
28...................................... 13,919 6.0265 1 3 5 8 12
29...................................... 5,282 3.4924 1 2 3 5 7
30...................................... 2 6.5000 2 2 11 11 11
31...................................... 3,897 4.0429 1 2 3 5 8
32...................................... 1,895 2.4776 1 1 2 3 5
34...................................... 23,811 4.9368 1 2 4 6 9
35...................................... 7,451 3.1094 1 1 3 4 6
36...................................... 2,117 1.5328 1 1 1 1 2
37...................................... 1,382 3.7685 1 1 2 5 8
38...................................... 97 2.8041 1 1 1 4 5
39...................................... 559 2.1163 1 1 1 2 4
40...................................... 1,549 3.8070 1 1 3 5 7
[[Page 27378]]
42...................................... 1,581 2.7381 1 1 1 3 6
43...................................... 94 3.3936 1 1 3 4 6
44...................................... 1,227 4.9935 2 3 4 6 9
45...................................... 2,668 3.1267 1 2 3 4 6
46...................................... 3,482 4.4730 1 2 3 6 8
47...................................... 1,402 3.0927 1 1 2 4 6
49...................................... 2,391 4.4676 1 2 3 6 9
50...................................... 2,429 1.8506 1 1 1 2 3
51...................................... 243 2.8354 1 1 1 3 8
52...................................... 223 1.8161 1 1 1 2 3
53...................................... 2,478 3.6186 1 1 2 4 8
55...................................... 1,481 2.9338 1 1 1 3 7
56...................................... 469 2.8955 1 1 1 3 6
57...................................... 711 3.6709 1 1 2 4 8
58...................................... 1 2.0000 2 2 2 2 2
59...................................... 116 2.6724 1 1 1 3 6
60...................................... 1 3.0000 3 3 3 3 3
61...................................... 254 5.1535 1 1 3 7 11
62...................................... 2 7.0000 1 1 13 13 13
63...................................... 3,000 4.3860 1 2 3 5 9
64...................................... 3,126 6.4997 1 2 4 8 14
65...................................... 40,407 2.8127 1 1 2 4 5
66...................................... 7,841 3.0778 1 1 2 4 6
67...................................... 385 3.6442 1 2 3 5 7
68...................................... 11,658 3.8813 1 2 3 5 7
69...................................... 3,769 3.0186 1 2 3 4 5
70...................................... 30 2.3333 1 1 2 3 4
71...................................... 80 3.4000 1 1 2 4 6
72...................................... 964 3.4035 1 1 3 4 6
73...................................... 7,697 4.4433 1 2 3 6 9
75...................................... 43,504 9.9907 3 5 7 12 20
76...................................... 44,508 11.1024 3 5 9 14 21
77...................................... 2,458 4.8031 1 2 4 7 10
78...................................... 39,504 6.5709 3 4 6 8 11
79...................................... 169,239 8.4557 3 4 7 11 16
80...................................... 8,077 5.3480 2 3 4 7 10
81...................................... 5 4.4000 1 1 3 8 8
82...................................... 64,299 6.8753 2 3 5 9 14
83...................................... 6,665 5.3655 2 3 4 7 10
84...................................... 1,575 3.2565 1 2 3 4 6
85...................................... 22,398 6.2473 2 3 5 8 12
86...................................... 2,250 3.5364 1 2 3 4 7
87...................................... 61,129 6.3127 1 3 5 8 12
88...................................... 404,045 5.0463 2 3 4 6 9
89...................................... 535,162 5.8340 2 3 5 7 11
90...................................... 48,843 3.9563 2 2 3 5 7
91...................................... 45 5.0444 1 2 3 5 13
92...................................... 15,809 6.2907 2 3 5 8 12
93...................................... 1,778 4.0079 1 2 3 5 7
94...................................... 12,813 6.2387 2 3 5 8 12
95...................................... 1,655 3.8127 1 2 3 5 7
96...................................... 56,893 4.5613 2 2 4 6 8
97...................................... 28,776 3.5275 1 2 3 4 6
98...................................... 9 3.6667 1 1 2 2 5
99...................................... 21,400 3.1554 1 1 2 4 6
100..................................... 8,324 2.1371 1 1 2 3 4
101..................................... 22,329 4.3853 1 2 3 6 9
102..................................... 5,644 2.6487 1 1 2 3 5
103..................................... 484 42.1240 9 12 23 53 92
104..................................... 20,637 14.3306 6 8 12 17 25
105..................................... 29,223 9.8741 4 6 8 11 18
106..................................... 3,498 11.4019 5 7 10 14 20
107..................................... 83,307 10.4339 5 7 9 12 17
108..................................... 6,508 9.7617 2 5 8 12 18
109..................................... 57,450 7.7160 4 5 6 9 13
110..................................... 54,856 8.7568 2 4 7 11 17
111..................................... 9,569 4.0574 1 2 4 6 7
113..................................... 39,734 12.4805 4 6 9 15 24
114..................................... 8,315 8.6592 2 4 7 11 17
[[Page 27379]]
115..................................... 19,805 7.4228 1 3 6 10 15
116..................................... 116,294 4.3974 1 2 3 6 9
117..................................... 4,731 4.3075 1 1 2 5 10
118..................................... 8,299 2.8976 1 1 1 4 7
119..................................... 1,237 5.2967 1 1 3 7 13
120..................................... 38,109 9.0051 1 3 6 12 20
121..................................... 164,425 6.2836 2 3 5 8 12
122..................................... 77,231 3.5159 1 2 3 5 7
123..................................... 38,627 4.7915 1 1 3 6 11
124..................................... 135,291 4.3838 1 2 3 6 9
125..................................... 91,946 2.7616 1 1 2 4 5
126..................................... 5,395 11.5218 3 6 9 15 22
127..................................... 676,101 5.2357 2 3 4 7 10
128..................................... 7,187 5.4446 2 3 5 7 9
129..................................... 3,853 2.5951 1 1 1 3 6
130..................................... 88,911 5.5991 2 3 5 7 10
131..................................... 27,124 4.0330 1 2 4 5 7
132..................................... 142,443 2.8904 1 1 2 4 5
133..................................... 8,694 2.2843 1 1 2 3 4
134..................................... 41,542 3.1609 1 2 2 4 6
135..................................... 7,810 4.4540 1 2 3 5 8
136..................................... 1,185 2.6641 1 1 2 3 5
138..................................... 208,716 3.9930 1 2 3 5 8
139..................................... 87,938 2.4733 1 1 2 3 5
140..................................... 55,735 2.5252 1 1 2 3 5
141..................................... 108,834 3.5704 1 2 3 4 7
142..................................... 52,684 2.5530 1 1 2 3 5
143..................................... 250,177 2.0911 1 1 2 3 4
144..................................... 94,588 5.5436 1 2 4 7 11
145..................................... 7,370 2.5700 1 1 2 3 5
146..................................... 10,785 10.2338 5 6 8 12 17
147..................................... 2,644 6.2266 3 5 6 8 9
148..................................... 134,125 12.2751 5 7 10 15 22
149..................................... 20,205 6.3062 4 5 6 7 9
150..................................... 21,184 11.3235 4 6 9 14 20
151..................................... 5,140 5.5586 2 3 5 7 10
152..................................... 4,578 8.3724 3 5 7 10 15
153..................................... 2,058 5.2546 3 4 5 7 8
154..................................... 28,368 13.2140 3 7 10 17 26
155..................................... 6,618 4.0801 1 2 3 6 8
156..................................... 4 2.5000 1 1 1 3 5
157..................................... 8,301 5.7459 1 2 4 7 12
158..................................... 4,362 2.6016 1 1 2 3 5
159..................................... 18,136 5.1194 1 2 4 7 10
160..................................... 12,203 2.6826 1 1 2 3 5
161..................................... 10,803 4.3270 1 2 3 6 9
162..................................... 6,421 1.9305 1 1 1 2 4
163..................................... 8 3.2500 1 1 2 3 6
164..................................... 5,400 8.3580 3 5 7 10 15
165..................................... 2,335 4.4882 2 3 4 6 7
166..................................... 4,206 4.7263 1 2 4 6 9
167..................................... 4,091 2.4133 1 1 2 3 4
168..................................... 1,425 4.8386 1 2 3 6 10
169..................................... 814 2.4005 1 1 2 3 5
170..................................... 15,682 10.8241 2 4 8 14 22
171..................................... 1,530 4.3333 1 2 4 6 9
172..................................... 31,435 6.9669 2 3 5 9 14
173..................................... 2,482 3.7808 1 2 3 5 8
174..................................... 252,303 4.7834 2 3 4 6 9
175..................................... 34,977 2.9157 1 2 3 4 5
176..................................... 13,498 5.2318 2 3 4 6 10
177..................................... 9,080 4.5719 2 3 4 6 8
178..................................... 3,382 3.1227 1 2 3 4 6
179..................................... 13,193 5.9431 2 3 5 7 11
180..................................... 90,752 5.4251 2 3 4 7 10
181..................................... 27,280 3.3710 1 2 3 4 6
182..................................... 273,118 4.4204 1 2 3 5 8
183..................................... 91,272 2.8962 1 1 2 4 5
184..................................... 69 3.2319 1 1 2 4 6
[[Page 27380]]
185..................................... 5,350 4.6680 1 2 3 6 10
186..................................... 6 6.6667 2 3 3 10 10
187..................................... 619 4.0307 1 2 3 6 8
188..................................... 84,099 5.5620 1 2 4 7 11
189..................................... 13,098 3.1005 1 1 2 4 6
190..................................... 75 5.1733 1 2 4 6 11
191..................................... 9,537 13.7975 3 6 10 17 28
192..................................... 1,322 6.2201 1 3 6 8 11
193..................................... 4,822 12.7242 5 7 10 16 23
194..................................... 650 6.7323 2 4 6 8 12
195..................................... 4,019 10.5175 4 6 9 13 19
196..................................... 998 5.6092 2 3 5 7 10
197..................................... 18,313 9.1566 3 5 7 11 17
198..................................... 5,418 4.4118 2 3 4 6 7
199..................................... 1,636 9.7353 2 4 7 13 21
200..................................... 1,076 10.4898 2 3 7 14 23
201..................................... 2,130 14.1469 3 6 11 18 29
202..................................... 26,756 6.3872 2 3 5 8 13
203..................................... 30,055 6.6816 2 3 5 9 13
204..................................... 65,585 5.7470 2 3 4 7 11
205..................................... 27,481 6.1736 2 3 5 8 12
206..................................... 2,057 3.7832 1 2 3 5 8
207..................................... 32,881 5.1924 1 2 4 7 10
208..................................... 10,188 2.8924 1 1 2 4 5
209..................................... 399,893 4.8600 3 3 4 5 7
210..................................... 122,843 6.8859 3 4 6 8 11
211..................................... 30,096 4.8394 3 4 4 6 7
212..................................... 9 7.0000 1 1 4 5 7
213..................................... 9,950 9.2035 2 4 7 12 18
216..................................... 8,770 7.9789 1 2 6 11 17
217..................................... 17,292 13.3846 3 5 9 16 28
218..................................... 23,796 5.5121 2 3 4 7 10
219..................................... 19,891 3.1961 1 2 3 4 6
220..................................... 1 1.0000 1 1 1 1 1
223..................................... 13,308 3.0326 1 1 2 4 6
224..................................... 11,738 1.9052 1 1 1 2 3
225..................................... 6,481 5.2626 1 2 4 7 11
226..................................... 5,874 6.5259 1 2 4 8 14
227..................................... 4,854 2.6360 1 1 2 3 5
228..................................... 2,534 4.1492 1 1 3 5 9
229..................................... 1,263 2.3286 1 1 2 3 5
230..................................... 2,456 5.5668 1 2 3 7 12
232..................................... 816 2.7132 1 1 1 2 6
233..................................... 9,940 7.3671 1 3 6 10 15
234..................................... 5,364 3.0626 1 1 2 4 7
235..................................... 5,107 4.8659 1 2 4 6 9
236..................................... 40,182 4.6505 1 3 4 6 8
237..................................... 1,782 3.6599 1 2 3 5 7
238..................................... 8,956 8.6382 3 4 7 10 17
239..................................... 46,252 6.2694 2 3 5 8 12
240..................................... 12,062 6.6231 2 3 5 8 13
241..................................... 3,173 3.7690 1 2 3 5 7
242..................................... 2,597 6.8814 2 3 5 9 14
243..................................... 96,552 4.6506 1 2 4 6 9
244..................................... 14,695 4.6521 1 2 4 6 9
245..................................... 5,861 3.2950 1 2 3 4 6
246..................................... 1,498 3.7216 1 2 3 5 7
247..................................... 20,507 3.3340 1 1 3 4 7
248..................................... 13,931 4.9200 1 3 4 6 9
249..................................... 12,932 3.6170 1 1 2 4 7
250..................................... 3,802 4.1302 1 2 3 5 8
251..................................... 2,375 2.7651 1 1 3 3 5
253..................................... 22,095 4.6939 2 3 4 6 8
254..................................... 10,763 3.1601 1 2 3 4 5
256..................................... 6,714 5.1008 1 2 4 6 10
257..................................... 15,758 2.6395 1 1 2 3 5
258..................................... 15,317 1.8212 1 1 2 2 3
259..................................... 3,517 2.6747 1 1 1 3 6
260..................................... 4,236 1.3973 1 1 1 1 2
[[Page 27381]]
261..................................... 1,776 2.0884 1 1 1 2 4
262..................................... 668 4.3204 1 1 3 6 9
263..................................... 23,192 11.4687 3 5 8 14 22
264..................................... 3,869 6.5585 2 3 5 8 13
265..................................... 4,103 6.6074 1 2 4 8 14
266..................................... 2,555 3.2337 1 1 2 4 7
267..................................... 241 4.4606 1 1 3 6 10
268..................................... 920 3.7978 1 1 2 4 8
269..................................... 9,852 8.5323 2 3 7 11 17
270..................................... 2,798 3.5615 1 1 2 5 7
271..................................... 19,436 7.2481 2 4 6 9 14
272..................................... 5,752 6.0176 2 3 5 7 12
273..................................... 1,343 3.9598 1 2 3 5 8
274..................................... 2,305 6.4586 1 3 5 8 13
275..................................... 230 3.6217 1 1 2 4 7
276..................................... 1,327 4.4574 1 2 4 6 8
277..................................... 100,811 5.7271 2 3 5 7 10
278..................................... 32,531 4.1962 2 2 4 5 7
279..................................... 10 5.3000 2 2 3 7 7
280..................................... 17,882 4.1159 1 2 3 5 8
281..................................... 7,536 2.8879 1 1 2 4 5
283..................................... 6,093 4.6606 1 2 4 6 9
284..................................... 2,029 2.9359 1 1 2 4 6
285..................................... 6,962 10.5315 3 5 8 13 20
286..................................... 2,502 5.8981 2 3 4 7 12
287..................................... 6,287 10.2537 3 5 8 13 20
288..................................... 5,524 4.9716 2 3 4 5 8
289..................................... 6,938 2.7257 1 1 1 2 6
290..................................... 9,964 2.1995 1 1 1 2 4
291..................................... 58 1.6379 1 1 1 2 3
292..................................... 6,534 10.4645 2 4 8 14 21
293..................................... 364 4.7033 1 1 3 6 9
294..................................... 98,755 4.5121 1 2 3 6 9
295..................................... 3,550 3.9721 1 2 3 5 7
296..................................... 280,547 5.0716 1 2 4 6 10
297..................................... 48,715 3.2855 1 2 3 4 6
298..................................... 111 3.1802 1 1 2 4 7
299..................................... 1,276 5.4412 1 2 4 7 11
300..................................... 18,798 6.1364 2 3 5 8 12
301..................................... 3,636 3.5954 1 2 3 4 7
302..................................... 8,722 8.5255 4 5 6 9 15
303..................................... 21,880 8.0372 3 4 6 9 15
304..................................... 12,572 8.8705 2 4 6 11 18
305..................................... 3,047 3.5510 1 2 3 4 7
306..................................... 7,077 5.3740 1 2 3 7 12
307..................................... 2,035 2.0708 1 1 2 2 3
308..................................... 7,299 6.2077 1 2 4 8 14
309..................................... 4,183 2.0995 1 1 1 2 4
310..................................... 24,884 4.3725 1 1 3 6 10
311..................................... 7,495 1.8220 1 1 1 2 3
312..................................... 1,524 4.5623 1 1 3 6 10
313..................................... 555 2.2559 1 1 1 3 5
314..................................... 2 40.5000 1 1 80 80 80
315..................................... 34,134 6.9586 1 1 4 9 16
316..................................... 119,645 6.5348 2 3 5 8 13
317..................................... 2,018 3.6051 1 1 2 4 7
318..................................... 5,782 6.0930 1 3 5 8 12
319..................................... 412 2.9320 1 1 2 4 6
320..................................... 188,165 5.2818 2 3 4 6 10
321..................................... 31,355 3.7221 1 2 3 5 7
322..................................... 50 3.2200 1 2 3 4 5
323..................................... 19,957 3.1681 1 1 2 4 6
324..................................... 7,040 1.9006 1 1 1 2 4
325..................................... 9,310 3.8056 1 2 3 5 7
326..................................... 2,732 2.6190 1 1 2 3 5
327..................................... 7 2.5714 1 1 2 3 4
328..................................... 742 3.7251 1 1 3 5 8
329..................................... 94 2.0851 1 1 1 3 5
331..................................... 51,439 5.5878 1 3 4 7 11
[[Page 27382]]
332..................................... 5,006 3.1596 1 1 2 4 6
333..................................... 255 5.7843 1 2 3 7 11
334..................................... 10,536 4.5813 2 3 4 5 8
335..................................... 12,727 3.0264 2 2 3 4 5
336..................................... 35,950 3.3945 1 2 2 4 7
337..................................... 29,532 2.0157 1 1 2 2 3
338..................................... 940 5.4851 1 2 3 7 13
339..................................... 1,481 4.7968 1 1 3 6 11
340..................................... 1 2.0000 2 2 2 2 2
341..................................... 3,580 3.2031 1 1 2 3 7
342..................................... 693 3.1977 1 1 2 4 7
344..................................... 3,580 2.5232 1 1 1 2 5
345..................................... 1,370 4.9051 1 1 3 6 11
346..................................... 4,890 5.8937 2 3 5 8 12
347..................................... 315 3.0762 1 1 2 4 7
348..................................... 3,401 4.3355 1 2 3 5 8
349..................................... 616 2.5049 1 1 2 3 5
350..................................... 6,748 4.4884 2 2 4 6 8
352..................................... 960 3.9740 1 2 3 5 7
353..................................... 2,600 6.4942 2 3 5 7 12
354..................................... 7,444 5.7016 3 3 4 6 10
355..................................... 5,590 3.1971 2 2 3 4 5
356..................................... 25,990 2.0785 1 1 2 3 3
357..................................... 5,663 8.3744 3 4 6 10 16
358..................................... 21,660 4.1750 2 2 3 5 7
359..................................... 32,036 2.5609 1 2 2 3 4
360..................................... 15,871 2.7521 1 1 2 3 4
361..................................... 346 3.2052 1 1 2 3 8
362..................................... 5 1.4000 1 1 1 2 2
363..................................... 2,527 3.6312 1 2 2 4 8
364..................................... 1,637 4.1307 1 1 3 5 8
365..................................... 1,843 8.1872 1 3 5 10 17
366..................................... 4,581 6.6619 1 3 5 8 14
367..................................... 487 3.0678 1 1 2 4 7
368..................................... 3,572 6.6551 2 3 5 8 13
369..................................... 3,482 3.3090 1 1 2 4 7
370..................................... 1,350 5.7911 2 3 4 5 9
371..................................... 1,691 3.4826 2 3 3 4 5
372..................................... 947 3.4805 2 2 2 3 5
373..................................... 4,145 2.2955 1 2 2 3 3
374..................................... 91 2.9341 1 2 2 3 6
376..................................... 325 3.4123 1 2 2 4 7
377..................................... 48 4.0833 1 2 3 5 8
378..................................... 175 2.5943 1 1 2 3 5
379..................................... 355 3.0028 1 1 2 3 5
380..................................... 99 1.9697 1 1 1 2 3
381..................................... 190 1.9053 1 1 1 2 4
382..................................... 49 1.6939 1 1 1 2 3
383..................................... 2,003 3.7913 1 1 3 4 7
384..................................... 129 2.6279 1 1 2 3 5
385..................................... 3 2.0000 1 1 2 3 3
387..................................... 1 55.0000 55 55 55 55 55
389..................................... 12 6.2500 2 3 5 9 10
392..................................... 2,271 9.6874 3 4 7 12 21
393..................................... 1 4.0000 4 4 4 4 4
394..................................... 2,605 7.5965 1 2 5 9 17
395..................................... 108,024 4.3238 1 2 3 5 9
396..................................... 17 4.4118 1 1 3 7 9
397..................................... 19,035 5.1743 1 2 4 6 10
398..................................... 18,162 5.8655 2 3 5 7 11
399..................................... 1,693 3.4826 1 2 3 4 6
401..................................... 5,845 11.5341 2 5 9 15 23
402..................................... 1,478 3.9831 1 1 3 5 9
403..................................... 31,947 8.1013 2 3 6 10 17
404..................................... 4,350 4.1069 1 2 3 5 8
405..................................... 1 31.0000 31 31 31 31 31
406..................................... 2,444 9.6579 2 4 7 12 20
407..................................... 643 4.0560 1 2 3 5 7
408..................................... 2,134 8.2291 1 2 5 10 20
[[Page 27383]]
409..................................... 2,154 6.1565 2 3 4 6 12
410..................................... 28,484 4.0951 1 2 4 5 6
411..................................... 7 2.2857 1 1 2 2 4
412..................................... 16 3.8125 1 1 3 6 7
413..................................... 5,349 7.0501 2 3 5 9 14
414..................................... 633 4.2354 1 2 3 5 8
415..................................... 43,349 14.3233 4 6 11 18 28
416..................................... 192,908 7.4362 2 4 6 9 14
417..................................... 38 5.8421 2 3 5 7 12
418..................................... 25,920 6.2986 2 3 5 8 12
419..................................... 16,446 4.5517 1 2 4 6 9
420..................................... 3,220 3.4202 1 2 3 4 6
421..................................... 10,745 4.0624 1 2 3 5 8
422..................................... 66 3.6970 1 2 2 4 6
423..................................... 8,116 8.3228 2 3 6 10 17
424..................................... 1,236 12.7929 2 4 9 15 26
425..................................... 16,189 3.7961 1 2 3 5 8
426..................................... 4,589 4.4655 1 2 3 6 9
427..................................... 1,596 4.3784 1 2 3 5 9
428..................................... 796 7.1382 1 2 5 8 14
429..................................... 27,249 5.8827 2 3 4 7 11
430..................................... 65,276 7.8291 2 3 6 10 16
431..................................... 314 6.8248 1 2 4 7 12
432..................................... 451 4.0111 1 2 3 4 7
433..................................... 5,554 3.1300 1 1 2 4 6
439..................................... 1,520 8.1855 1 3 5 9 17
440..................................... 5,771 9.0806 2 3 6 11 19
441..................................... 677 3.1374 1 1 2 4 6
442..................................... 17,571 8.5218 1 3 6 10 18
443..................................... 3,920 3.3663 1 1 3 4 7
444..................................... 5,754 4.2011 1 2 3 5 8
445..................................... 2,546 2.8610 1 1 2 4 5
447..................................... 6,514 2.5091 1 1 2 3 5
448..................................... 1 1.0000 1 1 1 1 1
449..................................... 33,181 3.7059 1 1 3 4 7
450..................................... 7,441 1.9790 1 1 1 2 4
451..................................... 1 1.0000 1 1 1 1 1
452..................................... 25,679 4.9178 1 2 3 6 10
453..................................... 5,687 2.7579 1 1 2 3 5
454..................................... 4,792 4.2398 1 2 3 5 8
455..................................... 1,070 2.4140 1 1 2 3 5
461..................................... 5,216 3.5861 1 1 2 4 8
462..................................... 9,650 10.8636 4 6 9 14 20
463..................................... 27,061 4.0439 1 2 3 5 8
464..................................... 7,232 2.9887 1 1 2 4 6
465..................................... 200 3.9100 1 1 1 3 6
466..................................... 1,737 4.0219 1 1 2 4 7
467..................................... 1,141 3.0035 1 1 2 3 6
468..................................... 52,318 12.7674 3 6 10 16 25
471..................................... 13,363 5.3722 3 3 4 6 8
473..................................... 8,095 12.4119 2 3 7 17 32
475..................................... 109,726 11.1546 2 5 9 15 22
476..................................... 3,657 11.0941 2 5 10 15 21
477..................................... 25,400 8.1660 1 3 6 11 17
478..................................... 108,112 7.3110 1 3 5 9 15
479..................................... 24,051 3.1906 1 1 2 4 7
480..................................... 611 21.0638 6 8 12 22 47
481..................................... 865 21.7584 13 17 20 25 33
482..................................... 5,296 12.5015 4 6 9 15 24
483..................................... 45,427 39.2033 15 22 33 48 70
484..................................... 336 14.5744 2 6 11 21 28
485..................................... 3,220 9.8264 4 5 7 11 19
486..................................... 2,094 12.7612 1 6 10 17 26
487..................................... 3,731 7.1702 1 3 6 9 15
488..................................... 769 16.9129 4 7 13 22 36
489..................................... 13,373 8.5374 2 3 6 10 17
490..................................... 5,462 5.4888 1 2 4 7 11
491..................................... 15,370 3.3853 1 2 3 4 6
492..................................... 3,140 14.9239 3 5 7 25 33
[[Page 27384]]
493..................................... 59,615 5.9843 1 3 5 8 11
494..................................... 28,880 2.5293 1 1 2 3 5
495..................................... 192 16.4167 7 9 12 19 31
496..................................... 2,479 8.8709 3 4 6 11 18
497..................................... 21,955 6.2773 3 4 5 7 11
498..................................... 15,754 4.0072 2 3 4 5 6
499..................................... 34,688 4.5204 1 2 3 6 9
500..................................... 49,936 2.4069 1 1 2 3 4
501..................................... 2,608 10.6031 4 5 8 13 20
502..................................... 771 6.1647 3 4 5 7 11
503..................................... 5,970 3.9084 1 2 3 5 7
504..................................... 125 27.6560 7 13 21 37 55
505..................................... 134 5.6567 1 1 1 5 11
506..................................... 919 16.8836 4 7 13 21 35
507..................................... 341 9.0411 2 4 7 13 19
508..................................... 631 7.8051 2 3 5 10 17
509..................................... 160 4.2688 1 2 3 5 9
510..................................... 1,651 6.7274 1 3 5 8 15
511..................................... 581 4.6076 1 1 3 6 10
512..................................... 481 13.1185 6 8 10 15 23
513..................................... 207 9.7585 5 6 8 10 15
515..................................... 8,131 5.1646 1 1 3 7 12
516..................................... 84,846 4.6338 2 2 4 5 9
517..................................... 198,743 2.5406 1 1 1 3 5
518..................................... 56,613 3.2508 1 1 2 4 7
519..................................... 9,004 5.1313 1 1 3 6 12
520..................................... 13,003 2.1170 1 1 2 2 4
521..................................... 30,898 5.7395 2 3 4 7 11
522..................................... 6,069 9.5670 4 5 8 12 20
523..................................... 15,456 4.0538 1 2 3 5 7
524..................................... 132,651 3.3690 1 2 3 4 6
525..................................... 571 17.2907 1 4 9 18 37
528..................................... 1,354 17.0990 6 10 15 22 31
529..................................... 4,687 10.5078 2 3 7 14 24
530..................................... 2,842 3.9170 1 2 3 5 8
531..................................... 3,802 9.9408 2 4 7 13 21
532..................................... 2,910 3.9704 1 1 3 5 8
533..................................... 43,264 4.1077 1 1 2 5 9
534..................................... 52,354 2.0108 1 1 1 2 4
535..................................... 6,005 10.9189 2 5 9 14 21
536..................................... 20,565 5.7310 1 2 4 8 12
537..................................... 6,870 7.0199 1 3 5 9 14
538..................................... 6,442 2.8788 1 1 2 4 6
539..................................... 4,472 11.1456 2 4 8 15 24
540..................................... 1,899 4.0590 1 1 3 5 8
----------------
11,713,347
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 8A.--Statewide Average Operating Cost-To-Charge Ratios for Urban
and Rural Hospitals (Case Weighted)--March 2003
------------------------------------------------------------------------
State Urban Rural
------------------------------------------------------------------------
Alabama............................................. 0.326 0.393
Alaska.............................................. 0.401 0.662
Arizona............................................. 0.334 0.453
Arkansas............................................ 0.424 0.413
California.......................................... 0.322 0.411
Colorado............................................ 0.408 0.532
Connecticut......................................... 0.501 0.538
Delaware............................................ 0.592 0.483
District of Columbia................................ 0.382 ........
Florida............................................. 0.330 0.344
Georgia............................................. 0.449 0.444
Hawaii.............................................. 0.402 0.447
Idaho............................................... 0.541 0.518
Illinois............................................ 0.384 0.476
Indiana............................................. 0.486 0.523
Iowa................................................ 0.456 0.587
Kansas.............................................. 0.376 0.558
Kentucky............................................ 0.458 0.462
Louisiana........................................... 0.383 0.459
Maine............................................... 0.542 0.499
Maryland............................................ 0.760 0.820
Massachusetts....................................... 0.499 0.553
Michigan............................................ 0.438 0.534
Minnesota........................................... 0.460 0.619
Mississippi......................................... 0.431 0.419
Missouri............................................ 0.389 0.459
Montana............................................. 0.510 0.516
Nebraska............................................ 0.415 0.525
Nevada.............................................. 0.284 0.461
New Hampshire....................................... 0.523 0.587
New Jersey.......................................... 0.343 ........
New Mexico.......................................... 0.473 0.479
New York............................................ 0.470 0.579
North Carolina...................................... 0.503 0.468
[[Page 27385]]
North Dakota........................................ 0.640 0.628
Ohio................................................ 0.481 0.567
Oklahoma............................................ 0.371 0.466
Oregon.............................................. 0.525 0.568
Pennsylvania........................................ 0.367 0.497
Puerto Rico......................................... 0.479 0.569
Rhode Island........................................ 0.484 ........
South Carolina...................................... 0.435 0.452
South Dakota........................................ 0.484 0.535
Tennessee........................................... 0.411 0.434
Texas............................................... 0.373 0.477
Utah................................................ 0.481 0.581
Vermont............................................. 0.522 0.596
Virginia............................................ 0.428 0.499
Washington.......................................... 0.532 0.581
West Virginia....................................... 0.572 0.545
Wisconsin........................................... 0.509 0.583
Wyoming............................................. 0.442 0.618
------------------------------------------------------------------------
Table 8B.--Statewide Average Capital Cost-to-Charge Ratios (Case
Weighted)--March 2003
------------------------------------------------------------------------
State Ratio
------------------------------------------------------------------------
Alabama....................................................... 0.040
Alaska........................................................ 0.053
Arizona....................................................... 0.033
Arkansas...................................................... 0.042
California.................................................... 0.031
Colorado...................................................... 0.043
Connecticut................................................... 0.036
Delaware...................................................... 0.050
District of Columbia.......................................... 0.026
Florida....................................................... 0.039
Georgia....................................................... 0.047
Hawaii........................................................ 0.041
Idaho......................................................... 0.045
Illinois...................................................... 0.037
Indiana....................................................... 0.051
Iowa.......................................................... 0.046
Kansas........................................................ 0.045
Kentucky...................................................... 0.045
Louisiana..................................................... 0.043
Maine......................................................... 0.035
Maryland...................................................... 0.013
Massachusetts................................................. 0.049
Michigan...................................................... 0.043
Minnesota..................................................... 0.042
Mississippi................................................... 0.041
Missouri...................................................... 0.040
Montana....................................................... 0.049
Nebraska...................................................... 0.047
Nevada........................................................ 0.032
New Hampshire................................................. 0.059
New Jersey.................................................... 0.030
New Mexico.................................................... 0.044
New York...................................................... 0.047
North Carolina................................................ 0.046
North Dakota.................................................. 0.065
Ohio.......................................................... 0.044
Oklahoma...................................................... 0.040
Oregon........................................................ 0.043
Pennsylvania.................................................. 0.035
Puerto Rico................................................... 0.043
Rhode Island.................................................. 0.033
South Carolina................................................ 0.046
South Dakota.................................................. 0.051
Tennessee..................................................... 0.046
Texas......................................................... 0.043
Utah.......................................................... 0.046
Vermont....................................................... 0.046
Virginia...................................................... 0.048
Washington.................................................... 0.052
West Virginia................................................. 0.045
Wisconsin..................................................... 0.050
Wyoming....................................................... 0.050
------------------------------------------------------------------------
Table 9.--Hospital Reclassifications and Redesignations by Individual Hospital--FY 2004
----------------------------------------------------------------------------------------------------------------
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
010044.............................................. 01 25 ..................
010072.............................................. 01 0450 0450
010089.............................................. 01 1000 ..................
010101.............................................. 01 0450 0450
010118.............................................. 01 5240 ..................
010120.............................................. 01 5160 ..................
010121.............................................. 01 5240 ..................
010126.............................................. 01 2180 ..................
010150.............................................. 01 5240 ..................
010158.............................................. 01 2030 ..................
020008.............................................. 02 0380 ..................
030007.............................................. 03 2620 ..................
030012.............................................. 03 6200 ..................
030033.............................................. 03 2620 ..................
030043.............................................. 03 8520 ..................
040014.............................................. 04 4400 ..................
040017.............................................. 04 26 ..................
040019.............................................. 04 4920 ..................
040020.............................................. 3700 4920 ..................
040026.............................................. 04 4400 ..................
040027.............................................. 04 7920 ..................
040041.............................................. 04 4400 ..................
040066.............................................. 04 4400 ..................
040069.............................................. 04 4920 ..................
040072.............................................. 04 4400 ..................
040076.............................................. 04 4400 ..................
040078.............................................. 04 4400 ..................
[[Page 27386]]
040080.............................................. 04 3700 ..................
040088.............................................. 04 7680 ..................
040091.............................................. 04 8360 ..................
040107.............................................. 04 8360 ..................
040119.............................................. 04 4400 ..................
050042.............................................. 05 6690 ..................
050045.............................................. 05 .................. 7320
050071.............................................. 7400 5775 ..................
050073.............................................. 8720 5775 ..................
050101.............................................. 8720 5775 ..................
050150.............................................. 05 6920 ..................
050174.............................................. 7500 8720 ..................
050228.............................................. 7360 5775 ..................
050230.............................................. 5945 4480 ..................
050236.............................................. 8735 .................. 4480
050236.............................................. 8735 4480 ..................
050251.............................................. 05 6720 ..................
050296.............................................. 05 7120 ..................
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 ..................
050668.............................................. 7360 5775 ..................
050686.............................................. 6780 5945 ..................
060001.............................................. 3060 2080 2080
060003.............................................. 1125 2080 2080
060013.............................................. 06 0200 ..................
060023.............................................. 2995 6520 ..................
060027.............................................. 1125 2080 2080
060044.............................................. 06 2080 ..................
060049.............................................. 06 2080 ..................
060057.............................................. 06 2995 ..................
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 0560 ..................
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 4900 ..................
100109.............................................. 10 5960 ..................
100150.............................................. 10 5000 ..................
100176.............................................. 8960 2710 ..................
100211.............................................. 8280 3980 ..................
100232.............................................. 10 5790 2900
100239.............................................. 8280 7510 ..................
100249.............................................. 10 8280 ..................
100268.............................................. 8960 2680 ..................
110001.............................................. 11 .................. 0520
[[Page 27387]]
110001.............................................. 11 0520 ..................
110002.............................................. 11 0520 ..................
110003.............................................. 11 3600 ..................
110016.............................................. 11 1800 ..................
110023.............................................. 11 0520 ..................
110025.............................................. 11 .................. 3600
110025.............................................. 11 3600 ..................
110029.............................................. 11 0520 ..................
110038.............................................. 11 10 ..................
110040.............................................. 11 0500 0500
110041.............................................. 11 0500 ..................
110050.............................................. 11 0520 ..................
110054.............................................. 11 0520 ..................
110074.............................................. 0500 .................. 0520
110075.............................................. 11 7520 ..................
110118.............................................. 11 0120 ..................
110122.............................................. 11 10 ..................
110150.............................................. 11 4680 ..................
110168.............................................. 11 0520 ..................
110187.............................................. 11 0520 ..................
110188.............................................. 11 0520 ..................
110189.............................................. 11 0520 ..................
110205.............................................. 11 0520 ..................
120028.............................................. 12 3320 ..................
130002.............................................. 13 6340 ..................
130003.............................................. 13 50 ..................
130011.............................................. 13 50 ..................
130018.............................................. 13 6340 ..................
130026.............................................. 13 6340 ..................
130028.............................................. 6340 7160 ..................
130049.............................................. 13 7840 ..................
130060.............................................. 13 1080 ..................
140014.............................................. 6120 1040 ..................
140015.............................................. 14 7040 ..................
140027.............................................. 14 1960 ..................
140031.............................................. 14 1400 ..................
140032.............................................. 14 7040 ..................
140034.............................................. 14 7040 7040
140040.............................................. 14 6120 ..................
140043.............................................. 14 6880 ..................
140046.............................................. 14 7040 ..................
140058.............................................. 14 7880 ..................
140064.............................................. 14 1960 ..................
140086.............................................. 14 7040 7040
140093.............................................. 14 1400 ..................
140102.............................................. 14 7880 7880
140110.............................................. 14 6120 ..................
140141.............................................. 14 7040 7040
140143.............................................. 14 6120 ..................
140160.............................................. 14 6880 ..................
140161.............................................. 14 1600 ..................
140164.............................................. 14 7040 ..................
140189.............................................. 14 1400 ..................
140230.............................................. 14 1400 1400
140234.............................................. 14 6120 ..................
140245.............................................. 14 .................. 7040
140271.............................................. 14 7800 7800
150002.............................................. 2960 1600 1600
150004.............................................. 2960 1600 1600
150006.............................................. 15 7800 ..................
150008.............................................. 2960 1600 1600
150011.............................................. 15 3480 3480
150015.............................................. 15 1600 1600
150027.............................................. 15 .................. 3480
150030.............................................. 15 3480 3480
150034.............................................. 2960 1600 1600
150036.............................................. 15 3850 ..................
150048.............................................. 15 3200 ..................
150051.............................................. 1020 .................. 3480
150062.............................................. 15 3480 3480
[[Page 27388]]
150065.............................................. 15 3480 ..................
150067.............................................. 15 .................. 3480
150069.............................................. 15 1640 1640
150076.............................................. 15 7800 ..................
150090.............................................. 2960 1600 1600
150096.............................................. 15 2330 ..................
150102.............................................. 15 7800 ..................
150105.............................................. 15 3480 ..................
150112.............................................. 15 3480 3480
150125.............................................. 2960 1600 1600
150126.............................................. 2960 1600 1600
150127.............................................. 15 3480 ..................
150132.............................................. 2960 1600 1600
150133.............................................. 15 2330 ..................
150146.............................................. 15 2330 ..................
150147.............................................. 2960 1600 1600
160001.............................................. 16 2120 ..................
160016.............................................. 16 2120 ..................
160026.............................................. 16 2120 ..................
160030.............................................. 16 2120 ..................
160037.............................................. 16 24 ..................
160057.............................................. 16 3500 ..................
160064.............................................. 16 24 ..................
160080.............................................. 16 6880 ..................
160088.............................................. 16 2120 ..................
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 ..................
170045.............................................. 17 8440 ..................
170058.............................................. 17 3710 ..................
170060.............................................. 17 28 ..................
170089.............................................. 17 0320 ..................
170094.............................................. 17 8440 ..................
170120.............................................. 17 3710 ..................
170131.............................................. 17 8440 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 ..................
180066.............................................. 18 5360 ..................
180069.............................................. 18 3400 ..................
180078.............................................. 18 3400 ..................
180102.............................................. 18 1660 ..................
180104.............................................. 18 1660 ..................
180116.............................................. 18 1660 ..................
180124.............................................. 18 5360 ..................
[[Page 27389]]
180125.............................................. 18 3400 ..................
180127.............................................. 18 4520 ..................
180132.............................................. 18 4280 ..................
180139.............................................. 18 4280 ..................
190001.............................................. 19 .................. 5560
190003.............................................. 19 3880 ..................
190010.............................................. 19 5560 ..................
190015.............................................. 19 5560 ..................
190025.............................................. 19 3880 ..................
190049.............................................. 19 .................. 5560
190054.............................................. 19 3880 ..................
190083.............................................. 19 5200 ..................
190086.............................................. 19 5200 ..................
190099.............................................. 19 3880 ..................
190106.............................................. 19 3880 ..................
190131.............................................. 19 5560 ..................
190218.............................................. 19 0220 ..................
200002.............................................. 20 6403 ..................
200020.............................................. 6403 1123 1123
200024.............................................. 4243 6403 ..................
200034.............................................. 4243 6403 ..................
200039.............................................. 20 6403 ..................
200040.............................................. 6403 .................. 1123
200050.............................................. 20 0733 ..................
200063.............................................. 20 6403 ..................
220060.............................................. 1123 0743 ..................
220077.............................................. 8003 3283 ..................
220123.............................................. 22 0743 ..................
230022.............................................. 23 0440 ..................
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 ..................
240011.............................................. 24 5120 5120
240013.............................................. 24 5120 ..................
240014.............................................. 24 5120 ..................
240016.............................................. 24 2520 ..................
240018.............................................. 24 .................. 5120
240023.............................................. 24 5120 ..................
240045.............................................. 24 2240 ..................
240052.............................................. 24 2520 ..................
240064.............................................. 24 2240 ..................
240069.............................................. 24 6820 ..................
240071.............................................. 24 .................. 5120
240072.............................................. 24 2240 ..................
240075.............................................. 24 6980 ..................
240088.............................................. 24 6980 ..................
240089.............................................. 24 5120 ..................
240100.............................................. 24 2985 ..................
240119.............................................. 24 2240 ..................
240121.............................................. 24 2240 ..................
240139.............................................. 24 5120 ..................
240142.............................................. 24 6980 ..................
240152.............................................. 24 5120 ..................
240187.............................................. 24 5120 ..................
250002.............................................. 25 2650 ..................
250004.............................................. 25 4920 ..................
[[Page 27390]]
250009.............................................. 25 3580 ..................
250025.............................................. 25 01 ..................
250030.............................................. 25 3560 ..................
250031.............................................. 25 3560 ..................
250034.............................................. 25 4920 ..................
250042.............................................. 25 4920 ..................
250058.............................................. 25 3285 ..................
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 7040 ..................
260034.............................................. 26 3760 ..................
260047.............................................. 26 1740 ..................
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 ..................
260164.............................................. 26 .................. 7040
260183.............................................. 26 7040 ..................
260186.............................................. 26 1740 ..................
270002.............................................. 27 0880 ..................
270003.............................................. 27 3040 ..................
270011.............................................. 27 3040 ..................
270017.............................................. 27 5140 ..................
270051.............................................. 27 5140 ..................
270057.............................................. 27 0880 ..................
270082.............................................. 27 3040 ..................
280009.............................................. 28 4360 ..................
280023.............................................. 28 4360 ..................
280032.............................................. 28 4360 ..................
280054.............................................. 28 4360 ..................
280058.............................................. 28 4360 ..................
280061.............................................. 28 53 ..................
280065.............................................. 28 3060 ..................
280077.............................................. 28 5920 ..................
280111.............................................. 28 5920 ..................
280125.............................................. 28 7720 ..................
290006.............................................. 29 6720 ..................
290008.............................................. 29 4120 ..................
300003.............................................. 30 1123 ..................
300005.............................................. 30 1123 ..................
300019.............................................. 30 1123 1123
300024.............................................. 30 .................. 1123
310001.............................................. 0875 5600 ..................
310002.............................................. 5640 5600 ..................
310003.............................................. 3640 5600 ..................
310015.............................................. 5640 0875 ..................
310021.............................................. 8480 5190 ..................
[[Page 27391]]
310031.............................................. 6160 5190 ..................
310032.............................................. 8760 6160 6160
310038.............................................. 5015 5600 ..................
310045.............................................. 0875 5600 ..................
310047.............................................. 0560 6160 ..................
310048.............................................. 5015 5640 ..................
310064.............................................. 0560 6160 ..................
310070.............................................. 5015 5600 ..................
310076.............................................. 5640 5600 ..................
310087.............................................. 8760 6160 ..................
310088.............................................. 0560 6160 ..................
310119.............................................. 5640 5600 ..................
320005.............................................. 32 0200 ..................
320006.............................................. 32 7490 ..................
320011.............................................. 32 7490 ..................
320013.............................................. 32 7490 ..................
320063.............................................. 32 5800 ..................
320065.............................................. 32 5800 ..................
330001.............................................. 5660 0875 0875
330004.............................................. 33 2281 ..................
330023.............................................. 2281 5660 5600
330027.............................................. 5380 5600 ..................
330084.............................................. 33 1303 ..................
330085.............................................. 33 8160 ..................
330103.............................................. 33 .................. 1280
330106.............................................. 5380 5600 ..................
330126.............................................. 5660 0875 0875
330135.............................................. 5660 0875 0875
330136.............................................. 33 8160 ..................
330157.............................................. 33 8160 ..................
330181.............................................. 5380 5600 ..................
330182.............................................. 5380 5600 ..................
330205.............................................. 5660 0875 0875
330209.............................................. 5660 0875 0875
330224.............................................. 33 3283 ..................
330235.............................................. 8160 .................. 6840
330239.............................................. 3610 2360 ..................
330250.............................................. 33 1303 ..................
330264.............................................. 5660 0875 0875
330307.............................................. 33 8160 ..................
330386.............................................. 33 5660 ..................
340003.............................................. 34 3120 ..................
340008.............................................. 34 2560 ..................
340010.............................................. 2980 6640 ..................
340013.............................................. 34 1520 ..................
340017.............................................. 34 0480 ..................
340021.............................................. 34 1520 ..................
340023.............................................. 34 0480 ..................
340027.............................................. 34 3150 ..................
340039.............................................. 34 .................. 1520
340050.............................................. 34 2560 ..................
340051.............................................. 34 3290 ..................
340052.............................................. 3120 1520 ..................
340064.............................................. 34 3120 ..................
340068.............................................. 34 9200 ..................
340071.............................................. 34 6640 6640
340088.............................................. 34 0480 ..................
340109.............................................. 34 5720 5720
340115.............................................. 34 6640 6640
340124.............................................. 34 6640 6640
340126.............................................. 34 6640 6640
340131.............................................. 34 3150 ..................
340143.............................................. 3290 1520 ..................
340147.............................................. 6895 6640 ..................
350003.............................................. 35 1010 ..................
350005.............................................. 35 2985 ..................
350006.............................................. 35 1010 ..................
350008.............................................. 35 1010 ..................
350009.............................................. 35 2520 ..................
350038.............................................. 35 2985 ..................
[[Page 27392]]
360002.............................................. 36 .................. 1680
360008.............................................. 36 3400 ..................
360010.............................................. 36 0080 ..................
360011.............................................. 36 1840 1840
360013.............................................. 36 2000 ..................
360014.............................................. 36 1840 ..................
360024.............................................. 36 1680 1680
360025.............................................. 36 1680 1680
360036.............................................. 36 0080 ..................
360037.............................................. 1680 0080 ..................
360039.............................................. 36 1840 1840
360046.............................................. 3200 .................. 1640
360054.............................................. 36 1480 ..................
360056.............................................. 3200 .................. 1640
360063.............................................. 36 1680 ..................
360065.............................................. 36 1680 1680
360071.............................................. 36 4320 4320
360076.............................................. 3200 .................. 1640
360078.............................................. 0080 1680 1680
360081.............................................. 8400 .................. 2160
360084.............................................. 1320 0080 ..................
360088.............................................. 36 1840 ..................
360090.............................................. 8400 .................. 2160
360092.............................................. 36 1840 1840
360095.............................................. 36 8400 ..................
360107.............................................. 36 8400 ..................
360109.............................................. 36 1840 1840
360112.............................................. 8400 0440 ..................
360121.............................................. 36 0440 ..................
360132.............................................. 3200 .................. 1640
360142.............................................. 36 .................. 1640
360144.............................................. 1680 0080 ..................
360150.............................................. 0080 .................. 1680
360159.............................................. 36 1840 ..................
360175.............................................. 36 3200 ..................
360186.............................................. 36 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 ..................
380002.............................................. 38 4890 ..................
380006.............................................. 38 .................. 6440
380022.............................................. 38 1890 ..................
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 ..................
[[Page 27393]]
390016.............................................. 39 6280 6280
390017.............................................. 39 6280 6280
390030.............................................. 39 6680 6680
390031.............................................. 39 6680 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 ..................
390163.............................................. 39 6280 ..................
390181.............................................. 39 6680 6680
390183.............................................. 39 6680 6680
390189.............................................. 39 3240 ..................
390197.............................................. 0240 6160 ..................
390201.............................................. 39 5640 5640
390263.............................................. 0240 6160 ..................
400018.............................................. 40 1310 ..................
410001.............................................. 6483 1123 1123
410004.............................................. 6483 1123 1123
410005.............................................. 6483 1123 1123
410006.............................................. 6483 1123 1123
410007.............................................. 6483 1123 1123
410008.............................................. 6483 1123 1123
410009.............................................. 6483 1123 1123
410010.............................................. 6483 1123 1123
410011.............................................. 6483 1123 1123
410012.............................................. 6483 1123 1123
410013.............................................. 6483 1123 1123
420020.............................................. 42 1440 ..................
420030.............................................. 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 ..................
430004.............................................. 43 6660 ..................
430008.............................................. 43 24 ..................
430012.............................................. 43 7760 ..................
430013.............................................. 43 7760 ..................
430014.............................................. 43 2520 ..................
430015.............................................. 43 6660 ..................
430047.............................................. 43 28 ..................
430048.............................................. 43 53 ..................
430089.............................................. 43 7720 ..................
440008.............................................. 44 3580 ..................
440020.............................................. 44 3440 ..................
440024.............................................. 44 1560 ..................
440050.............................................. 44 0480 ..................
440058.............................................. 44 1560 ..................
440059.............................................. 44 5360 ..................
440060.............................................. 44 3580 ..................
440067.............................................. 44 3840 ..................
440068.............................................. 44 3840 ..................
440072.............................................. 44 4920 ..................
440073.............................................. 44 5360 ..................
440148.............................................. 44 5360 ..................
440175.............................................. 44 3440 ..................
440180.............................................. 44 3840 ..................
440185.............................................. 44 1560 ..................
440186.............................................. 44 5360 ..................
[[Page 27394]]
440187.............................................. 44 18 ..................
440192.............................................. 44 5360 ..................
440200.............................................. 44 5360 ..................
440203.............................................. 44 1560 ..................
450007.............................................. 45 7240 ..................
450014.............................................. 45 8750 ..................
450080.............................................. 45 4420 ..................
450085.............................................. 45 9080 ..................
450098.............................................. 45 4420 ..................
450099.............................................. 45 0320 ..................
450140.............................................. 45 5800 ..................
450144.............................................. 45 5800 ..................
450146.............................................. 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 ..................
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 ..................
450623.............................................. 45 1920 ..................
450626.............................................. 45 8750 ..................
450653.............................................. 45 5800 ..................
450656.............................................. 45 8640 ..................
450694.............................................. 45 3360 ..................
450747.............................................. 45 1920 ..................
450755.............................................. 45 4600 ..................
450763.............................................. 45 0320 ..................
450770.............................................. 45 0640 ..................
460011.............................................. 46 6520 ..................
460021.............................................. 46 4120 ..................
460027.............................................. 46 6520 ..................
460032.............................................. 46 6520 ..................
460036.............................................. 46 6520 ..................
460039.............................................. 46 7160 ..................
470001.............................................. 47 30 ..................
470011.............................................. 47 1123 1123
470012.............................................. 47 6323 ..................
470018.............................................. 47 1123 1123
490001.............................................. 49 3660 ..................
490004.............................................. 49 1540 ..................
490005.............................................. 49 8840 ..................
490013.............................................. 49 4640 ..................
490018.............................................. 49 4640 ..................
490038.............................................. 49 3660 ..................
490047.............................................. 49 8840 ..................
490066.............................................. 5720 6760 ..................
490079.............................................. 49 3120 3120
490126.............................................. 49 6800 ..................
500002.............................................. 50 6740 ..................
500003.............................................. 50 7600 ..................
500007.............................................. 50 0860 ..................
500016.............................................. 50 7600 ..................
500031.............................................. 50 5910 ..................
500041.............................................. 50 6440 ..................
500059.............................................. 50 7600 ..................
[[Page 27395]]
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 ..................
520032.............................................. 52 4720 ..................
520037.............................................. 52 8940 ..................
520059.............................................. 6600 5080 5080
520066.............................................. 3620 4720 ..................
520071.............................................. 52 5080 5080
520076.............................................. 52 4720 ..................
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
530002.............................................. 53 1350 ..................
530008.............................................. 53 1350 ..................
530009.............................................. 53 1350 ..................
530015.............................................. 53 6340 ..................
530025.............................................. 53 2670 ..................
530032.............................................. 53 7160 ..................
----------------------------------------------------------------------------------------------------------------
Table 10.--Mean and Standard Deviation by Diagnosis-Related Groups
(DRGS)--FY 2004 \1\
------------------------------------------------------------------------
Mean + 1
DRG Cases standard
deviation
------------------------------------------------------------------------
1............................................. 23,157 $71,862
2............................................. 11,535 $41,916
3............................................. 3 $57,168
6............................................. 350 $15,743
7............................................. 14,489 $55,309
8............................................. 4,031 $33,403
9............................................. 1,677 $27,210
10............................................ 18,339 $25,124
11............................................ 3,244 $17,654
12............................................ 51,660 $17,776
13............................................ 6,919 $16,312
14............................................ 233,816 $24,738
15............................................ 92,167 $19,059
16............................................ 9,810 $25,016
17............................................ 2,700 $13,796
18............................................ 29,250 $20,071
19............................................ 8,385 $14,298
20............................................ 6,112 $57,114
21............................................ 1,869 $30,726
22............................................ 2,746 $21,754
23............................................ 11,062 $16,410
24............................................ 58,122 $19,963
25............................................ 26,945 $12,212
26............................................ 18 $22,836
27............................................ 4,348 $27,026
28............................................ 13,770 $26,999
29............................................ 5,226 $14,276
30............................................ 2 $19,365
31............................................ 3,834 $18,092
32............................................ 1,866 $11,256
34............................................ 23,474 $19,760
35............................................ 7,325 $12,760
36............................................ 2,079 $11,821
37............................................ 1,351 $21,123
38............................................ 94 $9,781
39............................................ 547 $12,494
40............................................ 1,508 $17,526
42............................................ 1,553 $14,008
43............................................ 93 $11,353
44............................................ 1,185 $13,306
45............................................ 2,622 $14,326
46............................................ 3,418 $16,038
47............................................ 1,373 $10,908
49............................................ 2,341 $34,744
50............................................ 2,385 $15,810
51............................................ 241 $16,991
52............................................ 216 $15,789
53............................................ 2,435 $23,943
55............................................ 1,458 $18,384
56............................................ 458 $16,976
[[Page 27396]]
57............................................ 700 $21,430
59............................................ 113 $16,063
61............................................ 249 $24,772
62............................................ 2 $20,652
63............................................ 2,964 $28,015
64............................................ 3,064 $27,189
65............................................ 39,700 $11,389
66............................................ 7,690 $11,535
67............................................ 379 $15,758
68............................................ 11,373 $12,869
69............................................ 3,665 $9,805
70............................................ 29 $6,582
71............................................ 79 $13,057
72............................................ 949 $13,674
73............................................ 7,561 $16,376
75............................................ 42,731 $60,129
76............................................ 43,909 $56,525
77............................................ 2,427 $23,987
78............................................ 38,870 $24,907
79............................................ 165,957 $32,680
80............................................ 7,866 $16,846
81............................................ 5 $20,229
82............................................ 63,317 $28,781
83............................................ 6,565 $19,177
84............................................ 1,552 $10,644
85............................................ 21,981 $24,242
86............................................ 2,201 $13,781
87............................................ 60,101 $27,456
88............................................ 396,200 $17,702
89............................................ 523,048 $20,511
90............................................ 47,344 $11,871
91............................................ 44 $14,737
92............................................ 15,549 $24,280
93............................................ 1,738 $14,448
94............................................ 12,597 $22,970
95............................................ 1,622 $12,263
96............................................ 55,628 $14,761
97............................................ 28,174 $10,803
98............................................ 9 $14,090
99............................................ 20,984 $13,983
100........................................... 8,129 $10,369
101........................................... 21,861 $17,290
102........................................... 5,503 $10,797
103........................................... 484 $378,244
104........................................... 20,223 $150,559
105........................................... 28,716 $108,046
106........................................... 3,432 $136,812
107........................................... 81,816 $99,133
108........................................... 6,341 $109,106
109........................................... 56,282 $73,253
110........................................... 53,777 $81,343
111........................................... 9,323 $49,746
113........................................... 39,244 $56,405
114........................................... 8,198 $33,220
115........................................... 19,499 $69,161
116........................................... 114,338 $44,903
117........................................... 4,622 $27,878
118........................................... 8,168 $31,457
119........................................... 1,211 $27,147
120........................................... 37,745 $46,550
121........................................... 161,616 $30,683
122........................................... 75,737 $19,715
123........................................... 38,021 $32,143
124........................................... 133,344 $27,371
125........................................... 90,371 $20,832
126........................................... 5,309 $51,405
127........................................... 663,251 $20,085
128........................................... 7,042 $14,239
129........................................... 3,774 $20,775
130........................................... 87,289 $18,660
131........................................... 26,583 $11,113
132........................................... 140,158 $12,462
133........................................... 8,475 $10,723
134........................................... 40,649 $11,970
135........................................... 7,697 $17,958
136........................................... 1,166 $11,432
138........................................... 204,872 $16,521
139........................................... 86,072 $10,173
140........................................... 54,193 $10,288
141........................................... 107,180 $14,813
142........................................... 51,782 $11,382
143........................................... 245,795 $10,741
144........................................... 93,108 $24,851
145........................................... 7,201 $11,714
146........................................... 10,627 $52,920
147........................................... 2,602 $29,373
148........................................... 132,078 $67,116
149........................................... 19,892 $27,061
150........................................... 20,888 $57,096
151........................................... 5,067 $25,243
152........................................... 4,490 $37,305
153........................................... 2,025 $21,509
154........................................... 27,969 $82,200
155........................................... 6,498 $25,001
156........................................... 4 $16,997
157........................................... 8,150 $25,875
158........................................... 4,273 $12,709
159........................................... 17,842 $26,972
160........................................... 11,973 $15,839
161........................................... 10,620 $22,659
162........................................... 6,290 $12,519
163........................................... 8 $9,397
164........................................... 5,322 $45,313
165........................................... 2,297 $22,967
166........................................... 4,142 $27,527
167........................................... 4,013 $16,618
168........................................... 1,406 $26,010
169........................................... 802 $14,782
170........................................... 15,473 $57,315
171........................................... 1,495 $23,568
172........................................... 30,878 $28,013
173........................................... 2,414 $15,971
174........................................... 247,933 $19,856
175........................................... 34,337 $11,032
176........................................... 13,301 $21,548
177........................................... 8,939 $18,108
178........................................... 3,315 $13,584
179........................................... 12,973 $21,773
180........................................... 88,999 $19,227
181........................................... 26,699 $10,651
182........................................... 268,140 $16,395
183........................................... 89,558 $11,492
184........................................... 69 $9,542
185........................................... 5,256 $17,532
186........................................... 6 $17,504
187........................................... 609 $15,462
188........................................... 82,829 $22,197
189........................................... 12,856 $12,176
190........................................... 75 $16,578
191........................................... 9,340 $88,382
192........................................... 1,299 $36,558
193........................................... 4,733 $68,254
194........................................... 638 $31,775
195........................................... 3,957 $59,356
196........................................... 969 $30,122
197........................................... 17,996 $50,435
198........................................... 5,289 $23,379
199........................................... 1,609 $48,963
200........................................... 1,069 $62,346
201........................................... 2,100 $75,551
202........................................... 26,307 $26,667
203........................................... 29,543 $28,095
204........................................... 64,510 $22,991
205........................................... 27,001 $24,271
206........................................... 2,015 $14,280
207........................................... 32,214 $22,980
208........................................... 9,967 $13,150
209........................................... 394,702 $35,979
210........................................... 121,348 $33,587
211........................................... 29,657 $22,493
212........................................... 9 $31,925
213........................................... 9,818 $37,689
216........................................... 8,691 $41,935
217........................................... 17,092 $61,011
218........................................... 23,524 $30,313
219........................................... 19,672 $19,359
223........................................... 13,125 $20,384
224........................................... 11,574 $14,926
225........................................... 6,390 $22,849
226........................................... 5,793 $30,350
227........................................... 4,783 $15,628
228........................................... 2,495 $22,908
229........................................... 1,245 $13,667
230........................................... 2,430 $25,765
232........................................... 809 $18,306
233........................................... 9,829 $40,036
234........................................... 5,300 $24,173
235........................................... 5,032 $14,695
236........................................... 39,468 $13,922
237........................................... 1,748 $11,857
238........................................... 8,729 $27,480
239........................................... 45,525 $20,661
240........................................... 11,846 $26,301
241........................................... 3,110 $12,646
242........................................... 2,542 $23,380
243........................................... 94,969 $15,031
244........................................... 14,423 $14,330
245........................................... 5,746 $9,757
246........................................... 1,473 $11,896
247........................................... 20,113 $11,410
248........................................... 13,674 $17,154
249........................................... 12,784 $13,336
250........................................... 3,727 $14,018
251........................................... 2,332 $9,097
253........................................... 21,753 $14,893
254........................................... 10,593 $8,759
256........................................... 6,586 $16,469
257........................................... 15,517 $16,712
258........................................... 15,055 $13,056
259........................................... 3,486 $17,996
260........................................... 4,160 $12,825
261........................................... 1,747 $17,565
262........................................... 653 $18,615
263........................................... 22,868 $41,675
264........................................... 3,819 $21,268
265........................................... 4,031 $31,156
266........................................... 2,516 $17,172
267........................................... 238 $20,021
268........................................... 895 $23,309
269........................................... 9,688 $35,630
270........................................... 2,743 $16,079
[[Page 27397]]
271........................................... 18,989 $20,610
272........................................... 5,658 $20,167
273........................................... 1,313 $12,601
274........................................... 2,264 $24,353
275........................................... 223 $12,616
276........................................... 1,304 $13,267
277........................................... 98,858 $17,235
278........................................... 31,750 $10,661
279........................................... 10 $15,979
280........................................... 17,551 $13,991
281........................................... 7,377 $9,589
283........................................... 5,976 $14,555
284........................................... 1,992 $8,504
285........................................... 6,869 $41,732
286........................................... 2,477 $39,318
287........................................... 6,166 $37,798
288........................................... 5,471 $41,746
289........................................... 6,830 $18,048
290........................................... 9,803 $16,847
291........................................... 58 $13,308
292........................................... 6,420 $55,995
293........................................... 356 $28,741
294........................................... 96,631 $15,356
295........................................... 3,475 $16,050
296........................................... 275,298 $17,000
297........................................... 47,552 $9,995
298........................................... 109 $9,503
299........................................... 1,253 $18,904
300........................................... 18,462 $22,372
301........................................... 3,554 $12,547
302........................................... 8,653 $61,825
303........................................... 21,521 $46,383
304........................................... 12,430 $47,807
305........................................... 3,009 $23,106
306........................................... 6,967 $24,014
307........................................... 1,983 $11,422
308........................................... 7,203 $31,717
309........................................... 4,094 $17,613
310........................................... 24,593 $22,507
311........................................... 7,407 $11,963
312........................................... 1,502 $21,429
313........................................... 547 $13,534
314........................................... 2 $815,660
315........................................... 33,535 $41,732
316........................................... 117,415 $26,424
317........................................... 1,994 $16,978
318........................................... 5,685 $24,541
319........................................... 403 $14,083
320........................................... 184,548 $17,149
321........................................... 30,606 $11,011
322........................................... 49 $9,127
323........................................... 19,641 $16,239
324........................................... 6,874 $9,611
325........................................... 9,136 $13,204
326........................................... 2,696 $8,569
327........................................... 7 $7,111
328........................................... 732 $15,295
329........................................... 93 $10,358
331........................................... 50,553 $21,469
332........................................... 4,905 $12,274
333........................................... 254 $19,142
334........................................... 10,300 $27,789
335........................................... 12,490 $19,981
336........................................... 35,495 $16,280
337........................................... 29,140 $10,776
338........................................... 929 $23,997
339........................................... 1,460 $22,362
341........................................... 3,545 $25,849
342........................................... 686 $14,916
344........................................... 3,549 $26,710
345........................................... 1,354 $22,352
346........................................... 4,775 $21,343
347........................................... 308 $11,845
348........................................... 3,361 $15,104
349........................................... 604 $9,831
350........................................... 6,602 $14,657
352........................................... 945 $14,499
353........................................... 2,491 $35,744
354........................................... 7,324 $28,230
355........................................... 5,481 $16,312
356........................................... 25,562 $14,230
357........................................... 5,570 $44,892
358........................................... 21,321 $22,339
359........................................... 31,420 $14,957
360........................................... 15,538 $16,445
361........................................... 339 $21,352
362........................................... 5 $16,578
363........................................... 2,471 $18,875
364........................................... 1,610 $18,054
365........................................... 1,815 $42,185
366........................................... 4,504 $25,764
367........................................... 477 $11,799
368........................................... 3,503 $23,599
369........................................... 3,419 $12,532
370........................................... 1,327 $18,299
371........................................... 1,662 $11,458
372........................................... 927 $10,237
373........................................... 4,076 $6,914
374........................................... 89 $13,913
376........................................... 316 $11,055
377........................................... 47 $21,747
378........................................... 171 $14,743
379........................................... 349 $7,238
380........................................... 98 $8,554
381........................................... 188 $10,611
382........................................... 48 $4,333
383........................................... 1,956 $10,030
384........................................... 129 $7,214
385........................................... 3 $34,210
389........................................... 12 $23,975
392........................................... 2,248 $66,268
394........................................... 2,567 $38,588
395........................................... 105,976 $16,486
396........................................... 17 $16,006
397........................................... 18,727 $25,519
398........................................... 17,860 $24,884
399........................................... 1,671 $13,548
401........................................... 5,768 $59,903
402........................................... 1,454 $22,863
403........................................... 31,365 $37,680
404........................................... 4,277 $18,437
406........................................... 2,391 $53,929
407........................................... 634 $24,003
408........................................... 2,081 $44,985
409........................................... 2,127 $25,574
410........................................... 28,001 $21,908
411........................................... 7 $7,483
412........................................... 15 $11,456
413........................................... 5,253 $27,415
414........................................... 622 $15,291
415........................................... 42,746 $75,112
416........................................... 189,451 $32,070
417........................................... 38 $22,076
418........................................... 25,456 $21,447
419........................................... 16,128 $17,016
420........................................... 3,139 $12,214
421........................................... 10,563 $14,503
422........................................... 66 $12,891
423........................................... 7,972 $36,726
424........................................... 1,224 $49,024
425........................................... 15,914 $13,506
426........................................... 4,462 $10,410
427........................................... 1,557 $10,483
428........................................... 782 $14,266
429........................................... 26,797 $15,953
430........................................... 64,123 $13,703
431........................................... 310 $12,670
432........................................... 443 $12,980
433........................................... 5,479 $5,805
439........................................... 1,493 $34,068
440........................................... 5,673 $36,892
441........................................... 668 $18,081
442........................................... 17,291 $48,763
443........................................... 3,848 $19,622
444........................................... 5,629 $14,813
445........................................... 2,485 $9,965
447........................................... 6,390 $10,119
449........................................... 32,589 $16,465
450........................................... 7,304 $8,328
452........................................... 25,308 $20,911
453........................................... 5,591 $10,522
454........................................... 4,691 $16,299
455........................................... 1,043 $9,576
461........................................... 5,133 $24,128
462........................................... 9,531 $19,503
463........................................... 26,512 $13,669
464........................................... 7,075 $9,864
465........................................... 192 $13,169
466........................................... 1,684 $14,122
467........................................... 1,106 $10,115
468........................................... 51,680 $77,692
470........................................... 52 $504,684
471........................................... 13,167 $54,184
473........................................... 7,976 $72,650
475........................................... 108,084 $75,747
476........................................... 3,608 $46,392
477........................................... 25,103 $37,665
478........................................... 106,238 $48,149
479........................................... 23,387 $27,938
480........................................... 610 $193,008
481........................................... 819 $122,102
482........................................... 5,175 $70,600
483........................................... 44,784 $328,441
484........................................... 334 $110,056
485........................................... 3,178 $61,849
486........................................... 2,077 $99,908
487........................................... 3,701 $40,225
488........................................... 760 $99,624
489........................................... 13,168 $37,620
490........................................... 5,356 $21,486
491........................................... 15,098 $31,213
492........................................... 3,052 $82,667
493........................................... 58,870 $35,610
494........................................... 28,431 $18,981
495........................................... 191 $165,379
496........................................... 2,444 $112,012
497........................................... 21,734 $66,414
498........................................... 15,556 $49,426
499........................................... 34,350 $27,633
500........................................... 49,302 $17,736
501........................................... 2,580 $51,260
[[Page 27398]]
502........................................... 761 $27,677
503........................................... 5,883 $24,011
504........................................... 125 $257,167
505........................................... 134 $36,044
506........................................... 916 $87,492
507........................................... 337 $37,309
508........................................... 612 $27,746
509........................................... 155 $13,241
510........................................... 1,625 $23,313
511........................................... 571 $13,248
512........................................... 481 $101,931
513........................................... 206 $107,611
515........................................... 8,028 $105,722
516........................................... 83,464 $45,394
517........................................... 194,015 $35,730
518........................................... 55,225 $36,574
519........................................... 8,892 $47,738
520........................................... 12,823 $29,760
521........................................... 30,454 $14,130
522........................................... 6,008 $10,049
523........................................... 15,103 $7,817
524........................................... 130,318 $14,293
525........................................... 562 $247,370
526........................................... 73,724 $42,080
527........................................... 194,015 $33,802
528........................................... 1,343 $140,528
529........................................... 4,633 $63,385
530........................................... 2,807 $24,282
531........................................... 3,766 $64,237
532........................................... 2,888 $30,290
533........................................... 42,601 $32,675
534........................................... 51,346 $20,340
535........................................... 5,896 $156,207
536........................................... 20,103 $118,567
537........................................... 6,765 $36,526
538........................................... 6,350 $19,355
539........................................... 4,388 $69,606
540........................................... 1,866 $25,633
------------------------------------------------------------------------
\1\ Cases are taken from the FY 2002 MedPAR file; DRGs are from GROUPER
V21.0.
Table 11.--Proposed LTC-DRGs Relative Weights and Geometric and Five-
Sixths of the Average Length of Stay--FY 2004
------------------------------------------------------------------------
5/6ths of
Geo-metric the
LTC-DRG Description Relative average average
weight length of length of
stay stay
------------------------------------------------------------------------
1 \5\ CRANIOTOMY AGE 17 W CC.
2 \8\ CRANIOTOMY AGE 17 W/O CC.
3 \8\ CRANIOTOMY AGE 0-17 1.9873 41.3 34.4
6 \8\ CARPAL TUNNEL 0.5711 20.8 17.3
RELEASE.
7 PERIPH & CRANIAL NERVE 1.5898 42.5 35.4
& OTHER NERV SYST PROC
W CC.
8 \4\ PERIPH & CRANIAL 1.4090 34.1 28.4
NERVE & OTHER NERV
SYST PROC W/O CC.
9 SPINAL DISORDERS & 1.5189 34.7 28.9
INJURIES.
10 NERVOUS SYSTEM 0.7590 23.4 19.5
NEOPLASMS W CC.
11 NERVOUS SYSTEM 0.7322 21.2 17.6
NEOPLASMS W/O CC.
12 DEGENERATIVE NERVOUS 0.7760 26.4 22.0
SYSTEM DISORDERS.
13 MULTIPLE SCLEROSIS & 0.8287 28.3 23.5
CEREBELLAR ATAXIA.
14 INTERCRANIAL HEMORRHAGE 0.9449 27.5 22.9
& STROKE W INFARCT.
15 NONSPECIFIC CVA & 0.9058 28.9 24.0
PRECEREBRAL OCCULUSION
W/O INFARCT.
16 NONSPECIFIC 0.9158 24.7 20.5
CEREBROVASCULAR
DISORDERS W CC.
17 NONSPECIFIC 0.5478 20.0 16.6
CEREBROVASCULAR
DISORDERS W/O CC.
18 CRANIAL & PERIPHERAL 0.8845 24.9 20.7
NERVE DISORDERS W CC.
19 CRANIAL & PERIPHERAL 0.6378 22.6 18.8
NERVE DISORDERS W/O CC.
20 NERVOUS SYSTEM 1.0135 25.1 20.9
INFECTION EXCEPT VIRAL
MENINGITIS.
21 \2\ VIRAL MENINGITIS... 0.7347 23.1 19.2
22 \2\ HYPERTENSIVE 0.7347 23.1 19.2
ENCEPHALOPATHY.
23 NONTRAUMATIC STUPOR & 1.0331 30.8 25.6
COMA.
24 SEIZURE & HEADACHE AGE 1.0059 28.1 23.4
17 W CC.
25 SEIZURE & HEADACHE AGE 0.8044 25.6 21.3
17 W/O CC.
26 \8\ SEIZURE & HEADACHE 0.7347 23.1 19.2
AGE 0-17.
27 TRAUMATIC STUPOR & 1.1071 28.8 24.0
COMA, COMA 1 HR.
28 TRAUMATIC STUPOR & 1.0527 29.2 24.3
COMA, COMA <1 HR AGE
17 W CC.
29 TRAUMATIC STUPOR & 0.9365 26.2 21.8
COMA, COMA <1 HR AGE
17 W/O CC.
30 \8\ TRAUMATIC STUPOR & 0.9785 27.4 22.8
COMA, COMA <1 HR AGE 0-
17.
31 \3\ CONCUSSION AGE 17 W CC.
32 \3\ CONCUSSION AGE 17 W/O CC.
33 \8\ CONCUSSION AGE 0-17 0.7347 23.1 19.2
34 OTHER DISORDERS OF 0.9885 28.5 23.7
NERVOUS SYSTEM W CC.
35 OTHER DISORDERS OF 0.7817 26.9 22.4
NERVOUS SYSTEM W/O CC.
36 \8\ RETINAL PROCEDURES. 0.5711 20.8 17.3
37 \8\ ORBITAL PROCEDURES. 0.5711 20.8 17.3
38 \8\ PRIMARY IRIS 0.5711 20.8 17.3
PROCEDURES.
39 \8\ LENS PROCEDURES 0.5711 20.8 17.3
WITH OR WITHOUT
VITRECTOMY.
40 \8\ EXTRAOCULAR 0.5711 20.8 17.3
PROCEDURES EXCEPT
ORBIT AGE 17.
41 \8\ EXTRAOCULAR 0.5711 20.8 17.3
PROCEDURES EXCEPT
ORBIT AGE 0-17.
42 \8\ INTRAOCULAR 0.5711 20.8 17.3
PROCEDURES EXCEPT
RETINA, IRIS & LENS.
43 \8\ HYPHEMA............ 0.5711 20.8 17.3
44 \1\ ACUTE MAJOR EYE 0.5711 20.8 17.3
INFECTIONS.
45 \8\ NEUROLOGICAL EYE 0.7347 23.1 19.2
DISORDERS.
46 \2\ OTHER DISORDERS OF 0.7347 23.1 19.2
THE EYE AGE 17 W CC.
[[Page 27399]]
47 \1\ OTHER DISORDERS OF 0.5711 20.8 17.3
THE EYE AGE 17 W/O CC.
48 \8\ OTHER DISORDERS OF 0.5711 20.8 17.3
THE EYE AGE 0-17.
49 \8\ MAJOR HEAD & NECK 1.4090 34.1 28.4
PROCEDURES.
50 \8\ SIALOADENECTOMY.... 0.9785 27.4 22.8
51 \8\ SALIVARY GLAND 0.9785 27.4 22.8
PROCEDURES EXCEPT
SIALOADENECTOMY.
52 \8\ CLEFT LIP & PALATE 0.9785 27.4 22.8
REPAIR.
53 \2\ SINUS & MASTOID 0.7347 23.1 19.2
PROCEDURES AGE 17.
54 \8\ SINUS & MASTOID 0.9785 27.4 22.8
PROCEDURES AGE 0-17.
55 \5\ MISCELLANEOUS EAR, 1.9873 41.3 34.4
NOSE, MOUTH & THROAT
PROCEDURES.
56 \8\ RHINOPLASTY........ 0.5711 20.8 17.3
57 \8\ T&A PROC, EXCEPT 0.9785 27.4 22.8
TONSILLECTOMY &/OR
ADENOIDECTOMY ONLY,
AGE 17.
58 \8\ T&A PROC, EXCEPT 0.9785 27.4 22.8
TONSILLECTOMY &/OR
ADENOIDECTOMY ONLY,
AGE 0-17.
59 \8\ TONSILLECTOMY &/OR 0.9785 27.4 22.8
ADENOIDECTOMY ONLY,
AGE 17.
60 \8\ TONSILLECTOMY &/OR 0.9785 27.4 22.8
ADENOIDECTOMY ONLY,
AGE 0-17.
61 \8\ MYRINGOTOMY W TUBE 1.4090 34.1 28.4
INSERTION AGE 17.
62 \8\ MYRINGOTOMY W TUBE 0.9785 27.4 22.8
INSERTION AGE 0-17.
63 \3\ OTHER EAR, NOSE, 0.9785 27.4 22.8
MOUTH & THROAT O.R.
PROCEDURES.
64 EAR, NOSE, MOUTH & 1.2957 27.9 23.2
THROAT MALIGNANCY.
65 \1\ DYSEQUILIBRIUM..... 0.5711 20.8 17.3
66 \1\ EPISTAXIS.......... 0.5711 20.8 17.3
67 \8\ EPIGLOTTITIS....... 0.9785 27.4 22.8
68 OTITIS MEDIA & URI AGE 0.8396 23.5 19.5
&17 W CC.
69 \1\ OTITIS MEDIA & URI 0.5711 20.8 17.3
AGE &17 W/O
CC.
70 \8\ OTITIS MEDIA & URI 0.5711 20.8 17.3
AGE 0-17.
71 \8\ LARYNGOTRACHEITIS.. 0.7347 23.1 19.2
72 \1\ NASAL TRAUMA & 0.5711 20.8 17.3
DEFORMITY.
73 OTHER EAR, NOSE, MOUTH 0.9506 23.7 19.7
& THROAT DIAGNOSES AGE
17.
74 \8\ OTHER EAR, NOSE, 0.5711 20.8 17.3
MOUTH & THROAT
DIAGNOSES AGE 0-17.
75 \5\ MAJOR CHEST 1.9873 41.3 34.4
PROCEDURES.
76 OTHER RESP SYSTEM O.R. 2.3848 42.2 35.1
PROCEDURES W CC.
77 \5\ OTHER RESP SYSTEM 1.9873 41.3 34.4
O.R. PROCEDURES W/O CC.
78 PULMONARY EMBOLISM..... 0.9226 24.8 20.6
79 RESPIRATORY INFECTIONS 0.9853 23.7 19.7
& INFLAMMATIONS AGE
17 W CC.
80 RESPIRATORY INFECTIONS 0.8550 22.8 19.0
& INFLAMMATIONS AGE
17 W/O CC.
81 \8\ RESPIRATORY 0.5711 20.8 17.3
INFECTIONS &
INFLAMMATIONS AGE 0-17.
82 RESPIRATORY NEOPLASMS.. 0.7759 20.4 17.0
83 \3\ MAJOR CHEST TRAUMA 0.9785 27.4 22.8
W CC.
84 \2\ MAJOR CHEST TRAUMA 0.7347 23.1 19.2
W/O CC.
85 PLEURAL EFFUSION W CC.. 0.9068 23.9 19.9
86 PLEURAL EFFUSION W/O CC 0.7121 24.9 20.7
87 PULMONARY EDEMA & 1.7382 32.9 27.4
RESPIRATORY FAILURE.
88 CHRONIC OBSTRUCTIVE 0.7996 21.0 17.5
PULMONARY DISEASE.
89 SIMPLE PNEUMONIA & 0.8676 22.9 19.0
PLEURISY AGE 17 W CC.
90 SIMPLE PNEUMONIA & 0.7429 21.7 18.0
PLEURISY AGE 17 W/O CC.
91 \8\ SIMPLE PNEUMONIA & 0.7347 23.1 19.2
PLEURISY AGE 0-17.
92 INTERSTITIAL LUNG 0.8403 21.8 18.1
DISEASE W CC.
93 INTERSTITIAL LUNG 0.7332 20.2 16.8
DISEASE W/O CC.
94 \7\ PNEUMOTHORAX W CC.. 0.7917 21.1 17.5
95 \7\ PNEUMOTHORAX W/O CC 0.7917 21.1 17.5
96 BRONCHITIS & ASTHMA AGE 0.7787 20.7 17.2
17 W CC.
97 BRONCHITIS & ASTHMA AGE 0.6616 22.5 18.7
17 W/O CC.
98 \8\ BRONCHITIS & ASTHMA 0.7347 23.1 19.2
AGE 0-17.
99 RESPIRATORY SIGNS & 1.0818 26.9 22.4
SYMPTOMS W CC.
100 RESPIRATORY SIGNS & 1.0374 26.0 21.6
SYMPTOMS W/O CC.
101 OTHER RESPIRATORY 1.0071 24.5 20.4
SYSTEM DIAGNOSES W CC.
102 OTHER RESPIRATORY 0.9460 24.2 20.1
SYSTEM DIAGNOSES W/O
CC.
103 \6\ HEART TRANSPLANT... 0.0000 0.0 0.0
104 \8\ CARDIAC VALVE & 1.9873 41.3 34.4
OTHER MAJOR
CARDIOTHORACIC PROC W
CARDIAC CATH.
105 \8\ CARDIAC VALVE & 1.9873 41.3 34.4
OTHER MAJOR
CARDIOTHORACIC PROC W/
O CARDIAC CATH.
106 \8\ CORONARY BYPASS W 1.9873 41.3 34.4
PTCA.
107 \8\ CORONARY BYPASS W 1.9873 41.3 34.4
CARDIAC CATH.
108 \5\ OTHER 1.9873 41.3 34.4
CARDIOTHORACIC
PROCEDURES.
109 \8\ CORONARY BYPASS W/O 1.9873 41.3 34.4
PTCA OR CARDIAC CATH.
110 \5\ MAJOR 1.9873 41.3 34.4
CARDIOVASCULAR
PROCEDURES W CC.
111 \8\ MAJOR 1.9873 41.3 34.4
CARDIOVASCULAR
PROCEDURES W/O CC.
113 AMPUTATION FOR CIRC 1.5870 40.5 33.7
SYSTEM DISORDERS
EXCEPT UPPER LIMB &
TOE.
114 UPPER LIMB & TOE 1.4854 39.9 33.2
AMPUTATION FOR CIRC
SYSTEM DISORDERS.
115 \5\ PRM CARD PACEM IMPL 1.9873 41.3 34.4
W AMI,HRT FAIL OR
SHK,OR AICD LEAD OR
GNRTR P.
[[Page 27400]]
116 \5\ OTH PERM CARD 1.9873 41.3 34.4
PACEMAK IMPL OR PTCA W
CORONARY ARTERY STENT
IMPLNT.
117 \3\ CARDIAC PACEMAKER 0.9785 27.4 22.8
REVISION EXCEPT DEVICE
REPLACEMENT.
118 \5\ CARDIAC PACEMAKER 1.9873 41.3 34.4
DEVICE REPLACEMENT.
119 \3\ VEIN LIGATION & 0.9785 27.4 22.8
STRIPPING.
120 OTHER CIRCULATORY 1.2476 34.1 28.4
SYSTEM O.R. PROCEDURES.
121 CIRCULATORY DISORDERS W 0.7531 21.9 18.2
AMI & MAJOR COMP,
DISCHARGED ALIVE.
122 CIRCULATORY DISORDERS W 0.6915 20.0 16.6
AMI W/O MAJOR COMP,
DISCHARGED ALIVE.
123 CIRCULATORY DISORDERS W 0.8856 19.0 15.8
AMI, EXPIRED.
124 \4\ CIRCULATORY 1.4090 34.1 28.4
DISORDERS EXCEPT AMI,
W CARD CATH & COMPLEX
DIAG.
125 \4\ CIRCULATORY 1.4090 34.1 28.4
DISORDERS EXCEPT AMI,
W CARD CATH W/O
COMPLEX DIAG.
126 ACUTE & SUBACUTE 0.8902 25.7 21.4
ENDOCARDITIS.
127 HEART FAILURE & SHOCK.. 0.7968 21.9 18.2
128 \1\ DEEP VEIN 0.5711 20.8 17.3
THROMBOPHLEBITIS.
129 CARDIAC ARREST, 1.4170 28.5 23.7
UNEXPLAINED.
130 PERIPHERAL VASCULAR 0.8207 25.0 20.8
DISORDERS W CC.
131 PERIPHERAL VASCULAR 0.6269 22.4 18.6
DISORDERS W/O CC.
132 ATHEROSCLEROSIS W CC... 0.8211 22.5 18.7
133 ATHEROSCLEROSIS W/O CC. 0.7264 22.6 18.8
134 HYPERTENSION........... 0.8971 28.4 23.6
135 CARDIAC CONGENITAL & 0.9873 23.8 19.8
VALVULAR DISORDERS AGE
17 W CC.
136 CARDIAC CONGENITAL & 0.7492 22.9 19.0
VALVULAR DISORDERS AGE
17 W/O CC.
137 \8\ CARDIAC CONGENITAL 0.7347 23.1 19.2
& VALVULAR DISORDERS
AGE 0-17.
138 CARDIAC ARRHYTHMIA & 0.9390 25.2 21.0
CONDUCTION DISORDERS W
CC.
139 CARDIAC ARRHYTHMIA & 0.6224 21.9 18.2
CONDUCTION DISORDERS W/
O CC.
140 ANGINA PECTORIS........ 0.6056 19.3 16.0
141 SYNCOPE & COLLAPSE W CC 0.6735 23.3 19.4
142 SYNCOPE & COLLAPSE W/O 0.5149 20.5 17.0
CC.
143 CHEST PAIN............. 0.7317 21.9 18.2
144 OTHER CIRCULATORY 0.8588 22.9 19.0
SYSTEM DIAGNOSES W CC.
145 OTHER CIRCULATORY 0.7001 21.4 17.8
SYSTEM DIAGNOSES W/O
CC.
146 \8\ RECTAL RESECTION W 1.9873 41.3 34.4
CC.
147 \8\ RECTAL RESECTION W/ 1.9873 41.3 34.4
O CC.
148 MAJOR SMALL & LARGE 1.9660 36.8 30.6
BOWEL PROCEDURES W CC.
149 \1\ MAJOR SMALL & LARGE 0.5711 20.8 17.3
BOWEL PROCEDURES W/O
CC.
150 \4\ PERITONEAL 1.4090 34.1 28.4
ADHESIOLYSIS W CC.
151 \8\ PERITONEAL 1.4090 34.1 28.4
ADHESIOLYSIS W/O CC.
152 \4\ MINOR SMALL & LARGE 1.4090 34.1 28.4
BOWEL PROCEDURES W CC.
153 \8\ MINOR SMALL & LARGE 1.4090 34.1 28.4
BOWEL PROCEDURES W/O
CC.
154 \5\ STOMACH, ESOPHAGEAL 1.9873 41.3 34.4
& DUODENAL PROCEDURES
AGE 17 W CC.
155 \8\ STOMACH, ESOPHAGEAL 1.9873 41.3 34.4
& DUODENAL PROCEDURES
AGE 17 W/O
CC.
156 \8\ STOMACH, ESOPHAGEAL 1.9873 41.3 34.4
& DUODENAL PROCEDURES
AGE 0-17.
157 \8\ ANAL & STOMAL 1.4090 34.1 28.4
PROCEDURES W CC.
158 \3\ ANAL & STOMAL 0.9785 27.4 22.8
PROCEDURES W/O CC.
159 \8\ HERNIA PROCEDURES 1.4090 34.1 28.4
EXCEPT INGUINAL &
FEMORAL AGE 17 W CC.
160 \8\ HERNIA PROCEDURES 1.4090 34.1 28.4
EXCEPT INGUINAL &
FEMORAL AGE 17 W/O CC.
161 \4\ INGUINAL & FEMORAL 1.4090 34.1 28.4
HERNIA PROCEDURES AGE
17 W CC.
162 \8\ INGUINAL & FEMORAL 0.5711 20.8 17.3
HERNIA PROCEDURES AGE
17 W/O CC.
163 \8\ HERNIA PROCEDURES 0.5711 20.8 17.3
AGE 0-17.
164 \8\ APPENDECTOMY W 1.9873 41.3 34.4
COMPLICATED PRINCIPAL
DIAG W CC.
165 \8\ APPENDECTOMY W 0.5711 20.8 17.3
COMPLICATED PRINCIPAL
DIAG W/O CC.
166 \8\ APPENDECTOMY W/O 1.9873 41.3 34.4
COMPLICATED PRINCIPAL
DIAG W CC.
167 \8\ APPENDECTOMY W/O 0.5711 20.8 17.3
COMPLICATED PRINCIPAL
DIAG W/O CC.
168 \5\ MOUTH PROCEDURES W 1.9873 41.3 34.4
CC.
169 \8\ MOUTH PROCEDURES W/ 0.5711 20.8 17.3
O CC.
170 \7\ OTHER DIGESTIVE 1.7827 42.2 35.1
SYSTEM O.R. PROCEDURES
W CC.
171 \7\ OTHER DIGESTIVE 1.7827 42.2 35.1
SYSTEM O.R. PROCEDURES
W/O CC.
172 DIGESTIVE MALIGNANCY W 0.8857 22.4 18.6
CC.
173 DIGESTIVE MALIGNANCY W/ 0.7843 21.9 18.2
O CC.
174 G.I. HEMORRHAGE W CC... 0.8741 24.8 20.6
175 G.I. HEMORRHAGE W/O CC. 0.6770 21.8 18.1
176 COMPLICATED PEPTIC 0.7835 20.6 17.1
ULCER.
177 \2\ UNCOMPLICATED 0.7347 23.1 19.2
PEPTIC ULCER W CC.
178 \1\ UNCOMPLICATED 0.5711 20.8 17.3
PEPTIC ULCER W/O CC.
179 INFLAMMATORY BOWEL 1.0317 26.2 21.8
DISEASE.
180 G.I. OBSTRUCTION W CC.. 0.9491 24.2 20.1
181 G.I. OBSTRUCTION W/O CC 0.7694 21.2 17.6
182 ESOPHAGITIS, GASTROENT 0.9666 25.5 21.2
& MISC DIGEST
DISORDERS AGE 17 W CC.
183 ESOPHAGITIS, GASTROENT 0.7038 22.4 18.6
& MISC DIGEST
DISORDERS AGE 17 W/O CC.
[[Page 27401]]
184 \8\ ESOPHAGITIS, 0.7347 23.1 19.2
GASTROENT & MISC
DIGEST DISORDERS AGE 0-
17.
185 DENTAL & ORAL DIS 0.6932 24.6 20.5
EXCEPT EXTRACTIONS &
RESTORATIONS, AGE 17.
186 \8\ DENTAL & ORAL DIS 0.7347 23.1 19.2
EXCEPT EXTRACTIONS &
RESTORATIONS, AGE 0-17.
187 \8\ DENTAL EXTRACTIONS 0.7347 23.1 19.2
& RESTORATIONS.
188 OTHER DIGESTIVE SYSTEM 1.0481 26.0 21.6
DIAGNOSES AGE 17 W CC.
189 OTHER DIGESTIVE SYSTEM 0.8501 23.5 19.5
DIAGNOSES AGE 17 W/O CC.
190 \8\ OTHER DIGESTIVE 0.7347 23.1 19.2
SYSTEM DIAGNOSES AGE 0-
17.
191 \4\ PANCREAS, LIVER & 1.4090 34.1 28.4
SHUNT PROCEDURES W CC.
192 \1\ PANCREAS, LIVER & 0.5711 20.8 17.3
SHUNT PROCEDURES W/O
CC.
193 \2\ BILIARY TRACT PROC 0.7347 23.1 19.2
EXCEPT ONLY CHOLECYST
W OR W/O C.D.E. W CC.
194 \2\ BILIARY TRACT PROC 0.7347 23.1 19.2
EXCEPT ONLY CHOLECYST
W OR W/O C.D.E. W/O CC.
195 \4\ CHOLECYSTECTOMY W 1.4090 34.1 28.4
C.D.E. W CC.
196 \8\ CHOLECYSTECTOMY W 0.9785 27.4 22.8
C.D.E. W/O CC.
197 \3\ CHOLECYSTECTOMY 0.9785 27.4 22.8
EXCEPT BY LAPAROSCOPE
W/O C.D.E. W CC.
198 \8\ CHOLECYSTECTOMY 0.9785 27.4 22.8
EXCEPT BY LAPAROSCOPE
W/O C.D.E. W/O CC.
199 \8\ HEPATOBILIARY 0.7347 23.1 19.2
DIAGNOSTIC PROCEDURE
FOR MALIGNANCY.
200 \2\ HEPATOBILIARY 0.7347 23.1 19.2
DIAGNOSTIC PROCEDURE
FOR NON-MALIGNANCY.
201 \5\ OTHER HEPATOBILIARY 1.9873 41.3 34.4
OR PANCREAS O.R.
PROCEDURES.
202 CIRRHOSIS & ALCOHOLIC 0.7529 22.7 18.9
HEPATITIS.
203 MALIGNANCY OF 0.6801 19.2 16.0
HEPATOBILIARY SYSTEM
OR PANCREAS.
204 DISORDERS OF PANCREAS 1.0141 23.4 19.5
EXCEPT MALIGNANCY.
205 DISORDERS OF LIVER 0.7334 22.3 18.5
EXCEPT MALIG,CIRR,ALC
HEPA W CC.
206 \2\ DISORDERS OF LIVER 0.7347 23.1 19.2
EXCEPT MALIG,CIRR,ALC
HEPA W/O CC.
207 DISORDERS OF THE 0.7940 22.1 18.4
BILIARY TRACT W CC.
208 \2\ DISORDERS OF THE 0.7347 23.1 19.2
BILIARY TRACT W/O CC.
209 \5\ MAJOR JOINT & LIMB 1.9873 41.3 34.4
REATTACHMENT
PROCEDURES OF LOWER
EXTREMITY.
210 \4\ HIP & FEMUR 1.4090 34.1 28.4
PROCEDURES EXCEPT
MAJOR JOINT AGE 17 W CC.
211 \2\ HIP & FEMUR 0.7347 23.1 19.2
PROCEDURES EXCEPT
MAJOR JOINT AGE 17 W/O CC.
212 \8\ HIP & FEMUR 0.7347 23.1 19.2
PROCEDURES EXCEPT
MAJOR JOINT AGE 0-17.
213 AMPUTATION FOR 1.3912 34.9 29.0
MUSCULOSKELETAL SYSTEM
& CONN TISSUE
DISORDERS.
216 \5\ BIOPSIES OF 1.9873 41.3 34.4
MUSCULOSKELETAL SYSTEM
& CONNECTIVE TISSUE.
217 WND DEBRID & SKN GRFT 1.4438 39.3 32.7
EXCEPT HAND,FOR
MUSCSKELET & CONN TISS
DIS.
218 \3\ LOWER EXTREM & 0.9785 27.4 22.8
HUMER PROC EXCEPT
HIP,FOOT,FEMUR AGE 17 W CC.
219 \8\ LOWER EXTREM & 0.9785 27.4 22.8
HUMER PROC EXCEPT
HIP,FOOT,FEMUR AGE 17 W/O CC.
220 \8\ LOWER EXTREM & 0.9785 27.4 22.8
HUMER PROC EXCEPT
HIP,FOOT,FEMUR AGE 0-
17.
223 \3\ MAJOR SHOULDER/ 0.9785 27.4 22.8
ELBOW PROC, OR OTHER
UPPER EXTREMITY PROC W
CC.
224 \8\ SHOULDER,ELBOW OR 0.7347 23.1 19.2
FOREARM PROC,EXC MAJOR
JOINT PROC, W/O CC.
225 FOOT PROCEDURES........ 0.8912 26.7 22.2
226 \4\ SOFT TISSUE 1.4090 34.1 28.4
PROCEDURES W CC.
227 \3\ SOFT TISSUE 0.9785 27.4 22.8
PROCEDURES W/O CC.
228 \3\ MAJOR THUMB OR 0.9785 27.4 22.8
JOINT PROC,OR OTH HAND
OR WRIST PROC W CC.
229 \8\ HAND OR WRIST PROC, 0.7347 23.1 19.2
EXCEPT MAJOR JOINT
PROC, W/O CC.
230 \4\ LOCAL EXCISION & 1.4090 34.1 28.4
REMOVAL OF INT FIX
DEVICES OF HIP & FEMUR.
232 \2\ ARTHROSCOPY........ 0.7347 23.1 19.2
233 OTHER MUSCULOSKELET SYS 0.9797 28.5 23.7
& CONN TISS O.R. PROC
W CC.
234 \2\ OTHER MUSCULOSKELET 0.7347 23.1 19.2
SYS & CONN TISS O.R.
PROC W/O CC.
235 FRACTURES OF FEMUR..... 0.8715 29.7 24.7
236 FRACTURES OF HIP & 0.7598 27.2 22.6
PELVIS.
237 \2\ SPRAINS, STRAINS, & 0.7347 23.1 19.2
DISLOCATIONS OF HIP,
PELVIS & THIGH.
238 OSTEOMYELITIS.......... 0.8818 28.5 23.7
239 PATHOLOGICAL FRACTURES 0.6892 22.4 18.6
& MUSCULOSKELETAL &
CONN TISS MALIGNANCY.
240 CONNECTIVE TISSUE 0.7118 21.4 17.8
DISORDERS W CC.
241 CONNECTIVE TISSUE 0.4744 19.4 16.1
DISORDERS W/O CC.
242 SEPTIC ARTHRITIS....... 0.7814 26.2 21.8
243 MEDICAL BACK PROBLEMS.. 0.6867 23.5 19.5
244 BONE DISEASES & 0.5664 20.1 16.7
SPECIFIC ARTHROPATHIES
W CC.
245 BONE DISEASES & 0.5134 19.5 16.2
SPECIFIC ARTHROPATHIES
W/O CC.
246 NON-SPECIFIC 0.5556 23.0 19.1
ARTHROPATHIES.
247 SIGNS & SYMPTOMS OF 0.5976 21.4 17.8
MUSCULOSKELETAL SYSTEM
& CONN TISSUE.
248 TENDONITIS, MYOSITIS & 0.7623 24.9 20.7
BURSITIS.
249 AFTERCARE, 0.8101 27.3 22.7
MUSCULOSKELETAL SYSTEM
& CONNECTIVE TISSUE.
250 FX, SPRN, STRN & DISL 0.8309 30.1 25.0
OF FOREARM, HAND, FOOT
AGE 17 W CC.
251 FX, SPRN, STRN & DISL 0.6031 26.7 22.2
OF FOREARM, HAND, FOOT
AGE 17 W/O
CC.
252 \8\ FX, SPRN, STRN & 0.7347 23.1 19.2
DISL OF FOREARM, HAND,
FOOT AGE 0-17.
253 FX, SPRN, STRN & DISL 0.8406 27.1 22.5
OF UPARM,LOWLEG EX
FOOT AGE 17
W CC.
254 FX, SPRN, STRN & DISL 0.7028 25.8 21.5
OF UPARM,LOWLEG EX
FOOT AGE 17
W/O CC.
255 \8\ FX, SPRN, STRN & 0.7347 23.1 19.2
DISL OF UPARM,LOWLEG
EX FOOT AGE 0-17.
256 OTHER MUSCULOSKELETAL 0.8577 26.6 22.1
SYSTEM & CONNECTIVE
TISSUE DIAGNOSES.
[[Page 27402]]
257 \3\ TOTAL MASTECTOMY 0.9785 27.4 22.8
FOR MALIGNANCY W CC.
258 \8\ TOTAL MASTECTOMY 0.9785 27.4 22.8
FOR MALIGNANCY W/O CC.
259 \8\ SUBTOTAL MASTECTOMY 0.9785 27.4 22.8
FOR MALIGNANCY W CC.
260 \8\ SUBTOTAL MASTECTOMY 0.9785 27.4 22.8
FOR MALIGNANCY W/O CC.
261 \5\ BREAST PROC FOR NON- 1.9873 41.3 34.4
MALIGNANCY EXCEPT
BIOPSY & LOCAL
EXCISION.
262 \1\ BREAST BIOPSY & 0.5711 20.8 17.3
LOCAL EXCISION FOR NON-
MALIGNANCY.
263 SKIN GRAFT &/OR DEBRID 1.4696 41.1 34.2
FOR SKN ULCER OR
CELLULITIS W CC.
264 SKIN GRAFT &/OR DEBRID 1.2160 39.9 33.2
FOR SKN ULCER OR
CELLULITIS W/O CC.
265 \7\ SKIN GRAFT &/OR 1.2294 34.7 28.9
DEBRID EXCEPT FOR SKIN
ULCER OR CELLULITIS W
CC.
266 \7\ SKIN GRAFT &/OR 1.2294 34.7 28.9
DEBRID EXCEPT FOR SKIN
ULCER OR CELLULITIS W/
O CC.
267 \8\ PERIANAL & 0.5711 20.8 17.3
PILONIDAL PROCEDURES.
268 \4\ SKIN, SUBCUTANEOUS 1.4090 34.1 28.4
TISSUE & BREAST
PLASTIC PROCEDURES.
269 OTHER SKIN, SUBCUT TISS 1.5232 45.2 37.6
& BREAST PROC W CC.
270 OTHER SKIN, SUBCUT TISS 1.0105 35.9 29.9
& BREAST PROC W/O CC.
271 SKIN ULCERS............ 0.9795 29.9 24.9
272 MAJOR SKIN DISORDERS W 0.7163 22.7 18.9
CC.
273 \1\ MAJOR SKIN 0.5711 20.8 17.3
DISORDERS W/O CC.
274 MALIGNANT BREAST 0.9469 24.9 20.7
DISORDERS W CC.
275 \2\ MALIGNANT BREAST 0.7347 23.1 19.2
DISORDERS W/O CC.
276 \1\ NON-MALIGANT BREAST 0.5711 20.8 17.3
DISORDERS.
277 CELLULITIS AGE 17 W CC.
278 CELLULITIS AGE 17 W/O CC.
279 CELLULITIS AGE 0-178... 0.5711 20.8 17.3
280 TRAUMA TO THE SKIN, 0.9719 29.3 24.4
SUBCUT TISS & BREAST
AGE 17 W CC.
281 TRAUMA TO THE SKIN, 0.7915 27.8 23.1
SUBCUT TISS & BREAST
AGE 17 W/O
CC.
282 \8\ TRAUMA TO THE SKIN, 0.7347 23.1 19.2
SUBCUT TISS & BREAST
AGE 0-17.
283 MINOR SKIN DISORDERS W 0.6998 20.7 17.2
CC.
284 MINOR SKIN DISORDERS W/ 0.6259 23.0 19.1
O CC.
285 AMPUTAT OF LOWER LIMB 1.5856 38.6 32.1
FOR ENDOCRINE,NUTRIT,&
METABOL DISORDERS.
286 ADRENAL & PITUITARY 1.4090 34.1 28.4
PROCEDURES8.
287 SKIN GRAFTS & WOUND 1.4793 41.7 34.7
DEBRID FOR ENDOC,
NUTRIT & METAB
DISORDERS.
288 \5\ O.R. PROCEDURES FOR 1.9873 41.3 34.4
OBESITY.
289 \8\ PARATHYROID 0.9785 27.4 22.8
PROCEDURES.
290 \8\ THYROID PROCEDURES. 0.9785 27.4 22.8
291 \8\ THYROGLOSSAL 0.9785 27.4 22.8
PROCEDURES.
292 OTHER ENDOCRINE, NUTRIT 1.5633 35.8 29.8
& METAB O.R. PROC W CC.
293 \3\ OTHER ENDOCRINE, 0.9785 27.4 22.8
NUTRIT & METAB O.R.
PROC W/O CC.
294 DIABETES AGE 35.
295 \3\ DIABETES AGE 0-35.. 0.9785 27.4 22.8
296 NUTRITIONAL & MISC 0.9560 26.3 21.9
METABOLIC DISORDERS
AGE 17 W CC.
297 NUTRITIONAL & MISC 0.7552 26.4 22.0
METABOLIC DISORDERS
AGE 17 W/O
CC.
298 \8\ NUTRITIONAL & MISC 0.7347 23.1 19.2
METABOLIC DISORDERS
AGE 0-17.
299 \2\ INBORN ERRORS OF 0.7347 23.1 19.2
METABOLISM.
300 ENDOCRINE DISORDERS W 0.8175 23.9 19.9
CC.
301 ENDOCRINE DISORDERS W/O 0.7287 22.9 19.0
CC.
302 \6\ KIDNEY TRANSPLANT.. 0.0000 0.0 0.0
303 \8\ KIDNEY,URETER & 1.9873 41.3 34.4
MAJOR BLADDER
PROCEDURES FOR
NEOPLASM.
304 \5\ KIDNEY,URETER & 1.9873 41.3 34.4
MAJOR BLADDER PROC FOR
NON-NEOPL W CC.
305 \1\ KIDNEY,URETER & 0.5711 20.8 17.3
MAJOR BLADDER PROC FOR
NON-NEOPL W/O CC.
306 \4\ PROSTATECTOMY W CC. 1.4090 34.1 28.4
307 \8\ PROSTATECTOMY W/O 1.4090 34.1 28.4
CC.
308 \4\ MINOR BLADDER 1.4090 34.1 28.4
PROCEDURES W CC.
309 \2\ MINOR BLADDER 0.7347 23.1 19.2
PROCEDURES W/O CC.
310 \4\ TRANSURETHRAL 1.4090 34.1 28.4
PROCEDURES W CC.
311 \1\ TRANSURETHRAL 0.5711 20.8 17.3
PROCEDURES W/O CC.
312 \4\ URETHRAL 1.4090 34.1 28.4
PROCEDURES, AGE 17 W CC.
313 \8\ URETHRAL 0.5711 20.8 17.3
PROCEDURES, AGE 17 W/O CC.
314 \8\ URETHRAL 0.5711 20.8 17.3
PROCEDURES, AGE 0-17.
315 OTHER KIDNEY & URINARY 1.5690 36.4 30.3
TRACT O.R. PROCEDURES.
316 RENAL FAILURE.......... 0.9869 24.5 20.4
317 \3\ ADMIT FOR RENAL 0.9785 27.4 22.8
DIALYSIS.
318 KIDNEY & URINARY TRACT 0.7466 21.7 18.0
NEOPLASMS W CC.
319 \1\ KIDNEY & URINARY 0.5711 20.8 17.3
TRACT NEOPLASMS W/O CC.
320 KIDNEY & URINARY TRACT 0.7744 23.5 19.5
INFECTIONS AGE 17 W CC.
321 KIDNEY & URINARY TRACT 0.6641 23.0 19.1
INFECTIONS AGE 17 W/O CC.
322 \8\ KIDNEY & URINARY 0.7347 23.1 19.2
TRACT INFECTIONS AGE 0-
17.
323 \2\ URINARY STONES W 0.7347 23.1 19.2
CC, &/OR ESW
LITHOTRIPSY.
324 \2\ URINARY STONES W/O 0.7347 23.1 19.2
CC.
[[Page 27403]]
325 KIDNEY & URINARY TRACT 0.8854 27.2 22.6
SIGNS & SYMPTOMS AGE
17 W CC.
326 KIDNEY & URINARY TRACT 0.7590 24.7 20.5
SIGNS & SYMPTOMS AGE
17 W/O CC.
327 \8\ KIDNEY & URINARY 0.7347 23.1 19.2
TRACT SIGNS & SYMPTOMS
AGE 0-17.
328 \1\ URETHRAL STRICTURE 0.5711 20.8 17.3
AGE 17 W CC.
329 \8\ URETHRAL STRICTURE 0.5711 20.8 17.3
AGE 17 W/O
CC.
330 \8\ URETHRAL STRICTURE 0.5711 20.8 17.3
AGE 0-17.
331 OTHER KIDNEY & URINARY 0.8847 23.8 19.8
TRACT DIAGNOSES AGE
17 W CC.
332 OTHER KIDNEY & URINARY 0.6201 22.1 18.4
TRACT DIAGNOSES AGE
17 W/O CC.
333 \8\ OTHER KIDNEY & 0.5711 20.8 17.3
URINARY TRACT
DIAGNOSES AGE 0-17.
334 \8\ MAJOR MALE PELVIC 0.9785 27.4 22.8
PROCEDURES W CC.
335 \8\ MAJOR MALE PELVIC 0.9785 27.4 22.8
PROCEDURES W/O CC.
336 \8\ TRANSURETHRAL 0.7347 23.1 19.2
PROSTATECTOMY W CC.
337 \8\ TRANSURETHRAL 0.7347 23.1 19.2
PROSTATECTOMY W/O CC.
338 \8\ TESTES PROCEDURES, 0.5711 20.8 17.3
FOR MALIGNANCY.
339 \1\ TESTES PROCEDURES, 0.5711 20.8 17.3
NON-MALIGNANCY AGE 17.
340 \8\ TESTES PROCEDURES, 0.5711 20.8 17.3
NON-MALIGNANCY AGE 0-
17.
341 \2\ PENIS PROCEDURES... 0.7347 23.1 19.2
342 \1\ CIRCUMCISION AGE 0.5711 20.8 17.3
17.
343 \8\ CIRCUMCISION AGE 0- 0.5711 20.8 17.3
17.
344 \2\ OTHER MALE 0.7347 23.1 19.2
REPRODUCTIVE SYSTEM
O.R. PROCEDURES FOR
MALIGNANCY.
345 \3\ OTHER MALE 0.9785 27.4 22.8
REPRODUCTIVE SYSTEM
O.R. PROC EXCEPT FOR
MALIGNANCY.
346 \7\ MALIGNANCY, MALE 0.7787 22.3 18.5
REPRODUCTIVE SYSTEM, W
CC.
347 \7\ MALIGNANCY, MALE 0.7787 22.3 18.5
REPRODUCTIVE SYSTEM, W/
O CC.
348 \1\ BENIGN PROSTATIC 0.5711 20.8 17.3
HYPERTROPHY W CC.
349 \1\ BENIGN PROSTATIC 0.5711 20.8 17.3
HYPERTROPHY W/O CC.
350 INFLAMMATION OF THE 1.1947 25.6 21.3
MALE REPRODUCTIVE
SYSTEM.
351 \8\ STERILIZATION, MALE 0.5711 20.8 17.3
352 \3\ OTHER MALE 0.9785 27.4 22.8
REPRODUCTIVE SYSTEM
DIAGNOSES.
353 \8\ PELVIC 1.9873 41.3 34.4
EVISCERATION, RADICAL
HYSTERECTOMY & RADICAL
VULVECTOMY.
354 \8\ UTERINE,ADNEXA PROC 1.9873 41.3 34.4
FOR NON-OVARIAN/
ADNEXAL MALIG W CC.
355 \8\ UTERINE,ADNEXA PROC 1.9873 41.3 34.4
FOR NON-OVARIAN/
ADNEXAL MALIG W/O CC.
356 \8\ FEMALE REPRODUCTIVE 1.4090 34.1 28.4
SYSTEM RECONSTRUCTIVE
PROCEDURES.
357 \8\ UTERINE & ADNEXA 1.4090 34.1 28.4
PROC FOR OVARIAN OR
ADNEXAL MALIGNANCY.
358 \8\ UTERINE & ADNEXA 1.4090 34.1 28.4
PROC FOR NON-
MALIGNANCY W CC.
359 \8\ UTERINE & ADNEXA 1.4090 34.1 28.4
PROC FOR NON-
MALIGNANCY W/O CC.
360 \4\ VAGINA, CERVIX & 1.4090 34.1 28.4
VULVA PROCEDURES.
361 \8\ LAPAROSCOPY & 0.5711 20.8 17.3
INCISIONAL TUBAL
INTERRUPTION.
362 \8\ ENDOSCOPIC TUBAL 0.5711 20.8 17.3
INTERRUPTION.
363 \8\ D&C, CONIZATION & 0.7347 23.1 19.2
RADIO-IMPLANT, FOR
MALIGNANCY.
364 \8\ D&C, CONIZATION 0.7347 23.1 19.2
EXCEPT FOR MALIGNANCY.
365 \5\ OTHER FEMALE 1.9873 41.3 34.4
REPRODUCTIVE SYSTEM
O.R. PROCEDURES.
366 MALIGNANCY, FEMALE 0.8153 23.0 19.1
REPRODUCTIVE SYSTEM W
CC.
367 \2\ MALIGNANCY, FEMALE 0.7347 23.1 19.2
REPRODUCTIVE SYSTEM W/
O CC.
368 INFECTIONS, FEMALE 0.6911 20.1 16.7
REPRODUCTIVE SYSTEM.
369 \3\ MENSTRUAL & OTHER 0.9785 27.4 22.8
FEMALE REPRODUCTIVE
SYSTEM DISORDERS.
370 \8\ CESAREAN SECTION W 0.9785 27.4 22.8
CC.
371 \8\ CESAREAN SECTION W/ 0.7347 23.1 19.2
O CC.
372 \8\ VAGINAL DELIVERY W 0.7347 23.1 19.2
COMPLICATING DIAGNOSES.
373 \8\ VAGINAL DELIVERY W/ 0.7347 23.1 19.2
O COMPLICATING
DIAGNOSES.
374 \8\ VAGINAL DELIVERY W 0.7347 23.1 19.2
STERILIZATION &/OR D&C.
375 \8\ VAGINAL DELIVERY W 0.7347 23.1 19.2
O.R. PROC EXCEPT
STERIL &/OR D&C.
376 \1\ POSTPARTUM & POST 0.5711 20.8 17.3
ABORTION DIAGNOSES W/O
O.R. PROCEDURE.
377 \8\ POSTPARTUM & POST 0.7347 23.1 19.2
ABORTION DIAGNOSES W
O.R. PROCEDURE.
378 \8\ ECTOPIC PREGNANCY.. 0.9785 27.4 22.8
379 \8\ THREATENED ABORTION 0.5711 20.8 17.3
380 \8\ ABORTION W/O D&C... 0.5711 20.8 17.3
381 \8\ ABORTION W D&C, 0.5711 20.8 17.3
ASPIRATION CURETTAGE
OR HYSTEROTOMY.
382 \8\ FALSE LABOR........ 0.5711 20.8 17.3
383 \8\ OTHER ANTEPARTUM 0.5711 20.8 17.3
DIAGNOSES W MEDICAL
COMPLICATIONS.
384 \8\ OTHER ANTEPARTUM 0.5711 20.8 17.3
DIAGNOSES W/O MEDICAL
COMPLICATIONS.
385 \1\ NEONATES, DIED OR 0.5711 20.8 17.3
TRANSFERRED TO ANOTHER
ACUTE CARE FACILITY.
386 \8\ EXTREME IMMATURITY. 0.7347 23.1 19.2
387 \8\ PREMATURITY W MAJOR 0.7347 23.1 19.2
PROBLEMS.
388 \8\ PREMATURITY W/O 0.7347 23.1 19.2
MAJOR PROBLEMS.
389 \8\ FULL TERM NEONATE W 0.7347 23.1 19.2
MAJOR PROBLEMS.
390 \8\ NEONATE W OTHER 0.7347 23.1 19.2
SIGNIFICANT PROBLEMS.
391 \8\ NORMAL NEWBORN..... 0.5711 20.8 17.3
392 \8\ SPLENECTOMY AGE 17.
[[Page 27404]]
393 \8\ SPLENECTOMY AGE 0- 0.7347 23.1 19.2
17.
394 \3\ OTHER O.R. 1.4090 34.1 28.4
PROCEDURES OF THE
BLOOD AND BLOOD
FORMING ORGANS4.
395 RED BLOOD CELL 0.9050 26.8 22.3
DISORDERS AGE 17.
396 \8\ RED BLOOD CELL 0.5711 20.8 17.3
DISORDERS AGE 0-17.
397 COAGULATION DISORDERS.. 1.0816 25.2 21.0
398 RETICULOENDOTHELIAL & 0.9248 23.0 19.1
IMMUNITY DISORDERS W
CC.
399 \1\ RETICULOENDOTHELIAL 0.5711 20.8 17.3
& IMMUNITY DISORDERS W/
O CC.
401 \5\ LYMPHOMA & NON- 1.9873 41.3 34.4
ACUTE LEUKEMIA W OTHER
O.R. PROC W CC.
402 \3\ LYMPHOMA & NON- 0.9785 27.4 22.8
ACUTE LEUKEMIA W OTHER
O.R. PROC W/O CC.
403 LYMPHOMA & NON-ACUTE 0.9099 22.7 18.9
LEUKEMIA W CC.
404 LYMPHOMA & NON-ACUTE 0.7410 17.9 14.9
LEUKEMIA W/O CC.
405 \8\ ACUTE LEUKEMIA W/O 0.7347 23.1 19.2
MAJOR O.R. PROCEDURE
AGE 0-17.
406 \5\ MYELOPROLIF DISORD 1.9873 41.3 34.4
OR POORLY DIFF NEOPL W
MAJ O.R.PROC W CC.
407 \8\ MYELOPROLIF DISORD 0.9785 27.4 22.8
OR POORLY DIFF NEOPL W
MAJ O.R.PROC W/O CC.
408 \3\ MYELOPROLIF DISORD 0.9785 27.4 22.8
OR POORLY DIFF NEOPL W
OTHER O.R.PROC.
409 RADIOTHERAPY........... 0.8961 25.1 20.9
410 \3\ CHEMOTHERAPY W/O 0.9785 27.4 22.8
ACUTE LEUKEMIA AS
SECONDARY DIAGNOSIS.
411 \3\ HISTORY OF 0.9785 27.4 22.8
MALIGNANCY W/O
ENDOSCOPY.
412 \5\ HISTORY OF 1.9873 41.3 34.4
MALIGNANCY W ENDOSCOPY.
413 OTHER MYELOPROLIF DIS 0.9603 25.2 21.0
OR POORLY DIFF NEOPL
DIAG W CC.
414 \2\ OTHER MYELOPROLIF 0.7347 23.1 19.2
DIS OR POORLY DIFF
NEOPL DIAG W/O CC.
415 O.R. PROCEDURE FOR 1.7239 40.9 34.0
INFECTIOUS & PARASITIC
DISEASES.
416 SEPTICEMIA AGE 17.
417 \8\ SEPTICEMIA AGE 0-17 0.9785 27.4 22.8
418 POSTOPERATIVE & POST- 0.8612 25.3 21.0
TRAUMATIC INFECTIONS.
419 \3\ FEVER OF UNKNOWN 0.9785 27.4 22.8
ORIGIN AGE 17 W CC.
420 \1\ FEVER OF UNKNOWN 0.5711 20.8 17.3
ORIGIN AGE 17 W/O CC.
421 \2\ VIRAL ILLNESS AGE 0.7347 23.1 19.2
17.
422 \8\ VIRAL ILLNESS & 0.5711 20.8 17.3
FEVER OF UNKNOWN
ORIGIN AGE 0-17.
423 OTHER INFECTIOUS & 0.9930 25.9 21.5
PARASITIC DISEASES
DIAGNOSES.
424 O.R. PROCEDURE W 1.2281 44.2 36.8
PRINCIPAL DIAGNOSES OF
MENTAL ILLNESS.
425 ACUTE ADJUSTMENT 0.6040 26.9 22.4
REACTION &
PSYCHOLOGICAL
DYSFUNCTION.
426 DEPRESSIVE NEUROSES.... 0.5583 23.3 19.4
427 \4\ NEUROSES EXCEPT 1.4090 34.1 28.4
DEPRESSIVE.
428 \1\ DISORDERS OF 0.5711 20.8 17.3
PERSONALITY & IMPULSE
CONTROL.
429 ORGANIC DISTURBANCES & 0.6562 27.4 22.8
MENTAL RETARDATION.
430 PSYCHOSES.............. 0.4808 22.6 18.8
431 \1\ CHILDHOOD MENTAL 0.5711 20.8 17.3
DISORDERS.
432 \1\ OTHER MENTAL 0.5711 20.8 17.3
DISORDER DIAGNOSES.
433 ALCOHOL/DRUG ABUSE OR 0.3416 14.6 12.1
DEPENDENCE, LEFT AMA.
439 SKIN GRAFTS FOR 1.4429 41.2 34.3
INJURIES.
440 WOUND DEBRIDEMENTS FOR 1.6794 39.4 32.8
INJURIES.
441 \5\ HAND PROCEDURES FOR 1.9873 41.3 34.4
INJURIES.
442 OTHER O.R. PROCEDURES 1.6280 46.4 38.6
FOR INJURIES W CC.
443 \3\ OTHER O.R. 0.9785 27.4 22.8
PROCEDURES FOR
INJURIES W/O CC.
444 TRAUMATIC INJURY AGE 0.9311 30.7 25.5
17 W CC.
445 TRAUMATIC INJURY AGE 0.8278 27.3 22.7
17 W/O CC.
446 \8\ TRAUMATIC INJURY 0.7347 23.1 19.2
AGE 0-17.
447 \3\ ALLERGIC REACTIONS 0.9785 27.4 22.8
AGE 17.
448 \8\ ALLERGIC REACTIONS 0.5711 20.8 17.3
AGE 0-17.
449 \3\ POISONING & TOXIC 0.9785 27.4 22.8
EFFECTS OF DRUGS AGE
17 W CC.
450 \3\ POISONING & TOXIC 0.9785 27.4 22.8
EFFECTS OF DRUGS AGE
17 W/O CC.
451 \8\ POISONING & TOXIC 0.5711 20.8 17.3
EFFECTS OF DRUGS AGE 0-
17.
452 COMPLICATIONS OF 0.9830 25.5 21.2
TREATMENT W CC.
453 COMPLICATIONS OF 0.8894 25.5 21.2
TREATMENT W/O CC.
454 \2\ OTHER INJURY, 0.7347 23.1 19.2
POISONING & TOXIC
EFFECT DIAG W CC.
455 \1\ OTHER INJURY, 0.5711 20.8 17.3
POISONING & TOXIC
EFFECT DIAG W/O CC.
461 O.R. PROC W DIAGNOSES 1.4214 36.6 30.5
OF OTHER CONTACT W
HEALTH SERVICES.
462 REHABILITATION......... 0.6528 22.7 18.9
463 SIGNS & SYMPTOMS W CC.. 0.7824 26.4 22.0
464 SIGNS & SYMPTOMS W/O CC 0.6259 25.2 21.0
465 \1\ AFTERCARE W HISTORY 0.5711 20.8 17.3
OF MALIGNANCY AS
SECONDARY DIAGNOSIS.
466 AFTERCARE W/O HISTORY 0.7783 22.6 18.8
OF MALIGNANCY AS
SECONDARY DIAGNOSIS.
467 OTHER FACTORS 1.4773 32.6 27.1
INFLUENCING HEALTH
STATUS.
468 EXTENSIVE O.R. 2.0716 43.7 36.4
PROCEDURE UNRELATED TO
PRINCIPAL DIAGNOSIS.
469 \6\ PRINCIPAL DIAGNOSIS 0.0000 0.0 0.0
INVALID AS DISCHARGE
DIAGNOSIS.
470 \6\ UNGROUPABLE........ 0.0000 0.0 0.0
471 \5\ BILATERAL OR 1.9873 41.3 34.4
MULTIPLE MAJOR JOINT
PROCS OF LOWER
EXTREMITY.
[[Page 27405]]
473 \2\ ACUTE LEUKEMIA W/O 0.7347 23.1 19.2
MAJOR O.R. PROCEDURE
AGE 17.
475 RESPIRATORY SYSTEM 2.0241 33.0 27.5
DIAGNOSIS WITH
VENTILATOR SUPPORT.
476 PROSTATIC O.R. 1.0056 32.9 27.4
PROCEDURE UNRELATED TO
PRINCIPAL DIAGNOSIS.
477 NON-EXTENSIVE O.R. 1.8688 40.7 33.9
PROCEDURE UNRELATED TO
PRINCIPAL DIAGNOSIS.
478 \7\ OTHER VASCULAR 1.3238 34.9 29.0
PROCEDURES W CC.
479 \7\ OTHER VASCULAR 1.3238 34.9 29.0
PROCEDURES W/O CC.
480 \6\ LIVER TRANSPLANT... 0.0000 0.0 0.0
481 \8\ BONE MARROW 0.5711 20.8 17.3
TRANSPLANT.
482 \5\ TRACHEOSTOMY FOR 1.9873 41.3 34.4
FACE,MOUTH & NECK
DIAGNOSES.
483 TRACH W MECH VENT 96+ 3.1562 54.9 45.7
HRS OR PDX EXCEPT
FACE,MOUTH & NECK DIAG.
484 \8\ CRANIOTOMY FOR 1.9873 41.3 34.4
MULTIPLE SIGNIFICANT
TRAUMA.
485 \8\ LIMB REATTACHMENT, 1.9873 41.3 34.4
HIP AND FEMUR PROC FOR
MULTIPLE SIGNIFICANT
TR.
486 \4\ OTHER O.R. 1.4090 34.1 28.4
PROCEDURES FOR
MULTIPLE SIGNIFICANT
TRAUMA.
487 OTHER MULTIPLE 1.2653 33.2 27.6
SIGNIFICANT TRAUMA.
488 \5\ HIV W EXTENSIVE 1.9873 41.3 34.4
O.R. PROCEDURE.
489 HIV W MAJOR RELATED 0.9656 22.1 18.4
CONDITION.
490 HIV W OR W/O OTHER 0.7956 20.5 17.0
RELATED CONDITION.
491 \8\ MAJOR JOINT & LIMB 1.9873 41.3 34.4
REATTACHMENT
PROCEDURES OF UPPER
EXTREMITY.
492 \8\ CHEMOTHERAPY W 0.9785 27.4 22.8
ACUTE LEUKEMIA AS
SECONDARY DIAGNOSIS OR
W USE HIGH DOSE
CHEMOTHERAPY AGENT.
493 \4\ LAPAROSCOPIC 1.4090 34.1 28.4
CHOLECYSTECTOMY W/O
C.D.E. W CC.
494 \4\ LAPAROSCOPIC 1.4090 34.1 28.4
CHOLECYSTECTOMY W/O
C.D.E. W/O CC.
495 \6\ LUNG TRANSPLANT.... 0.0000 0.0 0.0
496 \8\ COMBINED ANTERIOR/ 1.4090 34.1 28.4
POSTERIOR SPINAL
FUSION.
497 \3\ SPINAL FUSION W CC. 0.9785 27.4 22.8
498 \3\ SPINAL FUSION W/O 0.9785 27.4 22.8
CC.
499 \5\ BACK & NECK 1.9873 41.3 34.4
PROCEDURES EXCEPT
SPINAL FUSION W CC.
500 \4\ BACK & NECK 1.4090 34.1 28.4
PROCEDURES EXCEPT
SPINAL FUSION W/O CC.
501 \5\ KNEE PROCEDURES W 1.9873 41.3 34.4
PDX OF INFECTION W CC.
502 \2\ KNEE PROCEDURES W 0.7347 23.1 19.2
PDX OF INFECTION W/O
CC.
503 \3\ KNEE PROCEDURES W/O 0.9785 27.4 22.8
PDX OF INFECTION.
504 \8\ EXTENSIVE 3RD 1.9873 41.3 34.4
DEGREE BURNS W SKIN
GRAFT.
505 \3\ EXTENSIVE 3RD 0.9785 27.4 22.8
DEGREE BURNS W/O SKIN
GRAFT.
506 \2\ FULL THICKNESS BURN 0.7347 23.1 19.2
W SKIN GRAFT OR INHAL
INJ W CC OR SIG TRAUMA.
507 \2\ FULL THICKNESS BURN 0.7347 23.1 19.2
W SKIN GRFT OR INHAL
INJ W/O CC OR SIG
TRAUMA.
508 \2\ FULL THICKNESS BURN 0.7347 23.1 19.2
W/O SKIN GRFT OR INHAL
INJ W CC OR SIG TRAUMA.
509 \1\ FULL THICKNESS BURN 0.5711 20.8 17.3
W/O SKIN GRFT OR INH
INJ W/O CC OR SIG
TRAUMA.
510 \2\ NON-EXTENSIVE BURNS 0.7347 23.1 19.2
W CC OR SIGNIFICANT
TRAUMA.
511 \1\ NON-EXTENSIVE BURNS 0.5711 20.8 17.3
W/O CC OR SIGNIFICANT
TRAUMA.
512 \6\ SIMULTANEOUS 0.0000 0.0 0.0
PANCREAS/KIDNEY
TRANSPLANT.
513 \6\ PANCREAS TRANSPLANT 0.0000 0.0 0.0
515 \5\ CARDIAC 1.9873 41.3 34.4
DEFIBRILATOR IMPLANT W/
O CARDIAC CATH.
516 \8\ PERCUTANEOUS 0.9785 27.4 22.8
CARDIVASCULAR
PROCEDURE W AMI.
517 \4\ PERCUTANEOUS 1.4090 34.1 28.4
CARDIVASCULAR PROC W
NON-DRUG ELUTING STENT
W/O AMI.
518 \3\ PERCUTANEOUS 0.9785 27.4 22.8
CARDIVASCULAR PROC W/O
CORONARY ARTERY STENT
OR AMI.
519 \4\ CERVICAL SPINAL 1.4090 34.1 28.4
FUSION W CC.
520 \8\ CERVICAL SPINAL 0.9785 27.4 22.8
FUSION W/O CC.
521 ALCOHOL/DRUG ABUSE OR 0.5064 20.9 17.4
DEPENDENCE W CC.
522 ALCOHOL/DRUG ABUSE OR 0.4221 19.5 16.2
DEPENDENCE W
REHABILITATION THERAPY
W/O CC.
523 ALCOHOL/DRUG ABUSE OR 0.4366 21.9 18.2
DEPENDENCE W/O
REHABILITATION THERAPY
W/O CC.
524 TRANSIENT ISCHEMIA..... 0.6178 23.4 19.5
525 \8\ HEART ASSIST SYSTEM 1.9873 41.3 34.4
IMPLANT.
526 \8\ PERCUTANEOUS 1.4090 34.1 28.4
CARVIOVASCULAR PROC W
DRUG-ELUTING STENT W
AMI.
527 \8\ PERCUTANEOUS 1.4090 34.1 28.4
CARVIOVASCULAR PROC W
DRUG-ELUTING STENT W/O
AMI.
528 \8\ INTRACRANIAL 1.9873 41.3 34.4
VASCLUAR PROCEDURES
WITH PDX HEMORRHAGE.
529 \2\ VENTRICULAR SHUNT 0.7347 23.1 19.2
PROCEDURES WITH CC.
530 \8\ VENTRICULAR SHUNT 0.7347 23.1 19.2
PROCEDURES WITHOUT CC.
531 \8\ SPINAL PROCEDURES 1.4090 34.1 28.4
WITH CC.
532 \4\ SPINAL PROCEDURES 1.4090 34.1 28.4
WITHOUT CC.
533 \8\ EXTRACRANIAL 1.9873 41.3 34.4
VASCULAR PROCEDURES
WITH CC.
534 \5\ EXTRACRANIAL 1.9873 41.3 34.4
VASCULAR PROCEDURES
WITHOUT CC.
535 \8\ CARDIAC DEFIB 1.9873 41.3 34.4
IMPLANT WITH CARDIAC
CATH WITH AMI/HF/SHOCK.
536 \5\ CARDIAC DEFIB 1.9873 41.3 34.4
IMPLANT WITH CARDIAC
CATH WITHOUT AMI/HF/
SHOCK.
537 \8\ LOCAL EXCISION AND 0.7347 23.1 19.2
REMOVAL OF INTERNAL
FIXATION DEVICES
EXCEPT HIP AND FEMUR
WITH CC.
538 \4\ LOCAL EXCISION AND 1.4090 34.1 28.4
REMOVAL OF INTERNAL
FIXATION DEVICES
EXCEPT HIP AND FEMUR
WITHOUT CC.
539 \8\ LYMPHOMA AND 1.9873 41.3 34.4
LEUKEMIA WITH MAJOR
O.R. PROCEDURE WITH CC.
[[Page 27406]]
540 \1\ LYMPHOMA AND 0.5711 20.8 17.3
LEUKEMIA WITH MAJOR
O.R. PROCEDURE WITHOUT
CC.
------------------------------------------------------------------------
\1\ Proposed relative weights for these proposed LTC-DRGs were
determined by assigning these cases to proposed low volume quintile 1.
\2\ Proposed relative weights for these proposed LTC-DRGs were
determined by assigning these cases to proposed low volume quintile 2.
\3\ Proposed relative weights for these proposed LTC-DRGs were
determined by assigning these cases to proposed low volume quintile 3.
\4\ Proposed relative weights for these proposed LTC-DRGs were
determined by assigning these cases to proposed low volume quintile 4.
\5\ Proposed relative weights for these proposed LTC-DRGs were
determined by assigning these cases to proposed low volume quintile 5.
\6\ Proposed relative weights for these proposed LTC-DRGs were assigned
a value of 0.0000.
\7\ Proposed relative weights for these proposed LTC-DRGs were
determined after adjusting to account for nonmonotonicity (see step 5
above).
\8\ Proposed relative weights for these proposed LTC-DRGs were
determined by assigning these cases to the appropriate proposed low
volume quintile because they had no LTCH cases in the FY 2002 MedPAR.
Appendix A--Regulatory Analysis of Impacts
I. Background and Summary
We have examined the impacts of this proposed rule as required
by Executive Order 12866 (September 1993, Regulatory Planning and
Review) and the Regulatory Flexibility Act (RFA) (September 19,
1980, Pub. L. 96-354), section 1102(b) of the Social Security Act,
the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and
Executive Order 13132.
Executive Order 12866 directs agencies to assess all costs and
benefits of available regulatory alternatives and, if regulation is
necessary, to select regulatory approaches that maximize net
benefits (including potential economic, environmental, public health
and safety effects, distributive impacts, and equity). A regulatory
impact analysis (RIA) must be prepared for major rules with
economically significant effects ($100 million or more in any 1
year).
We have determined that this proposed rule is a major rule as
defined in 5 U.S.C. 804(2). Based on the overall percentage change
in payments per case estimated using our payment simulation model (a
2.5 percent increase), we estimate that the total impact of these
proposed changes for FY 2004 payments compared to FY 2003 payments
to be approximately a $2.1 billion increase. This amount does not
reflect changes in hospital admissions or case-mix intensity, which
would also affect overall payment changes.
The RFA requires agencies to analyze options for regulatory
relief of small businesses. For purposes of the RFA, small entities
include small businesses, nonprofit organizations, and government
agencies. Most hospitals and most other providers and suppliers are
small entities, either by nonprofit status or by having revenues of
$5 million to $25 million in any 1 year. For purposes of the RFA,
all hospitals and other providers and suppliers are considered to be
small entities. Individuals and States are not included in the
definition of a small entity.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis for any proposed rule that may have a
significant impact on the operations of a substantial number of
small rural hospitals. This analysis must conform to the provisions
of section 603 of the RFA. With the exception of hospitals located
in certain New England counties, for purposes of section 1102(b) of
the Act, we define a small rural hospital as a hospital with fewer
than 100 beds that is located outside of a Metropolitan Statistical
Area (MSA) or New England County Metropolitan Area (NECMA). Section
601(g) of the Social Security Amendments of 1983 (Pub. L. 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.
Section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L.
104-4) also requires that agencies assess anticipated costs and
benefits before issuing any proposed rule (or a final rule that has
been preceded by a proposed rule) that may result in an expenditure
in any one year by State, local, or tribal governments, in the
aggregate, or by the private sector, of $110 million. This proposed
rule would not mandate any requirements for State, local, or tribal
governments.
Executive Order 13132 establishes certain requirements that an
agency must meet when it promulgates a proposed rule (and subsequent
final rule) that imposes substantial direct requirement costs on
State and local governments, preempts State law, or otherwise has
Federalism implications. We have reviewed this proposed rule in
light of Executive Order 13132 and have determined that it would not
have any negative impact on the rights, roles, and responsibilities
of State, local, or tribal governments.
In accordance with the provisions of Executive Order 12866, this
proposed rule was reviewed by the Office of Management and Budget.
The following analysis, in conjunction with the remainder of
this document, demonstrates that this proposed rule is consistent
with the regulatory philosophy and principles identified in
Executive Order 12866, the RFA, and section 1102(b) of the Act. The
proposed rule would affect payments to a substantial number of small
rural hospitals as well as other classes of hospitals, and the
effects on some hospitals may be significant.
II. Objectives
The primary objective of the IPPS 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 proposed rule would further each
of these goals while maintaining the financial viability of the
hospital industry and ensuring access to high quality health care
for Medicare beneficiaries. We expect that these proposed changes
would ensure that the outcomes of this payment system are reasonable
and equitable while avoiding or minimizing unintended adverse
consequences.
III. Limitations of Our Analysis
The following quantitative analysis presents the projected
effects of our proposed policy changes, as well as statutory changes
effective for FY 2004, on various hospital groups. We estimate the
effects of individual proposed 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 proposed policy changes, and we do not make
adjustments for future changes in such variables as admissions,
lengths of stay, or case-mix. As we have done in previous proposed
rules, we are soliciting comments and information about the
anticipated effects of these proposed changes on hospitals and our
methodology for estimating them.
IV. Hospitals Included In and Excluded From the IPPS
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 45 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 48 such hospitals in Maryland
remain excluded from the IPPS under the waiver at section 1814(b)(3)
of the Act.
[[Page 27407]]
There are approximately 729 critical access hospitals (CAHs).
These small, limited service hospitals are paid on the basis of
reasonable costs rather than under the IPPS. The remaining 20
percent are specialty hospitals that are excluded from the IPPS.
These specialty hospitals include psychiatric hospitals and units,
rehabilitation hospitals and units, long-term care hospitals,
children's hospitals, and cancer hospitals. The impacts of our
proposed policy changes on these hospitals are discussed below.
Thus, as of April 2003, we have included 4,087 hospitals in our
analysis. This represents about 80 percent of all Medicare-
participating hospitals. The majority of this impact analysis
focuses on this set of hospitals.
V. Impact on Excluded Hospitals and Hospital Units
As of April 2003, there were 1,085 specialty hospitals excluded
from the IPPS that were paid instead on a reasonable cost basis
subject to the rate-of-increase ceiling under Sec. 413.40. Broken
down by specialty, there were 484 psychiatric, 214 rehabilitation,
296 long-term care, 80 children's, and 11 cancer hospitals. In
addition, there were 1,410 psychiatric units and 979 rehabilitation
units in hospitals otherwise subject to the IPPS. Under Sec.
413.40(a)(2)(i)(A), the rate-of-increase ceiling is not applicable
to the 48 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 IPPS 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 2004. 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 a
prospective payment system (IRF PPS) for cost reporting periods
beginning on or after January 1, 2002. For cost reporting periods
beginning during FY 2004, the IRF PPS is based on 100 percent of the
adjusted Federal IRF prospective payment amount, updated annually.
Therefore, these hospitals would not be impacted by this proposed
rule.
Effective for cost reporting periods beginning on or after
October 1, 2002, LTCHs are paid under a LTCH PPS, based on the
adjusted Federal prospective payment amount, updated annually. LTCHs
will receive a blended payment (Federal prospective payment and a
reasonable cost-based payment) over a 5-year transition period.
However, under the LTCH PPS, a LTCH 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 LTCH PPS
transition blend payment based on reasonable costs for inpatient
operating services would be determined by updating the LTCH'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 would 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 would be the amount of
excess costs that would not be reimbursed.
We note that, under Sec. 413.40(d)(3), an excluded hospital or
unit whose costs exceed 110 percent of its rate-of-increase limit
receives its rate-of-increase limit plus 50 percent of the
difference between its reasonable costs and 110 percent of the
limit, not to exceed 110 percent of its limit. In addition, under
the various provisions set forth in Sec. 413.40, certain excluded
hospitals and hospital units can obtain payment adjustments for
justifiable increases in operating costs that exceed the limit. At
the same time, however, by generally limiting payment increases, we
continue to provide an incentive for excluded hospitals and hospital
units to restrain the growth in their spending for patient services.
VI. Quantitative Impact Analysis of the Proposed Policy Changes Under
the IPPS for Operating Costs
A. Basis and Methodology of Estimates
In this proposed rule, we are announcing policy changes and
payment rate updates for the IPPS for operating and capital-related
costs. Based on the overall percentage change in payments per case
estimated using our payment simulation model (a 2.5 percent
increase), we estimate the total impact of these changes for FY 2004
payments compared to FY 2003 payments to be approximately a $2.1
billion increase. This amount does not reflect changes in hospital
admissions or case-mix intensity, which would also affect overall
payment changes.
We have prepared separate impact analyses of the proposed
changes to each system. This section deals with changes to the
operating prospective payment system. Our payment simulation model
relies on available data to enable us to estimate the impacts on
payments per case of certain changes we are proposing in this
proposed rule. However, there are other changes we are proposing for
which we do not have data available that would allow us to estimate
the payment impacts using this model. For those proposals, we have
attempted to predict the payment impacts of those proposed changes
based upon our experience and other more limited data.
The data used in developing the quantitative analyses of changes
in payments per case presented below are taken from the FY 2002
MedPAR file and the most current Provider-Specific File that is used
for payment purposes. Although the analyses of the changes to the
operating PPS do not incorporate cost data, data from the most
recently available hospital cost report were used to categorize
hospitals. Our analysis has several qualifications. First, we do not
make adjustments for behavioral changes that hospitals may adopt in
response to these proposed policy changes, and we do not adjust for
future changes in such variables as admissions, lengths of stay, or
case-mix. Second, due to the interdependent nature of the IPPS
payment components, it is very difficult to precisely quantify the
impact associated with each proposed change. Third, we draw upon
various sources for the data used to categorize hospitals in the
tables. In some cases, particularly the number of beds, there is a
fair degree of variation in the data from different sources. We have
attempted to construct these variables with the best available
source overall. However, for individual hospitals, some
miscategorizations are possible.
Using cases in the FY 2002 MedPAR file, we simulated payments
under the operating IPPS given various combinations of payment
parameters. Any short-term, acute care hospitals not paid under the
IPPSs (Indian Health Service hospitals and hospitals in Maryland)
were excluded from the simulations. The impact of payments under the
capital IPPS, or the impact of payments for costs other than
inpatient operating costs, are not analyzed in this section.
Estimated payment impacts of proposed FY 2004 changes to the capital
IPPS are discussed in section IX. of this Appendix.
The proposed changes discussed separately below are the
following:
[sbull] The effects of expanding the postacute care transfer
policy to 19 additional DRGs.
[sbull] The effects of the proposed annual reclassification of
diagnoses and procedures and the recalibration of the DRG relative
weights required by section 1886(d)(4)(C) of the Act.
[sbull] The effects of the proposed changes in hospitals' wage
index values reflecting wage data from hospitals' cost reporting
periods beginning during FY 2000, compared to the FY 1999 wage data,
including the effects of removing wage data for Part B costs of RCHs
and FQHCs.
[sbull] The effects of geographic reclassifications by the MGCRB
that will be effective in FY 2004.
[sbull] The total change in payments based on proposed FY 2004
policies relative to payments based on FY 2003 policies.
To illustrate the impacts of the proposed FY 2004 changes, our
analysis begins with a FY 2004 baseline simulation model using: the
FY 2003 DRG GROUPER (version 20.0); the current postacute care
transfer policy for 10 DRGs; the FY 2003 wage index; and no MGCRB
reclassifications. Outlier payments are set at 5.1 percent of total
operating DRG and outlier payments.
Each proposed and statutory policy change is then added
incrementally to this baseline model, finally arriving at an FY 2004
model incorporating all of the proposed changes. This allows us to
isolate the effects of each proposed change.
Our final comparison illustrates the percent change in payments
per case from FY
[[Page 27408]]
2003 to FY 2004. Five factors have significant impacts here. The
first is the update to the standardized amounts. In accordance with
section 1886(b)(3)(B)(i) of the Act, we are proposing to update the
large urban and the other areas average standardized amounts for FY
2004 using the most recently forecasted hospital market basket
increase for FY 2004 of 3.5 percent. Under section 1886(b)(3)(B)(iv)
of the Act, the updates to the hospital-specific amounts for sole
community hospitals (SCHs) and for Medicare-dependent small rural
hospitals (MDHs) are also equal to the market basket increase, or
3.5 percent.
A second significant factor that impacts changes in hospitals'
payments per case from FY 2003 to FY 2004 is the change in MGCRB
status from one year to the next. That is, hospitals reclassified in
FY 2003 that are no longer reclassified in FY 2004 may have a
negative payment impact going from FY 2003 to FY 2004; conversely,
hospitals not reclassified in FY 2003 that are reclassified in FY
2004 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. However, this effect is alleviated by section
1886(d)(10)(D)(v) of the Act, which provides 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 2003 will be 5.5 percent of total
DRG payments. When the FY 2003 final rule was published, we
projected FY 2003 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 2003 (as discussed in the Addendum to this
proposed rule) are reflected in the analyses below comparing our
current estimates of FY 2003 payments per case to estimated FY 2004
payments per case.
Fourth, we are proposing to expand the postacute care transfer
policy to 19 additional DRGs. This proposed expansion would result
in Medicare savings of $160 million because we would no longer pay a
full DRG payment for these cases. As a result, there would be a
lower total increase in Medicare spending for FY 2004.
Fifth, section 402(b) of Pub. L. 108-7 provided that the large
urban standardized amount of the Federal rate is applicable for all
IPPS hospitals for discharges occurring on or after April 1, 2003,
and before October 1, 2003. For discharges occurring on or after
October 1, 2003, the Federal rate will again be based on separate
average standardized amounts for hospitals in large urban areas and
for hospitals in other areas. The effect is to reduce the percent
increase in FY 2004 payments compared to those made in FY 2003.
B. Analysis of Table I
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 4,087 hospitals included in the analysis. This number
is 143 fewer hospitals than were included in the impact analysis in
the FY 2003 final rule (67 FR 50279). There are 98 new CAHs that
were excluded from last year's 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 2,582
hospitals located in urban areas (MSAs or NECMAs) included in our
analysis. Among these, there are 1,493 hospitals located in large
urban areas (populations over 1 million), and 1,089 hospitals in
other urban areas (populations of 1 million or fewer). In addition,
there are 1,505 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 2004 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 2,591,
1,572, 1,019, and 1,496, 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 2,976 nonteaching hospitals in our
analysis, 873 teaching hospitals with fewer than 100 residents, and
238 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. Therefore, hospitals in the rural DSH
categories represent hospitals that were not reclassified for
purposes of the standardized amount or for purposes of the DSH
adjustment. (However, they may 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 (149), SCHs (494), MDHs
(254), and hospitals that are both SCH and RRC (78) 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 2000
Medicare cost report files, if available (otherwise FY 1999 data are
used). Data needed to determine ownership status were unavailable
for 120 hospitals. Similarly, the data needed to determine Medicare
utilization were unavailable for 104 hospitals.
The next series of groupings concern the geographic
reclassification status of hospitals. The first grouping displays
all hospitals that were reclassified by the MGCRB for FY 2004. 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 Proposed Changes for FY 2004 Operating Prospective Payment System
[Percent changes in payments per case]
--------------------------------------------------------------------------------------------------------------------------------------------------------
New wage
Transfer index DRG & MCGRB ALL FY
Number of changes DRG New wage without wage reclassi- 2004
hosps.\1\ 2004 base changes data \4\ nonphys. index fication changes
\2\ \3\ part B changes \7\ \8\
\5\ \6\
(1) (2) (3) (4) (5) (6) (7) (8)
-----------------------------------------------------------------
By Geographic Location:
All hospitals............................................... 4,087 -0.2 0.0 -0.4 0.1 0.0 0.0 2.5
Urban hospitals............................................. 2,582 -0.2 0.0 -0.5 0.1 0.0 -0.4 2.5
Large urban areas (populations over 1 million).............. 1,493 -0.2 0.0 -0.4 0.0 -0.1 -0.4 2.6
[[Page 27409]]
Other urban areas (populations of 1 million of fewer)....... 1,089 -0.2 -0.1 -0.5 0.3 0.1 -0.2 2.2
Rural hospitals............................................. 1,505 -0.2 0.0 -0.2 0.0 0.5 2.6 3.1
Bed Size (Urban):
0-99 beds............................................... 626 -0.3 0.0 -0.1 0.3 0.6 -0.7 2.7
100-199 beds............................................ 916 -0.2 0.0 -0.4 0.2 0.1 -0.4 2.6
200-299 beds............................................ 507 -0.2 0.0 -0.5 0.1 -0.1 -0.3 2.3
300-499 beds............................................ 377 -0.2 0.0 -0.3 0.1 0.1 -0.3 2.5
500 or more beds........................................ 156 -0.1 -0.1 -0.8 0.1 -0.5 -0.4 2.3
Bed Size (Rural):
0-49 beds............................................... 690 -0.2 0.2 -0.3 0.0 0.7 0.6 3.4
50-99 beds.............................................. 477 -0.2 0.0 -0.2 0.0 0.5 1.0 3.3
100-149 beds............................................ 202 -0.2 0.0 -0.3 0.0 0.3 2.9 2.8
150-199 beds............................................ 70 -0.2 -0.1 0.0 0.0 0.7 4.6 2.7
200 or more beds........................................ 66 -0.1 -0.1 -0.1 0.0 0.4 4.8 3.0
Urban by Region:
New England............................................. 134 -0.4 0.0 -1.0 0.8 1.1 -0.1 2.7
Middle Atlantic......................................... 394 -0.2 0.0 -1.0 0.1 -0.7 0.1 1.7
South Atlantic.......................................... 372 -0.2 0.0 -0.4 0.1 -0.1 -0.5 2.5
East North Central...................................... 429 -0.2 0.0 -0.5 0.1 -0.1 -0.4 2.5
East South Central...................................... 155 -0.1 -0.1 0.3 0.1 0.6 -0.6 3.1
West North Central...................................... 176 -0.2 -0.1 0.1 0.1 0.3 -0.7 2.8
West South Central...................................... 329 -0.1 0.0 -0.4 0.0 -0.2 -0.6 2.5
Mountain................................................ 131 -0.2 -0.2 0.5 0.1 0.7 -0.5 3.5
Pacific................................................. 416 -0.2 -0.1 -0.4 0.1 -0.1 -0.4 2.5
Puerto Rico............................................. 46 0.0 -0.1 -0.1 0.0 -0.1 -0.7 2.9
Rural by Region:
New England............................................. 38 -0.2 -0.1 0.3 0.0 0.8 2.6 3.3
Middle Atlantic......................................... 67 -0.2 0.1 -0.1 0.0 0.3 2.4 2.6
South Atlantic.......................................... 221 -0.2 0.0 -0.3 0.0 0.2 2.9 2.3
East North Central...................................... 199 -0.2 -0.1 0.2 0.0 0.8 2.1 3.1
East South Central...................................... 232 -0.2 0.1 -0.2 0.0 0.4 2.8 3.0
West North Central...................................... 254 -0.1 -0.1 -0.2 0.1 1.0 1.9 3.8
West South Central...................................... 273 -0.1 0.1 -0.4 0.1 0.2 3.7 3.5
Mountain................................................ 127 -0.1 -0.1 -0.2 0.0 0.3 1.5 3.2
Pacific................................................. 89 -0.2 -0.1 -0.5 0.1 0.5 2.5 3.5
Puerto Rico............................................. 5 0.0 -0.1 -4.1 0.0 -4.1 0.4 -0.2
By Payment Classification:
Urban hospitals............................................. 2,591 -0.2 0.0 -0.5 0.1 0.0 -0.3 2.5
Large urban areas (populations over 1 million).............. 1,572 -0.2 0.0 -0.4 0.1 -0.1 -0.2 2.7
Other urban areas (populations of 1 million of fewer)....... 1,019 -0.2 -0.1 -0.5 0.3 0.1 -0.4 2.2
Rural areas................................................. 1,496 -0.2 0.0 -0.2 0.0 0.5 2.2 3.0
Teaching Status:
Non-teaching............................................ 2,976 -0.2 0.0 -0.3 0.1 0.2 0.4 2.6
Fewer than 100 Residents................................ 873 -0.2 -0.1 -0.2 0.1 0.2 -0.2 2.6
100 or more Residents................................... 238 -0.2 -0.1 -0.9 0.1 -0.5 -0.1 2.3
Urban DSH:
Non-DSH................................................. 1,381 -0.2 -0.1 -0.2 0.1 0.2 0.0 2.7
100 or more beds........................................ 1,398 -0.2 0.0 -0.6 0.1 -0.1 -0.3 2.4
Less than 100 beds...................................... 276 -0.3 0.0 -0.2 0.3 0.5 -0.5 2.4
Rural DSH:
Sole Community (SCH).................................... 484 -0.1 0.1 -0.2 0.0 0.5 0.4 3.7
Referral Center (RRC)................................... 161 -0.1 -0.1 -0.1 0.0 0.4 4.6 2.8
Other Rural: 100 or more beds........................... 75 -0.3 0.1 -0.5 0.0 0.1 1.0 1.9
Less than 100 beds...................................... 312 -0.3 0.2 -0.4 0.0 0.3 1.0 2.5
Urban teaching and DSH:
DSH..................................................... 771 -0.2 0.0 -0.6 0.1 -0.1 -0.3 2.5
Teaching and no DSH..................................... 273 -0.2 -0.1 -0.3 0.1 0.0 -0.2 2.6
No teaching and DSH..................................... 903 -0.2 0.0 -0.5 0.2 0.0 -0.2 2.3
No teaching and no DSH.................................. 644 -0.2 0.0 -0.2 0.1 0.3 -0.3 2.7
Rural Hospital Types:
[[Page 27410]]
Non special status hospitals............................ 521 -0.3 0.1 -0.4 0.0 0.3 1.0 2.2
RRC..................................................... 149 -0.2 -0.1 -0.1 0.0 0.6 5.9 2.6
SCH..................................................... 494 -0.1 0.0 -0.1 0.0 0.5 0.3 3.9
Medicare-dependent hospitals (MDH)...................... 254 -0.3 0.2 -0.2 0.0 0.8 0.7 3.3
SCH and RRC............................................. 78 0.0 -0.1 -0.1 0.0 0.3 1.4 3.3
Type of Ownership:
Voluntary............................................... 2,435 -0.2 0.0 -0.5 0.1 0.0 0.0 2.5
Proprietary............................................. 699 -0.2 0.0 -0.2 0.1 0.2 0.0 2.6
Government.............................................. 833 -0.2 0.0 -0.4 0.1 0.0 0.3 2.7
Unknown................................................. 120 -0.1 0.0 -1.1 0.0 -0.8 -0.4 1.8
Medicare Utilization as a Percent of Inpatient Days:
0-25.................................................... 304 -0.2 -0.1 0.0 0.0 0.1 -0.3 3.0
25-50................................................... 1,557 -0.2 0.0 -0.5 0.1 -0.1 -0.2 2.5
50-65................................................... 1,663 -0.2 0.0 -0.4 0.2 0.2 0.3 2.5
Over 65................................................. 459 -0.2 0.0 -0.1 0.1 0.4 0.7 2.7
Unknown................................................. 104 -0.2 -0.1 0.0 0.0 0.2 -0.6 3.0
Hospitals Reclassified by the Medicare Geographic Classification
Review Board: FY 2004 Reclassifications:
All Reclassified Hospitals...................................... 639 -0.2 0.0 -0.3 0.1 0.3 4.3 3.0
Standardized Amount Only.................................... 22 -0.2 0.0 -0.7 0.5 0.0 3.9 5.8
Wage Index Only............................................. 556 -0.2 0.0 -0.4 0.2 0.3 4.3 2.4
Both........................................................ 33 -0.2 -0.1 -0.4 0.2 0.2 6.0 3.1
Nonreclassified Hospitals....................................... 3,442 -0.2 0.0 -0.4 0.1 0.0 -0.62.5
All Reclassified Urban Hospitals................................ 136 -0.2 0.0 -0.5 0.3 0.1 4.0 2.7
Standardized Amount Only.................................... 13 -0.2 -0.1 -1.4 0.2 -1.2 0.9 2.4
Wage Index Only............................................. 82 -0.2 0.0 -0.7 0.3 0.1 3.9 2.3
Both........................................................ 41 -0.3 0.0 0.1 0.2 0.6 5.4 3.8
Urban Nonreclassified Hospitals............................. 2,415 -0.2 0.0 -0.5 0.1 -0.1 -0.6 2.4
All Reclassified Rural Hospitals................................ 503 -0.2 -0.1 -0.1 0.0 0.5 4.6 3.2
Standardized Amount Only.................................... 15 -0.2 0.1 -0.4 0.1 0.4 4.8 2.1
Wage Index Only............................................. 464 -0.1 -0.1 -0.1 0.0 0.5 4.2 3.2
Both........................................................ 24 -0.2 0.0 -0.1 0.0 0.5 8.7 3.8
Rural Nonreclassified Hospitals................................. 999 -0.2 0.1 -0.3 0.0 0.5 -0.5 2.8
Other Reclassified Hospitals (Section 1886(D)(8)(B))............ 34 -0.2 0.1 0.0 0.0 0.4 -2.0 1.8
......... ......... ......... ......... ......... ......... ......... .........
--------------------------------------------------------------------------------------------------------------------------------------------------------
\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 2002, and hospital cost report data are from reporting periods beginning in FY 2000 and FY 1999.
\2\ This column displays the payment impact of the expanded postacute care transfer policy.
\3\ This column displays the payment impact of the recalibration of the DRG weights based on FY 2002 MedPAR data and the DRG reclassification changes,
in accordance with section 1886(d)(4)(C) of the Act.
\4\ This column displays the impact of updating the wage index with wage data from hospitals' FY 2000 cost reports.
\5\ This column displays the impact of removing nonphysician Part B costs and hours from cost report data (Worksheet S-3, Part II, Line 5.01).
\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 removal of nonphysician Part B 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 3, 4, and 5, and
the proposed FY 2004 budget neutrality factor of 1.003133.
\7\ Shown here are the effects of geographic reclassifications by the Medicare Geographic Classification Review Board (MGCRB). The effects demonstrate
the FY 2004 payment impact of going from no reclassifications to the reclassifications scheduled to be in effect for FY 2004. Reclassification for
prior years has no bearing on the payment impacts shown here.
\8\ This column shows changes in payments from FY 2003 to FY 2004. It incorporates all of the changes displayed in columns 2, 6, and 7 (the changes
displayed in columns 3, 4, and 5 are included in column 6). It also reflects the impact of the FY 2004 update, changes in hospitals' reclassification
status in FY 2004 compared to FY 2003, and the difference in outlier payments from FY 2003 to FY 2004. The sum of these impacts may be different from
the percentage changes shown here due to rounding and interactive effect.
C. Impact of the Proposed Changes to the Postacute Care Transfer
Policy (Column 2)
In column 2 of Table I, we present the effects of the postacute
care transfer policy expansion, as discussed in section IV.A. of the
preamble to this proposed rule. We compared aggregate payments using
the FY 2003 DRG relative weights (GROUPER version 21.0) with the
expanded postacute care transfer policy to aggregate payments using
the proposed expanded postacute care transfer policy (with the
additional 19 DRGs). The changes we are proposing to make would
result in 0.2 percent lower payments to
[[Page 27411]]
hospitals overall. We estimate the total savings at approximately
$160 million.
To simulate the impact of this proposed policy, we calculated
hospitals' transfer-adjusted discharges and case-mix index values,
including the proposed additional 19 DRGs. The transfer-adjusted
discharge fraction is calculated in one of two ways, depending on
the transfer payment methodology. Under our current transfer payment
methodology, for all but the three DRGs receiving special payment
consideration (DRGs 209, 210, and 211), this adjustment is made by
adding 1 to the length of stay and dividing that amount by the
geometric mean length of stay for the DRG (with the resulting
fraction not to exceed 1.0). For example, a transfer after 3 days
from a DRG with a geometric mean length of stay of 6 days would have
a transfer-adjusted discharge fraction of 0.667 ((3+1)/6).
For transfers from any one of the three DRGs receiving the
alternative payment methodology, the transfer-adjusted discharge
fraction is 0.5 (to reflect that these cases receive half the full
DRG amount the first day), plus one half of the result of dividing 1
plus the length of stay prior to transfer by the geometric mean
length of stay for the DRG. None of the proposed 19 additional DRGs
would receive the alternative payment methodology. As with the above
adjustment, the result is equal to the lesser of the transfer-
adjusted discharge fraction or 1.
The transfer-adjusted case-mix index values are calculated by
summing the transfer-adjusted DRG weights and dividing by the
transfer-adjusted discharges. The transfer-adjusted DRG weights are
calculated by multiplying the DRG weight by the lesser of 1 or the
transfer-adjusted discharge fraction for the case, divided by the
geometric mean length of stay for the DRG. In this way, simulated
payments per case can be compared before and after the proposed
change to the transfer policy.
This proposed expansion of the policy has a negative 0.2 percent
payment impact overall among both urban and rural hospitals. There
is very small variation among all of the hospital categories from
this negative 0.2 percent impact. This outcome is different than the
impacts exhibited when we implemented the postacute care transfer
policy for the current 10 DRGs in the July 31, 1998 Federal Register
(63 FR 41108). At that time, the impact of going from no postacute
transfer policy to a postacute care transfer policy applicable to 10
DRGs was a 0.6 percent decrease in payments per case. In addition,
at that time, the impact was greatest among urban hospitals (0.7
percent payment decrease, compared to 0.4 percent among rural
hospitals).
The less dramatic impact observed for this proposed expansion to
additional DRGs is not surprising. The movement to transfer more and
more patients for postacute care sooner appears to have abated in
recent years. While it does appear that many patients continue to be
transferred for postacute care early in the course of their acute
care treatment, the rapid expansion of this trend that was apparent
during the mid-90s appears to have subsided. To a large extent, this
decline probably stems from the decreased payment incentives to
transfer patients to postacute care settings as a result of the
implementation of prospective payment systems for IRFs, SNFs, LTCHs,
and HHAs.
D. Impact of the Proposed Changes to the DRG Reclassifications and
Recalibration of Relative Weights (Column 3)
In column 3 of Table I, we present the combined effects of the
DRG reclassifications and recalibration, as discussed in section II.
of the preamble to this proposed rule. Section 1886(d)(4)(C)(i) of
the Act requires us annually to 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 2003 DRG relative
weights (GROUPER version 20.0) to aggregate payments using the
proposed FY 2004 DRG relative weights (GROUPER version 21.0). Both
simulations reflected the proposed expansion of the postacute care
transfer policy. 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
proposed budget neutrality factor of 1.003133 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 major DRG classification changes we are proposing are:
Creating additional DRGs that are split based on the presence or
absence of CCs; creating a new DRG for cases with ruptured brain
aneurysms; and creating a new DRG for cases involving the
implantation of a cardiac defibrillator where the patient
experiences acute myocardial infarction, heart failure, or shock. In
the aggregate, these proposed changes would result in 0.0 percent
change in overall payments to hospitals.
The overall level of the DRG weights are determined by the
normalization factor intended to ensure that recalibration by itself
neither increases nor decreases total payments under the IPPS.
Because we count transfer cases as a fraction of a case in the
recalibration process, expanding the postacute care transfer policy
to 19 additional DRGs would affect the proposed relative weights for
those DRGs. Therefore, we calculated the proposed FY 2004
normalization factor comparing the case-mix using the proposed FY
2004 DRG relative weights in which we treated postacute care
transfer cases in the 19 additional DRGs being proposed for FY 2004
as a fraction of a case with the case-mix using the FY 2003 DRG
relative weights without treating cases in these 19 additional DRGs
as transfer cases. As noted above, the proposed expansion of the
postacute care transfer policy impacts the overall level of the DRG
weights, contributing to the impacts seen in this column.
Rural hospitals with fewer than 50 beds would experience a 0.2
percent increase due to these changes, while rural hospitals with
more than 150 beds will experience a 0.1 percent decrease. Also,
RRCs and hospitals classified with both SCH and RRC would experience
a 0.1 percent decrease. MDHs would experience a 0.2 percent
increase. Hospitals in the urban Mountain census division would
experience the largest change, with a 0.2 percent decrease. Again,
these impacts are ultimately offset by the budget neutrality factor
of 1.003133.
E. Impact of Proposed Wage Index Changes (Columns 4 and 5)
Section 1886(d)(3)(E) of the Act requires that, beginning
October 1, 1993, we annually update the wage data used to calculate
the wage index. In accordance with this requirement, the proposed
wage index for FY 2004 is based on data submitted for hospital cost
reporting periods beginning on or after October 1, 1999 and before
October 1, 2000. As with column 3, the impact of the new data on
hospital payments is isolated in column 4 by holding the other
payment parameters constant in this simulation. That is, column 4
shows the percentage changes in payments when going from a model
using the FY 2003 wage index (based on FY 1999 wage data to a model
using the FY 2004 pre-reclassification wage index based on FY 2000
wage data).
The wage data collected on the FY 2000 cost reports are similar
to the data used in the calculation of the FY 2003 wage index. Also,
as described in section III.B of this preamble, the proposed FY 2004
wage index is calculated by removing the nonphysician Part B costs
and hours of RHCs and FQHCs, shown in column 5.
Column 4 shows the impacts of updating the wage data using FY
2000 cost reports. Overall, the new wage data would lead to a 0.4
percent reduction, but this reduction is offset by the budget
neutrality factor. Urban hospitals' wage indexes would decline by
0.5 percent, and rural hospitals' wage indexes would decline by 0.2
percent. Among regions, the largest impact of updating the wage data
is seen in rural Puerto Rico (a 4.1 percent decrease). Rural
hospitals in the Pacific and West South Central regions would
experience the next largest impact, a 0.5 percent and 0.4 percent
decrease, respectively. Rural New England and East North Central
regions would experience an increase of 0.3 percent and 0.2 percent,
respectively.
Among urban hospitals, New England and the Middle Atlantic
regions would experience 1.0 percent decreases, respectively. These
impacts result, respectively, from a 9.0 percent decrease in the
proposed FY 2004 wage index for Springfield, Massachusetts, and a
6.1 percent decrease in the Pittsburgh, Pennsylvania wage index. The
East South Central, West North Central, and Mountain regions would
experience increases of 0.3 percent, 0.1 percent, and 0.5 percent,
respectively.
The next column shows the impacts on the calculation of the
proposed FY 2004 wage index of removing nonphysician Part B data for
RHCs and FQHCs. Column 5 shows the impacts of removing nonphysician
Part B costs for RHCs and FQHCs. The effects of this proposed change
are relatively small with the
[[Page 27412]]
exception of New England, which would experience a 0.8 percent
decrease.
We note that the wage data used for the proposed wage index are
based upon the data available as of March 2003 and, therefore, do
not reflect revision requests received and processed by the fiscal
intermediaries after that date. To the extent these requests are
granted by hospitals' fiscal intermediaries, these revisions will be
reflected in the final rule. In addition, we continue to verify the
accuracy of the data for hospitals with extraordinary changes in
their data from the prior year.
The following chart compares the shifts in wage index values for
labor market areas for FY 2004 relative to FY 2003. This chart
demonstrates the impact of the changes for the proposed FY 2004 wage
index, including updating to FY 2000 wage data. The majority of
labor market areas (331) would experience less than a 5-percent
change. A total of 13 labor market areas would experience an
increase of more than 5 percent and less than 10 percent. Two areas
would experience an increase greater than 10 percent. A total of 24
areas would experience decreases of more than 5 percent and less
than 10 percent. Finally, 3 areas would experience declines of 10
percent or more.
------------------------------------------------------------------------
Number of labor
market areas
Percentage change in area wage index values ---------------------
FY 2003 FY 2004
------------------------------------------------------------------------
Increase more than 10 percent..................... 3 2
Increase more than 5 percent and less than 10 11 13
percent..........................................
Increase or decrease less than 5 percent.......... 343 331
Decrease more than 5 percent and less than 10 15 24
percent..........................................
Decrease more than 10 percent..................... 1 3
------------------------------------------------------------------------
Among urban hospitals, 45 would experience an increase of
between 5 and 10 percent and 8 more than 10 percent. A total of 64
rural hospitals would experience increases greater than 5 percent,
but none would experience greater than 10-percent increases. On the
negative side, 109 urban hospitals would experience decreases in
their wage index values of at least 5 percent but less than 10
percent. Nine urban hospitals and one rural hospital would
experience decreases in their wage index values greater than 10
percent. There are 25 rural hospitals that would experience
decreases in their wage index values of greater than 5 percent but
less than 10 percent. The following chart shows the projected impact
for urban and rural hospitals.
------------------------------------------------------------------------
Number of hospitals
Percentage change in area wage index values ---------------------
Urban Rural
------------------------------------------------------------------------
Increase more than 10 percent..................... 8 0
Increase more than 5 percent and less than 10 45 64
percent..........................................
Increase or decrease less than 5 percent.......... 2,436 1,714
Decrease more than 5 percent and less than 10 109 25
percent..........................................
Decrease more than 10 percent..................... 9 1
------------------------------------------------------------------------
F. Combined Impact of Proposed DRG and Wage Index Changes,
Including Budget Neutrality Adjustment (Column 6)
The impact of the DRG reclassifications and recalibration on
aggregate payments is required by section 1886(d)(4)(C)(iii) of the
Act to be budget neutral. In addition, section 1886(d)(3)(E) of the
Act specifies that any updates or adjustments to the wage index are
to be budget neutral. As noted in the Addendum to this proposed
rule, we compared simulated aggregate payments using the FY 2003 DRG
relative weights and wage index to simulated aggregate payments
using the proposed FY 2004 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.E. of the preamble of
this proposed rule, we are proposing to maintain the new technology
status of XigrisTM (approved in last year's final rule at
67 FR 50013). We estimate the proposed total add-on payments for
this new technology for FY 2004 would be $50 million.
We computed a proposed wage and recalibration budget neutrality
factor of 1.003133. The 0.0 percent impact for all hospitals
demonstrates that these proposed changes, in combination with the
proposed budget neutrality factor, are budget neutral. In Table I,
the combined overall impacts of the effects of both the proposed DRG
reclassifications and recalibration and the proposed updated wage
index are shown in column 6. The proposed changes in this column are
the sum of the proposed changes in columns 3, 4, and 5, combined
with the budget neutrality factor and the wage index floor for urban
areas required by section 4410 of Pub. L. 105-33 to be budget
neutral. There also may be some variation of plus or minus 0.1
percentage point due to rounding.
G. 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 7 reflect
the per case payment impact of moving from this baseline to a
simulation incorporating the MGCRB decisions for FY 2004. These
decisions affect hospitals' standardized amount and wage index area
assignments.
By February 28 of each year, the MGCRB makes reclassification
determinations that will be effective for the next fiscal year,
which begins on October 1. The MGCRB may approve a hospital's
reclassification request for the purpose of using another area's
standardized amount, wage index value, or both. The proposed FY 2004
wage index values incorporate all of the MGCRB's reclassification
decisions for FY 2004. The wage index values also reflect any
decisions made by the CMS Administrator through the appeals and
review process as of February 28, 2003. Additional changes that
result from the Administrator's review of MGCRB decisions or a
request by a hospital to withdraw its application will be reflected
in the final rule for FY 2004.
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 1.003133 to ensure that the effects of
reclassification are budget neutral. (See section II.A.4.b. of the
Addendum to this proposed rule.)
As a group, rural hospitals benefit from geographic
reclassification. Their payments would rise 2.6 percent in column 7.
Payments to urban hospitals would decline 0.4 percent. Hospitals in
other urban areas would experience an overall decrease in payments
of 0.2 percent, while large urban hospitals would lose 0.4 percent.
Among urban hospital groups (that is, bed size, census division, and
special payment status), payments generally would decline.
A positive impact is evident among most of the rural hospital
groups. The smallest increases among the rural census divisions are
0.4 and 1.5 percent for the Puerto Rico and Mountain regions,
respectively. The largest increases are in the rural South Atlantic
and West South Central regions. These regions would experience
increases of 2.9 and 3.7 percent, respectively.
Among all the hospitals that were reclassified for FY 2004
(including hospitals that received wage index reclassifications in
FY 2002 or FY 2003 that extend for 3 years), the MGCRB changes are
estimated to provide a 4.3 percent increase in payments. Urban
hospitals reclassified for FY 2004 are expected to receive an
increase of 4.0 percent, while rural reclassified hospitals are
expected to benefit from the MGCRB changes with a 4.6 percent
increase in payments. Overall, among hospitals that were
reclassified for purposes of the standardized amount only, a payment
increase of 3.9 percent is expected, while those reclassified for
purposes of the wage index only show a 4.3 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 0.6 percent for urban hospitals and 0.5
percent for rural hospitals.
H. All Changes (Column 8)
Column 8 compares our estimate of payments per case,
incorporating all changes reflected in this proposed rule for FY
2004 (including statutory changes), to our estimate of payments per
case in FY 2003. This column includes all of the proposed policy
changes. Because the reclassifications shown in column 7 do not
reflect FY 2003
[[Page 27413]]
reclassifications, the impacts of FY 2004 reclassifications only
affect the impacts from FY 2003 to FY 2004 if the reclassification
impacts for any group of hospitals are different in FY 2004 compared
to FY 2003.
Column 8 includes the effects of the 3.5 percent update to the
standardized amounts and the hospital-specific rates for MDHs and
SCHs. It also reflects the 0.4 percentage point difference between
the projected outlier payments in FY 2003 (5.1 percent of total DRG
payments) and the current estimate of the percentage of actual
outlier payments in FY 2003 (5.5 percent), as described in the
introduction to this Appendix and the Addendum to this proposed
rule. As a result, payments are projected to be 0.4 percent higher
in FY 2003 than originally estimated, resulting in a 0.4 percent
smaller increase than would otherwise occur.
Section 213 of Public Law 106-554 provides 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 2004, eligible
SCHs receive 100 percent of their 1996 hospital-specific rate. The
impact of this provision is modeled in column 8 as well.
The proposed expansion of the postacute care transfer policy
also reduces payments by paying for discharges to postacute care in
19 additional DRGs as transfers. Because FY 2003 payments reflect
full DRG payments for all cases in these 19 DRGs, there is a
negative impact due to the proposed expansion of this policy
compared to FY 2003. The net effect of this proposed policy, as
displayed in column 2, is also seen in the lower overall percent
change shown in column 8 comparing FY 2004 simulated payments per
case to FY 2003 payments.
Another influence on the overall change reflected in this column
is the requirement of section 402(b) of Public Law 108-7 that all
hospitals receive the large urban standardized amount for all
discharges occurring on or after April 1, 2003, and before October
1, 2003. For discharges occurring on or after October 1, 2003, the
Federal rate will again be calculated based on separate average
standardized amounts for hospitals in large urban areas and for
hospitals in other areas. The effect is to reduce the percent
increase reflected in the ``all changes'' column.
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 described above.
The overall change in payments per case for hospitals in FY 2004
would increases by 2.5 percent. Hospitals in urban areas would
experience a 2.5 percent increase in payments per case compared to
FY 2003. Hospitals in rural areas, meanwhile, would experience a 3.1
percent payment increase. Hospitals in large urban areas would
experience a 2.6 percent increase in payments.
Among urban census divisions, the largest payment increase was
3.5 percent in the Mountain region. Hospitals in the urban East
South Central region and in Puerto Rico would experience an overall
increase of 3.1 percent and 2.9 percent, respectively. The smallest
increase would occur in the Middle Atlantic, with an increase of 1.7
percent. These below average increases are primarily due to the
inflated outlier payments for some of these hospitals during FY 2003
compared to FY 2004. Among rural regions, the only hospital category
that would experience overall payment decreases is Puerto Rico,
where payments would decrease by 0.2 percent, largely due to the
updated wage data. In the West North Central region, payments are
projected to increase by 3.8 percent. West South Central and Pacific
regions also would benefit, both with 3.5 percent increases.
Among special categories of rural hospitals, those hospitals
receiving payment under the hospital-specific methodology (SCHs,
MDHs, and SCH/RRCs) would experience payment increases of 3.9
percent, 3.3 percent, and 3.3 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 would not experience negative
payment impacts from the decline in outlier payments from FY 2003 to
FY 2004 as would hospitals paid based on the national standardized
amounts.
Hospitals that were reclassified for FY 2004 are estimated to
receive a 3.0 percent increase in payments. Urban hospitals
reclassified for FY 2004 are anticipated to receive an increase of
2.7 percent, while rural reclassified hospitals are expected to
benefit from reclassification with a 3.2 percent increase in
payments. Overall, among hospitals reclassified for purposes of the
standardized amount, a payment increase of 5.8 percent is expected,
while those hospitals reclassified for purposes of the wage index
only would show an expected 2.4 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 1.8 percent.
Table II.--Impact Analysis of Proposed Changes for FY 2004 Operating Prospective Payment System
[Payments per case]
----------------------------------------------------------------------------------------------------------------
Average FY Average FY
Number of 2003 payment 2004 payment All FY 2004
hospitals per case \1\ per case \1\ changes
(1) (2) (3) (4)
-------------------------------------------------
By Geographic Location:
All hospitals............................... 4,087 7,423 7,612 2.5
Urban hospitals............................. 2,582 7,890 8,084 2.5
Large urban areas (populations over 1 1,493 8,368 8,586 2.6
million)...................................
Other urban areas (populations of 1 million 1,089 7,257 7,418 2.2
or fewer)..................................
Rural hospitals............................. 1,505 5,393 5,558 3.1
Bed Size (Urban):
0-99 beds............................... 626 5,479 5,625 2.7
100-199 beds............................ 916 6,658 6,829 2.6
200-299 beds............................ 507 7,610 7,788 2.3
300-499 beds............................ 377 8,445 8,660 2.5
500 or more beds........................ 156 10,027 10,261 2.3
Bed Size (Rural):
0-49 beds............................... 690 4,468 4,620 3.4
50-99 beds.............................. 477 5,037 5,204 3.3
100-149 beds............................ 202 5,430 5,582 2.8
150-199 beds............................ 70 5,780 5,937 2.7
200 or more beds........................ 66 6,792 6,993 3.0
Urban by Region:
New England............................. 134 8,326 8,555 2.7
Middle Atlantic......................... 394 8,916 9,064 1.7
South Atlantic.......................... 372 7,454 7,640 2.5
East North Central...................... 429 7,416 7,604 2.5
East South Central...................... 155 7,156 7,376 3.1
[[Page 27414]]
West North Central...................... 176 7,659 7,875 2.8
West South Central...................... 329 7,343 7,523 2.5
Mountain................................ 131 7,697 7,967 3.5
Pacific................................. 416 9,598 9,840 2.5
Puerto Rico............................. 46 3,329 3,426 2.9
Rural by Region:
New England............................. 38 6,841 7,067 3.3
Middle Atlantic......................... 67 5,426 5,565 2.6
South Atlantic.......................... 221 5,486 5,614 2.3
East North Central...................... 199 5,451 5,622 3.1
East South Central...................... 232 4,922 5,071 3.0
West North Central...................... 254 5,294 5,497 3.8
West South Central...................... 273 4,711 4,875 3.5
Mountain................................ 127 6,235 6,436 3.2
Pacific................................. 89 7,151 7,399 3.5
Puerto Rico............................. 5 2,553 2,548 -0.2
By Payment Classification:
Urban hospitals............................. 2,591 7,886 8,080 2.5
Large urban areas (populations over 1 1,572 8,283 8,502 2.7
million)...................................
Other urban areas (populations of 1 million 1,019 7,302 7,460 2.2
of fewer)..................................
Rural areas................................. 1,496 5,355 5,516 3.0
Teaching Status:
Non-teaching............................ 2,976 6,132 6,293 2.6
Fewer than 100 Residents................ 873 7,666 7,867 2.6
100 or more Residents................... 238 11,347 11,603 2.3
Urban DSH:
Non-DSH................................. 1,381 6,624 6,803 2.7
100 or more beds........................ 1,398 8,502 8,706 2.4
Less than 100 beds...................... 276 5,447 5,579 2.4
Rural DSH:
Sole Community (SCH).................... 484 5,239 5,434 3.7
Referral Center (RRC)................... 161 6,159 6,331 2.8
Other Rural: 100 or more beds........... 75 4,696 4,785 1.9
Less than 100 beds...................... 312 4,278 4,386 2.5
Urban teaching and DSH:
Both teaching and DSH................... 771 9,333 9,562 2.5
Teaching and no DSH..................... 273 7,618 7,814 2.6
No teaching and DSH..................... 903 6,852 7,009 2.3
No teaching and no DSH.................. 644 6,174 6,341 2.7
Rural Hospital Types:
Non special status hospitals............ 521 4,445 4,544 2.2
RRC..................................... 149 5,851 6,003 2.6
SCH..................................... 494 5,630 5,849 3.9
Medicare-dependent hospitals (MDH)...... 254 4,168 4,305 3.3
SCH and RRC............................. 78 6,757 6,982 3.3
Type of Ownership:
Voluntary............................... 2,435 7,532 7,722 2.5
Proprietary............................. 699 7,087 7,272 2.6
Government.............................. 833 7,164 7,356 2.7
Unknown................................. 120 7,431 7,565 1.8
Medicare Utilization as a Percent of
Inpatient Days:
0-25.................................... 304 9,997 10,294 3.0
25-50................................... 1,557 8,448 8,657 2.5
50-65................................... 1,663 6,450 6,613 2.5
Over 65................................. 459 5,764 5,916 2.7
Unknown................................. 104 6,720 6,921 3.0
Hospitals Reclassified by the Medicare
Geographic Classification Review Board: FY 2004
Reclassifications:
All Reclassified Hospitals...................... 639 6,883 7,088 3.0
Standardized Amount Only.................... 22 5,590 5,912 5.8
Wage Index Only............................. 556 6,914 7,077 2.4
Both........................................ 33 6,081 6,269 3.1
All Nonreclassified Hospitals................... 3,442 7,542 7,734 2.5
All Urban Reclassified Hospitals................ 136 8,787 9,020 2.7
Urban Nonreclassified Hospitals................. 13 6,211 6,358 2.4
Standardized Amount Only.................... 82 9,866 10,098 2.3
[[Page 27415]]
Wage Index Only............................. 41 6,934 7,200 3.8
Both........................................ 2,415 7,853 8,045 2.4
All Reclassified Rural Hospitals................ 503 6,006 6,199 3.2
Standardized Amount Only.................... 15 4,743 4,843 2.1
Wage Index Only............................. 464 6,014 6,205 3.2
Both........................................ 24 6,242 6,482 3.8
Rural Nonreclassified Hospitals................. 999 4,624 4,756 2.8
Other Reclassified Hospitals (Section 34 4,950 5,039 1.8
1886(d)(8)(B)).................................
----------------------------------------------------------------------------------------------------------------
\1\ These payment amounts per case do not reflect any estimates of annual case-mix increase.
Table II presents the projected impact of the proposed changes
for FY 2004 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 2003 with the average estimated per case
payments for FY 2004, 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 Other Policy Changes
In addition to those proposed changes discussed above that we
are able to model using our IPPS payment simulation model, we are
proposing various other changes in this proposed rule. Generally, we
have limited or no specific data available with which to estimate
the impacts of these proposed changes. Our estimates of the likely
impacts associated with these other proposed changes are discussed
below.
A. Changes to Bed and Patient Day Counting Policies
1. Background
Under IPPS, both the IME and the DSH adjustments utilize
statistics regarding the number of beds and patient days of a
hospital to determine the level of the respective payment
adjustment. For IME, hospitals receiving this adjustment want to
minimize their numbers of beds in order to maximize their resident-
to-bed ratio. For DSH, urban hospitals with 100 or more beds qualify
for a higher payment adjustment, so some hospitals have an incentive
to maximize their bed count to qualify for higher payments. Existing
regulations specify that the number of beds is determined by
counting the number of available bed days during the cost reporting
period and dividing that number by the number of days in the cost
reporting period.
2. Unoccupied Beds
Over the years, questions have 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. In section IV.C. of the
preamble of this proposed rule, we are proposing to base the
determination of whether a bed is available upon whether the unit
where the bed is located is staffed for patient care. If the bed is
located in a unit that was staffed by nurses to provide patient care
at any time during the 3 preceding months, all of the beds in the
unit would be counted for purposes of determining available bed days
during the current month. If no patient care were provided in that
unit during the 3 preceding months, the beds in the unit would be
excluded from the determination of available bed days during the
current month.
This proposal is primarily intended to establish clear and
consistent guidelines for hospitals and fiscal intermediaries to use
when determining whether beds should be counted. We do not
anticipate this proposal would have a significant impact on
payments. In some cases, previously uncounted beds would now be
counted, such as when a hospital is undertaking to remodel a unit
and that unit is temporarily unavailable for patient occupancy.
Under the proposed policy, if the remodeling is completed in less
than 3 months and patients are again being treated in the unit, all
of the beds in the unit would be counted as available for the entire
year.
3. Nonacute Care Beds and Days
The proposed rule would clarify that days attributable to a
nonacute care unit or ward, regardless of whether the unit or ward
is separately certified by Medicare or is adjacent to a unit or ward
used to provide an acute level of care, would not be included in the
count of bed or patient days. In a recent decision by the Ninth
Circuit Court of Appeals (Alhambra Hosp. v. Thompson, 259 F.3d 1017
(9th Cir. 2001)), the court found that our policy for counting
patient days did not preclude a hospital from counting the patient
days attributable to a nonacute care unit adjacent to an area of the
hospital subject to the IPPS. Under this ruling, hospitals within
the jurisdiction of the Ninth Circuit would be able to count those
patient days.
Because the Alhambra decision was based on a regulatory
interpretation, this proposed rule, when finalized, would supersede
the Alhambra decision in the Ninth Circuit. We estimate that if all
hospitals in the Ninth Circuit that could take advantage of this
ruling were currently doing so, the impact of this provision of the
proposed rule would be $184 million in reduced Medicare program
payments to the affected hospitals in FY 2004 for DSH. This estimate
reflects the impact of adding all days of non-Medicare certified
nursing facilities to the count of inpatient days for hospitals in
the nine States under the jurisdiction of the Ninth Circuit. For
example, in Alaska, nursing facility days constitute 11 percent of
total Medicaid inpatient days. If all of these nursing facility days
are currently included in the Medicaid inpatient days count, we
estimate this proposed provision would reduce Medicare DSH payments
to Alaska's hospitals by $662,097.
We are unable to estimate the effect of this proposed provision
on specific hospitals because we are not aware of specific hospitals
that are presently including those inpatient days in their
calculation of Medicaid days for purposes of determining their
Medicare DSH percentage. However, we expect the impact on any
particular hospital would be minimal (with no impact on the level of
beneficiary services), because the days attributable to patients
receiving these limited benefit programs should be only a small
portion of the overall Medicaid days at any particular hospital. No
other provider types would be affected. However, because our policy
is to count patient days and beds consistently, inclusion of the
days of postacute care units in the DSH calculation would lead to an
offsetting negative payment impact for teaching hospitals. The
inclusion of additional beds decreases the resident-to-bed ratios
used to calculate the IME adjustments. Therefore, the actual
potential impact on hospitals of this policy clarification is likely
to be significantly less than $184 million.
4. Observation and Swing-Beds
We are proposing to revise our regulations to clarify that
swing-bed and observation bed days are to be excluded from the count
of bed and patient days. Because this certification reflects our
current policy, despite the fact
[[Page 27416]]
that there has been some confusion and we have had adverse court
decisions, we do not anticipate this clarification would have a
significant impact on payments. We do not have data available that
would enable us to identify those hospitals that have not been
applying this policy and, therefore, would be required to change
their policy. Consequently, we are unable to quantify the impacts of
this clarification.
5. Labor, Delivery, Recovery, and Postpartum Beds and Days
Similarly, in the case of labor, delivery, recovery, and
postpartum rooms, we would clarify that it is necessary to apportion
the days and costs of a patient stay between the labor/delivery
ancillary cost centers and the routine adults and pediatrics cost
center on the basis of the percentage of time during the entire stay
associated with these various services. Because this is a
clarification of existing policy, we do not anticipate this proposed
change would have a significant payment impact. However, we do not
have data available that would enable us to identify those hospitals
that have not been applying this policy and, therefore, would be
required to change their policy. Consequently, we are unable to
quantify the impacts of this clarification.
6. Days Associated With Demonstration Projects Under Section 1115 of
the Act
Some States have demonstration projects that provide family
planning or outpatient drug benefits that are limited benefits that
do not include Medicaid coverage for inpatient services. In this
proposed rule, we also would clarify that any hospital inpatient
days attributed to a patient who is not eligible for Medicaid
inpatient hospital benefits either under the approved State plan or
through a section 1115 waiver must not be counted in the calculation
of Medicaid days for purposes of determining a hospital's DSH
percentage.
We estimated the potential impact of the proposed clarification
to our policy of excluding days associated with inpatients who are
eligible only for Medicaid outpatient benefits. We identified the
percentage of individuals receiving only outpatient family planning
benefits under Medicaid compared to all Medicaid-eligible
beneficiaries (this is currently the only outpatient-only category
for which we have numbers of eligible beneficiaries). These
percentages were calculated on a statewide basis for each State with
a family planning benefit. Based on these percentages, assuming
family planning beneficiaries use inpatient services at the same
rate as all other Medicaid beneficiaries, we estimated the amount of
total Medicare DSH payments for each State that may be attributable
to family planning beneficiaries' use of inpatient services.
For example, in Alabama, total Medicare DSH payments in 1999
(the latest year for which a complete database of cost reports from
all hospitals is available) were $97.1 million. Because the
percentage of family planning beneficiaries to total Medicaid
eligible beneficiaries is 11.24 percent, we estimated 11.24 percent
of $97.1 million in Medicare DSH payments, or $10.9 million, is the
maximum amount of Medicare DSH that may currently be attributable to
the inclusion of inpatient days for individuals who are only
eligible for outpatient family planning Medicaid benefits. Based on
this analysis, we have identified the potential impact upon
hospitals to be as much as $290 million in reduced DSH payments from
the Medicare program to those hospitals in FY 2004. Of this amount,
$170 million is attributable to California. This amount is not an
impact on State programs nor does it require States to spend any
additional money. We also note that we are not aware of any specific
hospitals that are including inpatient days attributable to
individuals with no inpatient Medicaid benefits. Therefore, this
estimate reflects the maximum potential impact, but the actual
impact is very likely to be much less.
We are unable to estimate the effect of this clarification on
specific hospitals because we are not aware of specific hospitals
that are presently including those inpatient days in their
calculation of Medicaid days for purposes of determining their
Medicare DSH percentage. However, we expect the impact on any
particular hospital would be minimal (with no impact on the level of
beneficiary services), because the days attributable to patients
receiving these limited benefit programs should be only a small
portion of the overall Medicaid days at any particular hospital. No
other provider types would be affected.
7. Dual-Eligible Patient Days
We are proposing to change our policy for counting days for
patients who are Medicare beneficiaries and also eligible for
Medicaid, to begin to count in the Medicaid fraction of the DSH
patient percentage the patient days of these dual-eligible Medicare
beneficiaries whose Medicare coverage has expired. Our current
policy regarding dual-eligible patient days is they are counted in
the Medicare fraction and excluded from the Medicaid fraction, even
if the patient has no Medicare Part A coverage or coverage has been
exhausted. However, we recognize it is often difficult for fiscal
intermediaries to differentiate the days for dual-eligible patients
whose Part A coverage has been exhausted. We believe the impact of
this proposed change would be minimal, both because situations where
dual-eligible patients exhaust their Medicare benefits occur
infrequently, and because, due to the administrative difficulty
separately identifying these days, in many cases they are already
included in the hospital's Medicaid fraction. Accordingly, we do not
have data available to allow us to quantify the impact of this
proposed change precisely.
8. Medicare+Choice (M+C) Days
We have received questions whether patients enrolled in a
Medicare+Choice (M+C) Plan should be counted in the Medicare
fraction or the Medicaid fraction of the DSH patient percentage
calculation. The questions stem from whether M+C plan enrollees are
entitled to Medicare Part A because M+C plans are administered
through Medicare Part C. We are proposing to clarify that once a
beneficiary elects Medicare Part C, those patient days attributable
to the beneficiary should not be included in the Medicare fraction
of the DSH patient percentage. These patient days should be included
in the count of total patient days in the Medicaid fraction (the
denominator), and the patient's days for an M+C beneficiary who is
also eligible for Medicaid would be included in the numerator of the
Medicaid fraction.
We do not have data readily available to assess the impacts of
this proposed change. In particular, it appears likely that there is
some variation in how these days are currently being handled from
one hospital and fiscal intermediary to the next. Nonetheless, we
believe there should not be a major impact associated with this
proposed change.
B. Costs of Approved Nursing and Allied Health Education Activities
1. Continuing Education
In section IV.E. of the preamble of this proposed rule, we are
proposing to clarify further the distinction between continuing
education, which is not eligible for pass-through payment, and
approved educational programs, which are eligible for pass-through
payment. An approved program that qualifies for pass-through payment
is generally a program of long duration designed to develop trained
practitioners in a nursing or allied health discipline, such as
professional nursing, in which the individual learns ``value-added''
skills that enable him or her to work in a particular capacity upon
completion of the program. Such a program is in contrast to a
continuing education program in which a practitioner, such as a
registered nurse, receives training in a specialized skill or a new
technology. While such training is undoubtedly valuable in enabling
the nurse to treat patients with special needs, the nurse, upon
completion of the program, continues to function as a registered
nurse, albeit one with an additional skill. We are proposing to
clarify our policy concerning not allowing pass-through payment for
continuing education because it has come to our attention that
certain programs, which in our view constitute continuing education,
such as pharmacy or clinical pastoral education, are inappropriately
receiving pass-through payment.
To the extent that Medicare would no longer pay for such
programs as pharmacy and clinical pastoral education, Medicare
payments would be reduced. We believe that these two programs
comprise a small fraction of the approximately $230 million that are
paid for all nursing and allied health education programs under
Medicare.
2. Nonprovider-Operated Nursing and Allied Health Education Programs
With Wholly Owned Subsidiary Educational Institutions
As discussed in section IV.E.3. of this proposed rule, we are
proposing that Medicare would not recoup reasonable cost payment
from hospitals that have received pass-through payment for portions
of cost reporting periods occurring on or before October 1, 2003
(the effective date of finalizing this proposed rule) for costs of
nursing or allied health education program(s) where the program(s)
had originally been operated by the hospital, and then operation
[[Page 27417]]
of program(s) had been transferred by the hospital to a wholly owned
subsidiary educational institution in order to meet accreditation
standards prior to October 1, 2003, and where the hospital had
continued to incur the costs of both the classroom and clinical
training portions of the programs while the program(s) were operated
by the educational institution. We estimate that the costs to the
Medicare program of this proposal would be approximately $10 to $20
million. We do not believe many hospitals fit the criteria described
above of previously receiving Medicare payment for direct operation
of nursing or allied health education program(s) and then
transferring operation of the program(s) to a wholly owned
subsidiary educational institution, all the while incurring the
classroom and clinical training costs of the program(s).
In addition, we are also proposing that, for portions of cost
reporting periods beginning on or after October 1, 2003, a hospital
that meets the criteria described above may continue to receive
reasonable cost payments for clinical training costs incurred by the
hospital for the nursing and allied health education program(s) that
were operated by the hospital prior to the date the hospital
transferred operation of the program(s) to its wholly owned
subsidiary educational institution (and ceased to be a provider-
operated program). We are further proposing that, with respect to
classroom costs, only those classroom costs incurred by the hospital
for the courses that were paid by Medicare on a reasonable cost
basis and included in the hospital's provider-operated program(s)
could continue to be reimbursed on a reasonable cost basis. We
estimate the costs to the Medicare program for this proposal would
be $1 to $2 million per year.
C. Prohibition Against Counting Residents Where Other Entities Have
Previously Incurred the Training Costs
As we explain in section IV.F.2. of the preamble of this
proposed rule, under section 1886(h) of the Act, hospitals may count
the time that residents spend training in nonhospital sites if they
meet certain conditions, including incurring ``all or substantially
all'' of the costs of training at the nonhospital site. Legislative
history indicates that the purpose of this provision is to encourage
hospitals to provide more training outside the traditional hospital
environment.
It has come to our attention that hospitals have been incurring
the costs of and receiving direct GME and IME payment for residency
training that had previously been occurring in nonhospital settings,
without the financial support of the hospitals. We believe that
where no new or additional training is provided in these nonhospital
settings, the receipt of Medicare payment in such cases is contrary
to Congressional intent and is, therefore, inappropriate. In
addition, it violates Medicare's anti-redistribution principle,
which states that Medicare will not share in the costs of
educational activities of a hospital that represent a redistribution
of costs from the community to the hospital. Accordingly, we are
proposing to revise our policy concerning counting residents to
ensure that Medicare IME and direct GME payments are not made to
hospitals for training that had already been in place in the absence
of the hospital's financial support. We are proposing that effective
October 1, 2003, in order for a hospital to receive IME and direct
GME payment, the hospital must have been continuously incurring the
direct GME costs of residents training in a particular program since
the date the resident first began training in the program in order
for the hospital to count the FTE residents.
By prohibiting payment for residency training that had been
previously supported by nonhospital institutions, this proposal
would reduce the amount of direct GME and IME payments received by
hospitals. Although we cannot estimate the impact on programs
nationally, we are aware that two hospitals in New York were
receiving over $10 million annually for payments for dental
residents training in nonhospital sites (including a site in
Hawaii). Another hospital in Boston was receiving over $2 million
annually for dental residents training at a dental school.
D. Rural Track GME Training Programs
1. Reduction in the Time Required for Training Residents in a Rural
Area
As explained in section IV.F.3 of the preamble of this proposed
rule, under existing regulations, if an urban hospital rotates
residents to a separately accredited rural track program in a rural
area for two-thirds of the duration of the training program, the
urban hospital may receive an increase in its FTE cap to reflect the
time those residents train at the urban hospital. When we first
implemented these regulations, we did so based on our understanding
that the Accreditation Council for Graduate Medical Education
(ACGME) requires that at least two-thirds of the duration of the
program be spent in a rural area. However, it has come to our
attention that, while the ACGME generally follows a one-third/two-
thirds model for accreditation, the rural training requirement is
actually somewhat less than two-thirds of the duration of the
program. Therefore, we are proposing to revise the regulations to
state that if an urban hospital rotates residents to a separately
accredited rural track program in a rural area for more than 50
percent of the duration of the training program, the urban hospital
may receive an increase in its FTE cap to reflect the time those
residents train at the urban hospital. We estimate that this
proposal would only slightly increase Medicare payments for IME and
direct GME costs.
2. Inclusion of Rural Track FTE Residents in the Rolling Average
Calculation
As explained in section IV.F.4 of the preamble of this proposed
rule, when we first issued the regulations concerning residents
training in a rural track program, we inadvertently did not specify
in regulations that these residents would be included in the
hospital's rolling average count of FTE residents used for computing
GME payment. We are proposing to make this technical clarification
to the regulations. We believe that this proposed provision would
not have a budget impact because it is a clarification of existing
policy.
VIII. Impact of Proposed Changes in the Capital PPS
A. General Considerations
Fiscal year 2001 was the last year of the 10-year transition
period established to phase in the PPS 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 V. of the preamble of this proposed rule, with the 10-year
transition period ending with hospital cost reporting periods
beginning on or after October 1, 2001 (FY 2002), beginning in FY
2004 capital prospective payment system payments for most hospitals
are based solely on the Federal rate. 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 December 2002 update of the FY 2002 MedPAR file
and the December 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 December 2002 update of the most recently available
hospital cost report data (FY 2000) to categorize hospitals. Our
analysis has several qualifications. First, we do not make
adjustments for behavioral changes that hospitals may adopt in
response to policy changes. Second, due to the interdependent nature
of the prospective payment system, it is very difficult to precisely
quantify the impact associated with each proposed change. Third, we
draw upon various sources for the data used to categorize hospitals
in the tables. In some cases (for instance, the number of beds),
there is a fair degree of variation in the data from different
sources. We have attempted to construct these variables with the
best available sources overall. However, for
[[Page 27418]]
individual hospitals, some miscategorizations are possible.
Using cases from the December 2002 update of the FY 2002 MedPAR
file, we simulated payments under the capital prospective payment
system for FY 2003 and FY 2004 for a comparison of total payments
per case. Any short-term, acute care hospitals not paid under the
general hospital inpatient prospective payment systems (Indian
Health Service Hospitals and hospitals in Maryland) are excluded
from the simulations.
As we explain in section III.A.4. of the Addendum of this
proposed rule, payments will no longer be made under the regular
exceptions provision under Sec. Sec. 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:
[sbull] We estimate that the Medicare case-mix index would
increase by 1.01505 percent in FY 2003 and would increase by 1.02010
percent in FY 2004.
[sbull] We estimate that the Medicare discharges will be
14,288,000 in FY 2003 and 14,507,000 in FY 2004 for a 1.5 percent
increase from FY 2003 to FY 2004.
[sbull] The Federal capital rate was updated beginning in FY
1996 by an analytical framework that considers changes in the prices
associated with capital-related costs and adjustments to account for
forecast error, changes in the case-mix index, allowable changes in
intensity, and other factors. The proposed FY 2004 update is 0.7
percent (see section III.A.1.a. of the Addendum to this proposed
rule).
[sbull] In addition to the proposed FY 2004 update factor, the
proposed FY 2004 Federal rate was calculated based on a GAF/DRG
budget neutrality factor of 1.0038, an outlier adjustment factor of
0.9455, and a (special) exceptions adjustment factor of 0.9995.
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. 412.304(c)(2))
are paid 100 percent of the Federal rate in FY 2004.
We used the actuarial model described above to estimate the
potential impact of our proposed changes for FY 2004 on total
capital payments per case, using a universe of 3,922 hospitals. As
described above, the individual hospital payment parameters are
taken from the best available data, including the December 2002
update of the FY 2002 MedPAR file, the December 2002 update to the
Provider-Specific File, and the most recent cost report data from
the December 2002 update of HCRIS. In Table III, we present a
comparison of total payments per case for FY 2003 compared to FY
2004 based on the proposed FY 2004 payment policies. Column 2 shows
estimates of payments per case under our model for FY 2003. Column 3
shows estimates of payments per case under our model for FY 2004.
Column 4 shows the total percentage change in payments from FY 2003
to FY 2004. The change represented in Column 4 includes the 0.7
percent update to the Federal rate, a 1.02010 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 1.0 percent in FY 2004. 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 different rates of
increase in capital payments per case (0.9 percent and 1.5 percent,
respectively). This difference is due to a projection that rural
hospitals will experience a larger increase in the GAF due to
reclassifications from rural to urban and a slightly larger increase
in DSH and IME payments from FY 2003 to FY 2004 compared to urban
hospitals.
All regions are estimated to receive an increase in total
capital payments per case. Changes by region vary from a minimum
increase of 0.4 percent (Middle Atlantic urban region) to a maximum
increase of 2.1 percent (New England rural region). Hospitals
located in Puerto Rico are expected to experience an increase in
total capital payments per case of 1.3 percent.
By type of ownership, government hospitals are projected to have
the largest rate of increase of total payment changes (1.2 percent).
Similarly, payments to voluntary hospitals will increase 1.0
percent, while payments to proprietary hospitals will increase 0.9
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 2004 compared to the effects of reclassification for FY 2003, we
show the average payment percentage increase for hospitals
reclassified in each fiscal year and in total. The reclassified
groups are compared to all other nonreclassified hospitals. These
categories are further identified by urban and rural designation.
Hospitals reclassified for FY 2004 as a whole are projected to
experience a 1.7 percent increase in payments. Payments to
nonreclassified hospitals would increase almost half as much (0.9
percent) as reclassified hospitals, overall. Hospitals reclassified
during both FY 2003 and FY 2004 are projected to receive an increase
in payments of 1.4 percent. Hospitals reclassified during FY 2004
only are projected to receive an increase in payments of 4.9
percent. This increase is primarily due to changes in the GAF (wage
index).
Table III.--Comparison of Total Payments Per Case
[FY 2003 payments compared to proposed FY 2004 payments]
----------------------------------------------------------------------------------------------------------------
Average FY Average FY
Number of 2003 payments/ 2004 payments/ Change
hospitals case case
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
All hospitals............................... 3,922 706 713 1.0
Large urban areas (populations over 1 1,420 808 815 0.9
million)...................................
Other urban areas (populations of 1 million 1,041 693 700 1.0
of fewer)..................................
Rural areas................................. 1,461 476 483 1.5
Urban hospitals............................. 2,461 758 765 0.9
0-99 beds............................... 549 529 535 1.0
100-199 beds............................ 884 643 649 1.0
200-299 beds............................ 501 728 735 0.9
300-499 beds............................ 373 809 817 1.1
500 or more beds........................ 154 959 967 0.8
Rural hospitals............................ 1,461 476 483 1.5
[[Page 27419]]
0-49 beds............................... 659 390 396 1.6
50-99 beds.............................. 469 440 446 1.4
100-149 beds............................ 198 483 488 1.2
150-199 beds............................ 70 524 530 1.3
200 or more beds........................ 65 594 606 2.0
By Region:
Urban by Region............................. 2,461 758 765 0.9
New England............................. 131 808 820 1.5
Middle Atlantic......................... 386 851 854 0.4
South Atlantic.......................... 356 724 729 0.8
East North Central...................... 409 726 734 1.0
East South Central...................... 152 684 695 1.6
West North Central...................... 168 732 741 1.3
West South Central...................... 303 711 715 0.6
Mountain................................ 119 732 744 1.6
Pacific................................. 393 893 904 1.2
Puerto Rico............................. 44 317 322 1.3
Rural by Region............................. 1,461 476 483 1.5
New England............................. 38 591 603 2.1
Middle Atlantic......................... 66 500 506 1.0
South Atlantic.......................... 218 490 496 1.2
East North Central...................... 195 490 497 1.6
East South Central...................... 229 435 443 1.6
West North Central...................... 248 468 477 1.9
West South Central...................... 263 426 432 1.5
Mountain................................ 117 506 511 0.9
Pacific................................. 82 564 574 1.7
By Payment Classification:
All hospitals............................... 3,922 706 713 1.0
Large urban areas (populations over 1 1,497 799 807 1.0
million)...................................
Other urban areas (populations of 1 million 972 697 703 0.9
of fewer)..................................
Rural areas................................. 1,453 474 479 1.2
Teaching Status:............................
Non-teaching............................ 2,829 580 586 1.0
Fewer than 100 Residents................ 857 733 741 1.1
100 or more Residents................... 236 1,074 1,083 0.8
Urban DSH:
100 or more beds.................... 1,373 798 806 1.0
Less than 100 beds.................. 258 528 531 0.7
Rural DSH:
Sole Community (SCH/EACH)........... 476 417 423 1.5
Referral Center (RRC/EACH).......... 161 546 553 1.2
Other Rural:
100 or more beds................ 72 447 448 0.3
Less than 100 beds.............. 301 405 410 1.3
Urban teaching and DSH:
Both teaching and DSH................... 762 876 885 1.0
Teaching and no DSH..................... 264 766 774 1.0
No teaching and DSH..................... 869 644 650 0.8
No teaching and no DSH.................. 574 627 634 1.1
Rural Hospital Types:
Non special status hospitals............ 495 426 430 0.8
RRC/EACH................................ 148 554 561 1.2
SCH/EACH................................ 482 437 444 1.4
Medicare-dependent hospitals (MDH)...... 250 394 400 1.6
SCH, RRC and EACH....................... 78 540 546 1.2
Hospitals Reclassified by the Medicare
Geographic Classification Review Board:
Reclassification Status During FY2003 and
FY2004:
Reclassified During Both FY2003 and 562 621 629 1.4
FY2004.................................
Reclassified During FY2004 Only..... 68 600 630 4.9
Reclassified During FY2003 Only..... 43 601 575 -4.2
FY2004 Reclassifications:
All Reclassified Hospitals.......... 630 619 630 1.7
All Nonreclassified Hospitals....... 3,258 723 729 0.9
All Urban Reclassified Hospitals.... 131 815 828 1.6
Urban Nonreclassified Hospitals..... 2,299 756 763 0.9
All Reclassified Rural Hospitals.... 499 528 537 1.8
Rural Nonreclassified Hospitals..... 959 410 414 0.9
[[Page 27420]]
Other Reclassified Hospitals (Section 34 486 472 -2.8
1886(D)(8)(B)).........................
Type of Ownership:
Voluntary............................... 2,404 719 726 1.0
Proprietary............................. 674 691 697 0.9
Government.............................. 813 645 652 1.2
Medicare Utilization as a Percent of
Inpatient Days:
0-25.................................... 291 901 914 1.4
25-50................................... 1,529 804 812 0.9
50-65................................... 1,645 615 621 1.0
Over 65................................. 446 556 561 1.0
----------------------------------------------------------------------------------------------------------------
Appendix B: Recommendation of Update Factors for Operating Cost Rates
of Payment for Inpatient Hospital Services
I. Background
Section 1886(e)(4)(A) 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 proposed update factors recommended under section
1886(e)(4) of the Act in this proposed rule, and the final update
factors recommended by the Secretary in the final rule. Accordingly,
this Appendix provides the recommendations of appropriate update
factors for the IPPS standardized amounts, the hospital-specific
rates for SCHs and MDHs, and the rate-of-increase limits for
hospitals and hospitals units excluded from the IPPS. We also
discuss our update framework and respond to MedPAC's recommendations
concerning the update factors.
II. Secretary's Recommendations
Section 1886(b)(3)(B)(i)(XIX) of the Act sets the FY 2004
percentage increase in the operating cost standardized amounts equal
to the rate of increase in the hospital market basket for IPPS
hospitals in all areas. Based on the Office of the Actuary's first
quarter 2003 forecast of the FY 2004 market basket increase, the
proposed update to the standardized amounts is 3.5 percent (that is,
the market basket rate of increase) for hospitals in both large
urban and other areas.
Section 1886(b)(3)(B)(iv) of the Act sets the FY 2004 percentage
increase in the hospital-specific rates applicable to SCHs and MDHs
equal to the rate set forth in section 1886(b)(3)(B)(i) of the Act
(that is, the same update factor as all other hospitals subject to
the IPPS, or the rate of increase in the market basket). Therefore,
the proposed update to the hospital-specific rate applicable to SCHs
and MDHs is also 3.5 percent.
Under section 1886(b)(3)(B)(ii) of the Act, the FY 2004
percentage increase in the rate-of-increase limits for hospitals and
hospital units excluded from the IPPS (psychiatric hospitals and
units, rehabilitation hospitals and units (now referred to as IRFs),
LTCHs, cancer hospitals, and children's hospitals) is the market
basket percentage increase. In the past, hospitals and hospital
units excluded from the IPPS have been paid based on their
reasonable costs subject to limits as established by the Tax Equity
and Fiscal Responsibility Act of 1982 (TEFRA). However, some of
these categories of excluded hospitals and units have begun to be
paid under prospective payment systems. Hospitals and units that
receive any hospital-specific payments will have those payments
subject to TEFRA limits for FY 2004. For these hospitals, the
proposed update is the percentage increase in the excluded hospital
market basket (currently estimated at 3.5 percent).
IRFs are paid under the IRF PPS for cost reporting periods
beginning on or after January 1, 2002. For cost reporting periods
beginning during FY 2004, the Federal prospective payment for IRFs
is based on 100 percent of the adjusted Federal IRF prospective
payment amount, updated annually.
Effective for cost reporting periods beginning during FY 2003,
LTCHs are paid under the LTCH PPS under which they receive payment
based on a 5-year transition period (see the August 30, 2002 final
rule (67 FR 55954)). An LTCH may elect to be paid on 100 percent of
the Federal prospective rate at the start of any of its cost
reporting periods during the 5-year transition period. For purposes
of the update factor, the portion of the LTCH PPS transition blend
payment based on reasonable costs for inpatient operating services
is determined by updating the LTCH's TEFRA limit by the current
estimate of the excluded hospital market basket (or 3.5 percent).
III. Update Framework
Consistent with current law, we are proposing an update
recommendation equal to the full market basket percentage increase
for the IPPS operating cost standardized amounts for FY 2004. We
also have analyzed changes in hospital productivity, scientific and
technological advances, practice pattern changes, changes in case-
mix, the effect of reclassification on recalibration, and forecast
error correction. A discussion of this analysis is below.
A. Productivity
Service level labor productivity is defined as the ratio of
total service output to full-time equivalent employees (FTEs). While
we recognize that productivity is a function of many variables (for
example, labor, nonlabor material, and capital inputs), we use the
portion of productivity attributed to direct labor since this update
framework applies to operating payment. To recognize that we are
apportioning the short-run output changes to the labor input and not
considering the nonlabor inputs, we weight our productivity measure
by the share of direct labor services in the market basket to
determine the expected effect on cost per case.
Our recommendation for the service productivity component is
based on historical trends in productivity and total output for both
the hospital industry and the general economy, and projected levels
of future hospital service output. MedPAC's predecessor, the
Prospective Payment Assessment Commission (ProPAC), estimated
cumulative service productivity growth to be 4.9 percent from 1985
through 1989 or 1.2 percent annually. At the same time, ProPAC
estimated total output growth at 3.4 percent annually, implying a
ratio of service productivity growth to output growth of 0.35.
Absent a productivity measure specific to Medicare patients, we
examined productivity (output per hour) and output (gross domestic
product) for the economy. Depending on the exact time period, annual
changes in productivity range from 0.30 to 0.35 percent of the
change in output (that is, a 1.0 percent increase in output would be
correlated with a 0.30 percent to a 0.35 percent change in output
per hour).
Under our framework, the recommended update is based in part on
expected productivity--that is, projected service output during the
year, multiplied by the historical ratio of service productivity to
total service output, multiplied by the share of direct labor in
total operating inputs, as calculated in the hospital market basket.
This method estimates an expected productivity improvement in the
same proportion to expected total service growth that has occurred
in the past and assumes that, at a minimum, growth in FTEs changes
[[Page 27421]]
proportionally to the growth in total service output. Thus, the
recommendation allows for unit productivity to be smaller than the
historical averages in years during which output growth is
relatively low and larger in years during which output growth is
higher than the historical averages. Based on the above estimates
from both the hospital industry and the economy, we have chosen to
employ the range of ratios of productivity change to output change
of 0.30 to 0.35.
The expected change in total hospital service output is the
product of projected growth in total admissions (adjusted for
outpatient usage), projected real case-mix growth, expected quality-
enhancing intensity growth, and net of expected decline in intensity
due to reduction of cost-ineffective practice. Case-mix growth and
intensity numbers for Medicare are used as proxies for those of the
total hospital, since case-mix increases (used in the intensity
measure as well) are unavailable for non-Medicare patients.
Normally, the expected FY 2004 hospital output growth would be
simply the sum of the expected change in intensity (1.0 percent),
projected admissions change (1.6 percent), and projected real case-
mix growth (1.0 percent--a definition of real case mix growth
appears below), or 3.6 percent. However, as discussed below and in
relation to the proposed capital update, we believe our intensity
estimate is skewed by hospitals' charge data. Therefore, we are
including only the projected changes in admissions and real case-mix
in our calculation of productivity gains. This results in an
estimate of 2.6 percent.
The share of direct labor services in the market basket
(consisting of wages, salaries, and employee benefits) is 61.6
percent. Multiplying the expected change in total hospital service
output (2.6 percent) by the ratio of historical service productivity
change to total service growth of 0.30 to 0.35 and by the direct
labor share percentage of 61.6 provides our productivity standard of
-0.6 to -0.5 percent. Because productivity gains hold down the rate
of increase in hospitals' costs, this factor is applied as a
negative offset to the market basket increase.
B. Intensity
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 non-cost-
effective services. Under the capital IPPS framework, we also make
an adjustment for changes in intensity. We calculate this adjustment
using the same methodology and data that are used in the framework
for the operating IPPS.
We calculate case-mix constant intensity as the change in total
Medicare charges per admission, adjusted for price level changes
(the Consumer Price Index (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.
However, as discussed above in relation to the proposed capital
update, because our intensity calculation relies heavily upon charge
data and we believe that this charge data may be inappropriately
inflated due to manipulation of charges to maximize outlier
payments, we are proposing a 0.0 percent adjustment for intensity in
FY 2004. In past fiscal years (1996 through 2000) when we found
intensity to be declining, we believed a zero (rather then negative)
intensity adjustment was appropriate. Similarly, we believe that it
is appropriate to propose a zero intensity adjustment for FY 2004
until we determine that any increase in charges can be tied to
intensity, rather than to attempts to maximize outlier payments.
C. Change in Case-Mix
Our analysis takes into account projected changes in real case-
mix, less the changes attributable to improved coding practices. We
define real case-mix change as actual changes in the mix (and
resource requirements) of Medicare patients, as opposed to changes
in coding behavior that result in assignment of cases to higher-
weighted DRGs but do not reflect greater resource requirements. For
our FY 2004 update recommendation, we are projecting a 1.0 percent
increase in the case-mix index. We do not believe changes in coding
behavior will impact the overall case-mix in FY 2004. As such, for
FY 2004, we estimate that real case-mix is equal to projected change
in case-mix. Thus, we are recommending a 0.0 percent adjustment for
case-mix.
D. Effect of FY 2002 DRG Reclassification and Recalibration
We estimate that DRG reclassification and recalibration for FY
2002 (GROUPER version 19.0) resulted in a 0 percent change in the
case-mix index when compared with the case-mix index that would have
resulted if we had not made the reclassification and recalibration
changes to the GROUPER (version 18.0). Therefore, we are
recommending a 0 percent adjustment for the effect of FY 2002 DRG
reclassification and recalibration.
E. Forecast Error Correction
We make a forecast error correction if the actual market basket
changes differ from the forecasted market basket by 0.25 percentage
points or more. There is a 2-year lag between the forecast and the
measurement of forecast error. The estimated market basket
percentage increase used to update the FY 2002 payment rates was 3.3
percent. Our most recent data indicates the actual FY 2002 increase
was 2.9 percent. The resulting forecast error in the FY 2002 market
basket rate of increase is (-0.4) percentage points. This
overestimate was due largely to a lower-than-expected increase in
energy costs that impacted natural gas and chemical prices. This
follows consecutive years where the market basket was under-forecast
by 0.7 percentage points each year.
The following is a summary of the update range supported by our
analyses:
HHS's FY 2004 Update Recommendation
------------------------------------------------------------------------
Market basket MB
------------------------------------------------------------------------
Policy Adjustment Factors:
Productivity........................ -0.6 to -0.5
Intensity....................... 0.0
Subtotal.................... -0.6 to -0.5
Case-Mix Adjustment Factors:
Projected Case-Mix Change........... 1.0
Real Across DRG Change.............. -1.0
Subtotal........................ 0.0
Effect of FY 2002 DRG Reclassification 0.0
and Recalibration.
Forecast Error Correction............... -0.4
Total Recommendation Update............. -1.0 to -0.9
------------------------------------------------------------------------
IV. MedPAC Recommendations for Assessing Payment Adequacy and Updating
Payments in Traditional Medicare
In the past, MedPAC recommended specific adjustments to its
update recommendation for each of the factors discussed under
section III. of this Appendix. In its March 2003 Report to Congress,
MedPAC assesses the adequacy of current payments and costs and the
relationship between payments and an appropriate cost base. MedPAC
stresses that the issue at hand is whether payments are too high or
too low, and not how they became such.
In the first portion of MedPAC's analysis on the assessment of
payment adequacy, the Commission reviews the relationship between
costs and payments (typically represented as a margin). Based on the
latest cost report data available, MedPAC estimated an inpatient
Medicare operating margin for
[[Page 27422]]
FY 2000 of 10.8 percent (down from 12.3 percent for FY 1999).
MedPAC also projects margins through FY 2003, making certain
assumptions about changes in payments and costs. On the payment
side, MedPAC applied the annual payment updates (as specified by law
for FYs 2001 through 2003) and then modeled the effects of other
policy changes that have affected the level of payments. On the cost
side, MedPAC estimated the increases in cost per unit of output over
the same time period at the rate of inflation as measured by the
applicable market basket index generated by CMS adjusted downward,
anticipating improvements in productivity. While no specific
Medicare inpatient margin is identified for a calendar year beyond
2000, MedPAC projected an overall Medicare margin for FY 2003 of 3.9
percent (page 41). The FY 2000 overall Medicare margin, as estimated
by MedPAC, was 5.0 percent.
In addition to considering the relationship between estimated
payments and costs, MedPAC also considered the following three
factors to assess whether current payments are adequate (page 42):
[sbull] Changes in access to or quality of care;
[sbull] Changes in the volume of services or number of
providers; and
[sbull] Change in providers' access to capital.
MedPAC's assessment of aggregate Medicare payments finds that
payments were at least adequate as of FY 2003.
MedPAC's recommendation related to updating payments under the
IPPS is that the Congress should increase the payment rates for the
IPPS by the rate of increase in the hospital market basket, less 0.4
percent, for FY 2004. MedPAC focuses on the operating update
exclusively because operating costs account for about 92 percent of
total hospital costs and because the operating update is of most
interest to Congress. Based on the current market basket estimate
for FY 2003 of 3.5 percent, this update would increase Medicare
inpatient payments to hospitals covered by IPPS by 3.1 percent.
Response: As described above, we are recommending a full market
basket update for FY 2004 consistent with current law. We believe
this will appropriately balance incentives for hospitals to operate
efficiently with the need to provide sufficient payments to maintain
access to quality care for Medicare beneficiaries.
Because the operating and capital prospective payment systems
remain separate, CMS continues to use separate updates for operating
and capital payments. The proposed update to the capital payment
rate is discussed in section III. of the Addendum to this proposed
rule.
[FR Doc. 03-11966 Filed 5-9-03; 3:51 pm]
BILLING CODE 4120-03-P