[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]



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Part II





Department of Health and Human Services





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Centers for Medicare & Medicaid Services



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42 CFR Parts 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  

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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.

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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

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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

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(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

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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

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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