[Federal Register Volume 68, Number 148 (Friday, August 1, 2003)]
[Rules and Regulations]
[Pages 45346-45672]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 03-19363]



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Part III





Department of Health and Human Services





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Centers of Medicare & Medicaid Services



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42 CFR Parts 412 and 413



Medicare Program; Changes to the Hospital Inpatient Prospective Payment 
Systems and Fiscal Year 2004 Rates; Final Rule

  Federal Register / Vol. 68, No. 148 / Friday, August 1, 2003 / Rules 
and Regulations  

[[Page 45346]]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 412 and 413

[CMS-1470-F]
RIN 0938-AL89


Medicare Program; Changes to the Hospital Inpatient Prospective 
Payment Systems and Fiscal Year 2004 Rates

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

ACTION: Final rule.

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SUMMARY: We are revising 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 final rule, we are describing changes 
to the amounts and factors used to determine the rates for Medicare 
hospital inpatient services for operating costs and capital-related 
costs. These changes are applicable to discharges occurring on or after 
October 1, 2003. We also are setting forth rate-of-increase limits as 
well as policy changes for hospitals and hospital units excluded from 
the IPPS that are paid on a cost basis subject to these limits.
    Among other changes that we are making are: changes to the 
classification of cases to the diagnosis-related groups (DRGS); changes 
to the long-term care (LTC)-DRGs and relative weights; the introduction 
of updated wage data used to compute the wage index; the approval of 
new technologies for add-on payments; changes to the policies governing 
postacute care transfers; payments to hospitals for the direct and 
indirect costs of graduate medical education; pass-through payments for 
nursing and allied health education programs; determination of hospital 
beds and patient days for payment adjustment purposes; and payments to 
critical access hospitals (CAHs).

EFFECTIVE DATES: The provisions of this final rule, except the 
provisions of Sec.  412.230(e)(2)(ii)(A) (because it grants an 
exemption) and Sec.  412.278(f)(2)(i), are effective on October 1, 
2003. The provisions of Sec.  412.230(e)(2)(ii)(A) and Sec.  
412.278(f)(2)(i) are effective on August 1, 2003. This rule is a major 
rule as defined in 5 U.S.C. 804(2). Pursuant to 5 U.S.C. 801(a)(1)(A), 
we are submitting a report to Congress on this rule on August 1, 2003.

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, and Long-Term Care 
(LTC)-DRGs.
Sandra Hetrick, (410) 786-4542, RCE Limits.

SUPPLEMENTARY INFORMATION:

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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 equivalent
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
LDP Labor, delivery, 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
NCVHS National Committee on Vital and Health 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

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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

Table of Contents

I. Background
    A. Summary
    B. Summary of the Provisions of the May 19, 2003 Proposed Rule
    C. Public Comments Received to the May 19, 2003 IPPS Proposed 
Rule
II. Changes to DRG Classifications and Relative Weights
    A. Background
    B. DRG Reclassification
    1. General
    2. Review of DRGs for Complications or Comorbidity (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 (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 CCs
    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 Sphincter
    C. Recalibration of DRG Weights
    D. LTC-DRG Reclassifications and Relative Weights for LTCHs for 
FY 2004
    1. Background
    2. Changes in the LTC-DRG Classifications
    a. Background
    b. Patient Classifications into DRGs
    3. Development of the Final 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 Final 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. Changes to the Hospital Wage Index
    A. Background
    B. FY 2004 Wage Index Update
    C. FY 2004 Wage Index Changes
    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 FY 2004 Wage Index
    F. 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 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, 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
    3. Application of RCE Limits
    4. Exceptions to RCE Limits
    5. Geographic Area Classifications for RCE Limits
V. PPS for Capital-Related Costs
VI. 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
    6. Implementation of a PPS for IRFs
    4. Development of a PPS for Inpatient Psychiatric Facilities
    5. Implementation of a PPS for LTCHs
    6. Report of Adjustment (Exception) Payments
    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--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

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    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 
for Urban Areas
    Table 4B--Wage Index and Capital Geographic Adjustment Factor 
for Rural Areas
    Table 4C--Wage Index and Capital Geographic Adjustment Factor 
for Hospitals That Are Reclassified
    Table 4F--Puerto Rico Wage Index and Capital Geographic 
Adjustment Factor
    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
    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 March 2003 GROUPER 
V20.0
    Table 7B--Medicare Prospective Payment System Selected 
Percentile Lengths of Stay: FY 2002 MedPAR Update March 2003 GROUPER 
V21.0
    Table 8A--Statewide Average Operating Cost-to-Charge Ratios for 
Urban and Rural Hospitals (Case-Weighted)
    Table 8B--Statewide Average Capital Cost-to-Charge Ratios (Case-
Weighted)
    Table 9--Hospital Reclassifications and Redesignations by 
Hospital--FY 2004
    Table 10--Thresholds to Qualify for New Technology Add-On 
Payments: FY 2004
    Table 11--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

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 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

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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 Public Law 106-
113 and section 307(b)(1) of Public Law 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 June 6, 2003 LTCH PPS final rule (68 FR 34122)). 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 Public Law 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 
(referred to as inpatient psychiatric facilities (IPFs).
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. Summary of the Provisions of the May 19, 2003 Proposed Rule

    On May 19, 2003, we published a proposed rule in the Federal 
Register (68 FR 27154) that set forth proposed changes to the Medicare 
IPPS for operating costs and for capital-related costs in FY 2004. We 
also set forth proposed 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. These changes were proposed to be effective 
for discharges occurring on or after October 1, 2003.
    The following is a summary of the major changes that we proposed 
and the issues we addressed in the May 19, 2003 proposed rule:
1. Changes to the DRG Reclassifications and Recalibrations of Relative 
Weights
    As required by section 1886(d)(4)(C) of the Act, we proposed annual 
adjustments to the DRG classifications and relative weights. Based on 
analyses of Medicare claims data, we proposed to establish a number of 
new DRGs and make changes to the designation of diagnosis and procedure 
codes under other existing DRGs.
    Among the proposed changes discussed were:
    [sbull] Expansion of the number of DRGs that are split on the basis 
of the presence or absence of complications or comorbidities (CCs). The 
DRGs we proposed to split were: DRG 4 (Spinal Procedures) into proposed 
new DRGs 531 and 532 (Spinal Procedures With and Without CC, 
respectively); DRG 5 (Extracranial Vascular Procedures) into proposed 
new DRGs 533 and 534 (Extracranial Vascular Procedures With and Without 
CC, respectively); DRG 231 (Local Excision and Removal of Internal 
Fixation Devices Except Hip and Femur) into proposed new DRGs 537 and 
538 (Local Excision and Removal of Internal Fixation Devices Except Hip 
and Femur With and Without CC, respectively); and DRG 400 (Lymphoma and 
Leukemia With Major O.R. Procedure) into proposed new DRGs 539 and 540 
(Lymphoma and Leukemia With Major O.R. Procedure With and Without CC, 
respectively).
    [sbull] Creation of a new DRG for patients with an intracranial 
vascular procedure and an intracranial hemorrhage. The DRG we proposed 
to create was DRG 528 (Intracranial Vascular Procedure With a Principal 
Diagnosis of Hemorrhage).
    [sbull] Creation of two new DRGs, differentiated on the basis of 
the presence or absence of a CC, for craniotomy patients with only a 
vascular shunt procedure. The DRGs we proposed to create were DRGs 529 
and 530 (Ventricular Shunt Procedure With CC and Without CC, 
respectively).
    [sbull] Creation of 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. The new DRGs we proposed were DRG 535 (Cardiac 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)
    [sbull] Changes in the DRG assignment of certain congenital 
anomalies that currently result in patients being assigned to newborn 
DRGs even when the patient is actually an adult. We also proposed 
adding to the list of major problems in newborns that affect DRG 
assignment.
    [sbull] Modification of DRG 492 (Chemotherapy With Acute Leukemia 
as

[[Page 45350]]

Secondary Diagnosis) to include in this DRG cases receiving high-dose 
Interleukin-2 (IL-2) chemotherapy for patients with advanced renal cell 
cancer and advanced melanoma.
    We also presented our analysis of applicants for add-on payments 
for high-cost new medical technologies and proposed a revision to the 
high-cost threshold for a new technology or medical service to qualify 
for add-on payments.
    [sbull] We proposed to continue to make add-on payments for Xigris.
    [sbull] We discussed new applications for add-on payments for FY 
2004.
    [sbull] We proposed to reduce the high-cost threshold for a new 
technology or medical service to qualify for add-on payments from 1 
standard deviation above the geometric mean standardized charge for 
cases in the DRGs to which the new technology is assigned to 75 percent 
of 1 standard deviation.
2. Changes to the Hospital Wage Index
    We proposed revisions to the wage index and the annual update of 
the wage data. Specific issues addressed in this section included the 
following:
    [sbull] The FY 2004 wage index update, using wage data from cost 
reporting periods that began during FY 2000.
    [sbull] 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] 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] Revisions to the wage index based on hospital 
redesignations and reclassifications.
    [sbull] 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 Changes to the PPS for Inpatient Operating and 
GME Costs
    In the proposed rule, we discussed several provisions of the 
regulations in 42 CFR Parts 412 and 413 and set forth certain proposed 
changes concerning the following:
    [sbull] Expansion of the current postacute transfer policy to 19 
additional DRGs.
    [sbull] 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] Changes in our policy relating to nursing and allied health 
education payments to wholly owned subsidiary educational institutions 
of hospitals.
    [sbull] Clarification of our policy relating to application of 
redistribution of costs and community support funds in determining a 
hospital's resident training costs.
    [sbull] 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.
    [sbull] Inclusion of FTE residents training in rural tracks in a 
hospital's rolling average calculation.
4. PPS for Capital-Related Costs
    We discussed the payment requirements for capital-related costs. We 
did not propose any changes to the policies on payments to hospitals 
for capital-related costs.
5. Changes for Hospitals and Hospital Units Excluded From the IPPS
    We discussed the following proposed revisions and clarifications 
concerning excluded hospitals and hospital units and CAHs:
    [sbull] Revisions 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 the May 19, 2003 proposed rule, we proposed 
changes to the amounts and factors for determining the FY 2004 
prospective payment rates for operating costs and capital-related 
costs. We also established the proposed threshold amounts for outlier 
cases. In addition, we addressed 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 of the proposed rule, we set forth an analysis of the 
impact that the proposed changes would have on affected hospitals.
8. Recommendation of Update Factor for Hospital Inpatient Operating 
Costs
    In Appendix B of the proposed rule, as required by sections 
1886(e)(4) and (e)(5) of the Act, we provided our recommendations of 
the appropriate percentage changes 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. In the proposed rule, we discussed the 
MedPAC recommendations concerning hospital inpatient payment policies 
and presented our response to those recommendations. For further 
information relating specifically to the MedPAC March 1 report or to 
obtain a copy of the report, contact MedPAC at (202) 220-3700 or visit 
MedPAC's Web site at: http://www.medpac.gov.

C. Public Comments Received in Response to the May 19, 2003 IPPS 
Proposed Rule

    We received approximately 4,200 timely items of correspondence 
containing multiple comments on the May 19, 2003 proposed rule. 
Summaries of the public comments and our responses to those comments 
are set forth below under the appropriate heading.

II. Changes to DRG Classifications and Relative Weights

A. Background

    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

[[Page 45351]]

resources used to treat cases in all DRGS.
    Congress recognized that it would be necessary to recalculate the 
DRG relative weights periodically to account for changes in resource 
consumption. Accordingly, section 1886(d)(4)(C) of the Act requires 
that the Secretary adjust the DRG classifications and relative weights 
at least annually. These adjustments are made to reflect changes in 
treatment patterns, technology, and any other factors that may change 
the relative use of hospital resources. Changes to the DRG 
classification system and the recalibration of the DRG weights for 
discharges occurring on or after October 1, 2003 are discussed below.

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 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 DRGs are for heart, liver, bone 
marrow, lung, simultaneous pancreas/kidney, and pancreas transplants 
(DRGs 103, 480, 481, 495, 512, and 513, respectively) and for 
tracheostomies (DRGs 482 and 483). Cases are assigned to these DRGs 
before they are classified 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 
that are 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, for example, 
extracorporeal shock wave lithotripsy for patients with a principal 
diagnosis of having urinary stones.
    Patient's 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). The MCE screens are designed to identify cases that 
require further review before classification into a DRG.
    After patient information is screened through the MCE and any 
further development of the claim is conducted, 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).

[[Page 45352]]

    After cases are screened through the MCE and assigned to a DRG by 
the GROUPER, a base DRG 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 additional factors associated with 
each hospital, such as IME and DSH adjustments. These additional 
factors increase the payment amount to hospitals above the base DRG 
payment.
    The records for all Medicare hospital inpatient discharges are 
maintained in the Medicare Provider Analysis and Review (MedPAR) file. 
The data in this file are used to evaluate possible DRG classification 
changes and to recalibrate the DRG weights. 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 
us to consider the feasibility of using particular non-MedPAR data, 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 non-
MedPAR data submitted. Generally, however, a significant sample of the 
non-MedPAR data should be submitted by mid-October for consideration in 
conjunction with the next year's proposed rule. This allows us time to 
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 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.
    In the May 19, 2003 proposed rule, we proposed numerous changes to 
the DRG classification system for FY 2004. The changes we proposed to 
the DRG classification system for FY 2004, the public comments we 
received concerning the proposed changes, the final DRG changes, and 
the methodology used to recalibrate the DRG weights are set forth 
below. The changes we are implementing in this final rule will be 
reflected in the revised FY 2004 GROUPER version 21.0 and effective for 
discharges occurring on or after October 1, 2003. Unless otherwise 
noted in this final rule, our DRG analysis is based on data from the 
March 2002 update of the FY 2002 MedPAR file, which contains hospital 
bills received through March 31, 2002, for discharges in FY 2002.
2. Review of DRGs for a Split Based on Presence or Absence of a CC
    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 DRGs that reflect a split based on the presence or 
absence of a CC. 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 the May 27, 1994 IPPS 
proposed rule, we described a refined DRG system based on a list of 
secondary diagnoses that have a major effect on the resources that 
hospitals use to treat 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 
based on the presence of a major CC, other CC, or both.\1\ However, we 
did not implement this refined system 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 ICD-
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. We believe that 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 for 
which 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 (Pub. L. 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).
    We are not proceeding with implementing a refined DRG system at 
this time, pending a decision whether to replace the ICD-9-CM coding 
system with another classification system. The refined DRG system 
discussed in the May 1994 IPPS proposed rule 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 
the 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 
additional 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

[[Page 45353]]

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 on 
average lengths of stay in these four DRGs.

------------------------------------------------------------------------
                                                               Average
               DRG                  Number of     Average     length of
                                      cases       charges        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 proposed 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 
Procedures With CC) (the proposed rule incorrectly included 
``Vascular'' in the title) and proposed DRG 534 (Extracranial 
Procedures Without CC) (the proposed rule incorrectly included 
``Vascular'' in the title) in 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 proposed that DRGs 4, 5, 231, and 400 would become invalid.
    Comment: Seven commenters supported the proposed expansion of the 
number of DRGs related to spinal procedures and extracranial vascular 
procedures and the removal of internal fixation devices. One commenter 
commended CMS for the proposed change to payments for implanting spinal 
code stimulation devices. Referring to proposed new DRGs 531 and 532, 
the commenter stated that most inpatients receiving a spinal cord 
stimulator implant have a comorbid condition, which adds significantly 
to the cost of care and can serve as a barrier to patient access. 
Another commenter specifically supported the new DRGs 533 and 534 for 
extracranial vascular procedures.
    One commenter expressed support for CMS' recognition of cost 
differences within a given DRG based on the presence or absence of a CC 
and encouraged CMS to continue to consider secondary diagnoses that can 
have a substantial effect on hospital resources when restructuring DRGs 
based on cost considerations.
    Response: We appreciate the support for these proposals and are 
adopting them as final without further modification.
    We are establishing new DRGs 531, 532, 533, 534, 537, 538, 539, and 
540, effective for discharges occurring on or after October 1, 2003. As 
a result of establishing these new DRGS, DRGs 4, 5, 231, and 400 are 
invalid, effective October 1, 2003. We will continue to monitor whether 
additional DRGs should be split based on the presence or absence of a 
CC.
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.
    Therefore, we conducted an analysis of the charges for 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. In the May 19, 2003 proposed rule, we proposed 
to create two separate new DRGs for: (1) cases with an intracranial 
vascular procedure and a principal diagnosis of an intracranial 
hemorrhage; and (2) 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.

[[Page 45354]]

    Based on this analysis, we proposed 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 proposed that cases involving intracranial 
vascular procedures without a principal diagnosis of hemorrhage would 
remain in DRGs 1 and 2.
    We indicated that 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 aneurysm
    [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 proposed to create two new DRGs, splitting with CC 
and without 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).
    We indicated that proposed new DRG 529 would consist of any 
principal diagnosis in MDC 1 (erroneously cited as MDC 5 in the 
proposed rule), 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
    We proposed that the proposed new DRG 530 would consist of any 
principal diagnosis in MDC 1 (erroneously cited as MDC 5 in the 
proposed rule) with one of the operating room procedures listed above 
for the proposed new DRG 529, but without the presence of a CC.
    Comment: Four commenters supported the proposed creation of two 
DRGs to capture ventricular shunt procedures. Ten commenters supported 
the proposed creation of new DRG 528 for an intracranial vascular 
procedure with a principal diagnosis of hemorrhage.
    Two commenters requested that CMS verify its GROUPER analysis and 
clarify in the final rule the estimated number of cases that will be 
assigned to DRG 528. One commenter also believed that CMS is 
underestimating the volume of hemorrhagic cases that would be assigned 
to this new DRG. The commenter indicated that its analysis of MedPAR 
2001 data demonstrated 1,550 cases.
    Response: We conducted an analysis based on later available MedPAR 
data and found 1,596 cases that would be assigned to DRG 528 (based on 
a full year of MedPAR data). This volume is consistent with the 
commenter's analysis, although different MedPAR files were used in the 
analysis. In the proposed rule (68 FR 27161), we reported 917 cases 
based on preliminary data (6 months' worth of cases) that we analyzed 
when we considered the proposed change in the DRG classification. There 
were actually 1,354 cases grouped to the proposed new DRG 528 for the 
proposed rule.
    Comment: One commenter suggested the creation of a new companion 
DRG to DRG 528 for intracranial vascular procedures for unruptured 
cerebral aneurysms. The commenter was concerned that the charges for 
endovascular repair of unruptured aneurysms is higher than other 
procedures currently assigned to DRG 2.
    Response: The average charges for unruptured aneurysm cases varied 
according to the DRG to which the cases were assigned. The average 
charges for these cases in DRG 1 were slightly higher than the overall 
charges for that DRG, of approximately $69,682 and $54,900, 
respectively. However, we found that these charges are consistent with 
the variation of charges within this DRG and, therefore, did not 
propose a change in the DRG reclassification. Similarly, for cases 
assigned to DRG 2, we found the average charges of approximately 
$36,077 are consistent with the overall average charges of that DRG of 
approximately $32,000. We will continue to monitor these cases.
    Comment: Three commenters requested a change to the DRG assignment 
of cases involving implantation of GLIADEL[reg] chemotherapy wafers to 
treat brain tumors.\2\ One of the commenters offered two options: 
create a new DRG or reassign these cases to DRG 484 (Craniotomy for 
Multiple Significant Trauma). The commenter cited an example in which 
CMS has in the past grouped together in the same DRG cases that are 
clinically dissimilar but similar in resource intensity when there were 
no other options available. For FY 1998 (62 FR 45974), coronary stent 
cases were moved from DRG 112 (Percutaneous Cardiovascular Procedures) 
to DRG 116 (Other Permanent Cardiac Pacemaker Implant or PTCA with 
Coronary Artery Stent Implant). In that instance, CMS concluded that, 
although coronary artery stent cases are not clinically similar to the 
pacemaker cases in DRG 116, the resource consumption of these

[[Page 45355]]

cases is very similar. The commenter contended that, absent another 
appropriate craniotomy DRG, the same argument could be applied to 
assigning cases with GLIADEL[reg] wafer to DRG 484.
---------------------------------------------------------------------------

    \2\ We also discuss this issue later in this preamble under 
section II.E.3.b. relative to the application for new technology 
add-on payments for the GLIADEL[reg] wafer.
---------------------------------------------------------------------------

    In a comment on the proposed rule, the manufacturer of this implant 
provided estimated FY 2003 average costs and charges for these cases. 
Its report indicated that the costs of the cases of $24,280 would be 
the same for cases assigned to DRG 1 and DRG 2, and the charges of the 
cases of $50,394 would be the same for both DRGs. The manufacturer 
requested that we analyze the available data in the FY 2003 MedPAR file 
to identify GLIADEL[reg] cases. The manufacturer believed these data 
support the need for a DRG change.
    One commenter agreed with our determination that this technology is 
currently reflected within the DRG weights and does not meet the 
definition of a new technology.
    Response: In our analysis of the data from the March 2003 update of 
the FY 2003 MedPAR file, we found a total of 61 cases in which the ICD-
9-CM procedure code 00.10 (Implantation of a chemotherapeutic agent) 
was reported for cases assigned to DRGs 1 and 2. There were 38 cases 
assigned to DRG 1 and 23 cases assigned to DRG 2. Consistent with the 
GROUPER logic for these DRGs that splits cases based on the presence or 
absence of CCs, we found that the average standardized charges in DRGs 
1 and 2 were approximately $64,864 and $42,624, respectively. We 
believe that while the charges for GLIADEL[reg] wafer cases may be 
higher than the average standardized charges for DRG 2, they are within 
the normal variation of the overall charges within each DRG.
    We note that the DRGs are a system of averages, and there is 
expected to be variation in the average charges for different 
procedures and services across all DRGs. Hospitals are expected to be 
able to finance some higher cost procedures with lower cost procedures 
within the same DRG as well as across DRGs. Although the average 
charges of the cases we identified in our analysis are somewhat higher 
than the average charges of all cases in these DRGs, they are within 
the range of other procedures included in these DRGs. By way of 
comparison, we are creating a new DRG for cases with an intracranial 
vascular procedure and a principal diagnosis of an intracranial 
hemorrhage on the basis of our analysis that showed the average charges 
for these cases were $113,884. This is approximately $59,000 more than 
the average charges in DRG 1 (more than the total charges for the 
GLIADEL[reg] cases reported by the commenter) and approximately $84,000 
more than the average charges in DRG 2.
    We also are concerned that there may be insufficient volume of 
cases to warrant the establishment of a new DRG for this technology. 
Thus, before considering the creation of a new DRG for these cases, we 
would like to review a full year of data, as well as consider 
alternative options if they appear warranted. It would also be 
necessary to provide opportunity for public comment on any potential 
changes to the DRG assignment of these cases before proceeding with a 
final change.
    Currently, DRG 484 includes complex, multiple significant trauma 
cases; that is, patients with a principal diagnosis of trauma and at 
least two significant trauma diagnosis codes (either as principal or 
secondary diagnosis) from different body site categories. While this 
DRG includes craniotomy, it is assigned to MDC 24 (Multiple Significant 
Trauma). While the treatment for glioblastoma multiforme is 
significant, we do not believe these cases are clinically similar to 
other cases currently assigned to DRG 484.
    We also are concerned that there may be insufficient volume to 
warrant the establishment of a new DRG for this technology, and we 
would like to review a full year of data, as well as consider 
alternative options if they appear warranted. It also would be 
necessary to provide opportunity for public comment on any potential 
changes before proceeding with a final change.
    Comment: Two commenters pointed out a typographical error in our 
proposal. The commenters indicated that we proposed new DRGs 529 and 
530 for placement in MDC 5; the correct MDC should have been MDC 1.
    Response: We agree with the commenters and have corrected this 
placement, as indicated in the discussion above.
    After consideration of the comments received, we are adopting as 
final the three new proposed DRGs 528, 529, and 530. These DRGS will be 
effective for discharges occurring on or after October 1, 2003.
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 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 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 proposed 
that patients who are assigned a principal diagnosis of code 780.02 
would 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 as proposed 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.
    Comment: An organization representing hospitals supported our 
proposed change, while other commenters opposed the change. The 
commenters who opposed the change stated that code 780.02 is included 
in the ICD-9-CM chapter for signs and symptoms of ill-defined 
conditions. The commenters believed that since this code is included in 
a chapter with ill-defined conditions, it would be inappropriate to 
move the code to DRG 429. The commenters stated that this

[[Page 45356]]

code does not describe a mental disorder; and disagreed with our 
statement in the proposed rule that code 780.02 was similar to codes 
293.81 and 293.82. The commenters further stated that they disagreed 
with our assertion that many patients with a diagnosis of transient 
alteration of awareness are treated in psychiatric facilities.
    Response: Our review of claims data indicates that code 780.02 is a 
frequent diagnosis for patients admitted to psychiatric hospitals. Many 
patients are likely to present with transient alteration of awareness 
at the time of admission to a psychiatric hospital. The cause of this 
transient alteration is likely to be diagnosed during the stay, leading 
to the assignment of another, more specific principal diagnosis.
    However, in many patients, this is not the case, and no underlying 
cause for the transient alteration of awareness is determined. When a 
more definitive diagnosis cannot be made, the patient is left with the 
diagnosis of alteration of awareness. We recognize the difficulty in 
assigning symptoms such as these to the most appropriate DRG. However, 
we will note that the average charges for DRG 23 (where the code is 
currently assigned) and DRG 429 are similar.
    Therefore, we are proceeding with the assignment of code 780.02 to 
DRG 429 based on a review of psychiatric hospital data as well as a 
clinical comparison of cases already assigned to DRG 429.
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 proposed 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.
    We received two comments in support of this change. Therefore, we 
are adopting as final our proposal to remove code 37.64 from DRGs 478 
and 479 and assign it to DRGs 110 and 111.
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
    Prior to the publication of the proposed rule, we received a 
recommendation to 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 as a principal diagnosis. 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,
                                                               Number of     Average       heart       Average
                             DRG                                 cases       charges    failure, or    charges
                                                                                        shock count
----------------------------------------------------------------------------------------------------------------
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 were admitted with 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 
proposed to split DRG 514 and create a new DRG for patients receiving a 
cardiac defibrillator implant with cardiac catheterization and with a 
principal diagnosis of 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 did not propose 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 proposed to create two new DRGs that would replace 
the current DRG 514. We indicated that the two proposed 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

[[Page 45357]]

shock as a principal diagnosis. We proposed to establish new DRG 535 
(Cardiac Defibrillator Implant With Cardiac Catheterization and With 
Acute Myocardial Infarction, Heart Failure, or Shock) and new 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)
    Prior to the publication of the proposed rule, 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] 37.95, 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 
is reported. The commenter indicated that a total defibrillator and 
CRT-D system may be replaced with a completely new system 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 37.95 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 proposed to 
delete DRG 514 and replace it with proposed new DRGs 535 and 536. 
Therefore, we proposed to add codes 37.95 and 00.54 to the list of 
procedure combinations that would result in assignment to DRG 515 or 
new proposed DRGs 535 and 536.
    Comment: Several commenters supported our proposed revision to DRG 
514 so that it would be split based on the presence or absence of a 
principal diagnosis of acute myocardial infarction, heart failure, or 
shock.
    One commenter pointed out a typographical error in the proposed 
rule in the code number cited for the procedure, Implantation of 
automatic cardioverter/defibrillator lead(s) only. The code number 
should have been 37.95 instead of 39.75.
    Response: We appreciate the support for our proposed revision of 
DRG 514. We have corrected the code number for Implantation of 
automatic cadioverter/defibrillator lead(s) only to 37.95 in the 
description of this issue above.
    Comment: Several commenters supported the addition of codes 37.95 
and 00.54 to the list of procedure combinations that would lead to an 
assignment of DRG 515 and new DRGs 535 and 536. However, one commenter 
suggested that, in addition to this combination, codes 37.97 
(Replacement of automatic cardioverter/defibrillator lead(s) only and 
00.54 also should be added to the procedure combination list under DRG 
515 and new DRGs 535 and 536. The commenter pointed out that both 
procedures would involve the insertion of a pulse generator and a lead 
so that resources required are equivalent to those for a total system 
implant.
    Response: We agree with the commenter that the combination of codes 
37.97 and 00.54 also would involve the implantation of a pulse 
generator and a lead. Therefore, in this final rule, we are adding the 
combination of procedure codes 37.97 and 00.54 to the list of procedure 
combinations that will lead to assignment to DRG 515 and new DRGs 535 
and 536.
    Comment: One commenter recommended that CMS also consider modifying 
DRGs 115 and 116 to recognize more combination groups of devices and 
leads. Specifically, the commenter recommended adding the following 
combination of codes to the list of procedure combinations under DRGs 
115 and 116:
    [sbull] 00.53, Implantation or replacement of CRT-P pulse generator 
only
    [sbull] 37.74, Implantation or replacement of epicardial pacemaker 
lead.
    Response: DRGs 115 and 116 have one of the most complex assignment 
structures of all the DRGs. The DRG logic for DRGs 115 and 116 involves 
three separate combinations of code groups that can possibly lead to 
these DRG assignments. Before making a

[[Page 45358]]

modification to one of the combination groups (particularly the 
procedure combinations), we believe we should analyze the impact of a 
modification to the currently existing types of device, lead, and 
diagnosis combinations. In the future, we will undertake a close review 
of DRGs 115 and 116 to determine if additional modifications, such as 
the one suggested, are needed.
    Comment: Two commenters supported the proposal to restructure DRG 
514 through the creation of new DRGs 535 and 536. One of the commenters 
supported the division of these new DRGs based on the presence or 
absence of acute myocardial infarction, heart failure, or shock. 
However, the commenter believed that this new structure would lead to 
significant confusion among hospital coders with respect to the coding 
of CRT-Ds. The commenter stated that hospital coders may be confused 
when a patient is admitted with one diagnosis, but then develops an 
acute myocardial infarction, heart failure, or shock after the 
admission but prior to discharge. In these cases, the acute myocardial 
infarction, heart failure, or shock would be a secondary diagnosis. The 
split of DRGs 535 and 536 is based on these conditions when they are 
the principal diagnosis (reason for the hospital admission). To 
eliminate the potential for misunderstanding, the commenter requested 
that the definition of DRG 535 be modified so that patients who receive 
CRT-D devices are assigned to DRG 535 when an ICD-9-CM diagnosis code 
for heart failure is present as either a principal or secondary 
diagnosis.
    Response: We appreciate the support from the commenters for our 
proposal to modify DRG 514 through the creation of new DRGs 535 and 
536. We note that the issue of coding the implantation of CRT-Ds has 
been covered through extensive articles in the American Hospital 
Association's Coding Clinic for ICD-9-CM. In the past, the coding of 
cases with acute myocardial infarction, heart failure, or shock has not 
been problematic for hospital coding specialists. However, should the 
DRG modifications lead to coding questions on CRT-D cases, we will ask 
the American Hospital Association to provide additional guidance in its 
Coding Clinic for ICD-9-CM. Furthermore, the DRG splits for an acute 
myocardial infarction, heart failure, or shock, which currently are 
included in DRGs 115 and 116, are based on these conditions being the 
principal diagnosis. As a result, this is a longstanding DRG logic 
precedent. We do not believe that replicating the logic used for 
splitting DRGs 115 and 116 and using it for DRGs 535 and 536 would 
create confusion for hospital coders. Rather, we believe hospital 
coders would easily recognize this type of longstanding DRG logic.
    Comment: Another commenter supported the proposal to split DRG 514 
into DRGs 535 and 536 based on the presence or absence of acute 
myocardial infarction, heart failure, or shock. The commenter stated 
that this split would ensure greater consistency within the DRG system 
and ensure adequate payment to hospitals for the higher costs patients 
receiving implantable cardioverter-defibrillator implants. However, the 
commenter recommended that DRG 515 undergo a similar split based on the 
presence or absence of acute myocardial infarction, heart failure, or 
shock. The commenter stated that the creation of these additional new 
DRGs would fully align payment logic across all pacemaker and 
implantable cardioverter-defibrillator implant devices. The 
manufacturer also believed that differences between average charges and 
average length of stay for these cases within DRG 515 would warrant 
this additional splitting of the DRG.
    Response: We appreciate the support for the revisions involving 
DRGs 514, 535, and 536. However, when we examined the data for DRGs 514 
and 515, we found that there were almost three times as many cases with 
an acute myocardial infarction, heart failure, or shock cases in DRG 
515 as in DRG 514. Those cases in DRG 514 with a principal diagnosis of 
an acute myocardial infarction, heart failure, or shock, had average 
charges approximately 20 percent greater than the average charges for 
all cases in DRG 514. However, cases with a principal diagnosis of an 
acute myocardial infarction, heart failure, or shock in DRG 515 had 
average charges that were only about 10 percent greater than all cases 
in this DRG. Therefore, there is a significantly greater need for the 
DRG split for DRG 514. We will continue to examine cases within this 
area, and specifically DRG 515, to determine if additional DRG 
refinements are needed in the future.
    Comment: One commenter, who supported the revisions to DRG 514 
through the new DRGs 535 and 536, expressed concern about our coverage 
decisions on automatic implantable cardioverter-defibrillators. The 
commenter believed the coverage was extremely restricted.
    Response: We appreciate the support of the commenter for new DRGs 
535 and 536. We will share the concerns relating to coverage decisions 
on automatic implantable cardioverter-defibrillators with our coverage 
staff.
5. MDC 8 (Diseases and Disorders of the Musculoskeletal System and 
Connective Tissue)
    Prior to the issuance of the proposed rule, 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 proposed to remove these codes 
from DRGs 497 and 498 and reassign them to DRGs 519 and 520.
    We did not receive any comments on this proposal. Therefore, we are 
adopting as final our proposal to remove codes 81.01 and 81.31 from 
DRGs 497 and 498 and reassign them to DRGs 519 and 520, effective for 
FY 2004.
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.
    Prior to the publication of the proposed rule, we 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

[[Page 45359]]

    [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
    [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 evaluated the recommendation and agreed 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 proposed 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
    Principal diagnosis code in MDC 15              Code title              MDC        Proposed DRG assignment
                                                                         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).
----------------------------------------------------------------------------------------------------------------

    Comment: Several commenters supported all of the proposed changes 
relating to congenital anomalies. One commenter supported the changes 
in general, but mentioned several concerns. While this commenter agreed 
that it was feasible to move these congenital conditions out of MDC 15, 
the commenter suggested that those patients who are still in the 
neonatal period (first 28 days of life) when admitted should continue 
to be classified to MDC 15.
    In addition, this commenter questioned whether the proposed DRG 
assignments were correct for codes 759.4 (Conjoined twins), code 759.7 
(Multiple congenital anomalies, not elsewhere classified), and 759.89 
(Specified congenital anomalies, not elsewhere classified). The 
commenter stated that although the proposed DRG assignments for these 
three DRGs may be appropriate based on the body system being treated 
for most cases, these DRGs do not necessarily reflect the body system 
affected or being treated. The commenter did not suggest alternative 
DRG assignments.
    Response: We acknowledge the commenter's point that, for a minority 
of cases, the admission will, in fact, be in the neonatal period. 
However, the majority of cases will continue to be patients well beyond 
the neonatal period. The proposed DRG modifications will correct the 
majority of inappropriate DRG assignments that occur when adults are 
assigned to MDC 15 (Newborns and Other Neonates with Conditions 
Originating in the Perinatal Period). In the future, we will examine 
other means to further refine this area, such as making new DRG 
assignments for congenital anomalies based on the age of the patient. 
However, at this point, we are attempting to resolve the problems 
created for the majority of patients.
    Regarding the commenter's concern that codes 759.4, 759.7, and 
759.89 may not always be appropriately assigned according to our 
proposal, the commenter did not suggest an alternative. The commenter 
agreed that many cases with these three codes will be assigned to the 
appropriate body system by using our proposed DRG assignments. We 
recognize that reassignment of these codes will not resolve all 
problems, and some cases may be assigned to the wrong body system based 
on the patient's actual condition. However, we note that these three 
codes are vague and do not specify a precise congenital anomaly by body 
system. Therefore, we had to rely on our medical advisors to determine 
the most appropriate DRG for the majority of cases. Our main concern 
was to correct the DRG assignment that resulted in adults being 
assigned to a neonatal DRG when they had a congenital anomaly. We will 
continue to examine the data for these cases to determine if additional 
modifications are needed in the future.
    Therefore, we are adopting the proposed revisions as final without 
modification.
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.
    Prior to the publication of the proposed rule, we received 
correspondence suggesting that the following diagnosis codes for heart 
failure, which are currently in MDC 5, be added to the list of 
secondary diagnosis of major problems for neonates under MDC 15.

[[Page 45360]]



------------------------------------------------------------------------
          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 codes for heart failure that existed prior 
to October 1, 2002, are classified as secondary diagnoses of major 
problems within MDC 15 and are currently assigned to DRGs 387 and DRG 
389. We stated in the proposed rule that these other heart failure 
diagnosis codes should be included as principal diagnosis of major 
problem codes within MDC 15. However, these heart failure codes are 
currently listed in the secondary, not principal, diagnoses of major 
problems within MDC 15.
    We agree that diagnosis codes 428.20 through 428.43 listed in the 
chart above should be included as secondary diagnosis of major problem 
codes within MDC 15, as are the other heart failure codes. Therefore, 
we proposed to add them to DRG 387 and 389.
    Comment: Several commenters supported the proposal to add codes 
428.20 through 428.43 (codes for heart failure that became effective 
October 1, 2002, listed in the chart above) to DRGs 387 and 389. The 
commenters agreed that the heart failure codes created on October 1, 
2002, should be assigned to DRGs 387 and 389 in the same fashion as 
were those heart failure codes created prior to October 1, 2002.
    One commenter indicated that we incorrectly described the addition 
of diagnosis codes 428.20 through 428.43 listed in the chart to the 
list of ``principal'' diagnosis of major problem codes. The commenter 
stated that we should have indicated that these codes would be added to 
the list of ``secondary'' diagnoses of major problem codes because this 
category is where the other heart failure codes are currently assigned.
    Response: We agree that the codes should have been described as an 
addition to the list of secondary diagnoses of major problem codes 
within DRGs 387 and 389. We have clarified this point in the 
description above.
    Comment: One commenter who supported the addition of the heart 
failure-related diagnosis codes (428.20 through 428.43) to DRGs 387 and 
389, asked for clarification of how diagnoses for combined codes that 
include congestive heart failure will be handled. The commenter 
mentioned code 402.91 (Hypertensive heart disease with heart failure, 
unspecified benign or malignant) as an example.
    Response: We will conduct an additional review of DRGs 387 and 389 
to determine if additional codes should be added to the list of 
secondary diagnoses of major problems for FY 2005. We encourage 
commenters to send their recommendations to us to assist in this 
review.
    We are adopting our proposal as final, with the clarification that 
the major problem codes are secondary, not principal, codes. 
Accordingly, we are adding codes 428.20 through 428.43 listed above to 
the list of secondary diagnoses of major problem codes within DRGs 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 Food and Drug 
Administration (FDA) approved the IL-2 product on the market for use 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 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 are admitted for the second cycle of therapy during 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, we have been informed by industry sources that, 
allegedly due to the level of payment for the DRGs to which these cases 
are currently assigned, only 100 to 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

[[Page 45361]]

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)). The code is effective for cases discharged on or 
after 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
    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 proposed to modify DRG 492 by adding new procedure code 00.15 to 
the logic. We indicated that assignment to this DRG would require the 
same two V-code principal diagnosis codes 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 proposed to change the title of DRG 492 to ``Chemotherapy 
With Acute Leukemia or With Use of High Dose Chemotherapy Agent''.
    In the proposed rule, we indicated that we would monitor cases with 
procedure code 00.15 as these data became available, and consider 
potential further refinements to DRG 492 as necessary.
    Comment: Five commenters supported our proposed change. One 
commenter who opposed the proposed change believed that classifying 
high-dose IL-2 therapy as chemotherapy would be a violation of coding 
advice published in the American Hospital Association's coding 
publication, Coding Clinic for ICD-9-CM, because IL-2 therapy is a 
biologic response modifier and is considered immunotherapy, not 
chemotherapy. Therefore, the commenter asserted that the use of either 
V58.1 or V67.2 as principal diagnosis codes for these cases would 
result in erroneous coding advice. The commenter added that Coding 
Clinic, Fourth Quarter, page 51, indicates that when a patient is 
admitted for immunotherapy, the code for the neoplasm should be 
assigned as the principal diagnosis.
    Response: We acknowledge the commenter's points concerning correct 
selection of principal diagnosis, as well as the advice published 
previously in Coding Clinic. However, the discussion of this topic has 
raised some concerns among the Cooperating Parties of AHA's Editorial 
Advisory Board. The advice given in the Fourth Quarter 1994 Coding 
Clinic predates the new treatment technology now available, which calls 
into question the correctness of the published advice. Therefore, this 
topic will be included on the agenda of an upcoming AHA Editorial 
Advisory Board meeting for further discussion and clarification. It is 
likely that new instructions will be issued in the next several months 
to clarify these coding instructions.
    Therefore, in anticipation of this clarification, we are adopting 
as final the proposed changes to DRG 492. We will continue to monitor 
this DRG for shifts in resource consumption and validity of DRG 
assignment, and will specifically monitor code 00.15 for appropriate 
placement in DRG 492.
8. MDC 23 (Factors Influencing Health Status and Other Contacts With 
Health Services)
a. Implantable Devices
    Prior to the publication of the proposed rule, 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 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, we believe it would be

[[Page 45362]]

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 
(Diseases 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 proposed 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.
    We received three comments that supported our proposal to move 
diagnosis codes V53.01, V53.02, and V53.09 from MDC 23 to MDC 1. 
Accordingly, we are adopting as final the proposed reassignment, 
effective for discharges occurring on or after October 1, 2003.
b. Malignancy Codes
    Prior to the issuance of the proposed rule, 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. Therefore, we proposed to 
add it to the list of secondary diagnoses in DRG 465.
    We received several comments that supported this DRG modification. 
Accordingly, we are adopting the proposal as final without 
modification.
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, in the May 19, 2003 proposed rule, we 
proposed 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] 574.91, 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
    Comment: Four commenters agreed in general with our decision to 
remove the above listed codes from the MCE in the edit ``Adult 
Diagnosis--Age Greater than 14.'' However, one commenter recommended 
that all ICD-9-CM codes in the 575 through 577 range be removed from 
the edit and listed several codes that appeared to be missing from our 
list. These codes were 575.4 (Perforation of gallbladder), 577.0 (Acute 
pancreatitis), and 577.1 (Chronic pancreatitis). In addition, three 
commenters pointed out that code 574.90 had been erroneously listed 
twice with different narrative descriptions.
    Response: We appreciate the commenters' interest in the correctness 
of the MCE. We also have received many telephone calls and e-mails 
concerning the typographical error with code 574.90. We have corrected 
the list above to reflect the correct code number, 574.91. As noted, 
the second narrative listing in the proposed rule correctly described 
code 574.91, not 574.90 (68 FR 27166).
    With regard to the comment concerning the absence of codes 575.4 
and 577.0 from the above list, we note that these codes are not 
included in the MCE edit. That is, these codes were never part of the 
MCE edit. With regard to code 577.1, this code is the last one on the 
list and was printed correctly in the proposed rule (68 FR 27166, third 
column).
    Accordingly, we are adopting as final the proposal to remove the 
listed codes from the MCE edit ``Adult Diagnosis--Age Greater than 
14,'' with the correction of the fifth digit of code 574.91 (Calculus 
of gallbladder and bile duct without cholecystitis with obstruction).
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

[[Page 45363]]

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 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, in the May 19, 
2003 proposed rule, we proposed modifications of the surgical hierarchy 
as set forth below.
    We proposed 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 proposed to reorder DRG 513 
(Pancreas Transplant) above DRG 512 (Simultaneous Pancreas/Kidney 
Transplant).
    [sbull] In MDC 1, we proposed 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 proposed 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 proposed 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 proposed 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).
    In the proposed rule, we were unable to test the effects of the 
proposed revisions to the surgical hierarchy and reflect these changes 
in the proposed relative weights because the revised GROUPER software 
was unavailable at the time the proposed rule was published. Rather, we 
simulated most major classification changes to approximate the 
placement of cases under the proposed reclassification, and then 
determined the average charge for each DRG. These average charges 
served as our best estimate of relative resources used for each 
surgical class. We have now tested the proposed surgical hierarchy 
changes using the revised GROUPER software, and are reflecting the 
final changes in the DRG relative weights in this final rule. Further, 
as discussed in section II.C. of the preamble of this final rule, the 
final recalibrated weights are different from the proposed weights 
because they were based on more complete data.
    Based on a test of the proposed revisions using the March 2003 
update of the FY 2002 MedPAR file and the revised GROUPER software, we 
have found that the proposed change in the pre-MDC DRGs to reorder DRG 
513 (Pancreas Transplant) above DRG 12 (Simultaneous Pancreas/Kidney 
Transplant) was not supported by the data. If this proposal were 
finalized, no cases would be assigned to DRG 512. The other proposed 
revisions are still supported by the data.
    Comment: Two commenters expressed support for the proposed

[[Page 45364]]

change in the surgical hierarchy. Another commenter requested a change 
in the surgical hierarchy for a case in which a spinal fusion with 
subsequent debridement is performed during the same admission. This 
case is assigned to DRG 217 (Wound Debridement and Skin Graft Except 
Hand, for Musculoskeletal and Connective Tissue Disease). The commenter 
requested that this case be reassigned to DRG 497 (Spinal Fusion Except 
Cervical With CC) because it has a higher DRG weight than DRG 217.
    Response: The surgical hierarchy places a patient with multiple 
procedures in the most resource intensive class, but this does not 
necessarily mean that the patient is assigned to the most resource 
intensive DRG. In this scenario, one surgical class is actually one 
DRG, and another surgical class is back and neck procedures. These 
classes encompass 7 DRGs (DRGs 496-500 and DRGs 519 and 520). The 
average charges for DRG 217 are approximately $15,000 more than the 
back and neck procedures class. DRG 217 is hierarchically ordered 
higher in the surgical group than DRG 497, which is the reason the case 
is assigned to DRG 217.
    Therefore, we are adopting the proposed changes in MDCs 1, 5, 8, 
and 17 as final. We are not making any changes in the pre-MDC DRGs.
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. We created the CC Exclusions List for the following reasons: 
(1) To preclude coding of CCs for closely related conditions; (2) to 
preclude duplicative 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 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 list of CCs, either by adding new CCs or deleting 
CCs already on the list. As we proposed in the May 19, 2003 proposed 
rule, we are not deleting any of the diagnosis codes on the CC list.
    As explained in the May 19, 1989 proposed rule (52 FR 18877) and 
the September 1, 1987 final notice (52 FR 33154), 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.
    [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. 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.\3\
    We proposed 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.) We 
proposed these changes in accordance with the principles established 
when we created the CC Exclusions List in 1987.
---------------------------------------------------------------------------

    \3\ See the September 30, 1988 final rule (53 FR 38485) for the 
revision made for the discharges occurring in FY 1989; the September 
1, 1989 final rule (54 FR 36552) for the FY 1990 revision; the 
September 4, 1990 final rule (55 FR 36126) for the FY 1991 revision; 
the August 30, 1991 final rule (56 FR 43209) for the FY 1992 
revision; the September 1, 1992 final rule (57 FR 39753) for the FY 
1993 revision; the September 1, 1993 final rule (58 FR 46278) for 
the FY 1994 revisions; the September 1, 1994 final rule (59 FR 
45334) for the FY 1995 revisions; the September 1, 1995 final rule 
(60 FR 45782) for the FY 1996 revisions; the August 30, 1996 final 
rule (61 FR 46171) for the FY 1997 revisions; the August 29, 1997 
final rule (62 FR 45966) for the FY 1998 revisions; the July 31, 
1998 final rule (63 FR 40954) for the FY 1999 revisions, the August 
1, 2000 final rule (65 FR 47064) for the FY 2001 revisions; 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.
---------------------------------------------------------------------------

    Tables 6G and 6H in the Addendum to this final rule contain the 
revisions to the 13 CC Exclusions List that will 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 will not be recognized by the GROUPER as valid 
CCs for the asterisked principal diagnosis.
    CCs that are deleted from the list are in Table 6H--Deletions from 
the CC Exclusions List. Beginning with discharges on or after October 
1, 2003, the indented diagnoses will be recognized by the GROUPER as 
valid CCs for the asterisked principal diagnosis.
    Comment: One commenter indicated that it was unable to provide 
meaningful comments on Tables 6G and 6H because of formatting errors in 
the printed tables. In addition, the commenter suggested that the 
changes in the tables should not be effective until a revised version 
was made available for public comment.
    Response: We apologize for the errors in the format of the tables, 
which were printer's errors. However, we note that the tables did 
contain the correct codes, even though the format of the columns was 
distorted. Therefore, we do not believe a delay in the effective date 
of the changes is warranted.
    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 22161; or by calling (800) 553-6847.
    Users should be aware of the fact that all revisions to the CC 
Exclusions List (FYs 1989, 1990, 1991, 1992, 1993, 1994, 1995, 1996, 
1997, 1998, 1999, 2000, 2002, and 2003) and those in Tables 6G and 6H 
of this 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,

[[Page 45365]]

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 2004 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 DRG 477, and some procedures from DRG 477 to DRG 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 producing assignment to 
DRG 468 or DRG 477 on the basis of volume, by procedure, to see if it 
would be appropriate to move procedure codes out of these DRGs into one 
of the surgical DRGs for the MDC into which the principal diagnosis 
falls. The data are arrayed two ways for comparison purposes. We look 
at a frequency count of each major operative procedure code. We also 
compare procedures across MDCs by volume of procedure codes within each 
MDC.
    We identify those procedures occurring in conjunction with certain 
principal diagnoses with sufficient frequency to justify adding them to 
one of the surgical DRGs for the MDC in which the diagnosis falls. 
Based on this year's review, we did not identify any necessary changes 
in procedures under DRG 477. Therefore, we did not propose moving any 
procedures from DRG 477 to one of the surgical DRGs in this final rule.
    However, in the proposed rule, we 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. 
Therefore, we proposed to assign code 50.29 to DRGs 170 and 171 in MDC 
6.
    We received several comments of support for our proposal to assign 
code 50.29 to DRGs 170 and 171 in MDC 6. Therefore, we are adopting the 
proposal as final without modification. As a result, code 50.29 will 
not result in assignment to DRG 468 when this procedure is performed on 
patient with a principal diagnosis 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 three DRGs to another 
of the three DRGs based on average charges and the 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 to move cases to 
keep the DRGs clinically similar or to provide payment for the cases in 
a similar manner. Generally, we move only those procedures for which we 
have an adequate number of discharges to analyze the data. Based on our 
review this year, we did not propose moving any procedures from DRG 476 
to DRGs 468 or 477, or from DRG 477 to DRGs 468 or 476.
    However, in the proposed rule, we identified several procedures 
that we proposed 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

[[Page 45366]]

    [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
    We note that the above codes being moved from DRG 468 to DRGs 476 
and 477 were erroneously listed in the May 19, 2003 proposed rule under 
section II.B.12.c., which related to adding diagnosis or procedure 
codes to MDCs, instead of section II.B.12.b., which discussed the 
reassignment of procedures among DRGs 468, 476, and 477. We regret any 
inconvenience this inadvertent listing may have caused.
    Comment: One commenter asked us to consider moving procedure code 
51.23, Laparoscopic cholecystectomy, from DRG 468 and adding it to DRG 
477. The commenter indicated that this procedure is often performed in 
the outpatient setting.
    Response: We believe that the commenter's request has merit. We 
will perform the necessary data analysis and will consider proposing 
this change in next fiscal year's rule if we find that the data support 
this change.
c. Adding Diagnosis or Procedure Codes to MDCs
    Based on our review this year, we did not propose adding any 
diagnosis codes to MDCs in this final rule. We did not receive any 
comments on the proposal.
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 individual 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 in Tables 6A and 6B of this final rule. 
Copies of the minutes of the procedure codes discussions at the 
Committee's 2002 meetings can be obtained from the CMS Web site: http://www.cms.gov/paymentsystems/icd9/. The minutes of the diagnoses codes 
discussions at the 2002 meetings 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 the 
proposed rule was published after the April meeting, we were able to 
include all new procedure codes that were approved subsequent to that 
meeting in Table 6B of the Addendum to the proposed rule, including the 
DRG assignments. However, the National Center for Health Statistics 
(NCHS) created and finalized three new severe acute respiratory 
syndrome (SARS) related codes after the proposed rule was published. 
These new codes, which were not listed in Table 6A of the Addendum to 
the proposed rule, have been included in Table 6A of the Addendum to 
this final rule. The new codes are as follows:
    [sbull] 079.82, SARS-associated coronavirus
    [sbull] 480.3, Pneumonia due to SARS-associated coronavirus
    [sbull] V01.82, Exposure to SARA-associated coronavirus
    These new codes have been identified with a footnote (1) in Table 
6A of the Addendum to this final rule.
    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.
    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 Management, 
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 
final rule. As we stated above, the code numbers and their titles were 
presented for public comment at the ICD-9-CM Coordination and 
Maintenance Committee meetings. Both oral and written comments were 
considered before the codes were approved. Accordingly, in the May 19, 
2003 proposed rule, we only solicited comments on the proposed DRG 
classification of these new codes.
    Comment: One commenter expressed concern about the MDC and DRG 
designations for new diagnosis code 752.89 (Other specified anomalies 
of genital organs) that was included in

[[Page 45367]]

Table 6A of the Addendum to the proposed rule. We had proposed 
assigning this new code to MDC 12 (Diseases and Disorders of the Male 
Reproductive System), and DRG 352 (Other Male Reproductive System 
Diagnoses). The commenter pointed out that this new code could apply to 
both males and females. Its predecessor code was assigned to MDC 12, 
DRG 352, as well as to MDC 13 (Diseases and Disorders of the Female 
Reproductive System) and DRGs 358 (Uterine and Adnexa Procedure for 
Non-Malignancy with CC), 359 (Uterine and Adnexa Procedure for Non-
Malignancy without CC), and 369 (Menstrual and Other Female 
Reproductive System Disorders).
    Response: The commenter is correct. Diagnosis code 752.89 would 
apply to both males and females and should have been included in both 
MDC 12 and MDC 13. In this final rule, we are assigning diagnosis code 
752.89 to MDC 13 under DRGs 358, 359, and 369 and have modified Table 
6A of the Addendum to this final rule accordingly.
    Comment: One commenter pointed out a typographical error for the 
code title for V15.87. The commenter indicated that the word 
``membrance'' should be changed to ``membrane''; that is, the title 
should read ``History of Extracorporeal Membrane Oxygenation (ECMO).''
    Response: We agree with the commenter and have corrected the title 
in Table 6A of the Addendum to this final rule.
    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 revised 
procedure code titles for FY 2004.
    The Department of Health and Human Services has been actively 
working on the development of new coding systems to replace the ICD-9-
CM. In December 1990, the National Committee on Vital and Health 
Statistics (NCVHS) issued a report noting that, while the ICD-9-CM 
classification system had been responsive to changing technologies and 
identifying new diseases, there was concern that the ICD classification 
might be stressed to a point where the quality of the system would soon 
be compromised. The ICD-10-CM (for diagnoses) and the ICD-10-PCS (for 
procedures) were developed in response to these concerns. These efforts 
have become increasingly important because of the growing number of 
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: http://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.
    Comment: Several commenters supported the move to ICD-10-CM and 
ICD-10-PCS as national coding standards. One commenter representing 
hospitals supported moving to these systems expeditiously. The 
commenter stated that ICD-10-CM and ICD-10-PCS are a vast improvement 
over ICD-9-CM and would provide greater specificity and detail in 
coding. Another commenter believed that the new systems would offer 
immediate and long-term benefits for specifying illness severity and 
accommodating a diverse array of new technologies that warrant 
expedited assignment under the DRG system.
    Response: We appreciate the support from many in the health care 
industry for ICD-10-CM and ICD-10-PCS. We agree with the importance of 
having and maintaining medical coding systems that accurately capture 
the patient's conditions and medical procedures. We also agree that 
ICD-9-CM is seriously constrained because of its structure and space 
limitations. We recognize that over 30 countries have implemented ICD-
10 to better capture medical conditions. Countries such as Canada and 
Australia have successfully implemented ICD-10 without serious 
ramifications to their data or reimbursement systems. We agree that it 
is important to capture information on new technologies. It is becoming 
increasingly difficult to do so using ICD-9-CM. We will continue 
working with NCVHS and the health care industry to determine if these 
new systems should be named as national coding standards.
14. Other Issues
    In addition to the specific topics discussed in section II.B.1. 
through 13. of this preamble, we considered a number of other DRG-
related issues in the May 19, 2003 proposed rule. 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, prior to the publication of 
the proposed rule, commenters contended that this DRG assignment is 
clinically and economically inappropriate for cochlear implants and 
requested a more specific DRG. The commenters contend that, like heart 
assist systems (for which 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. However, these cases 
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

[[Page 45368]]

$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 did not propose to 
change the DRG assignment of cochlear implants in the May 19, 2003 
proposed rule. However, we did encourage public comments as to whether 
a new DRG for cochlear implants (or some other solution) is warranted.
    Comment: Several commenters urged CMS to reassign cochlear 
implantation procedures to a DRG that has a weight appropriate to 
reflect the costs of cochlear implantation. The commenters stated that 
while a hospital's acquisition cost of the device itself averages 
approximately $23,800, the proposed payment for FY 2004 is 
approximately $8,233. While most cochlear implants have been and will 
continue to be performed on an outpatient basis, a small, but 
significant portion, particularly for Medicare beneficiaries, need to 
be conducted as an inpatient procedure. The commenters stated that the 
low volume of inpatient cases is a direct result of the inadequate 
payment rate.
    The commenters stated that cochlear implantation is clinically 
incongruent and economically inconsistent with the other procedures in 
DRG 49. The commenters believed that cochlear implants do not 
meaningfully affect the weighting of DRG 49 and proposed two options: 
Create a new DRG specifically for cochlear implants, or reassign 
cochlear implants cases to DRG 482 (Tracheostomy for Face, Mouth, and 
Neck Diagnoses).
    Response: We requested public input on possible solutions for these 
cases because we recognize the data indicate the charges for these 
cases are much higher than for other cases in DRG 49. However, we are 
concerned that the options suggested by commenters are not workable 
solutions. As we alluded to in the proposed rule, we have concerns 
about creating a new DRG for this procedure. We appreciate the point 
made by commenters that only those patients requiring inpatient care 
would receive the procedure in an inpatient setting, even if the DRG 
payment were increased. However, as we have stated previously, we are 
reluctant to create new DRGs for specific, low-volume procedures. Doing 
so would create a proliferation of DRGs and a loss of some of the 
efficiency incentives inherent in the current system. Hospitals are 
generally able to offset any losses on such procedures through 
corresponding payment advantages from other, less expensive procedures.
    The second option suggested, to reassign these cases to DRG 482, is 
inconsistent with the structure of that DRG, which requires that a 
tracheostomy be performed in order to be assigned to this DRG. 
Assigning cochlear implants to this DRG would fundamentally alter its 
structure, which could not be done without first proposing such a 
change for public review and comment.
    However, as we indicated above, we recognize the disparity in 
average charges for these cases compared to other cases in DRG 49, and 
will continue to evaluate possible reclassification options for FY 
2005.
b. Burn Patients on Mechanical Ventilation
    Prior to the publication of the proposed rule, concerns were 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 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.
    We received one comment from an organization representing coders 
that agreed with the importance of reporting code 96.72 and the need 
for further education on this issue. We will continue to monitor our 
data to assess

[[Page 45369]]

the payment for burn patients on mechanical ventilation in the future.
c. Multiple Level Spinal Fusion
    Prior to the publication of the proposed rule, 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 
final 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, in the May 19, 2003 proposed rule, we did not 
propose 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.
    Comment: Several commenters supported our proposal to wait for data 
using the new ICD-9-CM procedure codes for multiple level spinal 
fusions prior to making revisions to the spinal fusion DRGs. One 
commenter representing hospitals supported our proposal to continue 
with the current DRG classification system until sufficient data are 
available to evaluate a potential DRG change. Several commenters 
expressed their appreciation for the creation of the new codes for 
multiple level spinal fusion. They recognized the difficult challenge 
that was involved in developing this new classification system as part 
of ICD-9-CM.
    One commenter requested us to proceed with a DRG revision for 
multiple level spinal fusion without waiting for data using the new 
codes. This commenter stated that there are significant costs involved 
with increased instrumentation and hardware when multiple level spinal 
fusions are performed, and requested that we consider using non-MedPAR 
data to establish relative weights for new DRGs based on the levels of 
vertebrae involved. In addition, the commenter stated that there is a 
need to distinguish between fusions and refusions within the DRGs. The 
commenter stated that refusions vary significantly due to the existence 
of scar tissue and implants that need to be removed and replaced. 
Further, the commenter recommended that we split DRG 496 Combined 
anterior/posterior spinal fusion based on the presence or absence of a 
complication or comorbidity.
    Response: We appreciate the support of commenters that we wait for 
data from the reporting of the new codes for multiple level spinal 
fusion prior to proposing revisions to the spinal DRGs (rather than 
using non-MedPAR data prior to the availability of data using the new 
codes). We also appreciate the comments concerning the extensive effort 
it took on our part to develop a set of ICD-9-CM codes that could 
capture this type of information. We believe it is important to 
carefully examine hospital data prior to making any revisions for 
multiple level spinal fusions. Therefore, we will look at this data as 
we receive it and evaluate any need for DRG revisions. We will consider 
all the points raised by the commenters as we consider additional DRG 
revisions for spinal fusions in the future.
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 
from a commenter 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 these LVAD cases where a heart transplant is 
also performed during the same hospitalization are included in the DRG 
relative weight for DRG 103. Accordingly, we did not create a new DRG 
for these cases. 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 indicating the use of any 
heart assist system. We do not believe that 21 cases is a sufficient 
number of cases to support creation of an additional DRG. Therefore, in 
the May 19, 2003 proposed rule, we did not propose a change to the 
structure of either DRG 103 or DRG 525.
    Comment: Two commenters argued that procedure code 37.66 (Implant 
of an implantable, pulsatile heart assist system) does not fit 
clinically or financially with the following other procedure codes in 
DRG 525:
    [sbull] 37.62, Implant of other heart assist system,
    [sbull] 37.63, Replacement and repair of heart assist system,
    [sbull] 37.65, Implant of an external, pulsatile heart assist 
system
    [sbull] 37.66, Implant of an implantable, pulsatile heart assist 
system.
    One commenter indicated that, according to an analysis that it 
performed, Medicare data on procedure code 37.66 demonstrates that 
average charges ($342,725) and length of stay

[[Page 45370]]

(40.1 days) are significantly higher than data on all other procedures 
in DRG 525 (average charges ranging from $112,748 to $190,672) and 
(average length of stay ranging from 10.9 to 16.7). According to the 
commenter, the implantable pulsatile technology represents a different 
class of device and procedure (long-term support) compared to the less 
resource intensive, short-term devices used in other procedures in DRG 
525.
    The commenters requested three possible alternatives for the 
reclassification of procedure code 37.66: (1) Create a unique DRG for 
this procedure; (2) add this procedure code to DRG 103 (Heart 
Transplant); or (3) add a new technology add-on payment for code 37.66 
to DRG 525.
    Response: In response to comments we received on the creation of 
new DRG 525 last year, we noted that these four codes represent the 
most expensive cases in MDC 5 (67 FR 49991). However, the specific 
point made by the commenters this year, that procedure code 37.66 is 
significantly different in terms of clinical procedures and resource 
utilization from the other procedures in DRG 525, was not raised prior 
to this year's proposed rule.
    While we recognize the significant disparities referenced by the 
commenter warrant further consideration, the potential solutions 
suggested by the commenter are significant changes to the DRG system 
that warrant public comment. In particular, the reassignment of code 
37.66 to DRG 103 would result in inclusion of nontransplant cases in 
this existing single-procedure DRG. Therefore, in light of the 
significant impacts of each of the commenters' suggestions on the 
structure of the DRGs involved and the need to submit any such 
significant impacts to public review and comment, we are not changing 
DRG 525 for FY 2004. We appreciate the commenter bringing this issue to 
our attention. We will evaluate whether to make further changes to DRG 
525 in light of the information that there is significant disparity in 
the costs of the different procedures included in the DRG. We note that 
the outlier payment policy will help to offset extraordinarily 
expensive costs.
    Furthermore, the volume and mix of cases in this DRG is likely to 
change over the next year. Currently, CMS has approved the use of LVADs 
in two instances. They can be used as either a bridge to heart 
transplant or for support of blood circulation postcardiotomy (the 
period following open-heart surgery). In these two applications, the 
LVAD is used as temporary mechanical circulatory support. CMS is 
currently reviewing a request for expanded coverage for these devices 
as destination (or permanent) therapy for end-stage heart failure 
patients who are not candidates for heart transplantation. Destination 
therapy means that the patient will use the LVAD for the remainder of 
his or her life.
    We believe it will be helpful to have data on the resources and 
volume associated with any potential destination therapy cases prior to 
revising DRG 525.
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 in countries where drug-eluting stents were already being 
used compared to the average price of nondrug-eluting stents in those 
countries, we calculated a price differential of approximately $1,200. 
When we apply average overall hospital charge markups to this 
technology (based on weighted average cost-to-charge ratios), we 
estimated that the charge differential 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 estimated 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 drug-eluting stent 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.\4\
---------------------------------------------------------------------------

    \4\ Even though the DRG became 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 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 for 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.
    Comment: In response to our statement in the proposed rule that we 
would use the best available data to establish the FY 2004 relative 
weights for DRGs 526 and 527, one commenter (the manufacturer of the 
only FDA-approved drug-eluting stents at this time) commissioned an 
independent accounting firm to collect costs, charges, and utilization 
data from hospitals on drug-eluting and nondrug-eluting stents.
    The data were collected from a randomized, statistically 
significant sample of United States hospitals with interventional 
cardiac catherization laboratories. First, the firm identified those 
hospitals that performed coronary angioplasty on Medicare 
beneficiaries. The method used to identify these hospitals was first to 
review MedPAR data to isolate those hospitals with average volume in 
DRGs with a placement of coronary artery stent, ICD-9-CM procedure code 
(36.06). From this list of hospitals, it was necessary to eliminate 
those that appeared to have quality issues with the data. This resulted 
in a list of 1,033 hospitals for the ``population'' group from which 
the sample was drawn.
    A sample size sufficient to achieve a confidence level of 95 
percent that the results would be within 5 percent of the actual 
distribution (assuming a normal distribution) was then determined, and 
a randomized selection within each state identified 279 hospitals. An 
additional 30 hospitals from a preliminary phase of the study were 
added because these hospitals had already supplied nondrug-eluting 
stent data and had committed to supply drug-

[[Page 45371]]

eluting stent data. Therefore, the total sample size for the survey 
instrument was 309 hospitals.
    At the time of the survey, 83 of the selected hospitals had not yet 
received shipments of the drug-eluting stents and, hence, were not able 
to complete the survey because they had no cost or charge data for 
drug-eluting stents. The final number of completed surveys was 119 (or 
53 percent of the sample).
    The survey was designed to collect data regarding costs, charges, 
and utilization for drug-eluting stents at three different points in 
time: currently; October 1, 2003; and at full-maturity (defined as that 
point in time in which the hospital has achieved a stable and 
consistent usage of the drug-eluting stent). The data were submitted 
(including a sample of invoices) under a request for confidential 
treatment under the Freedom of Information Act.
    Based on the data collected, the commenter recommended that CMS 
increase the harge differential between nondrug-eluting and drug-
eluting stents to create a payment differential of $3,024. This 
represents the cost per case differential between nondrug-eluting stent 
and drug-eluting stent cases anticipated by surveyed hospitals on 
October 1, 2003. The current cost differential reported by the sample 
of hospitals was $2,721. The commenter estimated that our proposed 
methodology results in a payment differential of $1,451 and $1,495 
between DRGs 516 and 526, and DRGs 517 and 527, respectively. The 
surveyed hospitals reported average current and anticipated stents used 
per case of 1.4 and 1.5, respectively. Average projected utilization of 
drug-eluting stents relative to all stents was reported in the survey 
to currently be 33 percent, and by October 1, 2003, utilization is 
projected to be 69 percent.
    Another commenter noted that the actual cost per stents is 59 
percent higher than our projection of $1,200. The commenter also noted 
that most cases use 2 stents instead of the projected 1.5 stents, and, 
therefore, the net incremental charge difference should be $5,554 
instead of the $3,996 projected by CMS.
    Response: The data submitted was extensively detailed and helped us 
better understand the costs, charges, and utilization for all types of 
stents. As noted above, we stated in the proposed rule that we would 
use the best available data at the time of the final rule to establish 
the FY 2004 relative weights for DRGs 526 and 527, and these data are 
much more detailed and current than any other sources available to us 
at this time. These data are extremely useful to assess the 
appropriateness of our proposed methodology to determine the relative 
weights for DRGs 526 and 527.
    The commenter recommended that CMS establish a payment differential 
between DRGs for nondrug-eluting stents and drug-eluting stents of 
$3,024 to account for the estimated cost difference between the two 
types of stents. However, the DRG relative weights are established 
using the average charges per case of each DRG relative to the national 
average. Therefore, we examined the charge per case data from the 
sample.
    The commenter referred to a mean charge differential per case of 
$5,721, based on anticipated costs per drug-eluting stent on October 1, 
2003. However, we do not believe it is appropriate to use anticipated 
October 1, 2003 charges for several reasons. First, these data cannot 
be substantiated. As noted above, we received a sampling of current 
invoices that allowed us to verify the current costs per drug-eluting 
stent. These invoices cannot verify the $300 average per stent cost 
increase that reportedly will occur between the time the survey was 
conducted and October 1, 2003. Second, for all other DRGs, we are using 
charge data reflective of FY 2002 charges. Although we are establishing 
the FY 2004 relative weights in this final rule, using anticipated FY 
2004 charge data would result in 2-year later charge data being used to 
establish the DRG 526 and 527 relative weights, while FY 2002 charge 
data are used to establish all other relative weights. Therefore, we 
believe the current data more closely approximate the data used to 
determine the FY 2004 relative weights for the remainder of the DRGs. 
Finally, hospitals must rely upon the manufacturer of the only 
currently available drug-eluting stents for information on future 
pricing. We believe this raises questions as to the validity of the 
data due to the lack of independently verifiable pricing data for the 
future.
    Therefore, we are basing our evaluation of our proposed methodology 
on the sample data from the current period. The commenter reported a 
mean differential in charges per case of $4,859 for the current period. 
However, we are concerned that the mean differential in charges per 
case is unduly influenced by extraordinarily high charge markups 
reported on the part of some hospitals. For example, one hospital 
reported charging $28,000 per drug-eluting stent, while its costs per 
stent were only $3,023. This same hospital reported charges of $9,500 
for nondrug-eluting stents, with costs per stent of $1,010. To control 
the distorting impact such a hospital would have on the mean charge 
differential, we examined the geometric mean charge differential based 
on current charges per case.
    The survey data showed that, for seven hospitals, the charge per 
case was higher for nondrug-eluting stent cases. In order to calculate 
the geometric mean differential charge per case, it was necessary to 
remove these seven negative differentials. The result was a current 
geometric mean differential charge per case of $4,186. As an 
alternative to removing these seven negative numbers, we set them to a 
$1 differential, and calculated a geometric mean differential charge 
per case of $2,291. Based on the range of these results, we believe our 
proposed charge differential of $3,996 represents a reasonable 
approximation of the differential in charges per case, and we are 
proceeding to establish the DRG relative weights for DRGs 526 and 527 
for FY 2004 using this amount.
    We note that there is a difference between CMS and the commenter on 
the current cost difference between drug-eluting stents and nondrug-
eluting stents (our estimate began with a $1,200 per stent 
differential, while the survey found a $2,721 current differential). It 
appears that the reason our charges per case for drug-eluting stents 
and nondrug-eluting stents are not substantially different from the 
charges in the survey data, despite the discrepancy in the cost 
differential, is due to the fact that hospitals are not marking up 
drug-eluting stents by the same proportion as nondrug-eluting stents. 
From the data submitted by the commenter, we found the average charge 
increase for nondrug-eluting stents is 183 percent. The average charge 
increase for drug-eluting stents is 124 percent. This lower markup 
reduces the differential in charges relative to the actual costs 
hospitals may incur.
    Based on data submitted to us last year by the commenter, we 
proposed that 43 percent of stent cases from DRGs 516 and 517 would be 
reassigned to DRGs 526 and 527. However, based on the survey data, for 
FY 2004 we are changing our estimate to assume that 69 percent of 
coronary stent cases will be reassigned from DRGs 516 and 517 to DRGs 
526 and 527, respectively. We note that, although this percentage is 
based on anticipated utilization on October 1, 2003, it is not based on 
data that is only available from the manufacturer. We are continuing to 
assume a utilization rate of 1.5 stents per case.

[[Page 45372]]

    Comment: Many commenters argued that the proposed payment for drug-
eluting stents is inadequate and asked that CMS consider the data it 
has received to date from hospital claims to determine whether the 
proposed FY 2004 payment rate for drug-eluting stents is adequate. 
Other commenters requested that CMS use the most current United States 
data available (as opposed to data from the United Kingdom) to 
establish the DRG weights for FY 2004.
    Some commenters noted that current DRG weights account for 1.5 
stents per case, but that the number of stents per case is expected to 
rise because the insertion of drug-eluting stents is more technically 
challenging in comparison to competitive products. The commenters also 
noted that because drug-eluting stents are able to treat smaller 
vessels, more diffuse disease in diabetics, and longer lesions, a rise 
is expected in the stent per patient ratio. The commenters asked that 
CMS adjust its ratio of 1.5 stents per case to an amount closer to 2 
stents per case when recalibrating the DRG weights. Another commenter 
explained that, based on their analysis, an average of 1.7 drug-eluting 
stents is used per procedure and the average cost per drug-eluting 
stent is $3,195. The commenter requested that these amounts be used to 
compute the relative weights for DRGs 526 and 527. The commenter also 
noted that the payment rates for FY 2003 are higher than the payment 
rates for FY 2004 due to the decline in the DRG relative weights.
    One commenter suggested as an alternative to increasing the weights 
for drug-eluting stents that payment be contingent on the type and 
number of stents used per procedure. The commenter recommended that CMS 
set up revenue codes to indicate the type and number of stents used per 
case and make payment approximately $1,000 above the cost per stent.
    Another commenter also noted that the demand from hospitals for 
drug-eluting stents is much higher than the projected 43 percent of 
coronary artery stent cases. The commenter estimated that 85 to 90 
percent of all stent cases should be reassigned from DRGs 516 and 517 
to DRGs 526 and 527. Another commenter explained that drug-eluting 
stents, compared with nondrug-eluting stents, have already been shown 
to decrease angiographic restenosis in coronary arteries by more than 
half, which should reduce the need for repeat procedure rates from 20 
percent of cases to less than 5 percent. As a result, demand for drug-
eluting stents is expected to increase and the commenter estimated that 
70 percent of all coronary artery stent cases will involve the use of 
drug-eluting stents. Therefore, 70 percent of all stent cases should be 
moved to DRGs 526 and 527 to account for drug-eluting stents instead of 
the 43 percent proposed by CMS.
    One commenter explained that there are many added costs of using 
drug-eluting stents, such as that the area of blockage to be treated is 
to be predilated with an angioplasty balloon before and after 
implanting the stent, the use of intravascular ultrasound to ensure 
proper positioning and deployment of stents in certain cases, and 
increased length of time a patient spends in the cardiac 
catheterization laboratory. The commenter also added that percutaneous 
transluminal coronary angioplasty volume is expected to increase due to 
obesity, smoking, sedentary lifestyle, and diabetes. Therefore, the 
commenter recommended that CMS ensure that drug-eluting stents are 
adequately paid.
    Response: As described above, we used data submitted to us from a 
survey of U.S. hospitals to evaluate our proposed methodology. Our 
analysis indicates that the proposed charge differential and the number 
of stents per procedure in our methodology are appropriate. However, we 
have increased our assumed utilization rate of drug-eluting stents to 
69 percent from 43 percent, based on these data.
    With respect to the decline in the proposed FY 2004 DRG relative 
weights compared to FY 2003, every year we recalibrate the DRG weights 
comparing the average charge per DRG to all other DRGs. The weights of 
one DRG can change for numerous reasons (for example, increase or 
decrease in total cases or increase or decrease in charges) and cause 
weights from other DRGs to increase or decrease due to budget 
neutrality.
    As we proposed, we are maintaining DRGs 526 and 527 for FY 2004, 
and adopting the same methodology to establish the relative weights as 
we used for FY 2003. We have used the best available data to establish 
the final FY 2004 relative weights for DRGs 526 and 527 included in 
this final rule. We will continue to evaluate the appropriate 
assignment of these cases in the future.
    Comment: One commenter recommended that CMS move drug-eluting 
stents to DRGs 516 and 517 and adjust the weights, because CMS should 
not provide a financial incentive for hospitals to favor one therapy 
when other alternatives with equal or better outcomes are available. 
The commenter stated further that CMS should not create an incentive 
that promotes a more expensive treatment for which risks and benefits 
are not yet completely known. Another commenter suggested that drug-
eluting stents should receive add-on payments for new technology 
instead of receiving their own DRG payment.
    Response: We explained our rationale for creating new DRGs 525 and 
526 (instead of assigning these cases to DRGs 516 or 517 or approving a 
new technology add-on) in the August 1, 2002 IPPS final rule (67 FR 
50005) and refer the commenters to that rule for our response. We 
appreciate the commenter's continual input and interest in these 
issues.
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 
(Diseases and Disorders of the Digestive System), 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).
    Prior to the publication of the proposed rule, we 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: DRG 157 and DRG 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

[[Page 45373]]

170 and DRG 171 are higher weighted than DRGs 157 and 158.
    In the May 19, 2003 proposed rule, we did not propose to assign 
these cases to DRGs 170 and 171. Although we recognized that 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 stated that 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 proposed 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.
    Comment: Two commenters expressed concern that the procedures for 
insertion and removal of an artificial anal sphincter are assigned to 
DRG groupings that do not cover the cost of the device. In addition, 
one commenter stated that, as the surgeon must operate on two distinct 
areas of the patient's body, these procedures are more resource-
intensive and, therefore, are not clinically coherent with other 
procedures of low complexity in DRGs 157 and 158.
    Response: As noted above, the codes describing the implantation, 
revision, or removal of artificial anal sphincters were created for use 
beginning on October 1, 2002. Therefore, we do not have data on cases 
assigned to codes 49.75 and 49.76. Accordingly, we are not making any 
changes to the DRG assignments of these codes at this time. However, we 
will continue to monitor this procedure in the upcoming MedPAR data and 
will, in the future, consider modifications relating to DRG 
assignment(s) if warranted.

C. Recalibration of DRG Weights

    As we proposed, in this final rule we used 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 recalibrated 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. The FY 2002 MedPAR data 
used in this final rule include discharges occurring between October 1, 
2001 and September 30, 2002, based on bills received by CMS through 
March 31, 2003, 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 11,496,239 Medicare discharges. Discharges for 
Medicare beneficiaries enrolled in a Medicare+Choice managed care plan 
are excluded from this analysis. The data excludes CAHs, including 
hospitals that subsequently became CAHs after the period from which the 
data were taken. This is a change from the recalibration methodology in 
the proposed rule, where hospitals that subsequently became CAHs were 
included in the data. In this final rule, we changed the recalibration 
methodology for consistency with our change that excluded these CAHs 
from the data used to construct the wage index.
    The 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] 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 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.
    [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, a transfer case receiving 
payment 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.
    The new weights are normalized by an adjustment factor (1.45726) 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. of the preamble of this final 
rule, we are expanding the transfer policy applicable to postacute care 
transfers to a total of 29 DRGs (the current 10 DRGs, minus 2, plus 21 
additional DRGs), beginning in FY 2004. Because we count a transfer 
case as a fraction of a case as described above in the recalibration 
process, the expansion of the postacute care transfer policy to 
additional DRGs affects the relative weights for those DRGs. Therefore, 
we calculated the final FY 2004 normalization factor comparing: the 
case-mix using the final FY 2004 DRG relative weights in which we 
treated postacute care transfer cases in the additional DRGs for 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 additional DRGs as transfer cases.
    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 final 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 FY 2003 
weights of these DRGs by the percentage change in the average weight of 
the cases in the other DRGs.
    Comment: Commenters questioned the fact that the proposed weights 
for several DRGs declined from the prior fiscal year.
    Response: As described above, the relative weight for each DRG is

[[Page 45374]]

calculated by comparing the average charge for cases within each DRG 
(after removing statistical outliers) with the national average charge 
per case. Therefore, there are several factors that can cause a shift 
in the relative weight of a DRG from one fiscal year to the next. For 
example, even though the average charges of cases within a particular 
DRG may have increased, if they did not increase by an equal or greater 
percentage than the national average, the DRG relative weight would 
decline. In this final rule, the weights for 223 DRGs for FY 2004 
decline from those for FY 2003 (all but 38 DRGs by less than 5 
percent), while the weights for 299 DRGs for FY 2004 increased from 
those for FY 2003 (all but 39 DRGs by less than 5 percent).
    Section 1886(d)(4)(C)(iii) of the Act requires that, beginning with 
FY 1991, reclassification and recalibration changes be made in a manner 
that assures that the aggregate payments are neither greater than nor 
less than the aggregate payments that would have been made without the 
changes. Although normalization is intended to achieve this effect, 
equating the average case weight after recalibration to the average 
case weight before recalibration does not necessarily achieve budget 
neutrality with respect to aggregate payments to hospitals because 
payments to hospitals are affected by factors other than average case 
weight. Therefore, as we have done in past years and as discussed in 
section II.A.4.a. of the Addendum to this final rule, we are making a 
budget neutrality adjustment to ensure that the requirement of section 
1886(d)(4)(C)(iii) of the Act is met.
    Comment: One commenter expressed concern that the impact of the 
proposed DRG recalibration is a $3 million decrease in payments to its 
hospitals. The commenter was hopeful that the budget neutrality 
adjustment to ensure that the normalization of DRG weights is achieved 
will somehow restore the estimated negative impact.
    Response: As explained above and in the proposed rule, section 
1886(d)(4)(C)(iii) of the Act requires that the changes made through 
DRG reclassification and recalibration be made in a manner that assures 
that the aggregate payments are neither greater than nor less than the 
aggregate payment that would have been made without the changes. 
However, this requirement refers to aggregate national payments. 
Therefore, for individual hospitals, the impacts of these changes may 
be either positive or negative.

D. LTC-DRG Reclassifications and Relative Weights for LTCHs for FY 2004

1. Background
    In the June 6, 2003 LTCH PPS final rule (68 FR 34122) we changed 
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 final rule, we explained that the annual update 
of the long-term care diagnosis-related group (LTC-DRG) classifications 
and relative weights will 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 June 6, 
2003 LTCH PPS final rule (68 FR 34128), we specified that we will 
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. Furthermore, we stated that we will publish the 
annual update of the LTC-DRGs in the proposed and final rules for the 
IPPS.
    As we explained in the May 19, 2003 IPPS proposed rule (68 FR 
27173), we proposed revisions to the LTC-DRG classifications and 
relative weights and indicated that we would finalize them in the IPPS 
final rule, to be effective October 1, 2003 through September 30, 2004. 
The final LTC-DRGs and relative weights for FY 2004 in this final rule 
are based on the IPPS DRGs (GROUPER version 21.0) discussed in section 
II. of this final rule.
2. 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. L. 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 under the IPPS for acute care hospitals. Thus, 
under this final rule, we will use the IPPS version 21.0 GROUPER for FY 
2004 to process LTCH PPS claims. The 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 LTCH patients. In a departure from the IPPS, as we 
discussed in both the May 19, 2003 proposed rule (68 FR 27174) and the 
June 6, 2003 LTCH PPS final rule (68 FR 34132), we use low volume 
quintiles in determining the LTC-DRG weights for LTC-DRGs with less 
than 25 LTCH cases, 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 (LTC-DRGs with fewer than 25 
cases), as we discussed in the May 19, 2003 proposed rule (68 FR 
27176), 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 2004 LTC-DRGs (based on FY 2002 MedPAR 
data) appears in section II.D.3. of this final

[[Page 45375]]

rule.) We also adjust for cases in which the stay at the LTCH is less 
than or equal to five-sixths of the geometric average length of stay; 
that is, short-stay outlier cases (Sec.  412.529), as discussed in 
section II.D.4. of this preamble.
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 is paid for the case, it is important that 
the coding is accurate. As used under the IPPS, classifications and 
terminology used under 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).
    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.
    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 LTC-DRG can 
be made.
    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 LTC-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 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 
55981), one of the primary goals for the implementation of the LTCH PPS 
is to pay each LTCH an appropriate amount for the efficient delivery of 
care to Medicare patients. 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 LTC-DRG relative weights for FY 2004 in this final 
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 Version 21.0 of the CMS GROUPER for IPPS, as 
discussed in section II.B. of this preamble, to classify cases. 
Consistent with the methodology under the IPPS, we recalculated the FY 
2004 LTC-DRG

[[Page 45376]]

relative weights based on the best available data for this final rule.
    As we discussed in the May 19, 2003 proposed rule (68 FR 27151), 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 Pub. L. 90-248 (42 U.S.C. 1395b-1) 
or section 222(a) of Pub. L. 92-603 (42 U.S.C. 1395b-1). Therefore, in 
the development of the 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 that same proposed rule, 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 reasonable cost-based 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 reasonable 
cost-based reimbursement 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.
    After this issue was brought to our attention, we discovered that 
only data from the final bills were being extracted for the MedPAR 
file. Therefore, it was possible that the original MedPAR file was not 
receiving the correct principal diagnosis. 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 using LTCH claims data from the FY 2002 
MedPAR file for the determination of the FY 2004 LTC-DRG relative 
weights. Since at the time (FY 2002) LTCHs were still reimbursed under 
the 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 reasonable cost-based 
reimbursement system in FY 2002, payment was not dependent upon 
principal diagnosis as it is under a DRG-based system. Therefore, as we 
explained in the May 19, 2003 proposed rule (68 FR 27151), we are 
following 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 using these codes to 
group each LTCH case to a 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
    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, we use a hospital-
specific relative value method to calculate the LTC-DRG relative 
weights instead of the methodology used to determine the DRG relative 
weights under the 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, 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 under Sec.  412.523, 
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. 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 discussed 
in the May 19, 2003 proposed rule (68 FR 27176), 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 final rule, using LTCH

[[Page 45377]]

cases from the FY 2002 MedPAR file, we identified 173 LTC-DRGs that 
contained between 1 and 24 cases. This list of LTC-DRGs was then 
divided into one of the five low volume quintiles, each containing a 
minimum of 34 LTC-DRGs (173/5 = 34 with 3 LTC-DRGs as the remainder). 
For FY 2004, as we described in that same proposed rule, we are making 
an assignment to a specific low volume quintile by sorting the 173 low 
volume LTC-DRGs in ascending order by average charge. Since the number 
of LTC-DRGs with less than 25 LTCH cases is not evenly divisible by 
five, the average charge of the low volume LTC-DRG was used to 
determine which low volume quintile received the additional LTC-DRG. 
After sorting the 173 low volume LTC-DRGs in ascending order, we 
grouped the first fifth (34) of low volume LTC-DRGs with the lowest 
average charge into Quintile 1. The highest average charge cases are 
grouped into Quintile 5. Since the average charge of the 69th LTC-DRG 
in the sorted list is closer to the previous LTC-DRG's average charge 
(assigned to Quintile 2) than to the average charge of the 70th LTC-DRG 
in the sorted list (to be assigned to Quintile 3), we placed it into 
Quintile 2. This process was repeated through the remaining low volume 
LTC-DRGs so that 3 low volume quintiles contain 35 LTC-DRGs and 2 low 
volume quintiles contain 34 LTC-DRGs.
    In order to determine the relative weights for the LTC-DRGs with 
low volume for FY 2004, in accordance with the methodology described in 
the May 19, 2003 proposed rule (68 FR 27176), we used the five low 
volume quintiles described above. The composition of each of the five 
low volume quintiles shown below in Table 1 is used in determining the 
LTC-DRG relative weights for FY 2004. We determine a relative weight 
and (geometric) average length of stay for each of the five low volume 
quintiles using the formula that we apply to the regular LTC-DRGs (25 
or more cases), as described below in section II.D.4. of this preamble. 
We assign the same relative weight and average length of stay to each 
of the LTC-DRGs that make up that 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.--Composition of Low Volume Quintiles
------------------------------------------------------------------------
         LTC-DRG                            Description
------------------------------------------------------------------------
                               Quintile 1
------------------------------------------------------------------------
44......................  ACUTE MAJOR EYE INFECTIONS.
46......................  OTHER DISORDERS OF THE EYE AGE 17 W
                           CC.
47......................  OTHER DISORDERS OF THE EYE AGE 17 W/
                           O CC.
65......................  DYSEQUILIBRIUM.
66......................  EPISTAXIS.
69......................  OTITIS MEDIA & URI AGE 17 W/O CC.
93......................  INTERSTITIAL LUNG DISEASE W/O CC.
95......................  PNEUMOTHORAX W/O CC.
149.....................  MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC.
178.....................  UNCOMPLICATED PEPTIC ULCER W/O CC.
192.....................  PANCREAS, LIVER & SHUNT PROCEDURES W/O CC.
273.....................  MAJOR SKIN DISORDERS W/O CC.
276.....................  NON-MALIGANT BREAST DISORDERS.
284.....................  MINOR SKIN DISORDERS W/O CC.
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.
326.....................  KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE
                           17 W/O CC.
342.....................  CIRCUMCISION AGE 17.
344.....................  OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES
                           FOR MALIGNANCY.
348.....................  BENIGN PROSTATIC HYPERTROPHY W CC.
349.....................  BENIGN PROSTATIC HYPERTROPHY W/O CC.
367.....................  MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W/O CC.
376.....................  POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R.
                           PROCEDURE.
399.....................  RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O
                           CC.
414.....................  OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL
                           DIAG W/O CC.
428.....................  DISORDERS OF PERSONALITY & IMPULSE CONTROL.
431.....................  CHILDHOOD MENTAL DISORDERS.
432.....................  OTHER MENTAL DISORDER DIAGNOSES.
433.....................  ALCOHOL/DRUG ABUSE OR DEPENDENCE, LEFT AMA.
467.....................  OTHER FACTORS INFLUENCING HEALTH STATUS.
511.....................  NON-EXTENSIVE BURNS W/O CC OR SIGNIFICANT
                           TRAUMA.
538.....................  LOCAL EXCISION AND REMOVAL OF INTERNAL
                           FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT
                           CC.
540.....................  LYMPHOMA AND LEUKEMIA WITH MAJOR O.R.
                           PROCEDURE WITHOUT CC.
-------------------------
                               Quintile 2
------------------------------------------------------------------------
21......................  VIRAL MENINGITIS.
22......................  HYPERTENSIVE ENCEPHALOPATHY.
31**....................  CONCUSSION AGE 17 W CC.
53......................  SINUS & MASTOID PROCEDURES AGE 17.
61......................  MYRINGOTOMY W TUBE INSERTION AGE 17.
72......................  NASAL TRAUMA & DEFORMITY.
84......................  MAJOR CHEST TRAUMA W/O CC.
128.....................  DEEP VEIN THROMBOPHLEBITIS.

[[Page 45378]]

 
177.....................  UNCOMPLICATED PEPTIC ULCER W CC.
185.....................  DENTAL & ORAL DIS EXCEPT EXTRACTIONS &
                           RESTORATIONS, AGE 17.
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.
237.....................  SPRAINS, STRAINS, & DISLOCATIONS OF HIP,
                           PELVIS & THIGH.
275.....................  MALIGNANT BREAST DISORDERS W/O CC.
301.....................  ENDOCRINE DISORDERS W/O CC.
309.....................  MINOR BLADDER PROCEDURES W/O CC.
323.....................  URINARY STONES W CC, &/OR ESW LITHOTRIPSY.
324.....................  URINARY STONES W/O CC.
339.....................  TESTES PROCEDURES, NON-MALIGNANCY AGE 17.
341.....................  PENIS PROCEDURES.
420.....................  FEVER OF UNKNOWN ORIGIN AGE 17 W/O
                           CC.
421.....................  VIRAL ILLNESS AGE 17.
454.....................  OTHER INJURY, POISONING & TOXIC EFFECT DIAG W
                           CC.
455.....................  OTHER INJURY, POISONING & TOXIC EFFECT DIAG W/
                           O CC.
465.....................  AFTERCARE W HISTORY OF MALIGNANCY AS SECONDARY
                           DIAGNOSIS.
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 GRAFT OR INHAL INJ
                           W/O CC OR SIG TRAUMA.
508.....................  FULL THICKNESS BURN W/O SKIN GRAFT OR INHAL
                           INJ W CC OR SIG TRAUMA.
509.....................  FULL THICKNESS BURN W/O SKIN GRAFT OR INH INJ
                           W/O CC OR SIG TRAUMA.
510.....................  NON-EXTENSIVE BURNS W CC OR SIGNIFICANT
                           TRAUMA.
529.....................  VENTRICULAR SHUNT PROCEDURES WITH CC.
-------------------------
                               QUINTILE 3
------------------------------------------------------------------------
31*.....................  CONCUSSION AGE 17 W CC.
32*.....................  CONCUSSION AGE 17 W/O CC.
63......................  OTHER EAR, NOSE, MOUTH & THROAT O.R.
                           PROCEDURES.
83......................  MAJOR CHEST TRAUMA W CC.
117.....................  CARDIAC PACEMAKER REVISION EXCEPT DEVICE
                           REPLACEMENT.
129.....................  CARDIAC ARREST, UNEXPLAINED.
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.
225.....................  FOOT PROCEDURES.
226**...................  SOFT TISSUE PROCEDURES W CC.
233.....................  OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC
                           W CC.
234.....................  OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC
                           W/O CC.
257.....................  TOTAL MASTECTOMY FOR MALIGNANCY W CC.
262.....................  BREAST BIOPSY & LOCAL EXCISION FOR NON-
                           MALIGNANCY.
295.....................  DIABETES AGE 0-35.
299.....................  INBORN ERRORS OF METABOLISM.
317.....................  ADMIT FOR RENAL DIALYSIS.
325.....................  KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE
                           17 W CC.
347***..................  MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W/O CC.
352.....................  OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES.
369.....................  MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM
                           DISORDERS.
394.....................  OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD
                           FORMING ORGANS.
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.
419.....................  FEVER OF UNKNOWN ORIGIN AGE 17 W
                           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.
473.....................  ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE
                           17.
497.....................  SPINAL FUSION W CC.
498 *...................  SPINAL FUSION W/O CC.
503.....................  KNEE PROCEDURES W/O PDX OF INFECTION.
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.
532.....................  SPINAL PROCEDURES WITHOUT CC.
-------------------------

[[Page 45379]]

 
                               QUINTILE 4
------------------------------------------------------------------------
119.....................  VEIN LIGATION & STRIPPING.
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 7 W CC.
171.....................  OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W/O CC.
191.....................  PANCREAS, LIVER & SHUNT PROCEDURES W CC.
195.....................  CHOLECYSTECTOMY W C.D.E. W CC.
209.....................  MAJOR JOINT & LIMB REATTACHMENT PROCEDURES OF
                           LOWER EXTREMITY.
210.....................  HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT
                           AGE17 W CC.
216.....................  BIOPSIES OF MUSCULOSKELETAL SYSTEM &
                           CONNECTIVE TISSUE.
226 *...................  SOFT TISSUE PROCEDURES W CC.
227.....................  SOFT TISSUE PROCEDURES W/O CC.
228.....................  MAJOR THUMB OR JOINT PROC,OR OTH HAND OR WRIST
                           PROC W CC.
230.....................  LOCAL EXCISION & REMOVAL OF INT FIX DEVICES OF
                           HIP & FEMUR.
266 * * *...............  SKIN GRAFT &/OR DEBRID EXCEPT FOR SKIN ULCER
                           OR CELLULITIS W/O CC.
292.....................  OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC 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.
424.....................  O.R. PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL
                           ILLNESS.
427.....................  NEUROSES EXCEPT DEPRESSIVE.
443.....................  OTHER O.R. PROCEDURES FOR INJURIES W/O CC.
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.
505.....................  EXTENSIVE 3RD DEGREE BURNS W/O SKIN GRAFT.
517.....................  PERCUTANEOUS CARDIVASCULAR PROC W NON-DRUG
                           ELUTING STENT W/O AMI.
519.....................  CERVICAL SPINAL FUSION W CC.
531.....................  SPINAL PROCEDURES WITH CC.
537.....................  LOCAL EXCISION AND REMOVAL OF INTERNAL
                           FIXATION DEVICES EXCEPT HIP AND FEMUR WITH
                           CC.
-------------------------
                               QUINTILE 5
------------------------------------------------------------------------
1.......................  CRANIOTOMY AGE 17 W CC.
8 ***...................  PERIPH & CRANIAL NERVE & OTHER NERV SYST PROC
                           W/O CC.
32 **...................  CONCUSSION AGE 17 W/O CC.
40......................  EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE 17.
75......................  MAJOR CHEST PROCEDURES.
77......................  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.
148.....................  MAJOR SMALL & LARGE BOWEL PROCEDURES W CC.
154.....................  STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE
                           17 W CC.
168.....................  MOUTH PROCEDURES W CC.
201.....................  OTHER HEPATOBILIARY OR PANCREAS O.R.
                           PROCEDURES.
261.....................  BREAST PROC FOR NON-MALIGNANCY EXCEPT BIOPSY &
                           LOCAL EXCISION.
268.....................  SKIN, SUBCUTANEOUS TISSUE & BREAST PLASTIC
                           PROCEDURES.
288.....................  O.R. PROCEDURES FOR OBESITY.
304.....................  KIDNEY, URETER & MAJOR BLADDER PROC FOR NON-
                           NEOPL W CC.
345.....................  OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC
                           EXCEPT FOR MALIGNANCY.
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.
441.....................  HAND PROCEDURES FOR INJURIES.
450 **..................  POISONING & TOXIC EFFECTS OF DRUGS AGE 17 W/O CC.
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.

[[Page 45380]]

 
501.....................  KNEE PROCEDURES W PDX OF INFECTION W CC.
515.....................  CARDIAC DEFIBRILATOR IMPLANT W/O CARDIAC CATH.
533.....................  EXTRACRANIAL VASCULAR PROCEDURES WITH CC.
536.....................  CARDIAC DEFIB IMPLANT WITH CARDIAC CATH
                           WITHOUT AMI/HF/SHOCK.
------------------------------------------------------------------------
* One of the original 173 low volume LTC-DRGs initially assigned to a
  different low volume quintile; reassigned to this low volume quintile
  in addressing nonmonotonicity (see step 5 below).
** One of the original 173 low volume LTC-DRGs initially assigned to
  this low volume quintile; reassigned to a different low volume
  quintile in addressing nonmonotonicity (see step 5 below).
*** One of the original 173 low volume LTC-DRGs initially assigned to
  this low volume quintile; removed from the low volume quintiles in
  addressing nonmonotonicity (see step 5 below).

4. Steps for Determining the FY 2004 LTC-DRG Relative Weights
    As we noted previously, the FY 2004 LTC-DRG relative weights are 
determined in accordance with the methodology described in the May 19, 
2003 proposed rule (68 FR 27179). In summary, LTCH cases must be 
grouped in the appropriate LTC-DRG, while taking into account the low 
volume LTC-DRGs as described above, before the FY 2004 LTC-DRG relative 
weights can be determined. After grouping the cases in the appropriate 
LTC-DRG, we calculate the relative weights for FY 2004 in this final 
rule by first removing statistical outliers and cases with a length of 
stay of 7 days or less. Next, we adjust the number of cases in each 
LTC-DRG for the effect of short-stay outlier cases under Sec.  412.529. 
The short-stay adjusted discharges and corresponding charges are used 
to calculate ``relative adjusted weights'' in each LTC-DRG using the 
hospital-specific relative value method described above.
    Below we discuss in detail the steps for calculating the FY 2004 
LTC-DRG relative weights.

Step 1--Remove Statistical Outliers

    The first step in the calculation of the FY 2004 LTC-DRG relative 
weights is to remove statistical outlier cases. As we discussed in the 
May 19, 2003 proposed rule (68 FR 27179), 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 LTC-DRG. These statistical outliers are removed prior 
to calculating the 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 relative 
weights could result in an inaccurate relative weight that does not 
truly reflect relative resource use among the LTC-DRGs.

Step 2--Remove Cases With a Length of Stay of 7 Days or Less

    The FY 2004 LTC-DRG relative weights reflect the average of 
resources used on representative cases of a specific type. Generally, 
as we discussed in the May 19, 2003 proposed rule (68 FR 27179), cases 
with a length of stay 7 days or less do not belong in a LTCH because 
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 FY 2004 LTC-DRG relative 
weights, the value of many 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 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 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 we discussed in the May 19, 2003 proposed rule (68 FR 27179), 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 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 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 LTC-DRG.
    As we explained in that same proposed rule, counting short-stay 
outlier cases as full discharges with no adjustment in determining the 
LTC-DRG relative weights would lower the LTC-DRG relative weight for 
affected LTC-DRGs because the relatively lower charges of the short-
stay outlier cases would bring down the average charge for all cases 
within a LTC-DRG. This would result in an ``underpayment'' to nonshort-
stay outlier cases and an ``overpayment'' to short-stay outlier cases. 
Therefore, in this final rule, we adjust for short-stay outlier cases 
under Sec.  412.529 in this manner since it results in more appropriate 
payments for all LTCH cases.

Step 4--Calculate the FY 2004 LTC-DRG Relative Weights on an Iterative 
Basis

    As we discussed in the May 19, 2003 proposed rule (68 FR 27180), 
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 LTC-DRG, the FY 2004 LTC-DRG relative weight is calculated 
by dividing the average of the adjusted hospital-specific relative 
charge values (from above) for the LTC-DRG by the

[[Page 45381]]

overall average hospital-specific relative charge value across all 
cases for all LTCHs. Using these recalculated LTC-DRG relative weights, 
each LTCH's average relative weight for all of its cases (case-mix) is 
calculated by dividing the sum of all the LTCH's 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 LTC-DRG relative 
weights across all LTCHs. In this final 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 FY 2004 LTC-DRG Relative Weights to Account for 
Nonmonotonically Increasing Relative Weights

    As explained in section II.B. of this preamble, the FY 2004 CMS 
DRGs, upon which the FY 2004 LTC-DRGs are based, contain ``pairs'' that 
are differentiated based on the presence or absence of CCs. The 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 May 19, 2003 
proposed rule (68 FR 27180), 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 LTC-DRG 
means that cases classified into a ``without CC'' 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 LTC-DRGs.
    For a case to be assigned to a LTC-DRG with CCs, more coded 
information is called for (that is, at least one relevant secondary 
diagnosis), than for a case to be assigned to a 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 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, 
coding by LTCHs 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 discussed 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 LTC-DRG ``with CCs'' of a ``with CC''/``without 
CC'' pair have a lower average charge than the corresponding 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, as we discussed in the 
May 19, 2003 proposed rule (68 FR 27180), we grouped both the cases 
``with CCs'' and ``without CCs'' together for the purpose of 
calculating the FY 2004 LTC-DRG relative weights in this final rule. 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.
    There are three types of ``with CC'' and ``without CC'' pairs that 
could be nonmonotonic, that is, where the ``without CC'' LTC-DRG would 
have a higher average charge than the ``with CC'' LTC-DRG. For this 
final rule, using the LTCH cases in the December 2002 update of the FY 
2002 MedPAR file, we identified three of the types of nonmonotonic LTC-
DRG pairs.
    The first category of nonmonotonically increasing relative weights 
for FY 2004 LTC-DRG pairs ``with and without CCs'' contains 1 pair of 
LTC-DRGs in which both the LTC-DRG ``with CCs'' and the LTC-DRG 
``without CCs'' had 25 or more LTCH cases and, therefore, did not fall 
into one of the 5 low volume quintiles. For that type of nonmonotonic 
LTC-DRG pair, as discussed in the May 19, 2003 proposed rule (68 FR 
27180), we combine the LTCH cases and compute a new relative weight 
based on the case-weighted average of the combined LTCH cases of the 
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 LTC-DRG. This new relative weight is then assigned to 
both of the LTC-DRGs in the pair. In this final rule, for FY 2004, LTC-
DRGs 180 and 181 are in this category.
    The second category of nonmonotonically increasing relative weights 
for LTC-DRG pairs with and without CCs consists of 7 pairs of LTC-DRGs 
that has fewer than 25 cases, and each LTC-DRG is grouped to different 
low volume quintiles in which the ``without CC'' LTC-DRG is in a 
higher-weighted low volume quintile than the ``with CC'' LTC-DRG. For 
those pairs, as we discussed in the May 19, 2003 proposed rule (68 FR 
27181), 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 LTC-DRG. Based on the case-
weighted average LTCH charge, we determine which low volume quintile 
the ``combined LTC-DRG'' is grouped. Both LTC-DRGs in the pair are then 
grouped into the same low volume quintile, and thus would have the same 
relative weight. For FY 2004, in this final rule, the following LTC-
DRGs are in this category: LTC-DRGs 31 and 32 (low volume quintile 3); 
LTC-DRGs 193 and 194 (low volume quintile 2); LTC-DRGs 226 and 227 (low 
volume quintile 4); LTC-DRGs 449 and 450 (low volume quintile 3); LTC-
DRGs 493 and 494 (low volume quintile 4); LTC-DRGs 497 and 498 (low 
volume quintile 3); and LTC-DRGs 506 and 507 (low volume quintile 2).
    The third category of nonmonotonically increasing relative weights 
for LTC-DRG pairs with and without CCs consists of 6 pairs of LTC-DRGs 
where one of the LTC-DRGs has fewer than 25 LTCH cases and is grouped 
to a low volume quintile and the other LTC-DRG has 25 or more LTCH 
cases and has its own LTC-DRG relative weight, and the LTC-DRG 
``without CCs'' has the higher relative weight. As we discussed in the 
May 19, 2003 proposed rule (68 FR 27181), we remove the low volume LTC-
DRG from the low volume quintile and combine it with the other LTC-DRG 
for the computation of a new relative weight for

[[Page 45382]]

each of these LTC-DRGs. This new relative weight is assigned to both 
LTC-DRGs, so they each have the same relative weight. For FY 2004, in 
this final rule, the following LTC-DRGs are in this category: LTC-DRGs 
7 and 8; LTC-DRGs 205 and 206; LTC-DRGs 207 and 208; LTC-DRGs 265 and 
266; LTC-DRGs 346 and 347; and LTC-DRGs 478 and 479.

Step 6--Determine a FY 2004 LTC-DRG Relative Weight for LTC-DRGs With 
No LTCH Cases

    As we stated above, we determine the relative weight for each LTC-
DRG using charges reported in the December 2002 update of the FY 2002 
MedPAR file. Of the 518 LTC-DRGs for FY 2004, we identified 167 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 final rule, no 
patients who would have been classified to those LTC-DRGs were treated 
in LTCHs during FY 2002 and, therefore, no charge data were reported 
for those LTC-DRGs. Thus, in the process of determining the LTC-DRG 
relative weights, we are unable to determine weights for these 167 LTC-
DRGs using the methodology described in steps 1 through 5 above. 
However, since patients with a number of the diagnoses under these LTC-
DRGs may be treated at LTCHs beginning in FY 2004, we assign relative 
weights to each of the 167 ``no volume'' LTC-DRGs based on clinical 
similarity and relative costliness to one of the remaining 354 (518-167 
= 351) LTC-DRGs for which we are able to determine relative weights, 
based on FY 2002 claims data.
    As there are currently no LTCH cases in these ``no volume'' LTC-
DRGs, as we discussed in the May 19, 2003 proposed rule (68 FR 27181), 
we determine relative weights for the 167 LTC-DRGs with no LTCH cases 
in the FY 2002 MedPAR file used in this final rule by grouping them to 
the appropriate low volume quintile. This methodology is consistent 
with our methodology used in determining relative weights to account 
for the low volume LTC-DRGs described above.
    Our methodology for determining relative weights for the ``no 
volume'' LTC-DRGs is as follows: First, we crosswalk the no volume LTC-
DRGs by matching them to other similar 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 relative weight for the applicable low volume 
quintile to the no volume LTC-DRG if the LTC-DRG to which it is 
crosswalked is grouped to one of the low volume quintiles. If the LTC-
DRG to which the no volume LTC-DRG is crosswalked is not one of the 
LTC-DRGs to be grouped to one of the low volume quintiles, we compare 
the relative weight of the LTC-DRG to which the no volume LTC-DRG is 
crosswalked to the relative weights of each of the five quintiles and 
we assign the no volume LTC-DRG the relative weight of the low volume 
quintile with the closest weight. For this final rule, a list of the no 
volume FY 2004 LTC-DRGs and the FY 2004 LTC-DRG to which it is 
crosswalked in order to determine the appropriate low volume quintile 
for the assignment of a relative weight for FY 2004 is shown below in 
Table 2.

                    Table 2.--No Volume LTC-DRG Crosswalk and Quintile Assignment for FY 2004
----------------------------------------------------------------------------------------------------------------
                                                                  Cross-walked
            LTC-DRG                       Description                LTC-DRG       Low volume quintile assigned
----------------------------------------------------------------------------------------------------------------
2.............................  CRANIOTOMY AGE  17 W/              1  Quintile 5
                                 O CC.
3.............................  CRANIOTOMY AGE 0-17............               1  Quintile 5
6.............................  CARPAL TUNNEL RELEASE..........             251  Quintile 1
26............................  SEIZURE & HEADACHE AGE 0-17....              25  Quintile 2
30............................  TRAUMATIC STUPOR & COMA, COMA                29  Quintile 3
                                 <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 PROCEDURES........              47  Quintile 1
39............................  LENS PROCEDURES WITH OR WITHOUT              47  Quintile 1
                                 VITRECTOMY.
41............................  EXTRAOCULAR PROCEDURES EXCEPT                47  Quintile 1
                                 ORBIT AGE 0-17.
42............................  INTRAOCULAR PROCEDURES EXCEPT                47  Quintile 1
                                 RETINA, IRIS & LENS.
43............................  HYPHEMA........................              47  Quintile 1
45............................  NEUROLOGICAL EYE DISORDERS.....              46  Quintile 1
48............................  OTHER DISORDERS OF THE EYE AGE               47  Quintile 1
                                 0-17.
49............................  MAJOR HEAD & NECK PROCEDURES...              64  Quintile 4
50............................  SIALOADENECTOMY................              63  Quintile 3
51............................  SALIVARY GLAND PROCEDURES                    63  Quintile 3
                                 EXCEPT SIALOADENECTOMY.
52............................  CLEFT LIP & PALATE REPAIR......              63  Quintile 3
54............................  SINUS & MASTOID PROCEDURES AGE               63  Quintile 3
                                 0-17.
55............................  MISCELLANEOUS EAR, NOSE, MOUTH               63  Quintile 3
                                 & THROAD PROCEDURES.
56............................  RHINOPLASTY....................              72  Quintile 2
57............................  T&A PROC, EXCEPT TONSILLECTOMY               63  Quintile 3
                                 &/OR ADENOIDECTOMY ONLY, AGE
                                 17.
58............................  T&A PROC, EXCEPT TONSILLECTOMY               63  Quintile 3
                                 &/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 INSERTION                 63  Quintile 3
                                 AGE 0-17.
67............................  EPIGLOTTITIS...................              63  Quintile 3
70............................  OTITIS MEDIA & URI AGE 0-17....              69  Quintile 1
71............................  LARYNGOTRACHEITIS..............              97  Quintile 1
74............................  OTHER EAR, NOSE, MOUTH & THROAT              69  Quintile 1
                                 DIAGNOSES AGE 0-17.
81............................  RESPIRATORY INFECTIONS &                     69  Quintile 1
                                 INFLAMMATIONS AGE 0-17.
91............................  SIMPLE PNEUMONIA & PLEURISY AGE              90  Quintile 2
                                 0-17.
98............................  BRONCHITIS & ASTHMA AGE 0-17...              97  Quintile 1
104...........................  CARDIAC VALVE & OTHER MAJOR                 110  Quintile 5
                                 CARDIOTHORACIC PROC W CARDIAC
                                 CATH.
105...........................  CARDIAC VALVE & OTHER MAJOR                 110  Quintile 5
                                 CARDIOTHORACIC PROC W/O
                                 CARDIAC CATH.

[[Page 45383]]

 
106...........................  CORONARY BYPASS W PTCA.........             110  Quintile 5
107...........................  CORONARY BYPASS W CARDIAC CATH.             110  Quintile 5
109...........................  CORONARY BYPASS W/O PTCA OR                 110  Quintile 5
                                 CARDIAC CATH.
111...........................  MAJOR CARDIOVASCULAR PROCEDURES             110  Quintile 5
                                 W/O CC.
137...........................  CARDIAC CONGENITAL & VALVULAR               136  Quintile 2
                                 DISORDERS AGE 0-17.
146...........................  RECTAL RESECTION W CC..........             148  Quintile 5
147...........................  RECTAL RESECTION W/O CC........             148  Quintile 5
151...........................  PERITONEAL ADHESIOLYSIS W/O CC.             150  Quintile 4
153...........................  MINOR SMALL & LARGE BOWEL                   152  Quintile 4
                                 PROCEDURES W/O CC 155 STOMACH,
                                 ESOPHAGEAL & DUODENAL.
155...........................  STOMACH, ESOPHAGEAL & DUODENAL              171  Quintile 4
                                 PROCEDURES AGE 17 W/
                                 O CC.
156...........................  STOMACH, ESOPHAGEAL & DUODENAL              171  Quintile 4
                                 PROCEDURES AGE 0-17.
159...........................  HERNIA PROCEDURES EXCEPT                    161  Quintile 4
                                 INGUINAL & FEMORAL AGE 17 W CC.
160...........................  HERNIA PROCEDURES EXCEPT                    161  Quintile 4
                                 INGUINAL & FEMORAL AGE 17 W/O CC.
162...........................  INGUINAL & FEMORAL HERNIA                   178  Quintile 1
                                 PROCEDURES AGE 17 W/
                                 O CC.
163...........................  HERNIA PROCEDURES AGE 0-17.....             178  Quintile 1
164...........................  APPENDECTOMY W COMPLICATED                  148  Quintile 5
                                 PRINCIPAL DIAG W CC.
165...........................  APPENDECTOMY W COMPLICATED                  149  Quintile 1
                                 PRINCIPAL DIAG W/O CC.
166...........................  APPENDECTOMY W/O COMPLICATED                148  Quintile 5
                                 PRINCIPAL DIAG W CC.
167...........................  APPENDECTOMY W/O COMPLICATED                149  Quintile 1
                                 PRINCIPAL DIAG W/O CC.
169...........................  MOUTH PROCEDURES W/O CC........              72  Quintile 2
184...........................  ESOPHAGITIS, GASTROENT & MISC               183  Quintile 2
                                 DIGEST DISORDERS AGE 0-17.
186...........................  DENTAL & ORAL DIS EXCEPT                    185  Quintile 2
                                 EXTRACTIONS & RESTORATIONS,
                                 AGE 0-17.
187...........................  DENTAL EXTRACTIONS &                        185  Quintile 2
                                 RESTORATIONS.
190...........................  OTHER DIGESTIVE SYSTEM                      189  Quintile 2
                                 DIAGNOSES AGE 0-17.
196...........................  CHOLECYSTECTOMY W C.D.E. W/O CC             197  Quintile 3
198...........................  CHOLECYSTECTOMY EXCEPT BY                   197  Quintile 3
                                 LAPAROSCOPE W/O C.D.E. W/O CC.
199...........................  HEPATOBILIARY DIAGNOSTIC                    200  Quintile 2
                                 PROCEDURE FOR MALIGNANCY.
212...........................  HIP & FEMUR PROCEDURES EXCEPT               211  Quintile 2
                                 MAJOR JOINT AGE 0-17.
219...........................  LOWER EXTREM & HUMER PROC                   218  Quintile 3
                                 EXCEPT HIP, FOOT, FEMUR AGE
                                 17 W/O CC.
220...........................  LOWER EXTREM & HUMER PROC                   218  Quintile 3
                                 EXCEPT HIP, FOOT, FEMUR AGE 0-
                                 17.
224...........................  SHOULDER, ELBOW OR FOREARM                  234  Quintile 3
                                 PROC, EXC MAJOR JOINT PROC, W/
                                 O CC.
229...........................  HAND OR WRIST PROC, EXCEPT                  234  Quintile 3
                                 MAJOR JOINT PROC, W/O CC.
252...........................  FX, SPRN, STRN & DISL OF                    234  Quintile 3
                                 FOREARM, HAND, FOOT AGE 0-17.
255...........................  FX, SPRN, STRN & DISL OF UPARM,             234  Quintile 3
                                 LOWLEG EX FOOT AGE 0-17.
258...........................  TOTAL MASTECTOMY FOR MALIGNANCY             257  Quintile 3
                                 W/O CC.
259...........................  SUBTOTAL MASTECTOMY FOR                     257  Quintile 3
                                 MALIGNANCY W CC.
260...........................  SUBTOTAL MASTECTOMY FOR                     257  Quintile 3
                                 MALIGNANCY W/O CC.
267...........................  PERIANAL & PILONIDAL PROCEDURES             158  Quintile 3
279...........................  CELLULITIS AGE 0-17............              78  Quintile 3
282...........................  TRAUMA TO THE SKIN, SUBCUT TISS             281  Quintile 2
                                 & BREAST AGE 0-17.
286...........................  ADRENAL & PITUITARY PROCEDURES.              53  Quintile 2
289...........................  PARATHYROID PROCEDURES.........              53  Quintile 2
290...........................  THYROID PROCEDURES.............              53  Quintile 2
291...........................  THYROGLOSSAL PROCEDURES........              53  Quintile 2
293...........................  OTHER ENDOCRINE, NUTRIT & METAB              63  Quintile 3
                                 O.R. PROC W/O CC.
298...........................  NUTRITIONAL & MISC METABOLIC                297  Quintile 2
                                 DISORDERS AGE 0-17.
303...........................  KIDNEY, URETER & MAJOR BLADDER              304  Quintile 5
                                 PROCEDURES FOR NEOPLASM.
306...........................  PROSTATECTOMY W CC.............             310  Quintile 4
307...........................  PROSTATECTOMY W/O CC...........             310  Quintile 4
313...........................  URETHRAL PROCEDURES, AGE 17 W/O CC.
314...........................  URETHRAL PROCEDURES, AGE 0-17..             311  Quintile 1
322...........................  KIDNEY & URINARY TRACT                      326  Quintile 1
                                 INFECTIONS AGE 0-17.
327...........................  KIDNEY & URINARY TRACT SIGNS &              326  Quintile 1
                                 SYMPTOMS AGE 0-17.
328...........................  URETHRAL STRICTURE AGE 17 W CC.
329...........................  URETHRAL STRICTURE AGE 17 W/O CC.
330...........................  URETHRAL STRICTURE AGE 0-17....             311  Quintile 1
333...........................  OTHER KIDNEY & URINARY TRACT                332  Quintile 1
                                 DIAGNOSES AGE 0-17.
334...........................  MAJOR MALE PELVIC PROCEDURES W              345  Quintile 5
                                 CC.
335...........................  MAJOR MALE PELVIC PROCEDURES W/             345  Quintile 5
                                 O CC.
336...........................  TRANSURETHRAL PROSTATECTOMY W               341  Quintile 2
                                 CC.
337...........................  TRANSURETHRAL PROSTATECTOMY W/O             341  Quintile 2
                                 CC.
338...........................  TESTES PROCEDURES, FOR                      339  Quintile 2
                                 MALIGNANCY.
340...........................  TESTES PROCEDURES, NON-                     339  Quintile 2
                                 MALIGNANCY AGE 0-17.
343...........................  CIRCUMCISION AGE 0-17..........             339  Quintile 2
351...........................  STERILIZATION, MALE............             339  Quintile 2
353...........................  PELVIC EVISCERATION, RADICAL                365  Quintile 5
                                 HYSTERECTOMY & RADICAL
                                 VULVECTOMY.
354...........................  UTERINE, ADNEXA PROC FOR NON-               365  Quintile 5
                                 OVARIAN/ADNEXAL MALIG W CC.
355...........................  UTERINE, ADNEXA PROC FOR NON-               365  Quintile 5
                                 OVARIAN/ADNEXAL MALIG W/O CC.
356...........................  FEMALE REPRODUCTIVE SYSTEM                  360  Quintile 4
                                 RECONSTRUCTIVE PROCEDURES.
357...........................  UTERINE & ADNEXA PROC FOR                   360  Quintile 4
                                 OVARIAN OR ADNEXAL MALIGNANCY.

[[Page 45384]]

 
358...........................  UTERINE & ADNEXA PROC FOR NON-              360  Quintile 4
                                 MALIGNANCY W CC.
359...........................  UTERINE & ADNEXA PROC FOR NON-              360  Quintile 4
                                 MALIGNANCY W/O CC.
361...........................  LAPAROSCOPY & INCISIONAL TUBAL              149  Quintile 1
                                 INTERRUPTION.
362...........................  ENDOSCOPIC TUBAL INTERRUPTION..             149  Quintile 1
363...........................  D&C, CONIZATION & RADIO-                    367  Quintile 1
                                 IMPLANT, FOR MALIGNANCY.
364...........................  D&C, CONIZATION EXCEPT FOR                  367  Quintile 1
                                 MALIGNANCY.
370...........................  CESAREAN SECTION W CC..........             369  Quintile 3
371...........................  CESAREAN SECTION W/O CC........             367  Quintile 1
372...........................  VAGINAL DELIVERY W COMPLICATING             367  Quintile 1
                                 DIAGNOSES.
373...........................  VAGINAL DELIVERY W/O                        367  Quintile 1
                                 COMPLICATING DIAGNOSES.
374...........................  VAGINAL DELIVERY W                          367  Quintile 1
                                 STERILIZATION &/OR D&C.
375...........................  VAGINAL DELIVERY W O.R. PROC                367  Quintile 1
                                 EXCEPT STERIL &/OR D&C.
377...........................  POSTPARTUM & POST ABORTION                  367  Quintile 1
                                 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, ASPIRATION                  376  Quintile 1
                                 CURETTAGE OR HYSTEROTOMY.
382...........................  FALSE LABOR....................             376  Quintile 1
383...........................  OTHER ANTEPARTUM DIAGNOSES W                376  Quintile 1
                                 MEDICAL COMPLICATIONS.
384...........................  OTHER ANTEPARTUM DIAGNOSES W/O              376  Quintile 1
                                 MEDICAL COMPLICATIONS.
385...........................  NEONATES, DIED OR TRANSFERRED               367  Quintile 1
                                 TO ANOTHER ACUTE CARE FACILITY.
386...........................  EXTREME IMMATURITY.............             367  Quintile 1
387...........................  PREMATURITY W MAJOR PROBLEMS...             367  Quintile 1
388...........................  PREMATURITY W/O MAJOR PROBLEMS.             367  Quintile 1
389...........................  FULL TERM NEONATE W MAJOR                   367  Quintile 1
                                 PROBLEMS.
390...........................  NEONATE W OTHER SIGNIFICANT                 367  Quintile 1
                                 PROBLEMS.
391...........................  NORMAL NEWBORN.................             376  Quintile 1
392...........................  SPLENECTOMY AGE 17..             194  Quintile 2
393...........................  SPLENECTOMY AGE 0-17...........             194  Quintile 2
396...........................  RED BLOOD CELL DISORDERS AGE 0-             399  Quintile 1
                                 17.
405...........................  ACUTE LEUKEMIA W/O MAJOR O.R.               404  Quintile 2
                                 PROCEDURE AGE 0-17.
407...........................  MYELOPROLIF DISORD OR POORLY                408  Quintile 3
                                 DIFF NEOPL W MAJ O.R. PROC W/O
                                 CC.
411...........................  HISTORY OF MALIGNANCY W/O                   367  Quintile 1
                                 ENDOSCOPY.
412...........................  HISTORY OF MALIGNANCY W                     367  Quintile 1
                                 ENDOSCOPY.
417...........................  SEPTICEMIA AGE 0-17............             416  Quintile 3
422...........................  VIRAL ILLNESS & FEVER OF                    420  Quintile 2
                                 UNKNOWN ORIGIN AGE 0-17.
446...........................  TRAUMATIC INJURY AGE 0-17......             445  Quintile 2
448...........................  ALLERGIC REACTIONS AGE 0-17....             455  Quintile 2
451...........................  POISONING & TOXIC EFFECTS OF                455  Quintile 2
                                 DRUGS AGE 0-17.
481...........................  BONE MARROW TRANSPLANT.........             394  Quintile 3
484...........................  CRANIOTOMY FOR MULTIPLE                       1  Quintile 5
                                 SIGNIFICANT TRAUMA.
485...........................  LIMB REATTACHMENT, HIP AND                  209  Quintile 4
                                 FEMUR PROC FOR MULTIPLE
                                 SIGNIFICANT TR.
491...........................  MAJOR JOINT & LIMB REATTACHMENT             209  Quintile 4
                                 PROCEDURES OF UPPER EXTREMITY.
492...........................  CHEMOTHERAPY W ACUTE LEUKEMIA               410  Quintile 3
                                 AS SECONDARY DIAGNOSIS.
496...........................  COMBINED ANTERIOR/POSTERIOR                 210  Quintile 4
                                 SPINAL FUSION.
504...........................  EXTENSIVE 3RD DEGREE BURNS W                468  Quintile 5
                                 SKIN GRAFT.
516...........................  PERCUTANEOUS CARDIOVASCULAR                 518  Quintile 3
                                 PROCEDURE W AMI.
520...........................  CERVICAL SPINAL FUSION W/O CC..             498  Quintile 3
525...........................  HEART ASSIST SYSTEM IMPLANT....             468  Quintile 5
526...........................  PERCUTANEOUS CARDIOVASCULAR                 517  Quintile 4
                                 PROC W DRUG-ELUTING STENT W
                                 AMI.
527...........................  PERCUTANEOUS CARVIOVASCULAR                 517  Quintile 4
                                 PROC W DRUG-ELUTING STENT W/O
                                 AMI.
528...........................  INTRACRANIAL VASCULAR                         1  Quintile 5
                                 PROCEDURES WITH PDX HEMORRHAGE.
530...........................  VENTRICULAR SHUNT PROCEDURES                529  Quintile 2
                                 WITHOUT CC.
534...........................  EXTRACRANIAL VASCULAR                       500  Quintile 4
                                 PROCEDURES WITHOUT CC.
535...........................  CARDIAC DEFIB IMPLANT WITH                  515  Quintile 5
                                 CARDIAC CATH WITH AMI/HF/SHOCK.
539...........................  LYMPHOMA AND LEUKEMIA WITH                  401  Quintile 5
                                 MAJOR O.R. PROCEDURE WITH CC.
----------------------------------------------------------------------------------------------------------------

    To illustrate this methodology for determining the relative weights 
for the 164 LTC-DRGs with no LTCH cases, we are providing the following 
examples, which refer to the no volume 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 final rule for 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 
LTC-DRG 178 (Uncomplicated Peptic Ulcer Without CC), which is assigned 
to low volume quintile 1 for the purpose of determining the FY 2004 
relative weights, would display similar clinical and resource use. 
Therefore, we assign the same relative weight of LTC-DRG 178 of 0.4964 
(Quintile 1) for FY 2004 (Table 11 in the Addendum to this final rule) 
to LTC-DRG 163.
    Example 2: There were no LTCH cases in the FY 2002 MedPAR file used 
in this final rule for 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

[[Page 45385]]

determined that 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 LTC-DRG 91. 
There were over 25 cases in LTC-DRG 90. Therefore, it would not be 
assigned to a low volume quintile for the purpose of determining the 
LTC-DRG relative weights. However, under our established methodology, 
LTC-DRG 91, with no LTCH cases, would need to be grouped to a low 
volume quintile. We identified that the low volume quintile with the 
closest weight to LTC-DRG 90 (0.7318; see Table 11 in the Addendum to 
this final rule) would be low volume quintile 2 (0.7372; see Table 11 
in the Addendum to this final rule). Therefore, we assign LTC-DRG 91 a 
relative weight of 0.7372 for FY 2004.
    Furthermore, we are providing LTC-DRG relative weights of 0.0000 
for heart, kidney, liver, lung, pancreas, and simultaneous pancreas/
kidney transplants (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, 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 determine 
appropriate weights for the LTC-DRGs affected. At the present time, we 
are only including these six transplant LTC-DRGs in the GROUPER program 
for administrative purposes. Since we use the same GROUPER program for 
LTCHs as is used under the 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 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 
LTC-DRGs and to determine the relative weights in this final rule.
    Table 11 in the Addendum to this final rule lists the LTC-DRGs and 
their respective 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 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. As discussed below, for applicants for 
new technology add-on payments for FY 2005, we are establishing the 
criteria that will be applied to assess whether technologies would be 
inadequately paid under the DRGs 75 percent of 1 standard deviation 
(based on the logarithmic values of the charges and transformed back to 
charges) 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 final rule lists the 
qualifying criteria by DRG, based on the discharge data that we used to 
calculate the FY 2004 DRG weights. The thresholds that are published in 
this 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 FY 
2004 DRG weights in this final rule.
    Technology may be considered ``new'' for purposes of this provision 
within 2 or 3 years after the point at which data begin to become 
available reflecting the 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, 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. Applicants must submit a complete database 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

[[Page 45386]]

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 Pub. L. 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 
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.
    Comment: Some commenters asked that CMS ensure that the necessary 
software changes be made to accommodate newly approved technologies so 
that hospitals experience no delay in receiving add-on payments for new 
technologies. Commenters noted that, at the time they prepared their 
comments, it was unclear whether hospitals were receiving any new 
technology add-on payments for FY 2003. Given that $74.8 million was 
carved out of the FY 2003 standardized amount, it is critical that a 
reliable system be put in place to ensure that hospitals receive these 
add-on payments.
    Response: We regret the delay any hospital may be experiencing in 
receiving add-on payments for FY 2003. On December 13, 2002, we issued 
Program Memorandum A-02-124 that requested fiscal intermediaries to 
implement the new technology payment mechanism into the claims 
processing system by April 1, 2003. The changes outlined in this 
program memorandum were delayed until July 16, 2003, in order to ensure 
that the claims processing system could properly process these add-on 
payments.
    Comment: Several commenters pointed out that new ICD-9-CM codes are 
being created for procedures that were not typically captured and 
reported using ICD-9-CM coding. The commenters specifically mentioned 
the creation of new codes for types of drugs. Commenters are concerned 
about the types of medical record documentation that may be required 
for the administration of these drugs to be assigned an ICD-9-CM code. 
They asked if a physician order for a drug and a notation on a medical 
sheet that a nurse had in fact injected the drug were sufficient 
documentation. The commenters indicated that further guidance is needed 
regarding documentation requirements for ICD-9-CM codes for new 
services and technologies that have not traditionally been reported 
through the use of ICD-9-CM coding.
    One commenter recommended that the approval process for new 
technologies be revised to include a requirement that the applicant 
must barcode such item with appropriate detailed information. The 
commenter stated that the use of barcoding would reduce medical errors. 
The commenter also was concerned that the limit of 6 procedure codes 
that can be reported on the billing form may become problematic as more 
new technologies are approved in the future.
    Response: We have asked the AHA to schedule this topic for 
discussion by the Cooperating Parties for ICD-9-CM and the Editorial 
Advisory Board for Coding Clinic for ICD-9-CM. AHA agrees that this is 
a timely topic and has scheduled it for discussion in one of its 
upcoming ICD-9-CM meetings.
    We would like to explore further the commenter's suggestion to 
require applicants for new technology add-on payments to barcode the 
technology. We recognize the potential limitations of the current 
claims form, as well as the overall limitations of ICD-9-CM. As we have 
stated previously, we believe ICD-10-PCS offers great potential 
improvement for more specific coding that may limit the use of multiple 
ICD-9-CM codes to identify certain classes of patients.
    Comment: Commenters asked that CMS present a full and clear 
accounting for estimated and actual new technology add-on payments and 
their impact on the DRG base rate in each proposed and final rule in 
order to ensure that hospitals receive these add-on payments in full. 
Another commenter recommended that, similar to outlier payments, CMS 
should report every year on the extent to which the actual add-on 
payments per case exceeded or were lower than the amount removed from 
the standardized amounts.
    One commenter was concerned that additional payments might be 
carved out of the standardized amount for new technologies to ensure 
budget neutrality, and those payments might not be made because CMS' 
projection of spending for the add-on payments was too high or because 
hospitals failed to bill properly for add-on payments. The commenter 
recommended that CMS

[[Page 45387]]

split the budget neutrality adjustment for DRG reclassification and 
recalibration into two components in order to isolate the reduction 
associated with add-on payments for new technologies.
    Commenters did not agree that add-on payments for new technology 
should be budget neutral, and explained that the purpose of having 
additional payments for high-cost items was to compensate a hospital 
for its unrecovered cost. Because of budget neutrality, these high-cost 
items are not being properly paid. The commenter also noted that these 
high-cost items are also the cause of a higher than expected outlier 
payment.
    One commenter recommended that CMS develop a separate pool of money 
to fund new technology and remove it from the budget neutrality 
calculation. The commenter explained that, while the technology is new, 
there should be money set aside and accessed only by those hospitals 
utilizing that technology.
    Response: When we approve a new technology for add-on payments, we 
conduct an analysis based on the latest data available to estimate the 
total add-on payments that will be made for the new technology during 
the upcoming fiscal year and include the results in the annual proposed 
and final rules. Analyses of technologies approved for add-on payments 
for FY 2004 are presented below. These analyses include our analysis of 
available FY 2003 MedPAR data on the utilization of Xigris[reg] and the 
basis for our estimated payments for new technologies approved for FY 
2004. We also discuss this analysis in our description of budget 
neutrality in section II.A.4.a. of the Addendum to this final rule. We 
note that, based on our analysis, we have reduced considerably our 
estimate of add-on payments for Xigris[reg] from the FY 2003 level, 
which led to a smaller budget neutrality offset to the standardized 
amounts.
    As we stated above, the Congressional Report language accompanying 
section 533 of Pub. L. 106-554 clearly indicated Congress' intent that 
this provision be implemented in a budget neutral manner. Therefore, 
Congress is the appropriate body to consider concerns about the budget 
neutrality of this provision.
    We do not believe it necessary to establish a separate budget 
neutrality calculation or pool for these payments. The amount of the 
payments is clearly identified in the final rule. Like all of the 
budget neutrality calculations, it is a prospective estimate.
    Comment: Commenters recommended that CMS eliminate the use of case-
weighted averages in the calculation of the cost threshold for 
technologies that occur in more than one DRG. The commenter believed 
that the goal of add-on payments is to provide adequate payment for new 
technologies in the DRGs in which the technology is used. The commenter 
added that the use of a case-weighted average biases the cost threshold 
against technologies that occur in more than one DRG and places 
hospitals at a disadvantage in DRGs where the threshold would otherwise 
be met except for application of the case-weighted average.
    Commenters argued that our criteria for what is considered a new 
technology is not consistent with section 1886(d)(5)(K)(ii)(II) of the 
Act. The commenter stated that this provision was intended to provide 
for the collection of data with respect to the costs of a new medical 
service or technology for a period of not less than 2 years and not 
more than 3 years, ``beginning on the date on which an inpatient 
hospital code is issued with respect to the service or technology.'' 
Therefore, the commenter recommended that, instead of no longer 
considering technologies new because the related charges are already 
captured in the MedPAR data, CMS should only view a technology as 
ineligible on the grounds that it is no longer new if the agency can 
specifically identify a significant sample of cases involving use of 
the technology in the MedPAR data. One commenter noted that sufficient 
charge data to assess whether the new technology meets the cost 
threshold criterion are often only available through the MedPAR data 
after the new ICD-9-CM code becomes effective. Some commenters also 
recommended that CMS raise the add-on payment amount from 50 percent of 
the cost of the new technology to an 80-percent or 100-percent marginal 
cost factor.
    Another commenter asked CMS to provide established clinical 
requirements or criteria that would control substantial clinical 
improvement determinations.
    One commenter recommended that CMS deem products that fall within 
one of the following categories designated by the FDA to have met the 
substantial clinical improvement criterion: Drugs or biologicals that 
obtain fast track or accelerated approval; and drugs or biologicals 
approved after priority review or approved for orphan indication. The 
commenter recommended that CMS defer to the clinical expertise of the 
FDA with respect to these products and find that any product falling in 
the above categories satisfy the substantial clinical improvement 
criterion without further CMS analysis.
    In addition, many commenters addressed the proposed change to the 
cost threshold criterion. (We are addressing these comments in our 
discussion of specific proposals later in this section of the 
preamble.)
    Response: We appreciate the interest of the many stakeholders in 
ensuring that Medicare beneficiaries have full access to improvements 
in medical technology. We have previously discussed our position on 
each of the issues raised by the commenters on the proposed rule in 
detail in the September 7, 2001 final rule (66 FR 46905) and the August 
1, 2002 final rule (67 FR 50009). Our rationales for these policies 
have not changed since we discussed them in those final rules, and we 
did not propose changes to these policies in the May 19, 2003 proposed 
rule. Therefore, readers are referred to the September 7, 2001 final 
rule and the August 1, 2002 final rule for our responses to these 
comments. However, we will continue to assess each of these policies 
and would appreciate the commenters' continued input on these issues.
    Comment: One commenter suggested that CMS conduct a historical 
review of technologies that would have likely met the ``new'' and 
substantial improvement criteria and determine the relationship between 
the costs of those items and the new technology cost threshold. The 
commenter noted that such an analysis might provide useful insights as 
to whether a more flexible cost criterion is needed.
    Response: We will take this suggestion under consideration.
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

[[Page 45388]]

utilization of the technology due to the absence of the add-on payment.
    Therefore, for FY 2004, we will 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, in 
the May 19, 2003 proposed rule, we proposed 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 estimated in the proposed rule 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 indicated that this proposed 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 indicated that, before the 
publication of the FY 2004 IPPS final rule, we would reevaluate our 
assumptions regarding this estimate based on preliminary claims data 
from the FY 2003 MedPAR file.
    We have analyzed the claims from the March 2003 update to the FY 
2003 MedPAR file. We identified claims that had received Xigris[reg] 
based on the inclusion of procedure code 00.11. We identified only 
1,500 claims from this file. Although the March 2003 update of the FY 
2003 MedPAR probably only realistically includes about 5 months' worth 
of claims, it appears that a lower than expected number of cases are 
receiving this new technology at the present time.
    Therefore, in this final rule for FY 2004, we are lowering the 
total payments in proportion to the cases that have actually received 
this drug. We are doubling the number of cases in our March 2003 MedPAR 
update to an estimated 3,000 cases that will receive Xigris[reg] in FY 
2003. We recognize there may actually be more cases than this by the 
end of the year, as only about 5 months of data are accounted for in 
our analysis. Also, this estimate does not account for future increased 
use of the drug. However, these potential underestimates are offset by 
the fact that we are assuming all cases will qualify for the full 
$3,400 add-on payment. We believe these effects will largely offset one 
another. Therefore, the final projected costs for add-on payments are 
estimated to be $10 million. We will use this estimate in our budget 
neutrality calculations.
    Comment: One commenter supported our decision to continue paying 
add on payments for Xigris[reg], but disagreed with the proposed 
estimated decline in add-on payments in FY 2004 from $74.8 million to 
$50 million. The commenter explained that this conclusion was made 
using only first quarter FY 2003 MedPAR data and, since this technology 
is still in its infancy, the commenter believed FY 2003 MedPAR data 
will reflect an upward trend in its use and overall availability.
    Some commenters were concerned that first year utilization of any 
new technology is an inappropriate measure for CMS to rely on in 
determining the full extent of use of a new technology. They asserted 
that the gradual adoption of new technology and the time required for 
hospitals to adapt their coding and charge structures to new 
technologies make it difficult to base projections of the ultimate 
utilization and costs of new technology immediately following its 
introduction. In addition, one commenter explained that CMS' system 
delays in processing claims have led to a negative impact on both 
uptake of the technology and the data collection associated with its 
use.
    Also, the commenter explained that Congress required data relating 
to the cost of the technology be collected for not less than 2 years 
and not more than 3 years after an appropriate inpatient hospital 
service code is established. The commenter added that, because CMS 
publishes its proposed and final rules before the completion of a 
fiscal year, CMS would make its decision for FY 2005 with less than 2 
full year's worth of data. As a result, the commenters recommended that 
CMS make additional payments for the full 3 years so when it moves a 
new technology into a DRG, it does so based on accurate and reliable 
information about its cost and clinical use.
    Response: Before each fiscal year, we use the latest available data 
to determine if we should continue to pay add-on payments for approved 
new technologies. As stated above, we are continuing to pay for 
Xigris[reg] for FY 2004 because FY 2002 discharges may not reflect full 
utilization of the technology. Based on the March update of the FY 2003 
MedPAR file, we lowered our cost estimates from the proposed rule 
because a lower than projected number of cases is receiving this 
technology at the present time. Before FY 2005, we will again use the 
latest available data to determine whether we would propose to continue 
to make add-on payments for Xigris[reg] for FY 2005.
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 appear below.
a. Bone Morphogenetic Proteins (BMPs) for Spinal Fusions
    An application was submitted for the InFUSETM Bone 
Graft/LT-CAGETM Lumbar Tapered Fusion Device 
(InFUSETM) for approval as a new technology eligible for 
add-on payments. A similar application was submitted last year. 
However, we denied it because, based on the available data, the 
technology did not exceed the 1 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, see the 
August 1, 2002 IPPS final rule (67 FR 50016).
    On July 2, 2002, the FDA approved InFUSETM 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, we denied this application for

[[Page 45389]]

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, the applicant 
used data from the 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-CM 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 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 redefining 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, as proposed, we 
did not approve this technology on the basis of this analysis.
    The applicant also submitted data from actual cases involving the 
InFUSETM with single level fusions only. The data submitted 
included 31 claims from 4 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.
    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 in 
the May 19, 2003 proposed rule, we stated our intention 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 noted that some of these cases would 
involve multilevel spinal fusions, and that it would be necessary to 
adjust for those cases in order to remove them from the calculation of 
the average charges.
    We have analyzed data from the March update of FY 2003 MedPAR, 
containing claims data for the first 6 months of FY 2003. As discussed 
above, accounting for a lag time in claims processing, we are assuming 
that this data accounts for approximately 5 months of FY 2003 
discharges. We identified InFUSETM cases by the presence of 
the two new ICD-9-CM codes 84.51 and 84.52, used in combination with 
each other. We identified 117 and 88 cases in the March 2003 MedPAR 
data for DRGs 497 and 498, respectively.
    We standardized the charges 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, and calculated an average standardized charge of 
$64,931 for the 117 cases in DRG 497. For DRG 498, the average 
standardized charge was $58,266 for the 88 cases in our data. The 
average standardized charge across both DRGs was $62,752. As we noted 
in the proposed rule, we anticipate that some of these cases will 
involve multilevel spinal fusions. Based on the applicant's analysis of 
FY 2001 Standard Analytical File data in which they were able to 
distinguish between one, two, and three or more levels fused by using 
CPT codes on the physician claims, we determined that the average 
charges of single level fusions were about 78 percent of the average 
charges across all spinal fusions in the analysis. (It was not possible 
to independently match records from the Standard Analytical File in the 
time available after we attained the March 2003 MedPAR data.) However, 
as noted above, these data are from FY 2001 and did not include any 
cases involving InFUSETM. Therefore, we anticipate more of 
the cases in our data will be single-fusion cases, consistent with the 
FDA approval, and that the total charges in our data for single-level 
fusion cases will be higher than 78 percent of the average for all 
InFUSETM cases in our data. Given the relatively recent 
approval by the FDA of this product, we anticipate the majority of uses 
are in accordance with the FDA's approval criteria. Therefore, to 
estimate the average standardized charges of the single-level spinal 
fusion cases in our data, we estimated 90 percent of the average 
standardized charges of all the InFUSETM cases in our data 
would approximate the charges for single-level cases.
    Finally, because these were FY 2003 cases compared to FY 2002 
thresholds (based on FY 2001 cases), we adjusted the average charges 
(by the market basket) to be consistent with the FY 2002 thresholds. 
The resulting average standardized charge for the cases from our FY 
2003 MedPAR data for all InFUSETM cases across both DRGs 497 
and 498 was $53,376.
    We then calculated the case-weighted threshold amount across DRGs 
497 and 498 based on the proportion of cases in our data in each DRG. 
Since 57 percent of the cases we identified in our database were in DRG 
497, we applied this percentage to the threshold amount for DRG 497 of 
$58,040. We then added this amount to 43 percent of the threshold 
amount for DRG 498, for a combined threshold amount of $51,121. Because 
our data indicates that the average standardized charge for single-
level InFUSETM cases exceeds this threshold amount, this 
technology has met the cost criteria to qualify for new technology add-
on payments.
    Because the technology meets the cost threshold based on the MedPAR 
data, we evaluated whether it qualifies as a substantial clinical 
improvement. According to the applicant:
    ``InFUSETM Bone Graft is more appropriate to use and has 
been proven

[[Page 45390]]

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.''
    As indicated in the May 19, 2003 proposed rule, among the issues we 
planned to consider were: 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? In the May 19, 2003 proposed rule, we 
indicated we were 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.
    Since the May 19, 2003 proposed rule, we received from the sponsor 
of this application an analysis, prepared by an orthopedic surgeon, 
that showed limited evidence of results in a series of patients older 
than 65, all with good or better fusion results than the younger age 
group. That analysis presented evidence that older patients typically 
have better results than younger patients in the standard iliac crest 
bone harvesting fusion procedure. Finally, it included the results of 
bench testing of mesenchymal and osteoblastic cells that demonstrated 
response to rhBMP-2, including cells from elderly patients.
    The sum of this evidence does not preclude generalizing the results 
of InFUSETM trials to Medicare aged beneficiaries. In 
addition, the small series of Medicare-aged patients treated with 
InFUSETM technology, as well as the bench science on the 
response of elderly mesenchymal cells to rhBMP-2, do provide some 
positive, though limited, evidence for generalizability. These results, 
combined with the benefits of the elimination of the need to harvest 
bone from the iliac crest (and the associated complications), lead us 
to conclude that InFUSETM does meet the substantial 
improvement criteria. Therefore, we are approving InFUSETM 
for add-on payments under Sec.  412.88, to be effective for FY 2004.
    This approval is on the basis of using InFUSETM for a 
single-level, lumbar spinal fusions, consistent with the FDA's approval 
and the data presented to us by the applicant. Therefore, we intend to 
limit the add-on payment to cases using this technology for anterior 
lumbar fusions in DRGs 497 and 498. Cases involving InFUSETM 
that are eligible for the new technology add-on payment will be 
identified by assignment to DRGs 497 or 498 as a lumbar spinal fusion, 
with the combination of ICD-9-CM procedure codes 84.51 and 84.52.
    As explained above, we are limiting our approval of this technology 
to uses consistent with our substantial clinical improvement decision. 
Therefore, add-on payments are only available for use of the technology 
at a single-level. The average cost of the InFUSETM is 
reported to be $8,900, and a single level fusion requires two of the 
products. Therefore, the total cost for the InFUSETM for a 
single-level fusion is expected to be $17,800. Under Sec.  
412.88(a)(2), new technology add-on payments are limited to the lesser 
of 50 percent of the average cost of the device or 50 percent of the 
costs in excess of the DRG payment for the case. As a result, the 
maximum add-on payment for a case involving the InFUSETM is 
$8,900.
    For purposes of budget neutrality, it is necessary to estimate the 
additional payments that would be made under this provision during FY 
2004. We identified 205 cases in DRGs 497 and 498 in the March 2003 
update of the FY 2003 MedPAR data. For our FY 2004 budget neutrality 
estimate, we are projecting this number will grow to 500. Given this 
estimate and the maximum add-on payment of $8,900, we estimate the 
total amount of the add-on payments for the InFUSETM for FY 
2004 will be $4.4 million dollars.
    Comment: One commenter asked that CMS reconsider the decision to 
exclude multilevel fusions with InFUSETM from the cost 
threshold calculation. The commenter noted that excluding multilevel 
fusions with InFUSETM is inconsistent with FDA guidance, 
clinical practice and other CMS payment decisions for new technologies 
(notably the creation of DRGs for drug-eluting stents based on the 
presence of a condition not indicated on the product label, that is, 
acute myocardial infarction).
    Response: As stated previously, because the FDA has not approved 
this technology for multilevel fusions and the applicant has not 
submitted data to demonstrate this technology is a substantial clinical 
improvement for multilevel fusions, we cannot issue a substantial 
clinical improvement for multilevel fusions. In the September 7, 2001 
final rule implementing this provision (66 FR 46913), we stated our 
position that the special payments under this provision should be 
limited to those new technologies that have been demonstrated to 
represent a substantial improvement in caring for Medicare 
beneficiaries. Where such an improvement is not demonstrated, we 
continue to believe the incentives of the DRG system provide a useful 
balance to the introduction of new technologies, and no new technology 
add-on payment is necessary.
    Comment: In the proposed rule, we stated that, if 
InFUSETM meet the cost threshold, we would evaluate whether 
it qualifies as a substantial clinical improvement. One commenter noted 
that, assuming InFUSETM does meet the cost threshold, CMS 
would make a determination on whether the technology meets the 
substantial clinical improvement criterion without public input or the 
opportunity to address concerns that CMS may have. The commenter noted 
that these actions are inconsistent with the Administrative Procedure 
Act and CMS's pledge to be more open in its policy making.
    Response: Because of the many questions that remained at the time 
of the proposed rule, we were unable to determine if 
InFUSETM qualified as a substantial clinical improvement. 
However, in order to receive comments on this determination, we 
indicated certain issues we would consider when determining if 
InFUSETM qualifies as a substantial clinical improvement. As 
noted above, we received additional information that enabled us to 
approve this technology as a substantial clinical improvement. 
Therefore, we believe interested parties had sufficient information to 
provide informed comments.
    Comment: One commenter, a designer, manufacturer, and supplier of 
orthopedic devices and supplies, explained that the applicant's 
analysis probably includes cases for both posterior approaches or 
posterior instrumentation, or both, which are considered off-label uses 
from the indications approved by the FDA. Therefore, the commenter 
requested that cases that do not meet FDA approved indications, once 
identified, be eliminated from the analysis.
    The commenter also noted that once claims of InFUSETM 
can be identified

[[Page 45391]]

with MedPAR data, DRG weights become eligible for recalibration in 
order to reflect the appropriate payment within the assigned DRG. Once 
the weights of a DRG can be evaluated, a technology should no longer be 
classified as new. Also, the commenter stated that clinical trial 
results counter the claim of significant improvement, because 
information presented at the FDA Orthopedics and Rehabilitation Devices 
Panel public meeting on January 20, 2002, indicated that the 
InFUSETM product resulted in an equivalency to that of 
traditional bone grafting techniques. Although there was a decrease in 
donor site pain in a small number of subjects in the BMP group, 
compared with the control group, the commenter questioned whether this 
factor meets the criteria of substantial clinical improvement. The 
commenter also questioned the results of a published article on this 
technology.
    Response: One of the criteria for a substantial clinical 
improvement classification is avoidance of surgery. CMS determined that 
InFUSETM should be classified as a substantial improvement 
if the results of the clinical trials demonstrated outcomes at least 
equivalent to bone grafting, and the bone harvesting procedure was 
avoided. CMS clinical staff reviewed the literature and concluded that 
the current evidence did support grafting equivalence for the FDA 
approved indications and, therefore, InFUSETM met the 
substantial improvement standard. As described above, we did not rely 
on the applicant's analysis to determine the technology met the high-
cost threshold, but conducted direct analysis of available FY 2003 
MedPAR data.
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, 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 DRG weights for FY 2004 in this final rule 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 in section II.B.3.a of the May 19, 2003 proposed rule 
and above in this final rule, we examined the definitions of DRGs 1 and 
2 to determine whether they could be improved. As proposed, we are 
creating 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 for add-
payments regarding 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.
    Comment: One commenter supported CMS' determination that this 
technology is currently reflected within the DRG weights and does not 
meet the criteria of being called ``new.'' Another commenter commented 
that CMS' interpretation of whether a technology is ``new'' is 
inconsistent with the current statute. The commenter explained that 
section 1886 (d)(5)(K)(ii)(II) of Act states that CMS should collect 
data on new technologies ``for a period of not less than 2 years and 
not more than 3 years beginning on the date on which an inpatient 
hospital code is issued for the technology.'' Accordingly, the 
commenter believed it is inconsistent with the intent of Congress to 
deny new technology status to a product that has been on the market but 
for which there is no unique ICD-9 code that allows CMS to track the 
costs of cases in which it is utilized. The commenter urged CMS to 
reconsider its interpretation of the statute and approve 
GLIADEL[reg] as a new technology, making clear that a 
technology will be considered new for 2 to 3 years from the date that 
an ICD-9-CM code, specific to the technology, becomes available.

[[Page 45392]]

    Response: As stated above, we discussed our position on this issue 
in detail in the September 7, 2001 final rule (66 FR 46905). Our 
rationale for this policy has not changed since we discussed it in that 
final rule, and we did not propose changes to this policy in the May 
19, 2003 proposed rule. Therefore, we are denying this application for 
add-on payments for FY 2004.
4. Review of the High-Cost Threshold
    The current cost threshold for a new technology to qualify for add-
on payments is that the average standardized charges of cases involving 
the new technology must be demonstrated to exceed 1 standard deviation 
beyond the geometric mean of the standardized charges of the DRG to 
which the new technology will be assigned. If the new technology is 
assigned to more than one DRG, the qualifying threshold is equal to the 
case-weighted (based on the proportion of cases involving the new 
technology estimated to be assigned to each DRG) average threshold 
across all relevant DRGs. 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 commenting on this approach, MedPAC and some hospital 
associations supported the 1 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, under the IPPS, 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, in the May 19, 2003 proposed rule, 
we proposed to reduce the threshold to 75 percent of 1 standard 
deviation beyond the geometric mean standardized charge for all cases 
in the DRG to which the new medical service or technology is assigned 
(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.
    Comment: Some commenters were concerned that the revised threshold 
of 75 percent of the standard deviation remains too high. The 
commenters noted that even with the revised cost threshold, few 
technologies would qualify for add-on payments.
    On the assumption that the vast majority of technologies that would 
qualify for add-on payments would be identified by a new ICD-9-CM 
procedure code, one commenter identified a total of 26 ICD-9-CM 
procedure codes issued between the years of 1998 and 2001. The 
commenter then analyzed 2001 MedPAR data and found that only 2 of the 
26 procedures will exceed either the current 1 standard deviation 
threshold, and 4 would exceed the a threshold at 75 percent of 1 
standard deviation. The commenter also explained that the proposed 
reduction of the threshold is only an 8-percent reduction, and 
continues to block eligibility for add-on-payments for important new 
technologies, even where costs increase by 70 percent. The commenter 
recommended that CMS use a threshold based upon 75 percent of the 
standardized amount inflated to charges, plus the geometric mean 
charges for the DRG. The commenter identified 13 of the 26 procedures 
that would qualify using this threshold.
    Another commenter asked that CMS consider adopting separate 
criteria for biologics and devices, because they have different price 
levels and pricing patterns relative to drugs and relative to DRG 
standardized amounts. Other commenters recommended a threshold where 
the cost of the technology must exceed the cost of existing 
technologies by at least 50 percent of the DRG standardized amount, 
multiplied by the DRG weight, but not to exceed $7,500.
    One commenter was concerned that, because of budget neutrality, any 
reduction to the threshold for new technologies would allow more 
technologies to qualify for add-on payments and would therefore reduce 
payments for all other hospital inpatient services. The commenter 
explained that shifting money within the IPPS leaves some hospitals 
without additional money they need to ensure beneficiaries have access 
to the newest medical tests and treatments. Therefore, the commenter 
recommended that add-on payments continue to be limited to new, 
cutting-edge, breakthrough technologies with significant cost 
implications.
    Response: As stated in the August 1, 2002 final rule (67 FR 50011), 
it is our intention to implement this provision without fundamentally 
disrupting the

[[Page 45393]]

IPPS. A substantial number of cases receiving extra cost-based payments 
(or substantial disaggregation of the DRGs into smaller units of 
payment) would undermine the efficiency incentives of the DRG payment 
system. Also, we continue to believe a threshold based on the standard 
deviation is appropriate for this purpose. (For further reading on 
this, see the September 7, 2001 final rule (66 FR 46917).)
    The DRG system is an average-based system under which hospitals 
expect to finance costly cases through less costly cases. We believe 
the add-on policy envisioned by some commenter, that would reduce the 
maximum threshold across all DRGs to 75 percent of the standardized 
amount (approximately $3,300) adjusted to charges, would significantly 
disrupt the averaging principles of the IPPS. By assuming only 26 new 
technologies over a 4-year span, the analysis presented by the 
commenter dramatically underestimates the annual volume of new 
technologies that would be likely to meet such a reduced threshold. 
Industry sources cite over 1,000 companies producing medical devices, 
diagnostic products, and medical information systems in the U.S., 
producing over $70 billion worth of products annually. A very limited 
number of these products receive specific ICD-9-CM procedure codes, 
particularly in years prior to the establishment of the IPPS new 
technology add-on policy. A more accurate estimate of the number of 
technologies likely to be approved under this revised threshold could 
be attained by listing the technologies approved during that period 
with the average wholesale price.
    As stated above, we recognize the limited number of applications 
for add-on payments that have been submitted in the past 2 years and, 
therefore, we are lowering the threshold. We believe this new threshold 
is a fair balance that maintains the averaging principles of the IPPS 
while easing the qualifying requirement. Therefore, for FY 2005 and 
subsequent fiscal years, we are reducing the threshold to 75 percent of 
1 standard deviation (based on the logarithmic values of the charges) 
beyond the geometric mean standardized charges for all cases in the DRG 
to which the new medical service or technology is assigned, transformed 
back to charges.
    We disagree with the commenter's suggestion that we establish 
separate thresholds for biologics and devices. We believe the IPPS is 
intended to pay hospitals for their costs to treat patients, and 
physicians select from a range of options based on the medical needs of 
the patients. The payment system should be neutral with respect to 
those options. We are concerned that establishing separate thresholds 
for biologics and devices would indicate an inappropriate payment 
preference for one or the other option.
    Comment: Other commenters representing hospitals approved of the 
threshold proposed by CMS. One commenter explained that a threshold 
that limits the number of new technologies is necessary, as the 
administrative burden for hospitals and the program is significant for 
each additional item qualifying. Given the finite pool of funds, an 
abundance of qualifying technologies could result in prorata 
reductions, such as those that were experienced under the outpatient 
prospective payment system. With that in mind, the commenter asked that 
CMS look at other approval mechanisms that would direct the funds to be 
focused on significantly expensive new technologies that also have 
significant volumes nationally. For example, national expenditures 
projected by CMS for each technology seeking approval should exceed $30 
million. Assuming national total expenditures of $75 billion with a 1 
percent set aside at $750 million, and a marginal cost at 50 percent, 
25 technologies could be approved by CMS.
    As an alternative, the commenter recommended that CMS incorporate 
new technologies into the appropriate DRG without having to 
specifically code the new technology. The DRG weights would then be 
adjusted to reflect the increased costs associated with such new 
technologies rather than making a separate add-on payment. The 
commenter believed this would be a reasonable compromise between the 
need to incorporate new technologies into the DRGs, while avoiding an 
unduly burdensome coding and billing process.
    Response: We believe the incremental costs to hospitals associated 
with this provision should be minimal. Specifically, the additional 
payments are triggered by the presence of an ICD-9-CM code on the bill, 
information already required to process the claim for normal DRG 
payments. Accordingly, there should be little need for training or 
other operational changes in response to the approval of a new 
technology for add-on payments.
    Also, adding further criteria as suggested by the commenter would 
make it even more difficult for new technologies to qualify for add-on 
payments. In this final rule, it is our intention to lower the 
threshold in order to increase the number of applications we receive 
each year for add-on payments. With respect to the commenter's 
suggestion to incorporate a new technology in a DRG and raise the 
weight of the DRG based on the increased cost of the new technology, we 
are concerned that this suggestion would have the potential to create 
possibly large imbalances in the DRG weights if the predicted volume of 
a particular technology turns out to be inaccurate. We believe an add-
on payment is the most appropriate methodology to provide additional 
payments for qualifying high cost new technologies, while still 
maintaining the overall integrity of the DRG system.
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, in the May 19, 2003 proposed 
rule, we proposed 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.
    We did not receive any comments on this proposal and, therefore, 
are adopting it as final.
    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, in the May 19, 2003 proposed rule, we proposed that they 
would also be calculated on a case-by-case basis rather than included 
in the calculation of interim payment amounts. Therefore, we proposed 
to revise Sec.  412.116(e) to include this policy.
    We did not receive any comments on this proposal. Therefore, in 
this final rule, we are adopting the proposal as final without 
modification.

III. Changes to the Hospital Wage Index

A. Background

    Section 1886(d)(3)(E) of the Act requires that, as part of the 
methodology for determining prospective payments to hospitals, the 
Secretary must adjust the

[[Page 45394]]

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 
because 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. For purposes of the IPPS wage index, rural areas are 
counties outside a designated MSA, PMSA, or NECMA. For purposes of the 
wage index, we combine all of the rural counties in a State to 
calculate a rural wage index for that State.
    We note that, effective April 1, 1990, the term Metropolitan Area 
(MA) replaced the term MSA (which had been used since June 30, 1983) to 
describe the set of metropolitan areas consisting of MSAs, PMSAs, and 
CMSAs. The terminology was changed by OMB in the March 30, 1990 Federal 
Register to distinguish between the individual metropolitan areas known 
as MSAs and the set of all metropolitan areas (MSAs, PMSAs, and CMSAs) 
(55 FR 12154). For purposes of the IPPS, we 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 from hospitals for geographic 
reclassification from a rural area to a MSA, from one rural area to 
another rural area, or from one MSA to another MSA for purposes of 
payment under the IPPS.
    On June 6, 2003, the Office of Management and Budget (OMB) issued 
OMB Bulletin No. 03-04, announcing revised definitions of Metropolitan 
Statistical Areas and new definitions of Micropolitan Statistical Areas 
and Combined Statistical Areas. A copy of the bulletin may be obtained 
at the following Internet address: http://www.whitehouse.gov/omb/bulletins/b03-04.html. According to OMB, ``(t)his bulletin provides the 
definitions of all Metropolitan Statistical Areas, Metropolitan 
Divisions, Micropolitan Statistical Areas, Combined Statistical Areas, 
and New England City and Town Areas in the United States and Puerto 
Rico based on the standards published on December 27, 2000, in the 
Federal Register (65 FR 82228-82238) and Census 2000 data.''
    In the proposed rule, we stated that we would evaluate the new area 
designations and their possible effects on the Medicare hospital wage 
index. In addition, we proposed that the earliest usage of these new 
definitions would be the FY 2005 wage index.
    The new definitions recognize 49 new Metropolitan Statistical Areas 
and 565 new Micropolitan Statistical Areas, as well as extensively 
revising the construct of many of the existing Metropolitan Areas. For 
example, according to OMB's previous definition of the Asheville, NC 
MSA, this Metropolitan Statistical Area was comprised of Buncombe and 
Madison counties. When we apply the new definitions, Asheville's 
Metropolitan Statistical Area includes both Buncombe and Madison 
counties, as well as Henderson and Haywood counties. An example of a 
Micropolitan Statistical Area is that of Elizabeth City, NC which 
includes Camden, Pasquotank, and Perquimans counties. These were non-
Metropolitan Statistical Area counties in previous OMB definitions.
    In order to implement these changes for the IPPS, it is necessary 
to identify the new area designation for each county and hospital in 
the country. Because this process will have to be extensively reviewed 
and verified, we are unable to undertake it before publication of this 
final rule. In addition, because we wish to engage in notice and 
comment rulemaking, prior to adopting these changes, it would be 
impractical to have done so prior to this final rule. (We note that the 
OMB Bulletin was issued during the comment period and we did not 
receive any comments regarding whether the new definitions should be 
applied to the FY 2004 wage index or objecting to our proposed policy 
of implementing the changes in FY 2005 at the earliest.)
    Finally, geographic reclassification decisions for FY 2004 have 
already been made based on the previous Metropolitan Statistical Area 
definitions. These decisions would have to be individually reevaluated 
if we were to adopt the new OMB definitions for FY 2004. This would not 
be possible to accomplish while complying with the requirement of 
section 1886(d)(6) of the Act to publish this annual IPPS update final 
rule by August 1. For these reasons, at this time, we are not applying 
these new definitions to the FY 2004 wage index.
    Comment: Several commenters recommended that when CMS does 
implement OMB's new definitions, it should adopt the new 49 MSAs as 
outlined in the OMB Bulletin. However, the commenters mentioned that 
the adoption of the MSAs for FY 2004 would be premature, given the 
magnitude of the policy change. One commenter encouraged CMS to issue a 
rule or to elaborate on plans for the new Metropolitan and Micropolitan 
Statistical Area definition changes as soon as possible to allow time 
for impact analysis, as well as public comments and input. One 
commenter raised concerns with respect to the criteria that OMB used to 
define the new MSAs.
    Response: We indicated in the proposed IPPS rule that we would need 
to assess these new definitions before adopting them. In order to 
implement such a change, it will be necessary to identify the new area 
designation for each county and hospital in the country, requiring 
extensive review and verification. We will undertake this analysis as 
soon as possible. We intend to move very deliberately and expeditiously 
regarding these potentially vast changes. Any changes would be made 
through notice and comment rulemaking. Therefore, we are not addressing 
technical comments relating to the new MSAs in this document.
    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. 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. 
This adjustment is discussed in section II.4.a. of the Addendum to this 
final rule.
    As discussed below in section III.F. of this preamble, we also take 
into account the geographic reclassification of

[[Page 45395]]

hospitals in accordance with sections 1886(d)(8)(B) and 1886(d)(10) of 
the Act when calculating the wage index. 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. This adjustment is 
discussed in section II.4.b. of the Addendum to this final rule.
    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.
    Many commenters on the April 4, 2003 notice requested that CMS 
publish a more detailed proposed methodology, illustrating how the 
occupational mix index will be calculated and how it will be used to 
adjust the overall wage index. Other comments on the April 4, 2003 
notice included: CMS should develop or expand more categories to 
include all hospital employees; CMS should develop and publish a more 
reasonable timeframe for the hospitals to complete the survey, and a 
more reasonable timeframe for fiscal intermediaries to audit the 
occupational mix survey; CMS should clarify the relationship between 
the current annual cost report wage index schedule and the proposed 
occupational mix survey.
    We plan to publish a final notice of intent in the Federal 
Register, with a 30-day comment period. The notice will include any 
revisions to the survey published on April 4, 2003 based on the 
comments we received, a detailed timetable, and all audit guidelines. 
Subsequent to that, 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, with the intent to collect these 
data to be incorporated in the FY 2005 wage index.
    Comment: In response to the May 19, 2003 IPPS proposed rule, 
commenters requested that we publish a detailed proposed methodology, 
for comment, illustrating how the occupational mix index will be 
calculated and how it will be used to adjust the overall wage index.
    Response: Although our approach will not be finalized until 
publication of the FY 2005 rule, one possible approach to computing an 
occupational mix adjusted index is to first calculate, based on the 
hours collected for each occupational category from all hospitals 
nationally, a national average percentage attributable to each 
occupational category. Next, for each hospital, the total dollars and 
hours for each category would be summed, and an average hourly wage 
would be determined for each category by dividing dollars by hours. 
Each hospital's occupational mix adjusted average hourly wage would be 
calculated by multiplying each category's average hourly wage by the 
applicable weighting factors and then summing the results across all 
categories. Similar calculations would then be performed at the labor 
market level and the national level to construct an index.
    We intend to analyze the impacts of implementing an occupational 
mix adjusted index in the proposed rule for FY 2005. Based on the 
estimated impacts, we will also evaluate at that time the possibilities 
for blending such an index with the FY 2005 wage index calculated using 
our current methodology based on data from the Worksheet S-3, Part II 
of the Medicare cost report.

B. FY 2004 Wage Index Update

    The FY 2004 wage index values (effective for hospital discharges 
occurring on or after October 1, 2003 and before October 1, 2004) in 
section VI. of the Addendum to this final 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 data for the FY 2004 wage index were obtained from Worksheet S-
3, Parts II and III of the FY 2000 Medicare cost reports. Instructions 
for completing the Worksheet S-3, Parts II and III are in the Provider 
Reimbursement Manual, Part I, sections 3605.2 and 3605.3. The 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 (includes direct 
patient care, certain top management, pharmacy, laboratory, and 
nonteaching physician Part A services).
    [sbull] Wage-related costs (The September 1, 1994 Federal Register 
included a list of core wage-related costs that are included in the 
wage index, and discussed criteria for including other wage-related 
costs (59 FR 45356)).
    Consistent with the wage index methodology for FY 2003, the wage 
index for FY 2004 also excludes the direct and overhead salaries and 
hours for services not subject to IPPS payment, such as skilled nursing 
facility (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.
    These wage data are also currently used to calculate wage indexes 
applicable to other providers, such as SNFs, home health agencies, and 
hospices. They are also used for prospective payments to rehabilitation 
and long-term care hospitals, and for hospital outpatient services.

C. FY 2004 IPPS Wage Index

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 previously 
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 revised the FY 2000 Worksheet S-3 so that it now allows for the 
separate reporting of RHC and FQHC wage costs and hours. In the May 19, 
2003 proposed rule, we proposed to exclude the wage and hours data for 
RHCs and FQHCs from the hospital wage index calculation beginning with 
the FY 2004 wage index.
    We received several comments, all supporting this proposal. 
Therefore, beginning with the FY 2004 wage index, we are excluding the 
salaries, hours and wage-related costs associated with RHCs and FQHCs. 
This change is consistent with others we have implemented in our 
continuous effort to limit the wage index as much as possible to costs 
for which hospitals receive payment under

[[Page 45396]]

IPPS. An analysis of the effects of this change is included in the 
Appendix A of this final rule.
2. Paid Hours
    It has been the longstanding policy of CMS to calculate the wage 
index using paid hours rather than hours worked (see the September 1, 
1993 Federal Register, 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 a 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 
their control, to be the only hospitals with this category of 
nonproductive hours included in their wage index.
    In the May 19, 2003 proposed rule, we solicited comments on our 
policy that paid lunch hours should be excluded from the wage index. 
Specifically, we were interested in 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. We indicated that any change 
in our policy would not be implemented until, at the earliest, the FY 
2005 wage index.
    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 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 proposed to exclude from the wage index the 
paid hours associated with military and jury duty leave, beginning with 
the FY 2005 wage index. We also proposed that the associated salaries 
would continue to be reported on Worksheet S-3, Part II, Line 1 of the 
Medicare cost report.
    Comment: A few commenters agreed that paid lunch hours and hours 
associated with military and jury duty leave should be removed from the 
wage index. Many more commenters, including some national and state 
hospital associations and Medicare fiscal intermediaries, opposed or 
expressed concern about whether excluding paid lunch hours and hours 
associated with military and jury duty leave would result in a more 
accurate wage index.
    Those commenters who opposed the proposal to exclude paid lunch 
hours and hours associated with military and jury duty leave expressed 
concern that these changes would further complicate the wage index and 
that the additional data collection effort for providers might outweigh 
any benefits achieved through these changes. Further, the commenters 
believed that paid lunch hours, military, and jury leave affect all 
providers in the same way, so the changes would likely be immaterial. 
One commenter also expressed concern that excluding paid hours could 
cause hospitals to rewrite existing contracts to raise their wage 
index. In addition, some commenters cautioned that excluding these paid 
hours would be difficult for intermediaries to apply consistently; 
excluding these hours would require estimations because most payroll 
systems do not capture this data. Many commenters indicated that CMS 
had not published data to provide support that these changes are 
warranted.
    One commenter suggested that, if CMS excludes paid lunch hours, CMS 
should set a standard for hospitals to qualify for excluding the hours, 
such as the Fair Labor Standards Act requirements for payment. Another 
suggested that the determination of excluding paid lunch hours should 
be based on whether lunch is included for the purpose of computing the 
hourly wage rate used to pay for overtime. If paid lunch hours are 
included in the overtime payment computation, and excluding them would 
result in an hourly rate that is higher than what is usually used for 
overtime, the paid lunch hours should be excluded. If the paid lunch 
hours are not included in computing the hourly wage for overtime, and 
excluding them would result in the correct hourly wage rate that should 
be used for overtime, the lunch hours should be excluded. Two 
commenters recommended that the wage index should also exclude time 
associated with paid breaks from the wage index, but acknowledged that 
paid breaks are not usually tracked in payroll systems. One commenter 
recommended that CMS allow all hospitals in an area to include paid 
hours on a standard basis in order to eliminate differences that are 
more a matter of how hours are reported rather than actual difference 
in wages.
    Those commenters who opposed the exclusion of paid lunch hours were 
generally concerned that hospitals do not currently track paid lunch 
hours. They indicated that it would be a major burden for hospitals to 
change their systems to accommodate reporting the hours and the 
benefits are likely to be minimum.
    A few commenters suggested that, if a hospital pays its employees 
at the full rate for military and jury duty leave, the full associated 
hours should be included. However, they added that if a hospital pays 
its employees at a reduced rate for these leave categories, the 
hospital should exclude hours based on the fraction of the salary that 
is not paid. If the hospital does not pay for any military or jury duty 
leave, all of the associated hours should be excluded. The commenters 
believed that this treatment would be consistent with our longstanding 
policy to include hours associated with paid time off, while a 
hospital's average hourly rate would not be negatively impacted by the 
reduced rates that some hospitals pay for military and jury duty leave. 
One commenter recommended that CMS permit hospitals to exclude the 
hours, but not require such reporting.
    Several commenters opposed excluding paid hours associated with 
military and jury duty because they believe that military and jury duty 
leave affect all providers in the same way. Therefore, they believed 
that any changes in the wage index would likely be immaterial. Two 
commenters expressed concern that, if paid hours are excluded and wages 
are not, the wage index would be overstated. The

[[Page 45397]]

commenters recommended that, if CMS excludes paid hours associated with 
military and jury duty leave, for consistency, CMS should also exclude 
the related wages. Alternatively, the commenters recommended that CMS 
collect data on the wages and hours associated with military and jury 
duty first, so that the impact of excluding the hours can be determined 
before the policy is implemented. One commenter believed that CMS 
should only include in the wage index, hours associated with regular 
hours, overtime, and sick leave, because these paid leave or paid time 
off categories are consistently offered among hospitals. The commenter 
also believed other paid leave or paid time off categories such as 
vacation hours, maternity leave, bereavement leave, and vacation hours 
should be excluded because they are not consistently offered among 
hospitals. In addition, the commenter believed that when hospitals are 
competing for employees in the labor market, if offered, these paid 
leave or paid time off hours could vary from hospital to hospital. For 
example, hospital A will only pay 2 weeks for paid vacation leave, 
while hospital B will pay 4 weeks for paid vacation leave. Therefore, 
the commenter believed these other paid leave or paid time off leave 
hours should be excluded from the wage index.
    Response: As we stated above and in the proposed rule, it has been 
our longstanding policy to include paid hours in the calculation of the 
wage index because they more appropriately reflect a hospital's total 
wage costs. We solicited comments on the possible exclusion of paid 
lunch hours and proposed to exclude the paid hours associated with 
military and jury duty hours because of our concern that there were 
significant issues with the consistent treatment of these issues across 
hospitals that may impact the validity of the wage index. However, the 
comments indicate to us there is substantial disagreement with respect 
to whether either category of paid hours should be excluded from the 
wage index calculation. Therefore, we are not proceeding with either 
change at this time. We intend to explore a more comprehensive 
assessment of the use of paid hours in a future rule. For the FY 2005 
final wage index, we are including paid lunch hours, and hours 
associated with military leave and jury duty.

D. Verification of Wage Data From the Medicare Cost Reports

    The data file used to construct the wage index includes FY 2000 
data submitted to us as of June 27, 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 constructed the proposed FY 2004 wage index based on 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 stated 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.
    Prior to the proposed rule, we had 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 a separate provider type and 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. In the May 19, 2003 
proposed rule, we solicited comments on whether we should exclude wage 
data from such hospitals from the wage index calculation. However, we 
included the data for current CAHs in the proposed FY 2004 wage index 
if the CAH was paid under the IPPS during FY 2000 as an acute care 
hospital.
    Comment: Commenters, including national hospital associations, 
generally supported the removal of CAH wage data from the wage index. 
One commenter agreed that CAHs are dissimilar to IPPS hospitals and 
described a situation in which including a CAH has a negative impact on 
the other hospitals' wage index. One commenter agreed that CMS should 
exclude the costs, but expressed concern about the immediate financial 
impact that excluding CAHs might have on all hospitals in FY 2004. The 
commenter recommended that CMS examine the impact of removing CAH wage 
data from the wage index and make this analysis available for public 
comment. Another commenter recommended that CMS establish a date prior 
to the release of the wage index public use file that the facility must 
be certified as a CAH to be excluded from the wage index calculation.
    Several commenters opposed excluding CAH data from the wage index. 
Some commenters indicated that CMS does not exclude hospitals that 
converted to CAH status subsequent to the year used to derive DRG 
weights. Another commenter opposed excluding CAHs from the wage index 
because the commenter believed that the wage index should reflect 
conditions of a labor market at a specific point in time. The commenter 
believed that other conditions, such as closures, mergers, or 
expansions, are analogous circumstances and warned that excluding these 
hospitals would also distort the wage index. Another commenter 
recommended that CMS apply a hold-harmless policy.
    Response: CAHs represent a substantial number of hospitals with 
significantly different labor costs in many labor market areas where 
they exist. Using data collected for the proposed FY 2004 wage index, 
we found that, in 89 percent of all labor market areas with hospitals 
that converted to CAH status some time after FY 2000, the average 
hourly wage for CAHs is lower than the average hourly wage for other 
short-term hospitals in the area. In 79 percent of the labor market 
areas with CAHs, the average hourly wage for CAHs is lower than the 
average hourly wage for other short-term hospitals by 5 percent or 
greater. These results suggest that the wage data for CAHs, in general, 
are significantly different from other short-term hospitals.
    Further, we found that removing CAHs from the wage index would have 
a minimal redistributive effect on Medicare payments to hospitals. The 
majority of the labor market areas would decrease by only 0.30 percent 
in their wage index value. The actual payment impact would be even 
smaller because the wage index is applied to only the labor-related 
portion of the average standardized amount. Only 10 areas would 
experience a decrease in their wage index values greater than 0.30 
percent. The greatest negative impact is 9.57 percent. Meanwhile, 
positive impacts occur in 48 areas, 30 of which are in rural areas. 
Overall, removing CAHs from the wage index would have a minimal 
redistributive effect on Medicare payments to hospitals.
    We believe that removing CAHs from the wage index is prudent 
policy, given the substantial negative impact these hospitals have on 
the wage indexes in the areas where they are located and the minimal 
impact they have on the wage indexes of other areas. We note that we 
would continue to include the wage data for other terminating or 
converting hospitals for the period preceding their change in Medicare 
provider status, as long as those data do not fail any of our edits for 
reasonableness. This is because

[[Page 45398]]

we continue to believe that the wage data for these hospitals, unlike 
CAHs, are not necessarily unique compared to other short-term 
hospitals, and these terminating or converting hospitals provide an 
accurate reflection of the labor market area during the relevant past 
period.
    Therefore, beginning with the FY 2004 wage index, we are excluding 
from the wage index the wages and hours for all hospitals that are 
currently designated as a CAH, even if the hospital was paid under the 
IPPS during the cost reporting period used in calculating the wage 
index. We believe that this change improves the overall equity of the 
wage index. Therefore, it is important to proceed with this change for 
FY 2004. Consistent with our general approach to wage index changes, we 
are not holding other hospitals' payments harmless for this change.
    As recommended, any hospital that is designated as a CAH by 7 days 
prior to the publication of the preliminary wage index public use file 
are excluded from the calculation of the wage index. Hospitals 
receiving designation after this date will remain in the wage index 
calculation.
    We asked our fiscal intermediaries to revise or verify data 
elements that resulted in specific edit failures. The unresolved data 
elements that were included in the calculation of the proposed FY 2004 
wage index have been resolved and are reflected in the calculation of 
the final FY 2004 wage index. For the final FY 2004 wage index in this 
final rule, we removed data for 23 hospitals that failed edits. For 9 
of these hospitals, we were unable to obtain sufficient documentation 
to verify or revise the data because the hospitals are no longer 
participating in the Medicare program, are under new ownership, or are 
in bankruptcy status, and supporting documentation is no longer 
available. We identified 14 hospitals with incomplete or inaccurate 
data resulting in zero or negative, or otherwise aberrant, average 
hourly wages. Therefore, these hospitals were removed from the 
calculation. As a result, the final FY 2004 wage index is calculated 
based on FY 2000 wage data for 4,087 hospitals.

E. Computation of the FY 2004 Wage Index

    The method used to compute the FY 2004 wage index follows:
    Step 1--As noted above, we based the 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 are 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.
    Step 2--Salaries--The method used to compute a hospital's average 
hourly wage excludes certain costs that are not paid under the IPPS. 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. To determine total salaries plus 
wage-related costs, we added to the net hospital salaries the costs of 
contract labor for direct patient care, certain top management, 
pharmacy, laboratory, and nonteaching physician Part A services (Lines 
9, 9.01, 9.02, and 10), home office salaries and wage-related costs 
reported by the hospital on Lines 11 and 12, and nonexcluded area wage-
related costs (Lines 13, 14, and 18).
    We note that contract labor and home office salaries for which no 
corresponding hours are reported were not included. In addition, wage-
related costs for nonteaching physician Part A employees (Line 18) are 
excluded if no corresponding salaries are reported for those employees 
on Line 4.
    Step 3--Hours--With the exception of wage-related costs, for which 
there are no associated hours, we computed total hours using the same 
methods as described for salaries in Step 2.
    Step 4--For each hospital reporting both total overhead salaries 
and total overhead hours greater than zero, we then allocated overhead 
costs to areas of the hospital excluded from the wage index 
calculation. First, we determined the ratio of excluded area hours (sum 
of Lines 8 and 8.01 of Worksheet S-3, Part II) to revised total hours 
(Line 1 minus the sum of Part II, Lines 2, 3, 4.01, 5, 5.01, 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, 5.01, 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.

[[Page 45399]]



                    Midpoint of Cost Reporting Period
------------------------------------------------------------------------
         After                    Before             Adjustment 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 $24.8076.
    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 
$11.5905 for Puerto Rico. For each labor market area in Puerto Rico, we 
calculated the Puerto Rico-specific wage index value by dividing the 
area average hourly wage (as calculated in Step 7) by the overall 
Puerto Rico average hourly wage.
    Step 11--Section 4410 of Public Law 105-33 provides that, for 
discharges on or after October 1, 1997, the area wage index applicable 
to any hospital that is located in an urban area of a State may not be 
less than the area wage index applicable to hospitals located in rural 
areas in that State. Furthermore, this wage index floor is to be 
implemented in such a manner as to ensure that aggregate IPPS 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 
150 hospitals in 49 MSAs. The MSAs affected by this provision are 
identified by a footnote in Table 4A in the Addendum of this final 
rule.
    Comment: One commenter indicated that there are serious 
deficiencies in the payment rates to Iowa hospitals under IPPS because 
of the development and application of the wage index, and, accordingly, 
CMS must make revisions to the wage index in this final rule. The 
comment suggested that CMS should: reduce the labor-related portion of 
the standardized amount to which the wage index is applied; adjust the 
wage index upward to account for low Medicare payments; or utilize a 
wage index floor or compress the wage index.
    Response: We appreciate the concerns expressed by this commenter 
about the impact of the wage index upon Iowa's hospitals. We strive 
each year to ensure the wage index accurately reflects the relative 
wage differences across labor market areas. Further, the methodology we 
use to compute the wage index values is the same for all urban and 
rural hospitals. Therefore, the wage index values we include in the 
proposed and final rules for Iowa hospitals reflect the actual wage 
costs that are reported by these hospitals relative to those reported 
by hospitals across the nation.
    With respect to the commenter's specific recommendations, we 
address comments related to the labor-related portion of the 
standardized amounts in section VII. of the preamble of this final 
rule. With respect to the other recommendations raised, these were not 
proposed and, therefore, we do not wish to implement them in this final 
rule. We are willing to explore these and other options in the future 
and to work with the commenter to address the concerns expressed.
    Comment: One commenter indicated that we failed to address the 
problem associated with the exclusion of indirect patient care contract 
labor in the proposed rule. The commenter indicated that we recognized 
this problem in the FY 2002 final rule (67 FR 50022), but failed to 
carry out our commitment to address it.
    Response: We indicated last year it would be necessary to revise 
the cost report form and instructions in order to collect the data 
necessary to separately identify the costs and hours associated with 
the following contracted overhead services: administrative and general; 
housekeeping; and dietary. In Transmittal Number 10 of the Medicare 
cost report, we revised Worksheet S-3, Part II to collect contract 
labor costs associated with these services, effective with cost 
reporting periods beginning on or after October 1, 2003.
    We also indicated our final decision on whether to include contract 
indirect patient care labor costs in our calculation of the wage index 
will depend on the outcome of our analyses of the data collected and 
public comments.

F. Revisions to the Wage Index Based on Hospital Redesignation

1. General
    Under section 1886(d)(10) of the Act, the Medicare Geographic 
Classification Review Board (MGCRB) considers applications by hospitals 
for geographic reclassification for purposes of payment under the 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. The MGCRB issues its 
decisions by the end of February for

[[Page 45400]]

reclassification to become effective for the following fiscal year 
(beginning October 1). The regulations applicable to reclassifications 
by the MGCRB are located 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 located 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 was not yet complete at the time 
of publication of the proposed rule.
    As noted above, OMB announced the new Metropolitan and Micropolitan 
Statistical Area designations and definitions on June 6, 2003. These 
new designations have extensively revised the construct of many of the 
existing Metropolitan Areas and created many new designated areas. In 
order to implement these changes, we need to carefully evaluate the 
implications of these changes for each county and hospital nationwide. 
As a result, we are unable to incorporate these new standards for 
redesignating hospitals and, therefore, we are not implementing the new 
standards for purposes of redesignation for FY 2004 under section 
1886(d)(8)(B) of the Act. As a result, to qualify for redesignation 
under this section in FY 2004, hospitals must be located in counties 
that meet the 1990 standards.
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,\5\ the wage index values 
were determined by considering the following:
---------------------------------------------------------------------------

    \5\ 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 areas 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 age 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] 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.
    [sbull] The wage data for a reclassified urban hospital is included 
in both the wage index calculation of the area to which the hospital is 
reclassified (subject to the rules described above) and the wage index 
calculation of the urban area where the hospital is physically located.
    [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.
    The wage index values for FY 2004 are shown in Tables 4A, 4B, 4C, 
and 4F in the Addendum to this final rule. Hospitals that are 
redesignated must 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. Therefore, those areas with more than one wage 
index shown have hospitals from more than one State reclassified into 
them, and the rural wage index for a State in which at least one 
hospital is physically located is higher than the wage index for the 
area to which the hospital is reclassified.
    Tables 3A and 3B in the Addendum of this final rule list the 3-year 
average hourly wage for each labor market area before the redesignation 
of hospitals, based on FYs 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 final 
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 final FY 2004 wage index. The 3-year 
averages are calculated by dividing the sum of the dollars (adjusted to 
a common reporting

[[Page 45401]]

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.
    Table 9 in the Addendum of this final rule 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 (68 for wage index, 31 for the standardized 
amount, and 34 for both the wage index and the standardized amount), as 
well as hospitals that were reclassified for the wage index in either 
FY 2002 (451) or FY 2003 (55) and are, therefore, in either the second 
or third year of their 3-year reclassification. 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). Since publication of the May 19 proposed rule, the 
number of reclassifications has changed because some MGCRB decisions 
were still under review by the Administrator and because some hospitals 
decided to withdraw their requests for reclassification.
    Changes to the wage index that result from withdrawals of requests 
for reclassification, wage index corrections, appeals, and the 
Administrator's review process have been incorporated into the wage 
index values published in this final rule. The changes may affect not 
only the wage index value for specific geographic areas, but also the 
wage index value redesignated hospitals receive; that is, whether they 
receive the wage index value that includes the data for both the 
hospitals already in the area and the redesignated hospitals. Further, 
the wage index value for the area from which the hospitals are 
redesignated may be affected.
    Applications for FY 2005 reclassifications are due to the MCGRB by 
September 2, 2003. We note that this is also the deadline for canceling 
a previous wage index reclassification withdrawal or termination under 
Sec.  412.273(d). Applications and other information about MCGRB 
reclassifications may be obtained via the CMS Internet Web site at 
http://cms.hhs.gov/providers/prrb/mgcinfo.asp, or by calling the MCGRB 
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 announced its new Metropolitan and 
Micropolitan Statistical Area definitions on June 6, 2003. However, as 
noted previously as well as in the proposed rule, in order to implement 
these changes for the IPPS, it is necessary to identify the new area 
designations for each county and hospital in the country. This is not 
possible by the September 2, 2003 deadline for reclassification by the 
MCGRB for FY 2005. Therefore, hospitals submitting applications for 
reclassification by the MCGRB for FY 2005 should base those 
applications on the current MSAs. We plan to move deliberately in 
determining the implications the new definitions will have on 
hospitals' reclassification requests, and we are considering addressing 
these implications in the FY 2005 proposed rule.

G. Requests for Wage Data Corrections

    In the May 19, 2003 proposed rule, we described the process for 
hospitals to review and revise their FY 2000 wage data. 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. At that time, we also 
made available, at the same Internet address, a file showing each MSA's 
and rural areas's FY 2004 average hourly wage based on data then 
available compared to its FY 2003 average hourly wage. 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 were necessary to allow sufficient time to 
review and process the data so that the final wage index calculation 
could 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).
    The final wage data public use file was released in May 2003. 
Hospitals had an opportunity to examine both Table 2 of the proposed 
rule and the May 2003 final public use wage data file (which reflected 
revisions to the data used to calculate the values in Table 2) to 
verify the data CMS used to calculate the wage index.
    As with the file made available in January 2003, we made the final 
wage data released in May 2003 available to hospital associations and 
the public on the internet. However, the May 2003 public use file was 
made available solely for the limited purpose of identifying any 
potential errors made by CMS or the fiscal intermediary in the entry of 
the final wage data that result from the correction process described 
above (with the February 2003 deadline). Hospitals were encouraged to 
review their hospital wage data promptly after the release of the May 
2003 file. Data presented at that time could not be used by hospitals 
to initiate new wage data correction requests.
    If, after reviewing the May 2003 final file, a hospital believed 
that its wage data were incorrect due to a fiscal

[[Page 45402]]

intermediary or CMS error in the entry or tabulation of the final wage 
data, it was provided an opportunity to send a letter to both its 
fiscal intermediary and CMS that outlined why the hospital believed an 
error existed and provided all supporting information, including 
relevant dates (for example, when it first became aware of the error). 
These requests had to be received by CMS and the fiscal intermediaries 
no later than June 6, 2003.
    Changes to the hospital wage data were only made in those very 
limited situations involving an error by the intermediary or CMS that 
the hospital could not have known about before its review of the final 
wage data file. Specifically, at this stage of the process, neither the 
intermediary nor CMS accepted the following types of requests:
    [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) are 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), also 
Palisades General Hospital v. Thompson, No. 99-1230 (D.D.C. 2003)).
    Again, we believe the wage data correction process described above 
provides hospitals with sufficient opportunity to bring errors in their 
wage data to the fiscal intermediaries' attention. Moreover, because 
hospitals had access to the final wage data by early May 2003, they had 
the opportunity to detect any data entry or tabulation errors made by 
the fiscal intermediary or CMS before the development and publication 
of the FY 2004 wage index in this final rule, 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 publication in the final rule, we retain the right to 
make midyear changes to the wage index under very limited 
circumstances.
    Specifically, in accordance with Sec.  412.63(x)(2) of our existing 
regulations, we make midyear corrections to the wage index only in 
those limited circumstances in which a requesting hospital can show: 
(1) that the intermediary or CMS made an error in tabulating its data; 
and (2) that the requesting hospital could not have known about the 
error or did not have an opportunity to correct the error, before the 
beginning of FY 2004 (that is, by the June 6, 2003 deadline.) 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 indicated earlier, since a hospital had the opportunity to 
verify its data, and the fiscal intermediary notified the hospital of 
any changes, we do not expect that midyear corrections would be 
necessary. However, if the correction of a data error changes the wage 
index value for an area, the revised wage index value will be effective 
prospectively from the date the correction is approved.
    Comment: One commenter requested that CMS release all of the 
assumptions used in developing the MSA average hourly wage file posted 
on the Internet, including the midpoint of cost reporting period 
adjustment factors. The commenter also requested that CMS release a 
file with the average hourly wage by hospital prior to the proposed 
rule. The commenter believed that this information would facilitate a 
hospital's review of its wage data.
    Response: We agree that providing all of the assumptions used in 
calculating the wage index would be useful for hospitals and other 
interested parties. This year, we added to our Web site a spreadsheet 
that can be used to calculate a hospital's average hourly wage. 
Beginning with the release of the FY 2005 wage index, we will also 
publish on our Web site the midpoint of cost reporting period 
adjustment factors and a file that includes the average hourly wage for 
each hospital.
    Comment: One commenter recommended that CMS establish a wage index 
list server similar to those available for the various open door 
forums. The list server would allow CMS to e-mail interested parties 
when items, such as the wage index PUF and program memoranda, are 
released.
    Response: We currently notify all hospitals, through the fiscal 
intermediaries, regarding all public use files and program memorandum 
releases pertaining to the wage index. We also post this information on 
the IPPS Web site (http://cms.hhs.gov/providers/hipps/ippswage.asp). In 
addition, we make announcements regarding the wage index at the 
hospital open door forums. To supplement these efforts, we will also 
begin announcing the availability of wage index files and new program 
memoranda on the hospital open door forum Web site, at http://www.cms.hhs.gov/opendoor/. Those registered with the hospital open door 
forum list server will be automatically notified when there are 
announcements at this site pertaining to the wage index. Information on 
registering with the hospital open door forum list server is located at 
the open door forum Web site.
    Comment: One commenter expressed concern regarding the average 
hourly wage calculator available on the Internet, stating that they 
were unable to replicate the average hourly wage published in the 
proposed rule for its area hospitals using the May public use file data 
and the online calculator.
    Response: The average hourly wage values printed in the proposed 
rule, published on May 19, 2003 in the Federal Register, reflect the 
data saved in our database as of February 17, 2003. Alternatively, the 
May public use file was updated based on data collected through May 5, 
2003. Therefore, calculating an average hourly wage using the May data 
could yield discrepancies between the value published in the proposed 
rule and the number generated by the online calculator.

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

    In the May 19, 2003 proposed rule, we stated that although the wage 
data correction process described in section III.G. of the preamble of 
this final rule 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

[[Page 45403]]

the FY 1998 IPPS proposed rule (62 FR 29918) and in the FY 2002 IPPS 
proposed rule (66 FR 22682). In each discussion, we described 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 Memorandum A-02-94, October 4, 2002). Furthermore, 
fiscal intermediaries are required to explain and attempt to resolve 
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, nearly 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, in the May 19 proposed 
rule, we proposed 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. We proposed that 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 revised requests and conduct desk reviews of the data including all 
approved changes.
    Under the 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.
    Therefore, we proposed to revise the schedule to 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, the proposed schedule should decrease 
the likelihood that the final wage index will be dramatically different 
from the proposed wage index.
    Comment: Commenters stated their appreciation of the desire to 
expedite the process and reduce the workload of its fiscal 
intermediaries, but some were concerned about the additional workload 
these timeframes would place on hospitals.
    Some commenters were concerned about the 30-day review period for 
the hospitals, stating it would not be enough time to conduct a 
thorough and complete review of the detailed data, adding that a 45-day 
comment period should be the minimum review time for providers. 
Commenters also stated their concerns about adjusting to a new 
timetable while also collecting and submitting occupational mix data, 
and the possible adoption of the new MSA definitions for the FY 2005 
wage index. They believe any changes to the timeline should be 
postponed until the FY 2006 wage index.
    Other commenters were concerned about the additional workloads for 
hospitals whose fiscal year ends on June 30. These hospitals would most 
likely be preparing cost reports for the fiscal year just ended and 
this would be an additional burden. Another commenter expressed concern 
that the proposed rule did not mention the State hospital association 
notification for hospitals failing desk review edits and that the new 
deadlines would not afford hospitals any recourse to ensure accurate 
data. One commenter cited the major role its fiscal intermediary played 
in the delay of revisions to its wage index.
    Several other commenters generally supported the proposal to modify 
the wage index timetable, but with some modification. The commenters 
asked that hospitals have 75 days from the proposed October release of 
the public use file to submit revised data to the fiscal intermediaries 
and that CMS finalize the timetable in June rather than waiting until 
the final rule is published. The commenters believed this would allow 
virtually all hospitals the time they need to do a thorough and 
complete review to determine the accuracy of the detail data needed to 
compute an accurate wage index. Commenters also believed this would 
give fiscal intermediaries time to respond to hospital issues raised 
during the desk review period.
    Finally, other commenters expressed support for the timetable 
changes. These commenters believed the hospitals will have more time to 
review their wage data and there will be less of an administrative 
burden on fiscal intermediaries. Another commenter believed auditors' 
and hospitals' resources will be better utilized and this could help 
eliminate the problem of reauditing wage index data after revisions are 
submitted. Another commenter added that hospitals would be able to 
better determine how they compare to other hospitals and whether a 
reclassification would be appropriate using much more accurate data. 
Also, aberrant data would become more apparent earlier in the process.
    Response: Although hospitals will be required to review the data 
sooner, they are not being asked to perform any more reviews or work 
than currently. Therefore, we do not believe this change will be 
burdensome to hospitals. Hospitals will still have sufficient time to 
complete a thorough review of the data, because the data for the FY 
2005 wage index values will be taken from cost reporting periods 
beginning during FY 2001. These cost reports should have already been 
thoroughly reviewed

[[Page 45404]]

before being submitted to their fiscal intermediary and sent to CMS 
earlier this year.
    Further, since the ultimate goal is improvement of the wage index, 
we believe this will be achieved with a more streamlined process in 
which fiscal intermediary work is not duplicated and is instead focused 
on the final data submitted by hospitals instead of preliminary data, 
of which nearly 40 percent ends up being revised under the current 
timetable. As noted above, these revisions under the current process 
often nullify the desk reviews performed by the fiscal intermediary.
    We recognize the commenters' concern with respect to the 
interaction of this process with the collection of occupational mix 
data and the potential adoption of OMB's new MSA definitions. As we 
proceed with developing the details of the occupational mix data 
collection for the FY 2005 wage index, we intend to schedule that 
collection effort in a way that accommodates this revised timetable. 
The details of that schedule will be forthcoming shortly.
    Finally, as previously discussed, the ability of hospitals to 
assess whether they should request a withdrawal from a MGCRB 
reclassification will also be improved, thereby decreasing the 
likelihood that the final wage index will be dramatically different 
from the proposed wage index. For these reasons, we are adopting as 
final the proposed revisions to the wage data development timeline and 
will use the revised timeline for the development of the FY 2005 wage 
index.
    However, in order to address commenter concerns about the 30-day 
review period being too short, we are modifying the timetable to have 
the preliminary public use file on the CMS Web site in mid-September, 
thereby giving hospitals approximately 45 days instead of 30 days to 
review the preliminary wage data. Further instructions and a detailed 
timeline will be released in the form of a Program Memorandum.
    The following table illustrates the timetable that will be 
applicable for the development of the FY 2005 wage index:

------------------------------------------------------------------------
                                       Steps in wage index development
             Timeframe                             process
------------------------------------------------------------------------
Mid-September.....................  Preliminary and unaudited wage data
                                     file published as a public use file
                                     (PUF) on CMS Web site.
Mid-November......................  Deadline for hospitals to send
                                     requests for revisions to their
                                     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 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.
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:

[[Page 45405]]

    ``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, in the May 19, 2003 proposed rule, we proposed 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 did not propose 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.
    Comment: Commenters opposed the proposed expansion of the transfer 
policy to include all patients who are admitted to another IPPS 
hospital on the same day that the patient is discharged from an IPPS 
hospital. They argued that situations in which a limited number of 
hospitals are abusing the payment rules should be handled by review of 
those hospitals' claims, and not through a policy change that will 
place additional burdens on all hospitals.
    Response: We disagree that this policy expansion would create an 
additional burden on all hospitals. We note that it is our current 
policy to consider patients discharged from one IPPS hospital and 
admitted to another IPPS hospital on the same day as a transfer in all 
situations except LAMA situations, unless the original discharging 
hospital can document that the discharge was appropriate and unrelated 
to the subsequent same-day admission. We understand from the OIG that 
these situations are extremely rare, and in the vast majority of cases, 
same-day readmissions to another hospital are, in fact, transfers.
    Our proposal would merely extend this current policy to LAMA 
situations. As is the case under our present policy, we believe it will 
be exceedingly rare that a patient leaves one hospital in LAMA status, 
and is readmitted to a second hospital on the same day for an unrelated 
purpose. Because the need for a hospital to supply documentation would 
only arise in these rare situations, we do not believe this policy 
change creates an additional burden for hospitals.
    In relation to the appropriateness of a general policy expansion as 
opposed to a review and adjustment of individual hospital's claims, we 
believe a general policy expansion is necessary in this circumstance. 
As described in the proposed rule and above in this final rule, we 
considered proposing a policy that would be based on whether the 
hospital actively participated in the transfer and that would exempt 
from the transfer definition cases in which the hospital had absolutely 
no knowledge that the patient intended to go to another hospital. 
However, we did not propose such a policy because it would require a 
determination as to whether the hospital or the physician had

[[Page 45406]]

knowledge of the patient's intentions. We believed that if we adopted 
such a policy, 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.
    Comment: Several commenters wrote that CMS was overreacting to 
anecdotal examples and that the proposed policy was ``not sustainable 
under any application of reasonableness.'' They suggested that, rather 
than put the burden on all hospitals due to the abuse from these 
isolated incidents, hospitals should be evaluated from the frequency of 
LAMA discharges. Those that fall outside of the ``norm'' could be 
investigated, similar to the outlier studies.
    Response: We agree that the problems uncovered in the OIG's report 
on transfers reported as LAMAs are relatively small within the overall 
scope of the IPPS. In fact, we made the point to OIG in our comments on 
a draft of its report that their findings equated with one 
inappropriate LAMA discharge per hospital per year. However, the OIG 
found this problem was not spread equally across all hospitals, but 
occurred disproportionately in a small number of hospitals.
    We believe we are establishing clear and unequivocal policies for 
handling those situations that do occur and that this policy change 
will have a minimal impact on the majority of hospitals nationwide. 
Consequently, we are finalizing the change to our regulations 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, effective 
for discharges occurring on or after October 1, 2003.
    Comment: Commenters stated that the proposed expanded definition of 
a transfer provides no guidance to hospitals as to what would be 
acceptable documentation that the patient's treatment was completed at 
the time of discharge. Some commenters asked whether an exact match of 
the principal diagnoses codes for the two admissions would be used to 
determine that the same-day readmission was related to the prior 
discharge. One commenter suggested that it would be more appropriate 
for the fiscal intermediary to request medical documentation from both 
hospitals involved in the transfer in order to determine whether a 
transfer payment should be made to the transferring hospital, rather 
than solely requesting documentation from the transferring hospital.
    Another commenter asserted that CMS is placing the burden of 
correcting this situation on all hospitals rather than directing fiscal 
intermediaries to develop screens to identify these cases. In addition, 
they noted possible conflicts of sharing information between hospitals 
regarding patient care due to new HIPAA requirements.
    Response: We anticipate the documentation necessary to establish 
that the readmission was unrelated to the prior, same-day discharge 
would be similar to the type of documentation relied upon by fiscal 
intermediaries and Quality Improvement Organizations (QIOs) to evaluate 
whether patients were discharged prematurely. (For example, section 
4135 of the Peer Review Manual discusses discharge review.) That is, 
there are existing practices for determining that patients were 
medically unstable at discharge or the discharge was inconsistent with 
the patient's need for continued acute inpatient hospitalization. 
Therefore, there should be no breach in HIPAA disclosure requirements.
    We are developing claims processing systems edits to more 
accurately identify transfers that are inappropriately coded as 
discharges. These edits identify claims that are entered with 
inappropriate discharge codes and will prevent payment to the second 
hospital if there is already a discharge from another hospital in the 
system for the same beneficiary on the same day. If this situation 
occurs, the claim from the first hospital is sent back to the hospital 
for correction, and the second claim is paid. We expect a similar edit 
that identifies same-day readmissions following a LAMA discharge would 
be added to the claims processing system edits.
    Comment: One commenter requested clarification as to the 
appropriate discharge destination code in those situations when a 
patient left the first hospital against medical advice and the fiscal 
intermediary notifies this hospital of a subsequent same-day admission 
to another hospital.
    Response: This situation is similar to those situations in which a 
hospital believes and intends to discharge a patient to home, but is 
subsequently notified that the discharge qualifies under the postacute 
care transfer policy because the patient received qualifying postacute 
care. The hospital would submit an amended bill coded to reflect the 
fact that the hospital now has information that the patient received 
subsequent care.
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. In the May 19, 2003 
proposed rule, to avoid confusion and to be consistent with the changes 
to Sec.  412.4(b) described at section IV.A.3. of this preamble, we 
proposed to delete existing Sec.  412.4(b)(2) from the definition of a 
transfer. We did not receive any comments on this proposal. Therefore, 
we are deleting 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).

[[Page 45407]]

    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 care 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 care 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. We also agree that any future expansion must 
consider both the need to reduce payments to reflect cost-shifting out 
of the acute care setting 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 care 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 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 care 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 care 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

[[Page 45408]]

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      Percent of                                    Percent change
                                                                             all cases       all cases    Percent change  Percent change       in DRG
          DRG                       DRG title              All transfer   transferred to    transferred       in mean         in mean        relative
                                                               cases      postacute care   prior to mean  length of stay  length of stay    weight FYs
                                                                              setting     length of stay   FYs 1992-1998   FYs 1998-2003     1998-2003
--------------------------------------------------------------------------------------------------------------------------------------------------------
14....................  Intracranial Hemorrhage and              143,649           48.88           11.74          -29.17           -5.88            8.53
                         Stroke with Infarction.
113...................  Amputation for Circulatory                24,470           66.57           30.12          -32.17            7.22            9.21
                         System Disorders Except Upper
                         Limb and Toe.
209...................  Major Joint and Limb                     244,969           66.66           19.76          -47.52          -15.09           -8.09
                         Reattachment Procedures of
                         Lower Extremity.
210...................  Hip and Femur Procedures Except           87,253           76.26           35.67          -42.98           -6.15             0.1
                         Major Joint Age 17
                         With CC.
211...................  Hip and Femur Procedures Except           20,239           72.38           15.89          -44.44           -8.00            1.39
                         Major Joint Age 17
                         Without CC.
236...................  Fractures of Hip and Pelvis.....          26,583           69.86           11.20          -34.85           -6.98           -1.43
263...................  Skin Graft and/or Debridement             13,158           62.00           31.35          -41.45            4.49            9.36
                         for Skin Ulcer or Cellulitis
                         with CC.
264...................  Skin Graft and/or Debridement              1,759           49.97           18.81          -37.21            1.85            5.36
                         for Skin Ulcer or Cellulitis
                         Without CC.
429...................  Organic Disturbances and Mental           30,349           53.25           15.22          -28.95          -12.96           -5.27
                         Retardation.
483...................  Tracheostomy With Mechanical              21,818           52.93           27.34          -15.29            2.37            1.38
                         Ventilation 96 + Hours or
                         Principal Diagnosis Except
                         Face, Mouth, and Neck Diagnoses.
--------------------------------------------------------------------------------------------------------------------------------------------------------

    We indicated in the proposed rule that we believe 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. Therefore, we once again undertook 
the analysis to identify additional DRGs to which the policy might be 
expanded.
    However, we did not propose to expand the policy to all DRGs. 
Although we indicated that 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. It may not be appropriate to reduce payment for these latter 
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 proposed 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 appeared 
warranted.
    We also noted that MedPAC has 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 
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

[[Page 45409]]

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, in the May 19, 2003 proposed rule, we 
proposed 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 
proposed 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 proposed to include only DRGs where at least 10 percent of 
all cases were transferred to postacute care before the geometric mean 
length of stay. (We note that preceding sentence was stated incorrectly 
in the proposed rule. The criterion should have read ``at least 10 
percent of all cases that were transferred to postacute care were 
transferred 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 proposed 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 proposed 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) were 
not included in the May 19, 2003 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 were not included in the proposed rule for FY 2004. DRGs 
79 and 80 were excluded from the proposed rule because they did not 
exhibit a decline in length of stay of at least 7 percent over the past 
5 years.
    We noted that 7 of the proposed 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 proposed to include both DRGs under this 
expanded policy. If we were to include only DRG 130 in the transfer 
policy, we believed 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 proposed the 
following 19 DRGs to include under the postacute care transfer policy 
(in addition to the 10 DRGs already subject to the policy).

----------------------------------------------------------------------------------------------------------------
                                                    Percent of      Percent of
                                                     all cases       all cases    Percent change  Percent change
    DRG           DRG title        All transfer   transferred to    transferred       in mean         in mean
                                       cases      postacute care   prior to mean  length of stay  length of stay
                                                      setting     length of stay   FYs 1992-1998   FYs 1998-2003
----------------------------------------------------------------------------------------------------------------
12........  Degenerative Nervous          39,034           54.13           13.10          -21.74          -12.00
             System Disorders.
24........  Seizure and Headache          19,239           35.67           11.63          -20.75           -7.69
             Age 17
             With CC.
25........  Seizure and Headache           4,738           19.15            2.15          -14.29          -10.71
             Age 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                   79,242           52.52           20.46          -21.95          -11.67
             Disorders With AMI
             and Major
             Complication,
             Discharged Alive.
122.......  Circulatory                   33,028           48.91           24.09          -26.67          -23.08
             Disorders 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                  23,188           53.54           21.96          -22.67           -7.55
             Fractures and
             Musculoskeletal and
             Connective Tissue
             Malignancy.
243.......  Medical Back                  36,772           41.49           13.61          -14.00           -7.50
             Problems.
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            77,669           44.64           12.40          -23.88           -8.51
             Tract Infectious
             Age 17
             With CC.
321.......  Kidney and Urinary             8,610           29.90            5.67          -20.41          -13.89
             Tract Infections
             Age 17
             Without CC.
462.......  Rehabilitation......         147,211           56.59           22.69          -22.54          -11.43
468.......  Extensive O.R.                24,783           44.51           18.53          -20.30           -7.07
             Procedure Unrelated
             to Principal
             Diagnosis.
----------------------------------------------------------------------------------------------------------------

    We proposed 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

[[Page 45410]]

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, we 
compared the average charges for all cases with a length of stay of 1 
day to the average charges of all cases in a particular DRG. To qualify 
for the alternative methodology, we indicated that 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 proposed 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 
did not propose 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 made on the second day of the stay, regardless of 
which payment methodology is used. Therefore, in the May 19, 2003 
proposed rule, we proposed that none of the 19 additional DRGs that we 
were proposing to add to the postacute care transfer policy would be 
paid under the alternative payment methodology.
    We also 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 length of stay of both DRG 209 and 211 is over 4 days. 
In addition, DRG 210 is currently paid under the special payment 
methodology, but our current analysis indicates average charges for 1-
day stays are less than 50 percent of the average charges for all cases 
in the DRG. Nonetheless, DRG 210 is paired with DRG 211, which meets 
the criteria. Therefore, we proposed that DRG 210 would 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 proposed to include both DRGs in 
this pair under the special payment methodology. Accordingly, we 
proposed 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 noted 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.\6\ 
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 are compliant with our 
guidelines.
---------------------------------------------------------------------------

    \6\ The OIG report identification numbers are: A-04-00-02162, A-
04-00-01210, A-04-0122, and A-04-02-07005.
---------------------------------------------------------------------------

    Comment: Many commenters argued that any expansion of the postacute 
care transfer policy, and even the policy itself, undermines clinical 
decisionmaking and penalizes hospitals for providing the right care at 
the right time and in the right setting. Commenters further argued that 
the policy itself violates the original premise of the IPPS, because it 
makes it difficult or impossible for hospitals to break-even on 
patients who receive postacute care after discharge. One commenter 
argued that hospitals lose if patients are discharged prior to the mean 
length of stay, and they lose if patients are discharged after the mean 
length of stay.
    Commenters also argued the postacute care transfer policy is not 
good policy because it may create a perverse incentive for hospitals to 
increase patients' lengths of stay. One commenter expressed concern 
that longer lengths of stay would result from a shift in focus from 
per-case cost control to per-day cost control. The commenter suggested 
that this policy sends a conflicting message to hospital administrators 
who have taken steps recently to reduce their hospitals' average 
lengths of stay.
    Some commenters pointed out that the postacute care transfer policy 
fails to acknowledge or recognize that, for many patients, postacute 
care is already reflected in the IPPS base payment rate for many DRGs. 
In particular, hospitals in certain regions of the country have 
historically had lower average lengths of stay, and therefore, these 
hospitals are disproportionately impacted by this policy.
    Other commenters suggested the DRG relative weights are self-
adjusting, and as patients spend less time in the acute care setting 
and costs decrease, the DRG relative weights will begin to fall. 
Therefore, there is no need for a postacute care transfer policy.
    Commenters also noted the increasing costs of dealing with these 
higher cost cases, and that transfer payments do not adequately cover 
the costs of the newer and better treatment that is resulting in 
shorter lengths of stay. Commenters objected to the expansion of the 
policy due to the current financial pressure that many hospitals are 
currently under because of nursing shortages, inadequate Medicare 
payment for services they provide, and increasing costs associated with 
malpractice and insurance costs and increasing costs of pharmaceuticals 
and equipment. They also noted the financial burden in preparing to 
treat the aging ``baby boomer'' generation and costs associated with 
emergency management preparation.
    Commenters argued that many hospitals are suffering as a result of 
not receiving the full market basket update (accounting for inflation 
each year), and further expansion of the postacute care transfer policy 
will further limit their resources. In addition, they argued, Congress 
already addresses the issues of shorter lengths of stay when it 
determines the market basket update each year. In effect, they claimed, 
hospitals whose lengths of stay decline significantly are not praised, 
but penalized--twice--for their efforts to provide better care. One 
commenter wrote to ``respectfully submit that to deal with fraudulent 
providers in this sweeping manner is inconsistent and inappropriate.''
    Response: We disagree that the postacute care transfer policy is 
contrary to the fundamental theory of the IPPS. Concern that hospitals 
would shift a portion of the acute care services to other providers in 
response to the incentives of the IPPS has been an ongoing concern. In 
fact, in response to a comment during the first year of the IPPS on the 
hospital-to-hospital transfer policy, we stated that ``(t)he rationale 
for per diem payments as part of our transfer policy is that the 
transferring hospital generally provides only a limited amount of 
treatment. Therefore, payment of the full prospective payment rate 
would be unwarranted'' (49 FR 244). We also note that in its earliest 
update recommendations, the Prospective Payment Assessment Commission 
(a predecessor to MedPAC)

[[Page 45411]]

included what it called a site-of-service substitution adjustment to 
account for the shifting of portions of inpatient care to other 
settings.
    We disagree that the postacute care transfer policy creates a 
perverse incentive to keep patients in the hospital longer than 
necessary. Our view is the policy simply responds to changing medical 
practice and addresses the appropriate level of payment once clinical 
decisions about the most appropriate care in the most appropriate 
setting have been made. The validity of this position is substantiated 
by the finding that the geometric mean length of stay for 6 of the 10 
DRGs currently included in the policy have continued to fall since the 
policy was implemented.
    In regard to the comment that the policy fails to recognize that 
the DRG base payments reflect some degree of postacute care, we note 
that the policy is intended to recognize that, since the implementation 
of the IPPS, the use of postacute care has generally increased. For 
many DRGs, the use of postacute care continues to increase at a high 
rate. However, an increase in the frequency of the use of postacute 
care does not, by itself, necessitate a policy response. If patients 
continue to receive the full course of acute care in the IPPS setting 
prior to transfer, a full DRG payment is warranted. However, if 
patients begin to be transferred to postacute care settings to receive 
care that, during the IPPS base period, was provided in the IPPS 
setting, paying a full DRG would not be appropriate because some of the 
care on which the full DRG payment is based is now being provided in 
the postacute care setting.
    This shift in the setting where care is provided is not accounted 
for through DRG recalibration. During recalibration, reductions in the 
relative weights of certain DRGs result in increases in the weights of 
other DRGs. Therefore, there is no net reduction in the IPPS payments 
to hospitals, even though some of the care that used to be provided in 
the acute inpatient setting is now provided elsewhere.
    Comment: Commenters took issue with our evaluation of the impact of 
the postacute care transfer policy on the averaging aspects of the IPPS 
if the policy were expanded. Pointing to our statement in the August 1, 
2002 Federal Register that we intended to undertake a more 
comprehensive analysis of this issue, some commenters stated that we 
did not provide such a comprehensive analysis or include a discussion 
of the topic in the proposed rule.
    However, other commenters expressed appreciation for our analysis 
of the impacts of the existing policy in the proposed rule. One 
commenter noted that we had made some interesting and potentially valid 
points that an expanded transfer policy would eliminate or reduce some 
of the problems caused by making national average payments to all 
hospitals, regardless of treatment patterns and patient-mix within 
specific DRGs (although this commenter suggested that we address the 
payment inequities caused by expensive short-stay cases, or 
``inliers'').
    Several commenters noted that the recalculation of weights in the 
affected DRGs is unfair because, in the system of averages, transfers 
are accounted for as only partial cases but the remaining cases are not 
adjusted upward. The commenter wrote: ``[i]f a DRG's length of stay is 
declining, doesn't that suggest recalibration of the relative weight?'' 
The commenter believed inclusion of reduction in length of stay 
criteria ``begs the question of what is the true average length of stay 
for these particular DRGs. If these DRGs are experiencing a large 
percentage of cases transferred prior to the average length of stay, it 
logically follows that the average length of stay would be less.''
    Response: We regret that commenters perceived that we neglected to 
address this important issue. Our point in evaluating the DRG relative 
weights for the 10 DRGs that are currently included in the policy was 
to make the point that reducing the contribution of transfer cases in 
the DRG relative weight recalibration enhances the averaging mechanism 
for these DRGs. By treating transfer cases as less than a full 
discharge (reducing the denominator), we effectively inflate the 
charges (the numerator) to reflect the higher charges that would have 
occurred if the patient had been transferred. This increases, rather 
than decreases, the average charges (and thus the relative weights) for 
the affected DRGs.
    For example, the DRG weights for each of these 10 DRGs declined 
over the 5-year period (FYs 1993 through 1998) immediately preceding 
the implementation of this policy. However, as shown in the table 
above, the DRG weights for all but three of these DRGs have increased 
during the 5-years since implementation of this policy. Payments for 
all cases in these DRGs were declining as the number of cases being 
transferred to postacute care increased and the average length of the 
inpatient acute stay decreased. However, since implementation of the 
policy, payments for the cases that are not implicated under this 
policy are rising in most of the 10 DRGs. In those DRGs where the 
relative weight has declined in over the 5-year period since 
implementation of this policy, the geometric mean length of stay has 
continued to decline.
    As discussed above, the premise of the postacute care transfer 
policy is that hospitals have shifted some of the acute care formerly 
provided in the hospital into the postacute care setting. This distorts 
the averaging principle of the IPPS because the average case is now 
less expensive without a corresponding adjustment to the base rate. 
However, a high percentage of postacute care utilization by cases in a 
particular DRG does not, by itself, create a distortion, if the high 
postacute care utilization was also reflected in the calculation of the 
base rate.
    Therefore, to ensure that any proposed expansion of the postacute 
care transfer policy did not improperly distort the averaging 
principles of the IPPS, we evaluated the change in the mean lengths of 
stay for the DRGs we proposed to add to the policy to identify those in 
which the high postacute care utilization is resulting in shorter 
lengths of stay and lower costs. These shorter stays represent a shift 
in the site (and costs) of care relative to the base period, and, thus, 
a distortion in the averaging principle of the IPPS.
    Comment: Several commenters argued that the postacute care transfer 
policy is no longer necessary, as lengths of stay have stabilized and 
Medicare spending on postacute care has slowed. In particular, 
commenters pointed to the transition of postacute care provider types 
to prospective payment systems, which reduces the incentives for 
postacute care providers to agree to admit very sick patients from an 
acute care hospital. One commenter argued that the concept of duplicate 
payment for the same care is a misconception when both the acute and 
the postacute care providers are paid under a prospective payment 
system.
    Commenters claimed the policy puts an undue burden on them to be 
required to track patients after they are discharged to another 
setting. They claimed this creates an ``unworkable'' situation for them 
by making hospitals track patients and requiring frequent payment and 
claim readjustments. They noted the relatively small payment impact for 
all hospitals (only 0.2 percent) compared to the administrative burden 
hospitals will incur to administer the expansion of the policy.
    Response: We agree that postacute care providers are likely to be 
less willing to admit very sick patients under prospective payment 
systems than they were under cost reimbursement payment methodologies.

[[Page 45412]]

However, the incentives for acute care hospitals to reduce costs by 
transferring patients to a postacute care setting remain as strong as 
ever. Furthermore, duplicate payments would still exist if the acute 
care hospital is shifting costs for which it is paid under the IPPS to 
a postacute care provider; that is, receiving payment for the care 
under a prospective payment system (potentially at a rate even higher 
than its costs). Therefore, we believe there is still a need for the 
postacute care transfer policy, despite the adoption of prospective 
payment systems for most postacute care providers under Medicare. 
Similarly, it is appropriate to evaluate the need to expand the policy.
    Comment: Commenters suggested that, under our proposed criterion 
for selecting additional DRGs to cover under the policy, we should 
apply the same criteria to the existing postacute care transfer DRGs as 
to the new proposed DRGs. These commenters pointed out that 7 of the 10 
DRGs would not qualify under these criteria, and should no longer be 
included in the policy.
    One commenter argued that DRG 209 should be removed from the 
current list of DRGs subject to the postacute care transfer policy 
because the rate of decline in the average length of stay for this DRG 
had fallen dramatically since its inclusion in the postacute care 
transfer policy.
    In addition, one commenter applied the proposed criteria to more 
recent data and determined some of the DRGs proposed to be included in 
the policy no longer met all the criteria. Specifically, the commenter 
found that 11 of the 19 DRGs proposed to be included in the transfer 
policy fail to meet the criterion that at least 10 percent of the 
postacute care transfer cases occur prior to the geometric mean length 
of stay.
    Several commenters also noted that it appears our analysis 
identifying the 19 DRGs that were proposed to be added to the list 
included transfers from IPPS-exempt units. The commenters added that 
these units are not subject to the postacute care transfer policy and 
should not have been included in the analysis. The commenters pointed 
out that DRG 462 (Rehabilitation) only qualifies as a result of the 
inclusion of transfers from IPPS-exempt units in the analysis.
    Response: We do not believe it is necessary to evaluate whether the 
lengths of stay for the DRGs currently included in the policy are 
declining. One would expect that, to the extent patients were being 
transferred early in the episode of care to a postacute care setting in 
order to minimize costs to the acute care hospital (as opposed to a 
general shift in the clinical care for particular cases, which is more 
likely to result in a continued drop in the length of stay despite the 
inclusion of the DRG in the transfer policy), inclusion of a particular 
DRG in the postacute care transfer policy would be likely to stabilize 
the mean length of stay for the DRG. Therefore, we did not evaluate the 
current DRGs included in the policy to the 7-percent decline in the 
length of stay criterion.
    We also note that included in the commenter's list of 11 DRGs that 
it claim did not meet the new criteria, 6 of these DRGs are paired DRGs 
and were not selected based on meeting the criteria, but rather were 
included due to the paired nature of the DRG.
    We have analyzed the remaining 5 DRGs the commenter identified as 
having not met the criteria that at least 10 percent of all postacute 
care transfer cases occur before the geometric mean length of stay. 
However, it appears the commenter divided the total number of transfer 
cases by the total number of cases in the DRG, rather than dividing by 
the number of postacute care transfer cases. Using the data the 
commenter provided to us, we found that all but l DRG met the 10 
percent short-stay transfer definition we had proposed, with one DRG 
being a pair to another DRG that does meet the criterion.
    However, we do agree with the notion that, to be included in the 
postacute care transfer policy, DRGs currently included in the policy 
should continue to meet all of the other applicable criteria. In 
addition, concerns from the commenters encouraged us evaluate whether 
the variation from year to year might also needs to be accounted for in 
our new criteria. Therefore, in order to improve the year-to-year 
stability of all the DRGs included in the policy, in this final rule, 
we are adding the requirement that the criteria must be met during both 
of the 2 most recent years for which data are available. That is, to be 
included in the policy, a DRG must have, for both of the 2 most recent 
years for which data are available:
    [sbull] At least 14,000 cases postacute care transfer cases;
    [sbull] At least 10 percent of its postacute care transfers 
occurring before the geometric mean length of stay;
    [sbull] A geometric mean length of stay of at least 3 days; and
    [sbull] If a DRG is not already included in the policy, a decline 
in its geometric mean length of stay during the most recent 5 year 
period of at least 7 percent.
    Applying these criteria, we determined that DRG 263 no longer 
qualifies (there were only 13,588 postacute care transfer cases in this 
DRG during FY 2002). In addition, this is a paired DRG with DRG 264. 
Therefore, for FY 2004, we are no longer including DRGs 263 and 264 in 
the postacute care transfer policy.
    We also corrected the programming error noted by the commenters 
that allowed IPPS-exempt units to be included in the analysis. Removing 
these units from the analysis resulted in the exclusion of some DRGs 
that were proposed to be included in the policy, and the inclusion of 
some new DRGs. The table below displays all the DRGs that met the 
criteria during both of the 2 most recent years available (FYs 2001 and 
2002), as well as their paired-DRG if one of the DRGs meeting the 
criteria includes a CC/no-CC split.

----------------------------------------------------------------------------------------------------------------
                                                                               Percent of all
                                                                                    cases        Percent change
          DRG                        DRG title               DRG title care      transferred     in mean length
                                                             transfer cases     prior to mean   of stay FYs 1998-
                                                                               length of stay         2003
----------------------------------------------------------------------------------------------------------------
12.....................  Degenerative Nervous System                  28,103             31.42            -12.00
                          Disorders.
14.....................  Intracranial Hemorrhage and                 138,636             22.84             -5.88
                          Stroke with Infarction.
24.....................  Seizure and Headache Age 17 With CC.
25.....................  Seizure and Headache Age 17 Without CC.
88.....................  Chronic Obstructive Pulmonary                95,249             24.88            -10.87
                          Disease.
89.....................  Simple Pneumonia nad Pleurisy Age           175,526             31.83            -11.11
                          17 With CC.
90.....................  Simple Pneumonia and Pleurisy Age            47,987             12.51            -15.00
                          17 Without CC.
113....................  Amputation for Circulatory System            24,810             45.31              7.22
                          Disorders Except Upper Limb and
                          Toe.
121....................  Circulatory Disorders With AMI               55,629             22.42            -11.67
                          and Major Complication,
                          Discharged Alive.
122....................  Circulatory Disorders With AMI               71,838             10.53            -23.08
                          Without Major Complications
                          Discharged Alive.

[[Page 45413]]

 
127....................  Heart Failure & Shock............           196,581             24.18             -8.89
130....................  Peripheral Vascular Disorders                29,859             21.92            -11.76
                          With CC.
131....................  Peripheral Vascular Disorders                26,455             20.16            -19.51
                          Without CC.
209....................  Major Joint and Limb Reattachment           247,513             29.20            -15.09
                          Procedures of Lower Extremity.
210....................  Hip and Femur Procedures Except              89,612             46.77             -6.15
                          Major Joint Age 17
                          With CC.
211....................  Hip and Femur Procedures Except              20,584             21.89             -8.00
                          Major Joint Age 17
                          Without CC.
236....................  Fractures of Hip and Pelvis......            24,633             11.26             -6.98
239....................  Pathological Fractures and                   23,184             40.44             -7.55
                          Musculoskeletal and Connective
                          Tissue Malignancy.
277....................  Cellulitis Age 17 With            35,873             36.56             -7.84
                          CC.
278....................  Cellulitis Age 17                 31,857             13.24            -10.00
                          Without CC.
294....................  Diabetes Age 35.......            29,608             17.65            -15.00
296....................  Nutritional and Miscellaneous               106,923             29.26             -9.30
                          Metabolic Disorders Age 17 With CC.
297....................  Nutritional and Miscellaneous                48,116              7.25            -10.00
                          Metabolic Disorders Age 17 Without CC.
320....................  Kidney and Urinary Tract                     80,717             27.38             -8.51
                          Infections Age 17
                          With CC.
321....................  Kidney and Urinary Tract                     30,934             18.34            -13.89
                          Infections Age 17
                          Without CC.
395....................  Red Blood Cell Disorders Age 17.
429....................  Organic Disturbances and Mental              14,731             46.30            -12.96
                          Retardation.
468....................  Extensive O.R. Procedure                     25,114             41.26              7.07
                          Unrelated to Principal Diagnosis.
483....................  Tracheotomy With Mechanical                  20,034             49.56              2.37
                          Ventilation 96 + Hours or
                          Principal Diagnosis Except Face,
                          Mouth, and Neck Diagnoses.
----------------------------------------------------------------------------------------------------------------

    Transfers to postacute care from the DRGs listed in the above table 
will be included under this policy, effective for discharges occurring 
on or after October 1, 2003. As a result of our analysis in which we 
applied the new qualifying criteria, we removed DRG 263 and DRG 264 
from the current list of 10 DRGs, and we removed DRG 243 and DRG 462 
from the proposed list of additional 19 DRGs. However, we added four 
new DRGs (that were not included in our proposal) to the policy based 
on this analysis: DRG 88 (Chronic Obstructive Pulmonary Disease); DRG 
127 (Heart Failure and Shock); DRG 294 (Diabetes Age 35); 
and DRG 395 (Red Blood Cell Disorders, Age 17). We will 
review and update this list periodically to assess whether additional 
DRGs should be added or existing DRGs should be removed.
    Comment: One commenter contested the automatic inclusion of both 
DRGs in a paired-DRG combination. The commenter believed any incentive 
for hospitals not to include a code that would identify a complicating 
or comorbid condition would be very limited and would have negligible 
effect on hospital behavior. However, the commenter asserted that if 
CMS is going to include both DRGs in a paired-DRG combination, CMS must 
combine the data for the two DRGs when applying the selection criteria.
    Response: We include both DRGs from a paired-DRG combination 
because if we were to include only the ``with CC'' DRG from a ``with/
without CC'' DRG combination in the transfer policy, there would be an 
incentive for hospitals not to include any code that would identify a 
complicating or comorbid condition. We believe our approach of 
identifying either DRG from a paired-DRG combination individually for 
inclusion in the policy is appropriate.
    Comment: One commenter argued that DRG 468 should not be included 
in the policy because of the variation in the types of cases included 
in this DRG. The commenter pointed out that the cases in the DRG are, 
by definition, atypical, and the average lengths of stay for procedures 
included in this DRG vary widely. The commenter noted that ``every year 
CMS makes changes to the list of procedures that are assigned to this 
DRG. Therefore, a comparison of length of stay over time is not valid 
because the types of cases in the DRG change every year. The criterion 
that length of stay must have decreased by 7 percent compared to 1998 
cannot be applied to DRG 468.'' The commenter added that application of 
a per diem payment based on a mean length of stay to a DRG that 
contains such a wide variety of different types of cases will result in 
extreme inequities.
    One commenter argued for the exclusion of DRG 483 from the policy. 
The commenter argued that due to the large variation of lengths of stay 
for treatments in this DRG, the transfer policy has a very significant 
impact on payment for these cases that is unrelated to the use of 
postacute care.
    Response: We disagree that DRG 468 should be excluded from the 
policy because of the variation in the types of cases within this DRG. 
Over 40 percent of transfers to postacute care within this DRG occurred 
before the geometric mean length of stay. Although it is true the 
nature of this DRG makes it difficult to assess whether there is a 
trend to shift care out of the acute care setting into the postacute 
care setting or there is just a different mix of cases being assigned 
to this DRG, we believe it is equitable to adjust payments for short-
stay cases transferred to postacute care within this DRG. As noted 
above, application of this policy in the DRG recalibration process 
results in an overall increase in the payments for other cases in the 
DRG. Given the heterogeneous nature of this DRG, we believe this is 
appropriate.
    We have addressed similar concerns in the past with respect to the 
inclusion of DRG 483 in this policy.
    Comment: One comment noted that DRGs 121 and 122 should be included 
in the special payment provision due to the fact that ``these cases 
receive the most resource intensive services within the first day of 
the stay due to the acute nature of a myocardial infarction * * * 
[including care in] intensive care units, costly IV drug infusions, and 
multiple tests and monitoring.''
    Response: Based on the revised list of DRGs that meet the criteria 
as described above, we analyzed which of these DRGs qualified for the 
special payment methodology. The only DRGs that had charges for short-
stay transfer cases on the first day of stay that were greater than 50 
percent of the average charges of all cases across the DRG were DRGs 
209 and 211 (71 percent and 57 percent, respectively). Because DRG 211 
is paired with DRG 210, we included DRG 210 in the payment policy as 
well (our analysis showed that short-stay transfer cases had 40 percent 
of costs on the first

[[Page 45414]]

day of the stay compared to costs for all cases across the DRG). 
However, DRGs 121 and 122 did not meet the 50 percent threshold.
    Comment: Commenters again noted their objection to the expansion of 
the policy to all DRGs, even though we did not propose to expand the 
policy to all DRGs at this time. They refer to the language in section 
1886(d)(J) of the Act that states that only those DRGs that have a 
``high volume of discharges'' and ``disproportionate use of post 
discharge services'' could be included in an expanded postacute care 
transfer policy. Since this language would not apply to many DRGs, it 
makes this possibility ``implausible.''
    Commenters also argue that, since we admit we need to do further 
analysis before expanding the policy to all DRGs, it is unclear why we 
do not need to conduct further analysis to make an incremental 
expansion.
    Response: As noted previously, we did not propose to expand this 
policy to all DRGs because, for some 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 the 29 DRGs included in 
the policy effective October 1, 2003, we have determined the data 
indicate there is substantial utilization of postacute care early in 
the stay, leading to decreasing lengths of stay.
    Comment: Other commenters noted that, if we were focusing our 
efforts on analyzing lengths of stay in this manner, we should redirect 
our focus instead on a more thorough analysis of length of stay in 
particular regions to determine if changes are being adequately 
reflected in the yearly updates.
    Response: We recognize that lengths of stay have tended to vary by 
region, and that regions with shorter lengths of stay tend to also have 
lower average costs due to the fewer number of days that patient spend 
in the hospitals. One of the reasons for the variation is the greater 
reliance on postacute care earlier in the stay in those areas with 
lower average lengths of stay.
    We do not believe it would be appropriate to base the transfer 
payment methodology on regional average lengths of stay. The national 
standardized amounts, which apply across all regions, reflect costs and 
lengths of stay across all regions. To the extent hospitals in one area 
of the country are transferring patients early in the course of their 
treatment while hospitals in another part of the country are providing 
the entire treatment in the acute care hospital, adjusting payments for 
those hospitals transferring patients early in the stay and reflecting 
this in the process of recalibration maintains full DRG payments for 
hospitals in areas of the country providing the full course of 
treatment in the acute care hospital.

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 Pub. L. 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 in the May 19, 2003 proposed rule included 
all urban hospitals nationwide, and the proposed regional values for FY 
2004 were the 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 were based on 
discharges occurring during FY 2002 (October 1, 2001 through September 
30, 2002) and included bills posted to CMS' records through December 
2002.
    In the May 19, 2003 proposed rule, we proposed 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. (See the table set forth in the May 19, 
2003 proposed rule at 68 FR 27201.)

[[Page 45415]]

    Based on the latest data available (FY 2002 bills received through 
March 2003), in addition to meeting other criteria, hospitals with 
fewer than 275 beds, if they are to qualify for initial rural referral 
center status for cost reporting periods beginning on or after October 
1, 2003, must have a case-mix index value for FY 2003 that is at 
least--
    [sbull] 1.3373; 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 final median case-mix index values 
by region are set forth in the following table:

------------------------------------------------------------------------
                                                               Case-Mix
                           Region                            index value
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)....................       1.2245
2. Middle Atlantic (PA, NJ, NY)............................       1.2262
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV).....       1.3146
4. East North Central (IL, IN, MI, OH, WI).................       1.2489
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).....................       1.2705
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)...............       1.3482
9. Pacific (AK, CA, HI, OR, WA)............................       1.2845
------------------------------------------------------------------------

    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. In the May 
19, 2003 proposed rule, we proposed 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, in the May 19, 2003 proposed rule, we proposed that, in 
addition to meeting other criteria, a hospital, if it is to qualify for 
initial rural referral center status for cost reporting periods 
beginning on or after October 1, 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. (See the table set 
forth in the May 19, 2003 proposed rule at 68 FR 27201.)
    Based on the latest discharge data available for FY 2002, the final 
median number of discharges for urban hospitals by census region area 
are as follows:

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

    We reiterate that if an osteopathic hospital is to qualify for 
rural referral center status for cost reporting periods beginning on or 
after October 1, 2003, the hospital must have at least 3,000 discharges 
for its cost reporting period that began during FY 2002.
    We did not receive any comments on the criteria for rural referral 
centers.

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 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)(1)(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 a subject of this final 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.
    As described in the May 19, 2003 proposed rule, we are combining in 
this final rule our discussion of 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) because the underlying concepts are 
similar, and we believe they should generally be interpreted in a 
consistent manner for both purposes. Specifically, we proposed to 
clarify that

[[Page 45416]]

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).
    The remainder of this discussion pertains to beds and patient days 
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 the 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) 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 final rule 
clarifies the underlying principles for our bed and patient days 
counting policies and amends 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.
    Comment: One commenter expressed concern about our policy to use 
the same definition of beds for IME and DSH. The commenter argued that 
Congress used different terminology to define the types of beds that 
should be used for these two payment adjustments. Section 
1886(d)(5)(B)(vi)(I) of the Act indicates the IME adjustment is to be 
based on ``the hospital's available beds (as defined by the 
Secretary).'' For purposes of the DSH adjustment, section 
1886(d)(5)(F)(v) of the Act simply refers to the number of ``beds'' in 
the hospital. The commenter believed that, because the Act does not 
narrow the bed count for DSH purposes to those that are available, it 
is unlawful and inappropriate for CMS to use the available bed 
definition for DSH purposes.
    Response: We believe both statutory references cited by the 
commenter provide the Secretary with administrative discretion to 
define beds, one explicitly and one implicitly. In light of this 
discretion, we strongly believe it is important to apply a consistent 
definition for purposes of both IME and DSH adjustments, particularly 
because many hospitals receive both types of adjustments. We note that 
we have used available beds for purposes of determining whether 
hospitals qualify for DSH payments Congress directed us to make this 
adjustment in 1988. Since that time, Congress has amended the DSH 
provisions in the Act on numerous occasions, and certainly could have 
made clear its intention that we not use available beds for DSH 
purposes if that was its intent. Therefore, we disagree with this 
comment.
2. Unoccupied Beds
    We are still reviewing the large number of comments on our proposal 
on unoccupied beds in the May 19, 2003 proposed rule. Due to the number 
and nature of the comments we received on our proposed policy, we are 
addressing the public comments in a separate document. We refer 
individuals who are interested in reviewing the background information 
and discussion of the proposed policy to the May 19, 2003 proposed rule 
(68 FR 37202 through 37204).
3. Nonacute Care Beds and Days
    As noted above, our policies for counting beds are generally 
consistent with the method of reporting patient days for the purpose of 
calculating 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

[[Page 45417]]

IPPS, we read the statutory references to beds and days 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 generally 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, in the May 19, 2003 proposed rule, we 
proposed to revise our regulations to be more specific. Therefore, we 
proposed 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, believe that a patient-by-patient, day-by-day 
review of whether the care received would be paid under the IPPS would 
be unduly burdensome. Therefore, we believe it is more practical to 
apply this principle (that is, that we should consider only the 
inpatient days to which the IPPS applies) by using a proxy measure that 
is based upon the location at which the services were furnished.
    In particular, we proposed 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 (that is, a unit that provides an IPPS level of 
care is on the same floor of the hospital as a subacute care unit that 
does not provide an IPPS level of care).
    Exceptions to this policy to use the level of care generally 
provided in a unit or ward as proxy for the level of care provided to a 
particular patient on a particular day are outpatient observation bed 
days 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 and days are discussed further below. 
Another exception is healthy newborn nursery days. The costs, days, and 
beds associated with 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. Newborn nursery costs, days, and beds 
are treated this way because the 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 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 proposed 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).
    The 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 also 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 may be of a type that would 
be payable under the IPPS if the care was provided in an IPPS unit.
    We proposed 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 care that would be payable under the IPPS cannot be 
counted. We also proposed 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 generally furnish a level of care that would generally be payable 
under the IPPS.
    We note the proposed revisions were clarifications of our 
regulations to

[[Page 45418]]

reflect our longstanding interpretation of the statutory intent, 
especially relating to the calculation of the Medicare DSH patient 
percentage.
    Comment: Several commenters objected to our proposal and indicated 
that we were attempting to codify the Secretary's litigation position 
in Alhambra and administratively overrule the Ninth Circuit's decision 
in that case. Commenters asserted that the flaw in the proposal is that 
it is inconsistent with the Act to base the Medicaid days calculation 
of the DSH patient percentage on whether or not Medicare pays for the 
services that are generally provided within a unit. Specifically, 
commenters believed the proposal would restrict the definition of 
patient days in a way that is not authorized by the Act.
    Response: We disagree that our proposed clarification is 
inconsistent with the statute. First, the clarification is merely a 
codification of the Secretary's longstanding policy. In addition, we 
believe that interpreting the statute as we have historically done is 
reasonable and permissible. Section 1886(d)(5)(F)(vi)(II) of the Act 
governs the portion of the disproportionate share percentage made up of 
the percentage of patient days used by patients eligible for medical 
assistance under a title XIX State plan. Specifically, section 
1886(d)(5)(F)(vi)(II) of the Act states that the numerator of such 
fraction equals the ``number of the hospital's patient days for such 
period which consist of patients who (for such days) were eligible for 
medical assistance under a State plan approved under title XIX, but who 
were not entitled to benefits under part A of this title.'' The statute 
does not define the term ``hospital's patient days.'' Thus, the statute 
is ambiguous, and the Secretary has the authority to reasonably 
interpret that term.
    We note that although the calculation performed under section 
1886(d)(5)(F)(vi)(II) of the Act includes a count of patient days used 
by Medicaid-eligible individuals, the calculation actually is used to 
determine how much additional payment the hospital should receive under 
Medicare for the higher Medicare costs associated with treating a 
disproportionate share of low-income individuals. This point is 
demonstrated in the rationale for establishing the DSH adjustment as 
described in the Committee Report accompanying Pub. L. 99-272: 
``Hospitals that serve a disproportionate share of low-income patients 
have higher Medicare costs per case'' (H. Rept. No. 99-242(I), 99th 
Cong., 2d Sess., (1985), p. 16).
    Furthermore, we view section 1886(d)(5)(F)(vi)(II) of the Act as 
purely a Medicare, inpatient hospital provision, given that there 
already exists a distinct formula for computing DSH payments under 
title XIX--the Medicaid title. Because the DSH formula in title XVIII 
of the Act is intended to provide an add-on payment to inpatient 
hospitals for additional amounts they incur in treating low-income, 
Medicare patients, we believe it is reasonable to count only those days 
spent in wards or units that would generally provide an acute level of 
care.
    We believe it is reasonable to interpret the phrase, ``hospital's 
patient days,'' to mean only the hospital's inpatient days at a level 
of care that would be covered under the IPPS as a means to determine an 
IPPS payment adjustment. Further, we believe that it is 
administratively inefficient and impracticable to calculate a 
hospital's inpatient days based on a determination, on a day-by-day 
basis, of whether a particular patient in a particular inpatient bed is 
receiving a level of care that would be covered under the IPPS. 
Therefore, we proposed to use, as a proxy, the level of care that is 
generally provided in particular units or wards, and to exclude patient 
days attributable to units or wards in which care delivered is not 
generally of a type that would be covered under the IPPS.
    We also do not believe that by placing our longstanding 
interpretation of our rules in regulations we are unlawfully overruling 
or nullifying the decision by the Ninth Circuit in Alhambra Hospital v. 
Thompson, 259 F.3d 1071 (9th Cir. 2001). The Ninth Circuit decision 
focused on an interpretation of CMS' previous regulation at Sec.  
412.106(a)(1)(ii)--not on an interpretation of the statute. (For 
example, when the court stated the ``Standard of Review'' it would use 
to decide the case, it referred only to ``[o]ur review of an agency's 
interpretation of its own regulations.'' Alhambra at 1074). Although we 
respectfully disagree with the Ninth Circuits interpretation of the 
existing regulations, we are nonetheless amending them, through notice 
and comment rulemaking to ensure that going forward the regulations 
clearly reflect our longstanding position. Therefore, we do not agree 
with the commenter's assertion that our proposed policy is an illegal 
attempt to administratively overrule the Ninth Circuit's decision in 
Alhambra. Therefore, going forward, we plan to apply the clarified 
regulation to hospitals in all U.S. jurisdictions, including hospitals 
in the Ninth Circuit.
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 unit or 
ward. 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 days that those beds are 
used for observation services should be excluded from the available bed 
day count (even if the patient is ultimately admitted as an acute 
inpatient).
    A swing-bed is a bed that is otherwise available for use to provide 
acute inpatient care and is also occasionally used to provide SNF-level 
care. The criteria for a hospital to meet the requirements to be 
granted an approval from CMS to provide posthospital extended care 
services 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.\7\
---------------------------------------------------------------------------

    \7\ Ibid.
---------------------------------------------------------------------------

    Observation beds and swing-beds are both special, frequently 
temporary, alternative uses of acute inpatient care

[[Page 45419]]

beds. That is, only the days an acute inpatient care unit or ward 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 as described above stem from the fact that 
these days are not payable under the IPPS.
    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 
available to hospitals with more than 100 beds. 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).
    Although the Court in Clark found that Congress had not explicitly 
``addressed the question of whether swing and observation beds should 
be included in the count of beds in determining whether a hospital 
qualifies for the DSH adjustment,'' Clark, 314 F.3d at 245, the Court 
found that observation and swing-bed days were included under the 
``plain meaning'' of the regulation text at 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 of the rule that promulgated the regulatory provision 
at Sec.  412.106(a)(1)(ii) clarified its meaning (53 FR 38480, 
September 30, 1988):
    ``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 
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 
in Amisub v. Shalala, is based on the principle of counting beds in 
generally the same manner as the patient days and costs are counted. 
Our policy to exclude observation and swing-bed days under the 
regulations at Sec.  412.105(b) and Sec.  412.106(a)(1) stems from this 
policy.
    In the May 19, 2003 proposed rule, although we reiterated our 
longstanding policy that observation beds and swing bed days generally 
are excluded, we proposed to amend our policy with respect to 
observation bed days of patients who ultimately are admitted. We are 
still in the process of reviewing the comments and defer action until a 
later rule with respect this issue--for example, patients in 
observation beds who are ultimately admitted to the hospital.
    Comment: Some commenters objected to the exclusion of observation 
bed days from the available bed days count on the grounds that it is a 
flawed premise that the size of a hospital's bed complement should be 
impacted by the payment policy classification of the services provided 
to the patient. That is, a bed should not be excluded from the 
available bed day count because it is used to provide services not 
payable under the IPPS on a particular day.
    Response: When the application of IPPS payment policy is dependent 
on a determination of a hospital's number of beds, it seems reasonable 
to base that determination on the portion of the hospital that 
generates the costs that relate to those IPPS payments. As stated 
above, our bed counting policies start with the premise that the 
treatment of beds should be consistent with the treatment of the 
patient days and the costs of those days on the Medicare cost report. 
Therefore, we continue to believe it is appropriate to exclude 
outpatient observation bed days, even when the beds used to provide 
that service is located in a routine inpatient care unit or ward.
5. Labor, Delivery, and Postpartum Beds and Days
    Prior to December 1991, Medicare's policy on counting days for 
maternity patients was to count an inpatient day 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 to reflect our current policy.
    Our current policy regarding the treatment of labor and delivery 
bed days is described in Section 2205.2 of the PRM, which 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 inpatient 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 inpatient 
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).

[[Page 45420]]

    Increasingly, hospitals are redesigning their maternity areas from 
separate labor and delivery rooms, and postpartum rooms, to single 
multipurpose labor, delivery, and postpartum (LDP) rooms. In order to 
appropriately track the days and costs associated with LDP rooms, it is 
necessary to apportion them between the labor and delivery cost center, 
which is an ancillary cost center and the routine adults and pediatrics 
cost center. This is done under our policy by determining the 
proportion of the patient's stay in the LDP room that the patient was 
receiving ancillary services (labor and delivery) as opposed to routine 
adult and pediatric services (postpartum).
    An example of this would be if 25 percent of the patient's time in 
the LDP room was for labor/delivery services and 75 percent for routine 
care, over the course of a 4-day stay in the LDP room. In that case, 75 
percent of the time the patient spent in the LDP room is applied to the 
routine inpatient bed days and costs (resulting in 3 routine adults and 
pediatrics bed days for this patient, 75 percent of 4 total days). For 
purposes of determining the hospital bed count, the time that 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, in this 
example, 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 in the LDP room(s) during a typical month, and apply 
that percentage through the rest of the year.
    Comment: Some commenters stated that the LDP days that patients 
spend in routine inpatient wards of hospitals prior to the day those 
patients give birth are in areas of the hospital where routine 
inpatient beds are located, and they are not excluded from the IPPS. 
Therefore, the commenters asserted that these days should be counted in 
the patient days and available bed days counts. Commenters also pointed 
out the LDP days are in licensed beds, and argued that these days 
should be counted in their entirety.
    Other commenters supported our proposal to allow calculation of an 
average percentage of time LDP patients spend in labor/delivery 
compared to postpartum to be used to apportion LDP days. Commenters 
commended CMS for recognizing the cumbersome recordkeeping and 
reporting that would otherwise be required.
    One commenter suggested that it is not necessary for our policy 
applicable to counting patient days for purposes of the DSH computation 
to comply with other Medicare cost reporting policies, such as the need 
to separately allocate the ancillary costs associated with LDP rooms. 
The commenter cited prior PRRB appeals in which CMS took this position.
    Response: As we previously stated above and in the proposed rule, 
initially, Medicare's policy did count an inpatient day for an admitted 
maternity patient even if the patient was in the labor/delivery room at 
the census-taking hour. However, based on adverse court decisions, the 
policy was revised to state that the patient must first occupy an 
inpatient routine bed before being counted as an inpatient. With the 
development of LDP rooms, we found it necessary to apply this policy 
consistently in those settings, in order to appropriately apportion the 
costs between labor and delivery ancillary services and routine 
inpatient care.
    Although we have not previously formally specified in guidance or 
regulations the methodology for applying this policy to LDP rooms, this 
is not a new policy. However, as suggested by the commenters, we 
believe this policy may not have been applied consistently. Therefore, 
we believe it is important to clarify the policy as part of our 
discussion of our policies pertaining to counting patient bed days.
    We continue to believe the LDP apportionment described above is an 
appropriate policy and does not, in fact, impose a significant 
additional burden because hospitals are already required to allocate 
cost on the cost report between ancillary and routine costs. In 
addition, this allocation is already required to be consistent with our 
treatment of costs, days, and beds and is consistent with our other 
patient bed day policies. Therefore, this policy will be applied to all 
currently open and future cost reports. However, it is not necessary to 
reopen previously settled cost reports to apply this policy.
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 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 apply to 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 
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

[[Page 45421]]

Medicaid beneficiaries, including inpatient benefits. Because of the 
differences between expansion populations in these limited benefit 
demonstrations and traditional Medicaid beneficiaries, in the May 19, 
2003 proposed rule, we proposed 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 (which was added to the law by 
section 9105 of COBRA and was effective for discharges occurring on or 
after May 1, 1986), 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 proposed 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 the 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.
    The proposed revision addressed 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.
    Comment: Some commenters questioned our authority to require a 
patient obtain to covered inpatient benefits under either a Medicaid 
State plan or a section 1115 demonstration, in order to be included in 
the numerator of the Medicaid ratio for the DSH computation. One 
commenter pointed out that there are many circumstances under which an 
individual may have income low enough to qualify for Medicaid but still 
not qualify due to other qualifying criteria, and requested that all 
patient days of such individuals be counted as Medicaid-eligible.
    Response: As stated above and in the proposed rule, we do not 
believe patients covered under limited-benefit section 1115 
demonstration projects that are so limited that they are not similar to 
the medical assistance available under a Medicaid State plan should not 
be included in the count of Medicaid-eligible patients.
    Under a traditional State Medicaid program, States are required to 
offer inpatient benefits to all eligible beneficiaries (see section 
1902(a)(10)(A) of the Act). However, under the 1115 demonstration 
authority, the Secretary has permitted coverage for a limited set of 
services, such as pharmaceuticals or family planning services, and thus 
inpatient hospital services may be excluded for expansion populations 
under some of the section 1115 demonstration programs.
    Our intention in allowing hospitals to include patient days related 
to section 1115 expansion waiver populations was to include patient 
days of demonstration populations who receive benefits under the 
demonstration project that are similar to traditional Medicaid 
beneficiaries, including inpatient benefits.
    Comment: One commenter requested that the effective date of the 
proposed change be delayed until January 1, 2004, to allow fiscal 
intermediaries to contact States and identify specific coverage for 
their various section 1115 waiver populations.
    Response: Because the DSH adjustment is reconciled when hospitals' 
cost reports are settled, we do not believe it is necessary to delay 
the implementation of this policy until January 1, 2004. Furthermore, 
although we believe it would have been reasonable for hospitals or 
fiscal intermediaries to have applied this interpretation of our policy 
regarding the inclusion of section 1115 waiver days prior to this 
clarification, we recognize that there may be situations in which this 
policy was not already applied. Therefore, we are making this change 
and the regulation at Sec.  412.106(b)(4)(i) will be effective for 
discharges occurring on or after October 1, 2003.
7. Dual-Eligible Patient Days
    We are still reviewing the large number of comments received on the 
proposed provision relating to dual-eligible patient days in the May 
19, 2003. Due to the number and nature of the comments we received on 
our proposed policies, we are addressing the public comments in a 
separate document. We refer individuals who are interested in reviewing 
the background information and discussions regarding this policy to the 
May 19, 2003 proposed rule (68 FR 27207-27208).

[[Page 45422]]

8. Medicare+Choice (M+C) Days
    We are still reviewing the large number of comments we received on 
the proposed provision relating to the counting of Medicare+Choice days 
for purposes of the IME and DSH adjustments. Due to the number and 
nature of the comments we received on our proposed policies, we are 
addressing the public comments in a separate document. We refer 
individuals interested in reviewing the background information and the 
discussion regarding these policies to the May 19, 2003 proposed rule 
(68 FR 27208).

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 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.)
    We now more fully understand this particular hospital's situation 
and we have the administrative authority to establish a policy allowing 
corrections for this particular set of circumstances, in the proposed 
rule, we solicited 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.
    Comment: One commenter supported the proposed establishment of the 
exception. However, the commenter recommended that CMS consider 
allowing all hospitals to make corrections to the data that is used in 
reclassification determinations.
    Response: We continue to believe that requiring wage data 
corrections by specified deadlines is essential to ensuring that wage 
data is finalized in an efficient manner. We also continue to believe 
that final wage data published in the annual IPPS final rules should be 
as complete and accurate as possible. However, we believe that, in the 
limited circumstances raised in our proposed rule where the hospital 
could not have foreseen that its wage data would later be used in a 3-
year average, and the hospital was subject to the rural floor, it is 
feasible to permit a limited exception. Therefore, in this final rule, 
we are amending Sec.  412.230(e)(2)(ii)(A) to allow, for the limited 
purpose of qualifying for geographic reclassification, hospitals 
demonstrating that they meet the limited circumstances described in the 
amended regulation be considered for reclassification after taking into 
account revisions subsequent to its use to construct the wage index for 
IPPS payment purposes. We are not adopting a broader exception, because 
we continue to believe it is important to ensure that final wage data 
published in the annual IPPS final rule are complete and accurate. 
Creating a broad exception to allow for corrections of prior years' 
data would affect the accuracy and stability in the wage indices from 
year to year. Therefore, we will continue to require hospitals--other 
than hospitals meeting the limited exception described in Sec.  
412.230(e)(2)(ii)(A)--to ensure that their wage data are correct by 
applicable deadlines and will not allow for wage data corrections after 
such deadlines.

[[Page 45423]]

    Comment: Several hospitals who were interested in reclassifying, as 
a group, for purposes of the wage index, commented that their efforts 
to reclassify as an urban group have been unsuccessful primarily 
because they fail to meet the established requirement set forth in 
Sec.  412.234(c)(2) that the requesting hospitals must demonstrate that 
their costs exceed their current payments by 75 percent of the 
additional payments they would receive through reclassification. The 
commenters submitted several recommendations for our consideration to 
clarify or improve our policies and regulations. They recommended that 
we consider:
    [sbull] Allowing hospital groups to seek geographic 
reclassification for purposes of the wage index or standardized amount;
    [sbull] Allowing hospital groups seeking geographic 
reclassification to areas where the reclassification would not result 
in a different standardized amount to seek reclassification for 
purposes of the wage index without having to satisfy the criteria 
applicable to hospitals seeking reclassification for purposes of the 
standardized amount;
    [sbull] Allowing hospitals in NECMAs to seek reclassification to 
another MSA under the alternative criteria at Sec.  412.236(c);
    [sbull] Lowering the cost-to-payment threshold used to evaluate 
group reclassification applications; or
    [sbull] In order to evaluate the interrelationship between the area 
where the hospitals are located and the target area in which they are 
seeking to reclassify, replacing the cost comparison criteria used to 
evaluate reclassification eligibility for purposes of the standardized 
amount with a better indicator of the connection such as, census 
commuting patterns.
    Response: We appreciate the comments and recommendations presented 
by the hospitals and the importance of this issue. We note that, in 
developing the proposed rule, we did consider including a proposal to 
allow urban hospitals to reclassify as a group either for wage index or 
the standardized amount, or both. However, we did not go forward with 
the proposal because, upon further review, the criterion that hospitals 
demonstrate that their costs are in excess of their payments seemed 
appropriate. We will consider the commenters' recommendations in the 
future.
    Comment: One commenter recommended that CMS consider lowering the 
applicable qualifying thresholds at Sec.  412.230(c)(1)(iii) and (iv) 
for urban hospitals seeking reclassification for purposes of the wage 
index. The commenter specifically suggested that the threshold be 
lowered from 108 percent of the average hourly wage of hospitals in the 
area in which the hospital is located, and 84 percent of the average 
hourly wage of hospitals in the area to which the hospital seeks 
reclassification, to 106 percent and 82 percent, respectively, for 
urban hospitals. The commenter further recommended that, if the lower 
thresholds cannot be reduced for all urban hospitals, CMS consider 
implementing the lower thresholds for urban hospitals in areas where 
they are paid as if they are rural.
    Response: As pointed out by the commenter, this issue was 
discussed, in detail, in the August 1, 2000 Federal Register (65 FR 
47089 through 47090). While we will consider the recommendations for 
possible inclusion in a future proposed rule, we did not propose any 
changes or clarifications to the existing policy. Therefore, we are not 
adopting this comment.

E. Costs of Approved Nursing and Allied Health Education Activities 
(Sec.  413.85)

1. Background
    Medicare has historically paid providers for the program's 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 the May 19, 2003 proposed rule, we proposed 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 Pub. L. 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 Pub. L. 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

[[Page 45424]]

reasonable cost. Section 4004(b)(2) of Pub. L. 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 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.
    Prior to the issuance of the May 19, 2003 proposed rule, 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. In the proposed rule (68 
FR 27210), we stated that our use of the term ``certification'' does 
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 stated that we believe certification means 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, in the May 19, 
2003 proposed rule, we stated that 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 stated that we understood 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 the distinction 
between continuing education programs and approved education programs 
in the context of reasonable cost pass-through payments for nursing and 
allied health education activities, in the May 19, 2003 proposed rule, 
we proposed 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 proposed 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.''
    Comment: A large number of commenters responded to our proposal to 
clarify that, effective October 1, 2003, activities that do not lead to 
certification required to practice or begin employment in a nursing or 
allied health specialty would be treated as educational activities 
(continuing education) that are part of normal operating costs, and not 
as approved programs that are eligible for reasonable cost 
reimbursement. Many commenters strongly disagreed with the section of 
the proposed rule that included clinical pastoral education (CPE) as 
continuing education and stated that CMS must have been badly 
misinformed when writing the proposed rule. The commenters argued that 
CPE is a rigorous and structured education program accredited by the 
Association for Clinical Pastoral Education, Inc. (ACPE). The 
commenters stressed that, in varying amounts, CPE is a requirement for 
graduation for the master of divinity degree and for professional 
certification by the Association of Professional Chaplains (APC) as a 
health care chaplain, or as a CPE supervisor. Many commenters also 
noted prior Provider Reimbursement Review Board (PRRB) rulings that 
recognized chaplaincy as an allied health discipline, and asserted that 
hospitals that receive Medicare reasonable cost pass-through payment 
for CPE do so for the purpose of their professional CPE programs, not 
as continuing education for individuals already qualified to practice 
in hospital chaplaincy. Many commenters mentioned that the Joint 
Commission on Accreditation of Healthcare Organizations also recognizes 
chaplains as allied health professionals and considers them ``primary 
care providers.'' Similarly, commenters referred to various studies 
that have

[[Page 45425]]

shown the positive spiritual and therapeutic benefits of pastoral care. 
The commenters warned that removal of funding for CPE would represent a 
huge step backward for American health care. The commenters urged CMS 
to ensure continuing pass-through payments for CPE.
    Response: In the May 19, 2003 proposed rule (68 FR 27210), we 
stated that we received an inquiry requesting further clarification of 
what is meant by continuing education. We proceeded to explain what 
constitutes ``continuing education'' for the purpose of determining 
whether a nursing or allied health education activity would or would 
not qualify for Medicare reasonable cost pass-through payments. We 
acknowledge that the definition of ``continuing education'' for 
Medicare payment purposes may differ from the academic view of what, in 
general, constitutes such activities. In the proposed rule, we stated 
that we believed that provider-operated programs that do not lead to 
any specific certification or the ability to perform in the specialty 
would be classified as ``continuing education.''
    Our intent is to ensure that Medicare pass-through payments are 
only provided for programs that enable an individual to be employed in 
a capacity that he or she could not have been employed without having 
first completed a particular education program. We believe that, for 
Medicare purposes, training that enhances an individual's competencies, 
but does not permit that individual to be employed in a new capacity in 
which he or she could not have been employed without completing the 
additional training, would not qualify for Medicare reasonable cost 
pass-through payment. Medicare provides payments for such educational 
activities, but only under the methodology applicable to payment of 
normal operating costs. Our intent was simply to provide clarification 
for the purpose of distinguishing between those educational programs 
that qualify for reasonable cost pass-through payment (that is, 
programs that enable an individual to begin employment in a specialty 
as a whole) and those programs that should be paid as normal operating 
costs (that is, activities that are intended to enhance the current 
skill set of an individual's profession or advance an individual's 
professional career).
    Since publication of the proposed rule, we have learned from 
information provided by the ACPE and the APC that there are several 
levels of CPE. Specifically, the ACPE accredits three different levels 
of CPE. The first level of CPE is generally geared to interns and 
beginning residents. The second level of CPE is generally geared to 
residents doing specialization and preparation for chaplaincy 
certification. The third level is supervisory training, which is geared 
toward preparation for certification by the ACPE as a CPE supervisor.
    We understand that, as a part of the requirements for a master of 
divinity degree, many theological schools and seminaries require or 
strongly recommend completion of an internship, or 1 unit of CPE for 
graduation. A unit of CPE is 400+ hours of supervised CPE in a health 
care or institutional setting. Students taking either 1 or 2 units of 
CPE are generally referred to as interns. In addition, many faith 
groups require, at their national or regional levels, that individuals 
complete at least 1 unit of CPE in order for them to be ordained into 
professional ministry. Theological schools that offer doctoral degrees 
(for example, a doctor of philosophy, a doctor of ministry, or a doctor 
of theology) with specialties in pastoral counseling and related fields 
also generally require some amount of CPE as a part of those degree 
programs. Upon completion of a CPE internship, the health care 
institution typically reports to the theological school in which the 
student is enrolled that the student has successfully completed the 
internship, and the theological school subsequently awards credit for 
the training. Based upon information received from the commenters, we 
understand that completion of only an internship, or 400+ hours of CPE, 
would not qualify an individual for employment as a chaplain in a 
hospital setting.
    In contrast to CPE internships, CPE residents generally participate 
in a 1-year, or occasionally a 2-year, full-time CPE program. A 1-year 
residency typically consists of 4 units of postgraduate CPE (that is, 
1,600+ hours of supervised CPE), in a health care or institutional 
setting. Generally, individuals who undertake 1,600 hours of CPE do so 
in order to become a board-certified chaplain. The ACPE has established 
4 units, or 1,600 hours of supervised CPE, as the national minimum 
amount of CPE that is required to become a board-certified chaplain. 
However, some certifying boards or particular programs may require some 
additional hours of CPE for board certification. We note that, in 
instances where academic credit is granted for completion of 1 unit, or 
400 hours, of CPE prior to receipt of a degree, an individual seeking 
to become a board-certified chaplain generally must complete an 
additional 1,600 hours of CPE training.
    The board certification of chaplains is carried out by nationally 
recognized organizations that are part of the Commission on Ministry in 
Specialized Settings (COMISS), an umbrella network for pastoral care 
organizations that share the same standards of educational preparation 
and clinical training. These organizations include the Association of 
Professional Chaplains (APC), the National Association of Catholic 
Chaplains (NACC), the National Association of Jewish Chaplains (NAJC), 
and the Canadian Association for Pastoral Practice and Education 
(CAPPE). The ACPE accredits CPE training for all of these certifying 
organizations.
    Based on information received from the commenters, we understand 
that most health care organizations that are accredited by the Joint 
Commission on Accreditation of Healthcare Organizations (JCAHO) 
advertise for and recruit only board-certified chaplains, which means 
that qualified applicants for employment as hospital chaplains will 
usually have completed at least 1,600 hours of CPE.
    Individuals who seek to develop a health care chaplaincy 
specialization (for example, hospice, pediatrics, cardiology, 
rehabilitation, neurology) may undertake a second year of CPE 
residency. A second year of residency consists of an additional 4 units 
of CPE (or 1,600+ hours of supervised CPE). However, there is currently 
no established board certification process for residents completing a 
second year of CPE residency training.
    To be eligible to apply for supervisory CPE training, an individual 
must have completed at least 4 units (1 year) of CPE training. Upon 
completion of supervisory training, an individual becomes certified by 
the ACPE as a CPE supervisor and is qualified to develop and conduct 
CPE training for all ACPE-accredited programs.
    Based on information submitted by the commenters on the different 
levels of CPE training, two important points relative to Medicare 
reimbursement have become clear to us. First, in instances where 
internship training is completed as a prerequisite for a degree granted 
by an educational institution other than a hospital, such training is 
not provider-operated, and, therefore, does not qualify for Medicare 
reasonable cost pass-through payment under Sec.  413.85. Under Sec.  
413.85(f), a program is considered to be provider-operated only if the 
hospital directly incurs the training costs, directly controls the 
curriculum and the administration of

[[Page 45426]]

the program, employs the teaching staff, and provides and controls both 
clinical training and classroom instruction (where applicable). While a 
hospital may serve as the site for a CPE internship, such training is 
provided to satisfy curriculum requirements of a theological school, 
which grants the master degree upon completion of the internship. While 
the hospital might incur training costs and employ the supervising 
faculty, it would not ordinarily meet the other ``provider-operated'' 
criteria concerning controlling the curriculum and providing both the 
didactic and clinical training necessary for the degree. Thus, a CPE 
internship, or any other CPE training that is a requirement for a 
degree, whether it is undergraduate, graduate, or doctoral, is not 
eligible for Medicare reasonable cost pass-through payment.
    Secondly, a CPE residency consisting of 1,600 hours of training 
could be a provider-operated program and could also lead to 
certification and the ability to be employed in a new or different 
capacity. Specifically, a CPE residency consisting of approximately 
1,600 hours of training leads to board certification in chaplaincy, 
and, as we understand it, most JCAHO-accredited hospitals generally 
only employ board-certified chaplains. In consideration of these facts, 
the costs of CPE training programs that meet the requirements under 
Sec.  413.85, including accreditation by a nationally recognized 
accrediting body, direct operation by a provider, and lead to 
certification that is generally a requirement for employment in a 
particular specialty, may be eligible for Medicare reasonable cost 
pass-through payment.
    In the May 19, 2003 proposed rule (68 FR 27210), we proposed to 
revise the regulations at Sec.  413.85(h)(3) to state that activities 
treated as normal operating costs include ``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.'' We proposed 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.'' However, it 
is apparent from the comments we received that our proposed definition 
of ``certification'' was not clear. Some commenters believed we 
intended, through the proposed definition, to allow pass-through 
payments for the costs of a program that would only enhance an 
individual's set of skills. However, that was not our intent. We 
believe it would have been more appropriate to use the word ``and'' 
instead of the word ``or'', to further emphasize that pass-through 
payment would only apply to activities that enable an individual to 
practice and begin employment in a specialty, but would not apply to 
activities that serve to add to or to enhance an individual's current 
skill set.
    In addition, based on the comments received, we understand that 
there may be several distinct levels of training in a given health 
profession, and each level of training may be a requirement in order 
for an individual to work in a new capacity or ``specialty'' in that 
profession, but not a requirement to practice or begin employment in 
the specialty ``as a whole.'' Since a second level of training is not 
required to begin practicing in a profession, under the proposed 
definition, we would not have been able to allow for pass-through 
payments for a second (or potentially a third) level of training. 
Therefore, we understand that inclusion of the words ``as a whole'' in 
the proposed definition of ``certification'' was misleading. 
Consequently, where a subsequent level of training is a requirement to 
practice in a new specialty in a given profession, pass-through payment 
may be made for the subsequent level of training.
    Finally, we have concluded that it is not necessary to include a 
specific definition of ``certification'' at Sec.  413.85. In this final 
rule, we are deleting the proposed definition of ``certification'' from 
Sec.  413.85(c), and amending Sec.  413.85(h)(3) by removing the words 
``certification required'' and inserting the words ``the ability.'' We 
are also changing the word ``or'' to ``and''. Specifically, we are 
amending the proposed regulations at Sec.  413.85(h)(3) to state that 
activities treated as normal operating costs include ``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 the ability to practice and begin employment in a nursing 
or allied health specialty.''
    Our view of a ``specialty'' in the nursing and allied health 
education context is based on what the industry views as the standard 
of practice in a specific area within a profession. The training 
required to allow a person to serve in the ``specialty'' is tailored to 
the skill level and context that an individual is expected to use in 
that ``specialty.''
    Consistent with what we stated in the proposed rule, Medicare 
reasonable cost pass-through payments are only provided for programs 
that, according to industry norms, qualify an individual to be employed 
in a specialty in which the individual could not have been employed 
before completing a particular education program. Given the confusion 
expressed by commenters, we recognize the need to specify how we will 
determine whether completion of a particular education program enables 
an individual to be employed in a specialty. We will use ``industry 
norms'' as the standard to determine whether participation in a 
specialty enables an individual to be employed in a capacity that he or 
she could not have been employed without having first completed a 
particular education program. We are defining ``industry norm'' to mean 
that more than 50 percent of hospitals in a random, statistically valid 
sample require the completion of a particular training program before 
an individual may be employed in a specialty. (We understand that, in 
some instances, due to the unique staffing circumstances faced by many 
smaller hospitals, inclusion of small hospitals in the sample would 
introduce factors that are not typically representative of the industry 
as a whole and would skew the results inappropriately. In such a case, 
if appropriate, we would consider excluding hospitals with less than 
100 beds, which would still retain over 75 percent of all hospitals in 
the universe).
    Based on comments received, we believe that it is the ``industry 
norm'' to require a CPE residency and board certification for 
employment as a hospital chaplain. Since it is currently the ``industry 
norm'' for hospitals to employ only board-certified chaplains, and 
since completion of approximately 1,600 hours of CPE training is a 
requirement to practice and begin employment in hospital chaplaincy, we 
view hospital chaplaincy as a ``specialty'' of pastoral counseling. 
Consequently, a hospital that operates a CPE residency may be eligible 
for reasonable cost pass-through payment.
    Specifically, assuming all requirements under Sec.  413.85 are met, 
Medicare reasonable cost pass-through payments may only be made to 
hospitals for CPE hours that are not prerequisites for any academic 
degree, and are provided to students in order to obtain board 
certification in hospital chaplaincy. A hospital may not receive 
reasonable cost payment for any costs

[[Page 45427]]

incurred in connection with providing CPE that is undertaken to meet 
the requirements of an academic degree. In addition, since generally a 
minimum of approximately 1,600 hours of CPE is required to become a 
board-certified chaplain, any costs incurred for an individual 
participating in CPE training that exceeds the minimum number of hours 
required to obtain board certification would not be eligible to be paid 
on a reasonable cost basis.
    However, we note that we do not completely defer to the information 
provided by industry representatives in order to determine the 
``industry norm.'' Rather, if at any time we obtain information that 
calls our view of industry norms into question, we may make our own 
determination based on a random sample of hospitals. Therefore, 
assuming all other requirements under Sec.  413.85 are met, a hospital 
may receive reasonable cost pass-through payment for the hours of CPE 
for which academic credit is not granted (since those CPE hours are not 
generally provider-operated), and for the hours of CPE that may be used 
to satisfy training requirements for board certification. We will 
continue to allow reasonable cost payment for CPE that leads to board 
certification as long as we do not have evidence indicating that, based 
on a statistically valid, random sample, the ``industry norm'' is not 
to require board certification for chaplains that are employed by 
hospitals.
    We also recognize that industry norms are susceptible to change 
over time. Therefore, although it may not currently be the ``industry 
norm'' to require completion of a particular nursing or allied health 
education program in order to practice and begin employment in a 
particular specialty, it may become the ``industry norm'' in the 
future. If we find that it has become the ``industry norm,'' we may 
allow the hospitals operating those programs (and meeting the 
requirements at Sec.  413.85) to be paid for the costs of those 
programs on a reasonable cost basis.
    In relation to the commenters' recommendation that reasonable cost 
reimbursement should be provided for CPE supervisory training, we 
understand that, essentially, the purpose of the supervisory training 
is to prepare a chaplain to develop CPE programs and to teach interns 
and residents. We believe that CPE supervisors are practicing in the 
teaching profession, not within a nursing or allied health discipline. 
Furthermore, we do not believe that Congress intended to provide for 
reasonable cost pass-through payments for programs that are intended to 
produce instructors or teachers. While we recognize that CPE 
supervisors are necessary to train and prepare individuals for hospital 
chaplaincy, we believe that it is appropriate for the costs of 
supervisory programs in general to be treated as normal operating costs 
and paid accordingly.
    Comment: One commenter stated that our proposed definition of 
provider-operated programs intended to exclude programs ``that do not 
lead to certification required to practice or begin employment in a 
nursing or allied health specialty * * *'' is not appropriate in light 
of the growing number of skills that require intensive clinical 
experiences. Another commenter stated that this proposal will seriously 
hinder reversal of the nursing shortage across the nation and, as a 
result, will have an adverse impact on the quality and safety of care 
provided in hospitals. The commenters used the example of nurse 
residencies, which a number of hospitals across the country are hosting 
for registered nurses. The commenters explained that these residencies, 
which are postgraduate and typically last 1 year, are designed to equip 
the newly licensed nurse with the skills to care for patients who 
require the most complex and sophisticated diagnostic and therapeutic 
services, and to prepare the nurses for leadership roles earlier in 
their careers and give them the tools to improve the quality of care 
and reduce medical errors. The commenters claimed that the Federal 
Government has thus far provided minimal funding to help ameliorate the 
nursing shortage and, therefore, the proposed rule is particularly 
distressing. They urged CMS to include criteria in the final rule for 
pass-through payment of nurse residencies.
    Response: First, we do not believe that nurse residencies, which 
are intended to help integrate newly licensed nurses into complex acute 
care environments by enhancing their competencies and skills, are 
programs that qualify these nurses to be employed in a new specialty. 
Accordingly, it is more appropriate to treat such activities as normal 
operating costs. As we stated above, Medicare reasonable cost pass-
through payment will only be provided for programs that, according to 
industry norms, qualify an individual to be employed in a specialty in 
which the individual could not have been employed prior to completing a 
particular education program. Second, we note that nurse residencies do 
not qualify for reasonable cost payment because they also do not meet 
the requirement for accreditation by a national approving body under 
Sec.  413.85(d)(1)(i)(A). Therefore, while we are sympathetic to the 
commenters' concerns, we do not believe that it is appropriate at the 
present time to allow for pass-through payment to be made under the 
Medicare program for nurse residencies.
    Comment: Some commenters stated that CMS was ``entirely correct'' 
in identifying CPE as continuing education and concurred with our 
proposal to discontinue pass-through payments for CPE. One commenter 
contended that ACPE-accredited training is not primarily used to 
prepare students to be health care chaplains. Rather, CPE is primarily 
ministry training, and there are various ways that one can choose to 
use CPE. One commenter added that very few individuals who train in 
CPE, including those individuals in 1-year residencies, become employed 
as health care chaplains. The commenter further stated that CPE is 
``properly a funding responsibility of the church rather than the 
government''. The commenters argued that Medicare should not be 
supporting continuing education for religious care providers whose 
primary base and certifying group is their denomination or faith group.
    Another commenter presented a similar argument concerning pharmacy 
residencies and questioned why Medicare (that is, taxpayers) should 
subsidize these residency programs. The commenter claimed that 
hospitals ``use government monies in order to hire these `residents,' 
utilize them in `clinical' positions under the guise of postgraduate 
training, thereby bypassing having to use FTEs in the hospital pharmacy 
budget.'' The commentator believed that if hospitals and pharmacists 
were truly concerned with improving patient care, hospital pharmacy 
departments would train their own staff pharmacists to perform the 
clinical aspects themselves, rather than having taxpayers provide the 
funding.
    Response: We are sympathetic to the commenters' concerns. However, 
we understand that many CPE programs do occur in hospitals, and that, 
while there may be various kinds of CPE training, generally, completion 
of approximately 1,600 hours of CPE training is required for board 
certification and employment by a hospital. Therefore, we believe that 
CPE residencies that lead to board certification generally would not be 
considered continuing education.
    In response to the commenters' concerns about the taxpayers, 
through the Medicare program, providing support for CPE and pharmacy 
residencies, we note Medicare payment for these and other similar 
programs are made in accordance with the Medicare

[[Page 45428]]

statute. Under section 1861(v) of the Act, Congress provides for 
Medicare payments to be made in support of certain medical education 
activities. Currently, if a program meets the regulatory requirements 
under Sec.  413.85, which were specified earlier in this preamble, a 
hospital operating that program may qualify for Medicare reasonable 
cost pass-through payment.
    Comment: One commenter explained that a dietetic internship is a 
post-baccalaureate program that is one of the requirements for 
practicing as a registered dietitian. The commenter pointed out that 
the Commission on Accreditation of Dietetic Education (CADE) of the 
American Dietetic Association accredits these internships and the 
interns contribute directly to patient care in a hospital. The 
commenter urged us to continue to pay health care organizations for 
dietetic internships.
    Response: We appreciate the comment and note that, as long as a 
dietetic internship meets the requirements under Sec.  413.85 (and we 
do not find that it is not the industry norm to require this training 
to be employed as a registered dietitian), the hospital operating the 
internship may qualify for Medicare reasonable cost pass-through 
payment.
    Comment: A large number of commenters responded to our proposal to 
clarify that, effective October 1, 2003, training that does not lead to 
certification required to practice or begin employment in a nursing or 
allied health specialty would be treated as educational activities 
(continuing education) that are part of normal operating costs, and not 
as approved programs that are eligible for reasonable cost pass-through 
payments. Many commenters strongly disagreed with our proposal that 
included pharmacy residencies in the type of training that is 
considered continuing education and claimed that the proposed rule 
reflected a fundamental misunderstanding of pharmacy education. The 
commenters stated that educational seminars, workshops, and continuing 
education programs are generally performed outside the provider 
setting, and in most instances do not exceed 40 hours per year, whereas 
a pharmacy residency is a full-time commitment that lasts for 1 year. 
The commenters emphasized that the pharmacy residencies are structured, 
intensive programs that incorporate direct patient care experience 
where residents work as part of a clinical team and are required to 
complete a comprehensive project. The commenters contended that 
residency experience provides focused, invaluable training that yields 
proven positive clinical and financial outcomes. The commenters also 
noted that, while residencies are not a requirement for all hospital 
pharmacy positions, they are a requirement for most clinical specialist 
positions. The commenters maintained that residencies would be a more 
universal hiring requirement were it not for the current shortage of 
pharmacists and residency programs. The commenters stressed the 
benefits of clinical pharmacist involvement in patient care and 
cautioned that CMS' attempt at short-term cost savings will result in 
significant long-term cost of care increases. The commenters urged CMS 
to ensure continuing reasonable cost pass-through payments for pharmacy 
residencies.
    Response: As we stated above in response to the comments received 
from the clinical pastoral counseling community, in the May 19, 2003 
proposed rule (68 FR 27210), we explained what constitutes ``continuing 
education'' for the purpose of determining whether a nursing or allied 
health education activity would or would not qualify for Medicare 
reasonable cost pass-through payments. We acknowledge that the 
definition of ``continuing education'' for Medicare payment purposes 
may differ from the academic view of what, in general, constitutes such 
activities. As we stated earlier, we believe that provider-operated 
programs that do not lead to any specific certification, or the ability 
to perform in the specialty, would be classified as ``continuing 
education.''
    Our intent is to ensure that Medicare reasonable cost pass-through 
payments are only provided for programs that enable an individual to be 
employed in a capacity that he or she could not have been employed 
without having first completed a particular education program. We 
believe that, for Medicare purposes, training that enhances an 
individual's competencies, but does not permit that individual to be 
employed in a new specialty in which he or she could not have been 
employed without completing the additional training, would not qualify 
for Medicare reasonable cost pass-through payment. Medicare provides 
payment for such educational activities, but only under the methodology 
applicable to payments for normal operating costs. Our intent was to 
provide clarification for the purpose of distinguishing between those 
educational programs that qualify for reasonable cost pass-through 
payment (that is, programs that enable an individual to begin 
employment in a specialty), and those programs that should be paid as 
normal operating costs (that is, activities that are intended to 
enhance the current skill set of an individual for a profession or 
advance an individual's professional career).
    Since publication of the proposed rule, we have learned from 
information provided by the commenters that there are two categories of 
pharmacy residencies--pharmacy practice residencies and specialized 
pharmacy residencies, both of which are accredited by the American 
Society of Health-System Pharmacists (ASHP). If a pharmacist chooses to 
participate in residency training, he or she would generally do so 
after completion of an undergraduate bachelor of science degree or a 
doctor of pharmacy degree. (In some cases, residencies are offered as a 
part of a postgraduate degree (a master of science or a doctor of 
pharmacy). However, these programs would not meet our provider-operated 
criteria.) A pharmacy practice residency is typically a 1-year, 
organized, directed, postgraduate training program in a defined area of 
pharmacy practice that may take place in a variety of settings, 
including hospitals. For those seeking additional skills in a focused 
area of pharmacy practice (for example, oncology), an individual may 
choose to complete a second year of specialized pharmacy residency. 
Currently, ASHP, in partnerships with other professional organizations, 
accredits 17 second-year pharmacy residencies, in areas such as 
cardiology, geriatrics, infectious diseases, and oncology.
    Of the 17 second-year pharmacy residencies, only 5 of these 
residencies currently lead to board certification. The Board of 
Pharmaceutical Specialties (BPS) is the organization that administers 
the certifying examinations after completion of each of these five 
residencies. Upon completion of a residency in 1 of the other 12 
second-year residencies, the hospital in which the resident has trained 
issues a certificate to the pharmacist.
    We understand that many employers, including hospitals, 
increasingly are requiring completion of an ASHP-accredited first year 
pharmacy practice residency as a condition for employment as a clinical 
(``on the floor'') or direct patient care pharmacist. While a licensed 
pharmacist who has not completed a pharmacy practice residency might be 
hired by a hospital as a staff or distribution pharmacist, a hospital 
typically would only hire an individual who has completed at least a 1-
year pharmacy practice residency to fill a position that requires 
direct work with hospital patients. Some hospitals may even require 
their pharmacists to have completed a second-year

[[Page 45429]]

specialized residency before allowing those pharmacists to specialize 
on a particular group or type of patients. For example, before a 
pharmacist may work exclusively to design, implement, and monitor a 
course of treatment for oncology patients, some hospitals require that 
the pharmacist complete a residency in oncology pharmacy. However, many 
hospitals may employ pharmacists who have only completed a pharmacy 
practice residency to treat these groups or types of patients, 
including oncology patients.
    As we explained above in response to the comments on CPE, in the 
May 19, 2003 proposed rule (68 FR 27210), we proposed to revise the 
regulations at Sec.  413.85(h)(3) to state that activities treated as 
normal operating costs include ``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.'' We proposed 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.'' However, it is apparent from 
the comments we received that our proposed definition of 
``certification'' was not clear. Some commenters believed we intended, 
through the proposed definition, to allow pass-through payments for the 
costs of a program that would only enhance an individual's set of 
skills. However, that was not our intent. We believe it would have been 
more appropriate to use the word ``and'' instead of the word ``or'' to 
further emphasize that pass-through payment would only apply to 
activities that enable an individual to practice and begin employment 
in a specialty, but would not apply to activities that serve to add to 
or to enhance an individual's current skill set.
    In addition, based on the comments received, we understand that 
there may be several distinct levels of training in a given health 
profession, and each level of training may be a requirement in order 
for an individual to work in a new capacity or ``specialty'' in that 
profession, but not a requirement to practice or begin employment in 
the specialty ``as a whole.'' Since a second level of training is not 
required to begin practicing in a profession, under the proposed 
definition, we would not have been able to allow for pass-through 
payments for a second (or potentially a third) level of training. 
Therefore, we understand that inclusion of the words ``as a whole'' in 
the proposed definition of ``certification'' was misleading. 
Consequently, where a subsequent level of training is a requirement to 
practice in a new specialty in a given profession, pass-through payment 
may be made for the subsequent level of training.
    Finally, we have concluded that it is not necessary to include a 
specific definition of ``certification'' in the regulations at Sec.  
413.85. In this final rule, we are deleting the proposed definition of 
``certification'' from Sec.  413.85(c), and amending Sec.  413.85(h)(3) 
by removing the words ``certification required'' and inserting the 
words ``the ability.'' We are also changing the word ``or'' to ``and''. 
Specifically, we are amending the proposed Sec.  413.85(h)(3) to state 
that activities treated as normal operating costs include ``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 the ability to practice and begin employment in a nursing 
or allied health specialty.''
    As we stated above in response to the comments concerning CPE, our 
view of a ``specialty'' in the nursing and allied health education 
context is based on what the health care industry views as the standard 
of practice in a specific area within a profession. We are defining 
``industry norm'' to mean that more than 50 percent of hospitals in a 
random, statistically valid sample require the completion of a 
particular training program before an individual may be employed in a 
specialty. (We understand that, in some instances, due to the unique 
staffing circumstances faced by many smaller hospitals, inclusion of 
small hospitals in the sample would introduce factors that are not 
typically representative of the industry as a whole and would skew the 
results inappropriately. In such cases, we would consider excluding 
hospitals with less than 100 beds, which would still retain over 75 
percent of all hospitals in the sample universe.)
    Based on comments received, we believe that it is currently the 
``industry norm'' for hospitals to generally hire only pharmacists who 
have completed a pharmacy practice residency to work directly in 
patient care. Specifically, without having completed a pharmacy 
practice residency, a pharmacist would typically be employed by a 
hospital as a staff or distribution pharmacist, but not as a clinical 
pharmacist who works directly with patients to develop treatment plans. 
Since completion of a pharmacy practice residency has become a 
requirement by hospitals to practice or begin employment in a position 
that involves direct patient care, we would view ``hospital pharmacy'' 
as a ``specialty'' of the pharmacy profession. Accordingly, pharmacy 
practice residency training programs that meet the requirements under 
Sec.  413.85, including accreditation by a nationally recognized 
accrediting body, direct operation by a provider, and lead to 
certification that is a requirement for employment, may be eligible for 
Medicare reasonable cost pass-through payment.
    However, it is apparent from the comments that it is not unusual 
for a hospital to employ a pharmacist that has only completed a 
pharmacy practice residency in an area in which an accredited second-
year program exists (that is, geriatrics, cardiology, or oncology), 
without requiring the pharmacist to first complete that second-year 
residency program. For example, we would view further training in 
oncology pharmacy or cardiology pharmacy as specializations within the 
pharmacy field under the policy in this final rule. However, these 
second-year residencies would not qualify for reasonable cost pass-
through payment because, based on information received from commenters, 
it is not currently the ``industry norm'' to require completion of 
these programs before beginning work in these specialties. If we find 
in the future that it has become the ``industry norm'' for hospitals to 
require second-year pharmacy residencies, we may allow the hospitals 
operating those programs to be reimbursed for the costs of those 
programs on a reasonable cost basis.
3. Programs Operated by Wholly-Owned Subsidiary Educational 
Institutions of Hospitals
    Another matter that has come to our 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

[[Page 45430]]

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 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. In the May 19, 2003 proposed rule, we proposed 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 proposed 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 proposed that Medicare would not recoup reasonable cost 
payment from hospitals that have received pass-through payments for 
portions of cost reporting periods occurring before October 1, 2003 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 proposed 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 further proposed 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 the 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

[[Page 45431]]

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, we note that the proposed policy would 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 the 
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 October 1, 
2003 because our policy with respect to programs by a wholly-owned 
subsidiary of a hospital will have been clarified by that date (the 
date that this final rule is effective).
    We proposed to revise Sec.  413.85 by adding new paragraphs 
(d)(1)(iii) and (g)(3) to reflect the proposed payment policy.
    Comment: Several comments supported our proposal. Specifically, the 
commenters believed that the proposed rule is consistent with the 
recent expressions of Congressional intent reflected in the conference 
report to the 2003 Consolidated Appropriations Resolution, which 
recognize that there is a shortage of nursing and allied health 
professionals, and that payments made for programs that are operated by 
wholly-owned subsidiary educational institutions of hospitals should 
not be retrospectively recouped and may continue in the future.
    However, several commenters disagreed with the proposal under 
proposed Sec.  413.85(g)(3)(iii) that, effective for portions of cost 
reporting periods occurring on or after October 1, 2003, eligible 
hospitals could receive payment for the clinical training costs and for 
the classroom costs, but only those classroom costs incurred by the 
hospital for the courses that were included in the program(s) that had 
originally been provider-operated before transfer of operation of the 
program(s) to a wholly owned subsidiary educational institution. One 
commenter stated that such criteria regarding reimbursement of 
classroom costs appears to presume that while a hospital was operating 
its own program before transferring the operation of the program to a 
wholly-owned subsidiary, the hospital must have offered fewer or 
different programs. The commenter believed that our example in the 
preamble of the proposed rule seems to suggest that ``noncore'' or 
nonnursing related classes would be excluded from reasonable cost 
reimbursement, effective October 1, 2003. The commenter contended that 
we have incorrectly assumed that diploma programs include only nursing 
courses because, in fact, such diploma programs typically included 
general courses for English, basic science, math, and similar subjects. 
The commenter asked that we revise the preamble to clarify that courses 
for which costs were historically reimbursed would continue to qualify 
for reasonable cost payment without regard to whether they are ``core'' 
or ``noncore'' nursing courses.
    Other commenters argued that restricting reimbursement to courses 
originally offered by the provider-operated program would discourage 
providers from ensuring that training of health care professionals is 
kept up to date and would not allow providers to meet evolving 
requirements of accrediting organizations. One commenter noted that the 
conference report accompanying the Consolidated Appropriations 
Resolution for FY 2003 states that ``* * * 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 
program(s) * * *'' (Emphasis added) (H.R. Rept. No. 108-10, 108th 
Cong., 1st Sess., 1115 (2003)). The commenter believed this language 
indicates that Congress intended that schools should be reimbursed, not 
particular courses.
    In addition, commenters expressed concern that capping 
reimbursement for educational programs effective October 1, 2003, would 
further aggravate the existing shortage of appropriately trained 
healthcare workers. Finally, commenters suggested that the October 1, 
2003 effective date be postponed because this date will cause hardship 
for institutions currently in the process of creating educational 
organizations for the purpose of transitioning their programs to those 
educational organizations.
    Response: We acknowledge the commenters' general support of the 
proposed changes. In response to the commenters who disagreed with our 
proposal for limiting payment to certain classroom costs, as we stated 
in the preamble to the proposed rule (68 FR 27210), this proposed 
exception to the reasonable cost payment policy for programs operated 
by wholly-owned subsidiary educational institutions was based on a 
question that we received from a hospital pertaining to the language in 
the January 12, 2001 Federal Register (66 FR 3363) concerning hospitals 
that established their own educational institutions to meet 
accreditation standards. Specifically, the hospital that raised the 
issue previously received Medicare reasonable cost payment for the 
direct operation of nursing and 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 in 
question has continued to receive Medicare payments after the hospital 
moved operation of the programs to the wholly-owned subsidiary college. 
The hospital believed that, based on the cited preamble language in the 
January 12, 2001 Federal Register 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, that it is 
still the direct operator of the programs and should continue to 
receive pass-through treatment.
    As we stated in the proposed rule, 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).

[[Page 45432]]

As we stated in the 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).
    We explained that we understood that some hospitals 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. Accordingly, although we proposed to clarify in the 
proposed rule that, in general 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), we believed it would be unfair to recoup 
Medicare payments that have already been made to such a hospital that 
meets this very narrow fact pattern. Therefore, we proposed to add a 
limited exception to Sec.  413.85 to reflect the unique circumstances 
of such a hospital.
    First, we proposed that, for portions of cost reporting periods 
occurring on or before October 1, 2003, Medicare would not recoup 
reasonable cost payment from such a hospital that has received pass-
through payments 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.
    Second, since we believed that such a hospital's programs were no 
longer provider-operated, and therefore, should not continue in the 
future to receive full reasonable cost payments for the clinical and 
classroom costs of programs that are now operated by the wholly owned 
subsidiary educational institution, we proposed 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 
further proposed 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 were included in the 
hospital's provider-operated program(s) could continue to be reimbursed 
on a reasonable cost basis. That is, we proposed that 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).
    In proposing that, effective for portions of cost reporting periods 
occurring on or after October 1, 2003, we would only continue to pay on 
a reasonable cost basis for classroom costs associated with the courses 
that relate to the theory and practice of the particular nursing or 
allied health discipline(s) that were offered by the hospital when the 
hospital was the direct operator of the program(s), and not for 
additional classes needed to meet degree requirements provided as part 
of the nursing or allied health education programs, we did assume, as a 
commenter suggested, that diploma nursing programs typically only 
include courses related to the theory and practice of nursing. However, 
regardless of whether diploma programs include additional general 
courses other than ``core'' nursing courses, we continue to believe it 
is more appropriate to pay a hospital that meets the limited exception 
that allows continued payment for only those costs associated with 
courses included in the program(s) when the hospital was still the 
direct operator of the program(s). If, in fact, a hospital that meets 
the limited exception currently offers the same courses that it had 
offered when it was still the direct operator of the programs, we would 
continue to pay for the classroom costs associated with those courses, 
even if those courses do not relate directly to the theory and practice 
of the nursing or allied health program(s). However, if new courses, 
whether or not they are nursing-related or allied health-related 
course, have been added after the operation of the program(s) was 
transferred to a wholly owned subsidiary educational institution, we 
would not pay on a reasonable cost basis for the classroom costs 
associated with those new courses, effective October 1, 2003. If the 
courses offered currently are the same as the courses offered prior to 
transfer of the programs to the wholly owned subsidiary, but, for 
example, the names of the courses have changed, or there have been 
course substitutions, we would evaluate each course on an individual 
basis to determine whether we would continue to allow reasonable cost 
payment for those courses. All other things being equal (that is, after 
adjusting for inflation and changes in enrollment), our intent is not 
to pay more on a reasonable cost basis as of October 1, 2003, for 
classroom costs to such a hospital than we had paid to the hospital 
when the hospital was still the direct operator of the program(s).
    In response to the comments we received that urged us not to 
restrict the number of courses for which we would provide reasonable 
cost reimbursement due to concerns about evolving accreditation 
requirements and the existing nursing shortage, we emphasize again that 
this proposal is not at all broad in scope. Rather, based on the 
information we currently have available to us, we believe this 
provision would have a limited application.. Therefore, we do not 
believe that our proposal will aggravate the nursing shortage or 
adversely affect hospitals that otherwise meet the requirements for 
reasonable cost payment under Sec.  413.85 but add courses to their 
programs. Similarly, we do not believe that the effective date of 
October 1, 2003, will cause hardship to other providers that are 
currently in the process of transitioning their programs to educational 
organizations, since the proposed changes would only apply to a 
provider that had already created its own educational institution. We 
also note that, as indicated above, programs that transition in some 
respect to educational institutions created by providers could possibly 
be considered ``provider-operated'' under Sec.  413.85(f) and, if all 
other requirements are met, could qualify to receive reasonable cost 
reimbursement.
    Comment: One commenter disagreed with our statement in the proposed 
rule (68 FR 27211) 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

[[Page 45433]]

criteria under Sec.  413.85(f).'' Rather, the commenter believed that 
programs that are wholly owned or wholly controlled by a hospital are 
provider-operated programs. The commenter asserted that CMS'' 
distinction between provider-operated programs and wholly owned 
programs conflicts with CMS'' regulations at Sec.  413.17(c)(2) which 
state that ``If the provider obtains items of services, facilities, or 
supplies from an organization, even though it is a separate legal 
entity, and the organization is owned or controlled by the owner(s) of 
the provider, in effect the items are obtained from itself.'' The 
commenter also referenced Sec.  412.2(c)(5)(i) concerning the DRG 3-day 
payment window that applies to services provided by a hospital or by an 
entity wholly owned or operated by the hospital, and asserted that 
there is ``no rational basis'' for treating wholly owned or wholly 
controlled affiliates differently for purposes of pass-through payment.
    Response: The commenter is incorrect in stating that, in the 
proposed rule, we indicated that wholly owned (or wholly controlled) 
programs by definition cannot meet the provider-operated criteria and, 
therefore, would not qualify for reasonable cost pass-through payments. 
In fact, as we have stated in the January 12, 2001 final rule (66 FR 
3363), and reiterated in the preamble to the proposed rule, if the 
hospital that wholly owns the educational institution meets the 
provider-operated criteria, the hospital would qualify to receive 
reasonable cost pass-through payment. Specifically, we stated in the 
proposed rule (68 FR 27210) that ``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. * * * 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 premises of the hospital (emphasis added). 
Thus, while we still believe 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) (68 FR 27211), we reiterate that only in 
instances where the hospital continues to meet the provider-operated 
criteria under Sec.  413.85(f) would the hospital continue to qualify 
for reasonable cost pass-through payments, as it did prior to 
transferring operation of a provider-operated program(s) to a wholly 
owned educational institution.
    The commenter also mentioned the generally applicable ``related-
entity'' rules, and suggested that a wholly owned school would be a 
related entity that should be treated as if it is the provider. Thus, a 
wholly owned educational institution would remain provider-operated. 
However, we note that, for purposes of nursing or allied health 
education payment under Sec.  413.85, it is not sufficient for a 
program to be operated by a related entity. Rather, the ``related 
entity'' principles do not apply under the agency's nursing and allied 
health education payment policy because, as indicated in previous 
rulemakings, that policy requires that a program be directly operated 
by the provider itself. Requiring direct operation of a program by the 
provider ensures that, under Sec.  413.85(c), costs borne by related 
organizations (that is, the community) are not redistributed to the 
hospital and claimed as a pass-through under the Medicare program.
    Comment: Commenters requested clarification on whether the proposed 
change regarding providers that created wholly owned subsidiary 
educational institutions to meet accreditation requirements would have 
any effect on provider-operated nursing or allied health programs that 
have entered into written contracts with colleges or universities to 
award their degrees.
    Response: As we have explained in response to a previous comment, 
the proposed change was extremely limited in scope and only relates to 
hospitals with a unique set of circumstances surrounding operation of 
their programs by a wholly owned subsidiary educational institution. 
Therefore, the proposed changes do not have any impact on existing 
policy related to hospitals that enter into contracts with academic 
institutions to award their degrees. However, we stress that, in the 
instance where an academic institution other than the hospital grants 
the final certificate or degree upon completion of the program, the 
burden of proof is on the hospital to demonstrate that it, in fact, 
meets the ``provider-operated'' criteria under Sec.  413.85(f) before 
reasonable cost payment may be made to that hospital.
    Comment: One commenter believed that it is inappropriate to use the 
term ``wholly owned'' in reference to entities that, in many cases, are 
nonprofit institutions because, technically, nonprofit organizations 
are public trusts. The commenter suggested that it would be more 
accurate to refer to ``wholly owned'' or ``wholly controlled'' 
educational institutions.
    Response: We believe that, for purposes of payment under Sec.  
413.85, it is appropriate to use the term ``wholly owned.'' Although we 
recognize that nonprofit entities would not technically be ``wholly 
owned'' since they do not issue stock, we do not agree with the 
commenter that ``wholly controlled'' is an appropriate alternative 
because of the potential for confusion over issues relating to 
``control'' and ``provider operation.'' Further, we believe that the 
term ``wholly owned'' is commonly used in the context of nonprofit 
entities, and implies the kind of relationship we intend--where there 
is a single founder or member. Therefore, we will continue to use the 
term ``wholly owned subsidiary'' in the context of payment under Sec.  
413.85.
    We are finalizing the two proposals associated with programs 
operated by wholly owned subsidiary educational institutions of 
hospitals. Specifically, we are finalizing the proposal under new Sec.  
413.85(g)(3) that, 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, and then operation of the 
programs) 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). Further, reasonable cost payment will be made if a 
provider received 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 this wholly owned 
subsidiary educational institution (and ceased to be provider-operated 
program(s)). Such a provider would receive reasonable cost payments 
for: (a) The clinical training costs incurred for the program(s), and 
(b) classroom costs, but only those classroom costs incurred by the 
provider for the courses that were included in the programs that were

[[Page 45434]]

originally provider-operated prior to the transfer to a wholly owned 
subsidiary educational institution. That is, Medicare would pay on a 
reasonable cost basis for the classroom costs associated with the 
courses provided as part of the nursing or allied health education 
programs that were offered by the hospital when the hospital was the 
direct operator of the program(s). We would not allow such a hospital 
to be paid for additional classroom costs for courses that were not 
paid on a reasonable cost basis to the hospital in conjunction with its 
provider-operated programs.

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 (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

[[Page 45435]]

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 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

[[Page 45436]]

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 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 away, 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:

[[Page 45437]]

    ``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 413.85(c) and HCFA Pub. 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, in the May 19, 2003 proposed rule, we proposed 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 proposed this policy 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 proposed 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 
proposed 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 proposed 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

[[Page 45438]]

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) contained two 
provisions. Proposed Sec.  413.86(i)(1) stated the principles of 
community support and redistribution of costs: In relation to community 
support, we proposed 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 proposed 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 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 already proposed to make 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 Pub. 
L. 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 Pub. L. 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 Pub. L. 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 Pub. L. 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 believed it was 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 proposed 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 proposed to 
require

[[Page 45439]]

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 stated 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 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 all 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 the 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

[[Page 45440]]

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 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.
    We received a large number of comments from the public on this 
proposal. Following is a summary of these comments and our responses:
    Comment: Some commenters supported our proposed application of 
redistribution of cost and community support to direct GME. One 
commenter stated: ``We believe that the proposed changes * * * will 
result in more accurate and consistent reimbursement to providers. The 
changes provide more definitive guidance to providers and to 
intermediaries in applying the regulations. In addition, the changes 
will more closely match Medicare reimbursement with actual IPPS-type 
services. This is especially true in the case of dental residents, who 
typically spend little or no time caring for patients receiving IPPS 
type services.''
    Response: We agree with the commenters' assertions and appreciate 
the commenters' support of our proposals on redistribution of costs and 
community support.
    Comment: Many commenters disagreed with our proposed application of 
redistribution of cost and community support to direct GME. In general, 
they believed they did not receive proper notice of the application of 
the principles. One commenter stated: ``[t]he proposed change to the 
rules midstream, and only with respect to subsequent payment years, 
distorts the balance on which the established payment formula 
depends.'' Other commenters believed that, in the past, CMS has never 
suggested that incurring the costs of offsite training in the then-
current year would be a condition to hospitals' claiming those costs in 
future years. The commenters contended that nowhere in the regulations 
promulgated has CMS stated that, in order to receive GME and IME 
payments, a hospital must meet an additional requirement of incurring 
the training costs since the inception of the training program. The 
commenters believed it is inequitable to impose such a ``retroactive 
requirement.''
    The commenters stated that many hospitals that were contemplating 
whether to initiate a training program in a nonhospital setting, 
notified CMS in advance of establishing such a program, and requested 
CMS's approval. One commenter stated that, in numerous cases, 
``including some of the cases discussed in the regulatory preamble, CMS 
issued a written approval of the proposed training program. In such 
approval letters, CMS never mentioned the redistribution of costs and 
community support principles.''
    Finally, another commenter stated that there is nothing in the 
direct GME and IME statutes that supports CMS' decision to apply 
redistribution of costs and community support principles.
    Response: The principles of redistribution of cost and community 
support associated with Medicare's payments for GME have been in 
existence for over 35 years, that is, since the inception of the 
Medicare program in 1965. The principles have been continually 
reiterated in various regulations, manual provisions, and implementing 
instructions to fiscal intermediaries. We do not believe we have given 
the public any reason to conclude that the principles would not 
continue to be applicable. Several examples of our views on the 
principles

[[Page 45441]]

of redistribution of cost and community support were mentioned in the 
proposed rule. These included:
    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 away, 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. Rept. 
No. 404, 89th Cong., 1st Sess., 36 (1965); H.R. Rept. 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 regulations that evolved from the authorizing legislation, 
first published on November 22, 1966 (31 FR 14814), as well as Chapter 
4 of the Provider Reimbursement Manual in 1971, echoed the 
congressional committee report language from 1965 that Medicare would 
share in the costs of educational activities until communities bore 
them in some other way.
    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)
    Although the above language was written in the context of a 
regulation that clarified Medicare policy for provider (hospital) 
operated nursing and allied health education programs, we note that GME 
and nursing and allied health education programs were historically paid 
under the same regulations (the latest of which was codified at Sec.  
413.85) and the same cost principles. The quoted language is indicative 
of this relationship and the Agency's mindset that, while direct GME 
may have changed in the method of payment to a prospective payment, 
some principles, such as redistribution of cost and community support, 
continue to apply as they do with nursing and allied health education 
at Sec.  413.85(c). Further evidence of continued application is at 
existing Sec.  413.85(c) in the definition of ``redistribution of 
cost'': ``* * * costs for a school of nursing or allied health 
education or a medical school that were incurred by an educational 
institution and were not allowable to the provider [hospital] in its 
prospective payment or a rate-of-increase limit base year cost report, 
or graduate medical education per resident amount calculated under 
Sec.  413.86, are not allowable costs in subsequent fiscal years.'' 
(Emphasis added.) Therefore, even codified in regulations now is a 
policy that applies the principle of redistribution of cost to direct 
GME payments in subsequent years.
    Furthermore, Sec.  413.85(c), which was a codification of 
longstanding Medicare policy, was originally issued in the Federal 
Register on September 30, 1986 (51 FR 34793) and was further refined, 
but conceptually left unchanged, as of March 12, 2001 (see 66 FR 3358). 
Section 413.85(c) addressed the Congressional intent not to increase 
program costs resulting from redistribution of 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.''
    We note that the guidance 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 413.85(c) and HCFA Pub. 15-1, section 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.)
    We believe we have continually put the public on notice that the 
Medicare program has applied and continues to apply the principles of 
redistribution of costs and community support to payments for education 
costs, including direct GME payments to hospitals. Therefore, we do not 
believe that we have proposed changes to the rules ``in midstream'' as 
one commenter suggested. Nor do we believe, as the commenters 
suggested, that we have proposed a ``retroactive requirement.'' We have 
never disavowed the principles of redistribution of cost and community 
support. Rather, we have continually promulgated rules and program 
guidance on the application of the principles since the inception of 
the Medicare program.
    We again point to the Supreme Court case, Thomas Jefferson, to 
demonstrate CMS' longstanding policy on community support and 
redistribution of costs in the GME context. In Thomas Jefferson, the 
Secretary of Health and Human Services interpreted the regulation at 
Sec.  413.85(c) to deny reimbursement of educational costs that were 
borne in prior years by a hospital's affiliated medical school for 
purposes of calculating the direct GME base year allowable cost for the 
PRA. The U.S. Supreme Court affirmed the Secretary's interpretation of 
the redistribution of costs regulation. The Court found that:
    ``The regulation [at Sec.  413.85(c)] provides, in unambiguous 
terms, that the `costs' of these educational activities will not be 
reimbursed when they are

[[Page 45442]]

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).
    In addition, in response to the argument by the provider that CMS 
(then HCFA) had been silent in internal operating instructions in a 
1978 operating memorandum on the policies of redistribution and 
community support, as well as in another exchange of memoranda in 1982 
and other agency documentation, the Court stated that the omission in 
these documents of discussion of redistribution and community support 
is not indicative of a contrary policy on GME reimbursement: ``* * * 
the mere failure to address [the redistribution principle in an 
intermediary letter] hardly establishes an inconsistent policy on the 
part of the Secretary.'' Thomas Jefferson, 512 U.S. at 516.
    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 legislation that enacted Medicare, to impose a 
substantive limitation on medical education payment, even in the 
arguably novel context of calculating a hospital's GME costs for 
purposes of the base year PRA.
    To address the commenters' point that CMS ``never mentioned the 
redistribution of costs and community support principles'' in CMS 
``approval letters'' to hospitals that requested ``approval'' from CMS 
in advance of establishing a relationship with a nonhospital site in 
order to count the residents training in that setting, we note that 
when the letters were written to CMS in fiscal year end 1999-2002, it 
was not clear at all from the incoming correspondence that hospitals 
were not, in fact, rotating the hospital-based residents to the 
nonhospital setting in accordance with statutory intent. In other 
words, it was not clear from the incoming correspondence that a 
redistribution of costs was being contemplated by the hospitals. In 
addition, the letters did not explicitly mention that the costs of the 
program were currently being borne by the community in the contemplated 
arrangements. In the last 2 or 3 years, when hospitals met with or 
wrote to CMS for guidance on the nonhospital site policy under Sec.  
413.86(f)(4), we provided responses that were limited to the scope of 
the inquiries. We answered questions about the requirements of Sec.  
413.86(f)(4). It did not seem necessary to bring up the issue of 
``redistribution'' or ``community support'' because it was not apparent 
that the community had previously incurred the direct GME costs. It was 
not until the relatively recent audits by our fiscal intermediaries of 
the fiscal year ending 1998 and 1999 cost reports of certain hospitals 
that CMS became aware that cost shifting was occurring. With this 
awareness came the necessity to explicitly reassert and explain the 
application of the longstanding Medicare principles of redistribution 
of costs and community support.
    Comment: Several commenters have stated that the principles of 
redistribution of cost and community support do not apply in 
determination of a hospital's FTE resident count for direct GME. One 
commenter argued, in part relying on a Federal district court case, 
Episcopal Hospital v. Shalala, 1997 U.S. Dist. Lexis 8701 (E.Da.Pa. 
1997), to state: ``* * * CMS has argued, and the courts have agreed, 
that Medicare cost principles have no effect with respect to the direct 
GME payment method prescribed by section 1886(h) of the Act * * * these 
principles implement the statutory provision in section 1861(v) of the 
[Social Security] Act for payment of reasonable cost.'' This commenter 
also quoted extensively from the September 29, 1989 final rule to argue 
that the GME regulation ``construes the GME statute so as to preclude 
consideration of allowable costs incurred in connection with a 
resident's training.''
    Similarly, another commenter believed that Congress ``replaced the 
old reasonable cost payment system'' with a prospective payment 
methodology, and that those principles that formed the basis for 
reasonable cost payments for GME were no longer relevant. The commenter 
believed the redistribution of costs and community support principles 
have no application to the current payment methodology, which relies on 
FTEs and PRAs.
    Several commenters also disputed our citation to the Thomas 
Jefferson case for application of the principles to FTE counts. The 
commenters believed that CMS should not use this case in support of our 
policy because the case did not discuss applying the principles to the 
counting of residents. In addition, they believe the case was ``very 
limited'' and ``only discussed the establishment of base year resident 
costs, which were used in developing base payment rates.''
    Response: We disagree with the commenters that the principles of 
redistribution of costs and community support do not apply in 
determination of a hospital's FTE resident count for direct GME. When 
Congress enacted section 1886(h) of the Act as part of section 9202 of 
the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 
(Pub. L. 99-272) on April 7, 1986, it did not altogether ``preclude'' 
consideration of allowable costs in connection with a resident's 
training, as the first commenter suggests. Upon enactment of the new 
legislation, CMS (then HCFA) considered a hospital's allowable 
reasonable costs, and applied reasonable cost principles (including 
redistribution of costs and community support, as we have explained) to 
calculate a hospital's direct GME costs and FTE resident count in order 
to determine hospital-specific PRAs in the base year. Although in cost 
reporting years after the PRA base year, the applicable PRAs are 
largely determined by the statute, we believe that costs continue to be 
a factor in determining the number of FTE residents that may be counted 
by a hospital. For example, a hospital may only count FTE residents 
training at the hospital for which, as repeatedly described in the 
September 29, 1989 final rule, the hospital almost necessarily incurs 
some direct GME costs. Hospitals may also count FTE residents training 
in nonhospital sites only if the hospital incurs all or substantially 
all the training costs of the program at that site (and meets other 
regulatory requirements.) Thus, it cannot be said that our view of the 
statute ``precludes'' consideration of allowable costs associated with 
training residents.
    Although Congress did implement a prospective payment system for 
direct GME costs by enacting section 902 of COBRA 1985, we do not 
believe this means that all reasonable cost principles are no longer 
applicable under the revised system. Section 1886(h)(1) of the Act 
provides that: ``[n]ot withstanding section 1861(v) [defining 
reasonable cost], instead of any amounts that are otherwise payable 
under this title with respect to the reasonable costs of hospitals for 
direct graduate medical education costs, the Secretary shall provide 
for payments for such costs in accordance with paragraph (3) of this 
subsection.'' The statute literally provides that the reasonable cost 
payment method in section 1861(v) of the Act does not apply to section 
1886(h)(3) of the Act (but those principles do apply to the remainder 
of section 1886(h) of the Act), which is the paragraph that specifies 
the general prospective payment formula for direct GME (the direct GME 
PRA). Thus, section 1886(h)(1) of the Act does not, as the commenter 
suggested, preclude

[[Page 45443]]

any consideration of reasonable costs associated with the training of 
residents. Indeed, section 1886(h)(1) of the Act provides that, instead 
of payment under section 1861(v) of the Act, ``the Secretary shall 
provide for payment for such costs'', which refers back to ``the 
reasonable costs of hospitals for direct graduate medical education 
costs.'' Thus, the statutory provisions governing direct GME payments 
continue to contemplate that Medicare payments to hospitals will be 
made for reasonable costs even under the prospective payment that is 
based on direct GME PRAs and FTE residents. Therefore, we do not 
believe the statute precludes application of reasonable cost 
principles, including the principles of redistribution of costs and 
community support.
    Although we do recognize that certain reasonable cost principles 
are inherently contrary to a prospective payment system, others are 
compatible and may continue to be relevant, even upon implementation of 
the prospective payment. For example, in the case cited by the 
commenter, the Secretary and the court acknowledged that the principle 
of ``cross-subsidization'' found in section 1861(v)(1)(A) of the Act 
does not apply under a prospective payment context. The cross-
subsidization provision requires that, in determining the reasonable 
costs of services, the Medicare program must ensure that it bears 
fully, but exclusively, ``the necessary costs of efficiently delivering 
covered services'' to Medicare beneficiaries. Simply put, the provision 
requires the Medicare program to pay for all the costs associated with 
care for its beneficiaries, and no more, so that other parties are not 
subsidizing care provided to Medicare beneficiaries, and Medicare is 
not subsidizing care provided to non-Medicare beneficiaries. However, 
when Medicare payments are determined prospectively, the Medicare 
program necessarily ceases to be concerned about whether cross-
subsidization occurs--in other words, it is expected that a particular 
provider's costs may be higher or lower than the prospectively-
determined payment (hence, the underlying premise that prospective 
payment systems create incentives for providers to control costs and 
operate efficiently).
    In contrast, the principles of redistribution of costs and 
community support are completely congruent with the prospective payment 
system under section 1886(h) of the Act. Redistribution of costs and 
community support principles derive from legislative intent that was 
expressed at the enactment of the Medicare program, that the program 
should not assume payment for education costs that were previously 
funded by other sources. There is no reason to conclude that this 
intent changed with the enactment of the prospective payment 
methodology in section 1886(h) of the Act, with the addition of the FTE 
caps specified in section 1886(h)(4)(e) of the Act, or with the 
amendments that allow hospitals to count residents training in 
nonhospital sites for purposes of direct GME and IME payments. We do 
not believe that Congress intended by any of these enactments to enable 
an expansion in Medicare direct (or indirect) GME payments that result 
from cost shifting to hospitals. Rather, we believe section 1886(h) of 
the Act and later amendments were primarily directed toward limiting 
expansion of Medicare direct GME and IME payments. Therefore, we 
believe that the principles of redistribution of costs and community 
support are consistent with, and continue to be applicable under, the 
current direct GME payment system.
    We also believe it is appropriate to cite the Supreme Court in the 
Thomas Jefferson case. The commenters believed that the scope of the 
Supreme Court's opinion that supported the agency's application of the 
principles of redistribution of costs and community support is limited 
to the calculation of hospitals' reasonable costs of GME for the 
purpose of determining the base period PRA. However, as we stated 
above, the statutory provisions governing direct GME payments continue 
to contemplate that Medicare payments to hospitals will be made for 
``such costs'' even under the prospective payment methodology specified 
in section 1886(h) of the Act. In calculating the base year PRAs, the 
Agency allowed hospitals to count FTE residents where the hospitals 
were incurring direct GME costs associated with training those 
residents. This policy was clearly consistent with the principles of 
redistribution of costs and community support because the calculation 
of base year PRAs was dependent on the proper counting of FTE 
residents. Any opinion from the Court on the application of the 
principles to the base year costs would equally apply to FTE resident 
counts. Therefore, we believe the relevance of the Thomas Jefferson 
case is not limited to the establishment of base year costs, as the 
commenters suggested. Rather, the Court's opinion recognized that the 
principles of redistribution of costs and community support 
legitimately continue to apply under section 1886(h) of the Act. The 
Supreme Court's opinion is entirely relevant to the calculation of 
direct GME payments to hospitals in cost reporting periods on or after 
the PRA base year.
    Finally, to address the commenters' reference to the 1989 final 
rule to support the argument that CMS interpreted the statute to 
preclude consideration of costs in connection with counting FTE 
residents, we note that the cited rule is replete with suggestions that 
CMS expected hospitals to continue to incur some level of direct GME 
costs for training residents, even under the direct GME PRA-based 
payment methodology. For example, the final rule at 54 FR 40298 states:
    ``Nothing in section 1886(h) of the Act indicates that the bearing 
of costs in connection with particular residents is a factor in 
determining who should be counted. The law simply requires the 
Secretary to determine the average amount incurred to train residents 
during the specified base period and to make GME payments for the 
residents in the hospital's programs thereafter on that basis. There 
was no authorization to establish a two-tiered system to account both 
for residents whom the hospital incurs full training costs and for 
residents whom hospitals incur only supervisory and overhead costs 
because the residents' salaries are paid by another entity.'' (Ibid.)
    We believe the language quoted above from the 1989 rule is 
exemplary of the Agency's mindset (as well as of the mindset of the 
commenter in that rule) that the question of whether costs were 
incurred by the hospital was, and would continue to be, a consideration 
for purposes of direct GME payment.
    Comment: One commenter appeared to agree with what we stated in the 
proposed preamble at 68 FR 27216 that because IME regulations on 
counting residents at nonhospital sites cross-reference the direct GME 
nonhospital provisions, the provisions on redistribution of costs and 
community support would equally apply to IME FTE counts, as well as 
direct GME FTE counts, when counting residents in nonhospital settings. 
However, the commenter requested clarification on the issue of whether 
IME FTE residents counts in hospital settings would be subject to the 
community support and redistribution of costs provisions.
    Another commenter argued that the redistribution of costs and 
community support principles do not apply to FTE counts for purposes of 
IME payment. This commenter argues that there is no evidence indicating 
that a teaching hospital's operating costs bear any relation to past or 
present sources of funding for residents' training.

[[Page 45444]]

    Response: In response to the commenters' concerns regarding the 
application of the redistribution of costs principles and community 
support to counting residents for purposes of determining payments for 
IME for training in hospital settings, we agree with the commenters; 
the redistribution of costs and community support principles do not 
apply to FTE counts for residents training in hospital settings for 
purposes of IME payment. As we have explained in several regulations, 
the object of IME payments associated with resident training in 
hospital settings is to address the additional indirect operating costs 
that teaching hospitals incur in furnishing patient care (see 66 FR 
39896 or 54 FR 40286). Even if the redistribution of costs and 
community support principles could theoretically apply to training 
inside the hospital, we do not know how all of these additional 
indirect operating costs incurred by a hospital could be 
``redistributed'' to a nonhospital entity or could be borne by the 
community. As long as the hospital had consistently incurred at least 
some of those indirect costs, there could be no violation of 
redistribution of costs and community support principles, and no 
resulting disallowance of FTEs in calculating the hospital's IME 
adjustment. In any event, as stated above, we agree with the commenters 
because we believe the legislative history that gave rise to the 
principles of redistribution of costs and community support was focused 
on Medicare payments for direct GME.
    However, we note that, for training that occurs in nonhospital 
settings, the application of the principles of redistribution of costs 
and community support to direct GME FTE counts does have implications 
for IME payment for residency training in nonhospital settings. Under 
existing Sec.  412.105(f)(1)(ii)(C), which is 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 Sec.  413.86(f)(4)(iv) (the paragraph that 
specifically applies redistribution of costs and community support 
principles to FTE counts for purposes of direct GME) 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, IME payments are based on the concept 
that, as a direct result of the hospital's resident training program, 
the hospital incurs increased indirect costs for patient care. When 
Congress added section 1886(d)(5)(B)(iv) of the Act as part of Pub. L. 
105-33, the circumstances under which IME payments to a hospital could 
be made were broadened to allow the hospital to count the number of 
residents training outside the hospital setting under certain 
conditions, even though it is clear residents training outside the 
hospital cannot have any impact on the hospital's indirect patient care 
costs. Nevertheless, Congress authorized hospitals to receive IME 
payments by allowing hospitals to count FTE residents training in a 
nonhospital setting in accordance with section 1886(d)(5)(B)(iv) of the 
Act. As we have stated, we believe Congress intended the provisions of 
Pub. L. 105-33 to create an incentive (or remove a disincentive), 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. However, we believe IME 
payment to the hospital would be contrary to Congressional intent if 
there is a redistribution of costs or community support associated with 
residents training in a nonhospital site. We also believe the IME 
payment to the hospital was only intended by Congress to encourage the 
hospital to rotate residents from the hospital to the nonhospital site, 
not to encourage (or enable) existing training programs to transfer 
their costs to the hospital and thereby expand the hospitals Medicare 
IME payments.
    In addition, when Congress added section 1886(d)(5)(B)(iv) to the 
Act as part of Pub. L. 105-33, the statutory authority for IME payment 
for residents training at a nonhospital site 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 Pub. L. 105-33; section 1886(d)(5)(B)(iv) of the 
Act.) The statute requires a hospital to incur ``all or substantially 
all of the costs for the training program'' in the nonhospital setting 
in order to count FTE residents training there for purposes of both 
direct GME and IME payment. The link between the IME regulation at 
existing Sec.  412.105(f)(1)(ii)(c) and direct GME regulations at Sec.  
413.86(f)(4) implement this shared statutory requirement. As we have 
stated, we believe Congress intended hospitals to facilitate training 
in nonhospital sites that would not have occurred without the 
hospital's sponsorship, and for the hospital also to incur direct GME 
costs of the program in the nonhospital site as a precondition to 
counting the FTE residents training in nonhospital settings for 
purposes of IME payment. Thus, in the situation where a hospital 
currently is incurring direct GME costs at the nonhospital site but 
there has been a redistribution of costs or community support, a 
disallowance of direct GME payments, as well as a disallowance of IME 
payments, is appropriate.
    Comment: One commenter noted that proposed Sec.  413.86(i) 
(redistribution of costs and community support provision) applies not 
only to subparagraph (f)(4), the nonhospital site provision, but also 
to the remaining provisions of paragraph (f) and also to paragraphs 
(g)(4) through (g)(6). The commenter requested that CMS specify that 
the principles affect only the counting of residents in nonhospital 
sites and not the count of residents being trained in hospitals, both 
the inpatient and outpatient settings. In addition, this commenter 
believes such a clarification would also be consistent with other 
Medicare policy on counting FTE residents, such as the policy detailed 
in the August 1, 2002 final rule (67 FR 50077) concerning when 
residents rotate to other hospitals: ``which entity may count the 
residents for IME and Direct GME payments is based on where the actual 
training occurs, not which hospital is incurring the costs.''
    Response: While the primary reason we proposed to make the 
principles of redistribution of costs and community support explicit in 
the direct GME regulations was to specifically address the 
inappropriate scenarios described in the proposed rule whereby 
hospitals increase their FTE resident counts by assuming payment of 
training costs for residents in nonhospital sites that were previously 
funded by a nonhospital entity, we do not believe the principles are 
applicable in only this circumstance. In other words, the principles of 
community support and redistribution of costs apply generally to direct 
GME FTE counts, as we have explained. This holds true whether the 
counts relate to residents training in nonhospital sites (where we have 
seen the most

[[Page 45445]]

inappropriate counting), or to residents training inside the hospital--
inpatient or outpatient. Thus, it is technically possible to have a 
redistribution of direct GME costs for the training of residents inside 
the hospital setting (as well as in the nonhospital setting). 
Therefore, we are not adopting the commenter's suggestion to limit 
application of the principles to Sec.  413.86(f)(4) (the nonhospital 
site provision). However, we note that we believe a redistribution of 
all of the direct GME costs for training that occurs in a hospital 
setting would be rare. All of the direct costs of the program--resident 
salaries, teaching physician salaries, overhead expenses, etc., would 
need to be redistributed to an outside entity in order for there to be 
a disallowance of direct GME FTE residents for training inside the 
hospital due to redistribution of costs or community support.
    We contrast this application of the principles of redistribution of 
costs and community support in the current prospective payment system 
that depends upon PRA and FTE resident counts to application of the 
principles in the previous reasonable cost payment methodology that was 
based on cost finding and cost allocations. Under the former reasonable 
cost methodology, a hospital was eligible to receive direct GME payment 
for those direct GME costs that it incurred; however, any direct GME 
costs that were redistributed to the hospital were not allowable. We 
note that 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 413.85(c) and HCFA Pub. 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.)

    Thus, under the previous cost payment scheme, the principles of 
redistribution of costs and community support were applied to direct 
GME reasonable cost payment using a cost finding methodology. In 
contrast, in the current context where payment is no longer based 
solely on reasonable costs incurred, but on PRA and FTE resident 
counts, if the hospital can demonstrate that it has continuously 
incurred some of the direct GME costs of training the residents since 
the inception of the residency program at a training site, then no 
redistribution of costs or community support has taken place. As noted, 
current direct GME payments are no longer based on detailed cost 
finding of allowable costs of hospitals. Therefore, we believe it is 
appropriate to require that a hospital demonstrate that there has been 
no redistribution of costs or community support by proving that the 
hospital has incurred some of the direct GME costs of the program 
continuously since the inception of the program. Finally, contrary to 
the commenter's assertion, we believe we have been consistent with the 
other Medicare policies on counting residents, including the policy 
cited by the commenter concerning the prohibition on counting residents 
training at other hospitals. (See the August 1, 2002 final rule (67 FR 
60077). As stated above, there would be no redistribution of costs or 
community support if a hospital counts a resident when another hospital 
incurs the resident's salary, as long as the first hospital still 
incurs other direct GME costs associated with the training of that 
resident. In any case, as we explained above and also in the proposed 
rule, the principles of redistribution of costs and community support 
are not applicable to cost shifted between the hospitals, only costs 
shifted between a hospital and educational institutions or other 
organizations that are not Medicare providers.
    Comment: One commenter stated that a hospital was ``required'' to 
include in the calculation of its average per resident amount, time 
spent in the hospital by residents who were paid by ``other entities.'' 
This commenter quoted the September 29, 1989 final rule: ``the 1989 GME 
rule was modified after publication of the proposed rule in order `to 
require Medicare hospitals to count residents who are working in their 
facility even if the residents' salaries are fully paid by other 
entities, either Federal or non-Federal. This revised policy will apply 
to both GME base period and cost reporting periods subject to the new 
payment methodology.' 54 FR 40299 (emphasis added).''
    Response: We believe the language quoted above by the commenter 
from the 1989 final rule has been taken out of context. In essence, the 
commenter has generalized from the language selectively quoted above to 
support an argument that Medicare would have required a hospital to 
count resident time when the residents were ``paid by other entities,'' 
thereby supporting the commenter's argument that Medicare not only 
condones redistribution of costs but, in fact, would seem to 
``require'' them. However, we believe the language quoted by the 
commenter from a particular comment and response in the 1989 rule, if 
quoted in its full context, actually supports the CMS policy on the 
application of the principles of redistribution of costs and community 
support that as long as the hospital has continuously incurred at least 
some of the direct GME cost of the residency program since the 
inception of the program, there has been no redistribution of costs or 
community support and the hospital may count the FTE residents. 
Specifically, the commenters in that rule at 54 FR 40298 asked in 
relevant part: ``A particular problem referred to was the treatment of 
residents who are paid by medical schools, faculty practice plans, and 
others rather than by hospitals that participate in Medicare. It was 
pointed out that teaching hospitals incur other costs such as teaching 
physicians' salaries and overhead costs in connection with these 
residents, and it would be unfair not to count these residents for 
payment purposes.'' In our response to this comment, we stated, also in 
relevant part on 54 FR 40299: ``we note that some of the comments have 
led us to believe that, in addition to Federally-employed residents 
(for example, residents in Veterans Administration or Department of 
Defense programs), a significant number of residents are paid a salary 
by non-Federal, nonprovider entities (for example, medical schools or 
philanthropic agencies). As noted by the commenters, although no 
hospital participating in Medicare incurs salary costs for these 
residents, hospitals do incur other substantial GME costs associated 
with these residents. Therefore, we are modifying our proposed rule to 
require Medicare hospitals to count residents who are working in their 
facility even if the residents' salaries are fully paid by other 
entities, either Federal or nonfederal.'' (Emphasis added). It becomes 
apparent when the language quoted by the

[[Page 45446]]

commenter on this final rule is read in context that, even as far as 
back as the 1989 final rule, we acknowledged that hospitals may count 
the FTE residents where other entities may have incurred the residents' 
salaries, but where the hospitals still ``incur other substantial GME 
costs associated with these residents.'' This view is entirely 
consistent with the CMS application of redistribution of costs and 
community support. In a scenario where a nonhospital entity, such as a 
medical school, incurs the residents' salaries, we continue to believe 
that the hospital may count the FTE residents if the hospital can 
demonstrate that it has incurred other direct GME costs, such as the 
supervisory physician salaries, since the inception of the program.
    Comment: One commenter argued that when we explained our policy in 
the July 31, 1998 Federal Register (63 FR 40954) to require a written 
agreement indicating that the hospital must provide reasonable 
compensation for physicians' supervision of residents' training in the 
nonhospital setting, ``nothing was said about an additional requirement 
that a hospital must have continuously incurred this additional cost, 
as well as the residents' compensation required under the prior 
regulations, since the inception of the training program.'' This 
commenter further makes the point that in the final rule at 63 FR 
40986, in response to a comment that hospitals did not compensate 
nonhospital sites for supervisory teaching physician costs and it would 
not be fair to shift these costs to teaching hospitals, CMS responded:

    Hospitals and nonhospital sites will have 5 months following 
publication of this final rule to negotiate agreements that will 
allow hospitals to continue counting residents training in 
nonhospital sites for indirect and direct GME. These arrangements 
are related solely to financial arrangements for training in 
nonhospital sites. We do not believe that the agreements regarding 
these financial transactions will necessitate changes in the 
placement and training of residents.
    In response to the comment that it is unfair to shift costs to 
the hospital, we believe that it is appropriate to include 
supervisory costs in the nonhospital site as part of ``all or 
substantially all'' of the costs that hospitals must incur to count 
the resident. Currently, the hospital is able to count the resident 
even though the costs for that resident may be lower during the time 
when the resident trains outside the hospital. At the same time, the 
nonhospital site may have incurred costs for which it received no 
compensation. We believe that requiring the hospital to incur the 
costs associated with training in the nonhospital site is equitable 
to both the hospital and the nonhospital site and is consistent with 
the statutory requirement that the hospital must incur ``all or 
substantially all'' of the costs.

(63 FR 40995 (emphasis added by commenter).)
    The commenter believed that this explanation of the changes to the 
GME and IME rules, effective January 1, 1999, ``belies CMS' current 
assertion of a longstanding policy of applying the redistribution of 
costs and community support principles in the determination of the 
resident counts used to compute payment for GME and IME.''
    Response: The commenter has used the language quoted above from the 
1998 final rule to argue that when CMS (then HCFA) described the policy 
on counting residents in nonhospital sites for IME, ``nothing was said 
about an additional requirement that a hospital must have continuously 
incurred this additional cost * * * since the inception of the training 
program.'' The commenter has inferred from the language quoted above 
that CMS has not had a longstanding policy of applying the 
redistribution of costs and community support principles. However, we 
believe the language actually supports the longstanding existence of 
our policy in two ways. First, the quoted language demonstrates the 
agency's view that the nonhospital site policy was written from the 
standpoint of addressing the counting of residents when hospitals 
rotate residents from the hospital to the nonhospital site. Second, the 
quoted language is also indicative of the Agency's policy that as long 
as the hospital has continuously incurred at least some of the direct 
GME cost of the residency program since the inception of the program, 
there has been no redistribution of costs or community support and the 
hospital may count the FTE residents (assuming that other requirements 
are met).
    Specifically, the comment relating to the portion of the 1998 final 
rule quoted above stated at 63 FR 40994, in relevant part: ``One 
commenter noted that some arrangements between hospitals and 
nonhospital settings for the training of residents predate the GME base 
year. This commenter stated that hospitals did not compensate 
nonhospital sites for supervisory teaching physician costs and it would 
not be fair to shift these costs to teaching hospitals. The commenter 
also stated that teaching hospitals have already entered into written 
agreements with nonhospital sites under the existing rules.'' (Emphasis 
added.) In addition, as quoted above in the comment, we responded, in 
relevant part at 63 FR 40995 (with different emphasis):

    * * * hospitals and nonhospital sites will have 5 months 
following publication of this final rule to negotiate agreements 
that will allow hospitals to continue counting residents training in 
nonhospital sites for indirect and direct GME. These arrangements 
are related solely to financial arrangements for training in 
nonhospital sites. We do not believe that the agreements regarding 
these financial transactions will necessitate changes in the 
placement and training of residents.
    In response to the comment that it is unfair to shift costs to 
the hospital, we believe that it is appropriate to include 
supervisory costs in the nonhospital site as part of ``all or 
substantially all'' of the costs that hospitals must incur to count 
the resident. Currently, the hospital is able to count the resident 
even though the costs for that resident may be lower during the time 
when the resident trains outside the hospital. At the same time, the 
nonhospital site may have incurred costs for which it received no 
compensation. We believe that requiring the hospital to incur the 
costs associated with training in the nonhospital site is equitable 
to both the hospital and the nonhospital site and is consistent with 
the statutory requirement that the hospital must incur ``all or 
substantially all'' of the costs. Ibid.

    We believe the quoted comment and response from the 1998 rule paint 
a picture of a hospital that has had a pre-existing relationship with a 
nonhospital site involving rotation of residents from the hospital to 
the nonhospital site for a period of time during the residency program. 
The language we emphasized in the response--that the hospital may 
``continue to count residents'' when they train in the nonhospital 
sites, and that the hospital ``may count the resident even though the 
costs for the resident may be lower during the time when the resident 
trains outside the hospital''--clearly refers to a rotational 
arrangement between the hospital and the nonhospital site. In addition, 
according to the circumstances described by the commenter in the 1998 
rule, the hospitals had been incurring the residents' salaries, a 
direct GME cost, because they had formerly complied with the earlier 
regulation requiring that hospitals incur residents' salaries for 
purposes of meeting ``all or substantially all of the costs'' under 
Sec.  413.86(f)(3). We had no reason to believe that the hospitals had 
not incurred at least the residents' salaries since the inception of 
the training program (the commenters state that the arrangements 
``predate the GME base year''). In that event, the counting of 
residents in the nonhospital sites would not result in a redistribution 
of costs if, as of January 1, 1999, the hospital was required to incur 
the additional direct GME cost for supervisory physician costs while 
the residents rotate to the

[[Page 45447]]

nonhospital site. We believe that the commenter in the 1998 rule simply 
did not agree with the additional regulatory requirement finalized in 
the 1998 final rule that the hospital must also incur the supervisory 
physician costs for purposes of incurring ``all or substantially all of 
the costs,'' and hoped to label this new regulatory requirement as a 
``cost shift'' in order to avoid it. As we have explained, it appears 
that there has been no redistribution in the case described by the 1998 
final rule commenter because it can be inferred that the hospital had 
incurred at least some of the direct GME costs (the residents' 
salaries) since the inception of the program.
    Therefore, we believe the language the commenter quotes from the 
1998 rule is consistent with our clarifications in this final rule on 
redistribution of costs and community support. In addition, the 
language cited by the commenter supports our interpretation of the 
policy on counting residents in nonhospital sites that it was intended 
to address the situation when hospitals rotate residents from the 
hospital to the nonhospital site.
    Comment: Some commenters disputed the CMS interpretation of 
Congressional intent as discussed in the preamble of the proposed rule 
(see 68 FR 27213). One commenter stated: ``there is no support in the 
legislative history of the non-provider setting amendments [the 1986 
and 1997 amendments of the Act] for the Secretary's view that these 
changes were not intended to shift new costs to hospitals in support of 
on-going training in non-provider settings * * * it can be reasonably 
inferred that Congress was aware, and even intended, that some costs of 
existing residency training programs in non-provider settings would be 
shifted to hospitals in order for the hospitals to qualify for direct 
GME and IME funding under the 1986 and 1997 amendments of the Act.'' 
Similarly, another commenter stated that the Secretary ``must look 
elsewhere to the statute [other than section 1886(h)(4) of the Act] for 
support for his proposed rule; he cannot simply create out of whole 
cloth an interpretation that is inconsistent with the amendment's other 
provisions.''
    Response: The commenters would have us interpret and implement 
policy in a statutory vacuum. We believe we have reasonably discerned 
Congressional intent by interpreting the plain language of the statute 
at sections 1886(d)(5)(B) and 1886(h) of the Act in conjunction with 
the accompanying legislative history of these sections.
    As we stated in the preamble to the proposed rule, 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. In section 1886(d)(5)(B) of the Act (IME), the statute does 
not specify at all how FTE counts should be determined, and the plain 
language in the statute under section 1886 (h)(4) of the Act (direct 
GME) indicates that the Secretary ``shall establish rules'' for direct 
GME consistent with the statute. We also considered the deference 
expressed in 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--``[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.''(H.R. Conf. Rep. No. 105-217, 105th Cong., 1st Sess., 
821 (1997).
    Thus, in the absence of statutory specificity on determining FTE 
counts and the declared Congressional delegation 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.
    In addition, we have not, as the second commenter suggests, 
``created out of whole cloth'' an interpretation of the policy 
concerning counting residents in nonhospital settings that is 
``inconsistent with the amendment's other provisions,'' nor do we at 
all believe that ``it can be reasonably inferred that Congress was 
aware, and even intended, that some costs of existing residency 
training programs in non-provider settings would be shifted to 
hospitals in order for the hospitals to qualify for direct GME and IME 
funding under the 1986 and 1997 amendments of the Act,'' as the first 
commenter suggests. Rather, as we have stated, we believe that when 
Congress created the provisions on counting resident FTEs in 
nonhospital settings, it was creating a monetary incentive for 
hospitals to rotate residents from the hospital to nonhospital 
settings. We have drawn this conclusion, as we explained, from the 
legislative history of both the direct GME and IME provisions 
authorizing payments to hospitals for training in 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 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 inception 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 do not believe Congress intended 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 that authorizes 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 from the hospital 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 ``loss'' of IME payments acted as a disincentive and discouraged 
hospitals from rotating residents out of the hospital. It appears from 
the legislative history that 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.

[[Page 45448]]

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 ``add-on'' 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 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 situations 
where either the hospital rotated residents from the hospital to the 
nonhospital settings or where the hospital started new programs in the 
nonhospital settings (and incurred the direct GME costs from the 
programs' inception). The illustrative situations described above and 
in the proposed rule 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.
    Comment: One commenter cited section 1886(h)(5)(J) of the Act to 
support the general argument that CMS lacks the authority under the 
statute to ``impose additional conditions'' on counting FTE residents 
training in nonhospital sites--that is, the principles of 
redistribution of costs and community support. The commenter stated:

    This conclusion is further supported by Congress' treatment of 
family practice residency programs. In 42 U.S.C. Sec.  
1395ww(h)(5)(J), Congress provided a special payment provision for 
family practice residency programs. Specifically, Congress 
authorized hospitals to claim costs related to such programs even 
if, during the GME prospective payment base year--a year reimbursed 
under the reasonable cost system and a year to which the community 
support principle applied--the cost of such programs had been paid 
by the United States, a State, a political subdivision of the State, 
or an instrumentality of the State or political subdivision. 
Congress also provided that, in the event that such program payments 
were part of the PRA calculation during the GME base year, the 
payment in future years would be reduced ``in an amount equal to the 
proportion of such program funds received during the cost reporting 
period involved * * *.'' Thus, Congress has spoken to the issue of 
whether hospitals may claim costs in the current year if those costs 
have been paid in the past by third parties, and it has allowed 
reduction in current-year payments only if: (1) During the GME PPS 
base year, a third party had paid for the cost of the hospital's 
family practice residency program; and (2) as a result, the hospital 
had received a PRA that included an ``estimate of the amount that 
would have been recognized as reasonable * * * if the hospital had 
not received such funds.'' 42 U.S.C. Sec.  1395ww(h)(5)(J)(i). In 
all other situations, I submit, Congress does not permit the 
Secretary to reduce payments in the current year simply because, in 
the past, some third party may have paid the cost.

    Response: We disagree with the commenter that section 1886(h)(5)(J) 
of the Act supports the assertion that ``Congress has spoken to the 
issue'' of whether a hospital may claim third party costs and has 
allowed reductions in direct GME reimbursement resulting from 
redistribution of costs or community support in only the very limited 
circumstance of that exception in the Act. Generally, section 
1886(h)(5)(J) of the Act did two things: first, in subparagraph 
(J)(i)(1), Congress specifically allowed a hospital that only has an 
approved training program in family medicine and received a PRA in the 
base year of less than $10,000 for its family practice program, to 
receive a revised PRA that reflects the inclusion of ``funds from the 
United States, a State, or a political subdivision of a State * * *'' 
for the hospital's family practice program. Thus, the provision 
recognizes that ordinarily such funds would not be included in the 
hospital's base year per resident amount (because they were not 
incurred by the hospital in the base year). However, Congress 
explicitly created a narrow exception to the ``cost finding'' 
principles to allow such a hospital to include Federal, State, or local 
government grants to be included in the hospital's PRA base year 
calculation. Second, subparagraph (J)(i)(2) requires that direct GME 
payment to such a hospital that received a revised PRA amount under 
subparagraph (J)(i)(1) must also be reduced in subsequent cost 
reporting periods by the proportionate amount of funding the hospital 
receives from Federal, State, or local government payments. In other 
words, what subparagraph (J)(i)(2) does is to prohibit this hospital 
from receiving duplicative payments for the same GME program--both 
through the adjusted PRA and through continued Federal, State, and 
local government funding.
    The commenter argues that subparagraph (J)(i)(2) is the ``only'' 
situation where Congress has ``spoken'' about reductions in current 
year payment because of third party reimbursement. However, as we 
stated above, we believe the effect of subparagraph (J)(i)(2) is to 
prevent of duplicative payments for the same program that could 
otherwise occur in the narrow circumstances of the exception provided 
by section 1886(h)(5)(J), and has nothing to do with the continued 
applicability of the principles of redistribution of costs and 
community support. To the contrary, as we have stated, we believe that 
subparagraph (J)(i)(1) addresses a limited theoretical ``retroactive 
redistribution'' of costs and community support to allow a very narrow 
exception of allowing costs to be included in direct GME payment. Thus, 
we believe section 1886(h)(5)(J) of the Act would support our assertion 
that Congress intends application of redistribution of costs and 
community support to direct GME payment (except in the narrow 
circumstance of the type of hospital described in that section), rather 
than support the commenter's contrary assertion that the section is 
inconsistent with our proposal on application of the principles.
    Comment: One commenter suggested that the redistribution of costs 
and community support principles at nonhospital sites should apply on a 
``year-by-year basis,'' such that if another entity funds a training 
program during a particular fiscal year, the hospital would not be 
allowed to include the residents in its count for that fiscal year.
    Response: We believe the commenter's suggestion of a ``year-by-year 
basis'' policy is, in effect, already in place under existing Medicare 
policy without reference to the redistribution of costs or community 
support principles. Under the existing policy, where another entity 
funds a training program in a particular year while the residents are 
training at a nonhospital site--that is, incurs the residents' salaries 
and fringes, and the supervisory

[[Page 45449]]

physician costs (``all or substantially all of the costs''), the 
hospital may not include the residents in its FTE count for that fiscal 
year. This requirement, of course, is independent of the redistribution 
of costs and community support policy. It is based on the statutory 
requirement that allows a hospital to count residents training at 
nonhospital sites only if the hospital has incurred for all or 
substantially all of the costs of the program at that site during the 
hospital's fiscal year.
    Comment: One commenter stated that the 1989 final rule made clear 
that a hospital's resident count may also include residents for whom 
``community support was received'' through a State or local grant. 
Similarly, another commenter stated ``certain family medicine training 
programs that may have received outside funds, for example, State 
dollars, at any time in the past will be prohibited [by the hospital we 
proposed] from receiving GME reimbursement.''
    Similarly, another commenter stated that ``it is axiomatic'' that 
State-supported and public teaching hospitals receive State 
appropriations to support their residency programs. The commenter urged 
CMS to clarify that the application of the redistribution of costs and 
community support principles would not apply to State or local 
appropriations to public hospitals, with respect to the counting of FTE 
residents in either the hospital or the nonhospital setting.
    Response: As we explained in the 1989 final rule (54 FR 40302), 
grants that were restricted (those grants that were designated by the 
donor to pay for certain specified provider costs) or unrestricted were 
considered allowable costs of the hospital (including direct GME costs) 
when Medicare paid hospitals on a reasonable cost basis. The policy 
allowing payment to hospitals for costs that had been funded by grants 
was authorized by section 901 of the Omnibus Budget Reconciliation Act 
(OBRA) of 1980 (Pub. L. 96-499), which added section 1134 of the Act. 
Section 1134 of the Act applies to ``the reasonable costs of services 
provided by nonprofit hospitals or critical access hospitals.'' Section 
1134(1) of the Act specifies that a ``grant, gift or endowment or 
income therefrom which is to or for such a hospital * * *'' may not be 
deducted from the operating costs of such hospitals that are paid on a 
reasonable cost basis. Therefore, when hospitals were paid on a 
reasonable cost basis for direct GME costs, the ``community support'' 
that came from ``grants, gifts, or endowments'' was allowable under 
Medicare. We are clarifying in this final rule, that under the direct 
GME prospective payment methodology under section 1886(h) of the Act, 
if a hospital had received a grant, gift or endowment to subsidize its 
residency programs at the hospital, and the hospital requested direct 
GME payment for training the residents, it would not be considered 
community support. Under section 1134 of the Act, it is as if the 
hospital had itself incurred the cost for which it had received the 
grant subsidy. For example, if in 2003 a hospital received a State 
grant to fund its family practice program at the hospital, the grant 
would not be considered community support under our regulation. This is 
because we would treat the hospital as if itself incurred the costs for 
the family practice program, instead of the State grant.
    However, we note that this policy would not include ordinary State 
and local appropriations. As we mentioned in the January 12, 2001 final 
rule at 66 FR 3367, ``In administrative, legal and policy matters, we 
have consistently maintained that State appropriations for the cost of 
medical education activities constitute community support that is to be 
offset from a provider's allowable costs.'' Therefore, if a program 
were entirely funded by State or local appropriations, an inappropriate 
redistribution of costs would occur if the hospital subsequently begin 
to incur the costs of the residency program--for training inside or 
outside the hospital. Although, for most hospitals that receive State 
and local appropriations for their residency programs, the hospitals 
continuously incur (since the inception of the programs) some direct 
GME costs, there would be no disallowance of FTEs due to community 
support.
    We contrast the situation of a grant to a hospital with the 
situation of a grant to a nonhospital site. If, hypothetically, 
nonhospital sites were reimbursed by Medicare on a reasonable cost 
basis, and the nonhospital site had received grants to subsidize all of 
the direct GME costs for the residency program there, under section 
1134 of the Act, we would treat the costs the grant subsidized as if 
they were costs of the nonhospital site. If a hospital then tried to 
incur the direct GME costs, this could be a redistribution of costs or 
community support issue, since the hospital would be claiming FTE 
residents who had historically trained at the nonhospital site for whom 
the community had assumed the cost of that training, as described in 
the scenarios at 68 FR 27213.
    Comment: Several commenters objected to the sentence in the 
preamble to the proposed rule that stated: ``* * * 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.'' 
One commenter explained that there are a number of situations where a 
hospital is truly incurring the cost of having a resident at a site, 
but the hospital is not incurring the cost of the entire complement of 
residents. ``For example, if two different hospital programs each elect 
to send residents to the same clinic, under the interpretation in the 
[proposed rule], neither of the two hospitals would be able to count 
any of the residents because neither of the two programs would incur 
the cost of the full complement of residents.'' Another commenter 
believed that ``this change'' runs contrary to other current Medicare 
policies that focus on the resident rather than the program. The 
commenter believed that both the direct GME and IME regulations ``are 
replete with references to `resident' rather than `program'.'' The 
commenter believed that ``residency program'' is referenced only in the 
context of the requirement that, for residents to be counted for direct 
GME and IME payments, they must be part of an ``approved program'' 
(Sec.  413.86(f)(1)).
    Response: We understand the concerns of the commenters about the 
requirement for a hospital to incur ``all or substantially all of the 
cost'' of training residents in a training program at a nonhospital 
site. However, we do not believe this is a change in policy. We believe 
that the policy that requires a hospital to incur the cost of ``the 
program'' in the nonhospital site has existed since the passage of the 
direct GME provisions, section 9314 of the Omnibus Budget 
Reconciliation Act of 1986 (Pub. L. 99-509), and the passage of the IME 
provision, section 4621(b)(2) of the Balanced Budget Act of 1997 (Pub. 
L. 105-33), that permitted hospitals to continue to count residents in 
nonhospital sites, for purposes of direct GME and IME payment, if the 
hospital incurred ``all or substantially all of the cost'' of residents 
training in the program.
    As we explained in the proposed rule, 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.) Therefore, we believe a 
better reading of this language is that hospitals must incur all

[[Page 45450]]

or substantially all of the cost for the full complement of residents 
in the training program at the nonhospital site.
    We note that the policy that requires the hospital to incur the 
cost of the program does appear to be somewhat of a departure from 
other current Medicare policies on graduate medical education that 
focus on the resident rather than the program, as the commenter 
suggests. However, we believe the statutory provisions cited above 
require hospitals to assume the cost of the full complement of 
residents training in the program at the nonhospital sites in order to 
count any FTE residents training at that site.
    In addition, as we noted at 68 FR 27217 of the proposed rule, and 
also above, under policy on the application of the redistribution of 
costs and community support principles, it is permissible 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 is not permitted to 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.
    Comment: Several comments cited a letter from CMS (then the Health 
Care Finance Administration, or ``HCFA'') dated March 30, 1999 to C. 
Scott Litch of the American Association of Dental Schools (now the 
American Dental Education Association). Specifically, these commenters 
cited a sentence in the letter to Mr. Litch which stated: ``If a 
hospital establishes a new relationship with a dental clinic and meets 
the conditions for counting residents training outside the hospital, 
the hospital may count more residents currently for indirect and direct 
graduate medical education than were counted in 1996 if those residents 
are dental residents.'' One commenter stated that the ``new 
relationship'' referred to in the letter from CMS presupposes the 
existence of an ongoing program whose costs presumably had been met by 
means other than the hospital before the affiliation with a nonhospital 
dental clinic began. This commenter believed that this letter provided 
assurance to many hospitals that new affiliations with preexisting 
dental programs were permissible.
    Response: We do not agree with the commenter that the sentence in 
the letter to Mr. Litch ``presupposes the existence of an ongoing 
program'' where the costs of such a program ``had been met by means 
other than the hospital''. Rather, we believe the ``new relationship'' 
between the hospital and the dental clinic could be reconciled with 
application of the principles of redistribution of costs and community 
support and characterized by two possible interpretations, both of 
which would allow for the counting of residents in nonhospital sites--
(1) where the hospital would rotate residents from the hospital to the 
nonhospital site; or (2) where the hospital would fund new training 
slots at the nonhospital site (the dental clinic referred to in the Mr. 
Litch's letter). Such assignments from the hospital to the dental 
clinic, or new residency training slots, would be the ``new 
relationship,'' but in either case, no redistribution would occur. 
Therefore, we do not believe the letter from 1999 is necessarily 
inconsistent with the principles of redistribution of costs and 
community support described in the proposed rule.
    Comment: Many commenters, while remaining generally opposed to 
application of redistribution of costs and community support 
principles, requested that if CMS were to finalize the proposed rule, 
CMS apply the principles prospectively. One commenter, a dental school, 
explained that it had just admitted a new class of residents, many of 
whom will not complete their programs until 2006. The commenter 
believed that, in the application of the principles, CMS seeks to 
remove all Medicare funding for these residents retroactively. Along a 
similar vein, another commenter pointed out in support of the 
suggestion to apply the principles only prospectively, that the 
implementation of the proposed regulation would result in ``substantial 
dislocation and hardship to hospitals, dental and other schools, and 
the residents themselves.'' Therefore, the commenter believed CMS 
should indicate specifically in the final rule that such changes will 
only be applied to a provider's cost reporting period beginning on or 
after October 1, 2003, and CMS should not apply its final GME policy on 
redistribution of costs and community support to any prior cost 
reporting periods that remain open or unsettled, or are settled but 
potentially subject to reopening under the Medicare rules.
    In addition, several commenters requested clarification regarding 
the effective date for the proposed application of the principles of 
redistribution of costs and community support to FTE counts. 
Specifically, the commenters point to the following language in the 
proposed rule:
    [sbull] ``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.'' (68 FR 27215)
    [sbull] ``We 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.'' (68 FR 27216)
    [sbull] ``[i]f 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 payment with respect to those FTE residents would certainly 
be required.'' (68 FR 27216)
    [sbull] ``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 cost of 
residents training in a particular program since the date the residents 
first began training in the program in order for the hospital to count 
the FTE residents.'' (68 FR 27417)
    Response: We have stated that we believe the principles of 
redistribution of costs and community support are longstanding Medicare 
policy. While we have reminded the public of the continuing application 
of the principles in various regulations and program guidance, we also 
recognize that CMS has not had occasion to invoke them in Agency policy 
expressions relating specifically to direct GME payments since the 
direct GME PRA base year.
    As we have stated, we believe redistributions would occur only in 
rare circumstances for residency training inside the hospital. Between 
1987 and 1997 when hospitals could count FTE

[[Page 45451]]

residents training in nonhospital sites for purposes of direct GME 
payments, but not IME payments, we did not observe the kinds of 
inappropriate counting of FTE residents we described in our proposed 
rule. It is only since hospitals have been allowed to count FTE 
residents training in nonhospital sites for purposes of IME payment, 
that CMS has become aware that cost shifting has become prevalent in 
the hospital industry, which has implicated the principles of 
redistribution of costs and community support. Therefore, in general, 
we are implementing a prospective effective date of October 1, 2003, 
for purposes of payment. That is, for direct GME, effective for 
portions of cost reporting periods beginning with October 1, 2003, and 
for IME, effective for discharges occurring on or after October 1, 
2003, a hospital must have been continuously incurring direct GME costs 
of residents training in a particular program since the date the 
residents first began training in the program in order for the hospital 
to count the FTE residents. We note that the effective dates apply only 
as they relate to disallowances of FTEs and bear no relation to 
determinations of redistributions or community support. Therefore, in 
general, a fiscal intermediary that determines that a redistribution of 
costs has taken place for a particular hospital prior to October 1, 
2003, may disallow FTEs based on that determination beginning with 
October 1, 2003. For example, if a fiscal intermediary determines that 
a redistribution of costs has occurred that affected 10 FTEs for direct 
GME and IME during the hospital's cost report ending in fiscal year 
ending in 1999, the fiscal intermediary would take disallowances for 
those 10 FTEs, but not until October 1, 2003, for purposes of direct 
GME and IME payment.
    In addition, because we have received a large number of public 
comments expressing surprise and confusion regarding our policy on 
these principles, we are grandfathering residents who began training in 
a program on or before October 1, 2003. That is, an FTE resident who 
began training in a residency program on or before October 1, 2003 (the 
effective date of this final rule), and with respect to whom there has 
been a redistribution or community support, may continue to be counted 
by a hospital for purposes of direct GME and IME payments after October 
1, 2003, until the resident has completed training in that program, or 
until 3 years after the date the resident began training in that 
program, whichever comes first. We believe continued direct GME and IME 
payments to the hospital while the ``redistributed'' residents finish 
their training for up to 3 years is appropriate to address many 
situations in which nonhospital sites have made arrangements with 
hospitals to shift the costs of training those residents. We understand 
that, in nonhospital sites, virtually all dental residency programs are 
of a duration of 3 years in length or less. This policy addresses the 
situation pointed out by the dental school commenter and other 
commenters that a school may have just admitted a new class of 
residents, many of whom will not complete 3-year programs until 2006.
    We note that this prospective ``grandfather'' policy does not apply 
to resident FTEs with respect to whom there has been a redistribution 
of costs or community support, and who begin training after October 1, 
2003. In addition, those residents described above who began training 
in a program on or before October 1, 2003, may be counted until those 
particular residents finish their training in that program (or 3 years, 
whichever comes first). In order to count such residents, we are 
requiring that hospitals identify those residents (by social security 
number) to their fiscal intermediary and specify the length of time the 
hospital will be counting these FTE residents for direct GME and IME 
payment purposes.
    We note that the policy described above that effectively 
``grandfathers'' residents who began their training on or before 
October 1, 2003, applies only as it relates to payments to hospitals 
for those specified FTE residents, and bears no relation to 
determinations of whether a redistribution of costs or community 
support has taken place. Therefore, if a fiscal intermediary determines 
that a redistribution of costs has taken place with respect to 
residents counted by a particular hospital even prior to October 1, 
2003, the intermediary will disallow any FTEs based on that 
determination, beginning October 1, 2003, except for the 
``grandfathered'' residents. Hospitals that continue to count 
grandfathered FTE residents (where the costs of whom had been 
redistributed) may only do so until those residents finish their 
training in the specific program they were training in on or before or 
to October 1, 2003 (which would be no later than September 30, 2006, 3 
years after October 1, 2003).
    For example, a fiscal intermediary determines for a hospital's FYE 
December 31, 2003 cost report that a redistribution of costs has taken 
place with respect to certain FTEs the hospital counted for direct GME 
and IME (that is, the costs of training residents at a nonhospital site 
were incurred by a university from 1990 through 1999). Assume that 5 
FTEs began training in a 2-year orthodontics program in a dental school 
on July 1, 2003, and another 5 residents begin their training in the 
same program on July 1, 2004. The 5 FTEs who began training on July 1, 
2003, are ``grandfathered,'' and, therefore, the fiscal intermediary 
would not disallow these 5 FTEs as of October 1, 2003. The hospital may 
continue to count these 5 FTEs that began training on July 1, 2003 
through June 30, 2005, when they finish the 2-year orthodontics 
program. We note that subsequent to completion of the 2-year 
orthodontics program on June 30, 2005, if any of these 5 FTEs 
participate in additional GME training programs, the fiscal 
intermediary would disallow these FTEs because disallowances for 
redistribution of costs and community support relate to FTE slots and 
not specific residents.
    However, the 5 FTEs that began training in the 2-year orthodontics 
program on July 1, 2004 are not ``grandfathered,'' and, therefore, 
beginning July 1, 2004 of the hospital's December 31, 2004 cost report, 
the fiscal intermediary will disallow IME and direct GME payment 
associated with these 5 FTE slots.
    Comment: Commenters disputed the situations we cited in the 
preamble to the proposed rule that were supposed to be illustrative of 
what we believe to be inappropriate application of Medicare direct GME 
and IME policy at 68 FR 27213. One commenter, in particular, requested 
information on the identity of programs cited in the examples.
    Response: We do not believe it is appropriate to disclose the 
identities of those cited in the examples. Therefore, we are unable to 
respond to the commenters' points on the matter, except to state that 
the situations in the examples represent what we believed are the more 
``egregious'' scenarios involving redistribution of costs and community 
support principles and inappropriate counting of FTE residents, we note 
that the same issues arise, and the same principles apply, whether the 
counting of residents relates to training that is taking place in 
another country, another State, or on the same hospital campus, as the 
hospital.
    Comment: One commenter believed that CMS's policy on the 
application of the redistribution of costs and community support will 
lead to considerable, ``but needless,'' litigation over what it means 
to ``incur'' the costs of off-site training.
    Response: We disagree with the commenter and see no reason to be

[[Page 45452]]

concerned that these clarifications would result in any more litigation 
than other Medicare payment policies that are conditioned on whether a 
provider incurs costs. For example, for several decades, Medicare 
policy required that hospitals ``incur'' costs in order to receive 
payment from Medicare. The Medicare statute and regulations currently 
require that a hospital incur certain costs in order to count FTE 
residents training in nonhospital sites for purposes of direct GME and 
IME payments. We are unsure why the requirement under the policy on 
redistribution of costs and community support that a hospital ``incur'' 
the direct GME cost continuously for a residency program at a training 
site is any more complex than other cost requirements under Medicare.
    Comment: One commenter suggested that we craft a narrower solution 
to the issue of inappropriate counting of FTE residents in nonhospital 
sites by focusing the language on salary and benefits for residents. 
The commenter believed that CMS could state that, unless the hospital 
in 1999 had incurred the costs of salary and benefits for FTE residents 
who were training in offsite locations, the hospital may not receive 
direct GME and IME payment for training those FTE residents at the 
nonhospital sites today.
    Response: We do not believe a policy such as the one the commenter 
suggested--determining redistribution of costs based upon whether a 
hospital continuously incurs the residents' salaries and benefits 
during training in the nonhospital site-- is necessary or appropriate. 
This is because, under the policy on redistribution of costs and 
community support we describe in the proposed rule and in this final 
rule, a hospital that continuously incurs the residents' salaries and 
benefits (from 1999 or before) while the residents train in the 
nonhospital site, or even inside the hospital, would not be 
redistributing costs if the nonhospital site later incurs the other 
direct GME costs (such as supervisory physician salaries) in the 
nonhospital site. There would be no redistribution of costs because the 
hospital would have continuously incurred at least some of the direct 
GME costs (the residents' salaries and benefits) since the inception of 
the program. However, we note that even if there has not been a 
redistribution of costs or community support with FTE residents 
training in a nonhospital site in such a scenario, the hospital would 
still need to meet the requirements in the existing regulations (at 
Sec.  413.86(f) and Sec.  412.105(1)(ii)(c)) in order to count those 
FTE residents for purposes of direct GME and IME payment.
    For example, Hospital A has had a family practice program with 10 
FTE residents for about 20 years, for which the hospital has incurred 
the residents' salaries and fringes and some other (but not all) direct 
GME costs for the program. For the first time, in fiscal year ending 
2003, Hospital A rotates 2 FTE residents to an ambulatory clinic (a 
nonhospital site), and fulfills the requirements at Sec.  413.86(f)(4), 
including incurring ``all or substantially all of the costs'' of the 
training program in the nonhospital site. There is no redistribution of 
costs with respect to these 2 FTE residents because Hospital A has 
continuously incurred some of the direct GME costs of the program--the 
residents' salaries--and therefore it may count the 2 FTE residents 
training at the clinic (up to the hospital's FTE cap), since it also 
has complied with the requirements at Sec.  413.86(f)(4).
    Comment: Some commenters suggested that the application of 
redistribution of costs and community support principles would impose 
large administrative burdens on hospitals to demonstrate which entity 
has been ``continuously incurring'' the costs of the residency 
training. One commenter stated: ``[t]his burden would be additive to a 
policy that already is fraught with excessive administrative 
requirements.''
    One commenter asked if hospitals would be required to document 
responsibility for the costs of training residents prior to January 1, 
1999.
    Response: If the hospital has continuously been incurring at least 
some of the direct GME costs (for example, resident salaries or 
supervisory physician salaries) since the inception of the residency 
program, we do not believe any additional documentation is necessary 
beyond which hospitals are already required to maintain. If resident or 
supervisory physician salaries, for instance, are paid through the 
hospital payroll, the hospital will have kept documentation of such 
costs for Federal tax purposes.
    In response to the second comment, we stated in the proposed rule 
that January 1, 1999 should be used by our fiscal intermediaries as the 
date for determinations of whether a hospital or another entity has 
been incurring the costs of a training in a particular program at a 
training site for purposes of determining whether there has been a 
redistribution of costs or community support. This date was chosen as 
an administrative convenience because we believe it could otherwise be 
difficult for our fiscal intermediaries to obtain contemporaneous 
documentation that the hospitals have appropriately been incurring 
costs in earlier years. Therefore, we believe that, for purposes of 
determining redistribution of costs or community support, most 
hospitals would only be required to maintain appropriate documentation 
to demonstrate that they have continuously been incurring the direct 
GME costs from January 1, 1999 forward. However, as we mentioned in the 
proposed rule, if the fiscal intermediaries determine that there was a 
redistribution of costs or community support for a fiscal year ending 
for a cost report for a particular hospital prior to January 1, 1999, 
the hospital would be required to show contemporaneous documentation to 
prove otherwise.
    Comment: One commenter stated that it may be difficult to track 
residents that have been funded by some type of community support. The 
commenter described a scenario where a program at a hospital has four 
internal medicine residents and one is covered by some type of 
community support for a 3-year period. The commenter stated that it may 
be difficult to track that slot over the next 5, 10, or 20 years to 
avoid submitting it for future direct GME or IME payments.
    Response: As we stated above, we understand there may be 
administrative issues that hospitals must confront in their efforts to 
comply with the principles of redistribution of costs and community 
support. However, we do not believe it would very difficult to track 
the FTEs in a program that receives community support. Once the FTE 
residents for which community support is received have been identified, 
the hospital will know the number of FTE residents to remove from the 
count that is submitted in future cost reports (all of which will be 
subject to audit by our fiscal intermediaries). Using the commenter's 
example, if direct GME costs for one out of four FTEs in an internal 
medicine program is identified as being entirely subsidized by 
community support for three years (the duration of an internal medicine 
program), the hospital would know to refrain from counting one FTE in 
future cost reports, even after the 3 years of training for a 
particular resident has passed. This is because, as the commenter 
seemed to understand, the redistribution of costs and community support 
principles are applied to the FTE resident training slots of a 
hospital; the principles are not associated with a particular resident, 
to which the principles could apply differently from year to year.
    Comment: One commenter disagreed with the choice of words used in 
the

[[Page 45453]]

proposed definition of ``redistribution of costs'' at proposed Sec.  
413.86(b). As proposed, the definition states: ``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 who were in medical residency programs where the costs of the 
programs had previously been incurred by the educational institution.'' 
In particular, the commenter objected to the first part of the 
definition: ``an attempt by a hospital to increase the amount it is 
allowed to receive from Medicare.'' The commenter believed that the 
phrase was unnecessary to the definition and should be deleted.
    Response: We understand the concern of the commenter. However, we 
have used ``the attempt'' language at Sec.  413.86(b) for the proposed 
definition of ``redistribution of costs'' primarily because we have 
adopted the language of the existing regulation at Sec.  413.85(c) that 
defines ``redistribution of costs'' (now applicable to costs of 
approved nursing and allied health education activities). The language 
was not intended to be offensive. Rather, we meant it to be descriptive 
of a possible motive for a redistribution of costs. In light of the 
commenter's suggestion, we are revising the language to be purely 
descriptive of the scenario of the redistribution and not reflect a 
possible motive. Accordingly, we are revising the language at Sec.  
413.86(b) to state: ``Redistribution of costs'' occurs when a hospital 
counts FTE residents in medical residency programs and the costs of the 
programs had previously been incurred by an educational institution. In 
the future, we will consider conforming changes to the definition of 
``redistribution of costs'' at Sec.  413.85(c) as well.
    Comment: Some commenters believed that, through the enactment of 
the 1996 cap on the count of allopathic and osteopathic residents, 
Congress has already dealt with the problem that CMS is attempting to 
revisit with the proposed rule. The commenters believed that when 
Congress exempted the dental residents from the caps, it intended to 
create hospital incentives for dental training. The commenters believed 
that the CMS redistribution of costs and community support policy 
contradicts this Congressional intent.
    Response: We do not believe that when Congress instituted the caps 
on the count of residents with the Balanced Budget Act of 1997, it was 
aware that inappropriate counting of FTE residents could occur through 
redistribution of costs. CMS, itself, did not become aware that many 
hospitals were engaging in these cost shifting arrangements, very often 
involving dental residents since at least October 1, 1997, when 
hospitals were authorized to count FTE residents for purposes of IME 
payments, as well as direct GME payments, for training in nonhospital 
sites. As we stated above, it is only since the audits by our fiscal 
intermediaries of the fiscal year ending 1998 and 1998 cost reports 
that have occurred within the last 2 years that CMS became aware that 
significant cost shifting was taking place. Therefore, we do not 
believe Congress would have been in a position to consider whether to 
authorize cost shifting in its 1997 legislation. Thus, we do not 
believe, as the commenters do, that Congress expected, or tacitly 
condone, cost shifting to dental residents as a result of exempting the 
dental residents from the 1996 caps. Rather, we believe that when 
Congress exempted dental residents from the 1996 caps, it intended to 
allow more dental training to occur in the hospital, not to authorize 
cost shifting from dental schools to hospitals and to the Medicare 
program.
    Comment: One commenter asked what types of costs the hospital is 
required to incur for training in nonhospital sites in order for there 
to be no redistribution of costs or community support. Specifically, 
the commenter described a scenario under which a teaching hospital and 
a medical school are related parties and asked whether the teaching 
hospital is required to pay for the teaching physician services 
relating to offsite rotations at a medical school clinic before the FTE 
residents participating in the rotation can be counted for purposes of 
IME or direct GME payment.
    Response: We understand from the scenario described by the 
commenter that hospital-based residents are being rotated to the 
medical school clinic. As such, we assume that the hospital is already 
incurring at least the residents' salary and fringe benefits. 
Therefore, when rotating the residents to the clinic, the hospital is 
incurring at least some of the direct GME costs of training the 
residents. Under these circumstances, a redistribution of costs has not 
taken place. However, according to the requirements for counting FTE 
residents in nonhospital settings under Sec.  413.86(f)(4), among other 
requirements, the hospital is required to incur the portion of the 
teaching physicians' salaries and fringe benefits attributable to 
direct GME (by the term ``related party,'' we are assuming that the 
medical school clinic is not provider-based as specified under Sec.  
413.65, and therefore, is not considered part of the hospital). Thus, 
under the commenter's scenario, the hospital may be prohibited from 
counting the FTE residents, not because of redistribution of costs but 
because of failure to incur ``all or substantially all of the cost'' 
under Sec.  413.86(f)(4) if the hospital is not incurring the 
supervisory physician's salary attributable to direct GME.
    Comment: A number of commenters argued that the proposed 
application of the redistribution of costs and community support 
principles is bad public policy from the perspective of access, quality 
and cost-effectiveness of oral health care.
    Response: We understand that dental training programs provide much 
needed oral health care to the American public and did not 
intentionally target them with our policy on redistribution of costs 
and community support. However, we believe much of the inappropriate 
cost sifting to hospitals and to the Medicare program is related to 
dental residency programs--which is probably due to the fact that 
dental residents are exempted from the statutory 1996 FTE caps. 
Although we regret that publication of this rule may upset some newly 
formed relationships between hospitals and dental schools, we continue 
to believe that the Medicare program should not pay for nonhospital 
dental residency training that had previously been funded by other 
sources, without any sponsorship by hospitals or the Medicare program.
    Comment: One commenter stated that by establishing a PRA floor 
equal to 85 percent of the locality-adjusted national average PRA, 
Congress created an exception to the principles of community support 
and redistribution of costs. The commenter noted that this floor 
increased reimbursement to a number of teaching hospitals around the 
country whose own PRAs were low ``precisely'' because the community or 
another educational institution had been bearing the training costs in 
the GME PRA base year. Therefore, the commenter argued, the PRA floor 
``picked up'' some of those disallowed costs, and that Medicare is, in 
effect, currently paying for those costs in the PRAs that were raised 
to the floor.
    Response: The commenter is referring to section 311 of the Balanced 
Budget Refinement Act (BBRA) of 1999 (Pub. L. 106-113), which, for FY 
2001, established a floor PRA at 70 percent of the locality-adjusted 
national average PRA, and to section 511 of the Benefits Improvement 
and Protection Act (BIPA) of 2000 (Pub. L. 106-554), which, for FY 
2002, established a floor PRA at 85 percent of the locality-adjusted 
national average PRA. Regulations concerning

[[Page 45454]]

these provisions are implemented at Sec.  413.86(e)(4). These 
provisions were intended, in part, to narrow the disparities (both high 
and low) in direct GME payments to teaching hospitals across the 
country. One of the reasons a number of hospitals had low base year 
PRAs is because a significant amount of their GME costs in the PRA base 
year was incurred by another entity (that is, the ``community''). 
(Variations in base year PRAs were otherwise due to differences in 
hospital-specific accounting practices and differences in reimbursement 
methods for supervising physician and resident salaries.) By providing 
for increased GME payments to certain hospitals with low PRAs, we do 
not believe Congress implicitly condoned, or made an exception to, the 
redistribution of costs and community support principles. We note that 
Congress provided for an increase to the floor PRA for all hospitals 
that had PRAs below the floor, not just to hospitals that, in the base 
year, did not incur certain GME costs. Rather, we believe Congress 
intended to provide increased GME payments to hospitals with low PRAs, 
regardless of the reasons those particular hospitals may have had low 
PRAs, in an attempt to even out some of the disparity in PRAs, 
nationally.
    Comment: A commenter noted that the among the examples cited in the 
proposed rule at 68 FR 27213 as illustrative of inappropriate 
application of Medicare IME and direct GME policy, we described a 
situation where a hospital on the East Coast of the United States is 
counting dental residents training in nonhospital sites in Hawaii. The 
commenter believed that we have incorrect information regarding this 
program, and that there is, in fact, no redistribution of costs from 
the community to the Medicare program with respect to the program in 
Hawaii. Specifically, the commenter explained that in August 2002, a 
hospital in New York placed one dental resident in a clinic located in 
Honolulu. The New York hospital pays the costs of the resident's 
stipend and the supervising faculty's salary, and there is a written 
agreement between the hospital and the clinic. The commenter stated 
that in the future, the program anticipates placing additional 
residents at other nonhospital sites in Hawaii.
    Response: As we stated in the preambles to the proposed rule and 
this final rule, there would be no redistribution of costs or community 
support if, from the outset of the program, a hospital incurs direct 
GME costs. Therefore, if, in fact, a hospital in New York has been 
incurring direct GME costs for a training program located in a clinic 
in Hawaii since the program's inception, then there would be no 
redistribution of costs or community support. The hospital in New York 
could count FTE residents training in the nonhospital site as long as 
the applicable requirements are met.
    Comment: One commenter that described a scenario in which a 
university funded a family practice program for many years. However, in 
2000, a Federally Qualified Health Center (FQHC) entered into a written 
agreement with the university and began reimbursing the university for 
``all or substantially all'' of the costs of the program. The FQHC has 
been receiving Medicare direct GME payments since that time. The 
commenter stated that under the terms of the proposed rule, this FQHC 
would be ineligible for receipt of GME payments, since, prior to 2000, 
the program was funded exclusively by the university.
    Response: The commenter raised the point that the redistribution of 
costs and community support principles are applicable to providers 
other than hospitals that may receive Medicare payments for residency 
training. Specifically, FQHCs and RHCs under Sec.  405.2468, CAHs under 
Sec.  413.70, and Medicare+Choice organizations (MCO) under Sec.  
422.270 may qualify to receive payments for direct GME costs. We note 
that the existing regulations at Sec.  405.2468(f)(6) for FQHCs and 
RHCs, and at Sec.  422.270(c) for MCOs, already clearly state that the 
allowable direct GME costs of these entities are subject to the 
redistribution of costs and community support principles in Sec.  
413.85(c). We agree with the commenter and are also clarifying the 
regulations at Sec.  413.86(i) to clearly state that the principles of 
redistribution of costs and community support apply equally to 
hospitals, FQHCs, RHCs, CAHs, and MCOs. Therefore, we agree that, in 
the situation described by the commenter the FQHC would not be eligible 
for Medicare direct GME payments since the family practice program 
represents a redistribution of costs from the community (that is, the 
university) to the Medicare program (that is, the FQHC through direct 
GME payments).
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 1, 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

[[Page 45455]]

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 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, in the May 19, 2003 
proposed rule, we proposed to revise our regulations. Proposed Sec.  
413.86(g)(12) still addressed 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 ``two-thirds'' as the criterion 
to specify the amount of time residents training in the rural areas 
under regulations at Sec. Sec.  413.86(g)(12)(i) through (iv) and 
412.105(f)(1)(x), as under current policy, the proposal would use 
``one-half'' as the criterion. This proposal addressed 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 proposed 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 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, 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 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

[[Page 45456]]

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 in 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 proposed 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 the 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 provide GME payments for significant rural residency 
training.
    Comment: Several commenters supported our proposal that, effective 
for cost reporting periods beginning on or after October 1, 2003, an 
urban hospital would be allowed to include residents in its FTE count 
above its FTE cap for the time that the residents train at the urban 
hospital, if the residents rotate to a separately accredited rural 
track program in a rural area for more than one-half of the duration of 
the program. The commenters believed that this proposed policy better 
reflects Congressional intent to encourage training in rural areas, 
while allowing residency programs the flexibility to rotate residents 
back to urban areas for needed clinical experiences that are not 
available in the rural setting.
    One commenter recommended that the proposal should reduce the 
required rural training time even further, since research suggests that 
more than 50 percent of family practice residents who spend as little 
as 3 months training in rural areas end up practicing in rural 
settings.
    Response: We agree with the commenters 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. 
However, we do not agree that urban hospitals should be allowed to 
receive an increase in their FTE caps to include residents in its FTE 
count for the time that the residents train at the urban hospital, if 
the residents rotate to a rural area for one-half or less than one-half 
of the duration of the program. As we stated in the August 1, 2001 
Federal Register (66 FR 39904-39905), we interpret section 
1886(h)(4)(H)(iv) of the Act as only allowing for an urban hospital to 
receive an adjustment under the rural track provision if the rural 
track program is ``separately accredited.'' In order to be separately 
accredited as a rural track, the program must meet the ACGME's ``1-2'' 
criteria; that is, the residents are typically spending approximately 
two-thirds of the duration of the program in the rural area. We also 
explained that while we agree that post-residency retention in rural 
areas is important, we also believe it is important to prevent 
hospitals from receiving adjustments to their FTE caps in situations 
when only a nominal amount of training occurs in the rural area. 
Therefore, we are not adopting the commenter's request to allow an 
urban hospital to receive an increase in its FTE caps to include 
residents in its FTE count for the time that the residents train at the 
urban hospital, if the residents rotate to a rural area for one-half or 
less than one-half of the duration of the program.
    Comment: One commenter that works for a community health center 
(CHC) that treats a high percentage of patients below the poverty line 
expressed concern about the detrimental effects that shrinking hospital 
revenues are having on the training of family practice residents at the 
CHC and at other rural and community-based settings. The commenter 
noted that doubling the number of CHCs is a goal of the President, and 
urged that, if there should be further ``restraint'' on teaching 
programs, programs that expand into CHCs should be exempt from such 
restrictions.
    Response: We appreciate the comment. However, we note that since we 
did not specifically make any proposals related to residency training 
in community health centers, this comment is outside the scope of this 
final rule. Therefore, we are not responding to it at this time.
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 Pub. 
L. 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

[[Page 45457]]

Medicare patient load to determine Medicare direct GME payments).
    Section 407(c) of Pub. L. 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.
    In the May 19, 2003 proposed rule, we proposed 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 proposed 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.
    Comment: Commenters supported our proposal to revise Sec.  
413.86(g)(5) to clarify that 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. The commenters stated 
that allowing immediate inclusion of rural track resident counts will 
serve to assist urban hospitals in their development of educational 
partnerships with rural hospitals.
    Response: We appreciate the commenters support and, as explained 
below, are adopting revisions to the regulations concerning inclusion 
of rural track residents in the rolling average count of urban 
hospitals as final.
    Except for new rural track programs begun by urban hospitals that 
are first establishing an FTE cap under Sec.  413.86(g)(6)(i), or for 
rural hospitals that are establishing new rural track programs under 
Sec.  413.86(g)(6)(iii), we are implementing sections 1886(d)(5)(B) and 
1886(h)(4)(H) of the Act to require that FTE residents that are counted 
by an urban hospital based on the residents' participation in a rural 
track are included in the rolling average calculation. Accordingly, for 
IME and direct GME purposes, unless the rural track program is a new 
program under Sec.  413.86(g)(13) and qualifies for a cap adjustment 
under Sec.  413.86(g)(6)(i) or (g)(6)(iii), in instances where an urban 
hospital increases the number of residents it trains due to the 
establishment of a new or an expansion of an existing rural track 
program, the additional FTE residents in the rural track program are 
only gradually included (over a 3-year period) in the urban hospital's 
FTE count, since they are immediately included in the rolling average 
calculation of the urban hospital.
    The following is an example of how residents in a rural track would 
be included in the rolling average calculation:
    Assume that urban Hospital A, with a fiscal year end (FYE) date of 
June 30, had 10 unweighted FTE residents training in its cost reporting 
period ending June 30, 1996, thereby establishing an FTE cap of 10. 
Hospital A only trains primary care residents. In its cost reporting 
periods ending on June 30, 2002, and June 30, 2001, Hospital A again 
trained 10 FTE residents. However, in July 2002, Hospital A starts a 
rural training track program, adding 2 FTE residents. Since the 
additional rural track residents are included immediately in the 
rolling average, in FYE June 30, 2003, Hospital A's FTE residents for 
payment purposes equal 10.67 FTEs (12 + 10 + 10 / 3) and not 12 FTEs 
[(10 + 10 + 10 / 3) + 2], which would be the FTE count if FTEs in a 
rural track program were not subject to the rolling average 
calculation.
    We are finalizing our proposed revision of Sec.  413.86(g)(5) to 
add a new paragraph (vii) as explained above. In addition, we are 
finalizing our revision of 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 the 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).

[[Page 45458]]

    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, in the May 19, 2003 proposed rule, we proposed 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 proposed to revise the 
regulations at Sec.  413.86(b) to state ``Medicare GME affiliated 
group,'' and ``Medicare GME affiliation agreement''. We proposed to 
make 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.
    Comment: Commenters supported our proposal to change the terms 
``affiliated group'' and ``affiliation agreement'', as defined in Sec.  
413.86(b), to ``Medicare GME affiliated group'' and ``Medicare GME 
affiliation agreement'', respectively. The commenters believed that the 
changes in terminology will help distinguish these terms from other 
affiliation agreements that are entered into by hospitals, medical 
schools, and other institutions that sponsor residency training.
    Response: We agree with the commenters and are adopting as final 
the proposed changes throughout Sec.  412.105 for IME and Sec.  413.86 
for direct GME.

Out of Scope Comments Relating to GME

    Comment: Several comments addressed miscellaneous IME and direct 
GME issues, including the initial residency period (IRP) and volunteer 
physicians.
    Response: Because we did not propose any changes in policy 
concerning these issues, we are unable to respond to these comments at 
this time. We will consider them for purposes of future rulemaking.

G. 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 
under the IPPS or as 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 under either Part A or Part B is 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 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 update methodology for the 
RCE limits by replacing the CPI-U with the inflation factor for the 
physician fee schedule (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. Updated RCE Limits
    In the May 19, 2003 proposed rule, we indicated our intent to 
publish updated payment limits on the amount of allowable compensation 
for services furnished by physicians to providers in this FY 2004 IPPS 
final rule. These revised RCE limits are based on updated economic 
index data and replace the limits that were published in the Federal 
Register on May 5, 1997 (62 FR 24483). We calculated the revised RCE 
limits by using the methodology published in the Federal Register on 
October 31, 1997 (62 FR 59075). These limits are specified in the chart 
below and are effective for cost reporting periods beginning on or 
after January 1, 2004.
    The revised RCE limits are mere updates that have been calculated 
by applying the most recent economic index data. In the proposed rule, 
we did

[[Page 45459]]

not propose to change the methodology used to determine the limits. We 
indicated that, 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, 
indicated our belief that publication of the revised RCE limits in a 
proposed rule with opportunity for public comment was unnecessary, and 
that we found good cause to waive the procedure.
    Comment: One commenter was encouraged to learn of our proposal to 
publish updated RCE limits and suggested that these updates occur on an 
annual basis.
    Response: We will continue to review the RCE limits on a regular 
basis by applying the most recent economic index data and publish 
updates as necessary.
3. Application of RCE Limits
    This section, as well as the two following sections, is not 
describing new policy, but rather is simply a discussion of a 
continuation of the existing policies with respect to the application 
of and exceptions to the RCE limits and the geographic area 
classifications used for purposes of establishing the RCE limits. We 
will continue to use the RCE limits to compute Medicare payments when a 
physician is compensated by a provider that is subject to the RCE 
limits in some or all of its areas. We also will use these limits when 
the physician is compensated by any other related organization for 
physician administrative, supervisory, and other provider services paid 
under Medicare. In applying the RCE limits, the intermediary will 
assign each compensated physician to the most appropriate specialty 
category. If no specialty category is appropriate (for example, in 
determining the reasonable cost for an emergency room physician), the 
fiscal intermediary will use the RCE level for the ``Total'' category, 
which is based on income data for all physicians. The fiscal 
intermediary will determine the appropriate geographic area 
classification given in Table 9 of the addendum of this final rule.
    If the physician's contractual compensation covers all duties, 
activities, and services furnished to the provider and to its patients 
and the physician is employed full-time, the appropriate specialty 
compensation limit will be used and adjusted by the physician's 
allocation agreement to arrive at the program's share of allowable 
costs as physician compensation costs. In the absence of an allocation 
agreement, we generally will assume that 100 percent of the 
compensation was related to services paid under the physician fee 
schedule and that there are no allowable costs for the physician's 
services to the provider.
    If a physician's compensation from the provider represents payment 
only for services that benefit patients generally (that is, the 
physician bills fees for all services furnished to individual 
patients), the appropriate specialty compensation limit will be used. 
If a physician is employed by a provider to furnish services of general 
benefit to patients on other than a full-time basis, the RCE amount 
will be adjusted upward or downward to reflect the percentage of time 
his or her actual hours related to a full work year of 2,080 hours.
4. Exceptions to the RCE Limits
    Some providers, particularly but not exclusively small or rural 
hospitals, may be unable to recruit or maintain an adequate number of 
physicians at a compensation level within the prescribed limits. In 
accordance with section 1887(a)(2)(C) of the Act, if a provider is able 
to demonstrate to the intermediary its inability to recruit or maintain 
physicians at a compensation level allowable under the RCE limits (as 
documented, for example, by unsuccessful advertising through national 
medical or health care publications), the intermediary may grant an 
exception to the RCE limits established under these rules.
5. Geographic Area Classifications for RCE Limits
    We adjust the RCE limits to account for differences in salary 
levels by location as well as by specialty. Under our methodology for 
establishing limits, and in the limits set forth below, we have 
classified geographic areas into three types: nonmetropolitan areas, 
metropolitan areas less than 1 million, and metropolitan areas greater 
than 1 million.
    As we do for purposes of the IPPS and the physician fee schedule, 
we use the most current MSA designations for purposes of establishing 
the RCE limits. In New England, we use the NECMAs for this purpose. 
Tables 4A and 4B of the Addendum to this final rule includes 
information that identifies, by type of location (urban and rural), the 
geographic areas affected; that is, they list all MSAs and their 
constituent counties and identifies whether their population are 
classified as large urban. Any county not listed in the tables and all 
other affected U.S. possessions and territories not part of a State are 
considered rural areas. This information will enable providers, 
physicians, Medicare fiscal intermediaries, and other members of the 
public to determine which RCE limit level will apply in specific areas.

Estimates of FTE Annual Average Net Compensation Levels for Cost Reporting Periods Beginning on or After January
                                                    1, 2004 *
----------------------------------------------------------------------------------------------------------------
                                                                          Metropolitan areas  Metropolitan areas
                      Specialty                         Nonmetropolitan      less than one     greater than one
                                                             areas              million             million
----------------------------------------------------------------------------------------------------------------
Total...............................................             159,800             171,400             177,200
General/Family Practice.............................             142,500             136,700             138,700
Internal Medicine...................................             150,200             154,100             165,600
Surgery.............................................             182,900             204,100             208,000
Pediatrics..........................................             130,900             152,100             140,600
OB/GYN..............................................             200,300             194,500             196,400
Radiology...........................................             217,600             231,100             225,300
Psychiatry..........................................             138,700             142,500             154,100
Anesthesiology......................................             167,500             200,300             200,300
Pathology...........................................             208,000             219,500            215,700
----------------------------------------------------------------------------------------------------------------
*All figures are rounded to the nearest $100.


[[Page 45460]]

V. PPS for Capital-Related Costs

    In the May 19, 2003 proposed rule, we did not propose 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 final 
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) 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 payments for 
extraordinary circumstances are 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. 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, excluded psychiatric hospitals and 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

[[Page 45461]]

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 the PPS 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 VI.A.3. and 4. of this preamble contain 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.
    The 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 
3.4 percent. This percentage change in the market basket reflects the 
average change in the price of goods and services purchased by 
hospitals to furnish inpatient hospital services (as projected by 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
                                                    labor-     nonlabor-
       Class of excluded hospital or unit           related     related
                                                     share       share
------------------------------------------------------------------------
Psychiatric.....................................      $7,294      $2,899
------------------------------------------------------------------------

    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 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 Pub. L. 
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 Pub. L. 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 Pub. L. 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. We plan to issue in the Federal Register by

[[Page 45462]]

August 1, 2003 a final rule that will update the payment rates under 
the IRF PPS for FY 2004, to be effective for discharges occurring on or 
after October 1, 2003 and before October 1, 2004.
4. Development of a PPS for Inpatient Psychiatric Facilities
    We are in the process of developing a proposed rule that would 
establish a per diem PPS for inpatient psychiatric facilities (IPFs) 
(previously referred to as psychiatric hospitals and units) that is 
required under the provisions of section 124 of Pub. L. 106.113.
5. Implementation of a PPS for LTCHs
    In accordance with the requirements of section 123 of Pub. L. 106-
113, as modified by section 307(b) of Pub. L. 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.
    We published in the Federal Register on June 6, 2003 a final rule 
(68 FR 34122) that updated the payment rates for the LTCH PPS and made 
policy changes effective for a new LTCH PPS rate year of July l, 2003 
through June 30, 2004.
6. Report of Adjustment (Exception) Payments
    Section 4419(b) of Pub. L. 105-33 requires the Secretary to publish 
annually in the Federal Register a report describing the total amount 
of adjustment (exception) payments made to excluded hospitals and 
units, by reason of section 1886(b)(4) of the Act, during the previous 
fiscal year. However, the data on adjustment payments made during the 
previous fiscal year are not available in time to publish a report 
describing the total amount of adjustment payments made to all excluded 
hospitals and units.
    The process of requesting, adjudicating, and awarding an adjustment 
payment is likely to occur over a 2-year period or longer. First, an 
excluded hospital or unit must file its cost report for a fiscal year 
with its intermediary within 5 months after the close of its cost 
reporting period. The fiscal intermediary then reviews the cost report 
and issues a Notice of Program Reimbursement (NPR) within approximately 
2 months after the filing of the cost report. If the hospital's 
operating costs are in excess of the ceiling, the hospital may file a 
request for an adjustment payment within 6 months from the date of the 
NPR. The intermediary, or CMS, depending on the type of adjustment 
requested, then reviews the request and determines if an adjustment 
payment is warranted. This determination is often not made until more 
than 6 months after the date the request is filed. Therefore, it is not 
possible to provide data in this final rule. However, in an attempt to 
provide interested parties with data on the most recent adjustments for 
which we do have data, we are publishing data on adjustments that were 
processed by the fiscal intermediary or CMS during FY 2002.
    The table below includes the most recent data available from the 
fiscal intermediaries and CMS on adjustment payments that were 
adjudicated during FY 2002. As indicated above, the adjustments made 
during FY 2002 only pertain to cost reporting periods ending in years 
prior to FY 2001. Total adjustment payments awarded to excluded 
hospitals and units during FY 2002 are $8,541,349. The table depicts 
for each class of hospital, in the aggregate, the number of adjustment 
requests adjudicated, the excess operating cost over ceiling, and the 
amount of the adjustment payment.

----------------------------------------------------------------------------------------------------------------
                                                                              Excess cost over     Adjustment
                     Class of hospital                           Number            ceiling          payments
----------------------------------------------------------------------------------------------------------------
Rehabilitation............................................                14        $6,330,380        $1,058,646
Psychiatric...............................................                 7         7,524,434         3,717,465
Long-Term Care............................................                 2        23,462,335         1,713,364
Children's................................................                 4         3,336,306           997,269
Cancer....................................................                 1        70,078,995         1,018,919
Christian Science.........................................                 2           113,304            35,686
----------------------------------------------------------------------------------------------------------------

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 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 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

[[Page 45463]]

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.
    In the May 19, 2003 proposed rule, we proposed 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 also proposed 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.
    Comment: Several commenters disagreed with our proposal to require 
grandfathered hospitals-within-hospitals to continue to operate under 
the same terms and conditions that were in place on September 30, 1995 
(for example, adding beds). These commenters believed that the adoption 
of this proposal could result in a decertification of a number of 
LTCHs, thus depriving Medicare beneficiaries of specialized services 
and unique programs. They asserted that CMS is requiring these 
grandfathered hospitals-within-hospitals to either reverse their 
previously approved changes or lose their certification, which would 
retroactively reverse prior governmental approvals of LTCH changes. The 
commenters further asserted that there is no good reason to treat these 
hospitals any differently from other providers participating in the 
Medicare program, a practice that the commenters believed would result 
in inequitable treatment of patients as well as employees. Furthermore, 
the commenters expressed concern that the proposed effective date 
timeframe for implementation (that is, 60 days) is too short for 
purposes of implementing this proposed change because it would not 
allow adequate time for providers to undo previous changes.
    Response: We have reviewed the commenters' concerns with regard to 
our proposal to require ``grandfathered'' hospitals-within-hospitals to 
continue to operate under the same terms and conditions that were in 
place on September 30, 1995. We understand the commenters' concern that 
adoption of this change as proposed could adversely impact some 
grandfathered hospitals-within-hospitals that, over the years, have 
made changes to the terms and conditions under which they operate.
    After careful consideration of the comments, we have decided to 
revise Sec.  412.22(f) to state that if a hospital-within-a-hospital 
was excluded from the IPPS under the provisions of Sec.  412.22(f) 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 
provisions of Sec.  412.22(e) do not apply to the hospital as long as 
the hospital meets either of two conditions: First, under Sec.  
412.22(f)(1), the hospital continues to operate under the same terms 
and conditions, including the number of beds and square footage 
considered to be part of the hospital for purposes of Medicare 
participation and payment, in effect on September 30, 1995. Second, 
under Sec.  412.22(f)(2) a hospital that changed the terms and 
conditions under which it operates after September 30, 1995 but before 
October 1, 2003, may continue in its grandfathered status if it 
continues to operate under the same terms and conditions, including the 
number of beds and square footage considered to be part of the hospital 
for purposes of Medicare participation and payment, in effect on 
September 30, 2003. The second condition was added in recognition of 
commenters who suggested that hospitals be held harmless for past 
changes in their terms and conditions of operation. We note that any 
changes occurring on or after October 1, 2003, including changes in 
number of beds or square footage, could lead to a loss of grandfathered 
status.
    We want to reiterate that, in establishing grandfathering 
provisions, our general intent has been to protect existing hospitals 
from the potentially adverse impact of recent, more specific 
regulations that we now believe to be essential to the goals of the 
Medicare program. However, a hospital that continues to be excluded 
from the IPPS through grandfathered status may wish to alter the terms 
and conditions that were in effect either on September 30, 1995, or 
after October 1, 2003, as provided in revised Sec.  412.22(h). In that 
circumstance, in order to continue being paid as a hospital excluded 
from the IPPS, the hospital would need to comply with the general 
hospital-within-a-hospital requirements set forth in Sec.  412.22(e).
    We plan to review the issue of whether further revisions to this 
regulation should be made to allow more changes in operation by 
grandfathered hospital-within-hospitals, and welcome specific 
suggestions on this issue.

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

[[Page 45464]]

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, in the May 
19, 2003 proposed rule, we proposed to revise Sec. Sec.  
412.23(e)(3)(ii) and (iii) to reflect our longstanding interpretation 
of the regulations.
    Comment: One commenter suggested that we clarify the source of our 
data for computing the average length of stay for purposes of 
designation as a LTCH.
    Response: Although we did not propose any policy change regarding 
the average length of stay calculation, we did describe the data source 
for this calculation, which is set forth at Sec.  412.23(e)(3). 
Therefore, we will take this opportunity to correct an inadvertent 
misstatement of the data source for this calculation and clarify 
present data collection procedures. In the proposed rule, we stated 
that we relied on data from a ``. . . hospital's most recently filed 
cost report . . .'' for determining whether it qualified as a LTCH. 
However, the regulation does not specify or require that the hospital's 
cost report (Hospital and Hospital Health Care Complex Cost Report, CMS 
Form 2552-96) be the source of these data used in the determination for 
LTCH classification. Specifically, the regulation only notes that the 
calculation requires dividing the total Medicare inpatient days by the 
total number of Medicare discharges occurring for the hospital's most 
recent complete cost reporting period (Sec.  412.23(e)(3)). (A detailed 
description of the designation process is included in the August 30, 
2002 IPPS final rule (67 FR 55970 through 55974).)
    Prior to the October 1, 2002 implementation of the LTCH prospective 
payment system, we did rely on data from the most recently submitted 
cost report for this purpose. In addition, the calculation, for 
purposes of qualifying as a LTCH, was based on total days and 
discharges for all LTCH inpatients. However, with the implementation of 
the LTCH PPS, we revised Sec.  412.23(e)(3)(i) to only count total days 
and discharges for Medicare inpatients (67 FR 55970, August 30, 2002). 
Presently, we are unable to capture these data on our present cost 
reporting forms. Therefore, until the cost reporting form is revised, 
for purposes of the average length of stay calculation, we will be 
relying upon patient census data extracted from MedPAR files that 
reflect each LTCH's cost reporting period. Fiscal intermediaries and 
LTCHs have been informed of this course of action through official 
agency transmittals, but we want to emphasize that this temporary shift 
in data sources should have no effect on the evaluation policy set 
forth in regulations at Sec. Sec.  412.22(d) and 412.23(e)(3) and the 
procedures described in the August 30, 2002 final rule.

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 Sec.  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 Sec.  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. 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) an 
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, in the May

[[Page 45465]]

19, 2003 proposed rule, we proposed 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 Sec.  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 proposed 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. We emphasize that the second 
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.
    Comment: Some commenters stated that a major goal of the Medicare 
Rural Hospital Flexibility Program, under which reasonable cost payment 
to CAHs is authorized, is to ensure that isolated rural hospitals have 
access to critical health care services. The commenters believed that 
our proposal would undermine that goal by paying less than reasonable 
cost amounts for certain services. These commenters stated that, in 
some rural communities, there may be few, or no, reasonable 
alternatives to having laboratory tests performed by a CAH. Because of 
this, the commenters believed reasonable cost payment for CAH-performed 
laboratory tests is warranted, even when specimens are collected in 
settings other than the CAH from patients who are being registered as 
CAH patients for the sole purpose of generating higher Medicare payment 
for the tests.
    Response: We agree that an important goal of the CAH legislation is 
to pay on a reasonable cost basis for services that CAHs provide in 
their facilities to their inpatients and outpatients. However, we do 
not believe that legislation can or should be read so broadly as to 
authorize payment on a reasonable cost basis for laboratory services to 
patients who do not come to the CAH for those services, but receive 
them in other settings, including settings in which coverage for the 
services is available. We also do not agree that because the CAH may be 
one of only a few sources of laboratory services that the CAH should 
therefore be paid a higher amount for those services than would 
otherwise be the case. Therefore, we are not making any change to our 
proposal based on this comment.
    Comment: Several commenters stated that even when a sample is 
collected outside a CAH, the cost of processing in a CAH laboratory is 
incurred by the CAH. Because of this circumstance, the commenters 
recommended that payment be based on the payment method applicable to 
the site where the processing is done, so that payment for laboratory 
tests processed at a CAH would be paid on a reasonable cost basis, not 
under the fee schedule.
    Response: We believe the approach recommended by these commenters 
could create an inappropriate incentive to CAHs to expand their testing 
activities far beyond their normal service areas, in order to gain cost 
reimbursement for patients who have no other connection with the CAH 
other than having a specimen processed by the CAH. In some cases, this 
could result in payment being made on a cost basis for laboratory 
services to patients residing in suburban or even urban areas where 
there is no shortage of qualified laboratories. Such a result would 
only inappropriately increase payment to CAHs and create market 
distortions, because non-CAH laboratories performing exactly the same 
services may be paid substantially less for them. Therefore, we are not 
adopting this recommendation.
    Comment: One commenter agreed with our proposal as it applies to 
laboratory specimens drawn in health care providers or suppliers other 
than CAHs, such as SNFs or RHCs, but recommended that we allow 
reasonable cost payment for clinical diagnostic laboratory tests on 
specimens drawn in physician clinics that are located in close 
proximity to the CAH, if the CAH owns the clinic and supplies the 
personnel who collect the specimens.
    Response: While we considered this suggestion, we are not adopting 
it. A clinic of the type described by the commenter is not a part of 
the CAH, but is a physician office. We see no basis for treating such a 
non-CAH setting differently from other non-CAH facilities (such as 
RHCs) that are similarly owned and located. In the case of an 
ambulatory patient being seen in a physician office located in close 
proximity to the CAH, we do not believe it is unreasonable to expect 
the patient to go to the CAH for the laboratory service as he or she 
would for therapy or any other CAH outpatient service. Alternatively, 
the specimen may be collected during the physician visit and payment 
could be made to the CAH under the laboratory benefit, generally on a 
fee schedule basis.
    Comment: Some commenters stated that the proposed revision is not a 
clarification but a change from past policy.
    Response: We disagree with the commenter, but we do recognize from 
the questions raised on the issue that there has been some confusion 
about the policy among rural facilities. To clarify the agency policy 
in this area and ensure that all relevant issues are publicly noted, we 
set forth the clarification through notice and comment rulemaking 
procedures rather than through other processes, such as a program 
memorandum, a set of responses to ``frequently asked questions,'' or 
other document.
    Comment: One commenter stated that it is inappropriate for proposed 
changes to CAH payment to be published in the proposed IPPS regulation. 
The commenter recommended that if changes are to be made to the payment 
methodology for those facilities excluded from the IPPS rule, they 
should be published separately in the Federal Register, not in a 
proposed rule that would not normally be reviewed by officials 
associated with CAHs.
    Response: The IPPS proposed and final rules are published on an 
established and regular annual cycle and have been read for many years 
by a large health care population, including national, State, and local 
hospital associations as well as individual hospitals, including 
hospitals paid under the reasonable cost payment system as well as 
those paid under the IPPS. Because we recognize this as an important 
tool for disseminating information, we have used the IPPS publication 
in order to implement several major payment issues relating to CAHs. 
For example, changes in the CAH payment rules in Sec.  413.70 were 
included in the IPPS final rule published on August 1, 2002 (67 FR 
49982) and the IPPS final rule published on August 1, 2001 (66 FR 
39828). We believe this is an appropriate vehicle in providing the 
information necessary to allow the CAHs access to the information they 
need to continue to participate knowledgeably in the Medicare program. 
In fact, we received over 40 comments on the provision alone.

[[Page 45466]]

    Comment: Some commenters recommended that we withdraw our proposal 
because reasonable cost payment for clinical diagnostic laboratory 
tests on specimens collected in non-CAH settings can be an important 
revenue source for CAHs and yet would generate only a small amount of 
additional cost to the Medicare program.
    Response: For the reasons stated above and in the preamble to the 
proposed rule, we do not believe it is appropriate to pay on a 
reasonable cost basis for these laboratory tests. Moreover, doing so 
might create an unintended incentive for laboratories processing a 
substantial volume of tests to affiliate with CAHs, in order to obtain 
the higher level of payment for tests on individuals who are only 
nominally patients of the CAH. Therefore, we are not adopting this 
recommendation.
    Comment: Some commenters stated that beneficiaries, particularly 
frail, elderly individuals residing in remote rural areas, could be 
inconvenienced by our proposed clarification because they would now be 
required to travel to the CAH to obtain laboratory services payable on 
a reasonable cost basis. These commenters expressed concern that frail, 
elderly patients confined to nursing homes could be required by this 
policy to travel to CAHs to obtain needed laboratory tests.
    Response: Under our proposed clarification, Medicare would not deny 
payment for medically necessary clinical diagnostic laboratory tests 
that the CAH performs on specimens collected from patients in non-CAH 
locations. On the contrary, clinical diagnostic laboratory tests 
performed by CAHs on such specimens would be paid under the same 
conditions as would apply to such tests furnished by an independent 
laboratory. In such a case, a CAH would be providing independent 
laboratory services and generally would be paid under the laboratory 
fee schedule.
    Regarding the concern about the difficulty of travel for some 
beneficiaries, we believe it is an incorrect assumption that 
beneficiaries in rural areas will not have specimens collected in their 
homes or other locations if the CAH is not paid on a cost basis for the 
collection and travel. If it is medically necessary for the specimen to 
be collected in the patient's home, the laboratory benefit under 
Medicare Part B will pay the specimen collection fee (currently $3 per 
specimen), plus a separate travel allowance (currently at least 75 
cents per mile where the average round trip is more than 20 miles) for 
employees of independent, mobile or hospital-based laboratories to 
travel to the beneficiary's home. These payments are in addition to 
payment for performing the tests. (For further details on how specimen 
collection and travel fees are calculated, see CMS Transmittal AB-98-
33, Change Request 526, dated July 1998; this transmittal is 
available on the CMS Web site at www.cms.hhs.gov.) In many cases, the 
laboratories collect blood specimens in batches or groups of 
beneficiaries residing in neighboring areas. This can make the 
technicians' trips to beneficiaries' residences more cost-effective.
    In addition to laboratories, home health agencies that have 
laboratory provider numbers can perform blood draws at a beneficiary's 
residence and bill Medicare under the laboratory benefit, using the 
appropriate codes for specimen collection and travel. Agencies would be 
reimbursed the $3 specimen collection fee, plus travel costs determined 
by the Medicare contractor.
    It is also important to note that home health agencies with 
laboratory provider numbers may conduct some of the less complex blood 
tests themselves, receive the collection and travel fee, and receive a 
fee through the laboratory benefit for performing the tests. These are 
called the Clinical Laboratory Improvement Amendments (CLIA)-waived 
tests, and, among others, include: glucose (blood sugar levels for 
diabetic patients), fructosamine (also checks blood sugar levels but 
over longer period of time), hemoglobin (tests hemoglobin levels for 
patients with anemia), urine dip stick (tests urine for a variety of 
diseases/infections), and cholesterol/triglyceride (checks for lipid 
levels for patients with cardiovascular disease) tests.
    A variety of other providers can draw blood at a beneficiary's 
home, often in conjunction with other services necessitating the 
laboratory tests. For example, while a physician conducts a home visit 
for evaluation and management, the physician may also draw a blood 
specimen. If the physician meets applicable requirements under the 
laboratory benefit, he or she may receive an additional payment for the 
specimen collection.
    The physician also can arrange for a nurse practitioner, physician 
assistant, or clinical nurse specialist to conduct a home visit and 
draw blood when they examine the beneficiary. These clinicians are 
reimbursed at a rate equal to 85 percent of the physician fee schedule 
for a home visit, and if all applicable billing requirements are met, 
they are also paid specimen collection and travel fees.
    Regarding tests for nursing home patients, we note that if a CAH 
furnishes laboratory services to a beneficiary in an SNF stay covered 
by Part A, nonemergency diagnostic laboratory tests--regardless of 
whether furnished by the SNF directly or under an arrangement with the 
CAH--would be included within the SNF's bundled PPS per diem payment 
for the covered stay itself. If a CAH furnishes laboratory services to 
a beneficiary in an SNF stay not covered by Part A (for example, Part A 
benefits exhausted; no prior qualifying hospital stay; SNF level of 
care requirements not met), the SNF consolidated billing restrictions 
do not apply. However, if the SNF nonetheless elects to bill for such a 
beneficiary's laboratory services, section 1888(e)(9) of the Act 
provides that an SNF's Part B bills are to be paid in accordance with 
the fee schedule that applies to the particular item or service being 
billed.
    In the case of beneficiaries in nursing homes, patients are already 
under the care of an institution staffed with registered nurses, 
licensed practical nurses, and nursing assistants, and other health 
care workers who are presumably well-trained in collecting specimens 
for analysis, and the nursing homes are already being paid, by 
Medicare, Medicaid, private insurers, or other means for caring for the 
patient. Under these circumstances, it would not seem unreasonable to 
expect the nursing home to take responsibility for collecting the 
specimens.
    Because of the many ways in which specimen collection and travel 
are payable under Medicare, we do not expect beneficiaries to face 
reduced access to services under this proposal. We specifically reject 
the claims made by several commenters that beneficiaries would be able 
to obtain needed laboratory services only by traveling to the CAH to 
obtain them.
    Comment: Some commenters took exception to the preamble statements 
that allowing cost reimbursement for laboratory tests on specimens 
obtained by CAH personnel in non-CAH settings would duplicate existing 
coverage, create confusion for beneficiaries, and add to the costs of 
care furnished to Medicare patients. Regarding the costs of care, the 
commenters stated that because clinical diagnostic laboratory tests are 
not subject to deductible or coinsurance liability under Medicare, 
there would be no increase in out-of-pocket costs for beneficiaries.
    Response: Regarding duplication of coverage, we have explained in a 
response to an earlier comment the many ways in which Medicare now pays 
for specimen collection fees and

[[Page 45467]]

travel costs. Given this payment provision, adding another, more 
expensive payment option for the services would duplicate existing 
coverage without providing any benefit to anyone other than the 
operators of the CAHs. Despite the commenters' claims to the contrary, 
we continue to believe patients under the care of one provider (such as 
a SNF or RHC) might have questions as to why personnel from another 
provider are coming in to perform functions that could be performed by 
staff of the facility in which they are being treated. Finally, while 
there is no deductible or coinsurance liability associated with 
laboratory services, paying for services on a reasonable cost basis 
rather than on a fee schedule basis will ultimately drive up the cost 
of laboratory care provided under Medicare, increasing costs for 
taxpayers and contributing to general health care cost increases. To 
the extent Medicare Part B premiums will increase in the future because 
of current spending rises, we believe adopting the policy recommended 
by commenters would increase out-of-pocket costs for beneficiaries as 
well as for all other taxpayers.
    Comment: One commenter asked whether the proposed clarification of 
our policy on payment for clinical diagnostic laboratory tests would be 
applied prospectively only, or also retroactively.
    Response: Although this proposal represents a clarification of 
policy, we recognize that this policy has not been well understood in 
all areas. Therefore, we do not plan to direct Medicare contractors to 
routinely reopen and review past claims for compliance.
    After full consideration of public comments on these issues as 
summarized above, we are adopting our proposed changes to Sec.  413.70 
as final without change.

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 proposed to correct this reference.
    We did not receive any comments on this proposal and, therefore, 
are adopting the proposed technical change as final.

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 IPPS rules. 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 policies 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 B to 
this final 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: After reevaluation of this recommendation, in this final 
rule we are expanding the postacute care transfer policy to include 21 
additional DRGs for FY 2004, although we are removing 2 DRGs from the 
current list. A thorough discussion of this provision, 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: We define 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-related share using 
the most recently revised and rebased hospital market basket (1997-
based) is 72.495 percent.
    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. Again, in the May 19, 2003 
proposed rule, we did not propose to use the updated labor-related 
share for FY 2004 because we have not yet completed our research into 
the appropriateness of this updated measure. Specifically, we continue 
to review the labor-related share in two ways. First, we are performing

[[Page 45468]]

regression analysis with the expectation that it would help give an 
alternative indication of the labor-related share. Second, we continue 
to reevaluate the methodology we currently use for determining the 
labor-related share using the hospital market basket.
    Our regression analysis is an attempt 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). However, the 
findings from the regressions continue to be 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.
    We also continue to explore all options for alternative data or 
methodology for determining the labor-related share using the hospital 
market basket. We have researched various alternative data sources for 
use in further breaking down the cost categories in the market basket 
and have evaluated alternative methodologies to determine the 
feasibility of separating the labor-related portion or the portion that 
varies with local labor markets from the portion that does not vary. 
While each of these alternatives has strengths and weaknesses, it is 
not clear at this point that any one alternative data source or 
methodology is superior to the current methodology. We will continue to 
research these alternatives.
    Comment: Several commenters suggested the labor share should only 
be adjusted by those costs (wages and salaries and benefits) that are 
reflected in the wage index survey. Commenters suggested that CMS 
should consider reducing the labor-related share for rural hospitals or 
having different labor shares by geographic location.
    Response: We define the labor-related share to include all costs 
that are likely related to, influenced by, or vary with local labor 
markets, even if they could be purchased in a national market. This 
differs from the hospital wage index survey, which only collects direct 
labor and patient-related contract costs. Using only those direct labor 
costs reflected in the wage index survey would mean redefining the term 
labor-related share and would likely leave out many of the other costs 
that do vary with the local labor market.
    As indicated in prior rules, we continue to research alternative 
methodologies for determining the labor-related share, including 
reexamining the labor portion of each of the individual market basket 
categories. However, due to a lack of one definitive data source, our 
analysis is still preliminary and, therefore, we will continue to use 
71.066 percent as the labor-related share applicable to the 
standardized amounts while we conduct further analysis to determine the 
most appropriate methodology for determining the labor-related share.
    It is currently our policy to use a national labor-related share to 
apply to the national PPS standardized amounts. This policy has been in 
effect since the implementation of the IPPS in 1983. We will consider 
the commenters' recommended alternative approaches, such as different 
labor shares for urban and rural hospitals or labor shares that vary by 
more detailed geographic area, as part of our ongoing research efforts. 
However, until we have completed our research, we will continue to use 
only a national labor-related share, which is currently 71.066 percent 
and was calculated from the 1992-based market basket.
    Comment: One commenter believed that we should examine each of the 
categories currently included in the labor share and determine which 
portion of that category was actually labor-related or varied with the 
local labor market.
    Response: We agree with the commenter that it is important that the 
labor-related portion of the market basket include only those 
categories that are actually labor-related or vary with the local labor 
market. As we indicated in the May 19, 2003 rule, we are continuing to 
explore all options for accounting for the labor-related share, 
including reexamining each of the categories included in the current 
labor share (particularly professional fees, postage, and other labor-
intensive services) to make sure the labor share represents only those 
costs that do vary with the local labor market. However, our 
preliminary research has indicated that much of the data needed to 
break out details from each of the current market basket categories 
into labor and nonlabor-related components are not readily available on 
a national basis. We will continue to research various data sources for 
this information and will update the labor share as needed once our 
research is complete.
    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. In the May 19, 2003 
proposed rule, we published a list of data files that are available for 
purchase from CMS or that may be downloaded from the Internet free of 
charge (68 FR 27226 through 27228).

B. Collection of Information Requirements

    This final rule directly does not impose any collection and 
recordkeeping requirements. Consequently, it does not need to 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,

[[Page 45469]]

Puerto Rico, Reporting and recordkeeping requirements.

42 CFR Part 413

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

0
For the reasons stated in the preamble of this final rule, the Centers 
for Medicare & Medicaid Services amends 42 CFR chapter IV as follows:

PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL 
SERVICES

0
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).

0
2. Section 412.4 is amended by--
0
A. Revising paragraphs (b), (c), and (d).
0
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 must meet the following criteria for both of the 2 
most recent fiscal years for which data are available:
    (1) The DRG must have a geometric mean length of stay of at least 3 
days;
    (2) The DRG must have at least 14,000 cases identified as postacute 
care transfer cases.
    (3) The DRG must have at least 10 percent of the postacute care 
transfers occurring before the geometric mean length of stay for the 
DRG.
    (4) If the DRG is one of a paired DRG based on the presence or 
absence of a comorbidity or complication, one of the DRGs meets the 
criteria under specified paragraphs (d)(1) through (d)(3) of this 
section.
    (5) To initially qualify, the DRG meet the criteria specified in 
paragraphs (d)(1) through (d)(4) of this section and must have a 
decline in the geometric mean length of stay for the DRG during the 
most recent 5-year period of at least 7 percent. Once a DRG initially 
qualifies, the DRG is subject to the criteria specified under 
paragraphs (d)(1) through (d)(4) of this section for each subsequent 
fiscal year.
* * * * *

0
3. Section 412.22 is amended by:
0
A. Republishing the introductory text of paragraph (e)(5) and revising 
the first sentence of paragraph (e)(5)(i).
0
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 as long as the hospital either--
    (1) Continues to operate under the same terms and conditions, 
including the number of beds and square footage considered to be part 
of the hospital for purposes of Medicare participation and payment in 
effect on September 30, 1995; or
    (2) In the case of a hospital that changes the terms and conditions 
under which it operates after September 30, 1995, but before October 1, 
2003, continues to operate under the same terms and conditions, 
including the number of beds and square footage considered to be part 
of the hospital for purposes of Medicare participation and payment in 
effect on September 30, 2003.
* * * * *

0
4. Section 412.23 is amended by revising paragraphs (e)(3)(ii) and 
(e)(3)(iii) to read as follows:


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]

0
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''.

0
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.

* * * * *
    (a) Eligibility criteria. * * *
    (3) The DRG prospective payment rate otherwise applicable to 
discharges

[[Page 45470]]

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.

0
7. Section 412.105 is amended by--
0
A. In paragraph (a)(1), introductory text, revising the phrase 
``paragraph (f) of this section'' to read ``paragraphs (f) and (h) of 
this section''.
0
B. In paragraph (a)(1)(i), revising the phrase ``affiliated groups'' to 
read ``Medicare GME affiliated groups''.
0
C. Revising paragraph (b).
0
D. Adding a sentence at the end of paragraph (f)(1)(v).
0
E. In paragraph (f)(1)(vi), revising the phrase ``affiliated group'' to 
read ``Medicare GME affiliated group''.
0
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 of available bed days 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 excluded distinct part hospital units;
    (3) Beds otherwise countable under this section used for outpatient 
observation services, skilled nursing swing-bed services, or ancillary 
labor/delivery services;
    (4) Beds or bassinets in the healthy newborn nursery; and
    (5) 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 at an urban hospital 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.
* * * * *

0
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, 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.
* * * * *

0
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.

0
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.
* * * * *

0
10. Section 412.230 is amended by--
0
A. Republishing paragraph (e)(2) introductory text.
0
B. Revising paragraph (e)(2)(ii)(A).
    The revisions read as follows:


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

* * * * *
    (e) Use of urban or other rural area's wage index. * * *
    (2) Appropriate wage data. For a wage index change, the hospital 
must submit appropriate wage data as follows:
* * * * *
    (ii) * * *
    (A) For hospital-specific data, the hospital must provide a 
weighted 3-year average of its average hourly wages using data from the 
CMS hospital wage survey used to construct the wage index in effect for 
prospective payment purposes. However, for the limited purpose of 
qualifying for geographic reclassification based on wage data from cost 
reporting periods beginning prior to FY 2000, a hospital may request 
that its wage data be revised if the hospital is 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 its wage 
index.
* * * * *

[[Page 45471]]


0
11. Section 412.278 is amended by revising paragraph (f)(2)(i) to read 
as follows:


Sec.  412.278  Administrator's review.

* * * * *
    (f) * * *
    (2) The Administrator issues a decision in writing to the party 
with a copy to CMS--
    (i) Not later than 90 days following receipt of the party's request 
for review, except the Administrator may, at his or her discretion, for 
good cause shown, toll such 90 days; or
* * * * *

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

0
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).

0
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.
* * * * *

0
3. Section 413.85 is amended by--
0
A. Republishing the introductory text of paragraph (d)(1) and adding a 
new paragraph (d)(1)(iii).
0
B. Adding a new paragraph (g)(3).
0
C. 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.

* * * * *
    (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.
    (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 the ability to practice and begin 
employment in a nursing or allied health specialty.
* * * * *

0
4. Section 413.86 is amended by--
0
A. Under paragraph (b)--
0
(1) Removing the definitions of ``Affiliated group'' and ``Affiliation 
agreement''.
0
(2) Adding definitions of ``Community support'', ``Medicare GME 
affiliated agreement'', ``Medicare GME affiliated group'', and 
``Redistribution of costs'' in alphabetical order.
0
(3) Under the definition of ``Rural track FTE limitation'', revising 
the phrase ``paragraph (g)(11)'' to read ``paragraph (g)(12)''.
0
B. Revising the introductory text of paragraph (f).
0
C. Adding a new paragraph (f)(4)(iv).
0
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)''.
0
E. Revising the introductory text of paragraph (g)(4).
0
F. Revising paragraph (g)(4)(iv).
0
G. Revising the introductory text of paragraph (g)(5).
0
H. Adding a new paragraph (g)(5)(vii).
0
I. Revising paragraphs (g)(6)(i)(D) and (g)(6)(i)(E).
0
J. Revising paragraph (g)(7).
0
K. Revising the introductory text of paragraph (g)(12).
0
L. Revising paragraph (g)(12)(i).
0
M. Revising paragraph (g)(12)(ii), introductory text.
0
N. Revising paragraph (g)(12)(ii)(A).
0
O. Revising paragraph (g)(12)(ii)(B)(1)(i).
0
P. Revising paragraph (g)(12)(iii).
0
Q. Revising paragraph (g)(12)(iv), introductory text.

[[Page 45472]]

0
R. Revising paragraph (g)(12)(iv)(A).
0
S. Revising paragraph (g)(12)(iv)(B)(1).
0
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 numbers.
* * * * *
    ``Redistribution of costs'' occurs when a hospital counts FTE 
residents in medical residency programs and the costs of the program 
had previously been incurred by an 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.
    (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 a 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

[[Page 45473]]

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 1, 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:
    (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 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

[[Page 45474]]

residents in accordance with the provisions of paragraphs (f) and 
(g)(4) through (g)(6) and (g)(12) of this section. This rule also 
applies to providers that are paid for direct GME in accordance with 
Sec.  405.2468 of this chapter, Sec.  422.270 of this subchapter, and 
Sec.  413.70.
    (3)(i) Effective date. Subject to the provisions of paragraph 
(i)(3)(ii) of this section, payments made in accordance with 
determinations made under the provisions of paragraphs (i)(1) and 
(i)(2) of this section will be effective for portions of cost reporting 
periods occurring on or after October 1, 2003.
    (ii) Applicability for certain hospitals. With respect to an FTE 
resident who begins training in a residency program on or before 
October 1, 2003, and with respect to whom there has been a 
redistribution of costs or community support determined under the 
provisions of paragraphs (i)(1) and (i)(2) of this section, the 
hospital may continue to count the FTE resident until the resident has 
completed training in that program, or until 3 years after the date the 
resident began training in that program, whichever comes first.

(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance)
    Dated: July 23, 2003.
Thomas A. Scully,
Administrator, Centers for Medicare & Medicaid Services.
    Dated: July 24, 2003.
Tommy G. Thompson,
Secretary.

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

Addendum--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 amounts and factors 
for determining prospective payment rates for Medicare hospital 
inpatient operating costs and Medicare hospital inpatient capital-
related costs. We are also setting forth rate-of-increase 
percentages for updating the target amounts for hospitals and 
hospital units excluded from the 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 that reflects 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 
making 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 changes for 
determining the prospective payment rates for Medicare inpatient 
capital-related costs for FY 2004. Section IV. of this Addendum sets 
forth our 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 of this final rule are presented in section VI. of this 
Addendum.

II. 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 standardized amounts set forth in Tables 1A and 
1C of section VI. of this Addendum reflect--
    [sbull] Updates of 3.4 percent for all areas (that is, the full 
market basket percentage increase of 3.4 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 
determining 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

[[Page 45475]]

accordance with section 1886(b)(3)(B)(i) of the Act, the large urban 
average standardized amount is 1.6 percent higher than the other 
area average standardized amount.
    Section 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.
    As discussed previously, on June 6, 2003, OMB announced revised 
definitions of MSAs and new definitions of Micropolitan Statistical 
Areas and Combined Statistical Areas. In order to implement these 
changes for the IPPS, it is necessary to identify the new area 
designation for each county and hospital in the country. Because 
this process will have to be extensively reviewed and verified, we 
were unable to undertake it before publication of this final rule. 
Therefore, we are continuing to use MSAs based on OMB's definitions 
of MSAs prior to June 6, 2003. Based on those definitions, 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 
updating the arge 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 3.4 percent. Thus, for FY 2004, the update to the average 
standardized amounts equals 3.4 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 
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 final rule.
    Comment: One commenter recommended an increase to the market 
basket that would account for large increases in the costs of 
malpractice, pensions, health benefits, pharmaceuticals, and new 
technology that hospitals are facing.
    Response: The hospital market basket is structured to measure 
the change in prices for an exhaustive list of inputs used by 
hospitals in providing services. The index measures the ``pure'' 
price change of those inputs and appropriately does not measure 
changes in quantity or intensity. These nonprice factors include 
shifts in the skill mix of employees, increased amounts of labor 
purchased, increased malpractice coverage, the increased use of 
pharmaceuticals and technology in providing care, and movements 
toward more or less intensive pharmaceuticals and technology. 
Nonprice factors such as these may be contributing to the increases 
in cost that hospitals are currently facing.
    In addition, the most recent data available are used to forecast 
the market basket price changes and are intended to reflect 
conditions that hospitals will face in the upcoming fiscal year. As 
it is intended, the hospital market basket measures the national 
average price increase and will not reflect geographic differences 
from one geographic area to another. In other words, while one area 
may see a large surge in the prices of inputs, another area may 
actually be experiencing much smaller increases in the prices of 
these inputs. This may also be contributing to the increased costs 
to which the commenter referred. Therefore, we believe that the 
market basket is an accurate representation of the national average 
price increase facing hospitals in providing services, and the 3.4 
percent increase for FY 2004 provides an adequate update to 
hospitals to account for the inflationary increase in costs.

4. Other Adjustments to the Average Standardized Amounts

    As in the past, we 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 year's budget neutrality adjustments 
for reclassification and recalibration of the DRG weights and for 
updated wage data 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 
changes to the postacute care transfer policy discussed in section 
IV.A. of the preamble of this final rule 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 making a budget 
neutrality adjustment to ensure that the requirement of section 
1886(d)(4)(C)(iii) of the Act is met.
    Section 1886(d)(3)(E) of the Act requires us to update the 
hospital wage index on an annual basis beginning October 1, 1993. 
This provision also requires us to make any updates or adjustments 
to the wage index in a manner that ensures that aggregate payments 
to hospitals are not affected by the change in the wage index.
    Section 4410 of 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 final rule, we are 
approving two new technologies for add-on payments in FY 2004. We 
estimate that the total add-on payments for these new technologies 
will be $14.4 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

[[Page 45476]]

relative weights, wage index, and new technology add-on payments to 
aggregate payments using the FY 2004 relative weights and wage 
index, plus the 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 budget neutrality 
adjustment factor equal to 1.005522. We also adjust the Puerto Rico-
specific standardized amounts for the effect of DRG reclassification 
and recalibration. We computed a budget neutrality adjustment factor 
for Puerto Rico-specific standardized amounts equal to 1.001661. 
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 applying 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 applying an adjustment factor of 
0.992026 to ensure that the effects of reclassification are budget 
neutral.
    The adjustment factor is applied to the standardized amounts 
after removing the effects of the FY 2003 budget neutrality 
adjustment factor. We note that the FY 2004 adjustment reflects FY 
2004 wage index and standardized amount reclassifications approved 
by the MGCRB or the Administrator, and the effects of section 
1886(d)(10)(D)(v) of the Act to extend wage index reclassifications 
for 3 years.
    c. Outliers.--Section 1886(d)(5)(A) of the Act provides for 
payments in addition to the basic prospective payments, for 
``outlier'' cases 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 May 19, 2003 proposed rule, we proposed to establish a 
fixed-loss cost outlier threshold equal to the prospective payment 
rate for the DRG plus any IME and DSH payments, and any add-on 
payments for new technology, plus $50,645. However, we also stated 
that the final FY 2004 threshold was likely to be different from 
that proposed threshold, as a result of any changes to outlier 
policy subsequent to a proposed rule published on March 5, 2003. 
Subsequently, we published three central changes to our outlier 
policy in a final rule on June 9, 2003.
    The first of the changes was that fiscal intermediaries will 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 revised our regulations to 
specify that fiscal intermediaries will use either the most recent 
settled or the most recent tentative settled cost report, whichever 
is from the latest reporting period.
    The second change removed the 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 an established threshold (3 
standard deviations below the national geometric mean cost-to-charge 
ratio). We specified that hospitals will receive their actual cost-
to-charge ratios no matter how low their ratios actually fall.
    The third change added a provision to our regulations to provide 
that the outlier payments for some hospitals will become subject to 
reconciliation when the hospitals' cost reports are settled. In 
addition, outlier payments will be subject to an adjustment to 
account for the time value of any outlier overpayments or 
underpayments that are ultimately reconciled.
    To calculate the FY 2004 outlier thresholds, we simulated 
payments by applying FY 2004 rates and policies using cases from the 
FY 2002 MedPAR file. Therefore, in order to determine the 
appropriate FY 2004 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 continuing to use the 2-year average annual rate of 
change in charges per case to establish the 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 12.5978 percent 
annually, or 26.8 percent over 2 years.
    In the past, we used cost-to-charge ratios from the Provider 
Specific File, and multiplied these ratios by the charges for each 
case to estimate costs. After the changes in policy enacted by the 
final outlier rule this year, it is necessary to calculate more 
recent cost-to-charge ratios because fiscal intermediaries will now 
use the latest tentatively settled cost report instead of the latest 
settled cost report to determine a hospital's cost-to-charge ratio. 
Therefore, to approximate using the latest tentative settled cost 
reports in our estimate of the FY 2004 outlier threshold, we 
calculated updated cost-to-charge ratios using the following three 
steps: for each hospital, we matched charges-per-case to costs-per-
case from the most recent cost reporting year; we then divided each 
hospital's costs by its charges to calculate the cost-to-charge 
ratio for each hospital; and we multiplied charges from each case in 
the FY 2002 MedPAR (inflated to FY 2004) by this cost-to-charge 
ratio to calculate the cost per case. The final outlier rule also 
established the policy that fiscal intermediaries are to reconcile 
outlier payments at the time of cost report final settlement if a 
hospital's actual operating or capital cost-to-charge ratios are 
found to be substantially different from the cost-to-charge ratios 
used during that time period to make outlier payments.
    However, it is difficult to project which hospitals will be 
subject to reconciliation of their outlier payments using available 
data. For example, for most hospitals, the latest available cost 
data are from FY 2000. In addition, the amount of fiscal 
intermediary resources necessary to undertake reconciliation will 
ultimately influence the number of hospitals reconciled. Without 
actual experience with the reconciliation process, it is difficult 
to predict the number of hospitals that will be reconciled. However, 
as later data become available, particularly data reflecting 
hospital's latest tentative settled cost-to-charge ratios, we will 
be better able to assess the appropriate number of hospitals to be 
reconciled.
    Based on our analysis of hospitals that have been consistently 
overpaid recently for outliers, we have identified approximately 50 
hospitals we believe will be reconciled. Therefore, for these 
hospitals, to account for the fact that the reconciliation will 
result in

[[Page 45477]]

different outlier payments than predicted using the cost-to-charge 
ratios calculated as described above, we attempted to project each 
hospital's cost-to-charge ratio based on its rate of increase in 
charges per case based on FY 2002 charges, compared to costs 
(inflated to FY 2002 using actual market basket increases).
    Using this methodology, we are establishing a fixed-loss cost 
outlier threshold equal to the prospective payment rate for the DRG, 
plus any IME and DSH payments, and any add-on payments for new 
technology, plus $31,000.
    This single threshold will be applicable to qualify for both 
operating and capital outlier payments. We also are maintaining the 
marginal cost factor for cost outliers at 80 percent.
    Comment: One commenter supported our changes to the outlier 
payment methodology but asked that we reconsider and revise the 
outlier threshold to at least a level of increase consistent with 
prior years. Other commenters asked that we lower the threshold to 
reflect the financial impact of the new outlier policies, to allow 
deserving hospitals to qualify for outlier payments and to ensure 
that hospitals receive the statutory mandated level of 5 to 6 
percent of total DRG payments set aside for outliers. Another 
commenter reasoned that hospitals that have had their outlier 
payments dwindle to record low amounts will have no incentive to 
treat high-cost cases; therefore, the outlier threshold must be 
lowered. Another commenter noted that the current proposed threshold 
makes it almost impossible for hospitals to qualify for outlier 
payments and will cause hospitals to lose an extraordinary amount of 
money before additional outlier payments become available.
    Other commenters indicated that they had conducted research, 
using the 2001 MedPAR file, which showed that the threshold required 
to spend 5.1 percent of total DRG payments decreased by 45 percent 
when the cost-to-charge ratios used to estimate costs were updated 
from the latest final settled to the latest tentatively settled cost 
report. Based on this finding, the commenters recommended a 45-
percent reduction to the proposed outlier threshold, which would 
yield a threshold less than $28,000.
    Some commenters believed that, in light of the changes adopted 
this year, it is appropriate that CMS revert to using changes in 
hospital costs to set the charge inflation factor rather than 
changes in hospital charges. The commenters explained that the 
combination of the changes made to the outlier policy and a return 
to using a cost inflation factor would lead to a more accurate and 
lower threshold. Another commenter noted the previous problems using 
changes in costs and recommended that CMS use a blend of the rates-
of-increases for costs and charges to establish the charge inflation 
factor.
    One commenter recommended that CMS keep the outlier threshold at 
$33,560 until CMS can determine the impact of using the most current 
cost-to-charge ratio during a full fiscal year. Other commenters 
also recommended that CMS eliminate any increase in the outlier 
threshold because the new outlier regulations will have a 
significant impact on Medicare outlier payments for FY 2004.
    One commenter requested that CMS factor in the calculation of 
the threshold the fact that certain hospitals have distorted their 
charges significantly.
    One commenter submitted a model of the outlier threshold for FY 
2004 that incorporated the changes from the June 9, 2003 final rule. 
The commenter estimated the fixed-loss threshold to be $25,375 under 
these assumptions. The commenter also noted that the reconciliation 
process will reduce outlier payments and, accordingly, CMS should 
model a reduction in the outlier threshold to account for 
reconciliation, which would further lower the outlier threshold.
    One commenter suggested that CMS lower the outlier threshold 
because independent studies strongly suggest that final FY 2003 
outlier payments will fall short of the legislative mandate of 5 to 
6 percent. Another commenter suggested that the outlier threshold 
remain at its current level because outlier payments for the first 3 
months of FY 2003 represent 5.5 percent of total payments and, as a 
result, there does not seem to be any justification for such an 
increase. Another commenter explained that the transfer policy 
already reduces the payment to hospitals for short-stay cases and 
any increase in the outlier threshold will further penalize 
hospitals for treating high cost, medically complex cases.
    Response: As described above, we are reflecting the changes made 
to outliers from the June 9, 2003 final rule. These changes have 
resulted in a substantial reduction in the outlier threshold from 
the proposed level. We estimate the outlier threshold would be 
approximately $50,200 without accounting for the effects of these 
changes. Therefore, the final threshold is 37 percent lower due to 
the changes described above. This reduction in the outlier threshold 
will allow hospitals that have been negatively impacted by the 
increase in the FY 2003 threshold due to those hospitals that 
maximized their outlier payments by dramatically increasing charges 
to qualify for higher outlier payments due to the lower threshold.
    We are concerned that the outlier policy maintains its original 
intent to ensure hospitals are not significantly disadvantaged by 
unpredictable extraordinarily costly cases, and, therefore, we acted 
to close the loopholes in our prior policy through the final outlier 
rule. As a result of those changes, the threshold has fallen 
significantly from the proposed threshold.
    Comment: Another commenter asked that any final outlier 
threshold included in the final rule be subject to a 60-day review 
and comment period.
    Response: In the proposed rule, we noted that we would 
incorporate any final outlier policy changes in this final rule. We 
received many comments in response to the proposed rule, and we have 
considered them thoroughly in undertaking our analysis. Therefore, 
we do not believe there is any need for an additional public comment 
period on the changes. Accordingly, a fixed-loss threshold of 
$31,000 will be applied to calculate outlier payments for discharges 
occurring on or after October 1, 2003.
    Comment: One commenter asked that CMS implement a transition 
period to protect those hospitals harmed by the significant changes 
in the June 9, 2003 final outlier rule. The commenter explained that 
a transition period is justified and would be consistent with 
previous transition methodologies employed for CMS changes, such as 
those proposed.
    One commenter stated that any reconciliation would be 
inconsistent with the prospective nature of the IPPS.
    Response: We responded to similar comments in the June 9, 2003 
final rule on outliers (68 FR 34494). Therefore, we refer the 
commenters to that final rule.
    Comment: Two commenters stated that the criterion in the final 
rule on outliers that specifically addressed our policy on 
reconciliation (that if a hospital's cost-to-charge ratio changed by 
10 or more percentage points, a hospital would be subject to 
reconciliation) is flawed. The commenters believed that the 
criterion would tolerate vastly different rates of charge growth 
among hospitals, and hospitals with the lowest charges in relation 
to cost would be inappropriately subject to the greatest restriction 
in charge growth. The commenters provided an example where a 
hospital with a cost-to-charge ratio of .30 could mark up its 
charges by 50 percent in a 2-year period without triggering 
reconciliation, while another hospital with a cost-to-charge ratio 
of .80 would trigger reconciliation if charges grew by only 14 
percent. The commenters recommended that, because of this inequity 
in this criterion, CMS modify the trigger for outlier reconciliation 
by promulgating a scale of cost-to-charge ratios rather than a 
constant amount. The scale could be based upon a rate of tolerable 
charge growth, which CMS would choose.
    Response: We appreciate the suggestion by the commenters and 
will carefully evaluate the information provided by them. We note 
that fiscal intermediaries have discretion under the reconciliation 
policy to reconcile additional hospitals' cost reports based on 
analysis that indicates the outlier payments made to those hospitals 
are significantly inaccurate.
    Comment: One commenter explained that one health care system 
agreed to accept reduced outlier payments during FY 2003. The 
commenter asked that this reduction be accounted for in the 
calculation of the threshold.
    Response: Our calculation of the outlier threshold reflects the 
application of the outlier policies implemented by the June 9, 2003 
final rule. The agreement referred to by the commenter was based 
upon the application of policies prior to that final rule. 
Therefore, it has no bearing on the calculation of the FY 2004 
threshold described in this final rule.
    Comment: One commenter noted that outlier payments are 
increasing because DRG payments are not keeping pace with the high 
cost of treatment. The commenter added that adjusting the outlier 
threshold will only add to the problem of underfunded health care 
and, because health care is not a priority,

[[Page 45478]]

there will always be a struggle to pay for it. The commenter noted 
that there needs to be a determination of what care will be paid 
for, and then hospitals need to decide if they will provide the 
noncovered services.
    Another commenter believed that the final rule on outliers would 
affect hospitals that have applied outlier payments appropriately. 
The commenter also believed that Medicare beneficiaries would be 
impacted as community hospitals shift care to more costly tertiary 
care facilities due to concerns about underpayment for potentially 
complex patient cases. The commenter explained that it is concerned 
that claims processing errors in the application of the outlier 
provision may result in underreporting of services provided, which 
will perpetuate underpayments to hospitals and lead to long-term 
ramifications on the integrity of the data generated by the IPPS.
    Response: As discussed above, we lowered the outlier threshold 
in response to the new provisions on outliers. We anticipate that, 
as a result of the changes implemented by our June 5, 2003 final 
rule, outlier payments will be better targeted to truly high-cost 
cases. This will help alleviate the commenters' concerns.
    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 thresholds for FY 2004 will result in outlier 
payments equal to 5.1 percent of operating DRG payments and 4.8 
percent of capital payments based on the Federal rate.
    In accordance with section 1886(d)(3)(B), we reduced the FY 2004 
standardized amounts by the same percentage to account for the 
projected proportion of payments paid to outliers. The outlier 
adjustment factors to be applied to the standardized amounts for FY 
2004 are as follows:

------------------------------------------------------------------------
                                                 Operating     Capital
                                               standardized    federal
                                                  amounts        rate
------------------------------------------------------------------------
National.....................................      0.949236     0.952050
Puerto Rico..................................      0.976658     0.993231
------------------------------------------------------------------------

    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.
    The June 9, 2003 final rule eliminated the application of the 
statewide average for hospitals whose cost-to-charge ratios fall 
below 3 standard deviations from the national mean cost-to-charge 
ratio. However, for those hospitals for which the fiscal 
intermediary computes operating cost-to-charge ratios greater than 
1.203 or capital cost-to-charge ratios greater than 0.163, or 
hospitals for whom the fiscal intermediary is unable to calculate a 
cost-to-charge ratio (as described at Sec.  412.84(i)(3)), we are 
still using statewide average ratios to calculate costs to determine 
whether a hospital qualifies for outlier payments.\8\ Table 8A in 
section VI. of this Addendum contains the statewide average 
operating cost-to-charge ratios for urban hospitals and for rural 
hospitals for which the fiscal intermediary is unable to compute a 
hospital-specific cost-to-charge ratio within the above range. These 
statewide average ratios would replace the ratios published in the 
August 1, 2002 IPPS final rule (67 FR 50263). Table 8B in section 
VI. of this Addendum contains the comparable statewide average 
capital cost-to-charge ratios. Again, the cost-to-charge ratios in 
Tables 8A and 8B will 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. iii. FY 
2002 and FY 2003 outlier payments.
---------------------------------------------------------------------------

    \8\ These figures represent 3.0 standard deviations from the 
mean of the log distribution of cost-to-charge ratios for all 
hospitals.
---------------------------------------------------------------------------

    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 7.8 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 6.5 percent of actual total DRG payments, 1.4 
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. This estimate does not reflect the outlier policy 
changes implemented in the June 9, 2003 final rule that will become 
effective on August 8, 2003. Due to the limited time remaining in FY 
2003 during which these changes will be effective, we do not 
anticipate that these changes will substantially affect our 
estimate.

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 will be applying to 
all hospitals, except hospitals in Puerto Rico. As described in 
section II.A.1. of this Addendum, we are not revising the labor 
share of the national standardized amount from 71.1 percent.
    The following table illustrates the 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: $3,213.66..........  Labor: $2,974.75
 reclassification budget neutrality and         Nonlabor: $1,306.26.......  Nonlabor: $1,209.15
 outlier offset).
FY 2004 Update Factor.........................  1.034.....................  1.034
FY 2004 DRG Recalibrations and Wage Index       1.005522..................  1.005522
 Budget Neutrality Factor.
FY 2004 Reclassification Budget Neutrality      0.992026..................  0.992026
 Factor.
Adjusted for Blend of FY 2003 DRG               Labor: $3,314.31..........  Labor: $3,261.83
 Recalibration and Wage Index Budget            Nonlabor: $1,347.17.......  Nonlabor: $1,325.84
 Neutrality Factors (factor of 0.993209
 effective October 1, 2002; factor of 0.993012
 effective April 1, 2003).
FY 2004 Outlier Factor........................  0.949236..................  0.949236

[[Page 45479]]

 
Rate for FY 2004 (after multiplying FY 2003     Labor: $3,146.06..........  Labor: $3,096.25
 base rate by above factors).                   Nonlabor: $1,278.780......  Nonlabor: $1,258.54
----------------------------------------------------------------------------------------------------------------

    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 used 
to calculate the prospective payment rates for hospitals located in 
the 50 States, the District of Columbia, and Puerto Rico. This 
section addresses two types of adjustments to the standardized 
amounts that are made in determining the prospective payment rates 
as described in this Addendum.

1. Adjustment for Area Wage Levels

    Sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act require 
that we make an adjustment to the labor-related portion of the 
national and Puerto Rico prospective payment rates, respectively, to 
account for area differences in hospital wage levels. This 
adjustment is made by multiplying the labor-related portion of the 
adjusted standardized amounts by the appropriate wage index for the 
area in which the hospital is located. In section III. of the 
preamble to this final rule, we discuss the data and methodology for 
the FY 2004 wage index. The 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 adjusting the payments for hospitals in Alaska 
and Hawaii by multiplying the nonlabor portion of the standardized 
amounts by the appropriate adjustment factor contained in the table 
below.

------------------------------------------------------------------------
                                                               Cost of
                                                                living
                            Area                              adjustment
                                                                factor
------------------------------------------------------------------------
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 using for 
discharges occurring in FY 2004. These factors have been 
recalibrated as explained in section II. of the preamble of this 
final rule.

D. Calculation of Prospective Payment Rates for FY 2004

General Formula for Calculation of Prospective Payment Rates for FY 
2004

    The 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 amounts in Table 1A in section 
VI. of this Addendum.
    The prospective payment rate for SCHs equals the higher of the 
applicable Federal rate from Table 1A or the hospital-specific rate 
as described below. The 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 prospective payment rate for Puerto 
Rico equals 50 percent of the Puerto Rico rate plus 50 percent of 
the 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 budget neutrality adjustment factor (that is, by 
1.005522) as discussed in section II.A.4.a. of this Addendum. The 
resulting rate was used in determining the payment rate an SCH or 
MDH will 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 increasing the hospital-specific rates by 3.4 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

[[Page 45480]]

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. 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 used to 
determine the capital Federal rate for FY 2004, which will 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 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 capital 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 
capital Federal rate is adjusted annually by a factor equal to the 
estimated proportion of outlier payments under the capital Federal 
rate to total capital payments under the capital Federal rate. In 
addition, Sec.  412.308(c)(3) requires that the capital 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 capital 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 
capital 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 capital 
rate that was made in FY 1994, and Sec.  412.308(b)(3) describes the 
0.28 percent reduction to the capital rate made in FY 1996 as a 
result of the revised policy of paying for transfers. In FY 1998, we 
implemented section 4402 of Pub. L. 105-33, which requires that, for 
discharges occurring on or after October 1, 1997, and before October 
1, 2002, the unadjusted capital 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 capital 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 Pub. L. 
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 capital rate 
and 50 percent of the capital 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 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 capital Federal rate 
of $407.01 for FY 2003. Section 402(b) of Pub. L. 108-7 requires 
that, effective for discharges occurring on or after April 1, 2003, 
and before October 1, 2003, the capital Federal rate for operating 
costs for all IPPS hospitals is based on the large urban 
standardized amount. However, under current law for discharges 
occurring on or after October 1, 2003, the capital 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 Pub. L. 108-7 and the 
wage index and GAF corrections, we have established a capital PPS 
standard Federal rate of $406.93

[[Page 45481]]

effective for discharges occurring on or after April 1, 2003 through 
September 30, 2003. As we discussed in the May 19, 2003 proposed 
rule (68 FR 27238), the capital rates effective for discharges 
occurring on or after April 1, 2003 through September 30, 2003, were 
used in determining the final FY 2004 capital rates. As a result of 
the changes to the factors used to establish the capital Federal 
rate that are explained in this Addendum, the FY 2004 capital 
standard Federal rate is $415.47.
    In the discussion that follows, we explain the factors that were 
used to determine the FY 2004 capital Federal rate. In particular, 
we explain why the FY 2004 capital Federal rate has increased 2.10 
percent compared to the FY 2003 capital 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 
1.4 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)) and the projected decrease in outlier payments 
as a result of the IPPS outlier policy established in the June 9, 
2003 high-cost outlier final rule (68 FR 34494).
    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. Capital Standard Federal Rate Update

a. Description of the Update Framework

    Under Sec.  412.308(c)(1), the capital 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. In the May 19, 2003 proposed rule (68 FR 27239), we 
proposed an update factor of 0.7 for FY 2004 under that framework 
based on the best data available at that time. Under that same 
update framework based on more recent data, the final update factor 
for FY 2004 is 0.7 percent. This final update factor is based on a 
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 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 19, 2003 proposed rule (68 FR 27239), 
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 capital standard Federal rate in FY 1996 using an 
update framework that takes into account, among other things, 
allowable changes in the intensity of hospital

[[Page 45482]]

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, as we discussed in the 
May 19, 2003 proposed rule (68 FR 27239), 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 June 9, 
2003 high-cost outlier final rule (68 FR 34494). As we discussed in 
that final rule, because hospitals have the ability to increase 
their outlier payments through dramatic charge increases, we have 
made 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, our intensity calculation relies heavily 
upon charge data and we believe that this charge data may be 
inappropriately skewed. Therefore, in the May 19, 2003 proposed rule 
(68 FR 22739), we proposed a 0.0 percent adjustment for intensity 
for FY 2004. As we explained in that same proposed rule, 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 apply 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. We received no comments on our 
proposed 0.0 percent adjustment for intensity. Therefore, in this 
final rule, we are making a 0.0 percent adjustment for intensity in 
the update for FY 2004.
    Above we described the basis of the components used to develop 
the 0.7 percent final capital update factor for FY 2004 as shown in 
the table below.

         CMS's 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
                                                                ========
    Total 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. As we discussed in the May 19, 
2003 proposed rule (68 FR 27240), 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 capital Federal rate. Accordingly, we applied an outlier 
adjustment factor of 0.9469 to the FY 2003 capital Federal rate. 
Based on the thresholds as set forth in section II.A.4.c. of this 
Addendum, we estimate that outlier payments for capital will equal 
4.79 percent of inpatient capital-related payments based on the 
capital Federal rate in FY 2004. Therefore, we are establishing an 
outlier adjustment factor of 0.9521 to the capital Federal rate. 
Thus, the percentage of capital outlier payments to total capital 
standard payments for FY 2004 is lower than the percentage for FY 
2003. This projected decrease in capital outlier payments is mostly 
due to the changes in the IPPS outlier policy established in the 
June 9, 2003 high-cost outlier final rule (68 FR 34494).
    The outlier reduction factors are not built permanently into the 
capital rates; that is, they are not applied cumulatively in 
determining the capital Federal rate. Therefore, the net change in 
the outlier adjustment to the capital Federal rate for FY 2004 is 
1.0055 (0.9521/0.9469). The outlier adjustment increases the FY 2004 
capital Federal rate by 0.55 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 capital Federal rate 
be adjusted so that aggregate payments for the fiscal year based on 
the capital 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 capital 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 capital 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 factors for FY 2004, we compared (separately 
for the national capital rate and the Puerto Rico capital rate) 
estimated aggregate capital Federal rate payments based on the FY 
2003 DRG relative weights and the FY 2003 GAF to estimated aggregate 
capital Federal rate payments based on the FY 2004 relative weights 
and the 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 capital rate and 0.9963 for the Puerto Rico 
capital 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 capital rate for discharges occurring on or before April 1, 
2003 through September 30, 2003. The budget neutrality adjustment 
factor for the Puerto Rico capital rate remained

[[Page 45483]]

unchanged (0.9963). As we noted above, the capital rates effective 
for discharges occurring on or after April 1, 2003 through September 
30, 2003 were used in determining the FY 2004 capital 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 applying an 
incremental budget neutrality adjustment of 1.0051 for FY 2004 to 
the previous cumulative FY 2003 adjustment (0.9883), yielding a 
cumulative adjustment of 0.9933 through FY 2004. For the Puerto Rico 
GAF, we are applying an incremental budget neutrality adjustment of 
1.0002 for FY 2004 to the previous cumulative FY 2003 adjustment 
(0.9963), yielding a cumulative adjustment of 0.9965 through FY 
2004.
    We then compared estimated aggregate capital Federal rate 
payments based on the FY 2003 DRG relative weights and the FY 2003 
GAF to estimated aggregate capital Federal rate payments based on 
the FY 2004 DRG relative weights and the FY 2004 GAF. The 
incremental adjustment for DRG classifications and changes in 
relative weights is 1.0008 both nationally and for Puerto Rico. The 
cumulative adjustments for DRG classifications and changes in 
relative weights and for changes in the GAF through FY 2004 are 
0.9941 nationally and 0.9973 for Puerto Rico. The following table 
summarizes the adjustment factors for each fiscal year:

                     Budget Neutrality Adjustment for DRG Reclassifications and Recalibration and the Geographic Adjustment Factors
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                              National                                                 Puerto Rico
                                     -------------------------------------------------------------------------------------------------------------------
                                                 Incremental adjustment                                    Incremental adjustment
             Fiscal year             ---------------------------------------------             ---------------------------------------------
                                       Geographic         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\ 0.99771     \3\ 1.00009     \3\ 0.99780      0.99922  \3\ 1.00365     \3\ 1.00009     \3\ 1.00374      1.00508
2002................................  \4\ 0.99666     \4\ 0.99668     \4\ 0.99335      0.99268  \4\ 0.98991     \4\ 0.99668     \4\ 0.99662      0.99164
2003 \5\............................      0.99915         0.99662         0.99577      0.98848      1.00809         0.99662         1.00468      0.99628
2003 \6\............................  \7\ 0.99896     \7\ 0.99662     \7\ 0.99558      0.98830  \7\ 1.00809     \7\ 0.99662     \7\ 1.00468  \7\ 0.99628
2004................................  \8\ 1.00510         1.00081     \8\ 1.00591      0.99414  \8\ 1.00023     \8\ 1.00081     \8\ 1.00104     0.99731
--------------------------------------------------------------------------------------------------------------------------------------------------------
\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 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 capital rate 
and the Puerto Rico capital 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 published in the Federal Register on April 25, 2003 (68 FR 
22272), 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, as noted above, the capital rates effective 
for discharges occurring on or after April 1, 2003 through September 
30, 2003 were used in determining the FY 2004 capital rates.
    In the May 19, 2003 proposed rule (68 FR 27241), for FY 2004 we 
calculated a GAF/DRG budget neutrality factor of 1.0038. For this 
final rule, based on updated data, we are establishing a GAF/DRG 
budget neutrality factor of 1.0059 for FY 2004. The GAF/DRG budget 
neutrality factors are built permanently into the capital rates; 
that is, they are applied cumulatively in determining the capital 
Federal rate. This follows from the requirement that estimated 
aggregate payments each year be no more or less than they would have 
been in the absence of the annual DRG reclassification and 
recalibration and changes in the GAF. The incremental change in the 
adjustment from FY 2003 to FY 2004 is 1.0059. The cumulative change 
in the capital Federal rate due to this adjustment is 0.9941 (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 incremental factor for FY 2004: 0.9980 x 1.0053 x 0.9998 x 
0.9994 x 0.9987 x 0.9989 x 1.0028 x 0.9985 x 0.9979 x 0.9934 x 
0.9956 x 1.0059 = 0.9941).
    This 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.

[[Page 45484]]

4. Exceptions Payment Adjustment Factor

    Section 412.308(c)(3) requires that the capital standard 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 capital 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 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 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 
39912-39914), 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 March 2003.

------------------------------------------------------------------------
                                                         Cost reporting
                       PPS year                        periods 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 2001). While we have not yet received all 
of the FY 2001 cost reports, we do have a sufficient number of FY 
2001 cost reports to model a preliminary estimate of special 
exception payments for FY 2004. 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........................................            2           --
PPS XII.......................................            5           --
PPS XIII......................................            7           --
PPS XIV.......................................           13       0.0001
PPS XV........................................           17       0.0001
PPS XVI.......................................           24       0.0001
PPS XVII......................................           26       0.0001
PPS XVIII.....................................           29    * 0.0004
------------------------------------------------------------------------
* Preliminary estimate based on submission of cost reports available as
  of March 2003.

    We note that hospitals must complete their projects by the end 
of PPS XVIII in order to be eligible for special exceptions 
payments. With complete submission of the PPS XVIII (FY 2001) cost 
reports, we estimate that about 30 hospitals may 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, in the May 19, 
2003 proposed rule, we proposed to offset the capital Federal rate 
by 0.05 percent for special exceptions payments for FY 2004. For 
this final rule, based on updated data, we are offsetting the 
capital Federal rate by 0.05 percent for special exceptions payments 
for FY 2004. Therefore, the exceptions adjustment factor is equal to 
0.9995 (1-0.0005) to account for special exceptions payments in FY 
2004.
    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 capital Federal 
rate. Therefore, we applied an exceptions reduction factor of 0.9970 
(1-0.0030) in determining the FY 2003 capital Federal rate. As we 
stated above, we estimate that exceptions payments in FY 2004 will 
equal 0.05 percent of aggregate payments based on the FY 2004 
capital Federal rate. Therefore, we are applying an exceptions 
payment adjustment factor of 0.9995 (1-0.0005) to the capital 
Federal rate for FY 2004. The exceptions adjustment factor for FY 
2004 is 0.25 percent higher than the factor for FY 2003 published in 
the

[[Page 45485]]

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 capital rates; that is, the factors are not applied cumulatively 
in determining the capital Federal rate. Therefore, the net change 
in the exceptions adjustment factor used in determining the FY 2004 
capital Federal rate is 0.9995/0.9970, or 1.0025.

5. Capital Standard 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 published August 25, 2003 in the Federal Register (68 FR 
22272), we have established a capital Federal rate of $406.93 for 
discharges occurring on or after April 1, 2003 through September 30, 
2003. The capital rates effective for discharges occurring on or 
after April 1, 2003 through September 30, 2003, were used in 
determining the FY 2004 capital rates. In this final rule, we are 
establishing a capital Federal rate of $415.47 for FY 2004. The 
capital Federal rate for FY 2004 was calculated as follows:
    [sbull] The FY 2004 update factor is 1.0070; that is, the update 
is 0.70 percent.
    [sbull] The FY 2004 budget neutrality adjustment factor that is 
applied to the capital standard Federal payment rate for changes in 
the DRG relative weights and in the GAF is 1.0059.
    [sbull] The FY 2004 outlier adjustment factor is 0.9521.
    [sbull] The FY 2004 (special) exceptions payment adjustment 
factor is 0.9995.
    Since the capital 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 making no 
additional adjustments in the capital standard Federal rate for 
these factors, other than the budget neutrality factor for changes 
in the DRG relative weights and the GAF.
    We are providing a chart that shows how each of the factors and 
adjustments for FY 2004 affected the computation of the FY 2004 
capital Federal rate in comparison to the FY 2003 capital Federal 
rate. The FY 2004 update factor has the effect of increasing the 
capital Federal rate by 0.70 percent compared to the FY 2003 capital 
Federal rate, while the GAF/DRG budget neutrality factor has the 
effect of increasing the capital Federal rate by 0.59 percent. The 
FY 2004 outlier adjustment factor has the effect of increasing the 
capital Federal rate by 0.55 percent compared to the FY 2003 capital 
Federal rate. The FY 2004 exceptions payment adjustment factor has 
the effect of increasing the capital Federal rate by 0.25 percent 
compared to the exceptions payment adjustment factor for capital FY 
2003. The combined effect of all the changes is to increase the 
capital Federal rate by 2.10 percent compared to the FY 2003 capital 
Federal rate.

      Comparison of Factors and Adjustments: FY 2003 Capital Federal Rate and FY 2004 Capital Federal Rate
----------------------------------------------------------------------------------------------------------------
                                                      FY 2003         FY 2004         Change      Percent change
----------------------------------------------------------------------------------------------------------------
Update factor\1\................................          1.0110          1.0070          1.0070            0.70
GAF/DRG Adjustment Factor \1\...................          0.9957          1.0059          1.0059            0.59
Outlier Adjustment Factor \2\...................          0.9469          0.9521          1.0055            0.55
Exceptions Adjustment Factor \2\................          0.9970          0.9995          1.0025            0.25
Capital Federal Rate............................         $406.93         $415.47      \3\ 1.0210       \3\ 2.10
----------------------------------------------------------------------------------------------------------------
\1\ The update factor and the GAF/DRG budget neutrality factors are built permanently into the capital rates.
  Thus, for example, the incremental change from FY 2003 to FY 2004 resulting from the application of the 1.0059
  GAF/DRG budget neutrality factor for FY 2004 is 1.0059.
\2\ The outlier reduction factor and the exceptions adjustment factor are not built permanently into the capital
  rates; that is, these factors are not applied cumulatively in determining the capital rates. Thus, for
  example, the net change resulting from the application of the FY 2004 outlier adjustment factor is 0.9521/
  0.9469, or 1.0055.
\3\ The percent change in factors and adjustments may not sum due to rounding.

    We are also providing a chart that shows how the final FY 2004 
capital Federal rate differs from the proposed FY 2004 capital 
Federal rate.

 Comparison of Factors and Adjustments: FY 2004 Proposed Capital Federal Rate and FY 2004 Final Capital Federal
                                                      Rate
----------------------------------------------------------------------------------------------------------------
                                                    Proposed FY
                                                       2004        Final FY 2004      Change      Percent change
----------------------------------------------------------------------------------------------------------------
Update factor...................................          1.0070          1.0070          1.0000            0.00
GAF/DRG Adjustment Factor.......................          1.0038          1.0059          1.0021            0.21
Outlier Adjustment Factor.......................          0.9455          0.9521          1.0070            0.70
Exceptions Adjustment Factor....................          0.9995          0.9995          1.0000            0.00
Capital Federal Rate............................         $411.72         $415.47          1.0091            0.91
----------------------------------------------------------------------------------------------------------------

6. Special Capital 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 capital rate and 50 percent of the capital Federal rate. The 
Puerto Rico capital rate is derived from the costs of Puerto Rico 
hospitals only, while the capital 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 capital 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 capital 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 GAF budget neutrality factor is 
1.0002, while the DRG adjustment is 1.0008, for a combined 
cumulative adjustment of 0.9973.
    In computing the payment for a particular Puerto Rico hospital, 
the Puerto Rico portion of the capital 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 capital 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

[[Page 45486]]

Rico). In FY 1998, we implemented a 17.78 percent reduction to the 
Puerto Rico capital rate as a result of Pub. L. 105-33. In FY 2003, 
a small part of that reduction was restored.
    For FY 2003, before application of the GAF, the special capital 
rate for Puerto Rico hospitals was $198.29. With the changes we 
proposed to the factors used to determine the capital rate, the 
proposed FY 2004 special capital rate for Puerto Rico was $201.26. 
For this final rule, based on the final factors, the FY 2004 capital 
rate for Puerto Rico is $203.15.

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 
capital Federal rate in FY 2004. The applicable capital Federal rate 
was determined by making adjustments as follows:
    [sbull] For outliers, by dividing the capital 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 capital 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 
capital Federal rate.
    Hospitals also may receive outlier payments for those cases that 
qualify under the thresholds established for each fiscal year. 
Section 412.312(c) provides for a single set of thresholds to 
identify outlier cases for both inpatient operating and inpatient 
capital-related payments. The outlier thresholds for FY 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 $31,000.
    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 were 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.A. of the 
preamble of this final 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 to receive payment based on 100 
percent of the capital 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 capital 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

    Based on historical data available through the second quarter of 
2003, we forecast the CIPI to increase 0.7 percent in FY 2004. This 
reflects a projected 1.2 percent increase in vintage-weighted 
depreciation prices (building and fixed equipment, and movable 
equipment) and a 3.8 percent increase in other capital expense 
prices in FY 2004, partially offset by a 2.6 percent decline in 
vintage-weighted interest expenses in FY 2004. The weighted average 
of these three factors produces the 0.7 percent increase for the 
CIPI as a whole in FY 2004.

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

    As discussed in section VI. of the preamble of this final 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 100 percent 
of IRF PPS 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 LTCH 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 that is 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 psychiatric hospitals and 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 (as defined in Sec.  413.40(a)(3)). In addition, LTCHs that 
are paid under a blend methodology will have the TEFRA portion 
subject to the ceiling as well.
    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

[[Page 45487]]

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 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 market basket increase percentage of 3.4 
percent. This percentage change in the market basket reflects the 
average change in the price of goods and services purchased by 
hospitals to furnish inpatient hospital services (as projected by 
CMS' 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
                                                    labor-     nonlabor-
       Class of excluded hospital or unit           related     related
                                                     share       share
------------------------------------------------------------------------
Psychiatric.....................................      $7,294      $2,899
------------------------------------------------------------------------

    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.
    We are in the process of developing a proposed rule that would 
establish a per diem PPS for inpatient psychiatric facilities (IPFs) 
(previously referred to as psychiatric hospitals and units) that is 
required under the provisions of section 124 of Pub. L. 106-113.

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).
    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 final rule and in this Addendum. For purposes of 
this final rule, and to avoid confusion, we have retained the 
designations of Tables 1 through 5 that were first used in the 
September 1, 1983 initial prospective payment final rule (48 FR 
39844). Tables 1A, 1C, 1D, 2, 3A, 3B, 4A, 4B, 4C, 4F, 4G, 4H, 5, 6A, 
6B, 6C, 6D, 6E, 6F, 6G, 6H, 7A, 7B, 8A, 8B, 9, 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.--vised 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 March 2003 GROUPER V20.0
Table 7B.--Medicare Prospective Payment System Selected Percentile 
Lengths of Stay
    FY 2002 MedPAR Update March 2003 GROUPER V21.0
Table 8A.--Statewide Average Operating Cost-to-Charge Ratios--July 
2003
Table 8B.--Statewide Average Capital Cost-to-Charge Ratios--July 
2003
Table 9.--Hospital Reclassifications and Redesignations--FY 2004
Table 10.--Mean and .75 Standard Deviation by Diagnosis-Related 
Groups (DRGs)-July 2003
Table 11.--LTC-DRGs Relative Weights and Geometric and Five-Sixth of 
the Average Length of Stay-FY 2004

[[Page 45488]]



                   Table 1A.--National Adjusted Operating Standardized Amounts, Labor/Nonlabor
----------------------------------------------------------------------------------------------------------------
                    Large urban areas                                           Other areas
----------------------------------------------------------------------------------------------------------------
       Labor-related               Nonlabor-related              Labor-related             Nonlabor-related
----------------------------------------------------------------------------------------------------------------
               $3,145.06                    $1,278.78                   $3,095.27                   $1,258.54
----------------------------------------------------------------------------------------------------------------


                                   Table 1C.--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                      Large urban areas                                    Other areas
                                                     ---------------------------------------------------------------------------------------------------
                                                               Labor                   Nonlabor                  Labor                   Nonlabor
--------------------------------------------------------------------------------------------------------------------------------------------------------
National............................................                $3,119.61                $1,268.03                $3,119.61                $1,268.03
Puerto Rico.........................................                 1,510.12                   607.86                 1,486.22                   598.24
--------------------------------------------------------------------------------------------------------------------------------------------------------


            Table 1D.--Capital Standard Federal Payment Rate
------------------------------------------------------------------------
                                                                  Rate
------------------------------------------------------------------------
National.....................................................    $415.47
Puerto Rico..................................................     203.15
------------------------------------------------------------------------

    --------------------
* 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 45488]]



  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
----------------------------------------------------------------------------------------------------------------
                                    Average hourly      Average hourly      Average hourly      Average hourly
          Provider No.               wage FY 2002        wage FY 2003        wage FY 2004       wage ** (3yrs)
----------------------------------------------------------------------------------------------------------------
010001..........................             17.4467             17.9841             19.4061             18.2955
010004..........................             19.0010             20.1613             22.2673             20.4948
010005..........................             18.6554             19.9733             19.6063             19.4156
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             20.4309             19.5485
010010..........................             16.4664             17.7348             19.2644             17.7722
010011..........................             22.4292             24.8922             25.8231             24.3180
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             18.9177             17.8535
010021..........................             15.1241             25.3335             17.7595             18.4456
010022..........................             17.6435             22.1250             22.2266             20.3667
010023..........................             16.3209             18.4567             20.4900             18.3307
010024..........................             15.9034             17.3746             18.5942             17.2467
010025..........................             15.1548             17.4702             19.3649             17.3268
010027..........................             16.8595             16.5157             14.0974             15.7259
010029..........................             18.3605             19.3393             20.9868             19.6276
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             14.9333             15.0828
010035..........................             15.9439             20.7808             21.6182             19.2869
010036..........................             17.7166             18.7158             19.2501             18.5418
010038..........................             19.6098             19.6887             18.6578             19.2855
010039..........................             20.3406             21.3550             23.0339             21.6158
010040..........................             20.0983             20.4486             20.7779             20.4475
010043..........................             18.6640             17.3567             19.9012             18.6528
010044..........................             24.0265             23.4575             25.8561             24.4502
010045..........................             17.0417             18.7569             22.7713             19.2947
010046..........................             18.9737             18.8741             19.6754             19.1973
010047..........................             15.4190             13.4130             16.1695             14.9341
010049..........................             15.5246             16.3349             16.2973             16.0600
010050..........................             17.9830             20.3028             20.7398             19.6262
010051..........................             11.8108             12.3280             14.3007             12.8040

[[Page 45489]]

 
010052..........................             18.0653             19.8289             11.9019             15.6329
010053..........................             15.5649             15.4156             17.3238             16.1023
010054..........................             19.4955             20.9656             20.6382             20.3799
010055..........................             18.8590             19.5667             18.9664             19.1295
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             17.0447             16.6905
010062..........................             12.3259             16.9721             17.1786             15.3820
010064..........................             19.5256             20.5650             22.2280             20.6930
010065..........................             16.8752             17.0557             17.2698             17.0733
010066..........................             13.1559             14.8904             14.8696             14.3351
010068..........................             18.6925             23.4322             18.3308             20.2712
010069..........................             14.7211             15.4497             17.0957             15.7416
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             19.7620             18.8065
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
010092..........................             17.8144             18.5478             19.9351             18.7658
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             20.7787             19.7956
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             19.4106             18.1836
010114..........................             17.0760             19.3772             20.1763             18.8237
010115..........................             14.2261             15.3510             15.7873             15.0923
010118..........................             17.0834             17.4620             19.5302             17.9294
010119..........................             19.3942             19.5163             20.5245             19.8190
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             19.9647             19.5751
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             22.9969             20.8110
010134..........................             19.9856             18.5179             17.7717             18.7919
010137..........................             20.5828             21.3573             28.9402             23.2122
010138..........................             14.5254             14.1369             14.2024             14.2898
010139..........................             20.4331             20.5708             22.8390             21.2553
010143..........................             17.6212             18.9084             20.5639             19.0433
010144..........................             18.2040             18.8272             19.1497             18.7345
010145..........................             20.5895             20.8157             22.1394             21.2084

[[Page 45490]]

 
010146..........................             19.1415             18.3666             21.3083             19.5948
010148..........................             15.8349             18.4591             17.6830             17.3825
010149..........................             18.0156             19.0199             21.0086             19.3661
010150..........................             18.9359             19.4819             21.2360             19.9132
010152..........................             18.7677             19.8990             21.6038             20.0519
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                   *             26.6688
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                   *             29.7080
020008..........................             30.8691             31.8878             33.4543             32.1364
020009..........................             18.4660             18.5594                   *             18.5119
020010..........................             22.7559             23.7275             20.7928             22.3051
020011..........................             28.0658             27.5062                   *             27.7745
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                   *             24.0587
030001..........................             21.7869             22.8996             25.7513             23.3305
030002..........................             21.8375             23.1450             25.6038             23.5516
030003..........................             22.6804             23.9849             22.1436             22.9249
030004..........................             15.5478             13.8452                   *             14.6087
030006..........................             20.0273             20.5019             23.2881             21.1483
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             23.3663             21.1589
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                   *             15.6341
030027..........................             17.6555             18.5500             19.4583             18.5927
030030..........................             21.6932             23.1280             25.2425             23.1970
030033..........................             20.2820             20.3034             26.3814             22.2735
030034..........................             20.8689             19.5578                   *             20.1515
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                   *             18.6831
030043..........................             20.5598             20.5653             23.5172             21.6042
030044..........................             17.6575             18.6781             21.9503             19.2464
030047..........................             21.4412             22.7385                   *             22.1035
030049..........................             19.3580             19.7315                   *             19.5288
030054..........................             15.0657             15.7973                   *             15.4443
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

[[Page 45491]]

 
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             22.8953             21.6643
030083..........................             23.5229             23.5049             24.3273             23.8162
030085..........................             20.8690             21.6542             21.8196             21.4875
030087..........................             21.9465             23.1339             25.6351             23.5333
030088..........................             20.5340             21.4491             23.5761             21.9185
030089..........................             20.9516             22.0850             24.5055             22.5911
030092..........................             21.8308             19.6625             24.0515             21.9130
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             27.6299             25.3037
030101..........................             19.2547             21.1029             23.7661             21.3217
030102..........................             18.2413             21.5405             27.9419             22.5589
030103..........................                   *             28.9308             29.1105             29.0254
030104..........................                   *             32.8668             34.6026             33.8315
040001..........................             16.9178             16.3882             18.7141             17.4255
040002..........................             15.1107             16.1353             18.0776             16.4361
040003..........................             15.5740             15.5186             16.3918             15.8349
040004..........................             17.9034             19.0105             21.2335             19.4115
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             20.7114             20.0272
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             22.0408             19.7570
040019..........................             23.4163             21.0465             21.1711             21.7572
040020..........................             18.9844             17.6056             18.6419             18.3851
040021..........................             19.6835             21.3321             23.5620             21.5681
040022..........................             20.8281             19.2393             21.4194             20.3876
040024..........................             17.6607             17.1507             17.5750             17.4623
040025..........................             13.4705             14.8071                   *             14.1228
040026..........................             19.7924             21.0143             22.7699             21.2074
040027..........................             17.4431             17.7161             19.3388             18.1973
040028..........................             13.9946             15.2850                   *             14.6625
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                   *             15.1931
040045..........................             16.2469             16.6648             19.5573             17.3603
040047..........................             17.5336             18.6295             21.6323             19.2840
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             19.7335             18.3506

[[Page 45492]]

 
040058..........................             16.4278             19.3124                   *             17.6419
040060..........................             17.9805             15.4220                   *             16.5871
040062..........................             17.8902             19.4255             21.9336             19.7228
040064..........................             11.5029             13.3479                   *             12.3898
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                   *             17.8568
040071..........................             17.6144             18.4956             19.4324             18.4911
040072..........................             17.4960             21.3320             19.3079             19.3210
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             18.4470             20.0143
040081..........................             11.1332             12.4796             13.2797             12.2892
040082..........................             15.1331             16.4840                   *             15.7978
040084..........................             17.7295             18.3410             20.1163             18.7753
040085..........................             16.5216             14.1782             15.5811             15.3778
040088..........................             17.1624             18.3159             20.0032             18.4492
040090..........................             19.0824             16.6619                   *             17.8591
040091..........................             20.1378             20.2904             20.6688             20.3813
040093..........................             13.9741             14.7132                   *             14.3380
040100..........................             15.6833             17.0271             17.8889             16.9700
040105..........................             14.3896             14.8936             15.4697             14.9508
040106..........................             18.1341             19.0936                   *             18.6698
040107..........................             17.8628             20.6852             17.6695             18.7676
040109..........................             16.6278             16.2496             17.1706             16.6926
040114..........................             21.1231             21.3826             21.6849             21.4003
040118..........................             18.2123             19.6248             21.7913             19.9047
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             24.4646             22.0021
040135..........................             23.0084                   *                   *             23.0082
040136..........................                   *             21.4139                   *             21.4138
040137..........................                   *                   *             24.7813             24.7813
040138..........................                   *                   *             22.3523             22.3523
050002..........................             36.9630             30.2629             30.9729             32.2632
050006..........................             18.2061             22.4890             25.4604             22.0357
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             29.8401             28.3575
050014..........................             23.6745             25.1664             27.7646             25.5586
050015..........................             27.7731             28.2204             27.5652             27.8552
050016..........................             21.2045             22.7014             25.5508             23.2128
050017..........................             25.6178             25.7403             28.4911             26.6066
050018..........................             15.2903             16.5909             17.9621             16.7254
050022..........................             24.5254             26.2574             28.1312             26.3930
050024..........................             22.4274             21.5230             25.1425             23.0352
050025..........................             24.8245             26.0161             29.8262             26.8932
050026..........................             23.1904             23.4651             24.2564             23.6605
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             28.8046             25.7369
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

[[Page 45493]]

 
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             25.9389             24.7179
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             39.2529             38.3306
050073..........................             32.8555             36.1054             38.6763             35.9238
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             24.1091             23.8126
050079..........................             30.0167             36.5455             38.8981             35.1106
050082..........................             23.7617             23.7718             27.5022             24.9190
050084..........................             25.4517             25.1155             26.0607             25.5652
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                   *             17.1549
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             24.6726             23.8591
050099..........................             25.3722             26.2363             27.1282             26.2763
050100..........................             25.2031             23.9877             25.6798             24.9469
050101..........................             31.8957             33.1232             32.9866             32.6718
050102..........................             24.0014             22.6741             25.5763             24.0204
050103..........................             25.4133             23.5946             27.8079             25.5235
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             28.1938             27.5328
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             25.0858             20.5240
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             21.8719             21.1212
050128..........................             26.6132             26.2519             28.7668             27.1805
050129..........................             24.0108             23.7432             25.2780             24.3452

[[Page 45494]]

 
050131..........................             32.5462             33.0980             37.7844             34.4656
050132..........................             24.0173             24.1583             27.8805             25.3842
050133..........................             23.2093             23.9479             25.1948             24.1576
050135..........................             24.7157             23.2750                   *             23.9658
050136..........................             24.7280             28.0754             31.6146             27.9406
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             27.4051             24.9053
050167..........................             21.8796             21.9596             23.2022             22.3516
050168..........................             25.1937             27.1971             27.5313             26.5678
050169..........................             24.8407             24.7737             25.6896             25.1108
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             19.5327             17.3659
050193..........................             24.9444             25.5294             24.6307             25.0325
050194..........................             29.5678             28.5389             28.1413             28.7132
050195..........................             36.9068             39.1617             42.1735             39.4471
050196..........................             18.2411             19.4304             20.7257             19.5002
050197..........................             32.4030             34.6878                   *             33.4489
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             22.4773             22.4934
050215..........................             35.0459             31.6895             36.6063             34.4197
050217..........................             20.2042             21.3026             22.2055             21.2565
050219..........................             21.2458             21.7637             21.8649             21.6598
050222..........................             23.3563             23.0670             25.2922             23.9448
050224..........................             23.5101             24.8431             26.2108             24.9081
050225..........................             21.6820             22.0981             25.0218             22.9304
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             27.8896             27.3721
050232..........................             24.5245             25.8640             25.3439             25.2423
050234..........................             24.6126             25.0104             24.0754             24.5126
050235..........................             27.0922             26.0323             27.2838             26.7962
050236..........................             25.9458             27.7406             27.0687             26.9151
050238..........................             24.5823             25.1796             26.0312             25.2541
050239..........................             23.2711             24.9469             27.0866             25.1260
050240..........................             26.7620             28.8910             32.8542             29.7204
050241..........................             29.8345                   *                   *             29.8345

[[Page 45495]]

 
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                   *             28.8055
050261..........................             20.1040             19.4649             21.4693             20.3613
050262..........................             29.5550             30.8866             33.0425             31.0973
050264..........................             36.0331             33.2270             37.4741             35.5250
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             34.7422             34.0318
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             28.5504             26.8526
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             34.9646             32.5479
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             26.1707             23.8598
050299..........................             25.5035             24.6751             26.9870             25.7710
050300..........................             25.9228             26.0298             26.3182             26.1028
050301..........................             21.1403             24.7987             25.7167             23.8557
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             25.3372             26.5450
050315..........................             22.7359             22.5906             23.6638             23.0139
050320..........................             32.4809             31.6571             31.4570             31.8291
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             24.9274             23.6376
050336..........................             21.3402             22.0203             23.2687             22.1975
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             32.6572             28.8606
050353..........................             23.2699             24.1009             25.4309             24.2678
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

[[Page 45496]]

 
050367..........................             30.7328             31.7487             32.6760             31.7233
050369..........................             26.2234             26.6627             28.0909             27.0127
050373..........................             27.8275             29.9749             30.7301             29.4528
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             35.8014             33.0886
050382..........................             25.9244             26.3968             26.8949             26.4027
050385..........................                   *             27.1692                   *             27.1692
050388..........................             22.0122             17.6762                   *             19.7924
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                   *             16.2457
050406..........................             17.8596             21.5282                   *             19.5336
050407..........................             30.8346             32.0753             33.2894             32.0587
050410..........................             19.8508             17.1718             19.8436             18.9151
050411..........................             33.1943             33.1718             35.5207             33.9577
050414..........................             25.9723             24.5471             28.2381             26.2718
050417..........................             23.3005             23.3862             24.5360             23.7554
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                   *             23.2879
050430..........................             21.2275             25.2322             31.5171             24.6961
050432..........................             24.5630             26.0686             28.1105             26.3124
050433..........................             18.9021             17.7980             14.3846             17.2267
050434..........................                   *             24.0017                   *             24.0017
050435..........................             23.3426             22.5428             22.6618             22.8189
050438..........................             23.2583             25.3763             26.5535             25.0490
050440..........................             22.5400             25.4767                   *             23.9820
050441..........................             31.8774             33.4696             36.6680             33.8900
050443..........................             17.2875             16.8897                   *             17.0772
050444..........................             22.4530             22.6469             23.5299             22.8500
050446..........................             22.3422             20.3611                   *             21.2838
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             24.1694             21.4327
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             21.6981             17.5845
050471..........................             27.1597             29.4705             32.3570             29.6121
050476..........................             24.0253             25.9458             26.0482             25.3722
050477..........................             27.5819             30.8781             32.1676             30.2255
050478..........................             26.3306             28.1829             28.3893             27.6685
050481..........................             27.7973             28.5320             30.3890             28.9165
050482..........................             16.0114             21.6091                   *             18.2916
050485..........................             24.6906             25.2723             27.1437             25.6725
050488..........................             31.7481             33.8291             37.2438             34.4285
050491..........................             27.4600             27.7412             29.2987             28.1988

[[Page 45497]]

 
050492..........................             20.5030             23.4977             23.7383             22.6518
050494..........................             29.1296             30.2875             30.8706             30.1345
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             28.0102             26.8843
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             30.0985             27.0287
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
050535..........................             26.8511             27.7626             29.7904             28.1965
050537..........................             24.0354             26.2342             25.1292             25.1574
050539..........................             23.3846             23.7778             25.3328             24.1813
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             31.8525             30.3559
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             25.8719             24.0562
050559..........................             24.7866             26.3799             25.3299             25.4887
050561..........................             33.4423             34.2065             35.9611             34.5098
050564..........................             24.2091                   *                   *             24.2090
050565..........................             20.8349                   *                   *             20.8349
050566..........................             22.3448             21.7712                   *             22.0475
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             30.4934             30.4285
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                   *             25.7172             24.5880
050588..........................             24.5472             27.0506             30.5453             27.6351
050589..........................             23.8880             23.7918             27.9845             25.1893
050590..........................             24.4797             25.1100             27.0620             25.5289
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             24.6875             24.6305
050599..........................             26.0892             26.3782             27.7684             26.7559

[[Page 45498]]

 
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             37.4563             35.1739
050613..........................             30.2413             34.9768                   *             32.5464
050615..........................             27.5682             25.8698             29.4322             27.6985
050616..........................             24.9843             25.0016             23.1748             24.3242
050618..........................             21.4895             22.3548             22.3481             22.1206
050623..........................             27.5832             28.6475             29.9553             28.6716
050624..........................             26.4659             22.4030             23.3492             23.8718
050625..........................             27.5816             29.3665             30.8013             29.3364
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                   *             16.7440
050641..........................             17.1258             17.9379             21.5030             19.2373
050644..........................             22.1489                   *             28.4054             25.2877
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             55.9594             58.7058
050670..........................             24.6101             24.1626                   *             24.3757
050674..........................             32.4807             33.7845             36.8871             34.4747
050676..........................             20.2087             16.3948                   *             18.1923
050677..........................             33.6070             34.0936             36.2702             34.6349
050678..........................             22.7756             25.2143             27.1337             25.0885
050680..........................             31.4839             31.9166             32.7065             32.0475
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             37.3032             35.1892
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             18.6962             20.0478
050698..........................                   *             24.9559                   *             24.9559
050699..........................             17.5296             23.4611             26.0909             21.8689
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
050724..........................                   *                   *             23.7567             23.7567
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             21.4244             19.6205
060008..........................             18.4590             18.7097             19.8803             19.0217

[[Page 45499]]

 
060009..........................             22.7164             23.9272             24.7920             23.8281
060010..........................             23.6827             24.2735             25.8475             24.6131
060011..........................             22.3458             22.2058             25.8919             23.4930
060012..........................             19.4932             21.2980             22.6374             21.1159
060013..........................             19.1256             23.5248             23.3954             22.3367
060014..........................             24.3210             25.7701             27.0326             25.7458
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             24.7928             22.9453
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             27.1303             24.8437
060029..........................             18.2938             19.8498             19.7379             19.2937
060030..........................             20.3452             21.2612             22.8309             21.5553
060031..........................             22.5067             23.3995             23.8781             23.2637
060032..........................             22.8123             24.7678             27.1783             24.9890
060033..........................             16.0760             17.8514             16.7266             16.8791
060034..........................             23.2816             24.3652             26.1602             24.6636
060036..........................             18.5988             18.6521             19.4144             18.9130
060037..........................             15.4513             15.7495                   *             15.6040
060038..........................             14.3249             16.6525                   *             15.6518
060041..........................             19.1263             19.5872             20.8745             19.8909
060042..........................             20.8597             19.3967                   *             19.9173
060043..........................             13.4443             15.4073             19.1085             15.9780
060044..........................             20.8673             21.3102             25.6112             23.4887
060046..........................             22.2699             22.6819                   *             22.4792
060047..........................             17.1534             17.9173                   *             17.5379
060049..........................             23.0613             25.9592             25.3425             24.9252
060050..........................             19.0832                   *             20.4386             19.8467
060052..........................             14.8729             16.0543                   *             15.4475
060053..........................             18.0232             19.4746                   *             18.7228
060054..........................             20.4160             19.7753             21.1281             20.4312
060056..........................             18.1263             21.9586                   *             20.1887
060057..........................             25.4185             24.6599             24.3982             24.8074
060058..........................             13.8539             16.4504                   *             15.1564
060060..........................             15.6018             19.4418                   *             17.3849
060062..........................             16.8640             17.1032                   *             16.9796
060064..........................             22.7797             28.8746             29.1806             26.8320
060065..........................             24.5572             24.4554             29.2377             26.0841
060066..........................             17.2537             17.5556                   *             17.3996
060070..........................             18.8960             19.2220             22.6894             20.3042
060071..........................             17.4068             17.6452             20.1385             18.3916
060073..........................             17.0846             18.4971                   *             17.7673
060075..........................             23.8724             25.0552             27.7835             25.5595
060076..........................             20.3265             22.9426             23.6266             22.3373
060085..........................             14.3409             10.9724                   *             12.5324
060088..........................             13.7174             20.7211                   *             16.8131
060090..........................             16.3760             16.5321                   *             16.4540
060096..........................             20.8937             21.9951             26.4167             23.1494
060100..........................             23.9305             24.8116             28.0561             25.6542
060103..........................             23.5083             24.4962             26.6863             24.9275
060104..........................             21.1820             24.4248             26.7682             23.9805
060107..........................             21.9221                   *                   *             21.9222
060108..........................                   *             19.1327             19.0011             19.0448
060109..........................                   *             27.3180                   *             27.3180
060110..........................                   *                   *             29.8561             29.8561
070001..........................             26.3596             27.7441             29.9592             27.9941
070002..........................             26.1768             26.6881             28.1101             26.9593
070003..........................             27.5200             28.1721             29.8684             28.5356
070004..........................             24.2567             25.4310             25.7207             25.1218
070005..........................             26.9151             27.6733             29.8173             28.0976

[[Page 45500]]

 
070006..........................             28.6413             33.6291             33.3814             32.0737
070007..........................             26.3313             28.0875             29.0336             27.8511
070008..........................             24.2971             25.1362             24.3907             24.6106
070009..........................             24.1871             24.9408             25.6072             24.9173
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             29.7505             27.3887
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             30.3254             28.7921
070022..........................             26.9111             27.2423             29.7376             27.9567
070024..........................             24.8948             26.3544             28.3460             26.5801
070025..........................             25.4345             27.3592             28.3017             27.0096
070027..........................             26.8450             25.9279             36.9699             29.0675
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             34.3904             33.3381
070034..........................             29.4916             30.0744             32.8074             30.7406
070035..........................             24.1423             24.5996             26.1693             24.9143
070036..........................             29.9470             31.2961             35.0701             32.0463
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             23.6838             22.4133
080007..........................             21.3746             21.5415             23.4964             22.1696
090001..........................             21.5751             23.0365             29.5432             24.4308
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             23.7241             22.9485
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             22.6150             21.6357
100002..........................             21.0222             21.5772             22.5982             21.7602
100004..........................             15.4149             16.1638             15.6306             15.7493
100006..........................             21.2293             21.6922             23.3745             22.1765
100007..........................             22.1590             22.5317             24.3305             23.0600
100008..........................             20.8381             21.6416             22.7706             21.7804
100009..........................             22.1741             22.6370             24.7811             23.2097
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             24.1885             22.8575
100019..........................             23.5462             25.8297             24.2888             24.5531
100020..........................             20.7816             21.7421             23.5303             22.0615
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             20.1603             20.7988

[[Page 45501]]

 
100027..........................             14.7916             20.5889             23.8982             18.2776
100028..........................             19.3371             20.3751             21.8879             20.5632
100029..........................             20.8950             22.2553             24.6814             22.4835
100030..........................             20.5952             19.5604             21.8567             20.7315
100032..........................             19.7451             20.6543             21.6415             20.6364
100034..........................             19.5282             20.0099             23.1111             20.8438
100035..........................             23.8117             21.3519             22.6349             22.5792
100038..........................             24.5864             24.9548             25.7948             25.1579
100039..........................             21.7861             23.3111             23.8060             22.9806
100040..........................             18.6321             19.5154             22.4679             20.1990
100043..........................             18.8206             20.7688             21.7738             20.4584
100044..........................             22.7236             22.9474             23.9952             23.2248
100045..........................             21.0228             22.8096             25.2285             22.9374
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
100049..........................             19.1025             20.9490             21.8679             20.6413
100050..........................             17.9039             17.8960             20.0405             18.6106
100051..........................             17.9453             19.3258             20.0231             19.1698
100052..........................             18.1780             19.6620             20.5916             19.4656
100053..........................             19.6800             21.6634             23.7837             21.6611
100054..........................             21.1518             20.9612             22.0352             21.4046
100055..........................             18.8760             19.1324             19.6350             19.2002
100056..........................             21.8506             23.1737             25.9245             23.6383
100057..........................             19.5319             22.3406             24.6417             22.0507
100060..........................             23.5997                   *                   *             23.5997
100061..........................             22.9176             24.5277             26.1273             24.5205
100062..........................             21.4424             21.9054             24.9807             22.7317
100063..........................             18.4642             19.2510             21.5620             19.9030
100067..........................             18.4851             19.2168             23.8892             20.4263
100068..........................             19.8308             19.9648             23.7840             21.3340
100069..........................             17.3666             18.5789             19.6037             18.6041
100070..........................             20.0381             20.9592             23.5524             21.5325
100071..........................             17.7234             20.7461             21.7675             20.3419
100072..........................             20.5968             22.0317             23.5362             22.1454
100073..........................             22.2812             22.2425             23.5843             22.7262
100075..........................             19.4480             20.4604             22.3890             20.7468
100076..........................             17.8612             18.4815             19.6444             18.6617
100077..........................             19.0640             20.9482             22.3755             20.8572
100078..........................             19.2891             16.6003                   *             17.8844
100080..........................             22.7153             22.9720             22.8704             22.8570
100081..........................             15.4253             16.5149             16.8087             16.2486
100084..........................             22.7009             24.5682             24.1122             23.8713
100086..........................             23.3718             24.3067             25.2375             24.3294
100087..........................             23.6562             22.1764             26.5915             24.1164
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             18.5287             16.8485
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             20.3417             19.7704
100107..........................             20.0719             21.7553             23.3789             21.7356
100108..........................             20.1125             18.4127             14.8039             17.4685
100109..........................             20.8370             20.6007             23.0779             21.5126
100110..........................             20.1853             22.8127             24.4533             22.5939
100112..........................             15.2128             16.2109                   *             15.7583
100113..........................             21.3489             23.3380             24.3614             22.9690
100114..........................             22.8178             22.5326             25.3699             23.4863
100117..........................             20.6962             21.3085             23.9133             21.9869
100118..........................             20.7323             21.7067             24.1105             22.1068

[[Page 45502]]

 
100121..........................             18.5842             19.9033             23.1100             20.5301
100122..........................             19.2643             24.9765             24.1820             22.6871
100124..........................             20.4022             20.0867             24.3048             21.5323
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             25.4811             24.4722
100132..........................             18.7863             19.5259             21.1538             19.8114
100134..........................             15.9733             16.9302             18.3392             17.1001
100135..........................             19.1865             19.7675             20.4915             19.8235
100137..........................             19.5562             20.9015             20.4007             20.3128
100138..........................             14.9539             14.9760                   *             14.9656
100139..........................             15.2532             15.7378             18.2204             16.3584
100140..........................             19.0584             20.2288             22.5124             20.6430
100142..........................             18.4113             17.7250             20.0689             18.7079
100146..........................             21.3359             20.8381                   *             21.0641
100147..........................             15.2348             17.1566             17.1045             16.4924
100150..........................             21.5057             25.4269             22.9193             23.1341
100151..........................             23.8489             26.6143             26.6470             25.8202
100154..........................             20.4068             21.6715             23.0820             21.7335
100156..........................             18.4779             20.0348             20.6929             19.7809
100157..........................             22.6195             24.2188             23.1045             23.3126
100159..........................             10.7818             15.0633                   *             12.9868
100160..........................             23.3121             22.6942             23.4877             23.1680
100161..........................             22.3053             23.3612             24.6268             23.4502
100162..........................             20.3110             24.2950             23.8001             22.8069
100165..........................             22.6622                   *                   *             22.6623
100166..........................             21.2309             22.2419             23.7419             22.3795
100167..........................             23.2969             25.7676             26.4517             25.1920
100168..........................             20.3167             23.0121             24.6276             22.6616
100169..........................             20.3017             21.6397             23.4575             21.8200
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             24.5078             24.6849
100179..........................             23.0849             23.9633             24.1801             23.7691
100180..........................             21.5388             22.7781             24.9433             23.1701
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             26.6846             26.8004
100191..........................             21.0647             22.0526             24.1911             22.4941
100200..........................             23.8729             24.8878             24.8120             24.5400
100204..........................             20.2193             21.1922             22.2613             21.2482
100206..........................             20.1171             20.3436             22.8782             21.0874
100208..........................             20.7029             20.4678             24.1482             21.8277
100209..........................             23.3903             22.8236             23.8502             23.3700
100210..........................             21.8545             23.0431             26.0933             23.6634
100211..........................             20.7516             21.6367             24.3243             22.2366
100212..........................             21.1263             21.7239             22.6584             21.8516
100213..........................             21.1818             22.0176             24.4467             22.6180
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             21.2434             21.1576
100224..........................             21.8628             22.3567             23.0804             22.4588
100225..........................             21.5059             22.4619             23.9971             22.6579
100226..........................             21.8808             22.7301             23.8701             22.8717
100228..........................             20.8810             24.9691             26.2593             24.0864

[[Page 45503]]

 
100229..........................             18.2350             19.7259             21.0039             19.5689
100230..........................             22.5650             23.4169             25.0518             23.8929
100231..........................             18.7526             21.5712             23.5418             21.0310
100232..........................             19.8002             20.1459             21.8105             20.6232
100234..........................             21.6360             24.3355             24.9141             23.6582
100236..........................             20.6942             21.7886             23.9781             22.1000
100237..........................             23.2408             23.2712             26.7664             24.3476
100238..........................             20.8252             23.3747             24.6513             22.9237
100239..........................             19.4481             23.2242             25.0509             22.4527
100240..........................             21.0606             21.3495             23.0650             21.8213
100241..........................             17.1063             14.1059                   *             15.6623
100242..........................             18.6938             19.1097             20.4681             19.4815
100243..........................             20.8041             22.4495             23.2812             22.2413
100244..........................             20.5352             21.4386             23.4876             21.8968
100246..........................             21.9247             23.5614             26.7630             24.0120
100248..........................             21.2988             22.1553             23.8742             22.4825
100249..........................             18.1397             18.4932             21.3942             19.2694
100252..........................             19.8079             22.0976             22.6475             21.5855
100253..........................             22.4778             22.6517             23.6939             22.9719
100254..........................             19.5523             20.4410             23.2794             21.2417
100255..........................             21.0284             20.7228             22.9793             21.5458
100256..........................             21.2786             22.4844             24.1969             22.6427
100258..........................             20.0300             22.0790             24.5699             22.2126
100259..........................             21.1160             21.4991             24.1148             22.2915
100260..........................             24.9183             21.2413             23.5164             23.1305
100262..........................             21.0927             22.7137             23.8006             22.3809
100264..........................             19.9491             21.7410             22.4800             21.4196
100265..........................             18.2291             20.2664             21.0688             19.9095
100266..........................             19.3623             20.2821             21.5258             20.4415
100267..........................             21.7430             22.8054             23.3760             22.6752
100268..........................             24.0538             23.5414             26.0297             24.5763
100269..........................             22.5114             26.0271             24.9002             24.4895
100270..........................             16.7148             20.8217                   *             18.7430
100271..........................             20.8695             21.9823                   *             21.4488
100275..........................             21.4904             23.2920             23.1419             22.6892
100276..........................             24.1022             24.8251             25.4557             24.8136
100277..........................             19.7241             14.9157             25.2985             18.4223
100279..........................             22.5879             23.1776             24.8484             23.4843
100280..........................             18.1972             19.0157                   *             18.6075
100281..........................             23.0142             23.4729             25.3382             24.0569
100282..........................             18.4884             20.9256                   *             19.7594
100284..........................             18.9448             18.5716             22.3046             19.9187
110001..........................             20.1150             22.4535             24.0561             22.2069
110002..........................             19.5158             20.2149             20.4502             20.0753
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             28.2025             26.4671
110008..........................             18.5265             20.4972             22.6308             20.7088
110009..........................             17.4306             16.6452                   *             17.0362
110010..........................             23.9104             25.1930             27.2029             25.4211
110011..........................             18.9823             20.4028             23.2149             20.8820
110013..........................             18.9160             16.7833                   *             17.8487
110014..........................             18.1787             18.4463                   *             18.3068
110015..........................             20.9926             21.2600             23.2279             21.9187
110016..........................             14.2398             14.7571             18.8228             15.7864
110017..........................             22.2537             21.2970                   *             21.7842
110018..........................             22.1480             23.0577             24.7007             23.3525
110020..........................             19.4617             20.9687             23.3004             21.1787
110023..........................             22.0546             21.6512             23.5673             22.4650
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

[[Page 45504]]

 
110027..........................             14.7081             19.8976             19.8351             18.0251
110028..........................             29.1670             28.1695             25.9474             27.6479
110029..........................             21.2150             21.3694             22.7981             21.8333
110030..........................             19.6412             20.4656             22.2341             20.7841
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             24.0791             22.0313
110035..........................             22.7950             21.8646             24.2581             22.9820
110036..........................             24.9234             22.5481             24.4788             23.9524
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
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                   *             17.1524
110049..........................             16.8639             17.1396             18.9096             17.6498
110050..........................             19.2291             18.9048                   *             19.0644
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                   *             17.4730
110063..........................             18.5071             18.0256             25.0270             24.4605
110064..........................             19.1203             18.8742             21.7636             19.8777
110065..........................             16.3546             16.9829                   *             16.6570
110066..........................             22.4189             23.4554                   *             22.9140
110069..........................             20.9575             21.1513             21.0518             21.0559
110070..........................             17.3438             19.6361                   *             18.6196
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             24.4094             23.8133
110075..........................             20.1757             20.1604             20.4634             20.2673
110076..........................             21.9798             23.6127             23.8211             23.1622
110078..........................             24.0893             25.7416             28.2149             26.0373
110079..........................             22.1070             22.3641             22.8017             22.4150
110080..........................             19.1839             19.4635             24.1958             20.7509
110082..........................             24.3140             22.7015             27.2931             24.6475
110083..........................             23.1463             22.2609             24.6460             23.3708
110086..........................             16.6374             19.0164             18.8751             18.1588
110087..........................             22.7069             24.0994             25.7908             24.2653
110089..........................             19.3855             19.0453             20.6757             19.7052
110091..........................             21.5328             23.7110             24.3354             23.1945
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                   *             17.6373
110098..........................             16.0597             16.7800                   *             16.4502
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             21.8167             20.8132
110108..........................             25.2161             20.1140                   *             22.2083
110109..........................             16.4031             16.5977             18.7397             17.2348

[[Page 45505]]

 
110111..........................             18.3951             18.4274             20.9536             19.3428
110112..........................             19.8986             18.9574             20.4565             19.7953
110113..........................             15.9532             16.0942             18.0770             16.7135
110114..........................             16.4812             16.8297                   *             16.6546
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             20.4184             20.7024
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
110128..........................             18.0835             20.3046             28.4942             21.9309
110129..........................             19.0001             20.9442             21.8204             20.6124
110130..........................             14.6011             16.6915             17.5272             16.2937
110132..........................             16.3943             17.1820             17.2924             16.9658
110134..........................             19.8639             19.0305                   *             19.4185
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                   *             13.8938
110142..........................             13.9525             14.1203             16.3359             14.8326
110143..........................             22.5926             22.4254             24.3898             23.1388
110144..........................             17.5112             17.5678                   *             17.5388
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                   *             15.7696
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             26.4200             24.5439
110163..........................             18.6637             20.1183             21.9411             20.2136
110164..........................             21.2160             22.6605             23.7801             22.5540
110165..........................             20.8030             22.5604             23.4071             22.3021
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             24.0700             22.7532
110179..........................             22.0767             24.3673             26.0365             24.0945
110181..........................             12.9798             13.9591                   *             13.4445
110183..........................             22.5148             24.2899             26.4248             24.4133
110184..........................             22.1920             22.2761             24.3379             22.9563
110185..........................             17.7925             17.3330                   *             17.5916
110186..........................             18.3178             19.7172             21.1176             19.7561
110187..........................             19.8419             22.8248             23.2571             21.8964
110188..........................             23.7032             22.0258             24.4785             23.4118
110189..........................             20.8786             19.8454             21.4255             20.7155
110190..........................             18.3649             20.7292             21.9009             20.2241
110191..........................             21.4033             21.3404             24.0572             22.3044
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                   *             11.8061
110198..........................             24.8646             24.8275             28.0634             25.9885
110200..........................             17.7744             17.9631             20.1816             18.6638
110201..........................             20.9497             21.9313             24.1171             22.2994
110203..........................             22.7453             24.2062             30.2609             25.5883
110204..........................             30.7342             35.3699                   *             32.7584
110205..........................             21.3617             20.1405             23.1969             21.5575

[[Page 45506]]

 
110207..........................             14.7154             14.6045                   *             14.6569
110208..........................             15.6161             15.0350                   *             15.3251
110209..........................             18.6404             20.0629             17.4145             18.6822
110211..........................             26.9151             20.1024                   *             22.9486
110212..........................             14.3790             15.8420             18.7651             16.2466
110215..........................             18.1539             21.0263             22.5679             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                   *             24.2718
120004..........................             24.8632             26.1398             26.8010             25.9297
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                   *             16.6019
120010..........................             24.1923             24.9089             25.4050             24.8421
120011..........................             37.2759             35.2051             30.9308             34.0921
120012..........................             21.8507             22.0371                   *             21.9472
120014..........................             24.1208             25.3557             25.3682             24.9359
120015..........................             42.6465                   *                   *             42.6472
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                   *             27.8298
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                   *             18.6568
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                   *             16.1567
130009..........................             15.9701             20.8748                   *             18.2398
130010..........................             17.5119             17.7826                   *             17.6552
130011..........................             20.1147             22.1125             23.1120             21.7785
130012..........................             24.9976             24.2451                   *             24.6140
130013..........................             15.1129             22.6624             23.5316             20.2820
130014..........................             19.2107             19.8240             21.6495             20.2756
130015..........................             18.5913             16.4136                   *             17.4135
130016..........................             19.0516             20.1220                   *             19.6075
130017..........................             19.6875             19.9511                   *             19.8231
130018..........................             19.8425             20.0563             22.2249             20.7344
130019..........................             19.1711             19.5147                   *             19.3390
130021..........................             15.6155             14.4430             18.0007             15.8914
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                   *             20.5964
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                   *             18.2292
130034..........................             18.9483             20.5802                   *             19.7427
130035..........................             20.7770             17.2864                   *             19.1660
130036..........................             13.6362             15.1590             18.5921             15.7605
130037..........................             18.6856             19.2108                   *             18.9656
130043..........................             16.7904             17.6920                   *             17.2343
130044..........................             13.4513             18.7067                   *             15.9723

[[Page 45507]]

 
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                   *             17.0330
130056..........................             20.9476             28.8008                   *             24.4940
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
140002..........................             19.9284             20.9959             23.0207             21.2902
140003..........................             17.8595             18.0163             19.2097             18.3647
140004..........................             17.4574             18.9713                   *             18.2174
140005..........................             12.3002             12.4144             13.2365             12.6493
140007..........................             23.8585             24.9847             25.1836             24.6934
140008..........................             22.1111             24.2634             26.3287             24.2035
140010..........................             28.5635             28.0863             29.0224             28.6047
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                   *             21.8387
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             15.6616             15.7091
140025..........................             18.5135             21.7775                   *             20.0183
140026..........................             18.3220             19.7839             20.4084             19.5156
140027..........................             19.2149             20.5980             20.9855             20.2413
140029..........................             26.0833             28.5670             25.0485             26.4725
140030..........................             23.1760             25.3715             26.5733             25.0959
140031..........................             17.6067             16.9650                   *             17.2985
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                   *             16.4777
140036..........................             19.1076             21.2366                   *             20.1966
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                   *             18.7014
140042..........................             15.8892             16.1157                   *             16.0034
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                   *             14.8654
140048..........................             23.9545             23.8652             25.9122             24.5813
140049..........................             26.9483             26.7160             21.9546             25.3052
140051..........................             24.0796             24.7180             24.2472             24.3525
140052..........................             17.9571             21.0450             21.8161             20.1407
140053..........................             19.9620             20.9768             22.6099             21.1760
140054..........................             23.1576             23.9459             35.5659             27.3968
140055..........................             14.3603             15.8756                   *             15.1297
140058..........................             18.6861             19.1199             20.5089             19.4559
140059..........................                   *             18.2593             19.9777             19.0797
140061..........................             18.2039             18.4264             22.7515             19.6171
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             26.3521             25.7796
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                   *             17.5876

[[Page 45508]]

 
140070..........................             22.7153             25.2646             25.2960             24.2944
140074..........................             21.6052             22.2563                   *             21.9232
140075..........................             21.6434             21.8472             26.5350             22.9476
140077..........................             17.3647             17.3236             18.0487             17.5877
140079..........................             23.6928             22.7046             25.7090             24.0330
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
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             28.4219             26.7393
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             24.2166             23.0115
140095..........................             24.2859             25.5716             24.7706             24.8985
140097..........................             21.1719             21.8418                   *             21.5268
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             21.2404             19.5117
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             21.9880             20.7795
140112..........................             17.6974             18.1119                   *             17.9053
140113..........................             19.5584             26.2393             25.6621             23.5275
140114..........................             21.0976             23.0383             24.1926             22.8235
140115..........................             21.0433             20.4587             25.3410             22.2094
140116..........................             23.8993             25.5980             26.8924             25.5257
140117..........................             21.4876             22.0889             23.3531             22.3481
140118..........................             24.3260             25.3249             26.7350             25.4595
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             26.8595             26.5933
140124..........................             27.9813             30.6820             30.9648             29.8366
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             24.0458             21.8049
140135..........................             17.3985             18.2479             19.7919             18.5332
140137..........................             18.6330             20.4807             21.6017             20.2583
140138..........................             17.1968             14.5771                   *             15.8048
140139..........................             11.0397                   *                   *             11.0397
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             19.6429             19.1056
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             32.9291             28.5851
140151..........................             20.0310             20.8820             21.5167             20.8051
140152..........................             25.6011             28.3946             28.5468             27.5188
140155..........................             20.2778             24.2907             25.2034             23.1447

[[Page 45509]]

 
140158..........................             22.7988             23.7428             22.5638             23.0543
140160..........................             17.7921             19.8825             20.9986             19.6014
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             20.7849             19.4761
140167..........................             17.6525             18.8532             19.5959             18.7351
140168..........................             17.7453             18.2896             18.7503             18.2528
140170..........................             16.4107             17.6901             17.0666             17.0536
140171..........................             15.0237             15.2617             17.3214             15.8617
140172..........................             23.6262             24.8587             27.3373             25.2144
140173..........................             16.3924             16.0030                   *             16.1514
140174..........................             35.9320             22.0418             23.6893             25.2341
140176..........................             24.5338             26.3468             25.6824             25.5437
140177..........................             15.0827             20.3142             20.8526             18.2773
140179..........................             21.9859             22.7345             24.1539             22.9472
140180..........................             22.7996             22.7508             25.4022             23.6250
140181..........................             21.9864             22.6643             23.7308             22.8340
140182..........................             28.9515             25.1302             32.1969             28.8546
140184..........................             17.2401             17.9169             20.6499             18.6226
140185..........................             18.2867             18.8573             20.0903             19.0816
140186..........................             23.5034             25.6807             26.0970             25.1056
140187..........................             18.3331             19.4049             20.5829             19.4291
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             26.5789             24.2582
140205..........................             20.0784                   *             25.1010             22.9703
140206..........................             22.5109             22.8223             24.7616             23.3613
140207..........................             22.3905             25.4539             23.3197             23.6919
140208..........................             26.2527             28.3112             27.4671             27.3501
140209..........................             20.1557             20.2433             22.0813             20.8567
140210..........................             14.8248             15.5345             15.5339             15.3158
140211..........................             22.6265             22.8852             25.8556             23.8141
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                   *             18.6260
140223..........................             24.9017             26.2168             27.4355             26.1911
140224..........................             32.8292             25.6766             27.1725             28.2184
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             23.9205             21.9718
140240..........................             24.6949             25.1418             25.0325             24.9609
140242..........................             25.2317             26.1850             28.8686             26.8470
140245..........................             14.2481             15.1320             15.2537             14.8687
140246..........................             11.6267             15.0650             16.1305             14.1116
140250..........................             23.6449             25.3410             25.5501             24.8622
140251..........................             21.9435             23.5128             24.8256             23.4339
140252..........................             25.0220             26.4715             28.3479             26.6235
140253..........................             19.5858             18.4567                   *             19.0172
140258..........................             25.3622             25.0743             27.5741             26.0514

[[Page 45510]]

 
140271..........................             12.0079             16.0350             17.5175             14.8913
140275..........................             23.8171             22.9656             23.1871             23.2884
140276..........................             25.3134             26.1713             25.3222             25.5791
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             25.5805             25.1984
140288..........................             24.4331             25.8717             26.3572             25.5938
140289..........................             18.1747             17.7886             20.7506             18.9533
140290..........................             22.8590             26.5055             29.9098             26.4896
140291..........................             24.9537             26.8628             27.6675             26.5471
140292..........................             21.9950             26.8610             26.4077             25.1307
140294..........................             17.7301             19.4218             21.7473             19.5616
140300..........................             27.8436             28.9830             30.5172             29.1412
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             23.6169             22.5090
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             19.4763             19.3625
150010..........................             20.5570             21.2466             22.5445             21.4807
150011..........................             18.3275             19.9096             22.1559             20.1096
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             23.1616             23.0637
150017..........................             19.5339             20.6758             22.7979             21.0370
150018..........................             21.0496             22.8922             24.6138             22.9251
150019..........................             17.8585             19.8341             17.3170             18.2548
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             20.6926             20.0896
150024..........................             19.2295             19.8368             21.7593             20.1808
150025..........................             20.2750                   *                   *             20.2750
150026..........................             22.4978             21.9448             23.2169             22.5611
150027..........................             18.0335             19.4238             21.5766             19.7256
150029..........................             23.2454             24.8939             25.2067             24.4325
150030..........................             19.2406             20.7256             23.0196             21.0229
150031..........................             18.3463             21.3494             18.9179             19.4671
150033..........................             22.6741             23.0756             24.1701             23.2959
150034..........................             23.1533             23.3718             22.8812             23.1378
150035..........................             21.2374             22.3779             23.5468             22.3841
150036..........................             21.4567             22.1464                   *             21.8009
150037..........................             24.4611             22.3699             24.4997             23.7287
150038..........................             22.0572             20.3454             21.6608             21.3217
150039..........................             19.6215             16.0227                   *             17.5902
150042..........................             20.2221             18.0185             23.7838             20.4589
150043..........................             20.1741             20.6301                   *             20.4010
150044..........................             19.1309             19.8951             20.5156             19.8505
150045..........................             18.1670             20.6406             23.0361             20.5780
150046..........................             18.2543             19.4146             20.3453             19.3721
150047..........................             22.0145             21.9824             24.8786             22.8897
150048..........................             19.1648             21.1441             22.5181             20.9965
150049..........................             18.6451             21.6309             18.4942             19.5768
150050..........................             17.7354             18.0411                   *             17.8858
150051..........................             19.7257             20.6895             21.4009             20.6516
150052..........................             17.3750             18.8345             19.1070             18.4211
150053..........................             18.8632             18.3493                   *             18.6061
150054..........................             18.3916             19.3424                   *             18.8632
150056..........................             21.5774             23.0603             24.7841             23.1287

[[Page 45511]]

 
150057..........................             16.9736             17.4044             28.0884             20.1891
150058..........................             22.1409             23.0273             24.9479             23.3727
150059..........................             22.7360             23.1398             25.6737             23.8406
150060..........................             18.6159             19.5011             19.8990             19.3356
150061..........................             19.7968             19.4014             19.2826             19.4675
150062..........................             20.8274             21.2608             22.9214             21.6432
150063..........................             22.6525             24.8587             24.4091             23.9888
150064..........................             20.3865             20.6232             21.2512             20.7527
150065..........................             21.2153             21.4572             23.0636             21.9337
150066..........................             19.5313             19.6845                   *             19.6122
150067..........................             18.8862             20.5000             21.4374             20.3431
150069..........................             23.3969             23.5510             23.8353             23.5678
150070..........................             18.0827             18.9332             20.7413             19.2893
150071..........................             13.5111             16.4179                   *             15.0051
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             20.1119             17.8912
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             21.0651             19.5469
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             21.6806             21.8078
150090..........................             21.0945             21.9803             24.9021             22.5584
150091..........................             22.4640             26.5235             26.4248             25.0867
150092..........................             16.9179             18.2592                   *             17.6063
150094..........................             17.5244             16.8351                   *             17.1591
150095..........................             19.2749             22.3214                   *             20.8258
150096..........................             20.8204                   *             19.7975             20.2623
150097..........................             19.7751             21.1462             22.4565             21.2367
150098..........................             15.2829             16.4763                   *             15.8733
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                   *             19.0657
150104..........................             20.0765             21.3141             21.0799             20.8409
150105..........................             22.4412             21.6975                   *             22.0619
150106..........................             16.8714             18.7088             19.1976             18.3084
150109..........................             19.9066             21.7870             21.3123             21.0077
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             20.3863             19.0118
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             23.1464             22.1849
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             21.8807             20.1148
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

[[Page 45512]]

 
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
160009..........................             17.9886             19.0664                   *             18.5265
160012..........................             16.7112             17.9236                   *             17.3007
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                   *             15.8463
160020..........................             15.5384             15.7960             16.6092             15.9961
160021..........................             16.7617             16.7920                   *             16.7772
160023..........................             15.0099             15.3854                   *             15.1953
160024..........................             19.4764             20.5622             22.4256             20.7981
160026..........................             19.5260             20.4567             22.8967             20.9474
160027..........................             16.9417             18.2081                   *             17.5712
160028..........................             21.0000             22.9000             25.1998             22.9593
160029..........................             21.3457             22.2106             23.7268             22.4567
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             22.2660             20.4096
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                   *             19.5056
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             22.1550             20.6216
160048..........................             15.6856             17.2709             18.1174             16.9461
160049..........................             15.5673             15.3233                   *             15.4375
160050..........................             17.7878             21.1184             21.6247             20.1164
160051..........................             16.4261             15.8213                   *             16.1223
160052..........................             21.7647             22.1933                   *             21.9810
160054..........................             16.1981             16.5258                   *             16.3650
160055..........................             15.1674             17.6177                   *             16.3808
160056..........................             17.0172             17.9534                   *             17.4726
160057..........................             19.1378             19.6802             20.8345             19.9113
160058..........................             22.1061             22.2812             23.5663             22.6513
160060..........................             17.2825             17.7489                   *             17.5106
160061..........................             17.0938             17.2064                   *             17.1526
160062..........................             17.4388             18.8163                   *             18.1382
160063..........................             16.3583             17.3771                   *             16.8751
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                   *             19.8512
160069..........................             19.1640             20.5989             21.7197             20.4818
160070..........................             18.4588             17.7855                   *             18.1126
160072..........................             14.4141             15.3384             15.8236             15.1936
160073..........................             11.4997             15.5946                   *             13.3036
160074..........................             17.9513             18.4624             22.2989             19.4707
160075..........................             18.4613             20.7842                   *             19.5562
160076..........................             17.8824             19.1590             20.1603             19.0456
160077..........................             13.6658             15.0468                   *             14.3610
160079..........................             18.6333             20.5010             21.6562             20.2670
160080..........................             19.4925             19.6680             21.1713             20.1081

[[Page 45513]]

 
160081..........................             17.4466             19.1442             20.4415             18.9934
160082..........................             19.5322             20.7306             21.6230             20.6308
160083..........................             19.7542             21.3221             23.4670             21.4372
160085..........................             21.2557             19.1929                   *             20.1491
160086..........................             17.5308             19.0477                   *             18.2672
160088..........................             22.3655             23.8098                   *             23.1166
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                   *             18.1925
160095..........................             15.2722             16.4927                   *             15.8700
160097..........................             16.6790             17.7860                   *             17.2349
160098..........................             16.8670             16.8997                   *             16.8833
160099..........................             15.0880             16.0710                   *             15.5905
160101..........................             18.9788             19.6314             22.1741             20.2613
160102..........................             20.1161             14.4837                   *             17.0012
160103..........................             18.2741             19.6168                   *             18.9247
160104..........................             17.4829             21.0060             23.2832             20.6810
160106..........................             17.3474             19.4385             19.8906             18.8668
160107..........................             18.0097             18.8936             19.5110             18.7905
160108..........................             16.7779             17.7577                   *             17.2637
160109..........................             17.9873             18.2938                   *             18.1453
160110..........................             20.6215             20.9959             21.9299             21.2145
160111..........................             14.9965             15.1104                   *             15.0564
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                   *             15.3496
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                   *             17.6110
160130..........................             15.6666             16.2628                   *             15.9651
160131..........................             16.0424             16.5397             18.0485             16.8699
160134..........................             15.3012             14.6396                   *             14.9483
160135..........................             18.7711             18.3973                   *             18.6129
160138..........................             17.1491             18.3957                   *             17.7222
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                   *             17.3945
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                   *             16.5042
160153..........................             21.2085             22.7004             23.5212             22.4610
170001..........................             17.9218             18.5120             19.8150             18.7852
170004..........................             16.1442             17.2262                   *             16.6775
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             21.8587             20.2179
170013..........................             19.4667             20.1852             21.4954             20.4080
170014..........................             18.4931             19.6044             21.3416             19.7473
170015..........................             17.1302             17.2443             18.0485             17.4844
170016..........................             20.0675             22.1023             22.9479             21.7131
170017..........................             19.5994             19.7908             21.6323             20.3473

[[Page 45514]]

 
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              9.3514
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                   *             14.2743
170031..........................             14.2151             16.4660                   *             15.2706
170032..........................             16.3449             15.2207                   *             15.7798
170033..........................             19.1952             20.4533             20.0627             19.9270
170034..........................             16.9586             17.8239             18.1073             17.6353
170035..........................             17.0945             19.8334                   *             18.4676
170038..........................             13.8582             15.2505                   *             14.5672
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                   *             22.7910
170049..........................             20.7921             21.2917             22.9404             21.7361
170051..........................             16.4851             16.9003                   *             16.6903
170052..........................             15.2283             16.0948             15.8809             15.7508
170053..........................             14.6133             14.3628                   *             14.4847
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                   *             18.2470
170061..........................             15.0258             15.6412                   *             15.3202
170063..........................             14.1185             13.7611                   *             13.9331
170066..........................             16.2891             16.8009                   *             16.5466
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                   *             17.7331
170074..........................             17.3699             17.6543             18.5446             17.8791
170075..........................             13.6816             14.4939             15.6809             14.6514
170076..........................             14.6109             14.9392                   *             14.7742
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                   *             14.8705
170082..........................             13.7462             14.8154             15.9973             14.8264
170084..........................             13.0519             13.6517                   *             13.3503
170085..........................             17.5422             21.8907             17.2585             18.9901
170086..........................             19.7182             20.7298             22.1067             20.8528
170088..........................             13.4860                   *                   *             13.4860
170089..........................             15.4860             20.2263                   *             18.1131
170090..........................             10.9444             23.6837             16.3550             15.3916
170093..........................             14.0276             14.7803             15.0308             14.6148
170094..........................             21.2035             21.2484             20.1253             20.9151
170095..........................             15.3532             16.1078                   *             15.7358
170097..........................             17.7540             18.6023             18.9865             18.4524
170098..........................             16.6210             17.3480             18.6676             17.5026
170099..........................             14.3370             16.5247             15.8118             15.5495
170101..........................             18.0143             17.3381             17.9291             17.7556
170102..........................             14.2447             14.4499                   *             14.3487
170103..........................             17.9530             18.6172             20.1264             18.9371
170104..........................             21.0049             22.0671             23.6589             22.2552
170105..........................             16.7403             18.2788             18.3824             17.8166
170106..........................             17.7467                   *                   *             17.7468

[[Page 45515]]

 
170109..........................             16.9782             18.3483             20.7581             18.8210
170110..........................             18.5731             21.0637             16.5883             18.8196
170112..........................             15.4049             15.8097                   *             15.6012
170113..........................             14.6486             16.4938             19.9957             16.7158
170114..........................             16.2645             13.9726             17.4687             15.7793
170115..........................             12.9216             13.0253                   *             12.9743
170116..........................             18.1830             19.4278             20.8800             19.4962
170117..........................             16.8237             16.8301                   *             16.8270
170119..........................             15.2708             15.1982                   *             15.2357
170120..........................             17.4917             18.2832             18.5895             18.1013
170122..........................             21.1769             21.4588             22.2681             21.6171
170123..........................             23.6534             25.2122             25.0073             24.6043
170124..........................             15.0596             16.3925                   *             15.7353
170126..........................             13.5736             14.5527                   *             14.0496
170128..........................             14.1676             17.6259                   *             15.6677
170133..........................             18.8119             19.9778             20.0593             19.6138
170134..........................             14.6799             15.1932                   *             14.9285
170137..........................             19.3118             19.3344             21.4394             20.0379
170139..........................             14.3001             14.8157                   *             14.5522
170142..........................             17.7134             19.0547             19.8269             18.8721
170143..........................             16.0415             16.3258             18.0308             16.8248
170144..........................             20.4392             20.8488             23.9179             21.2803
170145..........................             19.0142             20.1494             20.5143             19.9005
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                   *             15.8733
170160..........................             14.4732             17.0629                   *             15.6980
170164..........................             17.4072             17.0791                   *             17.2470
170166..........................             12.7507             16.5113             17.8131             15.5313
170171..........................             13.1792             14.7051             14.7251             14.2074
170175..........................             20.1907             20.8671             22.5605             21.1305
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             26.8307             26.8217
170186..........................                   *             33.2457             28.5602             30.5574
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             20.5135             19.2747
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             22.6846             20.6134
180011..........................             19.0526             22.6798             18.8056             20.1971
180012..........................             19.0646             19.6614             20.2758             19.6759
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             20.9964             19.4334
180021..........................             17.0618             16.5376             17.6330             17.0802
180023..........................             17.4717             19.0574                   *             18.2571
180024..........................             16.5040             19.6313             22.3922             19.4653
180025..........................             15.4180             17.1875             18.3306             16.9977

[[Page 45516]]

 
180026..........................             15.0118             13.9959             15.5354             14.8403
180027..........................             17.5286             19.6928             20.5017             19.2757
180028..........................             15.7005             26.2220             20.6324             19.9445
180029..........................             17.7248             20.0841             20.4262             19.4335
180030..........................             17.9543             17.5043                   *             17.7176
180031..........................             13.1848             17.1003                   *             14.6814
180032..........................             17.2784             17.2362                   *             17.2589
180033..........................             15.4131             17.0498                   *             16.2281
180034..........................             16.3991             17.0349                   *             16.7087
180035..........................             21.3666             22.4651             24.3874             22.7541
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             23.2341             22.2487
180041..........................             16.3699             17.5950             19.1325             17.6429
180042..........................             17.1519             15.5660                   *             16.2972
180043..........................             14.6526             17.2414             20.6499             17.2898
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             20.0114             18.6877
180049..........................             16.5459             17.8418             18.5188             17.6210
180050..........................             17.1493             19.4992             19.9082             18.8700
180051..........................             17.5441             18.3028             18.8186             18.2489
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                   *             14.7232
180059..........................             14.7032             17.2542                   *             15.8589
180063..........................             12.4448             14.7338             15.5077             14.2770
180064..........................             15.5066             16.3894             21.1067             17.5598
180065..........................             11.1934             11.0966                   *             11.1508
180066..........................             19.8956             20.7907             21.1883             20.6121
180067..........................             20.1712             20.2762             22.0056             20.7541
180069..........................             16.2916             19.0836             20.3982             18.5550
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             18.9582             17.7773
180087..........................             15.6089             16.2378             16.4726             16.1124
180088..........................             22.1774             22.8908             23.7217             23.0858
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             22.4094             21.7406
180102..........................             18.5240             18.8169             20.1885             19.1448
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             17.7885             20.4030
180118..........................             16.9250             17.9017                   *             17.4046
180120..........................             15.3115             16.4226             20.4507             17.0636
180121..........................             20.0494             16.9570             16.9881             17.9386
180122..........................             18.1930             18.7549                   *             18.4837
180123..........................             21.1067             21.5962                   *             21.3452

[[Page 45517]]

 
180124..........................             18.8487             19.7138             20.5369             19.6944
180125..........................             14.9314             22.6609                   *             17.5824
180126..........................             14.3551             14.8501             14.5644             14.5905
180127..........................             17.6365             18.0498             20.0059             18.6352
180128..........................             18.2817             18.7194             19.8502             18.9725
180129..........................             22.3536             15.6637             14.1861             16.9914
180130..........................             20.6450             21.9413             23.4982             22.0567
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             23.0996             21.0830
180139..........................             20.5350             20.3816             20.6287             20.5179
180140..........................             15.2719             14.6466                   *             14.9413
180141..........................             23.8930             20.3404             22.6722             22.1534
180142..........................             20.7510                   *                   *             20.7510
180143..........................                   *             21.3197             20.1309             20.7446
190001..........................             18.1514             18.8583             20.4946             19.2128
190002..........................             19.8834             20.6057             20.7172             20.4121
190003..........................             19.9121             19.5115             20.7504             20.0615
190004..........................             18.3620             19.6755             20.5272             19.5326
190005..........................             17.5161             19.0994             20.0551             18.8486
190006..........................             17.5911             17.7333             18.8115             18.0279
190007..........................             14.4720             16.3633             17.9392             16.3508
190008..........................             19.2456             22.4797             20.3278             20.6463
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             18.7538             16.9778
190014..........................             17.8015             18.6929             17.0630             17.8584
190015..........................             18.9896             19.7673             20.6167             19.7967
190017..........................             17.5381             19.8449             18.3528             18.5693
190018..........................             11.1898             13.1355             19.2055             14.0443
190019..........................             18.3788             18.7344             20.8193             19.3423
190020..........................             17.6840             18.7252             18.5659             18.3279
190025..........................             16.8686             18.1892             19.9968             18.3102
190026..........................             18.5015             19.0130             19.9229             19.1670
190027..........................             17.4761             18.4070             19.4057             18.4089
190029..........................             19.1967             18.7344                   *             18.9666
190034..........................             18.0754             19.2007             16.8439             18.0233
190036..........................             20.0300             21.2960             23.3903             21.5497
190037..........................             19.9878             14.1323             15.6062             16.9453
190039..........................             19.0376             18.7625             20.4900             19.4221
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             21.1019             20.5823
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             21.1262             19.7488
190065..........................             18.3091             18.3280             20.3583             19.0184
190071..........................             16.4138             16.3822                   *             16.3974
190077..........................             16.5536             16.8829             17.0480             16.8252
190078..........................             16.9383             19.5879             19.8607             18.8295
190079..........................             17.9403             18.8187             20.5000             19.0592
190081..........................             14.9707             14.7919             11.4756             13.7796
190083..........................             18.4951             16.2970             18.4954             17.7997
190086..........................             16.5074             17.6237             18.2005             17.4309

[[Page 45518]]

 
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             25.4984             24.0286
190116..........................             17.3757             18.3223             17.8297             17.8503
190118..........................             16.3776             17.8543             17.5060             17.2223
190120..........................             17.2309             17.6708                   *             17.4476
190122..........................             15.3742             16.7189             17.7811             16.6133
190124..........................             20.1206             22.8245             23.3859             22.1043
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             24.4908             22.9222
190136..........................             15.1662             15.6286                   *             15.3892
190140..........................             14.6829             14.8738             15.4029             14.9883
190142..........................             16.2280             19.0464                   *             17.6182
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             19.8428             19.2603
190161..........................             15.9280             15.7807             16.5322             16.0786
190162..........................             20.1962             20.9645             20.7350             20.6423
190164..........................             18.2379             19.0473             20.2791             19.2845
190167..........................             17.7611             15.5795             17.2643             16.7861
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             25.2536             23.0962
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                   *             17.0775
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             19.7776             17.7558
190200..........................             21.6852             22.3510             24.1667             22.7347
190201..........................             19.7421             21.7185             21.4335             20.9991

[[Page 45519]]

 
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             21.5325             20.4305
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
190241..........................                   *                   *             24.2462             24.2462
190242..........................                   *                   *             18.6672             18.6672
200001..........................             18.2513             19.7903             21.6050             19.8942
200002..........................             22.3035             22.3145             22.0701             22.2222
200003..........................             18.4141             18.5779                   *             18.4971
200006..........................             21.0922             18.9818                   *             20.0361
200007..........................             18.1681             19.0387             21.0603             19.3368
200008..........................             21.5556             23.2883             25.1116             23.3957
200009..........................             21.4763             23.3090             24.9041             23.2536
200012..........................             19.1047             20.5141             21.8529             20.5012
200013..........................             17.9378             20.3793             22.8909             20.4397
200016..........................             17.1187             16.2939                   *             16.7047
200018..........................             17.8675             19.8848             21.1330             19.6434
200019..........................             19.9245             21.1893             23.1114             21.4018
200020..........................             22.3355             24.7433             27.0798             24.8624
200021..........................             20.7361             22.0144             24.9925             22.6569
200023..........................             20.2063                   *                   *             20.2063
200024..........................             20.8336             21.0633             22.9698             21.5997
200025..........................             20.4165             21.4247             22.9023             21.6004
200026..........................             17.9021             18.1459             19.7172             18.5708
200027..........................             19.4220             20.2100             21.0156             20.2414
200028..........................             18.8763             19.8886             21.2180             20.0108
200031..........................             16.1641             17.7875             18.8262             17.5634
200032..........................             19.4613             20.9148             23.0487             21.1916
200033..........................             22.4685             23.6298             25.1723             23.7287
200034..........................             20.4941             21.8266             23.5414             22.0096
200037..........................             20.3015             19.5004             22.6534             20.7355
200038..........................             21.2632             22.9220                   *             22.0751
200039..........................             20.1508             21.5695             22.1333             21.2851
200040..........................             18.9580             20.7744             21.8528             20.5334
200041..........................             18.8131             20.2986             21.3816             20.1961
200043..........................             19.4295             20.0280                   *             19.7244
200050..........................             20.2014             23.0314             23.4391             22.2180
200051..........................             22.0712                   *                   *             22.0712
200052..........................             17.6271             18.9290             19.0536             18.5591
200055..........................             18.5983             19.4998                   *             19.0402
200062..........................             18.4279             18.0949                   *             18.2587
200063..........................             21.2121             22.5265             23.0135             22.2678
200066..........................             17.0570             18.4281             19.5890             18.3751
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             29.4841             27.2832
210005..........................             21.3829             22.5304             24.7185             22.9229
210006..........................             19.3682             20.8607             24.7327             21.6597
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             23.7761             21.2714
210011..........................             21.4043             20.4017             22.3262             21.3567
210012..........................             21.3977             24.8430             25.2892             23.7249

[[Page 45520]]

 
210013..........................             19.4505             23.1649             23.0151             21.9197
210015..........................             18.7448             23.9651             23.8419             22.0261
210016..........................             26.5193             24.7441             27.2632             26.1662
210017..........................             18.5079             18.2963             19.0248             18.6083
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             19.3517             17.5295
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             24.0987             22.9560
210040..........................             23.4252             23.7067             25.4729             24.1964
210043..........................             22.4000             22.9504             22.2177             22.5015
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             24.7148             21.8854
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             23.5881             23.1051
210057..........................             26.0076             25.6142             27.3520             26.3322
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             27.1576             24.5485
220008..........................             22.0796             24.2393             25.6647             24.0447
220010..........................             22.0067             23.4009             24.5021             23.3133
220011..........................             29.5290             20.6390             32.2266             26.8387
220012..........................             31.2303             31.1041             32.0521             31.4899
220015..........................             23.1893             24.1348             25.0272             24.1474
220016..........................             23.0951             24.6149             25.7740             24.4672
220017..........................             25.1568             25.9000             28.9024             26.5392
220019..........................             19.8551             19.9268             21.6620             20.5000
220020..........................             22.4295             22.5375             23.5737             22.8711
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             25.4500             22.4846
220035..........................             23.1892             25.7456             26.8486             25.2168
220036..........................             24.4091             25.5771             28.2182             25.9570
220038..........................             22.3162             22.9821                   *             22.6423
220041..........................             27.5034             28.6790             28.8184             28.3414
220042..........................             26.0473             28.4675                   *             27.2387
220046..........................             23.3149             24.1931             26.1955             24.5514
220049..........................             27.2689             25.4358             26.7688             26.4669

[[Page 45521]]

 
220050..........................             22.5265             23.3330             23.7326             23.2036
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             22.4885             23.6768
220060..........................             28.0794             28.3950             29.6960             28.7409
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             27.5575             25.2252
220067..........................             27.5405             28.2685             22.4968             25.8119
220070..........................             20.9128             23.9850             26.2697             24.8446
220071..........................             27.4151             27.7679             27.7773             27.6608
220073..........................             26.1328             27.4778             27.9309             27.1753
220074..........................             24.3057             25.3331             25.7840             25.1801
220075..........................             22.5329             24.6982             26.0527             24.4363
220076..........................             23.2795             24.1224             24.8040             24.0785
220077..........................             26.1545             27.1503             26.7020             26.6704
220079..........................             22.0769             25.7305                   *             23.1834
220080..........................             22.1971             22.9911             24.7399             23.3385
220081..........................             29.6682             31.1326                   *             30.4202
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             29.4911             28.2821
220088..........................             23.4258             25.0671             26.5849             25.0216
220089..........................             25.4106             25.3521             28.9252             26.5987
220090..........................             23.3049             26.0265             26.5552             25.3702
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             27.0265             27.1375
220101..........................             27.0711             28.0856             26.9992             27.3742
220104..........................             28.7258                   *                   *             28.7258
220105..........................             21.9185             25.5692             26.7570             24.9300
220106..........................             25.9277             27.6812                   *             26.8476
220108..........................             23.4975             24.5939             26.0166             24.7052
220110..........................             29.1648             30.6173             33.0445             30.9588
220111..........................             24.7510             26.7573             27.7395             26.3905
220116..........................             32.0049             28.5716             30.9871             30.4812
220119..........................             23.8785             24.6344             25.9789             24.8166
220123..........................             32.4678             29.6084                   *             31.0767
220126..........................             23.6045             23.8123             26.9853             24.8811
220133..........................             29.3911             29.8366             33.0819             30.7739
220135..........................             28.3648             29.6837             31.9159             30.1085
220154..........................             21.1563             23.3590             25.6070             23.4930
220163..........................             29.2299             29.3552             29.9312             29.6034
220171..........................             24.9261             27.3487             27.2647             26.5898
230001..........................             20.0438             23.3051             22.0875             21.7854
230002..........................             23.0439             24.3115             23.7972             23.6903
230003..........................             21.2215             21.6493             22.4322             21.7672
230004..........................             20.5005             22.4538             23.0827             21.9931
230005..........................             17.0943             20.5596             20.3750             19.2300
230006..........................             20.4978             20.6985             22.0733             21.1112
230013..........................             22.2211             20.0954             20.4633             20.9362
230015..........................             20.6464             21.9499             21.7640             21.4230
230017..........................             22.9755             25.7900             26.1609             24.9780
230019..........................             23.6674             23.8779             24.7472             24.1266
230020..........................             21.8526             28.8869             25.8267             25.0794
230021..........................             19.8256             20.9145             22.0757             20.9148
230022..........................             21.9129             21.8808             22.2179             22.0038
230024..........................             24.9664             26.2155             24.7364             25.2298
230027..........................             19.6393             22.5114             21.2223             21.0886

[[Page 45522]]

 
230029..........................             22.1782             24.9754             26.7646             24.5358
230030..........................             18.6406             19.2441             19.9853             19.3164
230031..........................             19.9465             19.4676             22.1874             20.5558
230032..........................             24.8930             22.8436             23.8366             23.8513
230034..........................             19.4366             17.9276             18.5767             18.6094
230035..........................             17.7490             20.5906             18.0735             18.7098
230036..........................             23.8398             25.1507             25.9801             25.0254
230037..........................             23.2751             22.7382             24.4115             23.4697
230038..........................             21.9692             20.9389             23.4685             22.1152
230040..........................             20.7841             20.2451             21.8062             20.9418
230041..........................             21.7364             23.2870             24.2297             23.0470
230042..........................             21.3870             20.7745             21.8240             21.3299
230046..........................             25.3206             26.1787             28.2320             26.5218
230047..........................             22.3595             23.7178             24.3622             23.4689
230053..........................             26.8917             23.5702             26.1415             25.5713
230054..........................             20.8014             22.2105             23.0818             21.9613
230055..........................             20.8492             20.8930             20.9350             20.8938
230056..........................             17.8091             17.3516                   *             17.5708
230058..........................             21.0303             21.6619             22.4516             21.7265
230059..........................             20.7092             20.6540             21.2743             20.8742
230060..........................             19.8987             20.5120             22.3513             20.9455
230062..........................             18.8039             18.2283                   *             18.4950
230065..........................             22.7416             23.3414             26.3217             24.0577
230066..........................             23.0475             23.2790             23.9696             23.4290
230069..........................             24.2470             25.0212             26.0438             25.1015
230070..........................             21.5666             21.2476             22.8588             21.8801
230071..........................             23.1337             23.6398             23.6674             23.4732
230072..........................             20.4456             22.6533             22.9626             22.0164
230075..........................             22.5866             22.3632             22.6799             22.5400
230076..........................             24.7010             26.9662                   *             25.7305
230077..........................             20.2823             22.6781             29.2041             23.7945
230078..........................             17.9868             19.1638             20.5427             19.2537
230080..........................             20.2104             19.1810             20.2405             19.8736
230081..........................             19.0199             20.0464             20.4289             19.7958
230082..........................             19.0419             18.2165             21.3101             19.3810
230085..........................             23.4996             24.5765             24.2802             24.1339
230086..........................             20.1730             20.1461             27.8923             22.4120
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             25.1213             22.3453
230095..........................             17.6444             18.0582             19.1810             18.3175
230096..........................             22.7785             24.3004             26.7156             24.6007
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             27.4119             25.7958
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             19.9843             20.6199
230110..........................             19.7262             21.0925             21.5523             20.7782
230115..........................             19.6281             21.0361                   *             20.3009
230116..........................             14.5692             15.6064                   *             15.0755
230117..........................             25.6797             25.5154             28.1220             26.4781
230118..........................             20.6797             20.2770             22.2209             21.0377
230119..........................             22.6555             23.9898             25.3562             24.0351
230120..........................             20.3306             20.6105             22.7243             21.0521
230121..........................             21.3342             21.4615             22.3708             21.7224
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

[[Page 45523]]

 
230132..........................             26.1946             27.3637             29.0292             27.5003
230133..........................             17.1058             19.0770             20.4801             18.9081
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             23.8527             23.8745
230153..........................             18.7403             20.0098             22.8584             20.5717
230154..........................             15.4362             16.7152                   *             16.0814
230155..........................             20.5409             20.7546             18.0743             19.8594
230156..........................             25.6228             27.2254             27.7164             26.8324
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             24.7935             23.9629
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             24.4671             23.5848
230175..........................                   *             14.4932             22.5965             17.8784
230176..........................             23.8204             24.9032             24.6675             24.4504
230178..........................             17.3030             17.3428                   *             17.3243
230180..........................             18.5744             19.6062             20.9832             19.7598
230184..........................             19.7717             20.6406             21.4031             20.6108
230186..........................             15.7837             19.1289             21.6148             18.4668
230188..........................             16.2975             16.8687             18.8076             17.2358
230189..........................             17.9218             19.1990             22.7783             19.9127
230190..........................             26.4687             24.4643             27.3430             26.0988
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             26.9840             25.4785
230199..........................             20.6580             22.4592                   *             21.5622
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             20.3171             18.1693
230211..........................             21.8581             21.1245                   *             21.4701
230212..........................             24.2611             24.6420             26.0656             24.9839
230213..........................             15.5469             17.1062                   *             16.3453
230216..........................             21.0710             22.2137             23.4262             22.2338
230217..........................             22.2698             24.1455             24.3649             23.6068
230219..........................             20.0442             18.1277                   *             19.1295
230222..........................             21.9711             23.2545             24.6101             23.2761
230223..........................             22.6887             25.2666             28.5549             25.4631
230227..........................             22.3155             25.8826             27.7510             25.3402
230230..........................             22.3097             22.1703             23.9568             22.8400
230235..........................             17.7197             17.5940             19.9118             18.3853
230236..........................             25.9676             25.3251             25.7463             25.6755
230239..........................             17.8168             18.9790             19.8370             18.8918
230241..........................             20.7297             21.8472             24.2063             22.3226
230244..........................             22.2697             23.1175             23.9004             23.0804
230253..........................             21.0433             22.7706                   *             21.8858
230254..........................             22.6335             23.3714             24.2594             23.4070
230257..........................             21.3880             23.1794             24.8070             22.9716
230259..........................             22.3969             23.1768             24.8598             23.5220
230264..........................             17.4864             18.6598             17.4847             17.8541
230269..........................             24.0992             24.3772             25.3368             24.6276

[[Page 45524]]

 
230270..........................             22.5985             25.2665             22.8842             23.5619
230273..........................             22.8715             24.1278             25.8466             24.2438
230275..........................             20.8985             32.0037             29.4179             26.3638
230276..........................             25.8709             22.3313             23.4929             23.8465
230277..........................             23.9771             24.3351             25.3378             24.5551
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..........................                   *                   *             30.3423             30.3422
240001..........................             25.6936             26.6372             28.2239             26.9164
240002..........................             23.2307             24.2214             24.7674             24.0905
240004..........................             24.4030             25.6238             26.8197             25.6037
240005..........................             20.3193             20.2389                   *             20.2771
240006..........................             23.0715             25.7288             29.5789             26.1049
240007..........................             19.0850             20.7189             21.4367             20.4240
240008..........................             23.3783             22.7437                   *             23.0360
240009..........................             17.1187             17.4518                   *             17.2880
240010..........................             25.4752             28.3796             29.0955             27.6985
240011..........................             21.5875             22.5188             24.0365             22.7468
240013..........................             21.7544             25.1560             27.3855             24.7029
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             24.7516             21.9956
240021..........................             20.1457             19.0469             23.9570             20.9424
240022..........................             21.3234             23.0394             23.4702             22.5966
240023..........................             22.8224             22.3002                   *             22.5542
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             23.4857             22.7589
240037..........................             20.1195             21.4275             21.8392             21.1496
240038..........................             24.3957             26.4513             28.9676             26.5881
240040..........................             23.1352             22.8191             21.3870             22.2562
240041..........................             21.8655             21.9054                   *             21.8860
240043..........................             16.9859             18.0186             19.5532             18.2400
240044..........................             20.3339             22.5750             22.7482             21.8790
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                   *             22.9217
240052..........................                   *             22.3485             23.5899             22.9828
240053..........................             23.8693             24.4191             26.7122             25.0197
240056..........................             23.7139             24.8549             28.5169             25.8728
240057..........................             24.8686             25.3984             27.7600             26.0195
240058..........................             18.4009             19.0506                   *             18.6980
240059..........................             23.7808             25.3847             27.0517             25.4242
240061..........................             25.9951             27.9151             28.7372             27.5834
240063..........................             24.4031             25.8594             26.7960             25.7034
240064..........................             22.8578             24.6785             24.9928             24.2158
240065..........................             14.8734             14.4623                   *             14.6647
240066..........................             24.1143             25.5163             27.4066             25.7241
240069..........................             21.7991             23.3373             25.6943             23.6461
240071..........................             21.2463             22.6332             24.8036             22.9056
240072..........................             20.9529             21.5455                   *             21.2512
240073..........................             17.3559             17.9013                   *             17.6278
240075..........................             21.3357             21.9160             24.4084             22.5903

[[Page 45525]]

 
240076..........................             22.3280             23.6159             26.7112             24.3211
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             27.8807             26.6115
240082..........................             18.7995             20.2018                   *             19.5072
240083..........................             21.0317             22.3484             24.4352             22.5864
240084..........................             21.7421             23.1951             23.9942             22.9738
240085..........................             20.9778             20.7535                   *             20.8640
240086..........................             18.1401             18.1497                   *             18.1450
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                   *             20.2006
240093..........................             20.2400             20.7138             22.3968             21.1802
240094..........................             22.0247             22.5923             24.4166             23.1169
240096..........................             21.0417             20.2992                   *             20.6594
240097..........................             27.9496             29.7597             34.2812             30.8115
240098..........................             24.2296             23.9626                   *             24.0891
240099..........................             15.4964             18.8139                   *             17.0132
240100..........................             20.8325             24.1875             24.7500             23.2514
240101..........................             19.9837             22.1329             24.3455             22.2487
240102..........................             16.3659             15.5114                   *             15.9578
240103..........................             18.7510             21.0182             20.2325             19.9774
240104..........................             23.5351             25.1139             27.4947             25.4150
240106..........................             23.5005             23.9677             25.5890             24.4099
240107..........................             20.9004             21.2163             24.5581             22.1688
240108..........................             18.2427             17.6500                   *             17.9383
240109..........................             16.3216             15.1369             14.5891             15.2649
240110..........................             21.0277             21.7340                   *             21.3899
240111..........................             17.8617             19.9712                   *             18.9100
240112..........................             16.6244             17.2437                   *             16.9303
240114..........................             17.3682             18.3415                   *             17.8558
240115..........................             23.8675             24.6529             27.0312             25.2010
240116..........................             18.3520             17.3460                   *             17.8140
240117..........................             17.9941             18.6677             20.1436             18.9763
240119..........................             21.8289             23.0230                   *             22.4209
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                   *             17.1253
240130..........................             16.4271             17.7634                   *             17.0885
240132..........................             23.1452             24.5633             26.7063             24.8516
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                   *             17.8651
240139..........................             20.5496             21.0163             22.4472             21.2707
240141..........................             23.1009             23.6498             25.1597             24.0447
240142..........................             29.2238             24.0719                   *             26.3951
240143..........................             20.4266             20.7307             18.9442             20.0050
240144..........................             21.4469             23.1661                   *             22.2972
240145..........................             19.0689             17.6747             22.6062             19.4589
240146..........................             16.5412             17.3275                   *             16.9537
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                   *             18.9785
240154..........................             21.5052             21.5859             21.3809             21.4857
240155..........................             20.9385             23.6944                   *             22.3046

[[Page 45526]]

 
240157..........................             13.7309             20.0571                   *             16.8744
240160..........................             15.9014             16.4990                   *             16.1985
240161..........................             16.8809             18.0542                   *             17.5023
240162..........................             19.1542             19.3296             20.4807             19.6719
240163..........................             20.4760             22.2009                   *             21.3326
240166..........................             19.4131             19.4496             21.5002             20.1541
240169..........................             16.3958                   *                   *             16.3959
240170..........................             20.3779             21.5994                   *             20.9960
240171..........................             18.5172             19.6732                   *             19.0959
240172..........................             20.8606             20.3699                   *             20.6109
240173..........................             18.5187             18.3183                   *             18.4146
240179..........................             20.4004             17.7557             19.8250             19.2836
240184..........................             16.8917             17.6979                   *             17.2977
240187..........................             21.2736             23.2471             24.8879             23.1462
240193..........................             18.4664             26.6381                   *             22.8029
240196..........................             25.3479             26.2793             27.2901             26.3467
240200..........................             14.9076             18.7517                   *             16.6495
240207..........................             25.2814             26.0927             27.4330             26.3128
240210..........................             24.5664             25.6060             26.6545             25.6507
240211..........................             30.6260             34.7849             32.8805             32.7909
240213..........................                   *                   *             27.5104             27.5104
250001..........................             19.2756             20.2019             20.9338             20.1232
250002..........................             18.6938             19.6081             21.6643             20.0536
250003..........................             16.7570             18.7331                   *             17.7556
250004..........................             18.3860             19.2913             20.9295             19.5583
250005..........................             12.5834             13.7341                   *             13.1962
250006..........................             17.5192             19.4531             20.3061             19.0833
250007..........................             19.7562             20.9757             21.2226             20.6508
250008..........................             15.8506             15.8096                   *             15.8287
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                   *             13.8135
250025..........................             20.3625             21.9075             21.2651             21.1983
250027..........................             14.5445             15.1790             17.5936             15.6987
250029..........................             16.0682             14.8216                   *             15.4307
250030..........................             26.6173             25.5089             27.2140             26.4270
250031..........................             18.3825             19.8779             21.0894             20.1840
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
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

[[Page 45527]]

 
250058..........................             15.7197             16.2623             16.5565             16.1875
250059..........................             16.6494             17.9507             19.0733             17.8262
250060..........................             16.1804             12.6893             14.0155             14.2269
250061..........................             11.5108             12.0186             11.4573             11.6591
250063..........................             13.3092             15.0894                   *             14.1572
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             21.2224             18.7343
250071..........................             12.3488             13.1934             13.7056             13.0670
250072..........................             18.9487             21.0602             20.7827             20.1324
250077..........................             13.7404             13.9479             14.0318             13.8984
250078..........................             15.9739             17.4118             17.5186             17.0110
250079..........................             16.5835             16.1483             21.3505             18.0112
250081..........................             19.0358             18.1848             20.4513             19.1805
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             18.0473             16.7196
250088..........................             18.2736             19.3976                   *             18.8261
250089..........................             14.3027             15.0238             16.0202             15.0666
250093..........................             16.1506             16.8647             17.4413             16.7983
250094..........................             18.5063             18.9681             19.9619             19.1031
250095..........................             17.4217             18.4944             18.6616             18.1868
250096..........................             19.0584             19.3630             20.7246             19.7069
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                   *             17.6984
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                   *             22.9646
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             22.9071             18.9423
250122..........................             19.2990             19.8033             19.7966             19.6361
250123..........................             18.7863             22.1376             22.2184             21.1030
250124..........................             13.2490             14.4008             15.6866             14.4505
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             21.2490             20.3584
250141..........................             19.6692             21.6835             22.5187             21.4042
250145..........................             11.2120             11.2021                   *             11.2080
250146..........................             14.7781             15.4061             16.9341             15.6577
250148..........................             19.4233             23.1459                   *             21.1903
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             25.5927             24.0655
260006..........................             20.0994             22.1692             24.1078             22.0536
260008..........................             16.8893             18.2114             21.6256             18.7442

[[Page 45528]]

 
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             20.7837             18.6298
260018..........................             12.5301             13.6120             14.3278             13.5417
260019..........................                   *             18.3629                   *             18.3629
260020..........................             20.2241             21.0314             22.4709             21.2482
260021..........................             21.6237             23.3527             27.2478             23.9117
260022..........................             17.7772             18.7707             20.5417             18.9739
260023..........................             17.8649             18.5665             19.6324             18.6837
260024..........................             15.7815             15.6095             16.9968             16.1784
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                   *             12.3857
260031..........................             19.7249             22.5379             24.3626             22.0014
260032..........................             19.6728             20.3847             21.8830             20.6295
260034..........................             20.4902             20.5439             21.6108             20.9281
260035..........................             13.0071             15.1611             15.0468             14.4184
260036..........................             18.8104             20.1242             19.4559             19.4803
260039..........................             14.6644             15.9689                   *             15.3281
260040..........................             18.0140             18.5132             20.0422             18.9525
260042..........................             18.7514             20.8821                   *             19.9434
260044..........................             15.9206             16.7879             18.2413             17.0028
260047..........................             19.2247             20.2724             22.4585             20.5821
260048..........................             21.0602             22.4800             26.6363             23.4107
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                   *             16.6421
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             25.2958             22.8789
260063..........................             18.8973             19.7231             21.1284             19.8962
260064..........................             17.8033             18.3749             17.5188             17.8922
260065..........................             20.0975             20.6671             22.0058             20.9509
260066..........................             15.3460             15.3139                   *             15.3302
260067..........................             15.1837             14.5499             14.9791             14.8944
260068..........................             19.4240             20.7947             22.0951             20.7923
260070..........................             13.9510             18.7384             11.2251             14.4396
260073..........................             15.9182             16.9496             17.8184             16.9459
260074..........................             19.8915             20.4033             18.7639             19.6422
260077..........................             19.4482             20.5830             21.9947             20.6796
260078..........................             14.9463             16.0586             16.9217             15.9818
260079..........................             16.1453             16.4816                   *             16.3135
260080..........................             14.6832             13.1617             13.6815             13.7659
260081..........................             20.3053             20.2471             22.6627             21.1095
260082..........................             15.9858             18.2853                   *             17.1198
260085..........................             20.7051             21.5137             22.7394             21.6591
260086..........................             15.2927             16.7579             17.2049             16.4038
260091..........................             21.5464             22.0772             23.9975             22.5709
260094..........................             18.5395             19.7308             20.1043             19.4945
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                   *             16.5979
260102..........................             20.6361             21.2133             24.1041             22.0613
260103..........................             19.7146             19.9144             21.6192             20.4243
260104..........................             20.3176             21.6624             22.4769             21.5601
260105..........................             24.8181             22.8005             24.6572             24.0540

[[Page 45529]]

 
260107..........................             20.4269             22.5214             23.1564             21.9109
260108..........................             20.0034             20.9029             22.7975             21.3006
260109..........................             14.8181             15.9724                   *             15.3919
260110..........................             18.3227             19.5633             22.0026             19.9361
260113..........................             16.2223             16.1346             16.3440             16.2356
260115..........................             17.4698             19.3873             20.4880             19.0630
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             25.6579             24.1474
260141..........................             19.1893             19.0444             21.0771             19.7195
260142..........................             17.3084             18.2023             18.6412             18.0732
260143..........................             13.9040             15.4688                   *             14.6858
260147..........................             14.7769             15.8522             16.1172             15.5706
260148..........................             11.3524             12.6651                   *             11.9781
260158..........................             12.7699             13.9790                   *             13.3959
260159..........................             19.7951             20.9636             23.1093             21.1490
260160..........................             16.5792             18.4007             18.8723             17.9546
260162..........................             21.4099             20.7331             22.5705             21.6084
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                   *             14.9505
260175..........................             17.5625             18.3632             19.7939             18.5994
260176..........................             21.6044             23.2414             25.7802             23.6435
260177..........................             21.9014             22.9112             24.0550             23.0148
260178..........................             20.2796             20.8189             21.7704             20.9701
260179..........................             22.7185             21.4470             23.2824             22.4725
260180..........................             18.9881             19.5983             21.8585             20.1342
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             21.1331             19.7205
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             22.3912             21.7042
260207..........................                   *                   *             18.5247             18.5247
260208..........................                   *                   *             28.3159             28.3158
270002..........................             19.2387             19.0221             19.7588             19.3381
270003..........................             22.5019             20.7277             23.0396             22.0300
270004..........................             19.4834             20.1821             21.5577             20.5193
270006..........................             17.0715             15.1006                   *             15.8776
270007..........................             13.8824             15.5780                   *             14.6202
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                   *             18.3149
270017..........................             20.0152             22.1046             23.2320             21.7798
270019..........................             15.4128             18.5111                   *             16.8388
270021..........................             16.9457             18.0515             21.1624             18.5631
270023..........................             22.7181             22.7162             23.7486             23.1141

[[Page 45530]]

 
270026..........................             18.0568             20.1673                   *             19.1571
270027..........................             17.2091             17.2005                   *             17.2045
270028..........................             19.1177             19.6212                   *             19.3643
270029..........................             17.3710             18.2097                   *             17.8047
270032..........................             18.7811             19.3937             20.1801             19.4478
270033..........................             18.4876             20.7060                   *             19.5715
270035..........................             16.4302             17.9822                   *             17.2166
270036..........................             16.8552             16.1031             18.8787             17.3089
270039..........................             19.6796             20.3800                   *             20.0267
270040..........................             20.1242             20.1887             20.7239             20.3415
270041..........................             25.8153                   *                   *             25.8151
270044..........................             17.5137             19.2939                   *             18.3206
270048..........................             18.0666             17.4506                   *             17.7260
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                   *             15.8725
270057..........................             20.6714             20.1507             21.9997             20.9799
270058..........................             16.1412             18.4780                   *             17.1845
270059..........................             19.1808             16.9303                   *             17.9228
270060..........................             20.4148             21.3776                   *             20.7622
270063..........................             15.1049             16.4553                   *             15.7723
270073..........................             16.1937             16.6083                   *             16.4041
270079..........................             16.7048             19.5493                   *             18.0578
270080..........................             15.0705             16.6010                   *             15.8020
270081..........................             16.7389             18.0543             15.6834             16.8629
270082..........................             23.1245             23.3209             21.0150             22.5579
270083..........................             17.8554             16.8420                   *             17.3363
270084..........................             16.2958             15.7062             19.6105             17.1115
280001..........................             18.1831             18.7137                   *             18.4397
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                   *             17.3362
280017..........................             13.9939             16.9884                   *             15.5624
280018..........................             15.4496             16.6439                   *             16.0417
280020..........................             21.2467             21.9587             23.4577             22.2709
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                   *             15.4523
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             29.2221             26.6821
280031..........................              9.6321              9.6951                   *              9.6643
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                   *             16.5923
280040..........................             20.9896             21.5426             23.6597             22.1127
280041..........................             16.5503             16.6889                   *             16.6228
280042..........................             16.6239             16.4684                   *             16.5457
280043..........................             17.5937             16.8186                   *             17.2004
280045..........................             15.7630             17.7408                   *             16.6924
280046..........................             17.3214             17.9752                   *             17.6376
280047..........................             17.4735             21.3143             19.5815             19.4044

[[Page 45531]]

 
280048..........................             15.8100             17.9319                   *             16.9007
280049..........................             18.4365             19.4589                   *             18.9514
280050..........................             20.0379                   *                   *             20.0378
280051..........................             17.1942             19.6206                   *             18.3037
280052..........................             14.1201             14.9903                   *             14.5662
280054..........................             18.7575             19.4049             23.1191             20.4732
280055..........................             13.8129             14.2046                   *             14.0093
280056..........................             15.6135             15.6442                   *             15.6285
280057..........................             20.0686             21.4754             22.5480             21.4261
280058..........................             21.4868             22.8105                   *             22.1817
280060..........................             20.7022             22.4677             23.1128             22.1022
280061..........................             18.6370             20.2066             21.2901             20.0793
280062..........................             15.6018             16.1708                   *             15.8878
280064..........................             16.8330             18.2196                   *             17.5260
280065..........................             20.7370             21.6999             23.8128             22.1199
280066..........................             11.7207             12.2225                   *             11.9695
280068..........................             10.5987             10.5103                   *             10.5519
280070..........................             22.6201             18.7211                   *             20.3601
280073..........................             17.7698             18.3496                   *             18.0596
280074..........................             17.3143             13.6025                   *             15.0619
280075..........................             13.2230             13.3154                   *             13.2730
280076..........................             16.7488             16.1939                   *             16.4635
280077..........................             20.0148             21.1883             22.7244             21.3192
280079..........................             16.6117             17.1519                   *             16.8816
280080..........................             16.9487             16.1902                   *             16.5447
280081..........................             20.9606             23.3805             24.3199             22.8549
280082..........................             14.6173             15.4420                   *             15.0337
280083..........................             21.5336             20.8995                   *             21.2308
280084..........................             13.6536             13.2158                   *             13.4147
280085..........................             20.4825             20.8532             21.8473             21.1233
280089..........................             18.9567             19.9003                   *             19.4122
280090..........................             15.1274                   *                   *             15.1274
280091..........................             16.1866             16.3456                   *             16.2669
280092..........................             14.7912             13.3032                   *             14.0640
280094..........................             16.3474             16.9180                   *             16.6358
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                   *             15.8820
280105..........................             21.0735             23.7103             25.1401             23.2737
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                   *             18.2483
280117..........................             18.8279             20.3819             20.5464             19.9214
280118..........................             18.6524             17.8891             19.3465             18.6584
280123..........................             11.8582             23.6682             24.3539             18.1396
280125..........................             16.3944             17.2718             20.0643             17.8221
280126..........................                   *                   *             33.8917             33.8918
290001..........................             22.7450             24.3681             25.9590             24.4242
290002..........................             16.5419             16.7948             16.8363             16.7281
290003..........................             24.2175             25.4303             27.4732             25.7436
290005..........................             21.9814             22.7804             24.6877             23.2224
290006..........................             22.4063             22.4832             24.2211             23.1190
290007..........................             30.9075             34.9911             35.1020             33.7290
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                   *             20.4163
290012..........................             25.0430             25.5647             25.8036             25.4802

[[Page 45532]]

 
290013..........................             15.7932             20.2914                   *             17.6683
290014..........................             18.7829             20.2762                   *             19.5633
290015..........................             19.4504             20.2336                   *             19.8204
290016..........................             23.8656             21.8030             22.5111             22.7099
290019..........................             22.2045             22.5584             25.1684             23.3359
290020..........................             21.2380             19.5039             24.2374             21.4763
290021..........................             22.9488             24.1397             26.2510             24.4455
290022..........................             25.5011             25.3914             27.5364             26.1224
290027..........................             13.3769             13.1463             13.5030             13.3422
290032..........................             23.9504             26.9846             27.5425             26.3410
290036..........................             12.9074                   *                   *             12.9073
290038..........................             27.7030             26.0836                   *             26.8185
290039..........................             25.5024             26.6283             28.7598             27.0508
290041..........................             25.9905             27.7740             28.6294             27.7224
290042..........................             18.7527             18.7669                   *             18.7611
290043..........................             27.9053                   *                   *             27.9053
290045..........................                   *                   *             26.5644             26.5644
300001..........................             23.8567             25.7142             27.1312             25.6218
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                   *             20.2733
300009..........................             20.0938             20.1486                   *             20.1242
300010..........................             20.2130             21.0316             24.6296             21.8421
300011..........................             23.0279             23.8390             25.0979             24.0124
300012..........................             24.5619             25.8581             26.3914             25.6783
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             18.9756             17.3711
300017..........................             22.7191             23.9651             26.1105             24.3969
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                   *             19.7842
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                   *             20.7175
300029..........................             22.6013             23.8415             24.5772             23.7645
300033..........................             17.1632             17.4836                   *             17.3175
300034..........................             24.4975             25.2355             26.9093             25.5558
310001..........................             27.4730             31.1568             30.1786             29.6321
310002..........................             27.9728             28.7786             33.9058             30.2896
310003..........................             27.5624             29.3522             30.4234             29.1284
310005..........................             22.9712             23.9477             26.0227             24.3007
310006..........................             22.0894             24.1538             25.9000             24.0238
310008..........................             24.7618             26.4989             28.0970             26.4414
310009..........................             21.7094             23.2420             24.6353             23.1866
310010..........................             23.1060             24.5471             26.7889             24.8998
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             30.1767             29.1087
310016..........................             24.5206             26.0738             25.7368             25.3848
310017..........................             24.5976             25.1634             25.2636             25.0211
310018..........................             22.4779             24.1428             25.9108             24.1664
310019..........................             24.9914             28.5952             26.8663             26.7986
310020..........................             24.4152             25.0803             25.0147             24.8332
310021..........................             25.4393             27.8958             29.4003             27.4884
310022..........................             20.8258             23.3412             26.7487             23.5627
310024..........................             24.9521             27.0459             26.9499             26.3252

[[Page 45533]]

 
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             26.5224             25.1396
310036..........................             21.7187             23.0320                   *             22.3716
310037..........................             28.1289             28.7738             30.1264             29.0191
310038..........................             28.4893             28.1756             32.3865             29.6794
310039..........................             22.7317             23.6605             24.6045             23.6772
310040..........................             26.3573             26.5769             27.4041             26.7680
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             26.1353             26.1004
310048..........................             25.2870             23.4189             27.4050             25.3502
310049..........................             27.0842             25.6732             26.5332             26.4118
310050..........................             24.7988             23.7735             25.3772             24.6345
310051..........................             27.5378             28.6248             29.2386             28.4543
310052..........................             23.3973             24.9773             27.0324             25.0131
310054..........................             27.7376             27.6290             28.1880             27.8584
310057..........................             22.2572             22.2630             26.3903             23.6641
310058..........................             26.3765             25.3983             28.1753             26.6605
310060..........................             20.0997             21.4455             22.1914             21.1757
310061..........................             33.9582             23.4283             24.9678             26.7631
310063..........................             22.1080             21.2619             25.9868             22.9697
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             28.8791             27.3211
310074..........................             22.3588             24.2009             27.6789             24.7835
310075..........................             24.4788             23.9771             25.7726             24.7214
310076..........................             27.9918             29.6667             32.4533             30.0527
310077..........................             26.1251             26.7092             28.7352             27.1831
310078..........................             24.0587             24.5862             24.7753             24.4599
310081..........................             22.4086             23.3310             24.6082             23.4635
310083..........................             24.8204             25.0191             25.2465             25.0205
310084..........................             24.6049             25.4946             27.3680             25.8446
310086..........................             23.1719             23.4966             25.2751             23.9606
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
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             24.9090             24.6281
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             34.7468             32.0732
310120..........................             23.3200             22.6526             24.7079             23.4981
320001..........................             20.6225             21.5564             23.0290             21.8122

[[Page 45534]]

 
320002..........................             23.0983             25.5144             26.7332             25.2033
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             19.7656             19.7876
320016..........................             18.8519             18.8763             19.9326             19.2629
320017..........................             19.4498             20.4390             22.5460             20.8081
320018..........................             19.2336             20.3141             21.4650             20.3556
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                   *             21.3628
320032..........................             20.6871             21.4815                   *             21.0803
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                   *                   *             16.8769
320063..........................             17.9089             18.5600             20.7804             18.9108
320065..........................             18.6525             22.5428             19.9012             20.1608
320067..........................             15.3228             16.8015             13.9459             15.7173
320068..........................             18.5103             15.6864                   *             17.0317
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..........................                   *                   *             20.6771             20.6771
330001..........................             27.3996             28.6214             30.8509             29.0053
330002..........................             26.9341             27.1811             28.0882             27.3842
330003..........................             18.9211             19.3972             20.2744             19.5052
330004..........................             20.9501             22.5082             24.3703             22.6203
330005..........................             22.1957             22.6137             24.3578             23.0431
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             21.2063             19.9545
330014..........................             36.8669             32.4496             32.0824             33.6237
330016..........................             16.8016             18.7194             18.1603             17.8636
330019..........................             33.5369             31.5927             31.9042             32.2626
330020..........................             15.1142             16.6952                   *             15.9156
330023..........................             25.6512             26.6997             29.4538             27.3398
330024..........................             37.3316             35.7485             35.3598             36.0893
330025..........................             16.8687             17.6169             18.7663             17.7638
330027..........................             35.5255             35.1046             34.1281             34.9304
330028..........................             29.5294             31.7699             31.8452             31.1533
330029..........................             17.0016             19.4377             18.4354             18.2976
330030..........................             19.1085             18.0866             22.0574             20.0482
330033..........................             17.4444             19.5836             18.6316             18.5329
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

[[Page 45535]]

 
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             24.7766             22.4977
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             20.9282             20.1517
330058..........................             17.7672             18.1007             19.2916             18.3759
330059..........................             34.2426             35.0121             36.4176             35.2563
330061..........................             25.4082             26.8580             28.6725             26.9280
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             21.7299             19.4328
330075..........................             17.6385             19.2938             19.9781             18.9556
330078..........................             18.7884             18.0362             20.8379             19.1917
330079..........................             18.7622             18.9398             21.1153             19.6188
330080..........................             31.4424             34.6880             33.5537             33.2193
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                   *             15.2706
330094..........................             18.1582             18.8941             21.3659             19.4211
330095..........................             21.1096             21.1809             28.9794             22.2151
330096..........................             18.5149             20.0370             21.1648             19.9256
330097..........................             16.4433             16.1945             18.6291             17.0573
330100..........................             29.0916             28.9956             31.5775             29.8728
330101..........................             31.5914             35.3618             38.4810             34.9116
330102..........................             19.0058             21.0057             23.5253             21.0029
330103..........................             16.8110             17.3511             17.9017             17.3639
330104..........................             31.2074             31.9746             36.8451             33.4319
330106..........................             35.3775             36.2526             38.7822             36.7882
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
330116..........................             14.9610             16.8567                   *             15.8888
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             22.8078             20.9861
330126..........................             23.8957             25.1175             27.7155             25.5857
330127..........................             30.7356             40.0112             42.2836             37.9337
330128..........................             30.8242             34.3468             32.7050             32.6252
330132..........................             14.3673             14.8704             16.0311             15.1074
330133..........................             35.3576             37.5192             35.9692             35.9945
330135..........................             22.2670             23.5662             25.6504             23.7351
330136..........................             20.1043             20.4124             21.4225             20.6554
330140..........................             19.3615             21.1841             21.1787             20.5922
330141..........................             26.7096             27.5960             29.3283             27.9225
330144..........................             16.2517             17.1513             17.3920             16.9610
330148..........................             16.2782             16.7251             17.6560             16.8727
330151..........................             15.7594             15.2233             16.4028             15.7871
330152..........................             30.8314             33.5587             32.9336             32.8160

[[Page 45536]]

 
330153..........................             18.1776             19.4417             21.2843             19.6379
330157..........................             22.3804             23.1743             23.5522             23.0369
330158..........................             27.1228             29.3163             32.7159             29.6159
330159..........................             19.4998             20.2753             22.5580             20.7593
330160..........................             29.5885             30.7893             32.1266             30.7976
330162..........................             27.6010             27.9705             29.6042             28.3718
330163..........................             20.7456             21.4143             21.1517             21.0818
330164..........................             20.9003             22.0699             23.5427             22.1914
330166..........................             15.4420             17.0637             18.4262             17.0093
330167..........................             30.2346             32.0541             30.9667             31.0372
330169..........................             35.4794             36.3690             36.2725             36.0426
330171..........................             24.8035             25.1567             25.9946             25.3030
330175..........................             18.3116             18.8701             20.4628             19.1836
330177..........................             16.3704             16.6059             19.0005             17.2818
330179..........................             13.8953             16.0113                   *             14.8822
330180..........................             17.9877             19.2670             19.8951             19.0453
330181..........................             33.0908             34.6065             37.1218             34.9071
330182..........................             33.6531             33.3363             35.2415             34.0997
330183..........................             20.6164             20.3520                   *             20.4865
330184..........................             31.3706             28.4726             30.7479             30.2392
330185..........................             26.8612             27.8894             28.9787             27.9279
330188..........................             18.8000             20.2849             21.1196             20.1045
330189..........................             18.4498             23.5589             19.0726             20.2279
330191..........................             19.0348             19.5623             20.9392             19.8520
330193..........................             30.2260             32.5496             36.2427             32.8255
330194..........................             35.2036             35.6486             38.5372             36.5109
330195..........................             34.8966             34.4689             36.4249             35.2744
330196..........................             30.5799             28.9488             31.1915             30.2340
330197..........................             18.3527             19.2237             20.8386             19.4333
330198..........................             24.8590             25.6669             25.3622             25.3000
330199..........................             30.5409             28.0374             34.1354             30.7601
330201..........................             28.7861             30.0524             29.3745             29.3679
330202..........................             31.2575             35.4943             30.7990             32.6310
330203..........................             25.0345             25.9211             24.7422             25.2170
330204..........................             32.2005             31.1366             30.3699             31.2607
330205..........................             22.3490             24.9040             29.0622             25.3829
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             20.7967             20.2015
330214..........................             32.4292             32.3130             32.7647             32.5110
330215..........................             17.9863             19.0726             19.9226             18.9889
330218..........................             21.1890             21.4747             20.6012             21.0785
330219..........................             23.4310             25.1792             28.7448             25.6786
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             22.7847             21.2721
330225..........................             27.0379             28.0523             29.1744             28.0410
330226..........................             23.1859             21.6368             23.5405             22.8458
330229..........................             17.5326             18.2554             18.5590             18.1157
330230..........................             29.6283             30.6937             32.5997             30.9389
330231..........................             32.7200             32.4163             30.2184             31.7719
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             37.3866             34.3729
330241..........................             23.8638             24.7545             26.7598             25.1593
330242..........................             27.6384             28.3561             30.5172             28.8163

[[Page 45537]]

 
330245..........................             18.5161             20.7605             20.2037             19.8717
330246..........................             28.1205             29.8777             31.8857             29.8369
330247..........................             27.3937             32.5858             25.6063             28.6111
330249..........................             17.1320             17.6846             19.1469             18.0226
330250..........................             19.9619             20.8742             22.1272             21.0158
330254..........................             15.9123             15.7864                   *             15.8547
330258..........................             31.8910             32.6745                   *             32.2903
330259..........................             25.9994             26.3620             27.4131             26.5822
330261..........................             27.9766             30.0489             30.4771             29.5060
330263..........................             18.7378             19.5057             20.0831             19.4473
330264..........................             22.8099             24.9714             26.3652             24.7466
330265..........................             17.6301             21.1215             18.2547             19.0141
330267..........................             24.5939             27.8255             29.0499             27.1989
330268..........................             15.9060             16.8358             18.7991             17.2148
330270..........................             36.0824             33.0375             36.5976             35.2587
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             23.8793             22.1432
330285..........................             24.0491             24.5388             26.0446             24.8963
330286..........................             27.7762             28.0994             31.1344             29.0184
330290..........................             30.4706             34.3439             35.5617             33.3907
330293..........................             16.9238             17.3180             17.6507             17.2993
330304..........................             27.3562             29.2207             31.1146             29.2299
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             34.6302             33.3443
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             29.8140             28.8238
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             44.3387             38.5414
330386..........................             20.4231             21.4363             25.2063             22.3343
330389..........................             37.3749             33.1192             32.2112             34.0979
330390..........................             30.8744             31.7344             32.7450             31.7461
330393..........................             27.8352             31.9272             33.0953             30.9212
330394..........................             18.9343             19.6892             21.3678             19.9899
330395..........................             32.7494             33.2318             32.1089             32.8033
330396..........................             30.7961             32.8517             31.2429             31.6152
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                   *             16.5566
330401..........................                   *                   *             33.8633             33.8633
340001..........................             19.7093             22.0257             21.6113             21.1407
340002..........................             20.5253             22.9425             24.0145             22.6770
340003..........................             19.5145             19.6545             20.8205             19.9936
340004..........................             20.9863             23.0890             23.3756             22.5010
340005..........................             16.7176             16.6909             20.8149             18.1113
340006..........................             16.5709             16.1379                   *             16.3589
340007..........................             18.3399             18.3760             19.5208             18.7399
340008..........................             20.4157             22.6570             22.7338             21.9732
340009..........................             20.9178             20.6155                   *             20.8194

[[Page 45538]]

 
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             22.6757             23.7385
340015..........................             19.4676             20.3493             24.3410             21.2831
340016..........................             18.8958             19.4160             20.2859             19.5502
340017..........................             20.2775             20.6263             21.7083             20.8968
340018..........................             18.1751             16.4611             17.3480             17.2851
340019..........................             15.2887             15.9037             16.7901             15.9850
340020..........................             18.0897             19.2392             21.3385             19.6156
340021..........................             20.5813             22.0220             22.9208             21.8064
340022..........................             18.7714             20.6484             19.9078             19.7763
340023..........................             19.3146             19.9023             22.3591             20.5625
340024..........................             17.9130             19.1430             20.4906             19.1924
340025..........................             18.4628             19.1770             20.2864             19.3249
340027..........................             19.4548             19.4907             21.0975             19.9909
340028..........................             19.9403             20.6496             22.2028             21.0172
340030..........................             22.4709             23.9505             26.7753             24.2706
340031..........................             14.6370             15.4935                   *             15.0325
340032..........................             20.7444             22.0245             23.2204             21.9802
340035..........................             18.9930             18.5883             16.4821             17.7616
340036..........................             17.7619             18.4203             20.8313             18.9871
340037..........................             17.5829             18.3655             21.9524             19.3820
340038..........................             18.1493             20.3091             13.9936             16.9604
340039..........................             21.3711             22.4020             24.8246             22.8823
340040..........................             20.7237             21.1397             22.4777             21.4396
340041..........................             15.5873             16.3200             17.6319             16.5216
340042..........................             17.0034             19.1386             21.1107             19.0690
340044..........................             18.0863             18.9562             18.2154             18.4256
340045..........................             13.6182             20.2641             17.4067             16.7851
340047..........................             20.0744             21.5178             22.5199             21.3642
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                   *             24.4619
340053..........................             19.9915             23.2410             24.9768             22.5255
340054..........................             15.5090             16.6208                   *             15.9979
340055..........................             19.4035             20.8253             23.2990             21.1986
340060..........................             19.3410             20.8570             20.8076             20.3431
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
340065..........................             17.3530             23.2606             20.3296             20.0017
340067..........................             19.7187             22.4054             22.2565             21.2710
340068..........................             17.8065             18.8758             19.4487             18.7043
340069..........................             21.6728             22.5995             24.4650             22.9542
340070..........................             20.6829             21.3511             22.2605             21.4483
340071..........................             18.0767             19.3679             19.9561             19.1824
340072..........................             17.7129             18.7920             19.2773             18.5813
340073..........................             23.5832             24.0794             26.6829             24.9327
340075..........................             20.0081             19.7450             23.2904             21.0501
340080..........................             18.2061                   *                   *             18.2061
340084..........................             19.0103             19.6087             20.8175             19.7922
340085..........................             18.3179             20.3684             21.7112             20.1771
340087..........................             18.2255             20.2445             17.8215             18.7854
340088..........................             22.2322             22.6462             22.8687             22.5844
340089..........................             15.4760             16.1321                   *             15.8015
340090..........................             18.5287             18.7701             20.3261             19.2336
340091..........................             20.3861             21.2665             23.1430             21.6613
340093..........................             16.8903             16.5452                   *             16.7319
340094..........................                   *             21.0091                   *             21.0091
340096..........................             19.4696             20.9686             22.1174             20.8605
340097..........................             18.2399             20.0302             20.8690             19.7362

[[Page 45539]]

 
340098..........................             21.9578             23.4949             24.2262             23.3005
340099..........................             15.3752             16.9979             17.5114             16.5762
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             21.0960             20.4083
340109..........................             19.0532             19.3357             20.4341             19.6192
340111..........................             16.5976             17.2127                   *             16.9155
340112..........................             15.5142             16.9592                   *             16.2328
340113..........................             21.9883             24.4222             25.0729             23.8451
340114..........................             20.7261             21.7750             19.9142             20.7205
340115..........................             21.7586             24.7924             23.8284             23.3620
340116..........................             20.6800             21.6744             23.9643             22.1286
340119..........................             19.5827             20.5394             21.2239             20.4881
340120..........................             15.8240             16.9847             19.9860             17.6157
340121..........................             17.8771             19.0420             19.9409             18.9829
340123..........................             18.9078             21.5041             22.3711             20.9859
340124..........................             17.4185             17.5411             17.5691             17.5084
340125..........................             20.2748                   *                   *             20.2748
340126..........................             19.3734             21.2045             21.4271             20.6156
340127..........................             19.3842             21.4797             22.9672             21.3229
340129..........................             20.6521             21.0773             22.3260             21.4712
340130..........................             19.8707             20.5851             22.7687             21.1316
340131..........................             21.3849             23.2478             24.1370             22.9644
340132..........................             17.5711             17.7110             17.8771             17.7237
340133..........................             17.2138             17.5170             23.1444             19.0209
340137..........................             31.7702             39.9826             33.1750             34.5096
340138..........................                   *                   *             29.5285             29.5286
340141..........................             21.4986             23.2961             24.2033             23.0468
340142..........................             18.0766             18.1824             20.4320             18.9192
340143..........................             24.4098             21.9304             23.0416             23.0758
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             22.6057             21.5761
340148..........................             18.9912             20.6790             20.8156             20.1791
340151..........................             18.4733             19.0779             19.2593             18.9459
340153..........................             20.7533             21.7375             23.7426             22.0619
340155..........................             23.1021             25.0965             26.3663             24.8240
340158..........................             19.0843             20.0921             21.7489             20.4390
340159..........................             19.0338             19.4992             21.2983             19.9832
340160..........................             16.7170             17.1963             18.7569             17.6323
340164..........................             21.5769                   *                   *             21.5769
340166..........................             20.8270             22.0519             22.8349             21.9930
340168..........................             15.6071             15.4250             16.8277             15.9431
340171..........................             22.4779             22.7304             25.9603             23.8162
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                   *             20.3296
350006..........................             19.0343             19.1257             19.7577             19.2916
350007..........................             13.8824             13.9966                   *             13.9397
350008..........................             22.3783             23.4052                   *             22.8911
350009..........................             18.3688             19.3668             20.2558             19.3312
350010..........................             16.6272             16.7774             17.2489             16.8799
350011..........................             19.1944             20.6809             21.9111             20.4046
350012..........................             18.2524             16.0990                   *             17.4568
350013..........................             17.2596             17.8145                   *             17.5341
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

[[Page 45540]]

 
350018..........................             16.4939             16.3210                   *             16.4077
350019..........................             20.1608             20.6743             21.3589             20.7389
350021..........................             17.7123             16.3394                   *             16.9912
350023..........................             17.4983             18.3253                   *             17.9246
350024..........................             15.4788             15.7510                   *             15.6148
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                   *             16.0886
350034..........................             19.6445                   *                   *             19.6446
350035..........................             11.7675             12.6496                   *             12.2147
350038..........................             19.6854             19.5497                   *             19.6189
350039..........................             16.6278             14.8599                   *             15.7361
350041..........................             19.1341             23.1150                   *             21.1445
350042..........................             19.3309             19.3370                   *             19.3339
350043..........................             16.7433             17.6722             18.8378             17.7606
350044..........................             11.0601             10.9690                   *             11.0158
350047..........................             18.0094             19.9749                   *             18.9594
350049..........................             18.1993             16.8322                   *             17.5040
350050..........................             12.2183             25.2747                   *             15.7885
350051..........................             17.0653             16.9201                   *             16.9927
350053..........................             15.9160             16.7456                   *             16.3628
350055..........................             15.7916             16.1691                   *             15.9782
350056..........................             15.0995             15.7752                   *             15.4239
350058..........................             16.7034             16.1013             15.0197             15.9830
350060..........................             10.3076             10.5325                   *             10.4159
350061..........................             18.8790             19.6460             18.8494             19.1278
360001..........................             19.6655             20.3515             22.2387             20.7565
360002..........................             18.2613             19.6145             20.7586             19.4748
360003..........................             22.7521             23.2905             24.4144             23.4719
360006..........................             22.4436             22.6333             24.0814             23.0671
360007..........................             14.8213             15.3656             19.1316             16.2099
360008..........................             18.7961             19.8034             21.3795             20.0267
360009..........................             18.9935             19.6277             22.4076             20.3429
360010..........................             19.1852             20.5934             20.6291             20.1715
360011..........................             21.3659             19.5383             21.4293             20.6951
360012..........................             20.0525             23.0125             24.3618             22.5334
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
360017..........................             22.2740             22.7446             23.6181             22.8938
360018..........................             24.6686             24.6694             29.9085             26.0220
360019..........................             20.6480             21.4708             23.3006             21.7875
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             20.8825             19.1730
360027..........................             21.7650             22.8098             23.5907             22.7203
360028..........................             18.7174                   *                   *             18.7174
360029..........................             19.2928             19.7466             20.4925             19.8555
360030..........................             17.6058             19.0551                   *             18.3339
360031..........................             21.0687             21.0481             24.3482             22.0734
360032..........................             19.8020             19.8367             21.1743             20.2841
360034..........................             17.9594             19.4982             21.5621             19.7369
360035..........................             21.0674             22.6982             24.2433             22.6934
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             23.4642             20.4568
360040..........................             18.7425             19.9750             21.3307             20.0479
360041..........................             19.7968             21.9093             22.1352             21.3781
360042..........................             17.1952             19.3774                   *             18.2267
360044..........................             17.6882             17.8417             19.7212             18.4151

[[Page 45541]]

 
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             24.7150             24.1596
360049..........................             20.8393                   *             22.4938             21.5834
360050..........................             15.0568             15.6847                   *             15.3748
360051..........................             20.8757             21.2225             23.0658             21.7279
360052..........................             18.7931             19.8037             22.5005             20.3830
360054..........................             17.4911             17.5714             19.2884             18.1334
360055..........................             21.4112             22.8755             23.5586             22.6117
360056..........................             20.6968             23.4405             22.4475             22.2067
360057..........................             15.8569             16.0395                   *             15.9541
360058..........................             19.3306             19.0440             21.0768             19.7927
360059..........................             19.9304             23.2129             23.0775             22.0496
360062..........................             21.9195             24.4898             24.5746             23.8212
360063..........................             17.5108             20.2671                   *             18.8180
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                   *             15.7627
360068..........................             22.6227             22.6027             22.1110             22.4481
360069..........................             14.6597             18.5382             20.5349             17.7132
360070..........................             18.8406             19.4700             21.8228             20.0184
360071..........................             19.0302             19.6873             21.4478             20.0864
360072..........................             19.0166             20.8819             21.3736             20.4643
360074..........................             18.5889             19.9947             22.2368             20.2638
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             23.3799             22.9416
360079..........................             21.6644             23.9491             25.9623             23.8072
360080..........................             17.6369             18.0392             18.7213             18.1448
360081..........................             20.4614             20.7477             22.1973             21.1275
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             21.5983             20.5220
360087..........................             20.7969             21.1621             23.9638             22.0097
360088..........................             24.0822             20.5703                   *             22.1866
360089..........................             18.1941             19.5260             21.0229             19.5818
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             21.4623             20.5059
360094..........................             20.1227             21.1952             22.6440             21.2292
360095..........................             19.8521             21.3505             23.6518             21.6069
360096..........................             19.6726             20.9838             22.0673             20.9264
360098..........................             19.8178             20.8049             22.7645             21.0895
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                   *             19.5523
360109..........................             19.9237             17.3564             23.0178             19.9966
360112..........................             24.6335             25.7920             25.5910             25.3189
360113..........................             20.8154             22.8088             22.3348             21.9843
360114..........................             18.7509             19.4212                   *             19.0907
360115..........................             20.7652             21.0104             22.3926             21.3952
360116..........................             18.8319             20.1408             21.3809             20.0857
360118..........................             19.9141             21.0235                   *             20.4951
360121..........................             22.2175             21.9111             23.2515             22.4617
360123..........................             20.9792             21.9985             23.1310             22.1195

[[Page 45542]]

 
360125..........................             20.5508             21.6675             21.1408             21.0968
360126..........................             24.5387                   *             22.2409             23.5396
360127..........................             16.5559             18.2150                   *             17.4089
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             22.0958             21.4858
360134..........................             20.9564             21.6081             23.6817             22.0689
360136..........................             18.2194             18.5687                   *             18.3942
360137..........................             22.3648             23.1867             23.8947             23.1248
360140..........................             21.2881             18.3463                   *             19.7842
360141..........................             23.5343             23.5980             25.1442             24.0943
360142..........................             18.3188             19.6189             20.6728             19.5866
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             21.7215             20.4860
360152..........................             21.6005             20.9704             22.9352             21.8108
360153..........................             16.7399             16.1021             17.3367             16.7252
360154..........................             14.3593             14.9606             16.2416             15.1371
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             21.5114             20.5834
360163..........................             21.2689             22.1012             23.1500             22.1757
360165..........................             18.2417             19.6205                   *             18.9117
360170..........................             20.4407             19.7980             22.2815             20.8462
360172..........................             19.8909             22.3294             22.7104             21.5807
360174..........................             20.5399             20.5874             21.7129             20.9378
360175..........................             21.5450             22.0274             22.7887             22.1417
360176..........................             16.6228             17.6743                   *             17.1399
360177..........................             18.9576             19.6992             20.8194             19.8306
360178..........................             16.7962             18.0773             18.2393             17.6939
360179..........................             20.7069             21.3520             23.0678             21.6241
360180..........................             21.0146             22.9260             25.1499             22.9741
360185..........................             19.4858             20.0848             21.1245             20.2540
360186..........................             20.7572             18.1254                   *             19.4292
360187..........................             19.6535             20.8423             21.9499             20.7934
360188..........................             18.3057             16.4329                   *             17.4338
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                   *             18.6858
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                   *             19.7786
360218..........................             18.8204             20.7709             22.8059             20.8145
360230..........................             20.8042             21.2417             24.7681             22.2381
360231..........................             14.4168             12.7388                   *             13.4906
360234..........................             20.6131             21.0473             22.1787             21.3387
360236..........................             21.4628             20.5683             22.8821             21.6382
360239..........................             19.2375             20.9440             23.5802             21.2633
360241..........................             25.3741             23.7679             23.4061             24.1565
360245..........................             15.9782             16.7956             18.1015             16.9965
360247..........................             17.0776                   *                   *             17.0775

[[Page 45543]]

 
360249..........................             25.4331                   *                   *             25.4330
360250..........................                   *             50.5106                   *             50.5105
360253..........................                   *                   *             31.3006             31.3006
360254..........................                   *                   *             30.0791             30.0792
360255..........................                   *                   *             15.0964             15.0963
370001..........................             24.1929             22.0586             25.5838             23.8868
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             22.1596             19.3861
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             16.8631             15.8317
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             24.1009             22.4973
370029..........................             18.2580             19.3285             19.5811             19.0934
370030..........................             16.5803             18.4568             18.6541             17.9169
370032..........................             18.1538             18.9050             20.0827             19.0803
370033..........................             11.3210             15.3857                   *             13.1697
370034..........................             15.6288             16.2204             16.1541             15.9959
370036..........................             12.4070             11.7667             16.5843             13.2363
370037..........................             18.9556             20.6493             21.0719             20.2262
370038..........................             13.0210             15.4551                   *             14.1589
370039..........................             19.4498             22.7015             20.3137             20.7707
370040..........................             15.5109             16.8127             18.9981             17.0372
370041..........................             16.2316             14.7346             19.0145             16.6419
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                   *             19.7652
370060..........................             19.3051             17.9469             23.1897             20.1750
370063..........................             16.7342                   *                   *             16.7342
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             22.2318             18.5140
370079..........................             16.9201             17.5915                   *             17.2356
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                   *             19.0856

[[Page 45544]]

 
370086..........................             11.1900                   *                   *             11.1900
370089..........................             17.2638             17.9243             18.0505             17.7472
370091..........................             20.1822             20.8536             24.2117             21.6700
370092..........................             15.7678             16.8432                   *             16.3152
370093..........................             19.7008             22.1966             23.5685             21.8046
370094..........................             19.5462             19.5565             20.6507             19.9482
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             24.1115             22.1312
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             19.4933             18.4780
370121..........................             21.3099             20.5488                   *             20.9192
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                   *             14.6252
370138..........................             17.5551             17.4574             19.0403             18.0470
370139..........................             14.9964             16.0898             16.3223             15.8016
370140..........................             17.1393             17.4950                   *             17.3218
370141..........................             20.7798             19.8606             24.7859             21.7383
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
370165..........................             13.0375             12.9569                   *             12.9979
370166..........................             21.0797             19.4219             21.3628             20.6200
370169..........................             12.7138             14.8384             16.5607             14.5408
370176..........................             18.9951             19.6537             22.1455             20.2849
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             17.9270             17.1700
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
370196..........................                   *                   *             23.6334             23.6334
370199..........................                   *                   *             20.7075             20.7075
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
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             27.5184             25.2584
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

[[Page 45545]]

 
380009..........................             24.3851             25.1040             26.0012             25.1913
380010..........................             22.7276             24.1931             25.5234             24.1293
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                   *             20.9950
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                   *             22.1387
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             27.5115             25.2376
380040..........................             22.5477             22.6412             21.5958             22.2243
380042..........................             24.4172             21.6793                   *             22.9706
380047..........................             24.2524             25.2591             26.5017             25.3895
380048..........................             18.3005             18.2773                   *             18.2867
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             27.8551             25.0526
380061..........................             22.8781             24.1121             27.3827             24.9756
380062..........................             18.2148             26.1370                   *             22.4060
380064..........................             22.9160             27.0627                   *             25.0195
380065..........................             22.9608             23.3146                   *             23.1416
380066..........................             23.2794             23.1175             23.3581             23.2487
380069..........................             20.4882             21.2057                   *             20.8487
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                   *             21.9036
380081..........................             20.4082             22.9805             22.1822             21.8754
380082..........................             22.9606             23.7927             28.0668             25.0482
380083..........................             21.7431             22.4058                   *             22.0627
380084..........................             27.1689             31.0111                   *             28.8040
380087..........................             17.0380             21.3119                   *             19.2714
380088..........................             19.5346             24.8158                   *             22.0237
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
390001..........................             19.6732             20.3350             21.5154             20.5284
390002..........................             19.7833             20.8831             22.0646             20.9201
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             23.0378             22.0092
390007..........................             21.3839                   *                   *             21.3839
390008..........................             18.2743             19.5439             19.9417             19.2572
390009..........................             20.6241             22.5580             21.9459             21.7141
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

[[Page 45546]]

 
390013..........................             19.6562             20.2186             22.1679             20.7339
390015..........................             13.7352             14.3138                   *             14.0190
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             27.5504             25.9222
390023..........................             22.1044             23.9246             25.3767             23.8310
390024..........................             25.4606             27.7643             25.9806             26.4580
390025..........................             15.5523             14.0077             14.8690             14.8024
390026..........................             22.9718             23.6317             24.0326             23.5437
390027..........................             29.5940             29.4334             33.2139             30.7948
390028..........................             23.6571             22.7820             24.6796             23.7138
390029..........................             21.2661             24.4753                   *             22.6697
390030..........................             18.6887             18.9121             20.0598             19.2297
390031..........................             18.8162             19.2040             20.3568             19.4469
390032..........................             21.5105             18.5545             20.8450             20.3351
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             22.2351             22.2889
390043..........................             17.4764             17.6739             19.8641             18.3598
390044..........................             20.9831             21.3382             22.4235             21.5908
390045..........................             19.4677             20.2107             20.2082             19.9676
390046..........................             21.7445             21.3960             23.1271             22.1125
390047..........................             26.9709                   *                   *             26.9709
390048..........................             19.7992             18.9776             20.3523             19.7014
390049..........................             22.1586             22.8196             24.0933             23.0206
390050..........................             22.2639             24.9156             22.6951             23.1957
390051..........................             28.1385                   *                   *             28.1385
390052..........................             20.1195             21.2729             22.1380             21.1379
390054..........................             18.4975             19.4686             19.8602             19.2479
390055..........................             23.4017             25.7327             23.5292             24.2129
390056..........................             19.3901             21.4121             21.4239             20.7360
390057..........................             20.2395             21.6693             24.8235             22.2695
390058..........................             20.3520             20.7930             22.0113             21.0507
390061..........................             23.8722             22.8728             24.4550             23.7184
390062..........................             17.3750             17.4710             17.6303             17.4968
390063..........................             19.4965             20.1696             21.7120             20.4817
390065..........................             20.0473             20.2930             23.1384             21.2152
390066..........................             18.9296             19.0132             21.7717             19.8676
390067..........................             20.8162             21.9885             23.5136             22.0765
390068..........................             19.1109             21.6408             21.1177             20.4766
390070..........................             21.8549             22.7909             24.4403             23.0308
390071..........................             16.0100             18.9416             17.8117             17.5040
390072..........................             16.9232             16.9445             20.0561             17.9031
390073..........................             21.2623             22.2703             22.7073             22.0769
390074..........................             18.3093             19.7446             21.8456             19.9484
390075..........................             18.7695             19.5840             19.9774             19.3988
390076..........................             21.3290             19.7719             21.2039             20.7327
390078..........................             19.0156             20.6483                   *             19.7928
390079..........................             18.9269             19.5982             19.9169             19.5006
390080..........................             21.4707             22.2449             23.3742             22.3584
390081..........................             24.7461             25.6575             28.1056             26.2492
390083..........................                   *             26.1660                   *             26.1660
390084..........................             20.2529             17.0197             18.3551             18.4310
390086..........................             18.3563             19.7645             19.6488             19.2797
390088..........................             23.9506                   *                   *             23.9506
390090..........................             21.3759             20.5433             22.4688             21.4690
390091..........................             18.3770             19.0355             19.7361             19.0422
390093..........................             18.4442             20.0135             19.9209             19.4590

[[Page 45547]]

 
390095..........................             16.6930             17.9697             18.3939             17.6811
390096..........................             22.4382             22.2974             22.9502             22.5646
390097..........................             25.2845             24.7853             24.5304             24.8507
390100..........................             20.9263             21.1186             23.4155             21.8409
390101..........................             18.5039             19.0180             20.1271             19.2316
390102..........................             21.5496             19.3111             20.9807             20.6410
390103..........................             18.8667             20.4422             21.0637             20.0228
390104..........................             16.3255             16.2440             16.5081             16.3661
390106..........................             16.8439             17.4747                   *             17.1489
390107..........................             20.9841             20.6024             21.5852             21.0626
390108..........................             21.3142             22.0444             23.7842             22.3277
390109..........................             16.5299             17.4540             17.2667             17.0836
390110..........................             21.6464             21.6005             22.3968             21.8598
390111..........................             33.3971             27.1429             30.5814             30.4618
390112..........................             15.0065             14.8634             15.6710             15.1640
390113..........................             19.3634             19.9496             20.1160             19.8009
390114..........................             20.9533             19.8004             23.6162             21.4379
390115..........................             21.4287             22.3545             24.1951             22.7320
390116..........................             21.3671             22.6783             24.9581             22.9637
390117..........................             18.0769             18.9764             19.0983             18.7219
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             23.2232             22.1599
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             19.5296             19.3184
390132..........................             22.8414             24.1878             24.6889             23.9106
390133..........................             24.7561             24.1590             25.2110             24.7109
390135..........................             22.1905             22.2501             24.0445             22.8305
390136..........................             20.6286             16.8505             21.9531             19.6672
390137..........................             18.5397             19.4769             19.5457             19.1463
390138..........................             20.6936             20.7726             21.4705             20.9891
390139..........................             23.9757             24.8347             26.3622             25.0742
390142..........................             28.8877             28.4680             29.8874             29.0890
390145..........................             20.4228             20.4964             20.6580             20.5260
390146..........................             18.6505             20.1788             21.4580             20.0672
390147..........................             21.2492             21.7600             22.3135             21.7727
390150..........................             20.3155             20.8970             20.0261             20.3992
390151..........................             22.5206             23.6072             24.7843             23.6769
390152..........................             19.4017             20.2581             21.5474             20.4133
390153..........................             22.9707             23.9039             25.3391             24.1056
390154..........................             16.7052             17.8774             19.1300             17.9859
390156..........................             22.6398             24.0034             25.0801             23.9044
390157..........................             19.1783             20.2647             20.6933             20.0398
390160..........................             19.4463             19.4793             19.3598             19.4262
390162..........................             21.9188             21.3379             24.0291             22.4183
390163..........................             17.7564             18.1831             18.8585             18.2862
390164..........................             24.9750             26.1698             24.2334             25.0898
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             28.4490             26.7187
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             28.4842             27.3230
390181..........................             19.3832             18.8681                   *             19.1299
390183..........................             17.9848             17.4535             21.6811             18.9628

[[Page 45548]]

 
390184..........................             20.9349             21.1941             21.1962             21.1056
390185..........................             20.3877             20.3301             20.4476             20.3876
390189..........................             20.3338             19.6186             20.1365             20.0174
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             22.8349             21.9546
390198..........................             15.8833             16.6803             17.3937             16.6375
390199..........................             17.3865             17.7782             18.9787             18.0590
390200..........................             15.4012             18.2456             19.4471             17.7454
390201..........................             20.3533             21.3291             22.7849             21.5155
390203..........................             21.4989             22.4685             26.9436             23.7942
390204..........................             22.9616             22.7282             23.9673             23.2268
390209..........................             18.7059             16.8200                   *             17.7119
390211..........................             18.4213             19.4552             21.0450             19.6873
390213..........................             19.1553             20.1152                   *             19.6103
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             23.4385             21.1834
390222..........................             22.1548             22.7491             24.9345             23.2935
390223..........................             22.1775             18.9493             22.8725             21.2902
390224..........................             13.7518             17.2173             16.1289             15.4447
390225..........................             18.7290             19.0364             20.9232             19.6059
390226..........................             21.8481             22.8588             25.6917             23.3415
390228..........................             19.8180             19.6212             21.0164             20.1594
390231..........................             19.4798             21.0757             24.7757             21.7340
390233..........................             20.2309             20.5800             21.8043             20.8925
390235..........................             21.4200             19.9925             23.7068             21.4467
390236..........................             17.8735             19.1427             19.8687             18.9492
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             22.6146             22.4202
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             22.0008             21.0295
390265..........................             20.4950             20.4760             20.5948             20.5230
390266..........................             17.1966             17.6223             18.2424             17.6964
390267..........................             19.2665             20.2424             21.4801             20.3933
390268..........................             22.0909             22.2046             23.1124             22.4784
390270..........................             19.2074             20.7957             22.5258             20.8233
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             30.6300             29.8499
390286..........................                   *             22.9746             25.4499             24.2027
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

[[Page 45549]]

 
390297..........................                   *                   *             25.7318             25.7318
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             11.4041              9.6304
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              9.0138
400010..........................             10.8011              9.1359              9.2799              9.7479
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             14.6491             13.9317
400017..........................              9.2577              9.9167             10.7476              9.9817
400018..........................             10.6208             10.5583             10.8254             10.6669
400019..........................             10.8940             12.1251             13.6516             12.2168
400021..........................             12.1434             12.7462             13.5224             12.8271
400022..........................             12.2199             13.0915             15.2904             13.4548
400024..........................              9.2409              9.0826              9.8650              9.4011
400026..........................              5.8335              7.4280              5.9206              6.3365
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             16.5895             12.9754
400079..........................              9.7203              8.7218              8.7218              8.9772
400087..........................              9.8534              8.6480             10.7118              9.8615
400094..........................              7.9187              9.4600              9.2871              8.8796
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             12.8886             12.3304
400110..........................             10.5277             10.7228             12.0159             11.1009
400111..........................             10.9665             12.3311             12.7701             12.0404
400112..........................             10.8694             11.0634             12.2859             11.4080
400113..........................              8.3168              9.3000             10.4416              9.6011
400114..........................              7.0510              9.9477              9.7444              8.8440
400115..........................              8.5487              7.2203              7.0411              7.5166
400117..........................             10.8756             11.3351              9.7314             10.6287
400118..........................             11.4051             11.4317             12.4590             11.7860
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             10.5643             10.5707
400124..........................             12.2452             12.7323             14.1627             13.0714
400125..........................             10.2056             10.5997             10.5811             10.4664
410001..........................             23.1738             22.4972             24.0033             23.2235
410004..........................             21.0638             23.5408             23.6409             22.7712
410005..........................             22.7170             24.0086             24.6521             23.7686
410006..........................             23.8700             22.8959             26.1372             24.3270
410007..........................             23.1325             24.9846             27.7171             25.1159
410008..........................             24.9726             24.4792             25.4183             24.9582
410009..........................             24.3895             24.3760             26.9135             25.2049
410010..........................             28.4589             29.7315             30.3860             29.5220
410011..........................             26.1183             27.4880             29.7664             27.7381
410012..........................             24.1695             26.4570             28.1791             26.2184
410013..........................             24.8800             25.3688             28.9386             26.3621
420002..........................             20.7804             22.6182             25.1067             22.8141

[[Page 45550]]

 
420004..........................             20.9588             22.4680             23.4579             22.2290
420005..........................             17.9694             17.8202             19.5521             18.4820
420006..........................             19.1760             18.7153             22.7896             19.8079
420007..........................             18.6456             19.0199             22.0228             19.8823
420009..........................             19.9586             21.2566             18.6866             19.8536
420010..........................             18.0252             19.3267             19.1746             18.8763
420011..........................             18.0970             16.7523             17.7299             17.5010
420014..........................             18.0519             19.0455             21.2046             19.4445
420015..........................             20.1164             20.8736             23.1274             21.4737
420016..........................             15.5485             16.6448             17.0051             16.4309
420018..........................             21.8775             20.7779             20.4649             20.9903
420019..........................             17.1726             19.0199             19.6836             18.6013
420020..........................             20.3193             20.5801             22.1616             21.0728
420023..........................             20.4053             20.8600             23.2568             21.5753
420026..........................             21.8749             23.3072             23.7406             23.0011
420027..........................             19.2594             19.7322             21.0637             20.0499
420030..........................             20.6448             22.5159             22.6766             21.9685
420031..........................              8.2516             15.3605                   *             10.6827
420033..........................             23.1303             23.7974             26.2710             24.4383
420036..........................             21.3222             19.8285             20.6649             20.5448
420037..........................             22.7099             23.5244             25.5492             24.0161
420038..........................             18.6568             19.9829             21.6132             20.0798
420039..........................             18.3017             18.0055             21.9737             19.2483
420043..........................             19.7570             19.6834             21.8816             20.4303
420048..........................             18.8070             20.5531             21.9517             20.4950
420049..........................             19.4049             20.1765             21.2604             20.3295
420051..........................             19.1555             19.8549             20.6629             19.9007
420053..........................             18.1657             19.0780             19.9013             19.0557
420054..........................             20.2574             20.2275             20.8471             20.4420
420055..........................             16.8717             18.6782             19.6817             18.3873
420056..........................             15.1835             16.5491             20.0527             17.2450
420057..........................             20.5266             22.1312             17.6727             20.1808
420059..........................             17.1483             18.2093             20.2917             18.4487
420061..........................             17.3543             17.7047             19.9789             18.3969
420062..........................             21.7469             20.9032             17.4764             19.8282
420064..........................             16.0794             19.7067             20.9057             19.0582
420065..........................             19.9435             19.2150             22.0784             20.4983
420066..........................             18.0042             19.5366             20.7782             19.3987
420067..........................             19.7824             20.8524             22.8104             21.1856
420068..........................             18.5481             20.2580             21.7257             20.1957
420069..........................             18.1298             18.9017             17.6291             18.2134
420070..........................             17.3876             19.2186             20.3664             19.0084
420071..........................             20.3902             20.1897             21.8579             20.8383
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             24.3273             22.9650
420079..........................             21.0874             21.3177             23.3992             21.9864
420080..........................             21.9968             23.2871             26.7489             24.1988
420082..........................             21.7210             22.8516             23.6936             22.7569
420083..........................             22.6376             24.4499             24.8508             24.0155
420085..........................             21.6791             22.0071             24.4040             22.7952
420086..........................             20.2878             23.5303             24.5760             22.8222
420087..........................             19.8388             20.8217             22.4526             21.0450
420088..........................             19.9919             21.8979             23.5174             21.7712
420089..........................             20.5360             21.3954             23.3240             21.8074
420091..........................             20.3092             21.8367             23.7936             21.9046
420093..........................             18.3902             19.1299             21.4678             19.5913
420095..........................                   *             33.4632                   *             33.4634
420096..........................                   *             26.4863                   *             26.4864
430004..........................             19.6344             19.2737                   *             19.4433
430005..........................             16.4560             17.3400             18.2647             17.3726
430007..........................             14.6331             15.1494                   *             14.8985

[[Page 45551]]

 
430008..........................             18.1323             18.5234             20.0124             18.8898
430010..........................             19.8191             16.5750                   *             17.9984
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                   *             17.7353
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                   *             14.0594
430036..........................             15.6258             16.7827                   *             16.1636
430037..........................             18.1293             18.7009                   *             18.4202
430038..........................             18.4078                   *                   *             18.4078
430040..........................             14.4509             14.7860                   *             14.6153
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                   *             15.0665
430051..........................             18.8070             18.8697                   *             18.8400
430054..........................             14.8003             15.0101             17.8870             15.8667
430056..........................             10.3697             14.1914                   *             12.0169
430057..........................             17.2805             18.8777                   *             18.0992
430060..........................             10.0176              9.7678             10.6493             10.1353
430064..........................             14.2184             13.8666             14.3407             14.1427
430066..........................             15.6660             14.5957                   *             15.1085
430073..........................             15.3776             16.5112                   *             15.9305
430076..........................             13.9883             15.2453                   *             14.6206
430077..........................             19.8558             20.4361             21.6786             20.6834
430079..........................             14.1815             14.4154                   *             14.2974
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             22.0178             21.2905
440003..........................             19.3042             20.3756             21.6336             20.4509
440006..........................             21.4055             23.1483             24.3173             22.9919
440007..........................             14.8959             14.0612             14.8015             14.5822
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             21.1213             20.1775
440014..........................             16.1143             15.0656                   *             15.5948
440015..........................             22.0659             21.6106             23.4485             22.3272
440016..........................             16.2964             14.6142             20.1504             16.8295
440017..........................             20.4563             20.4705             21.8033             20.8965
440018..........................             17.4995             18.1620             21.2242             19.0126
440019..........................             21.5402             22.8463             21.8854             22.0914
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

[[Page 45552]]

 
440025..........................             16.3140             17.0997             19.1478             17.5703
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             22.2478             21.1521
440035..........................             19.3034             20.4168             21.4990             20.4205
440039..........................             21.6536             22.4158             25.0874             23.1050
440040..........................             16.9275             17.6781             16.9886             17.1928
440041..........................             14.9545             14.6684             15.5784             15.0621
440046..........................             19.3229             20.5562             22.3380             20.6463
440047..........................             17.8092             18.7469             18.7962             18.4413
440048..........................             21.4993             21.6132             23.1553             22.1163
440049..........................             18.7967             19.6920             21.1931             19.8880
440050..........................             18.2511             19.7915             21.1397             19.7737
440051..........................             16.0421             17.7067             19.0165             17.5455
440052..........................             19.8075             18.6589             18.1935             18.8415
440053..........................             19.6494             21.5253             22.0345             21.0746
440054..........................             13.3967             15.2154             15.4208             14.7050
440056..........................             16.2742             20.4903             19.3108             18.5997
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             20.2188             20.2562
440061..........................             22.5525             16.9234             19.5458             19.4254
440063..........................             19.8371             18.8072             19.7468             19.4529
440064..........................             18.9809             18.2678             19.4020             18.8736
440065..........................             18.8296             19.2282             19.9099             19.3487
440067..........................             17.2397             18.2973             19.5643             18.4105
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             19.6579             19.6208
440073..........................             19.5554             19.6290             20.7181             19.9917
440078..........................             16.0188             17.1645                   *             16.5456
440081..........................             19.3454             17.2905             18.3142             18.2349
440082..........................             22.6855             22.5590             26.1497             23.7116
440083..........................             13.7423             13.7630             15.7015             14.3937
440084..........................             13.7731             13.8085             15.0510             14.2295
440091..........................             20.1065             20.1359             23.0296             21.0909
440100..........................             14.7113             15.9969                   *             15.3629
440102..........................             14.5500             16.0783             16.6548             15.7421
440103..........................             18.6990                   *                   *             18.6990
440104..........................             22.6754             21.7135             21.9870             22.0956
440105..........................             17.1172             18.1375             19.2902             18.1888
440109..........................             17.7443             17.6399             17.3578             17.5716
440110..........................             17.4816             18.4998             19.9715             18.7259
440111..........................             23.2254             23.2111             24.9883             23.8046
440114..........................             15.0036             18.5327             20.1152             17.9248
440115..........................             18.5457             18.7054             18.5389             18.5956
440120..........................             16.3115             19.8997             22.4031             19.5197
440125..........................             19.4115             20.0599             21.1018             20.2091
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             23.3600             22.8900
440135..........................             22.2005             22.5452             23.9749             22.9815
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

[[Page 45553]]

 
440145..........................             18.3948             18.3850             18.2020             18.3221
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             22.8733             21.5258
440151..........................             18.3928             19.8977             21.1576             19.7369
440152..........................             22.7664             21.7382             22.7498             22.4243
440153..........................             16.5716             18.1781             19.9486             18.2431
440156..........................             21.7577             21.9374             23.7799             22.5299
440157..........................             18.4249             15.5316                   *             17.0805
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             21.2398             20.5594
440181..........................             17.7709             19.0915             19.6133             18.8053
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             22.1845             21.5612
440186..........................             19.7983             20.8600             23.0193             21.1673
440187..........................             17.5872             18.3729             19.9478             18.6211
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             24.4508             23.0024
440197..........................             21.8503             22.5282             24.2660             22.9060
440200..........................             19.8078             18.7302             16.7752             18.4446
440203..........................             16.2861             16.9819                   *             16.6264
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
440220..........................                   *                   *             21.9117             21.9117
450002..........................             21.4836             21.5141             24.0411             22.4013
450004..........................             16.7850             15.9452                   *             16.4042
450005..........................             16.6396             16.6354             21.7110             18.0529
450007..........................             19.1910             18.0269             18.3737             18.5024
450008..........................             17.6582             19.3745             20.1817             19.0466
450010..........................             17.6677             19.8998             20.3023             19.2481
450011..........................             20.8102             20.2963             22.1472             21.0609
450014..........................             17.5815             19.8846             20.6936             19.3710
450015..........................             21.6773             22.9820             23.9526             22.8711
450016..........................             18.3456             19.1522             20.1232             19.2132
450018..........................             23.2293             21.9921             22.9019             22.6021
450020..........................             19.1153             18.4642             19.1087             18.9021
450021..........................             23.3630             23.7663             25.0769             24.0893
450023..........................             17.6360             19.2808             19.1645             18.7230
450024..........................             18.5985             19.5584             20.7727             19.7057
450028..........................             19.1658             19.5905             22.7775             20.4223
450029..........................             17.7425             19.9505             19.9198             19.2371
450031..........................             29.6945             29.6772             21.7621             26.1343
450032..........................             14.6530             20.8525             20.5217             18.3019
450033..........................             21.0222             21.3766             26.5990             22.8755
450034..........................             18.8823             19.5233             21.6097             19.9960
450035..........................             20.3599             20.3146             24.1860             21.4818
450037..........................             19.9140             19.6532             23.1179             20.8871
450039..........................             19.7176             20.4660             22.0058             20.7406

[[Page 45554]]

 
450040..........................             19.6370             24.8621             21.2990             22.1496
450042..........................             18.8357             20.6041             21.8886             20.4547
450044..........................             21.0909             23.4476             24.1127             22.8038
450046..........................             17.3631             20.2917             20.9239             20.0838
450047..........................             16.9028             15.9525             21.8840             18.0090
450050..........................             17.7209             19.1390             19.5171             18.7476
450051..........................             21.1008             23.0010             24.5533             22.8745
450052..........................             15.5890             20.3702             17.6543             17.8920
450053..........................             17.2781             19.3347             18.6557             18.3562
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             22.0158             20.1655
450059..........................             19.8240             21.4873             22.8792             21.4779
450063..........................             12.7211             15.1779                   *             13.6764
450064..........................             19.7682             21.3929             19.1271             20.0460
450065..........................             23.3797             23.8471                   *             23.6194
450068..........................             23.3495             22.5626             24.0925             23.3338
450072..........................             18.0307             20.0134             20.3683             19.5324
450073..........................             16.5942             23.7700             19.2398             20.0099
450078..........................             13.2820             13.9324             14.8285             13.9373
450079..........................             20.6483             22.0609             24.0085             22.2224
450080..........................             18.6212             19.8414             21.0353             19.7911
450081..........................             17.5737             19.0276             19.2632             18.6116
450082..........................             16.8677             18.0688             16.6566             17.1967
450083..........................             23.3754             20.7446             22.5063             22.1900
450085..........................             20.0085             17.5001             18.1922             18.5095
450087..........................             21.9320             23.4141             24.5976             23.4136
450090..........................             15.5796             15.6090             17.1073             16.1114
450092..........................             17.9520             17.2058             16.0199             17.0396
450094..........................             23.2863             25.2158             25.8313             24.8017
450096..........................             18.6802             19.4430             19.8012             19.3176
450097..........................             19.7187             20.7653             22.2467             21.0001
450098..........................             19.0454             19.8469             20.4795             19.8538
450099..........................             20.4181             19.3493             21.4482             20.3831
450101..........................             17.7928             17.6368             20.1473             18.5186
450102..........................             19.8793             21.4361             20.9900             20.7697
450104..........................             17.0821             17.8219             19.7126             18.2038
450107..........................             24.1094             24.5034             23.2209             23.9133
450108..........................             15.2797             17.9596             18.8084             17.4498
450109..........................             10.5973             18.1085             15.1459             13.9232
450111..........................             21.4908                   *                   *             21.4908
450112..........................             18.1026             17.9624             20.2627             18.7413
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             24.2788             23.3063
450126..........................             21.4789             22.9423             24.1961             22.8519
450128..........................             18.1446             18.7067                   *             18.4296
450130..........................             18.9211             20.2613             19.6199             19.6368
450131..........................             17.4168             18.1401             20.0434             18.5074
450132..........................             21.8089             20.8908             22.4680             21.7157
450133..........................             26.0763             24.5319             25.3928             25.3029
450135..........................             20.4068             21.7038             22.5673             21.5916
450137..........................             23.4346             22.8653             24.9732             23.6854
450140..........................             17.3370             19.6205             18.3835             18.4738
450143..........................             15.0871             17.8206             18.4204             17.0420
450144..........................             17.4309             21.9135             21.3896             20.1692
450145..........................             16.1895             18.0437                   *             17.1256
450146..........................             15.5030             17.4391             16.6809             16.5128
450147..........................             19.0477             20.3019             21.7248             20.3699
450148..........................             20.4923             21.4982             22.1352             21.3649
450149..........................             21.7219             22.6138                   *             22.1667

[[Page 45555]]

 
450150..........................             17.8612             17.8804                   *             17.8714
450151..........................             16.4209             16.3279             17.9127             16.8202
450152..........................             17.7265             19.6105             20.0146             19.2384
450153..........................             18.6514             20.9651                   *             19.6822
450154..........................             13.9119             16.8748             16.5204             15.7956
450155..........................             13.3456             20.2582             18.4020             17.1145
450157..........................             15.3083             16.8569             17.8764             16.7446
450160..........................             10.6852             18.7780             20.7736             15.2692
450162..........................             21.9218             20.5032             26.0570             22.6007
450163..........................             17.8028             19.7675             19.8194             19.0677
450164..........................             17.7180             18.7103                   *             18.2191
450165..........................             17.3283             16.1010             16.1632             16.4885
450166..........................             11.0541             12.6627                   *             11.8721
450170..........................             14.3234             15.8525                   *             15.0719
450176..........................             17.2576             19.2397             19.1823             18.5579
450177..........................             15.2419             16.4503             17.2637             16.3229
450178..........................             16.0280             15.8597             19.1186             16.9564
450181..........................             18.6936             18.3600                   *             18.5293
450184..........................             20.0821             22.7744             24.0596             22.3298
450185..........................             11.5228             13.2015             14.3593             12.9076
450187..........................             18.5053             20.8105             22.6275             20.5632
450188..........................             15.1954             16.9800             17.6158             16.6235
450191..........................             20.9512             20.5883             23.2261             21.6512
450192..........................             21.2497             20.8315             20.1718             20.7147
450193..........................             23.1639             25.1215             26.6580             25.0322
450194..........................             20.7745             20.7152             22.7310             21.4587
450196..........................             17.8993             21.1226             20.1938             19.6870
450200..........................             19.2228             19.6496             20.4656             19.7649
450201..........................             17.1463             18.0646             19.5908             18.2573
450203..........................             19.3978             19.7978             22.9226             20.7388
450209..........................             20.0140             21.3218             23.4794             21.6108
450210..........................             16.3470             16.8532             16.7851             16.6843
450211..........................             18.8114             18.7305             20.0280             19.2048
450213..........................             19.0651             19.3440             21.1280             19.7979
450214..........................             20.5070             21.3448             22.4543             21.4482
450217..........................             12.7647             13.1840                   *             12.9705
450219..........................             17.6884             18.5534             21.0691             18.7782
450221..........................             15.2120             16.2308             19.6778             16.9127
450222..........................             19.8967             23.2779             23.5033             22.2859
450224..........................             20.1579             20.1723             20.4453             20.2606
450229..........................             16.7853             17.0346             17.9811             17.2535
450231..........................             19.1746             20.7709             21.3086             20.4242
450234..........................             16.3003             17.9478             22.3954             18.6856
450235..........................             16.3115             17.0143             18.7028             17.2571
450236..........................             16.4957             18.4551             17.7372             17.5626
450237..........................             19.0325             21.6497             22.4477             21.0610
450239..........................             17.8401             18.8416             19.3655             18.6917
450241..........................             16.4240             16.6046             17.4151             16.8266
450243..........................             13.6416             11.2035             13.0790             12.6321
450246..........................             16.7959             22.7940                   *             19.5014
450249..........................             11.7658             10.6467             13.1223             11.8062
450250..........................             13.6787             18.3361             13.3732             15.0054
450253..........................             13.2177             14.5492             16.6523             14.6986
450258..........................             16.7337             17.0724                   *             16.8994
450264..........................             14.5956             17.2825             13.5346             14.9127
450269..........................             12.7717             12.2970             12.6907             12.5661
450270..........................             14.4792             13.8881             13.9053             14.0814
450271..........................             16.7831             17.9570             18.3659             17.7341
450272..........................             18.4344             20.5888             21.4520             20.2033
450276..........................             14.0745             14.0779             12.8895             13.6150
450278..........................             15.2950             14.3931                   *             14.7982
450280..........................             22.2936             22.2648             23.1664             22.5953
450283..........................             15.1950             15.8224             17.1014             16.1659
450288..........................             18.8935             17.4817                   *             18.1670

[[Page 45556]]

 
450289..........................             20.3460             22.4656             23.7108             22.1634
450292..........................             20.5335             21.1511             23.4257             21.6168
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             17.6820             14.6856
450307..........................             17.0691             17.6757                   *             17.3739
450309..........................             13.3771             16.0363                   *             14.6950
450315..........................             21.4684             23.8151             26.4677             23.7712
450320..........................             20.6596             24.8602             26.8089             24.0198
450321..........................             14.7344             17.2289                   *             15.8859
450322..........................             29.1884             28.9834                   *             29.0897
450324..........................             19.1692             20.9081             23.8523             21.3049
450327..........................             13.3639             11.0983             14.3848             12.7752
450330..........................             19.8066             21.0921             22.9948             21.3142
450334..........................             13.8392             13.9812                   *             13.9103
450337..........................             25.5708                   *                   *             25.5709
450340..........................                   *             19.2611             20.0622             19.6678
450341..........................                   *             20.8814                   *             20.8814
450346..........................             18.9475             19.2769             20.1921             19.5923
450347..........................             19.3475             20.1899             21.7142             20.4550
450348..........................             13.3585             15.0069             15.6324             14.6025
450351..........................             19.3159             21.2842             22.2596             20.9600
450352..........................             20.1871             21.2035             21.8138             21.1211
450353..........................             16.0003             17.3274             19.5263             17.5681
450355..........................             11.8933             12.8876                   *             12.3798
450358..........................             23.0206             25.5767             25.9105             24.7573
450362..........................             18.1983             18.7687             20.6340             19.2155
450369..........................             15.3122             16.0667             16.5636             15.9500
450370..........................             16.1369             18.7539             19.0340             18.0704
450371..........................             16.0236             17.7591             17.3415             16.8971
450372..........................             22.0746             21.4050             22.9079             22.0659
450373..........................             17.9554             18.5716             17.7955             18.1170
450374..........................             15.1750             15.0146             15.0670             15.0810
450378..........................             23.4599             24.4143             25.8048             24.6304
450379..........................             22.8756             25.1931             29.0865             25.7747
450381..........................             16.7112             16.7237             19.0584             17.6325
450388..........................             19.7408             20.7989             22.4441             21.1047
450389..........................             18.8448             19.3156             20.7160             19.6532
450393..........................             22.4992             21.4405             23.8236             22.5782
450395..........................             18.0024             17.5236             19.1938             18.2716
450399..........................             15.3491             16.3333             19.1571             16.9654
450400..........................             18.6668             19.1345             20.1376             19.3717
450403..........................             22.8430             24.7657             24.6215             24.1271
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             26.7662             24.2202
450422..........................             28.0257             28.0395             29.0032             28.3661
450424..........................             18.7895             20.7634             22.0682             20.6438
450431..........................             22.0361             22.6766             22.9545             22.5599
450438..........................             15.4553             21.0474             19.2165             18.2799
450446..........................             20.7592             13.8011             14.1684             15.5340
450447..........................             18.0377             19.7532             21.0247             19.5725
450451..........................             18.2988             18.9519             21.1046             19.4672
450457..........................             19.6569                   *                   *             19.6569
450460..........................             14.6523             15.9446             17.9487             16.1581
450462..........................             22.1144             22.5413             24.0081             22.8970
450464..........................             15.5908             15.8121             16.1987             15.8774
450465..........................             15.4731             19.3928             19.4486             17.6468
450467..........................             17.0004             18.9388                   *             17.8588
450469..........................             22.1930             22.0389             24.0794             22.8914
450473..........................             19.7148             18.3813             18.6003             18.8420

[[Page 45557]]

 
450475..........................             16.9269             19.0010             20.9443             18.9625
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             22.3034             22.4026
450530..........................             21.1634             21.8988             23.3005             22.1616
450534..........................             20.1520             19.7410             22.5156             20.7023
450535..........................             21.0513             21.5449             23.7255             22.0993
450537..........................             20.1161             20.8849             22.5972             21.2300
450539..........................             18.7559             19.3681             18.4299             18.8532
450544..........................             23.6652             22.7282                   *             23.2148
450545..........................             20.2823             21.0792             21.7762             21.0259
450547..........................             18.1524             20.5049             22.6558             20.1983
450551..........................             16.6237             16.1437                   *             16.3738
450558..........................             20.7404             21.3116             21.4201             21.1518
450563..........................             22.0708             21.9935             27.5671             23.9083
450565..........................             17.3803             17.8058             17.2171             17.4667
450570..........................             19.0336                   *                   *             19.0336
450571..........................             18.2784             19.5325             21.5688             19.7274
450573..........................             17.3518             17.6157             18.6233             17.8792
450574..........................             14.6128             14.8549                   *             14.7345
450575..........................             22.5621             24.0386                   *             23.3408
450578..........................             18.0925             17.2863             17.3010             17.5480
450580..........................             16.7374             17.8224             18.5226             17.6863
450583..........................             14.4411             15.9430                   *             15.2044
450584..........................             14.6735             14.9237             16.9020             15.4896
450586..........................             13.8248             14.7433             14.9061             14.4503
450587..........................             18.0219             18.0014             19.0648             18.3640
450591..........................             17.7795             18.6714             19.6229             18.7114
450596..........................             21.6729             21.9445             24.3714             22.6695
450597..........................             17.6179             19.0641             19.9596             18.8329
450603..........................             23.5572             23.4924             20.6138             22.5917
450604..........................             17.6582             18.7465             19.5288             18.6690
450605..........................             19.4580             19.7400             22.0210             20.3694
450609..........................             17.0986             14.1776             16.6870             15.9595
450610..........................             21.5191             23.5626             24.7706             23.4743
450614..........................             16.5754                   *             18.5895             17.6527
450615..........................             15.2956             15.0621             17.2717             15.8832
450617..........................             20.8919             21.5004             22.7514             21.7690
450620..........................             16.0987             16.4330             17.1333             16.5680
450623..........................             23.1270             25.1122             25.1400             24.4887
450626..........................             18.4349             20.5225             17.7454             18.8435
450628..........................             18.6093             20.0411                   *             19.3786
450630..........................             20.9605             23.1840             24.8096             23.0353
450631..........................             21.6736             21.8940             22.8637             22.1659
450632..........................             13.9147             15.1416                   *             14.5084
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             24.2919             23.0328
450641..........................             15.7578             15.3652             17.4072             16.1535
450643..........................             16.8152             18.9088             20.2000             18.7134
450644..........................             22.7721             24.5834             24.4574             24.0080
450646..........................             19.1433             23.1240             21.8500             21.2678
450647..........................             24.2763             25.0549             26.8276             25.4018
450648..........................             15.0305             14.4884             17.3678             15.6152
450649..........................             16.6577             16.8505             17.5760             17.0475
450651..........................             22.7112             25.4679             26.9215             25.1260

[[Page 45558]]

 
450652..........................             17.2445                   *                   *             17.2446
450653..........................             19.2349             20.2436             22.7236             20.7352
450654..........................             14.5423             15.5858             16.3057             15.4780
450656..........................             18.2606             18.5874             20.7824             19.2080
450658..........................             17.2630             19.4139             19.6855             18.7689
450659..........................             23.0108             22.9344             26.0224             24.0406
450661..........................             18.9071             19.5504             20.0716             19.5103
450662..........................             19.3152             20.7973             26.3794             22.0858
450665..........................             16.1319             14.5158             15.8571             15.5177
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             19.9621             19.9838
450672..........................             21.4927             23.2623             25.3106             23.3562
450673..........................             13.7005             14.9115             16.3319             15.0676
450674..........................             22.2426             21.9624             24.8137             23.0636
450675..........................             21.4479             23.3954             24.8661             23.3355
450677..........................             20.6556             21.7366             22.9529             21.8092
450678..........................             24.1301             25.1841             28.1917             25.8918
450683..........................             22.8699             22.1965             24.5013             23.1739
450684..........................             21.9962             22.2380             23.8945             22.7570
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                   *             20.2752
450706..........................             22.0884             22.4329                   *             22.2641
450709..........................             22.1490             22.0123             23.4246             22.5690
450711..........................             19.8581             20.8047             22.1489             20.9512
450712..........................             15.9298             11.1086             18.4546             14.6487
450713..........................             22.6986             23.6189             24.4002             23.6310
450715..........................             22.5988             24.8068                   *             23.7226
450716..........................             20.9074             20.8913             24.8614             22.2839
450717..........................             20.6551             22.0243                   *             21.3435
450718..........................             22.1765             23.0051             24.9162             23.5065
450723..........................             20.8213             22.0633             24.1618             22.4391
450724..........................             20.3706             23.3799             21.9630             21.8831
450727..........................             17.9172             24.6125             16.0843             19.3135
450728..........................             19.8879             14.9265                   *             17.2495
450730..........................             23.0054             24.5952             27.8476             25.3002
450733..........................             20.2199             21.9921             23.8143             22.0738
45042...........................             21.8392             22.8135             25.1295             23.3180
450743..........................             19.6015             20.5017             23.7424             21.3472
450746..........................             30.2657             14.6683             11.1672             15.8134
450747..........................             20.3914             20.3870             21.5883             20.8604
450749..........................             19.1678             18.7138             17.8696             18.5551
450750..........................             13.8098                   *                   *             13.8098
450751..........................             19.9995             19.8170             23.3152             20.7533
450754..........................             16.7145             17.8497             19.2827             17.9575
450755..........................             19.8743             20.0667             19.2768             19.7781
450757..........................             14.9434             15.6425                   *             15.2936
450758..........................             19.0221             22.6196             22.8713             21.5676
450760..........................             19.2225             20.4209             23.2959             20.7991
450761..........................             15.7681             14.6511             15.5151             15.2848
450763..........................             18.6092             18.9713             19.8939             19.1937
450766..........................             23.3879             25.4057             27.2499             25.3311
450769..........................             18.4163             17.9879                   *             18.2056
450770..........................             19.0183             20.0632             19.9412             19.7010
450771..........................             21.8268             21.6946             25.0490             22.9471

[[Page 45559]]

 
450774..........................             16.2948                   *             21.7906             18.6936
450775..........................             21.3504             22.6526             23.6621             22.5576
450776..........................             14.1720             13.4263             14.6695             14.0866
450777..........................             19.0380             18.3119                   *             18.6460
450779..........................             21.6642             22.6216             23.8882             22.7424
450780..........................             19.0914             20.0824             21.9046             20.4076
450788..........................             19.6469             19.9817             21.4467             20.3179
450795..........................             22.5753             27.0250             19.1371             22.4874
450796..........................             19.2059             26.8539             22.4973             23.7266
450797..........................             16.4923             20.2356             18.6839             18.3681
450801..........................             17.9548             18.0598             19.7790             18.5904
450802..........................             17.1435             18.2460                   *             17.6977
450803..........................             21.6653             37.0925             23.8343             26.2012
450804..........................             19.0893             20.5225             22.8275             20.8633
450806..........................                   *             20.7906                   *             20.7906
450807..........................             13.4306             18.4410                   *             15.3677
450808..........................             17.4917             18.1728             18.6555             18.1215
450809..........................             19.7899             21.9845             23.8758             21.8428
450811..........................             19.9168             21.6115             22.7583             21.5237
450813..........................             14.5392             15.3780             21.7208             16.6296
450815..........................             21.2741                   *                   *             21.2742
450817..........................                   *                   *             28.4441             28.4441
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                   *             17.9757
450824..........................                   *             25.7488             24.5885             25.1472
450825..........................                   *             16.0793             18.8510             17.6091
450827..........................                   *             20.1310             29.5838             24.8201
450828..........................                   *             19.2902             20.9509             20.1462
450829..........................                   *             14.7121             14.4463             14.5541
450830..........................                   *                   *             24.7835             24.7834
450832..........................                   *                   *             24.8572             24.8572
450833..........................                   *                   *             18.3195             18.3196
450834..........................                   *                   *             21.7217             21.7217
450835..........................                   *                   *             24.8374             24.8374
450837..........................                   *                   *             24.2965             24.2964
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                   *             22.6125             20.9837
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                   *             21.0221
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                   *             21.8486
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

[[Page 45560]]

 
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             24.9214             23.7640
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                   *             17.7382
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
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                   *             21.0240
470018..........................             21.2406             24.8493             21.2904             22.3634
470020..........................             21.5688             21.9911                   *             21.7766
470023..........................             21.7139             22.5334             24.1395             22.7760
470024..........................             21.9807             23.2738             22.4659             22.5822
490001..........................             20.0570             21.4952             22.3622             21.3461
490002..........................             15.7365             16.5198             17.5098             16.5736
490003..........................             20.3237             20.7688             20.9782             20.6753
490004..........................             19.7074             20.7616             22.7154             21.0565
490005..........................             21.3318             23.1708             25.2213             23.2687
490006..........................             12.3253             19.8977             13.4277             15.2731
490007..........................             19.8938             20.7896             22.2526             20.9740
490009..........................             23.7659             24.7602             25.2181             24.6030
490011..........................             19.8042             19.8179             20.0136             19.8803
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             24.4682             23.7523
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             23.6489             22.3775
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             22.0040             20.5969
490047..........................             18.7614             20.1660             19.8220             19.5730

[[Page 45561]]

 
490048..........................             19.5417             20.9110             22.3138             20.9455
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                   *             21.2010
490057..........................             20.3160             21.1871             22.1612             21.2650
490059..........................             21.4801             24.1516             23.3895             22.9645
490060..........................             18.5917             19.3525             20.6028             19.5408
490063..........................             26.1930             28.0906             31.0162             28.4308
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                   *             18.5291
490088..........................             17.9141             19.1924             19.7549             18.9853
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             20.7388             19.2083
490094..........................             22.3033             20.2020             21.9886             21.4787
490097..........................             16.9518             16.6563             18.1022             17.2610
490098..........................             16.0488             18.5133             19.7116             18.0649
490099..........................             18.3985             19.2604                   *             18.8235
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             21.3883             19.5991
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             20.4660             19.9498
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             26.6420             25.5079
500002..........................             19.8476             22.9942             24.0374             22.2651
500003..........................             24.4333             25.1200             27.3435             25.6803
500005..........................             24.3870             26.2066             28.9512             26.5073
500007..........................             21.9911             24.7889             23.5774             23.3350
500008..........................             26.1737             27.2852             28.9380             27.5261
500011..........................             24.6554             25.7263             27.6762             26.0196
500012..........................             24.2799             24.5450             26.2263             25.0463
500014..........................             24.0990             25.0490             27.4248             25.5566

[[Page 45562]]

 
500015..........................             24.9923             25.9465             27.3397             26.1168
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             27.2967             26.7293
500025..........................             24.4825             27.3697             29.0400             26.8639
500026..........................             26.9884             26.6108             28.7532             27.4597
500027..........................             25.1125             27.7429             30.6901             27.9493
500028..........................             18.9556             19.0261                   *             18.9904
500029..........................             18.5042             19.3130                   *             18.9280
500030..........................             26.3828             28.5297             29.0487             28.0239
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             23.5414             22.3769
500039..........................             24.0007             25.4225             26.1409             25.2258
500041..........................             25.4376             24.7070             24.9005             25.0014
500043..........................             22.0466             24.1745                   *             23.1775
500044..........................             24.2212             24.7816             27.0880             25.3901
500045..........................             24.0526             24.6265                   *             24.3304
500048..........................             20.3207             20.6333                   *             20.4821
500049..........................             24.5997             26.5857             26.6407             25.8996
500050..........................             22.6563             23.0804             25.0907             23.6590
500051..........................             25.9447             26.7628             26.9538             26.5713
500053..........................             22.8399             24.2492             26.0112             24.3887
500054..........................             23.8089             25.7815             27.1965             25.6339
500055..........................             23.8622             23.7988             25.3095             24.3502
500057..........................             19.0479             20.5812             21.0357             20.2825
500058..........................             24.1106             26.5679             27.3411             26.0709
500059..........................             26.6270             25.3528                   *             25.9254
500060..........................             28.3655             29.6030             31.7480             29.9426
500061..........................             20.8624             24.5908                   *             22.7197
500062..........................             19.0557             19.1685                   *             19.1136
500064..........................             26.7000             27.5791             29.2539             27.8671
500065..........................             23.5671             24.0966             26.5881             24.7506
500068..........................             19.2638             20.9278                   *             20.1095
500069..........................             21.4542             22.4158                   *             21.9517
500071..........................             19.1428             22.3253             23.2071             21.4408
500072..........................             25.2001             25.7734             27.5706             26.2080
500073..........................             21.7698             22.5222                   *             22.1712
500074..........................             19.5981             20.6120             21.9018             20.7646
500077..........................             23.9410             24.5695             26.5692             25.0435
500079..........................             23.1041             24.7946             27.1775             25.0691
500080..........................             18.3883             18.8188                   *             18.6306
500084..........................             24.4044             25.0556             26.5864             25.4001
500085..........................             20.4517             20.7422                   *             20.5981
500086..........................             22.8829             24.2556             25.9705             24.3779
500088..........................             25.2478             26.4212             30.1689             27.0767
500089..........................             19.7166             20.3478                   *             20.0210
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                   *             24.2745
500097..........................             20.8774             21.4423                   *             21.1473
500098..........................             15.2040             17.8453                   *             16.5267
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                   *             18.1033
500107..........................             17.9489             17.4641                   *             17.7015
500108..........................             28.6229             26.1609             27.4156             27.3893
500110..........................             22.9775             23.5941             24.8448             23.8174
500118..........................             24.8034             24.7875             26.1971             25.2739

[[Page 45563]]

 
500119..........................             22.1192             23.9939             25.1576             23.7715
500122..........................             23.5264             24.4462             26.9006             25.0168
500123..........................             19.6646             21.7133                   *             20.9232
500124..........................             23.7742             24.6591             24.8357             24.4790
500125..........................             14.7910             15.6304                   *             15.2302
500129..........................             25.4685             25.2082             27.8351             26.2009
500132..........................             23.1822             21.9915                   *             22.6185
500134..........................             17.2430             15.9791             21.3919             17.5320
500139..........................             22.3053             23.7993             27.7281             24.5780
500141..........................             29.9695             28.1014             28.2968             28.7009
500143..........................             18.2570             18.7523             19.0982             18.7216
510001..........................             20.0429             20.2514             21.4247             20.5803
510002..........................             17.6392             19.1517             20.9822             19.2895
510005..........................             13.8621             13.8641                   *             13.8631
510006..........................             19.9609             19.9760             21.0214             20.3316
510007..........................             21.6761             22.9326             23.4411             22.6998
510008..........................             19.0513             19.9176             22.7595             20.6320
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             22.7534             21.9321
510023..........................             16.7777             17.6516             17.9267             17.4783
510024..........................             18.7461             19.6521             21.3662             19.9294
510026..........................             13.7952             14.8785             16.5389             14.9496
510027..........................             18.5945             20.5222                   *             19.5739
510028..........................             19.9208             22.4826             24.6543             22.2359
510029..........................             18.4668             18.9000             19.8202             19.0740
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                   *             14.4439
510038..........................             15.5576             15.9821             16.1016             15.8882
510039..........................             17.1461             17.4002             17.6173             17.3850
510043..........................             13.1308             14.4202             15.5857             14.3831
510046..........................             18.5896             18.7424             19.2802             18.8707
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             21.3404             19.7139
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                   *             17.8253
510081..........................             11.9701             10.4972                   *             11.2092
510082..........................             13.5946             16.0014             17.2891             15.5840
510084..........................             13.5339             14.9683                   *             14.2476
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             22.0838             20.7249
520003..........................             18.7956             18.7507             20.4234             19.3853
520004..........................             20.4591             21.1549             22.8530             21.4781
520006..........................             21.4884             22.4099                   *             21.9357

[[Page 45564]]

 
520007..........................             18.4629             18.3959                   *             18.4330
520008..........................             24.9395             24.4927             26.0931             25.2072
520009..........................             21.4638             19.8142             21.5169             20.8888
520010..........................             22.3311             25.5623             26.3964             24.7924
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                   *             21.8799
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                   *             21.1922
520026..........................             20.8546             22.4779             25.0504             22.8714
520027..........................             21.5868             22.1450             22.2089             21.9932
520028..........................             22.5941             22.0333             24.3592             23.0143
520029..........................             21.4197             21.5561                   *             21.4863
520030..........................             21.6311             22.7239             23.9474             22.8336
520031..........................             20.9875             21.2809                   *             21.1290
520032..........................             21.1069             24.1092             22.7220             22.6429
520033..........................             20.2520             21.0088             22.2650             21.1839
520034..........................             20.4307             21.5275             22.6160             21.7180
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                   *             22.1557
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             20.5069             20.2455
520049..........................             20.1667             21.8271             22.7424             21.6003
520051..........................             24.0460             23.4366             27.6695             25.0213
520053..........................             18.0851             18.9512                   *             18.5170
520054..........................             16.8363             16.6278                   *             16.7267
520057..........................             19.8492             20.6959             21.2729             20.6322
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             24.3043             23.3833
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                   *             21.2683
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             23.4414             22.2794
520083..........................             23.5787             24.2401             25.7108             24.5108
520084..........................             23.5446             21.8102             24.7909             23.3951
520087..........................             20.7821             22.2579             22.8974             22.0182
520088..........................             21.8931             22.3921             23.8938             22.6992
520089..........................             22.1055             23.2335             24.4435             23.2707
520090..........................             20.3645             20.9069                   *             20.6378
520091..........................             20.9440             22.2218             22.8914             22.0430
520092..........................             18.6248             19.7181             21.8662             20.1341

[[Page 45565]]

 
520094..........................             20.6179             21.3082             22.3925             21.4517
520095..........................             18.6425             21.9177             25.1402             21.7601
520096..........................             20.6668             21.6803             21.1759             21.1819
520097..........................             20.8016             22.2375             23.6512             22.2609
520098..........................             23.4707             25.0055             25.8184             24.7756
520100..........................             19.4788             20.5366             21.7072             20.6024
520101..........................             19.9875             20.0164                   *             20.0019
520102..........................             21.0138             22.3640             23.7739             22.4092
520103..........................             20.1092             22.2765             23.5984             22.0082
520107..........................             21.7907             23.8421             25.7379             23.7522
520109..........................             19.7609             20.3208             20.6356             20.2580
520110..........................             21.0055             22.3923                   *             21.7201
520111..........................             17.7673             18.2744             26.9667             20.3598
520112..........................             18.9577             17.6226             19.1409             18.5293
520113..........................             21.8852             23.1852             24.0822             23.0750
520114..........................             17.8476             18.5767             21.9848             19.3865
520115..........................             19.2248             21.4279                   *             20.3524
520116..........................             20.6922             22.2741             23.9066             22.2707
520117..........................             18.3963             19.3653                   *             19.9396
520118..........................             14.8626             13.9920                   *             14.4086
520121..........................             20.8492             20.9422                   *             20.8956
520122..........................             16.9335             16.9905                   *             16.9629
520123..........................             17.7986             19.8134             21.2360             19.6609
520124..........................             17.9205             19.2621                   *             18.5941
520130..........................             16.6873             18.8845             20.0277             18.5254
520131..........................             20.2591             21.0400                   *             20.6634
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             23.2573             21.8325
520138..........................             22.5599             23.1498             25.1434             23.6620
520139..........................             21.4042             22.8070             23.7727             22.6778
520140..........................             22.3671             22.5459             23.9176             22.9362
520142..........................             21.9432             21.4120                   *             21.6717
520144..........................             19.9120             20.5864                   *             20.2475
520145..........................             18.7958             20.3461             25.0771             20.8014
520146..........................             18.2370             18.6337                   *             18.4453
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             22.5440             23.5479
520153..........................             17.0863             18.5986                   *             17.8517
520154..........................             19.5994             21.0486             23.2635             21.3043
520156..........................             20.9638             20.7808             23.7157             21.8343
520157..........................             19.6008             21.6821                   *             20.6349
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             25.5470             23.5499
520171..........................             18.0785             18.1844                   *             18.1321
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
520192..........................                   *                   *             22.5643             22.5641
530002..........................             21.0560             23.0582             23.8852             22.6216
530003..........................             15.9523             17.1646                   *             16.5866
530004..........................             13.3788             17.4672             19.7857             16.7474
530005..........................             15.3255             18.4391                   *             16.9756
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             21.4890             17.2328

[[Page 45566]]

 
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                   *             19.7065
530023..........................             20.0677             21.6352             22.5534             21.5200
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
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. 148 / Friday, August 1, 2003 / Rules 
and Regulations  

[[Page 45566]]




   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.........................................    22.8434    22.3877
Albany, GA........................................    26.8394    25.0646
Albany-Schenectady-Troy, NY.......................    20.9741    19.8010
Albuquerque, NM...................................    22.9788    22.1382
Alexandria, LA....................................    19.8135    18.6733
Allentown-Bethlehem-Easton, PA....................    24.0178    23.0413
Altoona, PA.......................................    21.7576    21.1859
Amarillo, TX......................................    22.2017    20.8641
Anchorage, AK.....................................    30.1827    29.0196
Ann Arbor, MI.....................................    27.3610    25.9303
Anniston, AL......................................    19.9890    19.0540
Appleton-Oshkosh-Neenah, WI.......................    22.3237    21.2583
Arecibo, PR.......................................    10.2650    10.2305
Asheville, NC.....................................    24.0145    22.6770
Athens, GA........................................    24.2576    23.3576
Atlanta, GA.......................................    25.0274    23.5635
Atlantic-Cape May, NJ.............................    26.6718    25.8172
Auburn-Opelika, AL................................    20.9868    19.6276
Augusta-Aiken, GA-SC..............................    23.7818    23.2814
Austin-San Marcos, TX.............................    23.7418    22.5676
Bakersfield, CA...................................    24.2375    22.8607
Baltimore, MD.....................................    24.5068    23.1821
Bangor, ME........................................    24.4712    22.6991
Barnstable-Yarmouth, MA...........................    32.0118    31.0786
Baton Rouge, LA...................................    20.7683    19.4439
Beaumont-Port Arthur, TX..........................    20.8140    19.6576
Bellingham, WA....................................    29.0487    28.0239
Benton Harbor, MI.................................    22.0757    20.9454
Bergen-Passaic, NJ................................    28.8869    27.7302
Billings, MT......................................    22.1402    21.3587
Biloxi-Gulfport-Pascagoula, MS....................    22.3087    20.4967
Binghamton, NY....................................    20.8245    19.6736
Birmingham, AL....................................    22.7610    21.2316
Bismarck, ND......................................    19.6799    18.6613
Bloomington,IN....................................    21.4009    20.6516
Bloomington-Normal, IL............................    21.8206    21.0629
Boise City, ID....................................    22.7531    21.5699
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH..    27.7541    26.4283
Boulder-Longmont, CO..............................    24.8276    23.1313
Brazoria, TX......................................    20.1054    19.4362
Bremerton, WA.....................................    26.1409    25.2258
Brownsville-Harlingen-San Benito, TX..............    25.4556    21.9472
Bryan-College Station, TX.........................    22.2836    21.2298
Buffalo-Niagara Falls, NY.........................    23.7287    22.1616
Burlington, VT....................................    23.9756    23.1273
Caguas, PR........................................    10.2735    10.3098
Canton-Massillon, OH..............................    22.4122    21.0501
Casper, WY........................................    22.4716    22.0976
Cedar Rapids, IA..................................    21.9242    20.8155
Champaign-Urbana, IL..............................    24.4767    23.3108
Charleston-North Charleston, SC...................    23.0562    21.6706
Charleston, WV....................................    21.9412    21.1056
Charlotte-Gastonia-Rock Hill, NC-SC...............    24.0412    22.5876
Charlottesville, VA...............................    24.7694    24.2141
Chattanooga, TN-GA................................    22.4487    21.4283
Cheyenne, WY......................................    21.7314    20.1695
Chicago, IL.......................................    26.9106    25.7471
Chico-Paradise, CA................................    25.1840    23.2716
Cincinnati, OH-KY-IN..............................    23.2565    22.0537
Clarksville-Hopkinsville, TN-KY...................    20.3697    19.5203
Cleveland-Lorain-Elyria, OH.......................    23.8949    22.4359
Colorado Springs, CO..............................    24.2952    23.0525
Columbia, MO......................................    21.4825    20.1775
Columbia, SC......................................    21.9947    21.6170
Columbus, GA-AL...................................    21.4813    19.9213
Columbus, OH......................................    23.8368    22.6103
Corpus Christi, TX................................    21.0529    20.0005
Corvallis, OR.....................................    28.4536    27.0598
Cumberland, MD-WV.................................    20.2591    18.9863
Dallas, TX........................................    24.6430    23.3642
Danville, VA......................................    22.3229    20.7337
Davenport-Moline-Rock Island, IA-IL...............    22.2001    20.6175
Dayton-Springfield, OH............................    23.5163    21.8747
Daytona Beach, FL.................................    22.3855    21.1832
Decatur, AL.......................................    21.8128    20.7814
Decatur, IL.......................................    20.1642    18.9150
Denver, CO........................................    26.7753    24.8304
Des Moines, IA....................................    22.4988    20.7693
Detroit, MI.......................................    24.9570    24.1824
Dothan, AL........................................    19.1266    18.5999

[[Page 45567]]

 
Dover, DE.........................................    24.2251    22.9785
Dubuque, IA.......................................    21.9559    20.4460
Duluth-Superior, MN-WI............................    25.1306    24.0503
Dutchess County, NY...............................    27.0153    25.1274
Eau Claire, WI....................................    22.3936    21.0371
El Paso, TX.......................................    22.7218    21.6306
Elkhart-Goshen, IN................................    24.1721    22.8091
Elmira, NY........................................    20.6973    19.6769
Enid, OK..........................................    21.1469    19.7375
Erie, PA..........................................    21.2504    20.4729
Eugene-Springfield, OR............................    28.3045    26.4658
Evansville, Henderson, IN-KY......................    20.8266    19.5719
Fargo-Moorhead, ND-MN.............................    24.2066    22.2472
Fayetteville, NC..................................    22.2028    21.0390
Fayetteville-Springdale-Rogers, AR................    20.7450    19.4920
Flagstaff, AZ-UT..................................    28.0003    25.5509
Flint, MI.........................................    26.8272    25.6484
Florence, AL......................................    19.1407    18.2496
Florence, SC......................................    21.5166    20.4519
Fort Collins-Loveland, CO.........................    24.9739    23.6020
Fort Lauderdale, FL...............................    25.1107    24.0387
Fort Myers-Cape Coral, FL.........................    24.2518    22.5750
Fort Pierce-Port St. Lucie, FL....................    24.7279    23.4505
Fort Smith, AR-OK.................................    20.8140    18.9811
Fort Walton Beach, FL.............................    22.1527    21.6155
Fort Wayne, IN....................................    23.6812    22.0804
Fort Worth-Arlington, TX..........................    23.1224    22.0190
Fresno, CA........................................    25.0577    23.7002
Gadsden, AL.......................................    20.2758    19.8948
Gainesville, FL...................................    23.9479    22.6475
Galveston-Texas City, TX..........................    22.9264    22.5715
Gary, IN..........................................    23.2496    22.2496
Glens Falls, NY...................................    20.9392    19.5463
Goldsboro, NC.....................................    21.3024    20.4707
Grand Forks, ND-MN................................    21.3373    20.7295
Grand Junction, CO................................    23.8003    22.4013
Grand Rapids-Muskegon-Holland, MI.................    23.3944    22.6455
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...........    22.6468    21.8467
Greenville, NC....................................    22.4777    21.4396
Greenville-Spartanburg-Anderson, SC...............    23.0642    21.6183
Hagerstown, MD....................................    22.6614    20.9120
Hamilton-Middletown, OH...........................    22.7644    21.8133
Harrisburg-Lebanon-Carlisle, PA...................    22.6413    21.7012
Hartford, CT......................................    28.5484    26.9960
Hattiesburg, MS...................................    18.0540    17.5271
Hickory-Morganton-Lenoir, NC......................    22.8342    21.5753
Honolulu, HI......................................    27.4202    26.5871
Houma, LA.........................................    19.2012    18.8317
Houston, TX.......................................    24.2970    22.9364
Huntington-Ashland, WV-KY-OH......................    23.7059    22.5222
Huntsville, AL....................................    22.8430    21.1034
Indianapolis, IN..................................    24.4986    22.9037
Iowa City, IA.....................................    23.5910    22.6224
Jackson, MI.......................................    22.2026    21.6786
Jackson, MS.......................................    20.6489    19.8519
Jackson, TN.......................................    22.1981    21.3037
Jacksonville, FL..................................    23.5433    21.9817
Jacksonville, NC..................................    21.1107    19.0690
Jamestown, NY.....................................    19.1768    18.5426
Janesville-Beloit, WI.............................    22.9321    22.5285
Jersey City, NJ...................................    27.4614    26.1004
Johnson City-Kingsport-Bristol, TN-VA.............    20.3906    19.6130
Johnstown, PA.....................................    20.1558    19.6398
Jonesboro, AR.....................................    19.2565    18.7034
Joplin, MO........................................    21.4481    20.3222
Kalamazoo-Battlecreek, MI.........................    25.9432    24.7762
Kankakee, IL......................................    25.7423    24.2639
Kansas City, KS-MO................................    24.0023    22.6223
Kenosha, WI.......................................    24.1159    22.6827
Killeen-Temple, TX................................    22.6286    22.0631
Knoxville, TN.....................................    21.7911    20.8323
Kokomo, IN........................................    22.3466    21.1444
La Crosse, WI-MN..................................    22.8473    21.8008
Lafayette, LA.....................................    20.2761    19.6888
Lafayette, IN.....................................    21.2081    21.0348
Lake Charles, LA..................................    19.3730    18.3946
Lakeland-Winter Haven, FL.........................    21.7693    21.2439
Lancaster, PA.....................................    22.9333    21.5961
Lansing-East Lansing, MI..........................    24.0008    22.7120
Laredo, TX........................................    19.9917    19.1033
Las Cruces, NM....................................    21.4650    20.3556
Las Vegas, NV-AZ..................................    28.4828    26.7950
\1\ Lawrence, KS..................................  .........  .........
Lawton, OK........................................    20.4263    19.7110
Lewiston-Auburn, ME...............................    23.1828    21.7433
Lexington, KY.....................................    21.4595    20.3189
Lima, OH..........................................    23.5255    22.2651
Lincoln, NE.......................................    24.7884    23.5189
Little Rock-North Little Rock, AR.................    22.0469    21.0421
Longview-Marshall, TX.............................    22.5155    20.5262
Los Angeles-Long Beach, CA........................    29.1430    27.8976
Louisville, KY-IN.................................    22.8350    21.8979
Lubbock, TX.......................................    20.4375    20.4762
Lynchburg, VA.....................................    22.5683    21.4474
Macon, GA.........................................    22.1194    21.1586
Madison, WI.......................................    25.3588    24.2523
Mansfield, OH.....................................    20.3677    20.0909
Mayaguez, PR......................................    11.8482    11.3512
McAllen-Edinburg-Mission, TX......................    20.7063    19.5970
Medford-Ashland, OR...............................    26.6156    24.7374
Melbourne-Titusville-Palm Bay, FL.................    24.1528    23.3952
Memphis, TN-AR-MS.................................    22.2594    21.0284
Merced, CA........................................    23.9460    22.9922
Miami, FL.........................................    24.4448    23.1253
Middlesex-Somerset-Hunterdon, NJ..................    28.0828    26.5600
Milwaukee-Waukesha, WI............................    24.6768    23.3099
Minneapolis-St. Paul, MN-WI.......................    27.1814    25.6666
Missoula, MT......................................    21.5392    21.2648
Mobile, AL........................................    19.7516    18.8646
Modesto, CA.......................................    27.8581    25.5375
Monmouth-Ocean, NJ................................    27.0700    25.3662
Monroe, LA........................................    19.5724    18.9404
Montgomery, AL....................................    19.5356    17.8815
Muncie, IN........................................    21.6806    21.8078
Myrtle Beach, SC..................................    22.5122    21.0737
Naples, FL........................................    24.1885    22.8575
Nashville, TN.....................................    24.3495    22.8046
Nassau-Suffolk, NY................................    32.0836    31.2325
New Haven-Bridgeport-Stamford-Waterbury-Danbury,      30.6008    28.8874
 CT...............................................
New London-Norwich, CT............................    28.7359    27.3016
New Orleans, LA...................................    22.6662    21.2642
New York, NY......................................    34.5159    33.4648
Newark, NJ........................................    28.4574    26.9201
Newburgh, NY-PA...................................    28.4349    26.5830
Norfolk-Virginia Beach-Newport News, VA-NC........    21.2953    20.1214
Oakland, CA.......................................    36.8654    35.3917
Ocala, FL.........................................    24.0353    22.3921
Odessa-Midland, TX................................    23.0451    22.4675
Oklahoma City, OK.................................    22.1973    20.7818
Olympia, WA.......................................    27.0877    25.9904
Omaha, NE-IA......................................    24.0761    22.9780
Orange County, CA.................................    28.0961    26.5056
Orlando, FL.......................................    23.8528    22.6357
Owensboro, KY.....................................    20.6888    19.5760
Panama City, FL...................................    20.2643    20.3561
Parkersburg-Marietta, WV-OH.......................    19.8623    19.0009
Pensacola, FL.....................................    21.6272    20.1029
Peoria-Pekin, IL..................................    21.5796    20.4881
Philadelphia, PA-NJ...............................    26.8898    25.3667
Phoenix-Mesa, AZ..................................    25.0252    23.1478
Pine Bluff, AR....................................    19.4324    18.4911
Pittsburgh, PA....................................    21.9917    21.6912
Pittsfield, MA....................................    25.3885    23.9758
Pocatello, ID.....................................    22.3412    21.7279
Ponce, PR.........................................    11.6330    11.7569
Portland, ME......................................    24.5806    22.8110
Portland-Vancouver, OR-WA.........................    27.7033    25.8270
Providence-Warwick, RI............................    27.1208    25.4419

[[Page 45568]]

 
Provo-Orem, UT....................................    24.6487    23.2777
Pueblo, CO........................................    21.6891    20.4756
Punta Gorda, FL...................................    23.4973    21.6974
Racine, WI........................................    21.7768    21.4720
Raleigh-Durham-Chapel Hill, NC....................    24.6061    23.2373
Rapid City, SD....................................    21.7579    20.7364
Reading, PA.......................................    22.5640    21.8521
Redding, CA.......................................    28.0470    26.2716
Reno, NV..........................................    26.3924    24.8500
Richland-Kennewick-Pasco, WA......................    26.2126    25.7613
Richmond-Petersburg, VA...........................    23.0989    22.2365
Riverside-San Bernardino, CA......................    28.0369    26.3968
Roanoke, VA.......................................    21.4945    20.0801
Rochester, MN.....................................    29.0034    27.6344
Rochester, NY.....................................    23.2999    21.7673
Rockford, IL......................................    23.8812    22.2379
Rocky Mount, NC...................................    22.4234    21.4021
Sacramento, CA....................................    29.2650    27.4594
Saginaw-Bay City-Midland, MI......................    24.7875    22.8302
St. Cloud, MN.....................................    23.4868    22.6816
\1\ St. Joseph, MO................................  .........  .........
St. Louis, MO-IL..................................    22.3172    20.9395
Salem, OR.........................................    25.8986    24.0695
Salinas, CA.......................................    35.4282    34.0968
Salt Lake City-Ogden, UT..........................    24.4924    23.2233
San Angelo, TX....................................    21.0874    19.7140
San Antonio, TX...................................    21.9156    20.4598
San Diego, CA.....................................    27.5405    26.1970
San Francisco, CA.................................    35.8606    33.3285
San Jose, CA......................................    36.1362    33.5095
San Juan-Bayamon, PR..............................    12.1065    11.2275
San Luis Obispo-Atascadero-Paso Robles, CA........    28.2381    26.3416
Santa Barbara-Santa Maria-Lompoc, CA..............    25.7977    24.7645
Santa Cruz-Watsonville, CA........................    31.9761    31.6254
Santa Fe, NM......................................    26.3197    24.7347
Santa Rosa, CA....................................    31.8165    30.4128
Sarasota-Bradenton, FL............................    24.6181    23.0141
Savannah, GA......................................    23.4019    22.5251
Scranton-Wilkes Barre-Hazleton, PA................    20.7846    20.0327
Seattle-Bellevue-Everett, WA......................    28.5675    26.8843
Sharon, PA........................................    19.1498    18.3866
Sheboygan, WI.....................................    21.3074    20.1274
Sherman-Denison, TX...............................    23.9656    22.2184
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.......................................    26.9328    25.3371
Springfield, IL...................................    22.0988    20.5053
Springfield, MO...................................    20.8945    19.9103
Springfield, MA...................................    25.8461    25.1765
State College, PA.................................    21.5944    20.9171
Steubenville-Weirton, OH-WV.......................    20.7491    20.1726
Stockton-Lodi, CA.................................    25.7060    24.7659
Sumter, SC........................................    20.3664    19.0084
Syracuse, NY......................................    23.2541    22.4437
Tacoma, WA........................................    27.4633    26.2816
Tallahassee, FL...................................    21.0498    19.9557
Tampa-St. Petersburg-Clearwater, FL...............    22.4909    21.1327
Terre Haute, IN...................................    20.5698    19.8370
Texarkana, AR-Texarkana, TX.......................    20.1353    19.1483
Toledo, OH........................................    23.1784    22.6054
Topeka, KS........................................    22.5038    21.2556
Trenton, NJ.......................................    25.9846    24.5060
Tucson, AZ........................................    22.1900    20.9404
Tulsa, OK.........................................    22.6934    20.5926
Tuscaloosa, AL....................................    20.2900    19.1399
Tyler, TX.........................................    23.2339    22.2980
Utica-Rome, NY....................................    20.7625    19.6938
Vallejo-Fairfield-Napa, CA........................    33.0511    31.4566
Ventura, CA.......................................    27.3366    25.8578
Victoria, TX......................................    20.2203    19.7139
Vineland-Millville-Bridgeton, NJ..................    25.7088    24.0750
Visalia-Tulare-Porterville, CA....................    24.3519    22.5730
Waco, TX..........................................    20.7383    19.2135
Washington, DC-MD-VA-WV...........................    26.9401    25.5595
Waterloo-Cedar Falls, IA..........................    20.6706    19.0431
Wausau, WI........................................    23.9474    22.8336
West Palm Beach-Boca Raton, FL....................    24.2086    23.0506
Wheeling, OH-WV...................................    18.5167    18.0478
Wichita, KS.......................................    22.8238    22.1166
Wichita Falls, TX.................................    20.6081    19.2867
Williamsport, PA..................................    20.1552    19.7395
Wilmington-Newark, DE-MD..........................    26.8874    25.7166
Wilmington, NC....................................    23.6270    22.3947
Yakima, WA........................................    25.6274    24.6154
Yolo, CA..........................................    22.7407    22.1146
York, PA..........................................    22.5293    21.5429
Youngstown-Warren, OH.............................    22.7645    21.9498
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 (P.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...........................................    18.5095    17.5501
Alaska............................................    29.3667    28.1193
Arizona...........................................    22.9036    20.6368
Arkansas..........................................    19.1097    17.8462
California........................................    24.6268    22.9807
Colorado..........................................    23.0480    21.2325
Connecticut.......................................    30.1004    28.6608
Delaware..........................................    23.6122    22.0986
Florida...........................................    21.8790    20.6381
Georgia...........................................    21.2360    19.6529
Hawaii............................................    24.6034    24.3938
Idaho.............................................    22.1711    20.5606
Illinois..........................................    20.3932    19.0845
Indiana...........................................    21.8020    20.4901
Iowa..............................................    20.7936    19.3045
Kansas............................................    19.9482    18.5189
Kentucky..........................................    19.6987    18.7214
Louisiana.........................................    18.4100    17.6401
Maine.............................................    21.7717    20.5721
Maryland..........................................    22.5448    21.0794
Massachusetts.....................................    25.7740    25.8569
Michigan..........................................    21.9324    20.9463
Minnesota.........................................    23.0526    21.4147
Mississippi.......................................    19.2177    17.9189
Missouri..........................................    19.9049    18.6897
Montana...........................................    21.7432    20.0906
Nebraska..........................................    21.7975    19.3637
Nevada............................................    24.2285    22.6578
New Hampshire.....................................    24.7802    23.0565
New Jersey\1\.....................................  .........  .........
New Mexico........................................    20.4327    20.1351
New York..........................................    21.0650    19.9857
North Carolina....................................    20.8923    20.0240
North Dakota......................................    19.2168    18.1538
Ohio..............................................    21.7920    20.3411
Oklahoma..........................................    18.6216    17.6885
Oregon............................................    24.6914    23.6590
Pennsylvania......................................    20.6996    19.8537
Puerto Rico.......................................     9.9286    10.2348
Rhode Island\1\...................................  .........  .........
South Carolina....................................    20.9969    20.0185
South Dakota......................................    20.2488    18.5076
Tennessee.........................................    19.4835    18.4938
Texas.............................................    19.2213    18.1708
Utah..............................................    22.1713    21.3599
Vermont...........................................    22.9948    21.9226
Virginia..........................................    20.9960    19.7068
Washington........................................    25.6670    23.9261
West Virginia.....................................    19.8114    18.7534
Wisconsin.........................................    22.9879    21.4434
Wyoming...........................................    22.5088   20.9256
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban.


Table 4A.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
                               Urban Areas
------------------------------------------------------------------------
                                                        Wage
         Urban area  (constituent counties)             index      GAF
------------------------------------------------------------------------
0040 \2\ Abilene, TX................................    0.7748    0.8397
  Taylor, TX

[[Page 45569]]

 
0060 Aguadilla, PR..................................    0.4289    0.5601
  Aguada, PR
  Aguadilla, PR
  Moca, PR
0080 Akron, OH......................................    0.9443    0.9615
  Portage, OH
  Summit, OH
0120 Albany, GA.....................................    1.0819    1.0554
  Dougherty, GA
  Lee, GA
0160 \2\ Albany-Schenectady-Troy, NY................    0.8491    0.8940
  Albany, NY
  Montgomery, NY
  Rensselaer, NY
  Saratoga, NY
  Schenectady, NY
  Schoharie, NY
0200 Albuquerque, NM................................    0.9263    0.9489
  Bernalillo, NM
  Sandoval, NM
  Valencia, NM
0220 Alexandria, LA.................................    0.8004    0.8586
  Rapides, LA
0240 Allentown-Bethlehem-Easton, PA.................    0.9682    0.9781
  Carbon, PA
  Lehigh, PA
  Northampton, PA
0280 Altoona, PA....................................    0.8792    0.9156
  Blair, PA
0320 Amarillo, TX...................................    0.8950    0.9268
  Potter, TX
  Randall, TX
0380 Anchorage, AK..................................    1.2301    1.1524
  Anchorage, AK
0440 Ann Arbor, MI..................................    1.1029    1.0694
  Lenawee, MI
  Livingston, MI
  Washtenaw, MI
0450 Anniston, AL...................................    0.8058    0.8626
  Calhoun, AL
0460 \2\ Appleton-Oshkosh-Neenah, WI................    0.9266    0.9491
  Calumet, WI
  Outagamie, WI
  Winnebago, WI
0470 Arecibo, PR....................................    0.4138    0.5465
  Arecibo, PR
  Camuy, PR
  Hatillo, PR
0480 Asheville, NC..................................    0.9680    0.9780
  Buncombe, NC
  Madison, NC
0500 Athens, GA.....................................    0.9778    0.9847
  Clarke, GA
  Madison, GA
  Oconee, GA
0520 \1\ Atlanta, GA................................    1.0089    1.0061
  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..........................    1.0751    1.0508
  Atlantic, NJ
  Cape May, NJ
0580 Auburn-Opelika, AL.............................    0.8460    0.8918
  Lee, AL
0600 Augusta-Aiken, GA-SC...........................    0.9587    0.9715
  Columbia, GA
  McDuffie, GA
  Richmond, GA
  Aiken, SC
  Edgefield, SC
0640 \1\ Austin-San Marcos, TX......................    0.9570    0.9704
  Bastrop, TX
  Caldwell, TX
  Hays, TX
  Travis, TX
  Williamson, TX
0680 \2\ Bakersfield, CA............................    0.9927    0.9950
  Kern, CA
0720 \1\ Baltimore, MD..............................    0.9879    0.9917
  Anne Arundel, MD
  Baltimore, MD
  Baltimore City, MD
  Carroll, MD
  Harford, MD
  Howard, MD
  Queen Anne's, MD
0733 Bangor, ME.....................................    0.9864    0.9907
  Penobscot, ME
0743 Barnstable-Yarmouth, MA........................    1.2904    1.1908
  Barnstable, MA
0760 Baton Rouge, LA................................    0.8372    0.8854
  Ascension, LA
  East Baton Rouge, LA
  Livingston, LA
  West Baton Rouge, LA
0840 Beaumont-Port Arthur, TX.......................    0.8390    0.8867
  Hardin, TX
  Jefferson, TX
  Orange, TX
0860 Bellingham, WA.................................    1.1710    1.1142
  Whatcom, WA
0870 Benton Harbor, MI..............................    0.8899    0.9232
  Berrien, MI
0875 \1\ Bergen-Passaic, NJ.........................    1.1683    1.1124
  Bergen, NJ
  Passaic, NJ
0880 Billings, MT...................................    0.8925    0.9251
  Yellowstone, MT
0920 Biloxi-Gulfport-Pascagoula, MS.................    0.8993    0.9299
  Hancock, MS
  Harrison, MS
  Jackson, MS
0960 \2\ Binghamton, NY.............................    0.8491    0.8940
  Broome, NY
  Tioga, NY
1000 Birmingham, AL.................................    0.9175    0.9427
  Blount, AL
  Jefferson, AL
  St. Clair, AL
  Shelby, AL
1010 Bismarck, ND...................................    0.8001    0.8584
  Burleigh, ND
  Morton, ND
1020 \2\ Bloomington, IN............................    0.8788    0.9153
  Monroe, IN
1040 Bloomington-Normal, IL.........................    0.8796    0.9159
  McLean, IL
1080 Boise City, ID.................................    0.9195    0.9441
  Ada, ID
  Canyon, ID
1123 \1\ Boston-Worcester-Lawrence-Lowell-Brockton,     1.1188    1.0799
 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...........................    1.0008    1.0005
  Boulder, CO
1145 Brazoria, TX...................................    0.8105    0.8660
  Brazoria, TX
1150 Bremerton, WA..................................    1.0537    1.0365
  Kitsap, WA
1240 Brownsville-Harlingen-San Benito, TX...........    1.0261    1.0178
  Cameron, TX
1260 Bryan-College Station, TX......................    0.8983    0.9292
  Brazos, TX
1280 \1\ Buffalo-Niagara Falls, NY..................    0.9565    0.9700
  Erie, NY
  Niagara, NY
1303 Burlington, VT.................................    0.9665    0.9769
  Chittenden, VT
  Franklin, VT
  Grand Isle, VT
1310 Caguas, PR.....................................    0.4184    0.5506

[[Page 45570]]

 
  Caguas, PR
  Cayey, PR
  Cidra, PR
  Gurabo, PR
  San Lorenzo, PR
1320 Canton-Massillon, OH...........................    0.9034    0.9328
  Carroll, OH
  Stark, OH
1350 Casper, WY.....................................    0.9171    0.9425
  Natrona, WY
1360 Cedar Rapids, IA...............................    0.8838    0.9189
  Linn, IA
1400 Champaign-Urbana, IL...........................    0.9867    0.9909
  Champaign, IL
1440 Charleston-North Charleston, SC................    0.9294    0.9511
  Berkeley, SC
  Charleston, SC
  Dorchester, SC
1480 Charleston, WV.................................    0.8845    0.9194
  Kanawha, WV
  Putnam, WV
1520 \1\ Charlotte-Gastonia-Rock Hill, NC-SC........    0.9691    0.9787
  Cabarrus, NC
  Gaston, NC
  Lincoln, NC
  Mecklenburg, NC
  Rowan, NC
  Stanly, NC
  Union, NC
  York, SC
1540 Charlottesville, VA............................    0.9985    0.9990
  Albemarle, VA
  Charlottesville City, VA
  Fluvanna, VA
  Greene, VA
1560 Chattanooga, TN-GA.............................    0.9049    0.9339
  Catoosa, GA
  Dade, GA
  Walker, GA
  Hamilton, TN
  Marion, TN
1580 \2\ Cheyenne, WY...............................    0.9073    0.9356
  Laramie, WY
1600 \1\ Chicago, IL................................    1.0848    1.0573
  Cook, IL
  DeKalb, IL
  DuPage, IL
  Grundy, IL
  Kane, IL
  Kendall, IL
  Lake, IL
  McHenry, IL
  Will, IL
1620 Chico-Paradise, CA.............................    1.0152    1.0104
  Butte, CA
1640 \1\ Cincinnati, OH-KY-IN.......................    0.9380    0.9571
  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................    0.8320    0.8817
  Christian, KY
  Montgomery, TN
1680 \1\ Cleveland-Lorain-Elyria, OH................    0.9632    0.9747
  Ashtabula, OH
  Cuyahoga, OH
  Geauga, OH
  Lake, OH
  Lorain, OH
  Medina, OH
1720 Colorado Springs, CO...........................    0.9793    0.9858
  El Paso, CO
1740 Columbia, MO...................................    0.8660    0.9062
  Boone, MO
1760 Columbia, SC...................................    0.8866    0.9209
  Lexington, SC
  Richland, SC
1800 Columbus, GA-AL................................    0.8659    0.9061
  Russell, AL
  Chattahoochee, GA
  Harris, GA
  Muscogee, GA
1840 \1\ Columbus, OH...............................    0.9609    0.9731
  Delaware, OH
  Fairfield, OH
  Franklin, OH
  Licking, OH
  Madison, OH
  Pickaway, OH
1880 Corpus Christi, TX.............................    0.8486    0.8937
  Nueces, TX
  San Patricio, TX
1890 Corvallis, OR..................................    1.1470    1.0985
  Benton, OR
1900 \2\ Cumberland, MD-WV (MD Hospitals)...........    0.9088    0.9366
  Allegany, MD
  Mineral, WV
1900 Cumberland, MD-WV (WV Hospitals)...............    0.8166    0.8705
  Allegany, MD
  Mineral, WV
1920 \1\ Dallas, TX.................................    0.9934    0.9955
  Collin, TX
  Dallas, TX
  Denton, TX
  Ellis, TX
  Henderson, TX
  Hunt, TX
  Kaufman, TX
  Rockwall, TX
1950 Danville, VA...................................    0.8998    0.9302
  Danville City, VA
  Pittsylvania, VA
1960 Davenport-Moline-Rock Island, IA-IL............    0.8949    0.9268
  Scott, IA
  Henry, IL
  Rock Island, IL
2000 Dayton-Springfield, OH.........................    0.9490    0.9648
  Clark, OH
  Greene, OH
  Miami, OH
  Montgomery, OH
2020 Daytona Beach, FL..............................    0.9024    0.9321
  Flagler, FL
  Volusia, FL
2030 Decatur, AL....................................    0.8793    0.9157
  Lawrence, AL
  Morgan, AL
2040 \2\ Decatur, IL................................    0.8221    0.8745
  Macon, IL
2080 \1\ Denver, CO.................................    1.0793    1.0536
  Adams, CO
  Arapahoe, CO
  Broomfield, CO
  Denver, CO
  Douglas, CO
  Jefferson, CO
2120 Des Moines, IA.................................    0.9069    0.9353
  Dallas, IA
  Polk, IA
  Warren, IA
2160 \1\ Detroit, MI................................    1.0060    1.0041
  Lapeer, MI
  Macomb, MI
  Monroe, MI
  Oakland, MI
  St. Clair, MI
  Wayne, MI
2180 Dothan, AL.....................................    0.7734    0.8386
  Dale, AL
  Houston, AL
2190 Dover, DE......................................    0.9765    0.9838
  Kent, DE
2200 Dubuque, IA....................................    0.8850    0.9197
  Dubuque, IA
2240 Duluth-Superior, MN-WI.........................    1.0130    1.0089
  St. Louis, MN
  Douglas, WI
2281 Dutchess County, NY............................    1.0890    1.0601
  Dutchess, NY
2290 \2\ Eau Claire, WI.............................    0.9266    0.9491
  Chippewa, WI
  Eau Claire, WI
2320 El Paso, TX....................................    0.9159    0.9416
  El Paso, TX
2330 Elkhart-Goshen, IN.............................    0.9744    0.9824
  Elkhart, IN
2335 \2\ Elmira, NY.................................    0.8491    0.8940
  Chemung, NY

[[Page 45571]]

 
2340 Enid, OK.......................................    0.8524    0.8964
  Garfield, OK
2360 Erie, PA.......................................    0.8566    0.8994
  Erie, PA
2400 Eugene-Springfield, OR.........................    1.1410    1.0945
  Lane, OR
2440 \2\ Evansville-Henderson, IN-KY (IN Hospitals).    0.8788    0.9153
  Posey, IN
  Vanderburgh, IN
  Warrick, IN
  Henderson, KY
2440 Evansville-Henderson, IN-KY (KY Hospitals).....    0.8395    0.8871
  Posey, IN
  Vanderburgh, IN
  Warrick, IN
  Henderson, KY
2520 Fargo-Moorhead, ND-MN..........................    0.9758    0.9834
  Clay, MN
  Cass, ND
2560 Fayetteville, NC...............................    0.8950    0.9268
  Cumberland, NC
2580 Fayetteville-Springdale-Rogers, AR.............    0.8362    0.8847
  Benton, AR
  Washington, AR
2620 Flagstaff, AZ-UT...............................    1.1287    1.0864
  Coconino, AZ
  Kane, UT
2640 Flint, MI......................................    1.0814    1.0551
  Genesee, MI
2650 Florence, AL...................................    0.7766    0.8410
  Colbert, AL
  Lauderdale, AL
2655 Florence, SC...................................    0.8673    0.9071
  Florence, SC
2670 Fort Collins-Loveland, CO......................    1.0096    1.0066
  Larimer, CO
2680 \1\ Ft. Lauderdale, FL.........................    1.0436    1.0297
  Broward, FL
2700 Fort Myers-Cape Coral, FL......................    0.9776    0.9846
  Lee, FL
2710 Fort Pierce-Port St. Lucie, FL.................    1.0083    1.0057
  Martin, FL
  St. Lucie, FL
2720 Fort Smith, AR-OK..............................    0.8390    0.8867
  Crawford, AR
  Sebastian, AR
  Sequoyah, OK
2750 Fort Walton Beach, FL..........................    0.8930    0.9254
  Okaloosa, FL
2760 Fort Wayne, IN.................................    0.9546    0.9687
  Adams, IN
  Allen, IN
  De Kalb, IN
  Huntington, IN
  Wells, IN
  Whitley, IN
2800 \1\ Forth Worth-Arlington, TX..................    0.9321    0.9530
  Hood, TX
  Johnson, TX
  Parker, TX
  Tarrant, TX
2840 Fresno, CA.....................................    1.0101    1.0069
  Fresno, CA
  Madera, CA
2880 Gadsden, AL....................................    0.8195    0.8726
  Etowah, AL
2900 Gainesville, FL................................    0.9653    0.9761
  Alachua, FL
2920 Galveston-Texas City, TX.......................    0.9242    0.9475
  Galveston, TX
2960 Gary, IN.......................................    0.9372    0.9566
  Lake, IN
  Porter, IN
2975 \2\ Glens Falls, NY............................    0.8491    0.8940
  Warren, NY
  Washington, NY
2980 Goldsboro, NC..................................    0.8587    0.9009
  Wayne, NC
2985 Grand Forks, ND-MN (ND Hospitals)..............    0.8601    0.9019
  Polk, MN
  Grand Forks, ND
2985 \2\ Grand Forks, ND-MN (MN Hospitals)..........    0.9307    0.9520
  Polk, MN
  Grand Forks, ND
2995 Grand Junction, CO.............................    0.9881    0.9918
  Mesa, CO
3000 \1\ Grand Rapids-Muskegon-Holland, MI..........    0.9430    0.9606
  Allegan, MI
  Kent, MI
  Muskegon, MI
  Ottawa, MI
3040 Great Falls, MT................................    0.8882    0.9220
  Cascade, MT
3060 Greeley, CO....................................    0.9415    0.9596
  Weld, CO
3080 Green Bay, WI..................................    0.9479    0.9640
  Brown, WI
3120 \1\ Greensboro-Winston-Salem-High Point, NC....    0.9129    0.9395
  Alamance, NC
  Davidson, NC
  Davie, NC
  Forsyth, NC
  Guilford, NC
  Randolph, NC
  Stokes, NC
  Yadkin, NC
3150 Greenville, NC.................................    0.9129    0.9395
  Pitt, NC
3160 Greenville-Spartanburg-Anderson, SC............    0.9297    0.9513
  Anderson, SC
  Cherokee, SC
  Greenville, SC
  Pickens, SC
  Spartanburg, SC
3180 Hagerstown, MD.................................    0.9135    0.9399
  Washington, MD
3200 Hamilton-Middletown, OH........................    0.9176    0.9428
  Butler, OH
3240 Harrisburg-Lebanon-Carlisle, PA................    0.9127    0.9394
  Cumberland, PA
  Dauphin, PA
  Lebanon, PA
  Perry, PA
3283 1, 2 Hartford, CT..............................    1.2134    1.1416
  Hartford, CT
  Litchfield, CT
  Middlesex, CT
  Tolland, CT
3285 \2\ Hattiesburg, MS............................    0.7762    0.8407
  Forrest, MS
  Lamar, MS
3290 Hickory-Morganton-Lenoir, NC...................    0.9205    0.9449
  Alexander, NC
  Burke, NC
  Caldwell, NC
  Catawba, NC
3320 Honolulu, HI...................................    1.1071    1.0722
  Honolulu, HI
3350 Houma, LA......................................    0.7740    0.8391
  Lafourche, LA
  Terrebonne, LA
3360 \1\ Houston, TX................................    0.9794    0.9858
  Chambers, TX
  Fort Bend, TX
  Harris, TX
  Liberty, TX
  Montgomery, TX
  Waller, TX
3400 Huntington-Ashland, WV-KY-OH...................    0.9556    0.9694
  Boyd, KY
  Carter, KY
  Greenup, KY
  Lawrence, OH
  Cabell, WV
  Wayne, WV
3440 Huntsville, AL.................................    0.9208    0.9451
  Limestone, AL
  Madison, AL
3480 \1\ Indianapolis, IN...........................    0.9875    0.9914
  Boone, IN
  Hamilton, IN
  Hancock, IN
  Hendricks, IN
  Johnson, IN
  Madison, IN
  Marion, IN
  Morgan, IN
  Shelby, IN

[[Page 45572]]

 
3500 Iowa City, IA..................................    0.9510    0.9662
  Johnson, IA
3520 Jackson, MI....................................    0.8950    0.9268
  Jackson, MI
3560 Jackson, MS....................................    0.8355    0.8842
  Hinds, MS
  Madison, MS
  Rankin, MS
3580 Jackson, TN....................................    0.8948    0.9267
  Madison, TN
  Chester, TN
3600 \1\ Jacksonville, FL...........................    0.9490    0.9648
  Clay, FL
  Duval, FL
  Nassau, FL
  St. Johns, FL
3605 Jacksonville, NC...............................    0.8510    0.8954
  Onslow, NC
3610 \2\ Jamestown, NY..............................    0.8491    0.8940
  Chautauqua, NY
3620 \2\ Janesville-Beloit, WI......................    0.9266    0.9491
  Rock, WI
3640 Jersey City, NJ................................    1.1070    1.0721
  Hudson, NJ
3660 Johnson City-Kingsport-Bristol, TN-VA (TN          0.8223    0.8746
 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      0.8464    0.8921
 Hospitals).........................................
  Carter, TN
  Hawkins, TN
  Sullivan, TN
  Unicoi, TN
  Washington, TN
  Bristol City, VA
  Scott, VA
  Washington, VA
3680 \2\ Johnstown, PA..............................    0.8344    0.8834
  Cambria, PA
  Somerset, PA
3700 Jonesboro, AR..................................    0.7777    0.8418
  Craighead, AR
3710 Joplin, MO.....................................    0.8646    0.9052
  Jasper, MO
  Newton, MO
3720 Kalamazoo-Battlecreek, MI......................    1.0458    1.0311
  Calhoun, MI
  Kalamazoo, MI
  Van Buren, MI
3740 Kankakee, IL...................................    1.0377    1.0257
  Kankakee, IL
3760 \1\ Kansas City, KS-MO.........................    0.9675    0.9776
  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....................................    0.9721    0.9808
  Kenosha, WI
3810 Killeen-Temple, TX.............................    0.9122    0.9390
  Bell, TX
  Coryell, TX
3840 Knoxville, TN..................................    0.8784    0.9150
  Anderson, TN
  Blount, TN
  Knox, TN
  Loudon, TN
  Sevier, TN
  Union, TN
3850 Kokomo, IN.....................................    0.9008    0.9310
  Howard, IN
  Tipton, IN
3870 \2\ La Crosse, WI-MN...........................    0.9266    0.9491
  Houston, MN
  La Crosse, WI
3880 Lafayette, LA..................................    0.8191    0.8723
  Acadia, LA
  Lafayette, LA
  St. Landry, LA
  St. Martin, LA
3920 \2\ Lafayette, IN..............................    0.8788    0.9153
  Clinton, IN
  Tippecanoe, IN
3960 Lake Charles, LA...............................    0.7809    0.8442
  Calcasieu, LA
3980 Lakeland-Winter Haven, FL......................    0.8823    0.9178
  Polk, FL
4000 Lancaster, PA..................................    0.9244    0.9476
  Lancaster, PA
4040 Lansing-East Lansing, MI.......................    0.9675    0.9776
  Clinton, MI
  Eaton, MI
  Ingham, MI
4080 Laredo, TX.....................................    0.8059    0.8626
  Webb, TX
4100 Las Cruces, NM.................................    0.8653    0.9057
  Dona Ana, NM
4120 \1\ Las Vegas, NV-AZ...........................    1.1481    1.0992
  Mohave, AZ
  Clark, NV
  Nye, NV
4150 \2\ Lawrence, KS...............................    0.8041    0.8613
  Douglas, KS
4200 Lawton, OK.....................................    0.8234    0.8754
  Comanche, OK
4243 Lewiston-Auburn, ME............................    0.9345    0.9547
  Androscoggin, ME
4280 Lexington, KY..................................    0.8650    0.9055
  Bourbon, KY
  Clark, KY
  Fayette, KY
  Jessamine, KY
  Madison, KY
  Scott, KY
  Woodford, KY
4320 Lima, OH.......................................    0.9483    0.9643
  Allen, OH
  Auglaize, OH
4360 Lincoln, NE....................................    0.9992    0.9995
  Lancaster, NE
4400 Little Rock-North Little Rock, AR..............    0.8887    0.9224
  Faulkner, AR
  Lonoke, AR
  Pulaski, AR
  Saline, AR
4420 Longview-Marshall, TX..........................    0.9076    0.9358
  Gregg, TX
  Harrison, TX
  Upshur, TX
4480 \1\ Los Angeles-Long Beach, CA.................    1.1790    1.1194
  Los Angeles, CA
4520 \1\ Louisville, KY-IN..........................    0.9205    0.9449
  Clark, IN
  Floyd, IN
  Harrison, IN
  Scott, IN
  Bullitt, KY
  Jefferson, KY
  Oldham, KY
4600 Lubbock, TX....................................    0.8238    0.8757
  Lubbock, TX
4640 Lynchburg, VA..................................    0.9097    0.9372
  Amherst, VA
  Bedford, VA
  Bedford City, VA
  Campbell, VA
  Lynchburg City, VA
4680 Macon, GA......................................    0.8939    0.9261
  Bibb, GA
  Houston, GA
  Jones, GA
  Peach, GA
  Twiggs, GA
4720 Madison, WI....................................    1.0222    1.0151
  Dane, WI
4800 \2\ Mansfield, OH..............................    0.8784    0.9150
  Crawford, OH
  Richland, OH
4840 Mayaguez, PR...................................    0.4776    0.6029
  Anasco, PR
  Cabo Rojo, PR
  Hormigueros, PR
  Mayaguez, PR
  Sabana Grande, PR
  San German, PR
4880 McAllen-Edinburg-Mission, TX...................    0.8347    0.8836
  Hidalgo, TX
4890 Medford-Ashland, OR............................    1.0729    1.0494
  Jackson, OR

[[Page 45573]]

 
4900 Melbourne-Titusville-Palm Bay, FL..............    0.9736    0.9818
  Brevard, Fl
4920 \1\ Memphis, TN-AR-MS..........................    0.8973    0.9285
  Crittenden, AR
  DeSoto, MS
  Fayette, TN
  Shelby, TN
  Tipton, TN
4940 \2\ Merced, CA.................................    0.9927    0.9950
  Merced, CA
5000 \1\ Miami, FL..................................    0.9854    0.9900
  Dade, FL
5015 \1\ Middlesex-Somerset-Hunterdon, NJ...........    1.1320    1.0886
  Hunterdon, NJ
  Middlesex, NJ
  Somerset, NJ
5080 \1\ Milwaukee-Waukesha, WI.....................    0.9947    0.9964
  Milwaukee, WI
  Ozaukee, WI
  Washington, WI
  Waukesha, WI
5120 \1\ Minneapolis-St. Paul, MN-WI................    1.0957    1.0646
  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...................................    0.8848    0.9196
  Missoula, MT
5160 Mobile, AL.....................................    0.7962    0.8555
  Baldwin, AL
  Mobile, AL
5170 Modesto, CA....................................    1.1230    1.0827
  Stanislaus, CA
5190 \1\ Monmouth-Ocean, NJ.........................    1.1038    1.0700
  Monmouth, NJ
  Ocean, NJ
5200 Monroe, LA.....................................    0.7890    0.8502
  Ouachita, LA
5240 Montgomery, AL.................................    0.7875    0.8491
  Autauga, AL
  Elmore, AL
  Montgomery, AL
5280 \2\ Muncie, IN.................................    0.8788    0.9153
  Delaware, IN
5330 Myrtle Beach, SC...............................    0.9075    0.9357
  Horry, SC
5345 Naples, FL.....................................    0.9750    0.9828
  Collier, FL
5360 \1\ Nashville, TN..............................    0.9815    0.9873
  Cheatham, TN
  Davidson, TN
  Dickson, TN
  Robertson, TN
  Rutherford TN
  Sumner, TN
  Williamson, TN
  Wilson, TN
5380 \1\ Nassau-Suffolk, NY.........................    1.2933    1.1926
  Nassau, NY
  Suffolk, NY
5483 \1\ New Haven-Bridgeport-Stamford-Waterbury-...    1.2418    1.1599
  Danbury, CT
  Fairfield, CT
  New Haven, CT
5523 \2\ New London-Norwich, CT.....................    1.2134    1.1416
  New London, CT
5560 \1\ New Orleans, LA............................    0.9137    0.9401
  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...............................    1.3913    1.2538
  Bronx, NY
  Kings, NY
  New York, NY
  Putnam, NY
  Queens, NY
  Richmond, NY
  Rockland, NY
  Westchester, NY
5640 \1\ Newark, NJ.................................    1.1471    1.0985
  Essex, NJ
  Morris, NJ
  Sussex, NJ
  Union, NJ
  Warren, NJ
5660 Newburgh, NY-PA................................    1.1462    1.0979
  Orange, NY
  Pike, PA
5720 \1\ Norfolk-Virginia Beach-Newport News, VA-NC.    0.8584    0.9007
  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................................    1.5058    1.3235
  Alameda, CA
  Contra Costa, CA
5790 Ocala, FL......................................    0.9689    0.9786
  Marion, FL
5800 Odessa-Midland, TX.............................    0.9290    0.9508
  Ector, TX
  Midland, TX
5880 \1\ Oklahoma City, OK..........................    0.8948    0.9267
  Canadian, OK
  Cleveland, OK
  Logan, OK
  McClain, OK
  Oklahoma, OK
  Pottawatomie, OK
5910 Olympia, WA....................................    1.0919    1.0621
  Thurston, WA
5920 Omaha, NE-IA...................................    0.9705    0.9797
  Pottawattamie, IA
  Cass, NE
  Douglas, NE
  Sarpy, NE
  Washington, NE
5945 \1\ Orange County, CA..........................    1.1445    1.0968
  Orange, CA
5960 \1\ Orlando, FL................................    0.9615    0.9735
  Lake, FL
  Orange, FL
  Osceola, FL
  Seminole, FL
5990 Owensboro, KY..................................    0.8340    0.8831
  Daviess, KY
6015 \2\ Panama City, FL............................    0.8819    0.9175
  Bay, FL
6020 Parkersburg-Marietta, WV-OH (WV Hospitals).....    0.8007    0.8588
  Washington, OH
  Wood, WV
6020 \2\ Parkersburg-Marietta, WV-OH (OH Hospitals).    0.8784    0.9150
  Washington, OH
  Wood, WV
6080 \2\ Pensacola, FL..............................    0.8819    0.9175
  Escambia, FL
  Santa Rosa, FL
6120 Peoria-Pekin, IL...............................    0.8699    0.9090
  Peoria, IL
  Tazewell, IL
  Woodford, IL
6160 \1\ Philadelphia, PA-NJ........................    1.0839    1.0567
  Burlington, NJ
  Camden, NJ
  Gloucester, NJ
  Salem, NJ

[[Page 45574]]

 
  Bucks, PA
  Chester, PA
  Delaware, PA
  Montgomery, PA
  Philadelphia, PA
6200 \1\ Phoenix-Mesa, AZ...........................    1.0088    1.0060
  Maricopa, AZ
  Pinal, AZ
6240 Pine Bluff, AR.................................    0.7855    0.8476
  Jefferson, AR
6280 \1\ Pittsburgh, PA.............................    0.8865    0.9208
  Allegheny, PA
  Beaver, PA
  Butler, PA
  Fayette, PA
  Washington, PA
  Westmoreland, PA
6323 \2\ Pittsfield, MA.............................    1.0390    1.0265
  Berkshire, MA
6340 Pocatello, ID..................................    0.9212    0.9453
  Bannock, ID
6360 Ponce, PR......................................    0.4689    0.5953
  Guayanilla, PR
  Juana Diaz, PR
  Penuelas, PR
  Ponce, PR
  Villalba, PR
  Yauco, PR
6403 Portland, ME...................................    0.9909    0.9938
  Cumberland, ME
  Sagadahoc, ME
  York, ME
6440 \1\ Portland-Vancouver, OR-WA..................    1.1167    1.0785
  Clackamas, OR
  Columbia, OR
  Multnomah, OR
  Washington, OR
  Yamhill, OR
  Clark, WA
6483 \1\ Providence-Warwick-Pawtucket, RI...........    1.0932    1.0629
  Bristol, RI
  Kent, RI
  Newport, RI
  Providence, RI
  Washington, RI
6520 Provo-Orem, UT.................................    0.9936    0.9956
  Utah, UT
6560 \2\ Pueblo, CO.................................    0.9291    0.9509
  Pueblo, CO
6580 Punta Gorda, FL................................    0.9472    0.9635
  Charlotte, FL
66004\2\ Racine, WI.................................    0.9266    0.9491
  Racine, WI
6640 \1\ Raleigh-Durham-Chapel Hill, NC.............    0.9919    0.9944
  Chatham, NC
  Durham, NC
  Franklin, NC
  Johnston, NC
  Orange, NC
  Wake, NC
6660 Rapid City, SD.................................    0.8771    0.9141
  Pennington, SD
6680 Reading, PA....................................    0.9096    0.9372
  Berks, PA
6690 Redding, CA....................................    1.1306    1.0877
  Shasta, CA
6720 Reno, NV.......................................    1.0639    1.0433
  Washoe, NV
6740 Richland-Kennewick-Pasco, WA...................    1.0566    1.0384
  Benton, WA
  Franklin, WA
6760 Richmond-Petersburg, VA........................    0.9311    0.9523
  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...............    1.1302    1.0874
  Riverside, CA
  San Bernardino, CA
6800 Roanoke, VA....................................    0.8664    0.9065
  Botetourt, VA
  Roanoke, VA
  Roanoke City, VA
  Salem City, VA
6820 Rochester, MN..................................    1.1691    1.1129
  Olmsted, MN
6840 \1\ Rochester, NY..............................    0.9392    0.9580
  Genesee, NY
  Livingston, NY
  Monroe, NY
  Ontario, NY
  Orleans, NY
  Wayne, NY
6880 Rockford, IL...................................    0.9627    0.9743
  Boone, IL
  Ogle, IL
  Winnebago, IL
6895 Rocky Mount, NC................................    0.9039    0.9331
  Edgecombe, NC
  Nash, NC
6920 \1\ Sacramento, CA.............................    1.1797    1.1198
  El Dorado, CA
  Placer, CA
  Sacramento, CA
6960 Saginaw-Bay City-Midland, MI...................    0.9992    0.9995
  Bay, MI
  Midland, MI
  Saginaw, MI
6980 St. Cloud, MN..................................    0.9640    0.9752
  Benton, MN
  Stearns, MN
7000 \2\ St. Joseph, MO.............................    0.8024    0.8601
  Andrew, MO
  Buchanan, MO
7040 \1\ St. Louis, MO-IL...........................    0.8996    0.9301
  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......................................    1.0440    1.0299
  Marion, OR
  Polk, OR
7120 Salinas, CA....................................    1.4281    1.2764
  Monterey, CA
7160 \1\ Salt Lake City-Ogden, UT...................    0.9873    0.9913
  Davis, UT
  Salt Lake, UT
  Weber, UT
7200 San Angelo, TX.................................    0.8500    0.8947
  Tom Green, TX
7240 \1\ San Antonio, TX............................    0.8834    0.9186
  Bexar, TX
  Comal, TX
  Guadalupe, TX
  Wilson, TX
7320 \1\ San Diego, CA..............................    1.1102    1.0742
  San Diego, CA
7360 \1\ San Francisco, CA..........................    1.4455    1.2870
  Marin, CA
  San Francisco, CA
  San Mateo, CA
7400 \1\ San Jose, CA...............................    1.4567    1.2938
  Santa Clara, CA
7440 \1\ San Juan- Bayamon, PR......................    0.4880    0.6118
  Aguas Buenas, PR
  Barceloneta, PR
  Bayamon, PR
  Canovanas, PR
  Carolina, PR
  Catano, PR
  Ceiba, PR
  Comerio, PR
  Corozal, PR
  Dorado, PR
  Fajardo, PR
  Florida, PR
  Guaynabo, PR
  Humacao, PR
  Juncos, PR
  Los Piedras, PR
  Loiza, PR
  Luguillo, PR
  Manati, PR
  Morovis, PR
  Naguabo, PR

[[Page 45575]]

 
  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.....    1.1383    1.0928
  San Luis Obispo, CA
7480 Santa Barbara-Santa Maria-Lompoc, CA...........    1.0399    1.0272
  Santa Barbara, CA
7485 Santa Cruz-Watsonville, CA.....................    1.2890    1.1899
  Santa Cruz, CA
7490 Santa Fe, NM...................................    1.0610    1.0414
  Los Alamos, NM
  Santa Fe, NM
7500 Santa Rosa, CA.................................    1.2825    1.1858
  Sonoma, CA
7510 Sarasota-Bradenton, FL.........................    0.9931    0.9953
  Manatee, FL
  Sarasota, FL
7520 Savannah, GA...................................    0.9450    0.9620
  Bryan, GA
  Chatham, GA
  Effingham, GA
7560 Scranton--Wilkes-Barre--Hazleton, PA...........    0.8378    0.8859
  Columbia, PA
  Lackawanna, PA
  Luzerne, PA
  Wyoming, PA
7600 \1\ Seattle-Bellevue-Everett, WA...............    1.1516    1.1015
  Island, WA
  King, WA
  Snohomish, WA
7610 \2\ Sharon, PA.................................    0.8344    0.8834
  Mercer, PA
7620 \2\ Sheboygan, WI..............................    0.9266    0.9491
  Sheboygan, WI
7640 Sherman-Denison, TX............................    0.9661    0.9767
  Grayson, TX
7680 Shreveport-Bossier City, LA....................    0.9047    0.9337
  Bossier, LA
  Caddo, LA
  Webster, LA
7720 Sioux City, IA-NE..............................    0.8956    0.9273
  Woodbury, IA
  Dakota, NE
7760 Sioux Falls, SD................................    0.9271    0.9495
  Lincoln, SD
  Minnehaha, SD
7800 South Bend, IN.................................    0.9782    0.9850
  St. Joseph, IN
7840 Spokane, WA....................................    1.0857    1.0579
  Spokane, WA
7880 Springfield, IL................................    0.8908    0.9239
  Menard, IL
  Sangamon, IL
7920 Springfield, MO................................    0.8423    0.8891
  Christian, MO
  Greene, MO
  Webster, MO
8003 Springfield, MA................................    1.0419    1.0285
  Hampden, MA
  Hampshire, MA
8050 State College, PA..............................    0.8705    0.9094
  Centre, PA
8080 \2\ Steubenville-Weirton, OH-WV (OH Hospitals).    0.8784    0.9150
  Jefferson, OH
  Brooke, WV
  Hancock, WV
8080 Steubenville-Weirton, OH-WV (WV Hospitals).....    0.8364    0.8848
  Jefferson, OH
  Brooke, WV
  Hancock, WV
8120 Stockton-Lodi, CA..............................    1.0921    1.0622
  San Joaquin, CA
8140 \2\ Sumter, SC.................................    0.8464    0.8921
  Sumter, SC
8160 Syracuse, NY...................................    0.9374    0.9567
  Cayuga, NY
  Madison, NY
  Onondaga, NY
  Oswego, NY
8200 Tacoma, WA.....................................    1.1071    1.0722
  Pierce, WA
8240 \2\ Tallahassee, FL............................    0.8819    0.9175
  Gadsden, FL
  Leon, FL
8280 \1\ Tampa-St. Petersburg-Clearwater, FL........    0.9066    0.9351
  Hernando, FL
  Hillsborough, FL
  Pasco, FL
  Pinellas, FL
8320 \2\ Terre Haute, IN............................    0.8788    0.9153
  Clay, IN
  Vermillion, IN
  Vigo, IN
8360 Texarkana,AR-Texarkana, TX.....................    0.8117    0.8669
  Miller, AR
  Bowie, TX
8400 Toledo, OH.....................................    0.9359    0.9556
  Fulton, OH
  Lucas, OH
  Wood, OH
8440 Topeka, KS.....................................    0.9071    0.9354
  Shawnee, KS
8480 Trenton, NJ....................................    1.0474    1.0322
  Mercer, NJ
8520 \2\ Tucson, AZ.................................    0.9233    0.9468
  Pima, AZ
8560 Tulsa, OK......................................    0.9148    0.9408
  Creek, OK
  Osage, OK
  Rogers, OK
  Tulsa, OK
  Wagoner, OK
8600 Tuscaloosa, AL.................................    0.8179    0.8714
  Tuscaloosa, AL
8640 Tyler, TX......................................    0.9366    0.9561
  Smith, TX
8680 \2\ Utica-Rome, NY.............................    0.8491    0.8940
  Herkimer, NY
  Oneida, NY
8720 Vallejo-Fairfield-Napa, CA.....................    1.3371    1.2201
  Napa, CA
  Solano, CA
8735 Ventura, CA....................................    1.1019    1.0687
  Ventura, CA
8750 Victoria, TX...................................    0.8151    0.8694
  Victoria, TX
8760 Vineland-Millville-Bridgeton, NJ...............    1.0363    1.0247
  Cumberland, NJ
8780 \2\ Visalia-Tulare-Porterville, CA.............    0.9927    0.9950
  Tulare, CA
8800 Waco, TX.......................................    0.8360    0.8846
  McLennan, TX
8840 \1\ Washington, DC-MD-VA-WV....................    1.0860    1.0581
  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 \2\ Waterloo-Cedar Falls, IA...................    0.8382    0.8862
  Black Hawk, IA
8940 Wausau, WI.....................................    0.9744    0.9824
  Marathon, WI

[[Page 45576]]

 
8960 \1\ West Palm Beach-Boca Raton, FL.............    0.9759    0.9834
  Palm Beach, FL
9000 \2\ Wheeling, WV-OH (WV Hospitals).............    0.7986    0.8573
  Belmont, OH
  Marshall, WV
  Ohio, WV
9000 \2\ Wheeling, WV-OH (OH Hospitals).............    0.8784    0.9150
  Belmont, OH
  Marshall, WV
  Ohio, WV
9040 Wichita, KS....................................    0.9200    0.9445
  Butler, KS
  Harvey, KS
  Sedgwick, KS
9080 Wichita Falls, TX..............................    0.8307    0.8807
  Archer, TX
  Wichita, TX
9140 \2\ Williamsport, PA...........................    0.8344    0.8834
  Lycoming, PA
9160 Wilmington-Newark, DE-MD.......................    1.0838    1.0567
  New Castle, DE
  Cecil, MD
9200 Wilmington, NC.................................    0.9524    0.9672
  New Hanover, NC
  Brunswick, NC
9260 \2\ Yakima, WA.................................    1.0346    1.0236
  Yakima, WA
9270 \2\ Yolo, CA...................................    0.9927    0.9950
  Yolo, CA
9280 York, PA.......................................    0.9106    0.9379
  York, PA
9320 Youngstown-Warren, OH..........................    0.9176    0.9428
  Columbiana, OH
  Mahoning, OH
  Trumbull, OH
9340 Yuba City, CA..................................    1.0155    1.0106
  Sutter, CA
  Yuba, CA
9360 \2\ Yuma, AZ...................................    0.9233    0.9468
  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.............................................    0.7461    0.8183
Alaska..............................................    1.1838    1.1225
Arizona.............................................    0.9233    0.9468
Arkansas............................................    0.7703    0.8363
California..........................................    0.9927    0.9950
Colorado............................................    0.9291    0.9509
Connecticut.........................................    1.2134    1.1416
Delaware............................................    0.9557    0.9694
Florida.............................................    0.8819    0.9175
Georgia.............................................    0.8586    0.9009
Hawaii..............................................    0.9918    0.9944
Idaho...............................................    0.8937    0.9259
Illinois............................................    0.8221    0.8745
Indiana.............................................    0.8788    0.9153
Iowa................................................    0.8382    0.8862
Kansas..............................................    0.8041    0.8613
Kentucky............................................    0.7942    0.8540
Louisiana...........................................    0.7494    0.8207
Maine...............................................    0.8776    0.9145
Maryland............................................    0.9088    0.9366
Massachusetts.......................................    1.0390    1.0265
Michigan............................................    0.8851    0.9198
Minnesota...........................................    0.9307    0.9520
Mississippi.........................................    0.7762    0.8407
Missouri............................................    0.8024    0.8601
Montana.............................................    0.8765    0.9137
Nebraska............................................    0.8787    0.9153
Nevada..............................................    0.9767    0.9840
New Hampshire.......................................    0.9989    0.9992
New Jersey \1\......................................  ........  ........
New Mexico..........................................    0.8236    0.8756
New York............................................    0.8491    0.8940
North Carolina......................................    0.8422    0.8890
North Dakota........................................    0.7746    0.8395
Ohio................................................    0.8784    0.9150
Oklahoma............................................    0.7506    0.8216
Oregon..............................................    0.9953    0.9968
Pennsylvania........................................    0.8344    0.8834
Puerto Rico.........................................    0.4002    0.5341
Rhode Island \1\....................................  ........  ........
South Carolina......................................    0.8464    0.8921
South Dakota........................................    0.8162    0.8702
Tennessee...........................................    0.7854    0.8475
Texas...............................................    0.7748    0.8397
Utah................................................    0.8937    0.9259
Vermont.............................................    0.9496    0.9652
Virginia............................................    0.8464    0.8921
Washington..........................................    1.0346    1.0236
West Virginia.......................................    0.7986    0.8573
Wisconsin...........................................    0.9266    0.9491
Wyoming.............................................    0.9073   0.9356
------------------------------------------------------------------------
\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.............................................   0.9443   0.9615
Albany, GA............................................   1.0621   1.0421
Albuquerque, NM (NM hospitals)........................   0.9263   0.9489
Albuquerque, NM (CO hospitals)........................   0.9291   0.9509
Alexandria, LA........................................   0.8004   0.8586
Allentown-Bethlehem-Easton, PA........................   0.9682   0.9781
Altoona, PA...........................................   0.8792   0.9156
Amarillo, TX..........................................   0.8822   0.9177
Anchorage, AK.........................................   1.2301   1.1524
Ann Arbor, MI.........................................   1.0802   1.0543
Anniston, AL..........................................   0.7943   0.8541
Asheville, NC.........................................   0.9439   0.9612
Athens, GA............................................   0.9525   0.9672
Atlanta, GA...........................................   0.9955   0.9969
Atlantic-Cape May, NJ.................................   1.0489   1.0332
Augusta-Aiken, GA-SC..................................   0.9395   0.9582
Austin-San Marcos, TX.................................   0.9570   0.9704
Bangor, ME............................................   0.9864   0.9907
Barnstable-Yarmouth, MA...............................   1.2669   1.1759
Baton Rouge, LA.......................................   0.8372   0.8854
Bellingham, WA........................................   1.1358   1.0911
Benton Harbor, MI.....................................   0.8899   0.9232
Bergen-Passaic, NJ....................................   1.1683   1.1124
Billings, MT..........................................   0.8925   0.9251
Biloxi-Gulfport-Pascagoula, MS........................   0.8373   0.8855
Binghamton, NY........................................   0.8394   0.8870
Birmingham, AL........................................   0.9175   0.9427
Bismarck, ND..........................................   0.8001   0.8584
Bloomington-Normal, IL................................   0.8796   0.9159
Boise City, ID........................................   0.9195   0.9441
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH......   1.1188   1.0799
Burlington, VT........................................   0.9294   0.9511
Caguas, PR............................................   0.4184   0.5506
Casper, WY............................................   0.9171   0.9425
Champaign-Urbana, IL..................................   0.9422   0.9600
Charleston-North Charleston, SC.......................   0.9294   0.9511
Charleston, WV (WV Hospitals).........................   0.8533   0.8971
Charleston, WV (OH Hospitals).........................   0.8784   0.9150
Charlotte-Gastonia-Rock Hill, NC-SC...................   0.9578   0.9709
Charlottesville, VA...................................   0.9837   0.9888
Chattanooga, TN-GA....................................   0.9049   0.9339
Chicago, IL...........................................   1.0719   1.0487
Cincinnati, OH-KY-IN..................................   0.9380   0.9571
Clarksville-Hopkinsville, TN-KY.......................   0.8320   0.8817
Cleveland-Lorain-Elyria, OH...........................   0.9632   0.9747
Columbia, MO..........................................   0.8522   0.8963
Columbia, SC..........................................   0.8866   0.9209
Columbus, GA-AL (GA Hospitals)........................   0.8586   0.9009
Columbus, GA-AL (AL Hospitals)........................   0.8446   0.8908
Columbus, OH..........................................   0.9609   0.9731
Corpus Christi, TX....................................   0.8486   0.8937
Corvallis, OR.........................................   1.1196   1.0804
Dallas, TX............................................   0.9934   0.9955
Davenport-Moline-Rock Island, IA-IL...................   0.8949   0.9268
Dayton-Springfield, OH................................   0.9490   0.9648
Decatur, AL...........................................   0.8545   0.8979
Denver, CO............................................   1.0617   1.0419
Des Moines, IA........................................   0.9069   0.9353
Detroit, MI...........................................   1.0060   1.0041
Dothan, AL............................................   0.7734   0.8386
Duluth-Superior, MN-WI................................   1.0130   1.0089
Dutchess County, NY...................................   1.0687   1.0466

[[Page 45577]]

 
Elkhart-Goshen, IN....................................   0.9515   0.9665
Erie, PA..............................................   0.8491   0.8940
Eugene-Springfield, OR................................   1.0932   1.0629
Fargo-Moorhead, ND-MN.................................   0.9463   0.9629
Fayetteville, NC......................................   0.8782   0.9149
Flagstaff, AZ-UT......................................   1.1035   1.0698
Flint, MI.............................................   1.0659   1.0447
Florence, AL..........................................   0.7766   0.8410
Fort Collins-Loveland, CO.............................   1.0096   1.0066
Ft. Lauderdale, FL....................................   1.0436   1.0297
Fort Pierce-Port St. Lucie, FL........................   1.0083   1.0057
Fort Smith, AR-OK.....................................   0.8044   0.8615
Fort Walton Beach, FL.................................   0.8768   0.9139
Forth Worth-Arlington, TX.............................   0.9321   0.9530
Gadsden, AL...........................................   0.8195   0.8726
Grand Forks, ND-MN....................................   0.8601   0.9019
Grand Junction, CO....................................   0.9881   0.9918
Grand Rapids-Muskegon-Holland, MI.....................   0.9430   0.9606
Great Falls, MT.......................................   0.8882   0.9220
Greeley, CO...........................................   0.9415   0.9596
Green Bay, WI.........................................   0.9479   0.9640
Greensboro-Winston-Salem-High Point, NC...............   0.9022   0.9319
Greenville, NC........................................   0.9129   0.9395
Hamilton-Middletown, OH...............................   0.9176   0.9428
Harrisburg-Lebanon-Carlisle, PA.......................   0.9127   0.9394
Hartford, CT..........................................   1.1279   1.0859
Hickory-Morganton-Lenoir, NC..........................   0.9076   0.9358
Honolulu, HI..........................................   1.1071   1.0722
Houston, TX...........................................   0.9794   0.9858
Huntington-Ashland, WV-KY-OH..........................   0.9039   0.9331
Huntsville, AL........................................   0.8979   0.9289
Indianapolis, IN......................................   0.9875   0.9914
Iowa City, IA.........................................   0.9366   0.9561
Jackson, MS...........................................   0.8355   0.8842
Jackson, TN...........................................   0.8784   0.9150
Jacksonville, FL......................................   0.9490   0.9648
Johnson City-Kingsport-Bristol, TN-VA (VA Hospitals)..   0.8464   0.8921
Johnson City-Kingsport-Bristol, TN-VA (KY Hospitals)..   0.8223   0.8746
Jonesboro, AR (AR Hospitals)..........................   0.7777   0.8418
Jonesboro, AR (MO Hospitals)..........................   0.8024   0.8601
Joplin, MO............................................   0.8523   0.8963
Kalamazoo-Battlecreek, MI.............................   1.0458   1.0311
Kansas City, KS-MO....................................   0.9675   0.9776
Knoxville, TN.........................................   0.8784   0.9150
Kokomo, IN............................................   0.9008   0.9310
Lafayette, LA.........................................   0.8191   0.8723
Lakeland-Winter Haven, FL.............................   0.8823   0.9178
Las Vegas, NV-AZ......................................   1.1355   1.0909
Lawton, OK............................................   0.8107   0.8661
Lexington, KY.........................................   0.8441   0.8904
Lima, OH..............................................   0.9483   0.9643
Lincoln, NE...........................................   0.9559   0.9696
Little Rock-North Little Rock, AR.....................   0.8887   0.9224
Longview-Marshall, TX.................................   0.8906   0.9237
Los Angeles-Long Beach, CA............................   1.1790   1.1194
Louisville, KY-IN.....................................   0.9081   0.9361
Lubbock, TX...........................................   0.8238   0.8757
Lynchburg, VA.........................................   0.8905   0.9237
Macon, GA.............................................   0.8939   0.9261
Madison, WI...........................................   1.0076   1.0052
Medford-Ashland, OR...................................   1.0383   1.0261
Memphis, TN-AR-MS.....................................   0.8751   0.9127
Miami, FL.............................................   0.9854   0.9900
Milwaukee-Waukesha, WI................................   0.9789   0.9855
Minneapolis-St. Paul, MN-WI...........................   1.0957   1.0646
Missoula, MT..........................................   0.8848   0.9196
Mobile, AL............................................   0.7962   0.8555
Modesto, CA...........................................   1.1103   1.0743
Monmouth-Ocean, NJ....................................   1.1038   1.0700
Monroe, LA............................................   0.7890   0.8502
Montgomery, AL........................................   0.7875   0.8491
Nashville, TN.........................................   0.9552   0.9691
New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT...   1.2418   1.1599
New Orleans, LA.......................................   0.9137   0.9401
New York, NY..........................................   1.3913   1.2538
Newark, NJ............................................   1.1471   1.0985
Newburgh, NY-PA.......................................   1.1298   1.0872
Oakland, CA...........................................   1.5058   1.3235
Ocala, FL.............................................   0.9541   0.9683
Odessa-Midland, TX....................................   0.9039   0.9331
Oklahoma City, OK.....................................   0.8948   0.9267
Olympia, WA...........................................   1.0919   1.0621
Omaha, NE-IA..........................................   0.9705   0.9797
Orange County, CA.....................................   1.1445   1.0968
Orlando, FL...........................................   0.9615   0.9735
Peoria-Pekin, IL......................................   0.8699   0.9090
Philadelphia, PA-NJ...................................   1.0839   1.0567
Phoenix-Mesa, AZ......................................   1.0088   1.0060
Pine Bluff, AR........................................   0.7855   0.8476
Pittsburgh, PA........................................   0.8865   0.9208
Pittsfield, MA........................................   0.9756   0.9832
Pocatello, ID.........................................   0.9212   0.9453
Portland, ME..........................................   0.9619   0.9737
Portland-Vancouver, OR-WA.............................   1.1167   1.0785
Provo-Orem, UT........................................   0.9811   0.9870
Raleigh-Durham-Chapel Hill, NC........................   0.9691   0.9787
Rapid City, SD........................................   0.8771   0.9141
Reading, PA...........................................   0.8962   0.9277
Redding, CA...........................................   1.1306   1.0877
Reno, NV..............................................   1.0639   1.0433
Richland-Kennewick-Pasco, WA..........................   1.0358   1.0244
Richmond-Petersburg, VA...............................   0.9311   0.9523
Roanoke, VA...........................................   0.8664   0.9065
Rochester, MN.........................................   1.1691   1.1129
Rockford, IL..........................................   0.9402   0.9587
Sacramento, CA........................................   1.1797   1.1198
Saginaw-Bay City-Midland, MI..........................   0.9712   0.9802
St. Cloud, MN.........................................   0.9640   0.9752
St. Joseph, MO........................................   0.8544   0.8978
St. Louis, MO-IL......................................   0.8996   0.9301
Salinas, CA...........................................   1.4281   1.2764
Salt Lake City-Ogden, UT..............................   0.9873   0.9913
San Antonio, TX.......................................   0.8834   0.9186
Santa Fe, NM..........................................   0.9486   0.9645
Santa Rosa, CA........................................   1.2825   1.1858
Sarasota-Bradenton, FL................................   0.9931   0.9953
Savannah, GA..........................................   0.9450   0.9620
Seattle-Bellevue-Everett, WA..........................   1.1516   1.1015
Sherman-Denison, TX...................................   0.9166   0.9421
Shreveport-Bossier City, LA...........................   0.9047   0.9337
Sioux City, IA-NE (NE Hospitals)......................   0.8787   0.9153
Sioux City, IA-NE (SD Hospitals)......................   0.8750   0.9126
Sioux Falls, SD.......................................   0.9147   0.9408
South Bend, IN........................................   0.9676   0.9777
Spokane, WA...........................................   1.0673   1.0456
Springfield, IL.......................................   0.8908   0.9239
Springfield, MO.......................................   0.8225   0.8748
Stockton-Lodi, CA.....................................   1.0921   1.0622
Syracuse, NY..........................................   0.9374   0.9567
Tampa-St. Petersburg-Clearwater, FL...................   0.9066   0.9351
Texarkana, AR-Texarkana, TX...........................   0.7937   0.8537
Toledo, OH............................................   0.9359   0.9556
Topeka, KS............................................   0.8869   0.9211
Tucson, AZ............................................   0.9233   0.9468
Tulsa, OK.............................................   0.8902   0.9234
Tuscaloosa, AL........................................   0.8068   0.8633
Tyler, TX.............................................   0.9118   0.9387
Vallejo-Fairfield-Napa, CA............................   1.3371   1.2201
Victoria, TX..........................................   0.8151   0.8694
Waco, TX..............................................   0.8360   0.8846
Washington, DC-MD-VA-WV...............................   1.0860   1.0581
Waterloo-Cedar Falls, IA..............................   0.8382   0.8862
Wausau, WI............................................   0.9744   0.9824
West Palm Beach-Boca Raton, FL........................   0.9759   0.9834
Wichita, KS...........................................   0.8967   0.9281
Wichita Falls, TX.....................................   0.8307   0.8807
Wilmington-Newark, DE-MD..............................   1.0667   1.0452
Wilmington, NC........................................   0.9386   0.9575
York, PA..............................................   0.9106   0.9379
Youngstown-Warren, OH.................................   0.9176   0.9428
Rural Florida.........................................   0.8663   0.9064
Rural Illinois (IA Hospitals).........................   0.8382   0.8862
Rural Illinois (MO Hospitals).........................   0.8221   0.8745
Rural Kentucky........................................   0.7942   0.8540
Rural Louisiana.......................................   0.7494   0.8207
Rural Michigan........................................   0.8851   0.9198
Rural Minnesota.......................................   0.9307   0.9520
Rural Mississippi.....................................   0.7762   0.8407
Rural Missouri........................................   0.8024   0.8601
Rural Nebraska........................................   0.8787   0.9153
Rural Nevada..........................................   0.9238   0.9472
Rural New Hampshire...................................   0.9989   0.9992
Rural Texas...........................................   0.7748   0.8397
Rural Washington......................................   1.0346   1.0236
Rural Wyoming.........................................   0.8947   0.9266
------------------------------------------------------------------------


[[Page 45578]]


                Table 4F.--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF)
----------------------------------------------------------------------------------------------------------------
                                                                                   Wage index--
                         Area                            Wage index      GAF         reclass.      GAF--reclass.
                                                                                     hospitals       hospitals
----------------------------------------------------------------------------------------------------------------
Aguadilla, PR.........................................       0.9180       0.9431  ..............  ..............
Arecibo, PR...........................................       0.8856       0.9202  ..............  ..............
Caguas, PR............................................       0.8956       0.9273          0.8956          0.9273
Mayaguez, PR..........................................       1.0222       1.0151  ..............  ..............
Ponce, PR.............................................       1.0037       1.0025  ..............  ..............
San Juan-Bayamon, PR..................................       1.0445       1.0303  ..............  ..............
Rural Puerto Rico.....................................       0.8566       0.8994  ..............  ..............
----------------------------------------------------------------------------------------------------------------


         Table 4G.--Pre-Reclassified Wage Index for Urban Areas
------------------------------------------------------------------------
                                                                  Wage
              Urban area  (constituent counties)                  index
------------------------------------------------------------------------
0040 Abilene, TX..............................................    0.7748
  Taylor, TX
0060 Aguadilla, PR............................................    0.4289
  Aguada, PR
  Aguadilla, PR
  Moca, PR
0080 Akron, OH................................................    0.9208
  Portage, OH
  Summit, OH
0120 Albany, GA...............................................    1.0819
  Dougherty, GA
  Lee, GA
0160 Albany-Schenectady-Troy, NY..............................    0.8491
  Albany, NY
  Montgomery, NY
  Rensselaer, NY
  Saratoga, NY
  Schenectady, NY
  Schoharie, NY
0200 Albuquerque, NM..........................................    0.9263
  Bernalillo, NM
  Sandoval, NM
  Valencia, NM
0220 Alexandria, LA...........................................    0.7987
  Rapides, LA
0240 Allentown-Bethlehem-Easton, PA...........................    0.9682
  Carbon, PA
  Lehigh, PA
  Northampton, PA
0280 Altoona, PA..............................................    0.8771
  Blair, PA
0320 Amarillo, TX.............................................    0.8950
  Potter, TX
  Randall, TX
0380 Anchorage, AK............................................    1.2167
  Anchorage, AK
0440 Ann Arbor, MI............................................    1.1029
  Lenawee, MI
  Livingston, MI
  Washtenaw, MI
0450 Anniston, AL.............................................    0.8058
  Calhoun, AL
0460 Appleton-Oshkosh-Neenah, WI..............................    0.9266
  Calumet, WI
  Outagamie, WI
  Winnebago, WI
0470 Arecibo, PR..............................................    0.4138
  Arecibo, PR
  Camuy, PR
  Hatillo, PR
0480 Asheville, NC............................................    0.9680
  Buncombe, NC
  Madison, NC
0500 Athens, GA...............................................    0.9778
  Clarke, GA
  Madison, GA
  Oconee, GA
0520 Atlanta, GA..............................................    1.0089
  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....................................    1.0751
  Atlantic, NJ
  Cape May, NJ
0580 Auburn-Opelika, AL.......................................    0.8460
  Lee, AL
0600 Augusta-Aiken, GA-SC.....................................    0.9587
  Columbia, GA
  McDuffie, GA
  Richmond, GA
  Aiken, SC
  Edgefield, SC
0640 Austin-San Marcos, TX....................................    0.9570
  Bastrop, TX
  Caldwell, TX
  Hays, TX
  Travis, TX
  Williamson, TX
0680 Bakersfield, CA..........................................    0.9927
  Kern, CA
0720 Baltimore, MD............................................    0.9879
  Anne Arundel, MD
  Baltimore, MD
  Baltimore City, MD
  Carroll, MD
  Harford, MD
  Howard, MD
  Queen Anne's, MD
0733 Bangor, ME...............................................    0.9864
  Penobscot, ME
0743 Barnstable-Yarmouth, MA..................................    1.2904
  Barnstable, MA
0760 Baton Rouge, LA..........................................    0.8372
  Ascension, LA
  East Baton Rouge, LA
  Livingston, LA
  West Baton Rouge, LA
0840 Beaumont-Port Arthur, TX.................................    0.8390
  Hardin, TX
  Jefferson, TX
  Orange, TX
0860 Bellingham, WA...........................................    1.1710
  Whatcom, WA
0870 Benton Harbor, MI........................................    0.8899
  Berrien, MI
0875 Bergen-Passaic, NJ.......................................    1.1644
  Bergen, NJ
  Passaic, NJ
0880 Billings, MT.............................................    0.8925
  Yellowstone, MT
0920 Biloxi-Gulfport-Pascagoula, MS...........................    0.8993
  Hancock, MS
  Harrison, MS
  Jackson, MS
0960 Binghamton, NY...........................................    0.8491
  Broome, NY
  Tioga, NY
1000 Birmingham, AL...........................................    0.9175
  Blount, AL
  Jefferson, AL
  St. Clair, AL
  Shelby, AL
1010 Bismarck, ND.............................................    0.7933
  Burleigh, ND
  Morton, ND
1020 Bloomington, IN..........................................    0.8788
  Monroe, IN
1040 Bloomington-Normal, IL...................................    0.8796
  McLean, IL
1080 Boise City, ID...........................................    0.9172
  Ada, ID
  Canyon, ID
1123 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH (NH         1.1188
 Hospitals)...................................................
  Bristol, MA
  Essex, MA
  Middlesex, MA
  Norfolk, MA
  Plymouth, MA
  Suffolk, MA
  Worcester, MA
  Hillsborough, NH
  Merrimack, NH

[[Page 45579]]

 
  Rockingham, NH
  Strafford, NH
1125 Boulder-Longmont, CO.....................................    1.0008
  Boulder, CO
1145 Brazoria, TX.............................................    0.8105
  Brazoria, TX
1150 Bremerton, WA............................................    1.0537
  Kitsap, WA
1240 Brownsville-Harlingen-San Benito, TX.....................    1.0261
  Cameron, TX
1260 Bryan-College Station, TX................................    0.8983
  Brazos, TX
1280 Buffalo-Niagara Falls, NY................................    0.9565
  Erie, NY
  Niagara, NY
1303 Burlington, VT...........................................    0.9665
  Chittenden, VT
  Franklin, VT
  Grand Isle, VT
1310 Caguas, PR...............................................    0.4141
  Caguas, PR
  Cayey, PR
  Cidra, PR
  Gurabo, PR
  San Lorenzo, PR
1320 Canton-Massillon, OH.....................................    0.9034
  Carroll, OH
  Stark, OH
1350 Casper, WY...............................................    0.9073
  Natrona, WY
1360 Cedar Rapids, IA.........................................    0.8838
  Linn, IA
1400 Champaign-Urbana, IL.....................................    0.9867
  Champaign, IL
1440 Charleston-North Charleston, SC..........................    0.9294
  Berkeley, SC
  Charleston, SC
  Dorchester, SC
1480 Charleston, WV...........................................    0.8845
  Kanawha, WV
  Putnam, WV
1520 Charlotte-Gastonia-Rock Hill, NC-SC......................    0.9691
  Cabarrus, NC
  Gaston, NC
  Lincoln, NC
  Mecklenburg, NC
  Rowan, NC
  Stanly, NC
  Union, NC
  York, SC
1540 Charlottesville, VA......................................    0.9985
  Albemarle, VA
  Charlottesville City, VA
  Fluvanna, VA
  Greene, VA
1560 Chattanooga, TN-GA.......................................    0.9049
  Catoosa, GA
  Dade, GA
  Walker, GA
  Hamilton, TN
  Marion, TN
1580 Cheyenne, WY.............................................    0.9073
  Laramie, WY
1600 Chicago, IL..............................................    1.0848
  Cook, IL
  DeKalb, IL
  DuPage, IL
  Grundy, IL
  Kane, IL
  Kendall, IL
  Lake, IL
  McHenry, IL
  Will, IL
1620 Chico-Paradise, CA.......................................    1.0152
  Butte, CA
1640 Cincinnati, OH-KY-IN.....................................    0.9375
  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..........................    0.8211
  Christian, KY
  Montgomery, TN
1680 Cleveland-Lorain-Elyria, OH..............................    0.9632
  Ashtabula, OH
  Cuyahoga, OH
  Geauga, OH
  Lake, OH
  Lorain, OH
  Medina, OH
1720 Colorado Springs, CO.....................................    0.9793
  El Paso, CO
1740 Columbia, MO.............................................    0.8660
  Boone, MO
1760 Columbia, SC.............................................    0.8866
  Lexington, SC
  Richland, SC
1800 Columbus, GA-AL..........................................    0.8659
  Russell, AL
  Chattahoochee, GA
  Harris, GA
  Muscogee, GA
1840 Columbus, OH.............................................    0.9609
  Delaware, OH
  Fairfield, OH
  Franklin, OH
  Licking, OH
  Madison, OH
  Pickaway, OH
1880 Corpus Christi, TX.......................................    0.8486
  Nueces, TX
  San Patricio, TX
1890 Corvallis, OR............................................    1.1470
  Benton, OR
1900 Cumberland, MD-WV (WV Hospital)..........................    0.8166
  Allegany, MD
  Mineral, WV
1920 Dallas, TX...............................................    0.9934
  Collin, TX
  Dallas, TX
  Denton, TX
  Ellis, TX
  Henderson, TX
  Hunt, TX
  Kaufman, TX
  Rockwall, TX
1950 Danville, VA.............................................    0.8998
  Danville City, VA
  Pittsylvania, VA
1960 Davenport-Moline-Rock Island, IA-IL......................    0.8949
  Scott, IA
  Henry, IL
  Rock Island, IL
2000 Dayton-Springfield, OH...................................    0.9479
  Clark, OH
  Greene, OH
  Miami, OH
  Montgomery, OH
2020 Daytona Beach, FL........................................    0.9024
  Flagler, FL
  Volusia, FL
2030 Decatur, AL..............................................    0.8793
  Lawrence, AL
  Morgan, AL
2040 Decatur, IL..............................................    0.8221
  Macon, IL
2080 Denver, CO...............................................    1.0793
  Adams, CO
  Arapahoe, CO
  Broomfield, CO
  Denver, CO
  Douglas, CO
  Jefferson, CO
2120 Des Moines, IA...........................................    0.9069
  Dallas, IA
  Polk, IA
  Warren, IA
2160 Detroit, MI..............................................    1.0060
  Lapeer, MI
  Macomb, MI
  Monroe, MI
  Oakland, MI
  St. Clair, MI
  Wayne, MI
2180 Dothan, AL...............................................    0.7710
  Dale, AL
  Houston, AL
2190 Dover, DE................................................    0.9765
  Kent, DE
2200 Dubuque, IA..............................................    0.8850
  Dubuque, IA
2240 Duluth-Superior, MN-WI...................................    1.0130
  St. Louis, MN
  Douglas, WI
2281 Dutchess County, NY......................................    1.0890
  Dutchess, NY
2290 Eau Claire, WI...........................................    0.9266
  Chippewa, WI
  Eau Claire, WI
2320 El Paso, TX..............................................    0.9159
  El Paso, TX
2330 Elkhart-Goshen, IN.......................................    0.9744
  Elkhart, IN
2335 Elmira, NY...............................................    0.8491
  Chemung, NY
2340 Enid, OK.................................................    0.8524
  Garfield, OK
2360 Erie, PA.................................................    0.8566
  Erie, PA
2400 Eugene-Springfield, OR...................................    1.1410
  Lane, OR
2440 Evansville-Henderson, IN-KY (IN Hospitals)...............    0.8788
  Posey, IN
  Vanderburgh, IN
  Warrick, IN

[[Page 45580]]

 
  Henderson, KY
2520 Fargo-Moorhead, ND-MN....................................    0.9758
  Clay, MN
  Cass, ND
2560 Fayetteville, NC.........................................    0.8950
  Cumberland, NC
2580 Fayetteville-Springdale-Rogers, AR.......................    0.8362
  Benton, AR
  Washington, AR
2620 Flagstaff, AZ-UT.........................................    1.1287
  Coconino, AZ
  Kane, UT
2640 Flint, MI................................................    1.0814
  Genesee, MI
2650 Florence, AL.............................................    0.7716
  Colbert, AL
  Lauderdale, AL
2655 Florence, SC.............................................    0.8673
  Florence, SC
2670 Fort Collins-Loveland, CO................................    1.0067
  Larimer, CO
2680 Ft. Lauderdale, FL.......................................    1.0122
  Broward, FL
2700 Fort Myers-Cape Coral, FL................................    0.9776
  Lee, FL
2710 Fort Pierce-Port St. Lucie, FL...........................    0.9968
  Martin, FL
  St. Lucie, FL
2720 Fort Smith, AR-OK........................................    0.8390
  Crawford, AR
  Sebastian, AR
  Sequoyah, OK
2750 Fort Walton Beach, FL....................................    0.8930
  Okaloosa, FL
2760 Fort Wayne, IN...........................................    0.9546
  Adams, IN
  Allen, IN
  De Kalb, IN
  Huntington, IN
  Wells, IN
  Whitley, IN
2800 Forth Worth-Arlington, TX................................    0.9321
  Hood, TX
  Johnson, TX
  Parker, TX
  Tarrant, TX
2840 Fresno, CA...............................................    1.0101
  Fresno, CA
  Madera, CA
2880 Gadsden, AL..............................................    0.8173
  Etowah, AL                                                      0.9653
2900 Gainesville, FL..........................................
  Alachua, FL
2920 Galveston-Texas City, TX.................................    0.9242
  Galveston, TX
2960 Gary, IN.................................................    0.9372
  Lake, IN
  Porter, IN
2975 Glens Falls, NY..........................................    0.8491
  Warren, NY
  Washington, NY
2980 Goldsboro, NC............................................    0.8587
  Wayne, NC
2985 Grand Forks, ND-MN.......................................    0.8601
  Polk, MN
  Grand Forks, ND
2995 Grand Junction, CO.......................................    0.9594
  Mesa, CO
3000 Grand Rapids-Muskegon-Holland, MI........................    0.9430
  Allegan, MI
  Kent, MI
  Muskegon, MI
  Ottawa, MI
3040 Great Falls, MT..........................................    0.8773
  Cascade, MT
3060 Greeley, CO..............................................    0.9334
  Weld, CO
3080 Green Bay, WI............................................    0.9422
  Brown, WI
3120 Greensboro-Winston-Salem-High Point, NC..................    0.9129
  Alamance, NC
  Davidson, NC
  Davie, NC
  Forsyth, NC
  Guilford, NC
  Randolph, NC
  Stokes, NC
  Yadkin, NC
3150 Greenville, NC...........................................    0.9061
  Pitt, NC
3160 Greenville-Spartanburg-Anderson, SC......................    0.9297
  Anderson, SC
  Cherokee, SC
  Greenville, SC
  Pickens, SC
  Spartanburg, SC
3180 Hagerstown, MD...........................................    0.9135
  Washington, MD
3200 Hamilton-Middletown, OH..................................    0.9176
  Butler, OH
3240 Harrisburg-Lebanon-Carlisle, PA..........................    0.9127
  Cumberland, PA
  Dauphin, PA
  Lebanon, PA
  Perry, PA
3283 Hartford, CT.............................................    1.2134
  Hartford, CT
  Litchfield, CT
  Middlesex, CT
  Tolland, CT
3285 Hattiesburg, MS..........................................    0.7747
  Forrest, MS
  Lamar, MS
3290 Hickory-Morganton-Lenoir, NC.............................    0.9205
  Alexander, NC
  Burke, NC
  Caldwell, NC
  Catawba, NC
3320 Honolulu, HI.............................................    1.1053
  Honolulu, HI
3350 Houma, LA................................................    0.7740
  Lafourche, LA
  Terrebonne, LA
3360 Houston, TX..............................................    0.9794
  Chambers, TX
  Fort Bend, TX
  Harris, TX
  Liberty, TX
  Montgomery, TX
  Waller, TX
3400 Huntington-Ashland, WV-KY-OH.............................    0.9556
  Boyd, KY
  Carter, KY
  Greenup, KY
  Lawrence, OH
  Cabell, WV
  Wayne, WV
3440 Huntsville, AL...........................................    0.9208
  Limestone, AL
  Madison, AL
3480 Indianapolis, IN.........................................    0.9875
  Boone, IN
  Hamilton, IN
  Hancock, IN
  Hendricks, IN
  Johnson, IN
  Madison, IN
  Marion, IN
  Morgan, IN
  Shelby, IN
3500 Iowa City, IA............................................    0.9510
  Johnson, IA
3520 Jackson, MI..............................................    0.8950
  Jackson, MI
3560 Jackson, MS..............................................    0.8324
  Hinds, MS
  Madison, MS
  Rankin, MS
3580 Jackson, TN..............................................    0.8948
  Madison, TN
  Chester, TN
3600 Jacksonville, FL.........................................    0.9490
  Clay, FL
  Duval, FL
  Nassau, FL
  St. Johns, FL
3605 Jacksonville, NC.........................................    0.8510
  Onslow, NC
3610 Jamestown, NY............................................    0.8491
  Chautauqua, NY
3620 Janesville-Beloit, WI....................................    0.9266
  Rock, WI
3640 Jersey City, NJ..........................................    1.1070
  Hudson, NJ
3660 Johnson City-Kingsport-Bristol, TN-VA....................    0.8220
  Carter, TN
  Hawkins, TN
  Sullivan, TN
  Unicoi, TN
  Washington, TN
  Bristol City, VA
  Scott, VA
  Washington, VA
3680 Johnstown, PA............................................    0.8344
  Cambria, PA
  Somerset, PA
3700 Jonesboro, AR............................................    0.7762
  Craighead, AR
3710 Joplin, MO...............................................    0.8646
  Jasper, MO
  Newton, MO
3720 Kalamazoo-Battlecreek, MI................................    1.0458
  Calhoun, MI
  Kalamazoo, MI
  Van Buren, MI
3740 Kankakee, IL.............................................    1.0377
  Kankakee, IL
3760 Kansas City, KS-MO.......................................    0.9675
  Johnson, KS
  Leavenworth, KS
  Miami, KS

[[Page 45581]]

 
  Wyandotte, KS
  Cass, MO
  Clay, MO
  Clinton, MO
  Jackson, MO
  Lafayette, MO
  Platte, MO
  Ray, MO
3800 Kenosha, WI..............................................    0.9721
  Kenosha, WI
3810 Killeen-Temple, TX.......................................    0.9122
  Bell, TX
  Coryell, TX
3840 Knoxville, TN............................................    0.8784
  Anderson, TN
  Blount, TN
  Knox, TN
  Loudon, TN
  Sevier, TN
  Union, TN
3850 Kokomo, IN...............................................    0.9008
  Howard, IN
  Tipton, IN
3870 La Crosse, WI-MN.........................................    0.9266
  Houston, MN
  La Crosse, WI
3880 Lafayette, LA............................................    0.8173
  Acadia, LA
  Lafayette, LA
  St. Landry, LA
  St. Martin, LA
3920 Lafayette, IN............................................    0.8788
  Clinton, IN
  Tippecanoe, IN
3960 Lake Charles, LA.........................................    0.7809
  Calcasieu, LA
3980 Lakeland-Winter Haven, FL................................    0.8819
  Polk, FL
4000 Lancaster, PA............................................    0.9244
  Lancaster, PA
4040 Lansing-East Lansing, MI.................................    0.9675
  Clinton, MI
  Eaton, MI
  Ingham, MI
4080 Laredo, TX...............................................    0.8059
  Webb, TX
4100 Las Cruces, NM...........................................    0.8653
  Dona Ana, NM
4120 Las Vegas, NV-AZ.........................................    1.1481
  Mohave, AZ
  Clark, NV
  Nye, NV
4150 Lawrence, KS.............................................    0.8041
  Douglas, KS
4200 Lawton, OK...............................................    0.8234
  Comanche, OK
4243 Lewiston-Auburn, ME......................................    0.9345
  Androscoggin, ME
4280 Lexington, KY............................................    0.8650
  Bourbon, KY
  Clark, KY
  Fayette, KY
  Jessamine, KY
  Madison, KY
  Scott, KY
  Woodford, KY
4320 Lima, OH.................................................    0.9483
  Allen, OH
  Auglaize, OH
4360 Lincoln, NE..............................................    0.9992
  Lancaster, NE
4400 Little Rock-North Little Rock, AR........................    0.8887
  Faulkner, AR
  Lonoke, AR
  Pulaski, AR
  Saline, AR
4420 Longview-Marshall, TX....................................    0.9076
  Gregg, TX
  Harrison, TX
  Upshur, TX
4480 Los Angeles-Long Beach, CA...............................    1.1748
  Los Angeles, CA
4520 Louisville, KY-IN........................................    0.9205
  Clark, IN
  Floyd, IN
  Harrison, IN
  Scott, IN
  Bullitt, KY
  Jefferson, KY
  Oldham, KY
4600 Lubbock, TX..............................................    0.8238
  Lubbock, TX
4640 Lynchburg, VA............................................    0.9097
  Amherst, VA
  Bedford, VA
  Bedford City, VA
  Campbell, VA
  Lynchburg City, VA
4680 Macon, GA................................................    0.8916
  Bibb, GA
  Houston, GA
  Jones, GA
  Peach, GA
  Twiggs, GA
4720 Madison, WI..............................................    1.0222
  Dane, WI
4800 Mansfield, OH............................................    0.8784
  Crawford, OH
  Richland, OH
4840 Mayaguez, PR.............................................    0.4776
  Anasco, PR
  Cabo Rojo, PR
  Hormigueros, PR
  Mayaguez, PR
  Sabana Grande, PR
  San German, PR
4880 McAllen-Edinburg-Mission, TX.............................    0.8347
  Hidalgo, TX
4890 Medford-Ashland, OR......................................    1.0729
  Jackson, OR
4900 Melbourne-Titusville-Palm Bay, FL........................    0.9736
  Brevard, Fl
4920 Memphis, TN-AR-MS........................................    0.8973
  Crittenden, AR
  DeSoto, MS
  Fayette, TN
  Shelby, TN
  Tipton, TN
4940 Merced, CA...............................................    0.9927
  Merced, CA
5000 Miami, FL................................................    0.9854
  Dade, FL
5015 Middlesex-Somerset-Hunterdon, NJ.........................    1.1320
  Hunterdon, NJ
  Middlesex, NJ
  Somerset, NJ
5080 Milwaukee-Waukesha, WI...................................    0.9947
  Milwaukee, WI
  Ozaukee, WI
  Washington, WI
  Waukesha, WI
5120 Minneapolis-St. Paul, MN-WI..............................    1.0957
  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.............................................    0.8765
  Missoula, MT
5160 Mobile, AL...............................................    0.7962
  Baldwin, AL
  Mobile, AL
5170 Modesto, CA..............................................    1.1230
  Stanislaus, CA
5190 Monmouth-Ocean, NJ.......................................    1.0912
  Monmouth, NJ
  Ocean, NJ
5200 Monroe, LA...............................................    0.7890
  Ouachita, LA
5240 Montgomery, AL...........................................    0.7875
  Autauga, AL
  Elmore, AL
  Montgomery, AL
5280 Muncie, IN...............................................    0.8788
  Delaware, IN
5330 Myrtle Beach, SC.........................................    0.9075
  Horry, SC
5345 Naples, FL...............................................    0.9750
  Collier, FL
5360 Nashville, TN............................................    0.9815
  Cheatham, TN
  Davidson, TN
  Dickson, TN
  Robertson, TN
  Rutherford TN
  Sumner, TN
  Williamson, TN
  Wilson, TN
5380 Nassau-Suffolk, NY.......................................    1.2933
  Nassau, NY
  Suffolk, NY
5483 New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT......    1.2335
  Fairfield, CT
  New Haven, CT
5523 New London-Norwich, CT...................................    1.2134
  New London, CT
5560 New Orleans, LA..........................................    0.9137
  Jefferson, LA
  Orleans, LA
  Plaquemines, LA
  St. Bernard, LA
  St. Charles, LA
  St. James, LA
  St. John The Baptist, LA

[[Page 45582]]

 
  St. Tammany, LA
5600 New York, NY.............................................    1.3913
  Bronx, NY
  Kings, NY
  New York, NY
  Putnam, NY
  Queens, NY
  Richmond, NY
  Rockland, NY
  Westchester, NY
5640 Newark, NJ...............................................    1.1471
  Essex, NJ
  Morris, NJ
  Sussex, NJ
  Union, NJ
  Warren, NJ
5660 Newburgh, NY-PA..........................................    1.1462
  Orange, NY
  Pike, PA
5720 Norfolk-Virginia Beach-Newport News, VA-NC...............    0.8584
  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..............................................    1.4860
  Alameda, CA
  Contra Costa, CA
5790 Ocala, FL................................................    0.9689
  Marion, FL
5800 Odessa-Midland, TX.......................................    0.9290
  Ector, TX
  Midland, TX
5880 Oklahoma City, OK........................................    0.8948
  Canadian, OK
  Cleveland, OK
  Logan, OK
  McClain, OK
  Oklahoma, OK
  Pottawatomie, OK
5910 Olympia, WA..............................................    1.0919
  Thurston, WA
5920 Omaha, NE-IA.............................................    0.9705
  Pottawattamie, IA
  Cass, NE
  Douglas, NE
  Sarpy, NE
  Washington, NE
5945 Orange County, CA........................................    1.1326
  Orange, CA
5960 Orlando, FL..............................................    0.9615
  Lake, FL
  Orange, FL
  Osceola, FL
  Seminole, FL
5990 Owensboro, KY............................................    0.8340
  Daviess, KY
6015 Panama City, FL..........................................    0.8819
  Bay, FL
6020 Parkersburg-Marietta, WV-OH..............................    0.8007
  Washington, OH
  Wood, WV
6080 Pensacola, FL............................................    0.8819
  Escambia, FL
  Santa Rosa, FL
6120 Peoria-Pekin, IL.........................................    0.8699
  Peoria, IL
  Tazewell, IL
  Woodford, IL
6160 Philadelphia, PA-NJ......................................    1.0839
  Burlington, NJ
  Camden, NJ
  Gloucester, NJ
  Salem, NJ
  Bucks, PA
  Chester, PA
  Delaware, PA
  Montgomery, PA
  Philadelphia, PA
6200 Phoenix-Mesa, AZ.........................................    1.0088
  Maricopa, AZ
  Pinal, AZ
6240 Pine Bluff, AR...........................................    0.7833
  Jefferson, AR
6280 Pittsburgh, PA...........................................    0.8865
  Allegheny, PA
  Beaver, PA
  Butler, PA
  Fayette, PA
  Washington, PA
  Westmoreland, PA
6323 Pittsfield, MA...........................................    1.0390
  Berkshire, MA
6340 Pocatello, ID............................................    0.9006
  Bannock, ID
6360 Ponce, PR................................................    0.4689
  Guayanilla, PR
  Juana Diaz, PR
  Penuelas, PR
  Ponce, PR
  Villalba, PR
  Yauco, PR
6403 Portland, ME.............................................    0.9909
  Cumberland, ME
  Sagadahoc, ME
  York, ME
6440 Portland-Vancouver, OR-WA................................    1.1167
  Clackamas, OR
  Columbia, OR
  Multnomah, OR
  Washington, OR
  Yamhill, OR
  Clark, WA
6483 Providence-Warwick-Pawtucket, RI.........................    1.0932
  Bristol, RI
  Kent, RI
  Newport, RI
  Providence, RI
  Washington, RI
6520 Provo-Orem, UT...........................................    0.9936
  Utah, UT
6560 Pueblo, CO...............................................    0.9291
  Pueblo, CO
6580 Punta Gorda, FL..........................................    0.9472
  Charlotte, FL
6600 Racine, WI...............................................    0.9266
  Racine, WI
6640 Raleigh-Durham-Chapel Hill, NC...........................    0.9919
  Chatham, NC
  Durham, NC
  Franklin, NC
  Johnston, NC
  Orange, NC
  Wake, NC
6660 Rapid City, SD...........................................    0.8771
  Pennington, SD
6680 Reading, PA..............................................    0.9096
  Berks, PA
6690 Redding, CA..............................................    1.1306
  Shasta, CA
6720 Reno, NV.................................................    1.0639
  Washoe, NV
6740 Richland-Kennewick-Pasco, WA.............................    1.0566
  Benton, WA
  Franklin, WA
6760 Richmond-Petersburg, VA..................................    0.9311
  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.............................    1.1302
  Riverside, CA
  San Bernardino, CA
6800 Roanoke, VA..............................................    0.8664
  Botetourt, VA
  Roanoke, VA
  Roanoke City, VA
  Salem City, VA
6820 Rochester, MN............................................    1.1691
  Olmsted, MN
6840 Rochester, NY............................................    0.9392
  Genesee, NY
  Livingston, NY
  Monroe, NY
  Ontario, NY
  Orleans, NY
  Wayne, NY
6880 Rockford, IL.............................................    0.9627
  Boone, IL
  Ogle, IL
  Winnebago, IL
6895 Rocky Mount, NC..........................................    0.9039
  Edgecombe, NC
  Nash, NC
6920 Sacramento, CA...........................................    1.1797
  El Dorado, CA
  Placer, CA
  Sacramento, CA
6960 Saginaw-Bay City-Midland, MI.............................    0.9992
  Bay, MI
  Midland, MI
  Saginaw, MI
6980 St. Cloud, MN............................................    0.9468

[[Page 45583]]

 
  Benton, MN
  Stearns, MN
7000 St. Joseph, MO...........................................    0.8024
  Andrew, MO
  Buchanan, MO
7040 St. Louis, MO-IL.........................................    0.8996
  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................................................    1.0440
  Marion, OR
  Polk, OR
7120 Salinas, CA..............................................    1.4281
  Monterey, CA
7160 Salt Lake City-Ogden, UT.................................    0.9873
  Davis, UT
  Salt Lake, UT
  Weber, UT
7200 San Angelo, TX...........................................    0.8500
  Tom Green, TX
7240 San Antonio, TX..........................................    0.8834
  Bexar, TX
  Comal, TX
  Guadalupe, TX
  Wilson, TX
7320 San Diego, CA............................................    1.1102
  San Diego, CA
7360 San Francisco, CA........................................    1.4455
  Marin, CA
  San Francisco, CA
  San Mateo, CA
7400 San Jose, CA.............................................    1.4567
  Santa Clara, CA
7440 San Juan-Bayamon, PR.....................................    0.4880
  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...............    1.1383
  San Luis Obispo, CA
7480 Santa Barbara-Santa Maria-Lompoc, CA.....................    1.0399
  Santa Barbara, CA
7485 Santa Cruz-Watsonville, CA...............................    1.2890
  Santa Cruz, CA
7490 Santa Fe, NM.............................................    1.0610
  Los Alamos, NM
  Santa Fe, NM
7500 Santa Rosa, CA...........................................    1.2825
  Sonoma, CA
7510 Sarasota-Bradenton, FL...................................    0.9924
  Manatee, FL
  Sarasota, FL
7520 Savannah, GA.............................................    0.9433
  Bryan, GA
  Chatham, GA
  Effingham, GA
7560 Scranton--Wilkes-Barre--Hazleton, PA.....................    0.8378
  Columbia, PA
  Lackawanna, PA
  Luzerne, PA
  Wyoming, PA
7600 Seattle-Bellevue-Everett, WA.............................    1.1516
  Island, WA
  King, WA
  Snohomish, WA
7610 Sharon, PA...............................................    0.8344
  Mercer, PA
7620 Sheboygan, WI............................................    0.9266
  Sheboygan, WI
7640 Sherman-Denison, TX......................................    0.9661
  Grayson, TX
7680 Shreveport-Bossier City, LA..............................    0.9047
  Bossier, LA
  Caddo, LA
  Webster, LA
7720 Sioux City, IA-NE........................................    0.8956
  Woodbury, IA
  Dakota, NE
7760 Sioux Falls, SD..........................................    0.9271
  Lincoln, SD
  Minnehaha, SD
7800 South Bend, IN...........................................    0.9782
  St. Joseph, IN
7840 Spokane, WA..............................................    1.0857
  Spokane, WA
7880 Springfield, IL..........................................    0.8908
  Menard, IL
  Sangamon, IL
7920 Springfield, MO..........................................    0.8423
  Christian, MO
  Greene, MO
  Webster, MO
8003 Springfield, MA..........................................    1.0419
  Hampden, MA
  Hampshire, MA
8050 State College, PA........................................    0.8705
  Centre, PA
8080 Steubenville-Weirton, OH-WV (WV Hospitals)...............    0.8364
  Jefferson, OH
  Brooke, WV
  Hancock, WV
8120 Stockton-Lodi, CA........................................    1.0362
  San Joaquin, CA
8140 Sumter, SC...............................................    0.8464
  Sumter, SC
8160 Syracuse, NY.............................................    0.9374
  Cayuga, NY
  Madison, NY
  Onondaga, NY
  Oswego, NY
8200 Tacoma, WA...............................................    1.1071
  Pierce, WA
8240 Tallahassee, FL..........................................    0.8819
  Gadsden, FL
  Leon, FL
8280 Tampa-St. Petersburg-Clearwater, FL......................    0.9066
  Hernando, FL
  Hillsborough, FL
  Pasco, FL
  Pinellas, FL
8320 Terre Haute, IN..........................................    0.8788
  Clay, IN
  Vermillion, IN
  Vigo, IN
8360 Texarkana, AR-Texarkana, TX..............................    0.8117
  Miller, AR
  Bowie, TX
8400 Toledo, OH...............................................    0.9343
  Fulton, OH
  Lucas, OH
  Wood, OH
8440 Topeka, KS...............................................    0.9071
  Shawnee, KS
8480 Trenton, NJ..............................................    1.0474
  Mercer, NJ
8520 Tucson, AZ...............................................    0.9233
  Pima, AZ
8560 Tulsa, OK................................................    0.9148
  Creek, OK
  Osage, OK
  Rogers, OK
  Tulsa, OK
  Wagoner, OK
8600 Tuscaloosa, AL...........................................    0.8179
  Tuscaloosa, AL
8640 Tyler, TX................................................    0.9366
  Smith, TX
8680 Utica-Rome, NY...........................................    0.8491
  Herkimer, NY
  Oneida, NY
8720 Vallejo-Fairfield-Napa, CA...............................    1.3323
  Napa, CA
  Solano, CA
8735 Ventura, CA..............................................    1.1019
  Ventura, CA
8750 Victoria, TX.............................................    0.8151
  Victoria, TX
8760 Vineland-Millville-Bridgeton, NJ.........................    1.0363
  Cumberland, NJ
8780 Visalia-Tulare-Porterville, CA...........................    0.9927
  Tulare, CA
8800 Waco, TX.................................................    0.8360
  McLennan, TX
8840 Washington, DC-MD-VA-WV..................................    1.0860
  District of Columbia, DC

[[Page 45584]]

 
  Calvert, MD
  Charles, MD
  Frederick, MD
  Montgomery, MD
  Prince Georges, MD
  Alexandria City, VA
  Arlington, VA
  Clarke, VA
  Culpepper, 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.................................    0.8382
  Black Hawk, IA
8940 Wausau, WI...............................................    0.9653
  Marathon, WI
8960 West Palm Beach-Boca Raton, FL...........................    0.9759
  Palm Beach, FL
9000 Wheeling, WV-OH..........................................    0.7986
  Belmont, OH
  Marshall, WV
  Ohio, WV
9040 Wichita, KS..............................................    0.9200
  Butler, KS
  Harvey, KS
  Sedgwick, KS
9080 Wichita Falls, TX........................................    0.8307
  Archer, TX
  Wichita, TX
9140 Williamsport, PA.........................................    0.8344
  Lycoming, PA
9160 Wilmington-Newark, DE-MD.................................    1.0838
  New Castle, DE
  Cecil, MD
9200 Wilmington, NC...........................................    0.9524
  New Hanover, NC
  Brunswick, NC
9260 Yakima, WA...............................................    1.0346
  Yakima, WA
9270 Yolo, CA.................................................    0.9927
  Yolo, CA
9280 York, PA.................................................    0.9082
  York, PA
9320 Youngstown-Warren, OH....................................    0.9176
  Columbiana, OH
  Mahoning, OH
  Trumbull, OH
9340 Yuba City, CA............................................    1.0155
  Sutter, CA
  Yuba, CA
9360 Yuma, AZ.................................................    0.9233
  Yuma, AZ
------------------------------------------------------------------------


         Table 4H.--Pre-Reclassified Wage Index for Rural Areas
------------------------------------------------------------------------
                                                                  Wage
                         Nonurban area                            index
------------------------------------------------------------------------
Alabama.......................................................    0.7461
Alaska........................................................    1.1838
Arizona.......................................................    0.9233
Arkansas......................................................    0.7703
California....................................................    0.9927
Colorado......................................................    0.9291
Connecticut...................................................    1.2134
Delaware......................................................    0.9518
Florida.......................................................    0.8819
Georgia.......................................................    0.8560
Hawaii........................................................    0.9918
Idaho.........................................................    0.8937
Illinois......................................................    0.8221
Indiana.......................................................    0.8788
Iowa..........................................................    0.8382
Kansas........................................................    0.8041
Kentucky......................................................    0.7941
Louisiana.....................................................    0.7421
Maine.........................................................    0.8776
Maryland......................................................    0.9088
Massachusetts.................................................    1.0390
Michigan......................................................    0.8841
Minnesota.....................................................    0.9293
Mississippi...................................................    0.7747
Missouri......................................................    0.8024
Montana.......................................................    0.8765
Nebraska......................................................    0.8787
Nevada........................................................    0.9767
New Hampshire.................................................    0.9989
New Jersey \1\................................................  ........
New Mexico....................................................    0.8236
New York......................................................    0.8491
North Carolina................................................    0.8422
North Dakota..................................................    0.7746
Ohio..........................................................    0.8784
Oklahoma......................................................    0.7506
Oregon........................................................    0.9953
Pennsylvania..................................................    0.8344
Puerto Rico...................................................    0.4002
Rhode Island \1\..............................................  ........
South Carolina................................................    0.8464
South Dakota..................................................    0.8162
Tennessee.....................................................    0.7854
Texas.........................................................    0.7748
Utah..........................................................    0.8937
Vermont.......................................................    0.9269
Virginia......................................................    0.8464
Washington....................................................    1.0346
West Virginia.................................................    0.7986
Wisconsin.....................................................    0.9266
Wyoming.......................................................   0.9073
------------------------------------------------------------------------
\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 contian cases that could 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 45584]]



Table 5.--List of Diagnosis-Related Groups (DRGs), Relative Weighting Factors, and Geometric and Arthimetic Mean
                                              Length of Stay (LOS)
----------------------------------------------------------------------------------------------------------------
                                                                               Relative    Geometric  Arithmetic
       DRG          MDC            Type                   DRG title             weights    mean LOS    mean LOS
----------------------------------------------------------------------------------------------------------------
1...............       01  SURG                  CRANIOTOMY AGE 17 W CC.
2...............       01  SURG                  CRANIOTOMY AGE 17 W/O CC.
3...............       01  SURG *                CRANIOTOMY AGE 0-17........      1.9753       12.70       12.70
4...............       01  SURG                  NO LONGER VALID............      0.0000        0.00        0.00
5...............       01  SURG                  NO LONGER VALID............      0.0000        0.00        0.00
6...............       01  SURG                  CARPAL TUNNEL RELEASE......      0.8092        2.20        3.10
7...............       01  SURG                  PERIPH & CRANIAL NERVE &         2.6519        6.60        9.80
                                                  OTHER NERV SYST PROC W CC.
8...............       01  SURG                  PERIPH & CRANIAL NERVE &         1.5453        1.90        2.80
                                                  OTHER NERV SYST PROC W/O
                                                  CC.
9...............       01  MED                   SPINAL DISORDERS & INJURIES      1.4214        4.70        6.90
10..............       01  MED                   NERVOUS SYSTEM NEOPLASMS W       1.2448        4.80        6.50
                                                  CC.
11..............       01  MED                   NERVOUS SYSTEM NEOPLASMS W/      0.8571        3.00        4.10
                                                  O CC.
12..............       01  MED                   DEGENERATIVE NERVOUS SYSTEM      0.9259        4.50        5.90
                                                  DISORDERS.
13..............       01  MED                   MULTIPLE SCLEROSIS &             0.8176        4.00        5.00
                                                  CEREBELLAR ATAXIA.
14..............       01  MED                   INTRACRANIAL HEMORRHAGE &        1.2682        4.70        6.10
                                                  STROKE W INFARCT.
15..............       01  MED                   NONSPECIFIC CVA &                0.9677        3.90        4.90
                                                  PRECEREBRAL OCCLUSION W/O
                                                  INFARCT.

[[Page 45585]]

 
16..............       01  MED                   NONSPECIFIC CEREBROVASCULAR      1.2618        4.80        6.40
                                                  DISORDERS W CC.
17..............       01  MED                   NONSPECIFIC CEREBROVASCULAR      0.6991        2.50        3.20
                                                  DISORDERS W/O CC.
18..............       01  MED                   CRANIAL & PERIPHERAL NERVE       1.0026        4.20        5.50
                                                  DISORDERS W CC.
19..............       01  MED                   CRANIAL & PERIPHERAL NERVE       0.7041        2.80        3.50
                                                  DISORDERS W/O CC.
20..............       01  MED                   NERVOUS SYSTEM INFECTION         2.7394        8.00       10.50
                                                  EXCEPT VIRAL MENINGITIS.
21..............       01  MED                   VIRAL MENINGITIS...........      1.5138        5.00        6.60
22..............       01  MED                   HYPERTENSIVE ENCEPHALOPATHY      1.0737        3.90        5.10
23..............       01  MED                   NONTRAUMATIC STUPOR & COMA.      0.8239        3.20        4.30
24..............       01  MED                   SEIZURE & HEADACHE AGE 17 W CC.
25..............       01  MED                   SEIZURE & HEADACHE AGE 17 W/O CC.
26..............       01  MED                   SEIZURE & HEADACHE AGE 0-17      1.3730        2.20        4.10
27..............       01  MED                   TRAUMATIC STUPOR & COMA,         1.3370        3.20        5.20
                                                  COMA 1 HR.
28..............       01  MED                   TRAUMATIC STUPOR & COMA,         1.3386        4.40        6.10
                                                  COMA 1 HR AGE
                                                  <17 W CC.
29..............       01  MED                   TRAUMATIC STUPOR & COMA,         0.7087        2.70        3.50
                                                  COMA 1 HR AGE
                                                  <17 W/O CC.
30..............       01  MED *                 TRAUMATIC STUPOR & COMA,         0.3341        2.00        2.00
                                                  COMA <1 HR AGE 0-17.
31..............       01  MED                   CONCUSSION AGE 17 W CC.
32..............       01  MED                   CONCUSSION AGE 17 W/O CC.
33..............       01  MED *                 CONCUSSION AGE 0-17........      0.2098        1.60        1.60
34..............       01  MED                   OTHER DISORDERS OF NERVOUS       0.9931        3.70        5.00
                                                  SYSTEM W CC.
35..............       01  MED                   OTHER DISORDERS OF NERVOUS       0.6355        2.50        3.10
                                                  SYSTEM W/O CC.
36..............       02  SURG                  RETINAL PROCEDURES.........      0.6298        1.20        1.50
37..............       02  SURG                  ORBITAL PROCEDURES.........      1.0575        2.50        3.80
38..............       02  SURG                  PRIMARY IRIS PROCEDURES....      0.4669        1.90        2.80
39..............       02  SURG                  LENS PROCEDURES WITH OR          0.6285        1.50        2.10
                                                  WITHOUT VITRECTOMY.
40..............       02  SURG                  EXTRAOCULAR PROCEDURES           0.8937        2.70        3.80
                                                  EXCEPT ORBIT AGE 17.
41..............       02  SURG *                EXTRAOCULAR PROCEDURES           0.3401        1.60        1.60
                                                  EXCEPT ORBIT AGE 0-17.
42..............       02  SURG                  INTRAOCULAR PROCEDURES           0.7064        1.90        2.70
                                                  EXCEPT RETINA, IRIS & LENS.
43..............       02  MED                   HYPHEMA....................      0.5382        2.40        3.40
44..............       02  MED                   ACUTE MAJOR EYE INFECTIONS.      0.6597        4.00        5.00
45..............       02  MED                   NEUROLOGICAL EYE DISORDERS.      0.7250        2.50        3.10
46..............       02  MED                   OTHER DISORDERS OF THE EYE       0.7936        3.40        4.50
                                                  AGE 17 W CC.
47..............       02  MED                   OTHER DISORDERS OF THE EYE       0.5317        2.40        3.10
                                                  AGE 17 W/O CC.
48..............       02  MED *                 OTHER DISORDERS OF THE EYE       0.2996        2.90        2.90
                                                  AGE 0-17.
49..............       03  SURG                  MAJOR HEAD & NECK                1.7277        3.20        4.50
                                                  PROCEDURES.
50..............       03  SURG                  SIALOADENECTOMY............      0.8317        1.50        1.90
51..............       03  SURG                  SALIVARY GLAND PROCEDURES        0.8410        1.90        2.80
                                                  EXCEPT SIALOADENECTOMY.
52..............       03  SURG                  CLEFT LIP & PALATE REPAIR..      0.8018        1.40        1.80
53..............       03  SURG                  SINUS & MASTOID PROCEDURES       1.2520        2.20        3.60
                                                  AGE 17.
54..............       03  SURG *                SINUS & MASTOID PROCEDURES       0.4856        3.20        3.20
                                                  AGE 0-17.
55..............       03  SURG                  MISCELLANEOUS EAR, NOSE,         0.9247        2.00        3.00
                                                  MOUTH & THROAT PROCEDURES.
56..............       03  SURG                  RHINOPLASTY................      0.9233        1.90        2.90
57..............       03  SURG                  T&A PROC, EXCEPT                 1.1029        2.40        3.70
                                                  TONSILLECTOMY &/OR
                                                  ADENOIDECTOMY ONLY, AGE
                                                  17.
58..............       03  SURG *                T&A PROC, EXCEPT                 0.2757        1.50        1.50
                                                  TONSILLECTOMY &/OR
                                                  ADENOIDECTOMY ONLY, AGE 0-
                                                  17.
59..............       03  SURG                  TONSILLECTOMY &/OR               0.9557        1.90        2.70
                                                  ADENOIDECTOMY ONLY, AGE
                                                  17.
60..............       03  SURG *                TONSILLECTOMY &/OR               0.2099        1.50        1.50
                                                  ADENOIDECTOMY ONLY, AGE 0-
                                                  17.
61..............       03  SURG                  MYRINGOTOMY W TUBE               1.2334        3.10        5.20
                                                  INSERTION AGE 17.
62..............       03  SURG *                MYRINGOTOMY W TUBE               0.2973        1.30        1.30
                                                  INSERTION AGE 0-17.
63..............       03  SURG                  OTHER EAR, NOSE, MOUTH &         1.3759        3.00        4.40
                                                  THROAT O.R. PROCEDURES.
64..............       03  MED                   EAR, NOSE, MOUTH & THROAT        1.3089        4.30        6.50
                                                  MALIGNANCY.
65..............       03  MED                   DYSEQUILIBRIUM.............      0.5748        2.30        2.80
66..............       03  MED                   EPISTAXIS..................      0.5811        2.40        3.10
67..............       03  MED                   EPIGLOTTITIS...............      0.7780        2.90        3.70
68..............       03  MED                   OTITIS MEDIA & URI AGE           0.6531        3.10        3.90
                                                  >17 W CC.
69..............       03  MED                   OTITIS MEDIA & URI AGE           0.4987        2.50        3.00
                                                  >17 W/O CC.
70..............       03  MED                   OTITIS MEDIA & URI AGE 0-17      0.3188        2.00        2.40
71..............       03  MED                   LARYNGOTRACHEITIS..........      0.7065        2.50        3.40
72..............       03  MED                   NASAL TRAUMA & DEFORMITY...      0.6954        2.60        3.40
73..............       03  MED                   OTHER EAR, NOSE, MOUTH &         0.8184        3.30        4.50
                                                  THROAT DIAGNOSES AGE 17.
74..............       03  MED *                 OTHER EAR, NOSE, MOUTH &         0.3380        2.10        2.10
                                                  THROAT DIAGNOSES AGE 0-17.
75..............       04  SURG                  MAJOR CHEST PROCEDURES.....      3.0437        7.70       10.00
76..............       04  SURG                  OTHER RESP SYSTEM O.R.           2.8184        8.40       11.10
                                                  PROCEDURES W CC.
77..............       04  SURG                  OTHER RESP SYSTEM O.R.           1.2378        3.50        4.80
                                                  PROCEDURES W/O CC.
78..............       04  MED                   PULMONARY EMBOLISM.........      1.2731        5.60        6.60
79..............       04  MED                   RESPIRATORY INFECTIONS &         1.5974        6.70        8.50
                                                  INFLAMMATIONS AGE 17 W CC.

[[Page 45586]]

 
80..............       04  MED                   RESPIRATORY INFECTIONS &         0.8400        4.30        5.40
                                                  INFLAMMATIONS AGE 17 W/O CC.
81..............       04  MED *                 RESPIRATORY INFECTIONS &         1.5300        6.10        6.10
                                                  INFLAMMATIONS AGE 0-17.
82..............       04  MED                   RESPIRATORY NEOPLASMS......      1.3724        5.10        6.90
83..............       04  MED                   MAJOR CHEST TRAUMA W CC....      0.9620        4.30        5.40
84..............       04  MED                   MAJOR CHEST TRAUMA W/O CC..      0.5371        2.60        3.30
85..............       04  MED                   PLEURAL EFFUSION W CC......      1.1927        4.80        6.30
86..............       04  MED                   PLEURAL EFFUSION W/O CC....      0.6864        2.80        3.60
87..............       04  MED                   PULMONARY EDEMA &                1.3430        4.80        6.40
                                                  RESPIRATORY FAILURE.
88..............       04  MED                   CHRONIC OBSTRUCTIVE              0.9031        4.10        5.10
                                                  PULMONARY DISEASE.
89..............       04  MED                   SIMPLE PNEUMONIA & PLEURISY      1.0463        4.90        5.90
                                                  AGE 17 W CC.
90..............       04  MED                   SIMPLE PNEUMONIA & PLEURISY      0.6147        3.40        4.00
                                                  AGE 17 W/O CC.
91..............       04  MED                   SIMPLE PNEUMONIA & PLEURISY      0.7408        3.10        5.10
                                                  AGE 0-17.
92..............       04  MED                   INTERSTITIAL LUNG DISEASE W      1.2024        5.00        6.30
                                                  CC.
93..............       04  MED                   INTERSTITIAL LUNG DISEASE W/     0.7176        3.30        4.00
                                                  O CC.
94..............       04  MED                   PNEUMOTHORAX W CC..........      1.1340        4.70        6.30
95..............       04  MED                   PNEUMOTHORAX W/O CC........      0.6166        3.00        3.80
96..............       04  MED                   BRONCHITIS & ASTHMA AGE 17 W CC.
97..............       04  MED                   BRONCHITIS & ASTHMA AGE 17 W/O CC.
98..............       04  MED *                 BRONCHITIS & ASTHMA AGE 0-       0.9662        3.70        3.70
                                                  17.
99..............       04  MED                   RESPIRATORY SIGNS &              0.7032        2.40        3.20
                                                  SYMPTOMS W CC.
100.............       04  MED                   RESPIRATORY SIGNS &              0.5222        1.80        2.10
                                                  SYMPTOMS W/O CC.
101.............       04  MED                   OTHER RESPIRATORY SYSTEM         0.8654        3.30        4.40
                                                  DIAGNOSES W CC.
102.............       04  MED                   OTHER RESPIRATORY SYSTEM         0.5437        2.10        2.60
                                                  DIAGNOSES W/O CC.
103.............      PRE  SURG                  HEART TRANSPLANT...........     18.6081       26.10       42.40
104.............       05  SURG                  CARDIAC VALVE & OTH MAJOR        7.9351       12.20       14.40
                                                  CARDIOTHORACIC PROC W CARD
                                                  CATH.
105.............       05  SURG                  CARDIAC VALVE & OTH MAJOR        5.7088        8.20        9.90
                                                  CARDIOTHORACIC PROC W/O
                                                  CARD CATH.
106.............       05  SURG                  CORONARY BYPASS W PTCA.....      7.2936        9.60       11.40
107.............       05  SURG                  CORONARY BYPASS W CARDIAC        5.3751        9.20       10.40
                                                  CATH.
108.............       05  SURG                  OTHER CARDIOTHORACIC             5.3656        7.30        9.80
                                                  PROCEDURES.
109.............       05  SURG                  CORONARY BYPASS W/O PTCA OR      3.9401        6.70        7.70
                                                  CARDIAC CATH.
110.............       05  SURG                  MAJOR CARDIOVASCULAR             4.0492        6.20        8.90
                                                  PROCEDURES W CC.
111.............       05  SURG                  MAJOR CARDIOVASCULAR             2.4797        3.20        4.10
                                                  PROCEDURES W/O CC.
112.............       05  SURG                  NO LONGER VALID............      0.0000        0.00        0.00
113.............       05  SURG                  AMPUTATION FOR CIRC SYSTEM       3.0106       10.40       13.30
                                                  DISORDERS EXCEPT UPPER
                                                  LIMB & TOE.
114.............       05  SURG                  UPPER LIMB & TOE AMPUTATION      1.6436        6.30        8.70
                                                  FOR CIRC SYSTEM DISORDERS.
115.............       05  SURG                  PRM CARD PACEM IMPL W AMI/       3.5465        5.00        7.40
                                                  HR/SHOCK OR AICD LEAD OR
                                                  GNRTR.
116.............       05  SURG                  OTHER PERMANENT CARDIAC          2.3590        3.10        4.40
                                                  PACEMAKER IMPLANT.
117.............       05  SURG                  CARDIAC PACEMAKER REVISION       1.3951        2.60        4.30
                                                  EXCEPT DEVICE REPLACEMENT.
118.............       05  SURG                  CARDIAC PACEMAKER DEVICE         1.6089        2.00        2.90
                                                  REPLACEMENT.
119.............       05  SURG                  VEIN LIGATION & STRIPPING..      1.3739        3.20        5.30
120.............       05  SURG                  OTHER CIRCULATORY SYSTEM         2.3164        5.60        9.00
                                                  O.R. PROCEDURES.
121.............       05  MED                   CIRCULATORY DISORDERS W AMI      1.6169        5.30        6.60
                                                  & MAJOR COMP, DISCHARGED
                                                  ALIVE.
122.............       05  MED                   CIRCULATORY DISORDERS W AMI      1.0297        2.90        3.70
                                                  W/O MAJOR COMP, DISCHARGED
                                                  ALIVE.
123.............       05  MED                   CIRCULATORY DISORDERS W          1.5645        2.90        4.80
                                                  AMI, EXPIRED.
124.............       05  MED                   CIRCULATORY DISORDERS            1.4367        3.30        4.40
                                                  EXCEPT AMI, W CARD CATH &
                                                  COMPLEX DIAG.
125.............       05  MED                   CIRCULATORY DISORDERS            1.0947        2.20        2.80
                                                  EXCEPT AMI, W CARD CATH W/
                                                  O COMPLEX DIAG.
126.............       05  MED                   ACUTE & SUBACUTE                 2.5418        9.20       11.80
                                                  ENDOCARDITIS.
127.............       05  MED                   HEART FAILURE & SHOCK......      1.0265        4.20        5.30
128.............       05  MED                   DEEP VEIN THROMBOPHLEBITIS.      0.7285        4.60        5.50
129.............       05  MED                   CARDIAC ARREST, UNEXPLAINED      1.0229        1.70        2.60
130.............       05  MED                   PERIPHERAL VASCULAR              0.9505        4.50        5.70
                                                  DISORDERS W CC.
131.............       05  MED                   PERIPHERAL VASCULAR              0.5676        3.30        4.10
                                                  DISORDERS W/O CC.
132.............       05  MED                   ATHEROSCLEROSIS W CC.......      0.6422        2.30        2.90
133.............       05  MED                   ATHEROSCLEROSIS W/O CC.....      0.5559        1.80        2.30
134.............       05  MED                   HYPERTENSION...............      0.5954        2.50        3.20
135.............       05  MED                   CARDIAC CONGENITAL &             0.9282        3.40        4.50
                                                  VALVULAR DISORDERS AGE 17 W CC.
136.............       05  MED                   CARDIAC CONGENITAL &             0.5740        2.20        2.70
                                                  VALVULAR DISORDERS AGE 17 W/O CC.

[[Page 45587]]

 
137.............       05  MED *                 CARDIAC CONGENITAL &             0.8243        3.30        3.30
                                                  VALVULAR DISORDERS AGE 0-
                                                  17.
138.............       05  MED                   CARDIAC ARRHYTHMIA &             0.8355        3.10        4.00
                                                  CONDUCTION DISORDERS W CC.
139.............       05  MED                   CARDIAC ARRHYTHMIA &             0.5160        2.00        2.50
                                                  CONDUCTION DISORDERS W/O
                                                  CC.
140.............       05  MED                   ANGINA PECTORIS............      0.5305        2.00        2.50
141.............       05  MED                   SYNCOPE & COLLAPSE W CC....      0.7473        2.80        3.60
142.............       05  MED                   SYNCOPE & COLLAPSE W/O CC..      0.5761        2.10        2.60
143.............       05  MED                   CHEST PAIN.................      0.5480        1.70        2.10
144.............       05  MED                   OTHER CIRCULATORY SYSTEM         1.2260        3.90        5.60
                                                  DIAGNOSES W CC.
145.............       05  MED                   OTHER CIRCULATORY SYSTEM         0.5787        2.00        2.60
                                                  DIAGNOSES W/O CC.
146.............       06  SURG                  RECTAL RESECTION W CC......      2.7376        8.80       10.20
147.............       06  SURG                  RECTAL RESECTION W/O CC....      1.5375        5.60        6.20
148.............       06  SURG                  MAJOR SMALL & LARGE BOWEL        3.4025       10.10       12.30
                                                  PROCEDURES W CC.
149.............       06  SURG                  MAJOR SMALL & LARGE BOWEL        1.4590        5.80        6.30
                                                  PROCEDURES W/O CC.
150.............       06  SURG                  PERITONEAL ADHESIOLYSIS W        2.8711        9.20       11.30
                                                  CC.
151.............       06  SURG                  PERITONEAL ADHESIOLYSIS W/O      1.3061        4.40        5.60
                                                  CC.
152.............       06  SURG                  MINOR SMALL & LARGE BOWEL        1.9134        6.90        8.40
                                                  PROCEDURES W CC.
153.............       06  SURG                  MINOR SMALL & LARGE BOWEL        1.1310        4.70        5.30
                                                  PROCEDURES W/O CC.
154.............       06  SURG                  STOMACH, ESOPHAGEAL &            4.0212        9.90       13.30
                                                  DUODENAL PROCEDURES AGE
                                                  17 W CC.
155.............       06  SURG                  STOMACH, ESOPHAGEAL &            1.3043        3.00        4.10
                                                  DUODENAL PROCEDURES AGE
                                                  17 W/O CC.
156.............       06  SURG *                STOMACH, ESOPHAGEAL &            0.8489        6.00        6.00
                                                  DUODENAL PROCEDURES AGE 0-
                                                  17.
157.............       06  SURG                  ANAL & STOMAL PROCEDURES W       1.3152        4.00        5.80
                                                  CC.
158.............       06  SURG                  ANAL & STOMAL PROCEDURES W/      0.6517        2.00        2.60
                                                  O CC.
159.............       06  SURG                  HERNIA PROCEDURES EXCEPT         1.3744        3.80        5.10
                                                  INGUINAL & FEMORAL AGE 17 W CC.
160.............       06  SURG                  HERNIA PROCEDURES EXCEPT         0.8219        2.20        2.70
                                                  INGUINAL & FEMORAL AGE 17 W/O CC.
161.............       06  SURG                  INGUINAL & FEMORAL HERNIA        1.1676        3.00        4.30
                                                  PROCEDURES AGE 17 W CC.
162.............       06  SURG                  INGUINAL & FEMORAL HERNIA        0.6446        1.60        1.90
                                                  PROCEDURES AGE 17 W/O CC.
163.............       06  SURG *                HERNIA PROCEDURES AGE 0-17.      0.6965        2.10        2.10
164.............       06  SURG                  APPENDECTOMY W COMPLICATED       2.3306        7.00        8.40
                                                  PRINCIPAL DIAG W CC.
165.............       06  SURG                  APPENDECTOMY W COMPLICATED       1.2302        3.90        4.50
                                                  PRINCIPAL DIAG W/O CC.
166.............       06  SURG                  APPENDECTOMY W/O                 1.4317        3.60        4.70
                                                  COMPLICATED PRINCIPAL DIAG
                                                  W CC.
167.............       06  SURG                  APPENDECTOMY W/O                 0.8889        2.00        2.40
                                                  COMPLICATED PRINCIPAL DIAG
                                                  W/O CC.
168.............       03  SURG                  MOUTH PROCEDURES W CC......      1.3158        3.30        4.90
169.............       03  SURG                  MOUTH PROCEDURES W/O CC....      0.7525        1.80        2.40
170.............       06  SURG                  OTHER DIGESTIVE SYSTEM O.R.      2.8245        7.50       10.90
                                                  PROCEDURES W CC.
171.............       06  SURG                  OTHER DIGESTIVE SYSTEM O.R.      1.1912        3.30        4.30
                                                  PROCEDURES W/O CC.
172.............       06  MED                   DIGESTIVE MALIGNANCY W CC..      1.3670        5.20        7.00
173.............       06  MED                   DIGESTIVE MALIGNANCY W/O CC      0.7528        2.80        3.80
174.............       06  MED                   G.I. HEMORRHAGE W CC.......      1.0025        3.90        4.80
175.............       06  MED                   G.I. HEMORRHAGE W/O CC.....      0.5587        2.50        2.90
176.............       06  MED                   COMPLICATED PEPTIC ULCER...      1.0998        4.10        5.20
177.............       06  MED                   UNCOMPLICATED PEPTIC ULCER       0.9259        3.70        4.60
                                                  W CC.
178.............       06  MED                   UNCOMPLICATED PEPTIC ULCER       0.6940        2.60        3.10
                                                  W/O CC.
179.............       06  MED                   INFLAMMATORY BOWEL DISEASE.      1.0885        4.60        6.00
180.............       06  MED                   G.I. OBSTRUCTION W CC......      0.9642        4.20        5.50
181.............       06  MED                   G.I. OBSTRUCTION W/O CC....      0.5376        2.80        3.40
182.............       06  MED                   ESOPHAGITIS, GASTROENT &         0.8223        3.40        4.40
                                                  MISC DIGEST DISORDERS AGE
                                                  17 W CC.
183.............       06  MED                   ESOPHAGITIS, GASTROENT &         0.5759        2.30        2.90
                                                  MISC DIGEST DISORDERS AGE
                                                  17 W/O CC.
184.............       06  MED                   ESOPHAGITIS, GASTROENT &         0.4813        2.40        3.30
                                                  MISC DIGEST DISORDERS AGE
                                                  0-17.
185.............       03  MED                   DENTAL & ORAL DIS EXCEPT         0.8685        3.30        4.70
                                                  EXTRACTIONS &
                                                  RESTORATIONS, AGE 17.
186.............       03  MED *                 DENTAL & ORAL DIS EXCEPT         0.3236        2.90        2.90
                                                  EXTRACTIONS &
                                                  RESTORATIONS, AGE 0-17.
187.............       03  MED                   DENTAL EXTRACTIONS &             0.7778        3.00        4.00
                                                  RESTORATIONS.
188.............       06  MED                   OTHER DIGESTIVE SYSTEM           1.1088        4.10        5.60
                                                  DIAGNOSES AGE 17 W CC.
189.............       06  MED                   OTHER DIGESTIVE SYSTEM           0.5987        2.40        3.10
                                                  DIAGNOSES AGE 17 W/O CC.
190.............       06  MED                   OTHER DIGESTIVE SYSTEM           0.8104        3.70        5.20
                                                  DIAGNOSES AGE 0-17.
191.............       07  SURG                  PANCREAS, LIVER & SHUNT          4.2787        9.80       13.80
                                                  PROCEDURES W CC.
192.............       07  SURG                  PANCREAS, LIVER & SHUNT          1.8025        4.70        6.20
                                                  PROCEDURES W/O CC.
193.............       07  SURG                  BILIARY TRACT PROC EXCEPT        3.4211       10.40       12.80
                                                  ONLY CHOLECYST W OR W/O
                                                  C.D.E. W CC.

[[Page 45588]]

 
194.............       07  SURG                  BILIARY TRACT PROC EXCEPT        1.6030        5.70        6.70
                                                  ONLY CHOLECYST W OR W/O
                                                  C.D.E. W/O CC.
195.............       07  SURG                  CHOLECYSTECTOMY W C.D.E. W       3.0613        8.70       10.60
                                                  CC.
196.............       07  SURG                  CHOLECYSTECTOMY W C.D.E. W/      1.6117        4.80        5.60
                                                  O CC.
197.............       07  SURG                  CHOLECYSTECTOMY EXCEPT BY        2.5547        7.50        9.20
                                                  LAPAROSCOPE W/O C.D.E. W
                                                  CC.
198.............       07  SURG                  CHOLECYSTECTOMY EXCEPT BY        1.1831        3.80        4.40
                                                  LAPAROSCOPE W/O C.D.E. W/O
                                                  CC.
199.............       07  SURG                  HEPATOBILIARY DIAGNOSTIC         2.3953        7.00        9.80
                                                  PROCEDURE FOR MALIGNANCY.
200.............       07  SURG                  HEPATOBILIARY DIAGNOSTIC         3.0415        6.70       10.50
                                                  PROCEDURE FOR NON-
                                                  MALIGNANCY.
201.............       07  SURG                  OTHER HEPATOBILIARY OR           3.6841       10.20       14.20
                                                  PANCREAS O.R. PROCEDURES.
202.............       07  MED                   CIRRHOSIS & ALCOHOLIC            1.3120        4.80        6.40
                                                  HEPATITIS.
203.............       07  MED                   MALIGNANCY OF HEPATOBILIARY      1.3482        5.00        6.70
                                                  SYSTEM OR PANCREAS.
204.............       07  MED                   DISORDERS OF PANCREAS            1.1675        4.40        5.80
                                                  EXCEPT MALIGNANCY.
205.............       07  MED                   DISORDERS OF LIVER EXCEPT        1.2095        4.60        6.20
                                                  MALIG, CIRR, ALC HEPA W CC.
206.............       07  MED                   DISORDERS OF LIVER EXCEPT        0.7071        2.90        3.80
                                                  MALIG, CIRR, ALC HEPA W/O
                                                  CC.
207.............       07  MED                   DISORDERS OF THE BILIARY         1.1539        4.00        5.30
                                                  TRACT W CC.
208.............       07  MED                   DISORDERS OF THE BILIARY         0.6601        2.30        2.90
                                                  TRACT W/O CC.
209.............       08  SURG                  MAJOR JOINT & LIMB               2.0327        4.40        4.90
                                                  REATTACHMENT PROCEDURES OF
                                                  LOWER EXTREMITY.
210.............       08  SURG                  HIP & FEMUR PROCEDURES           1.8477        6.10        7.00
                                                  EXCEPT MAJOR JOINT AGE 17 W CC.
211.............       08  SURG                  HIP & FEMUR PROCEDURES           1.2544        4.50        4.90
                                                  EXCEPT MAJOR JOINT AGE 17 W/O CC.
212.............       08  SURG                  HIP & FEMUR PROCEDURES           1.4152        3.20        6.40
                                                  EXCEPT MAJOR JOINT AGE 0-
                                                  17.
213.............       08  SURG                  AMPUTATION FOR                   1.8904        6.70        9.20
                                                  MUSCULOSKELETAL SYSTEM &
                                                  CONN TISSUE DISORDERS.
214.............       08  SURG                  NO LONGER VALID............      0.0000        0.00        0.00
215.............       08  SURG                  NO LONGER VALID............      0.0000        0.00        0.00
216.............       08  SURG                  BIOPSIES OF MUSCULOSKELETAL      2.1107        5.00        8.00
                                                  SYSTEM & CONNECTIVE TISSUE.
217.............       08  SURG                  WND DEBRID & SKN GRFT            3.0020        9.00       13.40
                                                  EXCEPT HAND, FOR
                                                  MUSCSKELET & CONN TISS DIS.
218.............       08  SURG                  LOWER EXTREM & HUMER PROC        1.5750        4.30        5.50
                                                  EXCEPT HIP, FOOT, FEMUR
                                                  AGE 17 W CC.
219.............       08  SURG                  LOWER EXTREM & HUMER PROC        1.0258        2.70        3.20
                                                  EXCEPT HIP, FOOT, FEMUR
                                                  AGE 17 W/O CC.
220.............       08  SURG *                LOWER EXTREM & HUMER PROC        0.5881        5.30        5.30
                                                  EXCEPT HIP, FOOT, FEMUR
                                                  AGE 0-17.
221.............       08  SURG                  NO LONGER VALID............      0.0000        0.00        0.00
222.............       08  SURG                  NO LONGER VALID............      0.0000        0.00        0.00
223.............       08  SURG                  MAJOR SHOULDER/ELBOW PROC,       1.0573        2.20        3.00
                                                  OR OTHER UPPER EXTREMITY
                                                  PROC W CC.
224.............       08  SURG                  SHOULDER, ELBOW OR FOREARM       0.7898        1.60        1.90
                                                  PROC, EXC MAJOR JOINT
                                                  PROC, W/O CC.
225.............       08  SURG                  FOOT PROCEDURES............      1.1704        3.60        5.30
226.............       08  SURG                  SOFT TISSUE PROCEDURES W CC      1.5529        4.50        6.60
227.............       08  SURG                  SOFT TISSUE PROCEDURES W/O       0.8190        2.10        2.60
                                                  CC.
228.............       08  SURG                  MAJOR THUMB OR JOINT PROC,       1.1639        2.70        4.20
                                                  OR OTH HAND OR WRIST PROC
                                                  W CC.
229.............       08  SURG                  HAND OR WRIST PROC, EXCEPT       0.7064        1.80        2.30
                                                  MAJOR JOINT PROC, W/O CC.
230.............       08  SURG                  LOCAL EXCISION & REMOVAL OF      1.3147        3.60        5.60
                                                  INT FIX DEVICES OF HIP &
                                                  FEMUR.
231.............       08  SURG                  NO LONGER VALID............      0.0000        0.00        0.00
232.............       08  SURG                  ARTHROSCOPY................      0.9674        1.80        2.70
233.............       08  SURG                  OTHER MUSCULOSKELET SYS &        2.0024        5.00        7.40
                                                  CONN TISS O.R. PROC W CC.
234.............       08  SURG                  OTHER MUSCULOSKELET SYS &        1.1977        2.20        3.10
                                                  CONN TISS O.R. PROC W/O CC.
235.............       08  MED                   FRACTURES OF FEMUR.........      0.7580        3.80        4.90
236.............       08  MED                   FRACTURES OF HIP & PELVIS..      0.7358        3.90        4.80
237.............       08  MED                   SPRAINS, STRAINS, &              0.5983        2.90        3.70
                                                  DISLOCATIONS OF HIP,
                                                  PELVIS & THIGH.
238.............       08  MED                   OSTEOMYELITIS..............      1.3564        6.50        8.70
239.............       08  MED                   PATHOLOGICAL FRACTURES &         1.0614        5.10        6.40
                                                  MUSCULOSKELETAL & CONN
                                                  TISS MALIGNANCY.
240.............       08  MED                   CONNECTIVE TISSUE DISORDERS      1.3153        4.90        6.70
                                                  W CC.
241.............       08  MED                   CONNECTIVE TISSUE DISORDERS      0.6358        3.00        3.80
                                                  W/O CC.

[[Page 45589]]

 
242.............       08  MED                   SEPTIC ARTHRITIS...........      1.1695        5.30        6.90
243.............       08  MED                   MEDICAL BACK PROBLEMS......      0.7525        3.70        4.70
244.............       08  MED                   BONE DISEASES & SPECIFIC         0.7155        3.70        4.70
                                                  ARTHROPATHIES W CC.
245.............       08  MED                   BONE DISEASES & SPECIFIC         0.4786        2.60        3.30
                                                  ARTHROPATHIES W/O CC.
246.............       08  MED                   NON-SPECIFIC ARTHROPATHIES.      0.6063        3.00        3.80
247.............       08  MED                   SIGNS & SYMPTOMS OF              0.5724        2.60        3.30
                                                  MUSCULOSKELETAL SYSTEM &
                                                  CONN TISSUE.
248.............       08  MED                   TENDONITIS, MYOSITIS &           0.8585        3.80        4.90
                                                  BURSITIS.
249.............       08  MED                   AFTERCARE, MUSCULOSKELETAL       0.6744        2.50        3.60
                                                  SYSTEM & CONNECTIVE TISSUE.
250.............       08  MED                   FX, SPRN, STRN & DISL OF         0.7091        3.20        4.10
                                                  FOREARM, HAND, FOOT AGE
                                                  17 W CC.
251.............       08  MED                   FX, SPRN, STRN & DISL OF         0.4578        2.30        2.80
                                                  FOREARM, HAND, FOOT AGE
                                                  17 W/O CC.
252.............       08  MED *                 FX, SPRN, STRN & DISL OF         0.2553        1.80        1.80
                                                  FOREARM, HAND, FOOT AGE 0-
                                                  17.
253.............       08  MED                   FX, SPRN, STRN & DISL OF         0.7581        3.70        4.70
                                                  UPARM, LOWLEG EX FOOT AGE
                                                  17 W CC.
254.............       08  MED                   FX, SPRN, STRN & DISL OF         0.4464        2.60        3.20
                                                  UPARM, LOWLEG EX FOOT AGE
                                                  17 W/O CC.
255.............       08  MED *                 FX, SPRN, STRN & DISL OF         0.2974        2.90        2.90
                                                  UPARM, LOWLEG EX FOOT AGE
                                                  0-17.
256.............       08  MED                   OTHER MUSCULOSKELETAL            0.8190        3.80        5.10
                                                  SYSTEM & CONNECTIVE TISSUE
                                                  DIAGNOSES.
257.............       09  SURG                  TOTAL MASTECTOMY FOR             0.8913        2.10        2.60
                                                  MALIGNANCY W CC.
258.............       09  SURG                  TOTAL MASTECTOMY FOR             0.7018        1.60        1.80
                                                  MALIGNANCY W/O CC.
259.............       09  SURG                  SUBTOTAL MASTECTOMY FOR          0.9420        1.80        2.70
                                                  MALIGNANCY W CC.
260.............       09  SURG                  SUBTOTAL MASTECTOMY FOR          0.6854        1.20        1.40
                                                  MALIGNANCY W/O CC.
261.............       09  SURG                  BREAST PROC FOR NON-             0.8944        1.60        2.10
                                                  MALIGNANCY EXCEPT BIOPSY &
                                                  LOCAL EXCISION.
262.............       09  SURG                  BREAST BIOPSY & LOCAL            0.9533        2.90        4.30
                                                  EXCISION FOR NON-
                                                  MALIGNANCY.
263.............       09  SURG                  SKIN GRAFT &/OR DEBRID FOR       2.0556        8.30       11.50
                                                  SKN ULCER OR CELLULITIS W
                                                  CC.
264.............       09  SURG                  SKIN GRAFT &/OR DEBRID FOR       1.0605        5.00        6.60
                                                  SKN ULCER OR CELLULITIS W/
                                                  O CC.
265.............       09  SURG                  SKIN GRAFT &/OR DEBRID           1.5984        4.20        6.60
                                                  EXCEPT FOR SKIN ULCER OR
                                                  CELLULITIS W CC.
266.............       09  SURG                  SKIN GRAFT &/OR DEBRID           0.8791        2.30        3.20
                                                  EXCEPT FOR SKIN ULCER OR
                                                  CELLULITIS W/O CC.
267.............       09  SURG                  PERIANAL & PILONIDAL             0.9574        2.90        4.50
                                                  PROCEDURES.
268.............       09  SURG                  SKIN, SUBCUTANEOUS TISSUE &      1.1513        2.40        3.80
                                                  BREAST PLASTIC PROCEDURES.
269.............       09  SURG                  OTHER SKIN, SUBCUT TISS &        1.7747        6.00        8.50
                                                  BREAST PROC W CC.
270.............       09  SURG                  OTHER SKIN, SUBCUT TISS &        0.8129        2.50        3.60
                                                  BREAST PROC W/O CC.
271.............       09  MED                   SKIN ULCERS................      1.0280        5.60        7.20
272.............       09  MED                   MAJOR SKIN DISORDERS W CC..      1.0185        4.60        6.00
273.............       09  MED                   MAJOR SKIN DISORDERS W/O CC      0.6192        3.00        3.90
274.............       09  MED                   MALIGNANT BREAST DISORDERS       1.1574        4.70        6.50
                                                  W CC.
275.............       09  MED                   MALIGNANT BREAST DISORDERS       0.5729        2.40        3.40
                                                  W/O CC.
276.............       09  MED                   NON-MALIGANT BREAST              0.6471        3.50        4.50
                                                  DISORDERS.
277.............       09  MED                   CELLULITIS AGE 17 W CC.
278.............       09  MED                   CELLULITIS AGE 17 W/O CC.
279.............       09  MED                   CELLULITIS AGE 0-17........      0.7779        4.00        5.30
280.............       09  MED                   TRAUMA TO THE SKIN, SUBCUT       0.7109        3.20        4.10
                                                  TISS & BREAST AGE 17 W CC.
281.............       09  MED                   TRAUMA TO THE SKIN, SUBCUT       0.4866        2.30        2.90
                                                  TISS & BREAST AGE 17 W/O CC.
282.............       09  MED *                 TRAUMA TO THE SKIN, SUBCUT       0.2586        2.20        2.20
                                                  TISS & BREAST AGE 0-17.
283.............       09  MED                   MINOR SKIN DISORDERS W CC..      0.7322        3.50        4.70
284.............       09  MED                   MINOR SKIN DISORDERS W/O CC      0.4215        2.30        2.90
285.............       10  SURG                  AMPUTAT OF LOWER LIMB FOR        2.0825        7.90       10.60
                                                  ENDOCRINE, NUTRIT,&
                                                  METABOL DISORDERS.
286.............       10  SURG                  ADRENAL & PITUITARY              2.0342        4.40        5.90
                                                  PROCEDURES.
287.............       10  SURG                  SKIN GRAFTS & WOUND DEBRID       1.8899        7.70       10.30
                                                  FOR ENDOC, NUTRIT & METAB
                                                  DISORDERS.
288.............       10  SURG                  O.R. PROCEDURES FOR OBESITY      2.1498        3.90        5.00
289.............       10  SURG                  PARATHYROID PROCEDURES.....      0.9441        1.80        2.70
290.............       10  SURG                  THYROID PROCEDURES.........      0.8938        1.70        2.20
291.............       10  SURG                  THYROGLOSSAL PROCEDURES....      0.6468        1.40        1.60
292.............       10  SURG                  OTHER ENDOCRINE, NUTRIT &        2.7336        7.30       10.60
                                                  METAB O.R. PROC W CC.
293.............       10  SURG                  OTHER ENDOCRINE, NUTRIT &        1.3896        3.20        4.70
                                                  METAB O.R. PROC W/O CC.
294.............       10  MED                   DIABETES AGE 35.      0.7800        3.50        4.60

[[Page 45590]]

 
295.............       10  MED                   DIABETES AGE 0-35..........      0.7975        3.00        4.00
296.............       10  MED                   NUTRITIONAL & MISC               0.8639        4.00        5.10
                                                  METABOLIC DISORDERS AGE
                                                  17 W CC.
297.............       10  MED                   NUTRITIONAL & MISC               0.5085        2.70        3.30
                                                  METABOLIC DISORDERS AGE
                                                  17 W/O CC.
298.............       10  MED                   NUTRITIONAL & MISC               0.4537        2.40        3.10
                                                  METABOLIC DISORDERS AGE 0-
                                                  17.
299.............       10  MED                   INBORN ERRORS OF METABOLISM      0.9466        3.80        5.50
300.............       10  MED                   ENDOCRINE DISORDERS W CC...      1.1001        4.70        6.20
301.............       10  MED                   ENDOCRINE DISORDERS W/O CC.      0.6158        2.80        3.60
302.............       11  SURG                  KIDNEY TRANSPLANT..........      3.2343        7.20        8.50
303.............       11  SURG                  KIDNEY, URETER & MAJOR           2.3659        6.40        8.00
                                                  BLADDER PROCEDURES FOR
                                                  NEOPLASM.
304.............       11  SURG                  KIDNEY, URETER & MAJOR           2.3856        6.20        8.90
                                                  BLADDER PROC FOR NON-NEOPL
                                                  W CC.
305.............       11  SURG                  KIDNEY, URETER & MAJOR           1.1854        2.80        3.60
                                                  BLADDER PROC FOR NON-NEOPL
                                                  W/O CC.
306.............       11  SURG                  PROSTATECTOMY W CC.........      1.2257        3.50        5.40
307.............       11  SURG                  PROSTATECTOMY W/O CC.......      0.6145        1.70        2.10
308.............       11  SURG                  MINOR BLADDER PROCEDURES W       1.5993        4.00        6.20
                                                  CC.
309.............       11  SURG                  MINOR BLADDER PROCEDURES W/      0.8991        1.70        2.10
                                                  O CC.
310.............       11  SURG                  TRANSURETHRAL PROCEDURES W       1.1502        2.90        4.40
                                                  CC.
311.............       11  SURG                  TRANSURETHRAL PROCEDURES W/      0.6258        1.50        1.80
                                                  O CC.
312.............       11  SURG                  URETHRAL PROCEDURES, AGE         1.0841        3.00        4.50
                                                  17 W CC.
313.............       11  SURG                  URETHRAL PROCEDURES, AGE         0.6814        1.70        2.20
                                                  17 W/O CC.
314.............       11  SURG *                URETHRAL PROCEDURES, AGE 0-      0.4984        2.30        2.30
                                                  17.
315.............       11  SURG                  OTHER KIDNEY & URINARY           2.0796        3.70        7.00
                                                  TRACT O.R. PROCEDURES.
316.............       11  MED                   RENAL FAILURE..............      1.2987        4.90        6.60
317.............       11  MED                   ADMIT FOR RENAL DIALYSIS...      0.8503        2.40        3.60
318.............       11  MED                   KIDNEY & URINARY TRACT           1.1871        4.40        6.10
                                                  NEOPLASMS W CC.
319.............       11  MED                   KIDNEY & URINARY TRACT           0.6771        2.20        2.90
                                                  NEOPLASMS W/O CC.
320.............       11  MED                   KIDNEY & URINARY TRACT           0.8853        4.30        5.40
                                                  INFECTIONS AGE 17 W CC.
321.............       11  MED                   KIDNEY & URINARY TRACT           0.5685        3.10        3.70
                                                  INFECTIONS AGE 17 W/O CC.
322.............       11  MED                   KIDNEY & URINARY TRACT           0.4625        2.80        3.30
                                                  INFECTIONS AGE 0-17.
323.............       11  MED                   URINARY STONES W CC, &/OR        0.8088        2.40        3.20
                                                  ESW LITHOTRIPSY.
324.............       11  MED                   URINARY STONES W/O CC......      0.4797        1.60        1.90
325.............       11  MED                   KIDNEY & URINARY TRACT           0.6553        2.90        3.80
                                                  SIGNS & SYMPTOMS AGE 17 W CC.
326.............       11  MED                   KIDNEY & URINARY TRACT           0.4206        2.10        2.60
                                                  SIGNS & SYMPTOMS AGE 17 W/O CC.
327.............       11  MED *                 KIDNEY & URINARY TRACT           0.3727        3.10        3.10
                                                  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 0-17      0.3210        1.60        1.60
331.............       11  MED                   OTHER KIDNEY & URINARY           1.0618        4.20        5.60
                                                  TRACT DIAGNOSES AGE 17 W CC.
332.............       11  MED                   OTHER KIDNEY & URINARY           0.5982        2.40        3.20
                                                  TRACT DIAGNOSES AGE 17 W/O CC.
333.............       11  MED                   OTHER KIDNEY & URINARY           0.9483        3.70        5.70
                                                  TRACT DIAGNOSES AGE 0-17.
334.............       12  SURG                  MAJOR MALE PELVIC                1.4810        3.90        4.60
                                                  PROCEDURES W CC.
335.............       12  SURG                  MAJOR MALE PELVIC                1.0835        2.80        3.00
                                                  PROCEDURES W/O CC.
336.............       12  SURG                  TRANSURETHRAL PROSTATECTOMY      0.8595        2.60        3.40
                                                  W CC.
337.............       12  SURG                  TRANSURETHRAL PROSTATECTOMY      0.5869        1.80        2.00
                                                  W/O CC.
338.............       12  SURG                  TESTES PROCEDURES, FOR           1.2316        3.50        5.50
                                                  MALIGNANCY.
339.............       12  SURG                  TESTES PROCEDURES, NON-          1.1345        2.90        4.80
                                                  MALIGNANCY AGE 17.
340.............       12  SURG *                TESTES PROCEDURES, NON-          0.2853        2.40        2.40
                                                  MALIGNANCY AGE 0-17.
341.............       12  SURG                  PENIS PROCEDURES...........      1.2739        1.90        3.20
342.............       12  SURG                  CIRCUMCISION AGE 17.
343.............       12  SURG *                CIRCUMCISION AGE 0-17......      0.1551        1.70        1.70
344.............       12  SURG                  OTHER MALE REPRODUCTIVE          1.3306        1.60        2.50
                                                  SYSTEM O.R. PROCEDURES FOR
                                                  MALIGNANCY.
345.............       12  SURG                  OTHER MALE REPRODUCTIVE          1.1671        3.00        4.90
                                                  SYSTEM O.R. PROC EXCEPT
                                                  FOR MALIGNANCY.
346.............       12  MED                   MALIGNANCY, MALE                 1.0213        4.50        5.90
                                                  REPRODUCTIVE SYSTEM, W CC.
347.............       12  MED                   MALIGNANCY, MALE                 0.5417        2.20        3.00
                                                  REPRODUCTIVE SYSTEM, W/O
                                                  CC.
348.............       12  MED                   BENIGN PROSTATIC                 0.7472        3.30        4.40
                                                  HYPERTROPHY W CC.
349.............       12  MED                   BENIGN PROSTATIC                 0.4608        2.00        2.50
                                                  HYPERTROPHY W/O CC.
350.............       12  MED                   INFLAMMATION OF THE MALE         0.7370        3.60        4.50
                                                  REPRODUCTIVE SYSTEM.
351.............       12  MED *                 STERILIZATION, MALE........      0.2379        1.30        1.30
352.............       12  MED                   OTHER MALE REPRODUCTIVE          0.7097        2.90        4.00
                                                  SYSTEM DIAGNOSES.
353.............       13  SURG                  PELVIC EVISCERATION,             1.8390        4.90        6.50
                                                  RADICAL HYSTERECTOMY &
                                                  RADICAL VULVECTOMY.

[[Page 45591]]

 
354.............       13  SURG                  UTERINE, ADNEXA PROC FOR         1.4808        4.70        5.70
                                                  NON-OVARIAN/ADNEXAL MALIG
                                                  W CC.
355.............       13  SURG                  UTERINE, ADNEXA PROC FOR         0.8912        3.00        3.20
                                                  NON-OVARIAN/ADNEXAL MALIG
                                                  W/O CC.
356.............       13  SURG                  FEMALE REPRODUCTIVE SYSTEM       0.7556        1.80        2.10
                                                  RECONSTRUCTIVE PROCEDURES.
357.............       13  SURG                  UTERINE & ADNEXA PROC FOR        2.2737        6.70        8.40
                                                  OVARIAN OR ADNEXAL
                                                  MALIGNANCY.
358.............       13  SURG                  UTERINE & ADNEXA PROC FOR        1.1807        3.40        4.20
                                                  NON-MALIGNANCY W CC.
359.............       13  SURG                  UTERINE & ADNEXA PROC FOR        0.8099        2.30        2.60
                                                  NON-MALIGNANCY W/O CC.
360.............       13  SURG                  VAGINA, CERVIX & VULVA           0.8661        2.20        2.80
                                                  PROCEDURES.
361.............       13  SURG                  LAPAROSCOPY & INCISIONAL         1.0793        2.20        3.20
                                                  TUBAL INTERRUPTION.
362.............       13  SURG *                ENDOSCOPIC TUBAL                 0.3041        1.40        1.40
                                                  INTERRUPTION.
363.............       13  SURG                  D&C, CONIZATION & RADIO-         0.9374        2.60        3.60
                                                  IMPLANT, FOR MALIGNANCY.
364.............       13  SURG                  D&C, CONIZATION EXCEPT FOR       0.9098        2.90        4.10
                                                  MALIGNANCY.
365.............       13  SURG                  OTHER FEMALE REPRODUCTIVE        2.1284        5.30        8.20
                                                  SYSTEM O.R. PROCEDURES.
366.............       13  MED                   MALIGNANCY, FEMALE               1.2826        4.80        6.80
                                                  REPRODUCTIVE SYSTEM W CC.
367.............       13  MED                   MALIGNANCY, FEMALE               0.5588        2.30        3.10
                                                  REPRODUCTIVE SYSTEM W/O CC.
368.............       13  MED                   INFECTIONS, FEMALE               1.1657        5.10        6.70
                                                  REPRODUCTIVE SYSTEM.
369.............       13  MED                   MENSTRUAL & OTHER FEMALE         0.6065        2.40        3.30
                                                  REPRODUCTIVE SYSTEM
                                                  DISORDERS.
370.............       14  SURG                  CESAREAN SECTION W CC......      1.0119        4.20        5.70
371.............       14  SURG                  CESAREAN SECTION W/O CC....      0.6317        3.20        3.50
372.............       14  MED                   VAGINAL DELIVERY W               0.5520        2.70        3.50
                                                  COMPLICATING DIAGNOSES.
373.............       14  MED                   VAGINAL DELIVERY W/O             0.3856        2.00        2.30
                                                  COMPLICATING DIAGNOSES.
374.............       14  SURG                  VAGINAL DELIVERY W               0.7402        2.50        3.00
                                                  STERILIZATION &/OR D&C.
375.............       14  SURG *                VAGINAL DELIVERY W O.R.          0.5806        4.40        4.40
                                                  PROC EXCEPT STERIL &/OR
                                                  D&C.
376.............       14  MED                   POSTPARTUM & POST ABORTION       0.5693        2.50        3.40
                                                  DIAGNOSES W/O O.R.
                                                  PROCEDURE.
377.............       14  SURG                  POSTPARTUM & POST ABORTION       1.0321        3.10        4.10
                                                  DIAGNOSES W O.R. PROCEDURE.
378.............       14  MED                   ECTOPIC PREGNANCY..........      0.7950        2.00        2.60
379.............       14  MED                   THREATENED ABORTION........      0.3626        2.00        3.00
380.............       14  MED                   ABORTION W/O D&C...........      0.4323        1.60        2.00
381.............       14  SURG                  ABORTION W D&C, ASPIRATION       0.5257        1.50        1.90
                                                  CURETTAGE OR HYSTEROTOMY.
382.............       14  MED                   FALSE LABOR................      0.2190        1.30        1.70
383.............       14  MED                   OTHER ANTEPARTUM DIAGNOSES       0.5123        2.70        3.80
                                                  W MEDICAL COMPLICATIONS.
384.............       14  MED                   OTHER ANTEPARTUM DIAGNOSES       0.3485        1.90        2.60
                                                  W/O MEDICAL COMPLICATIONS.
385.............       15  MED *                 NEONATES, DIED OR                1.3855        1.80        1.80
                                                  TRANSFERRED TO ANOTHER
                                                  ACUTE CARE FACILITY.
386.............       15  MED *                 EXTREME IMMATURITY OR            4.5687       17.90       17.90
                                                  RESPIRATORY DISTRESS
                                                  SYNDROME, NEONATE.
387.............       15  MED *                 PREMATURITY W MAJOR              3.1203       13.30       13.30
                                                  PROBLEMS.
388.............       15  MED *                 PREMATURITY W/O MAJOR            1.8827        8.60        8.60
                                                  PROBLEMS.
389.............       15  MED *                 FULL TERM NEONATE W MAJOR        3.2052        4.70        4.70
                                                  PROBLEMS.
390.............       15  MED *                 NEONATE W OTHER SIGNIFICANT      1.1344        3.40        3.40
                                                  PROBLEMS.
391.............       15  MED *                 NORMAL NEWBORN.............      0.1536        3.10        3.10
392.............       16  SURG                  SPLENECTOMY AGE 17.
393.............       16  SURG *                SPLENECTOMY AGE 0-17.......      1.3571        9.10        9.10
394.............       16  SURG                  OTHER O.R. PROCEDURES OF         1.9338        4.70        7.60
                                                  THE BLOOD AND BLOOD
                                                  FORMING ORGANS.
395.............       16  MED                   RED BLOOD CELL DISORDERS         0.8307        3.20        4.40
                                                  AGE 17.
396.............       16  MED                   RED BLOOD CELL DISORDERS         0.6986        2.90        4.20
                                                  AGE 0-17.
397.............       16  MED                   COAGULATION DISORDERS......      1.2648        3.70        5.20
398.............       16  MED                   RETICULOENDOTHELIAL &            1.2360        4.50        5.90
                                                  IMMUNITY DISORDERS W CC.
399.............       16  MED                   RETICULOENDOTHELIAL &            0.6651        2.70        3.50
                                                  IMMUNITY DISORDERS W/O CC.
400.............       17  SURG                  NO LONGER VALID............      0.0000        0.00        0.00
401.............       17  SURG                  LYMPHOMA & NON-ACUTE             2.8946        8.10       11.60
                                                  LEUKEMIA W OTHER O.R. PROC
                                                  W CC.
402.............       17  SURG                  LYMPHOMA & NON-ACUTE             1.1430        2.70        4.00
                                                  LEUKEMIA W OTHER O.R. PROC
                                                  W/O CC.
403.............       17  MED                   LYMPHOMA & NON-ACUTE             1.8197        5.80        8.20
                                                  LEUKEMIA W CC.
404.............       17  MED                   LYMPHOMA & NON-ACUTE             0.8658        3.00        4.10
                                                  LEUKEMIA W/O CC.
405.............       17  MED *                 ACUTE LEUKEMIA W/O MAJOR         1.9241        4.90        4.90
                                                  O.R. PROCEDURE AGE 0-17.
406.............       17  SURG                  MYELOPROLIF DISORD OR            2.7055        6.90        9.70
                                                  POORLY DIFF NEOPL W MAJ
                                                  O.R.PROC W CC.

[[Page 45592]]

 
407.............       17  SURG                  MYELOPROLIF DISORD OR            1.2410        3.20        4.10
                                                  POORLY DIFF NEOPL W MAJ
                                                  O.R.PROC W/O CC.
408.............       17  SURG                  MYELOPROLIF DISORD OR            2.1984        4.80        8.20
                                                  POORLY DIFF NEOPL W OTHER
                                                  O.R.PROC.
409.............       17  MED                   RADIOTHERAPY...............      1.2439        4.60        6.10
410.............       17  MED                   CHEMOTHERAPY W/O ACUTE           1.0833        3.20        4.10
                                                  LEUKEMIA AS SECONDARY
                                                  DIAGNOSIS.
411.............       17  MED *                 HISTORY OF MALIGNANCY W/O        0.3948        4.70        4.70
                                                  ENDOSCOPY.
412.............       17  MED                   HISTORY OF MALIGNANCY W          0.5679        2.50        3.60
                                                  ENDOSCOPY.
413.............       17  MED                   OTHER MYELOPROLIF DIS OR         1.3224        5.20        7.10
                                                  POORLY DIFF NEOPL DIAG W
                                                  CC.
414.............       17  MED                   OTHER MYELOPROLIF DIS OR         0.7370        3.20        4.20
                                                  POORLY DIFF NEOPL DIAG W/O
                                                  CC.
415.............       18  SURG                  O.R. PROCEDURE FOR               3.6276       10.40       14.40
                                                  INFECTIOUS & PARASITIC
                                                  DISEASES.
416.............       18  MED                   SEPTICEMIA AGE 17.
417.............       18  MED                   SEPTICEMIA AGE 0-17........      0.9612        4.40        5.70
418.............       18  MED                   POSTOPERATIVE & POST-            1.0672        4.80        6.30
                                                  TRAUMATIC INFECTIONS.
419.............       18  MED                   FEVER OF UNKNOWN ORIGIN AGE      0.8476        3.60        4.60
                                                  17 W CC.
420.............       18  MED                   FEVER OF UNKNOWN ORIGIN AGE      0.6107        2.80        3.40
                                                  17 W/O CC.
421.............       18  MED                   VIRAL ILLNESS AGE 17.
422.............       18  MED                   VIRAL ILLNESS & FEVER OF         0.7248        2.50        3.70
                                                  UNKNOWN ORIGIN AGE 0-17.
423.............       18  MED                   OTHER INFECTIOUS &               1.8155        5.90        8.40
                                                  PARASITIC DISEASES
                                                  DIAGNOSES.
424.............       19  SURG                  O.R. PROCEDURE W PRINCIPAL       2.4074        8.00       13.10
                                                  DIAGNOSES OF MENTAL
                                                  ILLNESS.
425.............       19  MED                   ACUTE ADJUSTMENT REACTION &      0.6781        2.80        3.80
                                                  PSYCHOSOCIAL DYSFUNCTION.
426.............       19  MED                   DEPRESSIVE NEUROSES........      0.5087        3.20        4.50
427.............       19  MED                   NEUROSES EXCEPT DEPRESSIVE.      0.5012        3.10        4.40
428.............       19  MED                   DISORDERS OF PERSONALITY &       0.7291        4.50        7.10
                                                  IMPULSE CONTROL.
429.............       19  MED                   ORGANIC DISTURBANCES &           0.8291        4.50        6.10
                                                  MENTAL RETARDATION.
430.............       19  MED                   PSYCHOSES..................      0.6801        5.60        7.90
431.............       19  MED                   CHILDHOOD MENTAL DISORDERS.      0.6620        4.40        6.90
432.............       19  MED                   OTHER MENTAL DISORDER            0.6513        2.90        4.00
                                                  DIAGNOSES.
433.............       20  MED                   ALCOHOL/DRUG ABUSE OR            0.2904        2.20        3.10
                                                  DEPENDENCE, LEFT AMA.
434.............       20  MED                   NO LONGER VALID............      0.0000        0.00        0.00
435.............       20  MED                   NO LONGER VALID............      0.0000        0.00        0.00
436.............       20  MED                   NO LONGER VALID............      0.0000        0.00        0.00
437.............       20  MED                   NO LONGER VALID............      0.0000        0.00        0.00
438.............       20  ....................  NO LONGER VALID............      0.0000        0.00        0.00
439.............       21  SURG                  SKIN GRAFTS FOR INJURIES...      1.7547        5.20        8.20
440.............       21  SURG                  WOUND DEBRIDEMENTS FOR           1.8878        5.80        9.10
                                                  INJURIES.
441.............       21  SURG                  HAND PROCEDURES FOR              0.9662        2.10        3.10
                                                  INJURIES.
442.............       21  SURG                  OTHER O.R. PROCEDURES FOR        2.4200        5.60        8.60
                                                  INJURIES W CC.
443.............       21  SURG                  OTHER O.R. PROCEDURES FOR        0.9787        2.50        3.40
                                                  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..      0.2983        2.40        2.40
447.............       21  MED                   ALLERGIC REACTIONS AGE 17.
448.............       21  MED *                 ALLERGIC REACTIONS AGE 0-17      0.0981        2.90        2.90
449.............       21  MED                   POISONING & TOXIC EFFECTS        0.8352        2.60        3.70
                                                  OF DRUGS AGE 17
                                                  W CC.
450.............       21  MED                   POISONING & TOXIC EFFECTS        0.4246        1.60        2.00
                                                  OF DRUGS AGE 17
                                                  W/O CC.
451.............       21  MED *                 POISONING & TOXIC EFFECTS        0.2648        2.10        2.10
                                                  OF DRUGS AGE 0-17.
452.............       21  MED                   COMPLICATIONS OF TREATMENT       1.0455        3.50        4.90
                                                  W CC.
453.............       21  MED                   COMPLICATIONS OF TREATMENT       0.5113        2.10        2.80
                                                  W/O CC.
454.............       21  MED                   OTHER INJURY, POISONING &        0.8153        3.00        4.20
                                                  TOXIC EFFECT DIAG W CC.
455.............       21  MED                   OTHER INJURY, POISONING &        0.4773        1.80        2.40
                                                  TOXIC EFFECT DIAG W/O CC.
456.............       22  ....................  NO LONGER VALID............      0.0000        0.00        0.00
457.............       22  MED                   NO LONGER VALID............      0.0000        0.00        0.00
458.............       22  SURG                  NO LONGER VALID............      0.0000        0.00        0.00
459.............       22  SURG                  NO LONGER VALID............      0.0000        0.00        0.00
460.............       22  MED                   NO LONGER VALID............      0.0000        0.00        0.00
461.............       23  SURG                  O.R. PROC W DIAGNOSES OF         1.1692        2.20        3.60
                                                  OTHER CONTACT W HEALTH
                                                  SERVICES.
462.............       23  MED                   REHABILITATION.............      0.9747        9.00       11.00
463.............       23  MED                   SIGNS & SYMPTOMS W CC......      0.6856        3.10        4.10
464.............       23  MED                   SIGNS & SYMPTOMS W/O CC....      0.4982        2.40        3.00
465.............       23  MED                   AFTERCARE W HISTORY OF           0.8881        2.00        3.90
                                                  MALIGNANCY AS SECONDARY
                                                  DIAGNOSIS.

[[Page 45593]]

 
466.............       23  MED                   AFTERCARE W/O HISTORY OF         0.8088        2.20        3.90
                                                  MALIGNANCY AS SECONDARY
                                                  DIAGNOSIS.
467.............       23  MED                   OTHER FACTORS INFLUENCING        0.5274        1.90        3.70
                                                  HEALTH STATUS.
468.............  .......  ....................  EXTENSIVE O.R. PROCEDURE         3.8454        9.40       13.10
                                                  UNRELATED TO PRINCIPAL
                                                  DIAGNOSIS.
469.............  .......  **                    PRINCIPAL DIAGNOSIS INVALID      0.0000        0.00        0.00
                                                  AS DISCHARGE DIAGNOSIS.
470.............  .......  **                    UNGROUPABLE................      0.0000        0.00        0.00
471.............       08  SURG                  BILATERAL OR MULTIPLE MAJOR      3.0576        4.70        5.40
                                                  JOINT PROCS OF LOWER
                                                  EXTREMITY.
472.............       22  SURG                  NO LONGER VALID............      0.0000        0.00        0.00
473.............       17  MED                   ACUTE LEUKEMIA W/O MAJOR         3.4885        7.40       12.70
                                                  O.R. PROCEDURE AGE 17.
474.............       04  SURG                  NO LONGER VALID............      0.0000        0.00        0.00
475.............       04  MED                   RESPIRATORY SYSTEM               3.6000        8.00       11.30
                                                  DIAGNOSIS WITH VENTILATOR
                                                  SUPPORT.
476.............  .......  SURG                  PROSTATIC O.R. PROCEDURE         2.2477        8.00       11.10
                                                  UNRELATED TO PRINCIPAL
                                                  DIAGNOSIS.
477.............  .......  SURG                  NON-EXTENSIVE O.R.               1.8873        5.40        8.30
                                                  PROCEDURE UNRELATED TO
                                                  PRINCIPAL DIAGNOSIS.
478.............       05  SURG                  OTHER VASCULAR PROCEDURES W      2.3743        4.90        7.30
                                                  CC.
479.............       05  SURG                  OTHER VASCULAR PROCEDURES W/     1.4300        2.40        3.20
                                                  O CC.
480.............      PRE  SURG                  LIVER TRANSPLANT...........      9.7823       14.00       21.10
481.............      PRE  SURG                  BONE MARROW TRANSPLANT.....      6.1074
1...............     9.20  21.80
482.............      PRE  SURG                  TRACHEOSTOMY FOR FACE,           3.4803        9.60       12.50
                                                  MOUTH & NECK DIAGNOSES.
483.............      PRE  SURG                  TRAC W MECH VENT 96+HRS OR      16.7762       34.20       41.60
                                                  PDX EXCEPT FACE, MOUTH &
                                                  NECK DX OSES.
484.............       24  SURG                  CRANIOTOMY FOR MULTIPLE          5.4179        9.70       14.50
                                                  SIGNIFICANT TRAUMA.
485.............       24  SURG                  LIMB REATTACHMENT, HIP AND       3.2121        7.90       10.00
                                                  FEMUR PROC FOR MULTIPLE
                                                  SIGNIFICANT TRA.
486.............       24  SURG                  OTHER O.R. PROCEDURES FOR        4.8793        8.70       12.90
                                                  MULTIPLE SIGNIFICANT
                                                  TRAUMA.
487.............       24  MED                   OTHER MULTIPLE SIGNIFICANT       2.0057        5.30        7.30
                                                  TRAUMA.
488.............       25  SURG                  HIV W EXTENSIVE O.R.             4.8118       11.70       17.00
                                                  PROCEDURE.
489.............       25  MED                   HIV W MAJOR RELATED              1.8603        6.00        8.60
                                                  CONDITION.
490.............       25  MED                   HIV W OR W/O OTHER RELATED       1.0512        3.90        5.50
                                                  CONDITION.
491.............       08  SURG                  MAJOR JOINT & LIMB               1.7139        2.80        3.40
                                                  REATTACHMENT PROCEDURES OF
                                                  UPPER EXTREMITY.
492.............       17  MED                   CHEMOTHERAPY W ACUTE             3.8371        9.30       14.90
                                                  LEUKEMIA OR W USE OF HI
                                                  DOSE CHEMOAGENT.
493.............       07  SURG                  LAPAROSCOPIC                     1.8302        4.40        6.00
                                                  CHOLECYSTECTOMY W/O C.D.E.
                                                  W CC.
494.............       07  SURG                  LAPAROSCOPIC                     1.0034        2.00        2.50
                                                  CHOLECYSTECTOMY W/O C.D.E.
                                                  W/O CC.
495.............      PRE  SURG                  LUNG TRANSPLANT............      8.5551       13.40       16.20
496.............       08  SURG                  COMBINED ANTERIOR/POSTERIOR      5.6839        6.80        8.90
                                                  SPINAL FUSION.
497.............       08  SURG                  SPINAL FUSION EXCEPT             3.4056        5.20        6.30
                                                  CERVICAL W CC.
498.............       08  SURG                  SPINAL FUSION EXCEPT             2.5319        3.60        4.00
                                                  CERVICAL W/O CC.
499.............       08  SURG                  BACK & NECK PROCEDURES           1.4244        3.30        4.50
                                                  EXCEPT SPINAL FUSION W CC.
500.............       08  SURG                  BACK & NECK PROCEDURES           0.9369        2.00        2.40
                                                  EXCEPT SPINAL FUSION W/O
                                                  CC.
501.............       08  SURG                  KNEE PROCEDURES W PDX OF         2.6393        8.30       10.70
                                                  INFECTION W CC.
502.............       08  SURG                  KNEE PROCEDURES W PDX OF         1.4192        5.10        6.20
                                                  INFECTION W/O CC.
503.............       08  SURG                  KNEE PROCEDURES W/O PDX OF       1.2233        3.00        3.90
                                                  INFECTION.
504.............       22  SURG                  EXTENSIVE 3RD DEGREE BURNS      11.6215        0.30        8.00
                                                  W SKIN GRAFT.
505.............       22  MED                   EXTENSIVE 3RD DEGREE BURNS       2.0006        2.30        5.60
                                                  W/O SKIN GRAFT.
506.............       22  SURG                  FULL THICKNESS BURN W SKIN       4.1070       12.10       16.90
                                                  GRAFT OR INHAL INJ W CC OR
                                                  SIG TRAUMA.
507.............       22  SURG                  FULL THICKNESS BURN W SKIN       1.8154        6.50        9.20
                                                  GRFT OR INHAL INJ W/O CC
                                                  OR SIG TRAUMA.
508.............       22  MED                   FULL THICKNESS BURN W/O          1.3775        5.60        8.00
                                                  SKIN GRFT OR INHAL INJ W
                                                  CC OR SIG TRAUMA.
509.............       22  MED                   FULL THICKNESS BURN W/O          0.6426        3.10        4.40
                                                  SKIN GRFT OR INH INJ W/O
                                                  CC OR SIG TRAUMA.
510.............       22  MED                   NON-EXTENSIVE BURNS W CC OR      1.1812        4.60        6.80
                                                  SIGNIFICANT TRAUMA.
511.............       22  MED                   NON-EXTENSIVE BURNS W/O CC       0.6753        3.20        4.70
                                                  OR SIGNIFICANT TRAUMA.
512.............      PRE  SURG                  SIMULTANEOUS PANCREAS/           5.3405       11.10       13.20
                                                  KIDNEY TRANSPLANT.
513.............      PRE  SURG                  PANCREAS TRANSPLANT........      6.1594        8.70       10.00
514.............       05  SURG                  NO LONGER VALID............      0.0000        0.00        0.00
515.............       05  SURG                  CARDIAC DEFIBRILLATOR            5.3366        3.00        5.20
                                                  IMPLANT W/O CARDIAC CATH.
516.............       05  SURG                  PERCUTANEOUS CARDIOVASC          2.6911        3.80        4.80
                                                  PROC W AMI.
517.............       05  SURG                  PERC CARDIO PROC W NON-DRUG      2.1598        1.80        2.50
                                                  ELUTING STENT W/O AMI.

[[Page 45594]]

 
518.............       05  SURG                  PERC CARDIO PROC W/O             1.7494        2.30        3.40
                                                  CORONARY ARTERY STENT OR
                                                  AMI.
519.............       08  SURG                  CERVICAL SPINAL FUSION W CC      2.4266        3.20        5.10
520.............       08  SURG                  CERVICAL SPINAL FUSION W/O       1.5780        1.70        2.10
                                                  CC.
521.............       20  MED                   ALCOHOL/DRUG ABUSE OR            0.7115        4.30        5.80
                                                  DEPENDENCE W CC.
522.............       20  MED                   ALC/DRUG ABUSE OR DEPEND W       0.5226        7.70        9.70
                                                  REHABILITATION THERAPY W/O
                                                  CC.
523.............       20  MED                   ALC/DRUG ABUSE OR DEPEND W/      0.3956        3.30        4.10
                                                  O REHABILITATION THERAPY W/
                                                  O CC.
524.............       01  MED                   TRANSIENT ISCHEMIA.........      0.7320        2.70        3.40
525.............       05  SURG                  HEART ASSIST SYSTEM IMPLANT     11.4372        8.90       17.00
526.............       05  SURG                  PERCUTNEOUS CARDIOVASULAR        2.9891        3.60        4.50
                                                  PROC W DRUG ELUTING STENT
                                                  W AMI.
527.............       05  SURG                  PERCUTNEOUS CARDIOVASULAR        2.4483        1.80        2.50
                                                  PROC W DRUG ELUTING STENT
                                                  W/O AMI.
528.............       01  SURG                  INTRACRANIAL VASCULAR PROC       7.2205       14.20       17.50
                                                  W PDX HEMORRHAGE.
529.............       01  SURG                  VENTRICULAR SHUNT                2.2529        5.30        8.20
                                                  PROCEDURES W CC.
530.............       01  SURG                  VENTRICULAR SHUNT                1.2017        2.80        3.60
                                                  PROCEDURES W/O CC.
531.............       01  SURG                  SPINAL PROCEDURES W CC.....      3.0552        6.80        9.90
532.............       01  SURG                  SPINAL PROCEDURES W/O CC...      1.4482        2.90        4.00
533.............       01  SURG                  EXTRACRANIAL PROCEDURES W        1.6678        2.70        4.10
                                                  CC.
534.............       01  SURG                  EXTRACRANIAL PROCEDURES W/O      1.0748        1.60        2.00
                                                  CC.
535.............       05  SURG                  CARDIAC DEFIB IMPLANT W          8.1560        8.10       11.00
                                                  CARDIAC CATH W AMI/HF/
                                                  SHOCK.
536.............       05  SURG                  CARDIAC DEFIB IMPLANT W          6.2775        3.90        5.80
                                                  CARDIAC CATH W/O AMI/HF/
                                                  SHOCK.
537.............       08  SURG                  LOCAL EXCIS & REMOV OF INT       1.8185        4.70        7.00
                                                  FIX DEV EXCEPT HIP & FEMUR
                                                  W CC.
538.............       08  SURG                  LOCAL EXCIS & REMOV OF INT       0.9919        2.10        2.90
                                                  FIX DEV EXCEPT HIP & FEMUR
                                                  W/O CC.
539.............       17  SURG                  LYMPHOMA & LEUKEMIA W MAJOR      3.3846        7.40       11.20
                                                  OR PROCEDURE W CC.
540.............       17  SURG                  LYMPHOMA & LEUKEMIA W MAJOR      1.2891        2.90       4.00
                                                  OR PROCEDURE W/O CC.
----------------------------------------------------------------------------------------------------------------
* Medicare data have been supplemented by data from 19 States for low volume DRGs.
** DRGs 469 and 470 contian cases that could 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.












  Federal Register / Vol. 68, No. 148 / Friday, August 1, 2003 / Rules 
and Regulations  

[[Page 45594]]




                                         Table 6A.--New Diagnosis Codes
----------------------------------------------------------------------------------------------------------------
  Diagnosis
    code               Description                   CC               MDC                     DRG
----------------------------------------------------------------------------------------------------------------
  \1\ 079.82  SARS-associated coronavirus.  Y                             15  390
                                                                          18  421, 422
      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               N                             10  300, 301
               aldosteronism.
      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  387,\2\ 389 \2\
               without crisis.                                            16  395, 396
      282.42  Sickle-cell thalassemia with  Y                             15  387,\2\ 389 \2\
               crisis.                                                    16  395, 396
      282.49  Other thalassemia...........  Y                             15  387,\2\ 389 \2\
                                                                          16  395, 396
      282.64  Sickle-cell/Hb-C disease      Y                             16  395, 396
               with 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       Y                             16  398, 399
               state.
      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          N                              1  12
               dementia.
      331.82  Dementia with Lewy bodies...  N                              1  12

[[Page 45595]]

 
      348.30  Encephalopathy, unspecified.  N                              1  16, 17
                                                                          25  489 \3\
      348.31  Metabolic encephalopathy....  N                              1  16, 17
                                                                          25  489 \3\
      348.39  Other encephalopathy........  N                              1  16, 17
                                                                          25  489 \3\
      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
      480.31  Pneumonia due to SARS-        Y                              4  89, 90, 91
               associated coronavirus.                                    15  390
                                                                          25  489
      493.81  Exercise induced              N                              4  96, 97, 98
               bronchospasm.
      493.82  Cough variant asthma........  N                              4  96, 97, 98
  \1\ 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         N                             12  348, 349
               urinary 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,
               delivered, with or without                                     372, 374,
               mention of antepartum                                          375
               condition.
      674.52  Peripartum cardiomyopathy,    Y                             14  370, 371,
               delivered, with mention of                                     372, 374,
               postpartum condition.                                          375
      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.                                            13  358, 359,
                                                                              369
      766.21  Post-term infant............  N                             15  391
      766.22  Prolonged gestation of        N                             15  391
               infant.
      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,
               test (oral).                                                   298
      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

[[Page 45596]]

 
      959.12  Other injury of abdomen.....  N                             21  444, 445, 446
                                                                          24  487
      959.13  Fracture of corpus            N                             21  444, 445, 446
               cavernosum 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.
  \1\ V01.82  Exposure to SARS-associated   N                             15  390
               coronavirus.                                               23  467
      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
               Membrane 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
      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,       N                             23  467
               Other 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
               non-steroidal anti-
               inflammatories.
      V58.65  Long-term (current) use of    N                             23  465, 466
               steroids.
      V64.41  Laparoscopic surgical         N                             23  467
               procedure converted 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     N                             23  467
               for 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\ The SARS-related codes were created after publication of the May 19, 2003 proposed rule.
\2\ Classified as a Major Problem.
\3\ 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          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      N \1\
              vertebrae.
      81.63  Fusion or refusion of 4-8      N \1\
              vertebrae.
      81.64  Fusion or refusion of 9 or     N \1\
              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 Procedure Codes
----------------------------------------------------------------------------------------------------------------
  Diagnosis
    code               Description                   CC               MDC                     DRG
----------------------------------------------------------------------------------------------------------------
      255.1   Hyperaldosteronism..........  N                             10  300, 301
      277.8   Other specified disorders of  N                             10  299
               metabolism.

[[Page 45597]]

 
      282.4   Thalassemias................  Y                             15  387,\1\ 389 \1\
                                                                          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  489 \2\
      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,        N                              8  247
               pelvic 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
      766.2   Post term infant, not         N                             15  391
               [gE]heavy for dates[gE].
      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
     493.92  Asthma, unspecified, with      Y                              4  96, 97, 98
              (acute) exacerbation.

[[Page 45598]]

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


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                                   Table 7A.--Medicare Prospective Payment System Selected Percentile Lengths of Stay
                                                    [FY 2002 Medpar Update March 2003 Grouper V20.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                            Arithmetic
                   DRG                       Number of    mean length of       10th            25th            50th            75th            90th
                                            discharges         stay         percentile      percentile      percentile      percentile      percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1.......................................          29,410            10.9               3               5               8              14              22
2.......................................          14,837             5.1               1               2               4               7              10
3.......................................               3             6.0               1               1               4              13              13
4.......................................           6,793             7.3               1               2               5               9              16
5.......................................          95,905             3.0               1               1               2               3               7
6.......................................             360             3.0               1               1               2               4               7
7.......................................          14,744             9.9               2               4               7              12              20
8.......................................           4,140             2.8               1               1               1               3               7
9.......................................           1,741             6.7               1               3               5               8              12
10......................................          18,736             6.4               2               3               5               8              13
11......................................           3,312             4.0               1               2               3               5               8
12......................................          52,693             5.8               2               3               4               7              11
13......................................           7,144             5.0               2               3               4               6               9
14......................................         237,827             5.9               2               3               5               7              11
15......................................          94,552             4.9               2               3               4               6               9
16......................................           9,982             6.3               2               3               5               8              12
17......................................           2,757             3.2               1               1               2               4               6
18......................................          29,858             5.5               2               3               4               7              10
19......................................           8,583             3.5               1               2               3               5               7
20......................................           6,244            10.2               3               5               8              13              20
21......................................           1,894             6.6               2               3               5               8              13
22......................................           2,794             5.1               2               2               4               6              10
23......................................          12,654             4.2               1               2               3               5               8
24......................................          59,420             4.9               1               2               4               6              10
25......................................          27,639             3.2               1               2               3               4               6
26......................................              20             4.1               1               1               2               3               4
27......................................           4,470             5.2               1               1               3               7              11
28......................................          14,063             6.0               1               3               5               8              12
29......................................           5,344             3.5               1               2               3               4               7
30......................................               3             5.7               2               2               4              11              11
31......................................           3,976             4.0               1               2               3               5               8
32......................................           1,932             2.5               1               1               2               3               5
34......................................          23,918             4.9               1               2               4               6               9
35......................................           7,483             3.1               1               1               3               4               6
36......................................           2,125             1.5               1               1               1               1               2
37......................................           1,392             3.8               1               1               2               5               8
38......................................              98             2.8               1               1               1               4               5
39......................................             563             2.1               1               1               1               2               4
40......................................           1,555             3.8               1               1               3               5               7
42......................................           1,592             2.7               1               1               1               3               6
43......................................              95             3.4               1               1               3               4               6
44......................................           1,231             5.0               2               3               4               6               9
45......................................           2,690             3.1               1               2               3               4               6
46......................................           3,495             4.5               1               2               3               6               8
47......................................           1,415             3.1               1               1               2               4               6
49......................................           2,392             4.5               1               2               3               6               9
50......................................           2,439             1.9               1               1               1               2               3
51......................................             243             2.8               1               1               1               3               8
52......................................             224             1.8               1               1               1               2               3
53......................................           2,485             3.6               1               1               2               4               8
55......................................           1,489             2.9               1               1               1               3               7
56......................................             476             2.9               1               1               1               3               6
57......................................             715             3.7               1               1               2               4               8
58......................................               1             2.0               2               2               2               2               2
59......................................             117             2.7               1               1               1               3               6
60......................................               1             3.0               3               3               3               3               3
61......................................             255             5.2               1               1               3               7              11
62......................................               2             7.0               1               1              13              13              13
63......................................           3,038             4.4               1               2               3               5               9
64......................................           3,149             6.5               1               2               4               8              13
65......................................          40,527             2.8               1               1               2               4               5
66......................................           7,876             3.1               1               1               2               4               6
67......................................             387             3.6               1               2               3               5               7
68......................................          11,695             3.9               1               2               3               5               7
69......................................           3,782             3.0               1               2               3               4               5
70......................................              32             2.4               1               1               2               3               4
71......................................              80             3.4               1               1               2               4               6
72......................................             972             3.4               1               1               3               4               6
73......................................           7,740             4.4               1               2               3               6               9

[[Page 45624]]

 
75......................................          43,515            10.0               3               5               7              12              20
76......................................          44,651            11.1               3               5               9              14              21
77......................................           2,484             4.8               1               2               4               7              10
78......................................          39,668             6.6               3               4               6               8              11
79......................................         169,669             8.5               3               4               7              11              16
80......................................           8,115             5.3               2               3               4               7              10
81......................................               5             4.4               1               1               3               8               8
82......................................          64,585             6.9               2               3               5               9              14
83......................................           6,788             5.4               2               3               4               7              10
84......................................           1,616             3.2               1               2               3               4               6
85......................................          22,461             6.2               2               3               5               8              12
86......................................           2,262             3.5               1               2               3               4               7
87......................................          61,337             6.3               1               3               5               8              12
88......................................         405,367             5.0               2               3               4               6               9
89......................................         536,888             5.8               2               3               5               7              11
90......................................          49,023             4.0               2               2               3               5               7
91......................................              45             5.0               1               2               3               5              13
92......................................          15,881             6.3               2               3               5               8              12
93......................................           1,782             4.0               1               2               3               5               7
94......................................          12,922             6.2               2               3               5               8              12
95......................................           1,672             3.8               1               2               3               5               7
96......................................          57,107             4.6               2               2               4               6               8
97......................................          28,950             3.5               1               2               3               4               6
98......................................               9             3.7               1               1               2               2               5
99......................................          21,531             3.2               1               1               2               4               6
100.....................................           8,350             2.1               1               1               2               3               4
101.....................................          22,498             4.4               1               2               3               6               9
102.....................................           5,699             2.6               1               1               2               3               5
103.....................................             495            42.4               9              12              23              54              96
104.....................................          20,732            14.3               6               8              12              17              25
105.....................................          29,353             9.9               4               6               8              11              18
106.....................................           3,515            11.4               5               7              10              14              20
107.....................................          83,704            10.4               5               7               9              12              17
108.....................................           6,543             9.8               2               5               8              12              18
109.....................................          57,705             7.7               4               5               6               9              13
110.....................................          55,056             8.8               2               4               7              11              18
111.....................................           9,618             4.1               1               2               4               6               7
113.....................................          39,897            12.5               4               6               9              15              24
114.....................................           8,369             8.6               2               4               7              11              17
115.....................................          19,879             7.4               1               3               6              10              15
116.....................................         116,607             4.4               1               2               3               6               9
117.....................................           4,751             4.3               1               1               2               5              10
118.....................................           8,319             2.9               1               1               1               4               7
119.....................................           1,257             5.3               1               1               3               7              13
120.....................................          38,350             9.0               1               3               6              12              20
121.....................................         164,602             6.3               2               3               5               8              12
122.....................................          77,383             3.5               1               2               3               5               7
123.....................................          38,786             4.8               1               1               3               6              11
124.....................................         135,861             4.4               1               2               3               6               9
125.....................................          92,387             2.8               1               1               2               4               5
126.....................................           5,422            11.5               3               6               9              15              22
127.....................................         678,154             5.2               2               3               4               7              10
128.....................................           7,226             5.4               2               3               5               7               9
129.....................................           3,884             2.6               1               1               1               3               6
130.....................................          89,220             5.6               2               3               5               7              10
131.....................................          27,255             4.0               1               2               4               5               7
132.....................................         142,959             2.9               1               1               2               4               5
133.....................................           8,743             2.3               1               1               2               3               4
134.....................................          41,755             3.2               1               2               2               4               6
135.....................................           7,825             4.5               1               2               3               5               8
136.....................................           1,191             2.7               1               1               2               3               5
138.....................................         209,417             4.0               1               2               3               5               8
139.....................................          88,233             2.5               1               1               2               3               5
140.....................................          56,027             2.5               1               1               2               3               5
141.....................................         109,260             3.6               1               2               3               4               7
142.....................................          52,906             2.6               1               1               2               3               5
143.....................................         251,335             2.1               1               1               2               3               4
144.....................................          95,251             5.5               1               2               4               7              11
145.....................................           7,414             2.6               1               1               2               3               5

[[Page 45625]]

 
146.....................................          10,813            10.2               5               6               8              12              17
147.....................................           2,649             6.2               3               5               6               8               9
148.....................................         134,602            12.3               5               7              10              15              22
149.....................................          20,279             6.3               4               5               6               7               9
150.....................................          21,258            11.3               4               6               9              14              20
151.....................................           5,171             5.6               2               3               5               7              10
152.....................................           4,594             8.4               3               5               7              10              15
153.....................................           2,069             5.2               3               4               5               7               8
154.....................................          28,481            13.2               3               7              10              17              26
155.....................................           6,654             4.1               1               2               3               6               8
156.....................................               4             2.5               1               1               1               3               5
157.....................................           8,336             5.7               1               2               4               7              12
158.....................................           4,379             2.6               1               1               2               3               5
159.....................................          18,211             5.1               1               2               4               7              10
160.....................................          12,263             2.7               1               1               2               3               5
161.....................................          10,838             4.3               1               1               3               6               9
162.....................................           6,447             1.9               1               1               1               2               4
163.....................................               8             3.3               1               1               2               3               6
164.....................................           5,432             8.4               3               5               7              10              15
165.....................................           2,351             4.5               2               3               4               6               7
166.....................................           4,228             4.7               1               2               4               6               9
167.....................................           4,121             2.4               1               1               2               3               4
168.....................................           1,437             4.8               1               2               3               6              10
169.....................................             811             2.4               1               1               2               3               5
170.....................................          15,746            10.8               2               4               8              14              22
171.....................................           1,535             4.3               1               2               4               6               9
172.....................................          31,608             7.0               2               3               5               9              14
173.....................................           2,503             3.8               1               2               3               5               8
174.....................................         253,175             4.8               2               3               4               6               9
175.....................................          35,116             2.9               1               2               3               4               5
176.....................................          13,542             5.2               2               3               4               6              10
177.....................................           9,121             4.6               2               2               4               6               8
178.....................................           3,396             3.1               1               2               3               4               6
179.....................................          13,263             5.9               2               3               5               7              11
180.....................................          91,043             5.4               2               3               4               7              10
181.....................................          27,384             3.4               1               2               3               4               6
182.....................................         274,383             4.4               1               2               3               5               8
183.....................................          91,766             2.9               1               1               2               4               5
184.....................................              75             3.3               1               1               2               4               7
185.....................................           5,415             4.7               1               2               3               6              10
186.....................................               6             6.7               2               3               3              10              10
187.....................................             637             4.1               1               2               3               6               8
188.....................................          84,442             5.6               1               2               4               7              11
189.....................................          13,179             3.1               1               1               2               4               6
190.....................................              76             5.1               1               2               4               6              10
191.....................................           9,576            13.8               3               6              10              17              28
192.....................................           1,322             6.2               1               3               6               8              11
193.....................................           4,844            12.7               5               7              10              16              23
194.....................................             651             6.7               2               4               6               8              12
195.....................................           4,041            10.5               4               6               9              13              19
196.....................................           1,007             5.6               2               3               5               7              10
197.....................................          18,401             9.2               3               5               7              11              17
198.....................................           5,446             4.4               2               3               4               6               7
199.....................................           1,644             9.8               2               4               7              13              21
200.....................................           1,082            10.5               2               3               7              14              23
201.....................................           2,146            14.2               4               6              10              18              29
202.....................................          26,905             6.4               2               3               5               8              13
203.....................................          30,167             6.7               2               3               5               9              13
204.....................................          65,940             5.7               2               3               4               7              11
205.....................................          27,684             6.2               2               3               5               8              12
206.....................................           2,079             3.8               1               2               3               5               8
207.....................................          33,045             5.2               1               2               4               7              10
208.....................................          10,244             2.9               1               1               2               4               5
209.....................................         401,363             4.9               3               3               4               5               7
210.....................................         123,436             6.9               3               4               6               8              11
211.....................................          30,259             4.8               3               4               4               6               7
212.....................................              10             6.4               1               1               3               5               7
213.....................................          10,018             9.2               2               4               7              12              18
216.....................................           8,808             8.0               1               2               6              11              17

[[Page 45626]]

 
217.....................................          17,420            13.4               3               5               9              16              28
218.....................................          24,033             5.5               2               3               4               7              10
219.....................................          20,076             3.2               1               2               3               4               6
220.....................................               1             1.0               1               1               1               1               1
223.....................................          13,406             3.0               1               1               2               4               6
224.....................................          11,846             1.9               1               1               1               2               3
225.....................................           6,539             5.3               1               2               4               7              11
226.....................................           5,895             6.5               1               2               4               8              14
227.....................................           4,883             2.6               1               1               2               3               5
228.....................................           2,553             4.1               1               1               3               5               9
229.....................................           1,274             2.3               1               1               2               3               5
230.....................................           2,474             5.6               1               2               3               7              12
231.....................................          13,405             5.0               1               1               3               6              11
232.....................................             825             2.7               1               1               1               2               6
233.....................................          10,014             7.4               1               3               6              10              15
234.....................................           5,408             3.1               1               1               2               4               7
235.....................................           5,150             4.9               1               2               4               6               9
236.....................................          40,417             4.6               1               3               4               6               8
237.....................................           1,790             3.7               1               2               3               5               7
238.....................................           9,003             8.6               3               4               7              10              17
239.....................................          46,422             6.3               2               3               5               8              12
240.....................................          12,147             6.6               2               3               5               8              13
241.....................................           3,197             3.8               1               2               3               5               7
242.....................................           2,621             6.9               2               3               5               9              14
243.....................................          97,186             4.7               1               2               4               6               9
244.....................................          14,757             4.7               1               2               4               6               9
245.....................................           5,890             3.3               1               2               3               4               6
246.....................................           1,501             3.8               1               2               3               5               7
247.....................................          20,607             3.3               1               1               3               4               7
248.....................................          14,008             4.9               1               3               4               6               9
249.....................................          13,006             3.6               1               1               2               4               7
250.....................................           3,835             4.1               1               2               3               5               8
251.....................................           2,403             2.8               1               1               3               3               5
253.....................................          22,265             4.7               2               3               4               6               8
254.....................................          10,865             3.2               1               2               3               4               5
256.....................................           6,755             5.1               1               2               4               6              10
257.....................................          15,803             2.6               1               1               2               3               5
258.....................................          15,399             1.8               1               1               2               2               3
259.....................................           3,531             2.7               1               1               1               3               6
260.....................................           4,255             1.4               1               1               1               1               2
261.....................................           1,801             2.1               1               1               1               2               4
262.....................................             674             4.3               1               1               3               6               9
263.....................................          23,297            11.5               3               5               8              14              22
264.....................................           3,898             6.6               2               3               5               8              13
265.....................................           4,132             6.6               1               2               4               8              14
266.....................................           2,567             3.2               1               1               2               4               7
267.....................................             242             4.4               1               1               3               6              10
268.....................................             931             3.8               1               1               2               4               8
269.....................................           9,911             8.5               2               3               7              11              17
270.....................................           2,824             3.6               1               1               2               5               7
271.....................................          19,513             7.2               2               4               6               9              14
272.....................................           5,770             6.0               2               3               5               7              12
273.....................................           1,351             4.0               1               2               3               5               8
274.....................................           2,328             6.5               1               3               5               8              13
275.....................................             232             3.6               1               1               2               4               7
276.....................................           1,333             4.5               1               2               4               6               8
277.....................................         101,243             5.7               2               3               5               7              10
278.....................................          32,701             4.2               2               2               4               5               7
279.....................................              10             5.3               2               2               3               7               7
280.....................................          18,038             4.1               1               2               3               5               8
281.....................................           7,650             2.9               1               1               2               4               5
283.....................................           6,106             4.7               1               2               4               6               9
284.....................................           2,039             2.9               1               1               2               4               6
285.....................................           7,012            10.5               3               5               8              13              20
286.....................................           2,511             5.9               2               3               4               7              12
287.....................................           6,330            10.3               3               5               8              13              20
288.....................................           5,684             5.0               2               3               4               5               8
289.....................................           6,977             2.7               1               1               1               2               6
290.....................................          10,000             2.2               1               1               1               2               4

[[Page 45627]]

 
291.....................................              60             1.6               1               1               1               2               3
292.....................................           6,576            10.5               2               4               8              14              21
293.....................................             368             4.7               1               1               3               6               9
294.....................................          99,279             4.5               1               2               3               6               9
295.....................................           3,603             4.0               1               2               3               5               7
296.....................................         281,526             5.1               1               2               4               6              10
297.....................................          48,952             3.3               1               2               3               4               6
298.....................................             117             3.1               1               1               2               4               6
299.....................................           1,291             5.5               1               2               4               7              11
300.....................................          18,877             6.1               2               3               5               8              12
301.....................................           3,649             3.6               1               2               3               4               7
302.....................................           8,941             8.5               4               5               6               9              15
303.....................................          21,890             8.0               3               4               6               9              15
304.....................................          12,646             8.9               2               4               6              11              18
305.....................................           3,058             3.5               1               2               3               4               7
306.....................................           7,087             5.4               1               2               3               7              12
307.....................................           2,041             2.1               1               1               2               2               3
308.....................................           7,321             6.2               1               2               4               8              14
309.....................................           4,198             2.1               1               1               1               2               4
310.....................................          24,966             4.4               1               1               3               6              10
311.....................................           7,518             1.8               1               1               1               2               3
312.....................................           1,532             4.6               1               1               3               6              10
313.....................................             558             2.3               1               1               1               3               5
314.....................................               2            40.5               1               1              80              80              80
315.....................................          34,371             7.0               1               1               4               9              16
316.....................................         120,183             6.5               2               3               5               8              13
317.....................................           2,045             3.6               1               1               2               4               7
318.....................................           5,811             6.1               1               3               5               8              12
319.....................................             416             2.9               1               1               2               4               6
320.....................................         188,879             5.3               2               3               4               6              10
321.....................................          31,494             3.7               1               2               3               5               7
322.....................................              55             3.3               1               2               3               4               5
323.....................................          20,049             3.2               1               1               2               4               6
324.....................................           7,086             1.9               1               1               1               2               4
325.....................................           9,360             3.8               1               2               3               5               7
326.....................................           2,755             2.6               1               1               2               3               5
327.....................................               7             2.6               1               1               2               3               4
328.....................................             748             3.7               1               1               3               5               8
329.....................................              92             2.1               1               1               1               3               5
331.....................................          51,750             5.6               1               3               4               7              11
332.....................................           5,046             3.2               1               1               2               4               6
333.....................................             269             5.7               1               2               3               7              11
334.....................................          10,565             4.6               2               3               4               5               8
335.....................................          12,782             3.0               2               2               3               4               5
336.....................................          36,048             3.4               1               2               2               4               7
337.....................................          29,654             2.0               1               1               2               2               3
338.....................................             941             5.5               1               2               3               7              13
339.....................................           1,491             4.8               1               1               3               6              11
340.....................................               1             2.0               2               2               2               2               2
341.....................................           3,599             3.2               1               1               2               3               7
342.....................................             694             3.2               1               1               2               4               7
344.....................................           3,598             2.5               1               1               1               2               5
345.....................................           1,376             4.9               1               1               3               6              11
346.....................................           4,919             5.9               2               3               5               8              12
347.....................................             318             3.0               1               1               2               4               6
348.....................................           3,416             4.3               1               2               3               5               8
349.....................................             619             2.5               1               1               2               3               5
350.....................................           6,778             4.5               2               2               4               6               8
352.....................................             968             4.0               1               2               3               5               8
353.....................................           2,585             6.5               2               3               5               7              12
354.....................................           7,455             5.7               3               3               4               6              10
355.....................................           5,602             3.2               2               2               3               4               5
356.....................................          26,093             2.1               1               1               2               3               3
357.....................................           5,648             8.4               3               4               6              10              16
358.....................................          21,749             4.2               2               2               3               5               7
359.....................................          32,221             2.6               1               2               2               3               4
360.....................................          15,906             2.8               1               1               2               3               4
361.....................................             348             3.2               1               1               2               3               7
362.....................................               5             1.4               1               1               1               2               2

[[Page 45628]]

 
363.....................................           2,529             3.6               1               2               2               4               8
364.....................................           1,643             4.1               1               1               3               5               8
365.....................................           1,842             8.2               1               3               5              10              17
366.....................................           4,601             6.7               1               3               5               8              14
367.....................................             489             3.1               1               1               2               4               7
368.....................................           3,592             6.6               2               3               5               8              13
369.....................................           3,510             3.3               1               1               2               4               7
370.....................................           1,390             5.8               2               3               4               5               9
371.....................................           1,764             3.5               2               3               3               4               5
372.....................................             979             3.5               2               2               2               3               5
373.....................................           4,246             2.3               1               2               2               3               3
374.....................................             100             3.0               2               2               2               3               6
376.....................................             332             3.5               1               2               2               4               7
377.....................................              53             4.1               1               2               3               5               8
378.....................................             175             2.6               1               1               2               3               5
379.....................................             365             3.0               1               1               2               3               5
380.....................................              98             2.0               1               1               1               2               3
381.....................................             194             1.9               1               1               1               2               4
382.....................................              49             1.7               1               1               1               2               3
383.....................................           2,031             3.8               1               2               3               4               7
384.....................................             133             2.6               1               1               2               3               5
385.....................................               3             2.0               1               1               2               3               3
387.....................................               1            55.0              55              55              55              55              55
389.....................................              12             6.3               2               3               5               9              10
390.....................................              20             4.3               1               2               3               5               7
392.....................................           2,292             9.7               3               4               7              12              21
393.....................................               1             4.0               4               4               4               4               4
394.....................................           2,614             7.6               1               2               5               9              17
395.....................................         108,545             4.3               1               2               3               5               9
396.....................................              19             4.2               1               1               2               5               9
397.....................................          19,105             5.2               1               2               4               6              10
398.....................................          18,238             5.9               2               3               5               7              11
399.....................................           1,698             3.5               1               2               3               4               6
400.....................................           6,366             9.0               1               3               6              12              21
401.....................................           5,876            11.5               2               5               9              15              23
402.....................................           1,480             4.0               1               1               3               5               9
403.....................................          32,056             8.1               2               3               6              10              17
404.....................................           4,368             4.1               1               2               3               5               8
405.....................................               1            31.0              31              31              31              31              31
406.....................................           2,435             9.7               2               4               7              12              20
407.....................................             645             4.1               1               2               3               5               7
408.....................................           2,131             8.2               1               2               5              10              20
409.....................................           2,166             6.2               2               3               4               6              12
410.....................................          28,518             4.1               1               2               4               5               6
411.....................................               7             2.3               1               1               2               2               4
412.....................................              17             3.6               1               1               3               6               7
413.....................................           5,371             7.0               2               3               5               9              14
414.....................................             638             4.2               1               2               3               5               8
415.....................................          43,615            14.4               4               6              11              18              28
416.....................................         193,642             7.4               2               4               6               9              14
417.....................................              41             5.7               2               2               5               7              12
418.....................................          26,059             6.3               2               3               5               8              12
419.....................................          16,513             4.6               1               2               4               6               9
420.....................................           3,233             3.4               1               2               3               4               6
421.....................................          10,805             4.1               1               2               3               5               8
422.....................................              68             3.7               1               2               2               3               6
423.....................................           8,149             8.3               2               3               6              10              17
424.....................................           1,249            13.1               2               4               9              15              26
425.....................................          16,274             3.8               1               2               3               5               8
426.....................................           4,619             4.5               1               2               3               6               9
427.....................................           1,614             4.4               1               2               3               5               9
428.....................................             800             7.1               1               2               5               8              14
429.....................................          26,027             6.0               2               3               4               7              11
430.....................................          65,641             7.8               2               3               6              10              16
431.....................................             319             6.8               1               2               4               7              12
432.....................................             454             4.0               1               2               3               5               8
433.....................................           5,603             3.1               1               1               2               4               6
439.....................................           1,532             8.2               1               3               5               9              17
440.....................................           5,838             9.1               2               3               6              11              19

[[Page 45629]]

 
441.....................................             690             3.1               1               1               2               4               6
442.....................................          17,683             8.5               1               3               6              10              18
443.....................................           3,949             3.4               1               1               3               4               7
444.....................................           5,831             4.2               1               2               3               5               8
445.....................................           2,592             2.9               1               1               2               4               5
447.....................................           6,551             2.5               1               1               2               3               5
448.....................................               1             1.0               1               1               1               1               1
449.....................................          33,429             3.7               1               1               3               4               7
450.....................................           7,534             2.0               1               1               1               2               4
451.....................................               1             1.0               1               1               1               1               1
452.....................................          25,827             4.9               1               2               3               6              10
453.....................................           5,733             2.8               1               1               2               3               5
454.....................................           4,822             4.2               1               2               3               5               8
455.....................................           1,086             2.4               1               1               2               3               5
461.....................................           5,281             3.6               1               1               2               4               8
462.....................................           9,763            10.9               4               6               9              14              19
463.....................................          27,225             4.0               1               2               3               5               8
464.....................................           7,273             3.0               1               1               2               4               6
465.....................................             203             3.9               1               1               1               3               6
466.....................................           1,761             4.0               1               1               2               4               7
467.....................................           1,167             3.6               1               1               2               3               6
468.....................................          52,616            12.8               3               6              10              16              25
471.....................................          13,425             5.4               3               3               4               6               8
473.....................................           8,123            12.4               2               3               7              17              32
475.....................................         110,111            11.2               2               5               9              15              22
476.....................................           3,675            11.1               2               5              10              15              21
477.....................................          25,578             8.2               1               3               6              11              17
478.....................................         108,616             7.3               1               3               5               9              16
479.....................................          24,164             3.2               1               1               2               4               7
480.....................................             627            21.1               6               8              12              22              47
481.....................................             867            21.8              13              17              20              24              33
482.....................................           5,312            12.5               4               6               9              15              24
483.....................................          45,887            39.5              15              22              33              49              70
484.....................................             346            14.5               2               6              11              21              30
485.....................................           3,279             9.9               4               5               7              12              19
486.....................................           2,225            12.8               1               6              10              17              26
487.....................................           3,908             7.2               1               3               6               9              15
488.....................................             777            17.0               4               7              13              22              36
489.....................................          13,457             8.6               2               3               6              10              18
490.....................................           5,499             5.5               1               2               4               7              11
491.....................................          15,451             3.4               1               2               3               4               6
492.....................................           3,115            14.9               3               5               7              25              33
493.....................................          59,856             6.0               1               3               5               8              11
494.....................................          29,005             2.5               1               1               2               3               5
495.....................................             200            16.1               7               9              12              19              30
496.....................................           2,506             8.9               3               4               6              11              18
497.....................................          22,601             6.4               3               4               5               7              11
498.....................................          16,204             4.0               2               3               4               5               6
499.....................................          34,803             4.5               1               2               3               6               9
500.....................................          50,192             2.4               1               1               2               3               4
501.....................................           2,615            10.6               4               5               8              13              20
502.....................................             784             6.2               3               4               5               7              11
503.....................................           6,020             3.9               1               2               3               5               7
504.....................................             128            28.0               7              13              21              38              55
505.....................................             136             5.6               1               1               1               4              10
506.....................................             926            16.9               4               7              13              21              35
507.....................................             346             9.1               2               4               7              13              19
508.....................................             634             7.8               2               3               5              10              17
509.....................................             161             4.3               1               2               3               5               9
510.....................................           1,660             6.7               1               3               5               8              15
511.....................................             592             4.7               1               1               3               6              10
512.....................................             505            13.2               6               8              10              15              23
513.....................................             215            10.0               5               6               8              10              16
514.....................................          26,940             6.9               1               2               5               9              15
515.....................................           8,312             5.2               1               1               3               7              12
516.....................................          52,442             4.6               2               2               4               5               9
517.....................................         119,770             2.5               1               1               1               3               5
518.....................................          49,376             3.4               1               1               2               4               7
519.....................................           8,549             4.9               1               1               3               6              11

[[Page 45630]]

 
520.....................................          12,798             2.1               1               1               1               2               4
521.....................................          30,971             5.7               2               3               4               7              11
522.....................................           6,047             9.6               3               5               8              12              20
523.....................................          15,530             4.0               1               2               3               5               7
524.....................................         133,080             3.4               1               2               3               4               6
525.....................................             584            16.8               1               4               9              18              37
526.....................................          32,121              NA              NA              NA              NA              NA              NA
527.....................................          84,729              NA              NA              NA              NA              NA              NA
                                         ----------------
                                              11,761,542
--------------------------------------------------------------------------------------------------------------------------------------------------------


                                   Table 7B.--Medicare Prospective Payment System Selected Percentile Lengths of Stay
                                                    [FY 2002 Medpar Update March 2003 Grouper V21.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                            Arithmetic
                   DRG                       Number of    mean length of       10th            25th            50th            75th            90th
                                             disharges         stay         percentile      percentile      percentile      percentile      percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1.......................................          24,378            10.8               3               5               8              14              21
2.......................................          11,909             5.3               1               3               4               7              10
3.......................................               3             6.0               1               1               4              13              13
6.......................................             360             3.0               1               1               2               4               7
7.......................................          14,886             9.8               2               4               7              12              20
8.......................................           4,213             2.8               1               1               1               3               7
9.......................................           1,741             6.7               1               3               5               8              12
10......................................          18,736             6.4               2               3               5               8              13
11......................................           3,312             4.0               1               2               3               5               8
12......................................          52,693             5.8               2               3               4               7              11
13......................................           7,144             5.0               2               3               4               6               9
14......................................         237,827             5.9               2               3               5               7              11
15......................................          94,552             4.9               2               3               4               6               9
16......................................           9,982             6.3               2               3               5               8              12
17......................................           2,757             3.2               1               1               2               4               6
18......................................          29,858             5.5               2               3               4               7              10
19......................................           8,583             3.5               1               2               3               5               7
20......................................           6,244            10.2               3               5               8              13              20
21......................................           1,894             6.6               2               3               5               8              13
22......................................           2,794             5.1               2               2               4               6              10
23......................................          11,327             4.3               1               2               3               5               8
24......................................          59,420             4.9               1               2               4               6              10
25......................................          27,639             3.2               1               2               3               4               6
26......................................              20             4.1               1               1               2               3               4
27......................................           4,470             5.2               1               1               3               7              11
28......................................          14,063             6.0               1               3               5               8              12
29......................................           5,344             3.5               1               2               3               4               7
30......................................               3             5.7               2               2               4              11              11
31......................................           3,976             4.0               1               2               3               5               8
32......................................           1,932             2.5               1               1               2               3               5
34......................................          23,938             4.9               1               2               4               6               9
35......................................           7,506             3.1               1               1               3               4               6
36......................................           2,125             1.5               1               1               1               1               2
37......................................           1,392             3.8               1               1               2               5               8
38......................................              98             2.8               1               1               1               4               5
39......................................             563             2.1               1               1               1               2               4
40......................................           1,555             3.8               1               1               3               5               7
42......................................           1,592             2.7               1               1               1               3               6
43......................................              95             3.4               1               1               3               4               6
44......................................           1,231             5.0               2               3               4               6               9
45......................................           2,690             3.1               1               2               3               4               6
46......................................           3,495             4.5               1               2               3               6               8
47......................................           1,415             3.1               1               1               2               4               6
49......................................           2,392             4.5               1               2               3               6               9
50......................................           2,439             1.9               1               1               1               2               3
51......................................             243             2.8               1               1               1               3               8
52......................................             224             1.8               1               1               1               2               3
53......................................           2,485             3.6               1               1               2               4               8
55......................................           1,489             2.9               1               1               1               3               7
56......................................             476             2.9               1               1               1               3               6
57......................................             715             3.7               1               1               2               4               8

[[Page 45631]]

 
58......................................               1             2.0               2               2               2               2               2
59......................................             117             2.7               1               1               1               3               6
60......................................               1             3.0               3               3               3               3               3
61......................................             255             5.2               1               1               3               7              11
62......................................               2             7.0               1               1              13              13              13
63......................................           3,038             4.4               1               2               3               5               9
64......................................           3,149             6.5               1               2               4               8              13
65......................................          40,527             2.8               1               1               2               4               5
66......................................           7,876             3.1               1               1               2               4               6
67......................................             387             3.6               1               2               3               5               7
68......................................          11,695             3.9               1               2               3               5               7
69......................................           3,782             3.0               1               2               3               4               5
70......................................              32             2.4               1               1               2               3               4
71......................................              80             3.4               1               1               2               4               6
72......................................             972             3.4               1               1               3               4               6
73......................................           7,740             4.4               1               2               3               6               9
75......................................          43,515            10.0               3               5               7              12              20
76......................................          44,651            11.1               3               5               9              14              21
77......................................           2,484             4.8               1               2               4               7              10
78......................................          39,668             6.6               3               4               6               8              11
79......................................         169,669             8.5               3               4               7              11              16
80......................................           8,115             5.3               2               3               4               7              10
81......................................               5             4.4               1               1               3               8               8
82......................................          64,585             6.9               2               3               5               9              14
83......................................           6,788             5.4               2               3               4               7              10
84......................................           1,616             3.2               1               2               3               4               6
85......................................          22,461             6.2               2               3               5               8              12
86......................................           2,262             3.5               1               2               3               4               7
87......................................          61,337             6.3               1               3               5               8              12
88......................................         405,367             5.0               2               3               4               6               9
89......................................         536,888             5.8               2               3               5               7              11
90......................................          49,023             4.0               2               2               3               5               7
91......................................              45             5.0               1               2               3               5              13
92......................................          15,881             6.3               2               3               5               8              12
93......................................           1,782             4.0               1               2               3               5               7
94......................................          12,922             6.2               2               3               5               8              12
95......................................           1,672             3.8               1               2               3               5               7
96......................................          57,107             4.6               2               2               4               6               8
97......................................          28,950             3.5               1               2               3               4               6
98......................................               9             3.7               1               1               2               2               5
99......................................          21,531             3.2               1               1               2               4               6
100.....................................           8,350             2.1               1               1               2               3               4
101.....................................          22,498             4.4               1               2               3               6               9
102.....................................           5,699             2.6               1               1               2               3               5
103.....................................             495            42.4               9              12              23              54              96
104.....................................          20,732            14.3               6               8              12              17              25
105.....................................          29,353             9.9               4               6               8              11              18
106.....................................           3,515            11.4               5               7              10              14              20
107.....................................          83,704            10.4               5               7               9              12              17
108.....................................           6,543             9.8               2               5               8              12              18
109.....................................          57,705             7.7               4               5               6               9              13
110.....................................          55,100             8.8               2               4               7              11              18
111.....................................           9,622             4.1               1               2               4               6               7
113.....................................          39,897            12.5               4               6               9              15              24
114.....................................           8,369             8.6               2               4               7              11              17
115.....................................          19,878             7.4               1               3               6              10              15
116.....................................         116,606             4.4               1               2               3               6               9
117.....................................           4,751             4.3               1               1               2               5              10
118.....................................           8,319             2.9               1               1               1               4               7
119.....................................           1,257             5.3               1               1               3               7              13
120.....................................          38,350             9.0               1               3               6              12              20
121.....................................         164,602             6.3               2               3               5               8              12
122.....................................          77,383             3.5               1               2               3               5               7
123.....................................          38,786             4.8               1               1               3               6              11
124.....................................         135,861             4.4               1               2               3               6               9
125.....................................          92,387             2.8               1               1               2               4               5
126.....................................           5,422            11.5               3               6               9              15              22
127.....................................         678,154             5.2               2               3               4               7              10
128.....................................           7,226             5.4               2               3               5               7               9
129.....................................           3,884             2.6               1               1               1               3               6

[[Page 45632]]

 
130.....................................          89,220             5.6               2               3               5               7              10
131.....................................          27,255             4.0               1               2               4               5               7
132.....................................         142,959             2.9               1               1               2               4               5
133.....................................           8,743             2.3               1               1               2               3               4
134.....................................          41,755             3.2               1               2               2               4               6
135.....................................           7,825             4.5               1               2               3               5               8
136.....................................           1,191             2.7               1               1               2               3               5
138.....................................         209,417             4.0               1               2               3               5               8
139.....................................          88,233             2.5               1               1               2               3               5
140.....................................          56,027             2.5               1               1               2               3               5
141.....................................         109,260             3.6               1               2               3               4               7
142.....................................          52,906             2.6               1               1               2               3               5
143.....................................         251,335             2.1               1               1               2               3               4
144.....................................          95,251             5.5               1               2               4               7              11
145.....................................           7,414             2.6               1               1               2               3               5
146.....................................          10,813            10.2               5               6               8              12              17
147.....................................           2,649             6.2               3               5               6               8               9
148.....................................         134,602            12.3               5               7              10              15              22
149.....................................          20,279             6.3               4               5               6               7               9
150.....................................          21,258            11.3               4               6               9              14              20
151.....................................           5,171             5.6               2               3               5               7              10
152.....................................           4,594             8.4               3               5               7              10              15
153.....................................           2,069             5.2               3               4               5               7               8
154.....................................          28,481            13.2               3               7              10              17              26
155.....................................           6,654             4.1               1               2               3               6               8
156.....................................               4             2.5               1               1               1               3               5
157.....................................           8,336             5.7               1               2               4               7              12
158.....................................           4,379             2.6               1               1               2               3               5
159.....................................          18,211             5.1               1               2               4               7              10
160.....................................          12,263             2.7               1               1               2               3               5
161.....................................          10,838             4.3               1               1               3               6               9
162.....................................           6,447             1.9               1               1               1               2               4
163.....................................               8             3.3               1               1               2               3               6
164.....................................           5,432             8.4               3               5               7              10              15
165.....................................           2,351             4.5               2               3               4               6               7
166.....................................           4,228             4.7               1               2               4               6               9
167.....................................           4,121             2.4               1               1               2               3               4
168.....................................           1,437             4.8               1               2               3               6              10
169.....................................             811             2.4               1               1               2               3               5
170.....................................          15,751            10.8               2               4               8              14              22
171.....................................           1,538             4.3               1               2               4               6               9
172.....................................          31,608             7.0               2               3               5               9              14
173.....................................           2,503             3.8               1               2               3               5               8
174.....................................         253,175             4.8               2               3               4               6               9
175.....................................          35,116             2.9               1               2               3               4               5
176.....................................          13,542             5.2               2               3               4               6              10
177.....................................           9,121             4.6               2               2               4               6               8
178.....................................           3,396             3.1               1               2               3               4               6
179.....................................          13,263             5.9               2               3               5               7              11
180.....................................          91,043             5.4               2               3               4               7              10
181.....................................          27,384             3.4               1               2               3               4               6
182.....................................         274,383             4.4               1               2               3               5               8
183.....................................          91,766             2.9               1               1               2               4               5
184.....................................              75             3.3               1               1               2               4               7
185.....................................           5,415             4.7               1               2               3               6              10
186.....................................               6             6.7               2               3               3              10              10
187.....................................             637             4.1               1               2               3               6               8
188.....................................          84,442             5.6               1               2               4               7              11
189.....................................          13,179             3.1               1               1               2               4               6
190.....................................              76             5.1               1               2               4               6              10
191.....................................           9,576            13.8               3               6              10              17              28
192.....................................           1,322             6.2               1               3               6               8              11
193.....................................           4,844            12.7               5               7              10              16              23
194.....................................             651             6.7               2               4               6               8              12
195.....................................           4,041            10.5               4               6               9              13              19
196.....................................           1,007             5.6               2               3               5               7              10
197.....................................          18,401             9.2               3               5               7              11              17
198.....................................           5,446             4.4               2               3               4               6               7
199.....................................           1,644             9.8               2               4               7              13              21
200.....................................           1,082            10.5               2               3               7              14              23

[[Page 45633]]

 
201.....................................           2,146            14.2               4               6              10              18              29
202.....................................          26,905             6.4               2               3               5               8              13
203.....................................          30,167             6.7               2               3               5               9              13
204.....................................          65,940             5.7               2               3               4               7              11
205.....................................          27,684             6.2               2               3               5               8              12
206.....................................           2,079             3.8               1               2               3               5               8
207.....................................          33,045             5.2               1               2               4               7              10
208.....................................          10,244             2.9               1               1               2               4               5
209.....................................         401,363             4.9               3               3               4               5               7
210.....................................         123,436             6.9               3               4               6               8              11
211.....................................          30,259             4.8               3               4               4               6               7
212.....................................              10             6.4               1               1               3               5               7
213.....................................          10,018             9.2               2               4               7              12              18
216.....................................           8,808             8.0               1               2               6              11              17
217.....................................          17,420            13.4               3               5               9              16              28
218.....................................          24,033             5.5               2               3               4               7              10
219.....................................          20,076             3.2               1               2               3               4               6
220.....................................               1             1.0               1               1               1               1               1
223.....................................          13,406             3.0               1               1               2               4               6
224.....................................          11,846             1.9               1               1               1               2               3
225.....................................           6,539             5.3               1               2               4               7              11
226.....................................           5,895             6.5               1               2               4               8              14
227.....................................           4,883             2.6               1               1               2               3               5
228.....................................           2,553             4.1               1               1               3               5               9
229.....................................           1,274             2.3               1               1               2               3               5
230.....................................           2,474             5.6               1               2               3               7              12
232.....................................             825             2.7               1               1               1               2               6
233.....................................          10,014             7.4               1               3               6              10              15
234.....................................           5,408             3.1               1               1               2               4               7
235.....................................           5,150             4.9               1               2               4               6               9
236.....................................          40,417             4.6               1               3               4               6               8
237.....................................           1,790             3.7               1               2               3               5               7
238.....................................           9,003             8.6               3               4               7              10              17
239.....................................          46,422             6.3               2               3               5               8              12
240.....................................          12,147             6.6               2               3               5               8              13
241.....................................           3,197             3.8               1               2               3               5               7
242.....................................           2,621             6.9               2               3               5               9              14
243.....................................          97,186             4.7               1               2               4               6               9
244.....................................          14,757             4.7               1               2               4               6               9
245.....................................           5,890             3.3               1               2               3               4               6
246.....................................           1,501             3.8               1               2               3               5               7
247.....................................          20,607             3.3               1               1               3               4               7
248.....................................          14,008             4.9               1               3               4               6               9
249.....................................          13,006             3.6               1               1               2               4               7
250.....................................           3,835             4.1               1               2               3               5               8
251.....................................           2,403             2.8               1               1               3               3               5
253.....................................          22,265             4.7               2               3               4               6               8
254.....................................          10,865             3.2               1               2               3               4               5
256.....................................           6,774             5.1               1               2               4               6              10
257.....................................          15,803             2.6               1               1               2               3               5
258.....................................          15,399             1.8               1               1               2               2               3
259.....................................           3,531             2.7               1               1               1               3               6
260.....................................           4,255             1.4               1               1               1               1               2
261.....................................           1,801             2.1               1               1               1               2               4
262.....................................             674             4.3               1               1               3               6               9
263.....................................          23,297            11.5               3               5               8              14              22
264.....................................           3,898             6.6               2               3               5               8              13
265.....................................           4,132             6.6               1               2               4               8              14
266.....................................           2,567             3.2               1               1               2               4               7
267.....................................             242             4.4               1               1               3               6              10
268.....................................             931             3.8               1               1               2               4               8
269.....................................           9,911             8.5               2               3               7              11              17
270.....................................           2,824             3.6               1               1               2               5               7
271.....................................          19,513             7.2               2               4               6               9              14
272.....................................           5,770             6.0               2               3               5               7              12
273.....................................           1,351             4.0               1               2               3               5               8
274.....................................           2,328             6.5               1               3               5               8              13
275.....................................             232             3.6               1               1               2               4               7
276.....................................           1,333             4.5               1               2               4               6               8
277.....................................         101,243             5.7               2               3               5               7              10

[[Page 45634]]

 
278.....................................          32,701             4.2               2               2               4               5               7
279.....................................              10             5.3               2               2               3               7               7
280.....................................          18,038             4.1               1               2               3               5               8
281.....................................           7,650             2.9               1               1               2               4               5
283.....................................           6,106             4.7               1               2               4               6               9
284.....................................           2,039             2.9               1               1               2               4               6
285.....................................           7,012            10.5               3               5               8              13              20
286.....................................           2,511             5.9               2               3               4               7              12
287.....................................           6,330            10.3               3               5               8              13              20
288.....................................           5,684             5.0               2               3               4               5               8
289.....................................           6,977             2.7               1               1               1               2               6
290.....................................          10,000             2.2               1               1               1               2               4
291.....................................              60             1.6               1               1               1               2               3
292.....................................           6,576            10.5               2               4               8              14              21
293.....................................             368             4.7               1               1               3               6               9
294.....................................          99,279             4.5               1               2               3               6               9
295.....................................           3,603             4.0               1               2               3               5               7
296.....................................         281,526             5.1               1               2               4               6              10
297.....................................          48,952             3.3               1               2               3               4               6
298.....................................             117             3.1               1               1               2               4               6
299.....................................           1,291             5.5               1               2               4               7              11
300.....................................          18,877             6.1               2               3               5               8              12
301.....................................           3,649             3.6               1               2               3               4               7
302.....................................           8,941             8.5               4               5               6               9              15
303.....................................          21,890             8.0               3               4               6               9              15
304.....................................          12,646             8.9               2               4               6              11              18
305.....................................           3,058             3.5               1               2               3               4               7
306.....................................           7,087             5.4               1               2               3               7              12
307.....................................           2,041             2.1               1               1               2               2               3
308.....................................           7,321             6.2               1               2               4               8              14
309.....................................           4,198             2.1               1               1               1               2               4
310.....................................          24,966             4.4               1               1               3               6              10
311.....................................           7,518             1.8               1               1               1               2               3
312.....................................           1,532             4.6               1               1               3               6              10
313.....................................             558             2.3               1               1               1               3               5
314.....................................               2            40.5               1               1              80              80              80
315.....................................          34,371             7.0               1               1               4               9              16
316.....................................         120,183             6.5               2               3               5               8              13
317.....................................           2,045             3.6               1               1               2               4               7
318.....................................           5,811             6.1               1               3               5               8              12
319.....................................             416             2.9               1               1               2               4               6
320.....................................         188,879             5.3               2               3               4               6              10
321.....................................          31,494             3.7               1               2               3               5               7
322.....................................              55             3.3               1               2               3               4               5
323.....................................          20,049             3.2               1               1               2               4               6
324.....................................           7,086             1.9               1               1               1               2               4
325.....................................           9,360             3.8               1               2               3               5               7
326.....................................           2,755             2.6               1               1               2               3               5
327.....................................               7             2.6               1               1               2               3               4
328.....................................             748             3.7               1               1               3               5               8
329.....................................              92             2.1               1               1               1               3               5
331.....................................          51,750             5.6               1               3               4               7              11
332.....................................           5,046             3.2               1               1               2               4               6
333.....................................             269             5.7               1               2               3               7              11
334.....................................          10,565             4.6               2               3               4               5               8
335.....................................          12,782             3.0               2               2               3               4               5
336.....................................          36,048             3.4               1               2               2               4               7
337.....................................          29,654             2.0               1               1               2               2               3
338.....................................             941             5.5               1               2               3               7              13
339.....................................           1,491             4.8               1               1               3               6              11
340.....................................               1             2.0               2               2               2               2               2
341.....................................           3,599             3.2               1               1               2               3               7
342.....................................             694             3.2               1               1               2               4               7
344.....................................           3,598             2.5               1               1               1               2               5
345.....................................           1,376             4.9               1               1               3               6              11
346.....................................           4,919             5.9               2               3               5               8              12
347.....................................             318             3.0               1               1               2               4               6
348.....................................           3,416             4.3               1               2               3               5               8
349.....................................             619             2.5               1               1               2               3               5
350.....................................           6,778             4.5               2               2               4               6               8

[[Page 45635]]

 
352.....................................             968             4.0               1               2               3               5               8
353.....................................           2,585             6.5               2               3               5               7              12
354.....................................           7,455             5.7               3               3               4               6              10
355.....................................           5,602             3.2               2               2               3               4               5
356.....................................          26,093             2.1               1               1               2               3               3
357.....................................           5,648             8.4               3               4               6              10              16
358.....................................          21,749             4.2               2               2               3               5               7
359.....................................          32,221             2.6               1               2               2               3               4
360.....................................          15,906             2.8               1               1               2               3               4
361.....................................             348             3.2               1               1               2               3               7
362.....................................               5             1.4               1               1               1               2               2
363.....................................           2,529             3.6               1               2               2               4               8
364.....................................           1,643             4.1               1               1               3               5               8
365.....................................           1,842             8.2               1               3               5              10              17
366.....................................           4,601             6.7               1               3               5               8              14
367.....................................             489             3.1               1               1               2               4               7
368.....................................           3,592             6.6               2               3               5               8              13
369.....................................           3,510             3.3               1               1               2               4               7
370.....................................           1,390             5.8               2               3               4               5               9
371.....................................           1,764             3.5               2               3               3               4               5
372.....................................             979             3.5               2               2               2               3               5
373.....................................           4,246             2.3               1               2               2               3               3
374.....................................             100             3.0               2               2               2               3               6
376.....................................             332             3.5               1               2               2               4               7
377.....................................              53             4.1               1               2               3               5               8
378.....................................             175             2.6               1               1               2               3               5
379.....................................             365             3.0               1               1               2               3               5
380.....................................              98             2.0               1               1               1               2               3
381.....................................             194             1.9               1               1               1               2               4
382.....................................              49             1.7               1               1               1               2               3
383.....................................           2,031             3.8               1               2               3               4               7
384.....................................             133             2.6               1               1               2               3               5
385.....................................               2             1.5               1               1               2               2               2
387.....................................               1            55.0              55              55              55              55              55
392.....................................           2,292             9.7               3               4               7              12              21
393.....................................               1             4.0               4               4               4               4               4
394.....................................           2,614             7.6               1               2               5               9              17
395.....................................         108,545             4.3               1               2               3               5               9
396.....................................              19             4.2               1               1               2               5               9
397.....................................          19,105             5.2               1               2               4               6              10
398.....................................          18,238             5.9               2               3               5               7              11
399.....................................           1,698             3.5               1               2               3               4               6
401.....................................           5,876            11.5               2               5               9              15              23
402.....................................           1,480             4.0               1               1               3               5               9
403.....................................          32,056             8.1               2               3               6              10              17
404.....................................           4,368             4.1               1               2               3               5               8
405.....................................               1            31.0              31              31              31              31              31
406.....................................           2,435             9.7               2               4               7              12              20
407.....................................             645             4.1               1               2               3               5               7
408.....................................           2,131             8.2               1               2               5              10              20
409.....................................           2,166             6.2               2               3               4               6              12
410.....................................          28,518             4.1               1               2               4               5               6
411.....................................               7             2.3               1               1               2               2               4
412.....................................              17             3.6               1               1               3               6               7
413.....................................           5,371             7.0               2               3               5               9              14
414.....................................             638             4.2               1               2               3               5               8
415.....................................          43,615            14.4               4               6              11              18              28
416.....................................         193,642             7.4               2               4               6               9              14
417.....................................              41             5.7               2               2               5               7              12
418.....................................          26,059             6.3               2               3               5               8              12
419.....................................          16,513             4.6               1               2               4               6               9
420.....................................           3,233             3.4               1               2               3               4               6
421.....................................          10,805             4.1               1               2               3               5               8
422.....................................              68             3.7               1               2               2               3               6
423.....................................           8,149             8.3               2               3               6              10              17
424.....................................           1,264            13.1               2               4               9              15              26
425.....................................          16,274             3.8               1               2               3               5               8
426.....................................           4,619             4.5               1               2               3               6               9
427.....................................           1,614             4.4               1               2               3               5               9
428.....................................             800             7.1               1               2               5               8              14

[[Page 45636]]

 
429.....................................          27,358             5.9               2               3               4               7              11
430.....................................          65,641             7.8               2               3               6              10              16
431.....................................             319             6.8               1               2               4               7              12
432.....................................             454             4.0               1               2               3               5               8
433.....................................           5,603             3.1               1               1               2               4               6
439.....................................           1,532             8.2               1               3               5               9              17
440.....................................           5,838             9.1               2               3               6              11              19
441.....................................             690             3.1               1               1               2               4               6
442.....................................          17,683             8.5               1               3               6              10              18
443.....................................           3,949             3.4               1               1               3               4               7
444.....................................           5,831             4.2               1               2               3               5               8
445.....................................           2,592             2.9               1               1               2               4               5
447.....................................           6,551             2.5               1               1               2               3               5
448.....................................               1             1.0               1               1               1               1               1
449.....................................          33,429             3.7               1               1               3               4               7
450.....................................           7,534             2.0               1               1               1               2               4
451.....................................               1             1.0               1               1               1               1               1
452.....................................          25,827             4.9               1               2               3               6              10
453.....................................           5,733             2.8               1               1               2               3               5
454.....................................           4,822             4.2               1               2               3               5               8
455.....................................           1,086             2.4               1               1               2               3               5
461.....................................           5,012             3.7               1               1               2               4               8
462.....................................           9,763            10.9               4               6               9              14              19
463.....................................          27,225             4.0               1               2               3               5               8
464.....................................           7,273             3.0               1               1               2               4               6
465.....................................             203             3.9               1               1               1               3               6
466.....................................           1,761             4.0               1               1               2               4               7
467.....................................           1,126             3.6               1               1               2               3               6
468.....................................          51,697            12.8               3               6              10              16              25
471.....................................          13,425             5.4               3               3               4               6               8
473.....................................           8,123            12.4               2               3               7              17              32
475.....................................         110,111            11.2               2               5               9              15              22
476.....................................           3,674            11.1               2               5              10              15              21
477.....................................          26,494             8.3               1               3               6              11              17
478.....................................         108,594             7.3               1               3               5               9              15
479.....................................          24,163             3.2               1               1               2               4               7
480.....................................             627            21.1               6               8              12              22              47
481.....................................             867            21.8              13              17              20              24              33
482.....................................           5,312            12.5               4               6               9              15              24
483.....................................          45,887            39.5              15              22              33              49              70
484.....................................             346            14.5               2               6              11              21              30
485.....................................           3,279             9.9               4               5               7              12              19
486.....................................           2,225            12.8               1               6              10              17              26
487.....................................           3,908             7.2               1               3               6               9              15
488.....................................             756            17.0               4               7              13              22              36
489.....................................          13,475             8.6               2               3               6              10              18
490.....................................           5,502             5.5               1               2               4               7              11
491.....................................          15,451             3.4               1               2               3               4               6
492.....................................           3,115            14.9               3               5               7              25              33
493.....................................          59,856             6.0               1               3               5               8              11
494.....................................          29,005             2.5               1               1               2               3               5
495.....................................             200            16.1               7               9              12              19              30
496.....................................           2,506             8.9               3               4               6              11              18
497.....................................          22,093             6.3               3               4               5               7              11
498.....................................          15,887             4.0               2               3               4               5               6
499.....................................          34,803             4.5               1               2               3               6               9
500.....................................          50,192             2.4               1               1               2               3               4
501.....................................           2,615            10.6               4               5               8              13              20
502.....................................             784             6.2               3               4               5               7              11
503.....................................           6,020             3.9               1               2               3               5               7
504.....................................             128            28.0               7              13              21              38              55
505.....................................             136             5.6               1               1               1               4              10
506.....................................             926            16.9               4               7              13              21              35
507.....................................             346             9.1               2               4               7              13              19
508.....................................             634             7.8               2               3               5              10              17
509.....................................             161             4.3               1               2               3               5               9
510.....................................           1,660             6.7               1               3               5               8              15
511.....................................             592             4.7               1               1               3               6              10
512.....................................             505            13.2               6               8              10              15              23
513.....................................             215            10.0               5               6               8              10              16

[[Page 45637]]

 
515.....................................           8,312             5.2               1               1               3               7              12
516.....................................          33,015             4.6               2               2               4               5               9
517.....................................          68,536             2.5               1               1               1               3               5
518.....................................          49,374             3.4               1               1               2               4               7
519.....................................           9,057             5.1               1               1               3               6              12
520.....................................          13,115             2.1               1               1               1               2               4
521.....................................          30,971             5.7               2               3               4               7              11
522.....................................           6,047             9.6               4               5               8              12              20
523.....................................          15,530             4.1               1               2               3               5               7
524.....................................         133,080             3.4               1               2               3               4               6
525.....................................             584            16.8               1               4               9              18              37
526.....................................          51,533              NA              NA              NA              NA              NA              NA
527.....................................         135,957              NA              NA              NA              NA              NA              NA
528.....................................           1,596            17.3               6              10              15              22              32
529.....................................           3,671             8.2               1               3               5              11              19
530.....................................           2,698             3.6               1               2               3               4               7
531.....................................           3,859             9.9               2               4               7              13              20
532.....................................           2,973             3.9               1               1               3               5               8
533.....................................          43,392             4.1               1               1               2               5               9
534.....................................          52,512             2.0               1               1               1               2               4
535.....................................           6,099            10.9               2               6               9              14              21
536.....................................          20,841             5.8               1               2               4               8              12
537.....................................           6,921             7.0               1               3               5               9              14
538.....................................           6,484             2.9               1               1               2               4               6
539.....................................           4,472            11.2               2               4               8              15              24
540.....................................           1,894             4.0               1               1               3               5               8
                                         ----------------
                                              11,761,542
--------------------------------------------------------------------------------------------------------------------------------------------------------


 Table 8A.--Statewide Average Operating Cost-To-Charge Ratios--July 2003
------------------------------------------------------------------------
                        State                           Urban     Rural
------------------------------------------------------------------------
Alabama.............................................     0.327     0.397
Alaska..............................................     0.402     0.662
Arizona.............................................      0.34     0.449
Arkansas............................................     0.425     0.413
California..........................................     0.322     0.408
Colorado............................................     0.394     0.532
Connecticut.........................................     0.504     0.542
Delaware............................................      0.56     0.483
District of Columbia................................      0.38  ........
Florida.............................................      0.33     0.345
Georgia.............................................     0.449     0.444
Hawaii..............................................     0.402     0.447
Idaho...............................................     0.541     0.513
Illinois............................................     0.383     0.475
Indiana.............................................     0.484     0.514
Iowa................................................     0.456     0.583
Kansas..............................................     0.367     0.549
Kentucky............................................     0.451     0.461
Louisiana...........................................     0.377     0.459
Maine...............................................     0.542     0.503
Maryland............................................      0.76      0.82
Massachusetts.......................................     0.499     0.523
Michigan............................................     0.437     0.534
Minnesota...........................................     0.461     0.614
Mississippi.........................................     0.432     0.418
Missouri............................................     0.389     0.454
Montana.............................................      0.51     0.512
Nebraska............................................     0.415     0.525
Nevada..............................................     0.284     0.461
New Hampshire.......................................     0.523     0.586
New Jersey..........................................     0.335  ........
New Mexico..........................................     0.474     0.477
New York............................................     0.469     0.583
North Carolina......................................     0.503     0.468
North Dakota........................................      0.64     0.619
Ohio................................................     0.475     0.567
Oklahoma............................................     0.371     0.467
Oregon..............................................     0.525     0.578
Pennsylvania........................................     0.368     0.497
Puerto Rico.........................................     0.479     0.569
Rhode Island........................................     0.484  ........
South Carolina......................................     0.435     0.451
South Dakota........................................     0.484     0.535
Tennessee...........................................     0.407     0.436
Texas...............................................     0.372     0.475
Utah................................................     0.481     0.581
Vermont.............................................     0.522     0.596
Virginia............................................     0.427     0.495
Washington..........................................     0.532     0.581
West Virginia.......................................     0.562     0.527
Wisconsin...........................................     0.505     0.581
Wyoming.............................................     0.442     0.618
------------------------------------------------------------------------


  Table 8B.--Statewide Average Capital Cost-To-Charge Ratios--July 2003
------------------------------------------------------------------------
                             State                                Ratio
------------------------------------------------------------------------
Alabama.......................................................     0.040
Alaska........................................................     0.053
Arizona.......................................................     0.034
Arkansas......................................................     0.042
California....................................................     0.031
Colorado......................................................     0.045
Connecticut...................................................     0.036
Delaware......................................................     0.048
District of Columbia..........................................     0.027
Florida.......................................................     0.038
Georgia.......................................................     0.047
Hawaii........................................................     0.041
Idaho.........................................................     0.046
Illinois......................................................     0.037
Indiana.......................................................     0.050
Iowa..........................................................     0.046
Kansas........................................................     0.045
Kentucky......................................................     0.045
Louisiana.....................................................     0.043
Maine.........................................................     0.036
Maryland......................................................     0.013
Massachusetts.................................................     0.049
Michigan......................................................     0.044
Minnesota.....................................................     0.042
Mississippi...................................................     0.041
Missouri......................................................     0.040
Montana.......................................................     0.049
Nebraska......................................................     0.047
Nevada........................................................     0.032
New Hampshire.................................................     0.058
New Jersey....................................................     0.030
New Mexico....................................................     0.044
New York......................................................     0.046
North Carolina................................................     0.046
North Dakota..................................................     0.065
Ohio..........................................................     0.044
Oklahoma......................................................     0.040
Oregon........................................................     0.043
Pennsylvania..................................................     0.035

[[Page 45638]]

 
Puerto Rico...................................................     0.046
Rhode Island..................................................     0.029
South Carolina................................................     0.046
South Dakota..................................................     0.051
Tennessee.....................................................     0.046
Texas.........................................................     0.043
Utah..........................................................     0.045
Vermont.......................................................     0.046
Virginia......................................................     0.048
Washington....................................................     0.052
West Virginia.................................................     0.044
Wisconsin.....................................................     0.049
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
010010..............................................                  01                3440                3440
010012..............................................                  01                2880  ..................
010022..............................................                  01                2880  ..................
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  ..................
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                4480
050251..............................................                  05                6720  ..................
050296..............................................                  05                7120  ..................
050325..............................................                  05                5170  ..................
050335..............................................                  05                5170  ..................
050419..............................................                  05                6690  ..................
050457..............................................                7360                5775  ..................
050494..............................................                  05                6920  ..................
050510..............................................                7360                5775  ..................
050541..............................................                7360                5775  ..................

[[Page 45639]]

 
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
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  ..................
080002..............................................                  08  ..................                0720
080004..............................................                2190                9160  ..................
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                2710                2710
100109..............................................                  10                5960  ..................
100150..............................................                  10                5000  ..................
100176..............................................                8960                2710  ..................
100211..............................................                8280                3980  ..................
100217..............................................                  10                2710                2710
100232..............................................                  10                5790                2900
100239..............................................                8280                7510  ..................
100249..............................................                  10                8280  ..................
100268..............................................                8960                2680  ..................
110001..............................................                  11                0520                0520
110002..............................................                  11                0520  ..................
110003..............................................                  11                3600  ..................
110016..............................................                  11                1800  ..................
110023..............................................                  11                0520  ..................
110025..............................................                  11                3600                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                  29  ..................
130003..............................................                  13                  50  ..................
130011..............................................                  13                  50  ..................
130018..............................................                  13                6340  ..................
130026..............................................                  13                6340  ..................
130028..............................................                6340                7160  ..................

[[Page 45640]]

 
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  ..................
140112..............................................                  14                6120                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
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
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  ..................
170001..............................................                  17                9040  ..................
170006..............................................                  17                3710  ..................

[[Page 45641]]

 
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
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  ..................
180125..............................................                  18                3400  ..................
180127..............................................                  18                4520  ..................
180132..............................................                  18                4280  ..................
180139..............................................                  18                4280  ..................
190001..............................................                  19  ..................                5560
190003..............................................                  19                3880  ..................
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  ..................

[[Page 45642]]

 
230040..............................................                  23                3720                3000
230054..............................................                  23                3080  ..................
230080..............................................                  23                6960  ..................
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  ..................
240119..............................................                  24                2240  ..................
240121..............................................                  24                2240  ..................
240139..............................................                  24                5120  ..................
240142..............................................                  24                6980  ..................
240152..............................................                  24                5120  ..................
240187..............................................                  24                5120  ..................
250002..............................................                  25                2650  ..................
250004..............................................                  25                4920  ..................
250009..............................................                  25                3580  ..................
250030..............................................                  25                3560  ..................
250031..............................................                  25                3560  ..................
250034..............................................                  25                4920  ..................
250042..............................................                  25                4920  ..................
250069..............................................                  25                3560  ..................
250078..............................................                3285                0920  ..................
250081..............................................                  25                3560  ..................
250082..............................................                  25                6420  ..................
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  ..................

[[Page 45643]]

 
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  ..................
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                5660  ..................
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  ..................

[[Page 45644]]

 
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
340115..............................................                  34                6640                6640
340124..............................................                  34                6640                6640
340126..............................................                  34                6640                6640
340143..............................................                3290                1520  ..................
340147..............................................                6895                6640  ..................
350003..............................................                  35                1010  ..................
350005..............................................                  35                2985  ..................
350006..............................................                  35                1010  ..................
350009..............................................                  35                2520  ..................
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  ..................
360039..............................................                  36                1840                1840
360046..............................................                3200  ..................                1640
360054..............................................                  36                1480  ..................
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  ..................
360108..............................................                  36                4800                4800
360109..............................................                  36                1840                1840
360112..............................................                8400                0440  ..................
360121..............................................                  36                0440  ..................
360132..............................................                3200  ..................                1640
360142..............................................                  36  ..................                1640
360150..............................................                0080  ..................                1680
360159..............................................                  36                1840  ..................
360175..............................................                  36                1840  ..................
360197..............................................                  36                1840                1840
360211..............................................                8080  ..................                6280
370004..............................................                  37                3710  ..................
370006..............................................                  37                8560  ..................
370014..............................................                  37                7640  ..................
370015..............................................                  37                8560  ..................
370018..............................................                  37                8560  ..................
370022..............................................                  37                4200  ..................
370023..............................................                  37                4200  ..................

[[Page 45645]]

 
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  ..................
380084..............................................                7080                6440  ..................
380090..............................................                  38                2400  ..................
390006..............................................                  39                3240  ..................
390008..............................................                  39                6280                6280
390013..............................................                  39                3240  ..................
390016..............................................                  39                6280                6280
390017..............................................                  39                6280                6280
390030..............................................                  39                0240                6680
390031..............................................                  39                6680                6680
390048..............................................                  39                3240  ..................
390052..............................................                  39                0280  ..................
390065..............................................                  39                8840                9280
390079..............................................                  39                0960  ..................
390091..............................................                  39                6280  ..................
390093..............................................                  39                6280  ..................
390110..............................................                3680                6280  ..................
390113..............................................                  39                9320  ..................
390133..............................................                0240                6160  ..................
390138..............................................                  39                8840  ..................
390150..............................................                  39                6280  ..................
390151..............................................                  39                8840  ..................
390163..............................................                  39                6280  ..................
390181..............................................                  39                6680                6680
390183..............................................                  39                6680                6680
390189..............................................                  39                3240  ..................
390197..............................................                0240                6160  ..................
390201..............................................                  39                5660                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  ..................
420068..............................................                  42                0600  ..................
420070..............................................                8140                1760  ..................
420071..............................................                  42                0600  ..................
420080..............................................                  42                7520  ..................
420085..............................................                5330                9200  ..................
430004..............................................                  43                6660  ..................

[[Page 45646]]

 
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  ..................
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  ..................

[[Page 45647]]

 
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                0860  ..................
500007..............................................                  50                0860  ..................
500016..............................................                  50                7600  ..................
500031..............................................                  50                5910  ..................
500041..............................................                  50                6440  ..................
500059..............................................                  50                7600  ..................
500072..............................................                  50                7600  ..................
500079..............................................                8200  ..................                7600
510001..............................................                  51                6280  ..................
510002..............................................                  51                6800  ..................
510006..............................................                  51                6280  ..................
510024..............................................                  51                6280                6280
510028..............................................                  51                1480  ..................
510046..............................................                  51                1480  ..................
510047..............................................                  51                6280  ..................
510048..............................................                  51                3400  ..................
510062..............................................                  51                1480  ..................
510070..............................................                  51                1480  ..................
510071..............................................                  51                1480  ..................
520002..............................................                  52                8940  ..................
520006..............................................                  52                8940  ..................
520018..............................................                  52                5120  ..................
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  ..................
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  ..................
530009..............................................                  53                1350  ..................
530015..............................................                  53                6340  ..................
530025..............................................                  53                2670  ..................
530032..............................................                  53                7160  ..................
----------------------------------------------------------------------------------------------------------------


[[Page 45648]]


  Table 10.--Mean and .75 Standard Deviation by Diagnosis-Related Group
                            (DRG)--July 2003
------------------------------------------------------------------------
                                                              Mean + .75
                      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
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

[[Page 45649]]

 
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
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

[[Page 45650]]

 
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
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...........................................       33,015      $45,394
517...........................................       68,536      $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...........................................       51,533      $42,080
527...........................................      135,957      $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
------------------------------------------------------------------------


Table 11.--FY 2004 LTC-DRGs, Relative Weights, Geometric Average Length of Stay, and 5/6th of the Average Length
                                                     of Stay
----------------------------------------------------------------------------------------------------------------
                                                                                     Geometric     5/6th of the
         LTC-DRG                        Description                  Relative     average length  average length
                                                                      weight          of stay         of stay
----------------------------------------------------------------------------------------------------------------
1                          \5\ CRANIOTOMY AGE 17 W CC          2.0841            40.0            33.3
2                          \8\ CRANIOTOMY AGE  17 W/O          2.0841            40.0            33.3
                            CC.
3                          \8\ CRANIOTOMY AGE 0-17..............          2.0841            40.0            33.3
6                          \8\ CARPAL TUNNEL RELEASE............          0.4964            18.5            15.4
7                          \7\ PERIPH & CRANIAL NERVE & OTHER             1.5754            41.0            34.1
                            NERV SYST PROC W CC.
8                          \7\ PERIPH & CRANIAL NERVE & OTHER             1.5754            41.0            34.1
                            NERV SYST PROC W/O CC.
9                          SPINAL DISORDERS & INJURIES..........          1.5025            32.9            27.4
10                         NERVOUS SYSTEM NEOPLASMS W CC........          0.7549            23.4            19.5
11                         NERVOUS SYSTEM NEOPLASMS W/O CC......          0.7281            22.0            18.3
12                         DEGENERATIVE NERVOUS SYSTEM DISORDERS          0.7485            25.8            21.5
13                         MULTIPLE SCLEROSIS & CEREBELLAR                0.7530            25.9            21.5
                            ATAXIA.
14                         INTERCRANIAL HEMORRHAGE & STROKE W             0.9196            27.4            22.8
                            INFARCT.
15                         NONSPECIFIC CVA & PRECEREBRAL                  0.8714            28.8            24.0
                            OCCULUSION W/O INFARCT.
16                         NONSPECIFIC CEREBROVASCULAR DISORDERS          0.9125            23.9            19.9
                            W CC.
17                         NONSPECIFIC CEREBROVASCULAR DISORDERS          0.5262            20.4            17.0
                            W/O CC.
18                         CRANIAL & PERIPHERAL NERVE DISORDERS           0.8225            23.9            19.9
                            W CC.
19                         CRANIAL & PERIPHERAL NERVE DISORDERS           0.6236            22.7            18.9
                            W/O CC.
20                         NERVOUS SYSTEM INFECTION EXCEPT VIRAL          1.0097            24.8            20.6
                            MENINGITIS.
21                         \2\ VIRAL MENINGITIS.................          0.7372            23.5            19.5
22                         \2\ HYPERTENSIVE ENCEPHALOPATHY......          0.7372            23.5            19.5
23                         NONTRAUMATIC STUPOR & COMA...........          0.9033            28.8            24.0
24                         SEIZURE & HEADACHE AGE 17           0.8527            26.2            21.8
                            W CC.
25                         SEIZURE & HEADACHE AGE 17           0.7727            24.1            20.0
                            W/O CC.
26                         \8\ SEIZURE & HEADACHE AGE 0-17......          0.7372            23.5            19.5
27                         TRAUMATIC STUPOR & COMA, COMA 1 HR.
28                         TRAUMATIC STUPOR & COMA, COMA 1 HR AGE 17 W CC.
29                         TRAUMATIC STUPOR & COMA, COMA 1 HR AGE 17 W/O CC.
30                         \8\ TRAUMATIC STUPOR & COMA, COMA <1           0.9562            26.1            21.7
                            HR AGE 0-17.
31                         \7\ CONCUSSION AGE 17 W CC          0.9562            26.1            21.7

[[Page 45651]]

 
32                         \7\ CONCUSSION AGE 17 W/O           0.9562            26.1            21.7
                            CC.
33                         \8\ CONCUSSION AGE 0-17..............          0.7372            23.5            19.5
34                         OTHER DISORDERS OF NERVOUS SYSTEM W            0.9140            27.8            23.1
                            CC.
35                         OTHER DISORDERS OF NERVOUS SYSTEM W/O          0.6651            24.5            20.4
                            CC.
36                         \8\ RETINAL PROCEDURES...............          0.4964            18.5            15.4
37                         \8\ ORBITAL PROCEDURES...............          0.4964            18.5            15.4
38                         \8\ PRIMARY IRIS PROCEDURES..........          0.4964            18.5            15.4
39                         \8\ LENS PROCEDURES WITH OR WITHOUT            0.4964            18.5            15.4
                            VITRECTOMY.
40                         \5\ EXTRAOCULAR PROCEDURES EXCEPT              2.0841            40.0            33.3
                            ORBIT AGE 17.
41                         \8\ EXTRAOCULAR PROCEDURES EXCEPT              0.4964            18.5            15.4
                            ORBIT AGE 0-17.
42                         \8\ INTRAOCULAR PROCEDURES EXCEPT              0.4964            18.5            15.4
                            RETINA, IRIS & LENS.
43                         \8\ HYPHEMA..........................          0.4964            18.5            15.4
44                         \1\ ACUTE MAJOR EYE INFECTIONS.......          0.4964            18.5            15.4
45                         \8\ NEUROLOGICAL EYE DISORDERS.......          0.4964            18.5            15.4
46                         \1\ OTHER DISORDERS OF THE EYE AGE             0.4964            18.5            15.4
                            17 W CC.
47                         \1\ OTHER DISORDERS OF THE EYE AGE             0.4964            18.5            15.4
                            17 W/O CC.
48                         \8\ OTHER DISORDERS OF THE EYE AGE 0-          0.4964            18.5            15.4
                            17.
49                         \8\ MAJOR HEAD & NECK PROCEDURES.....          1.3569            32.5            27.0
50                         \8\ SIALOADENECTOMY..................          0.9562            26.1            21.7
51                         \8\ SALIVARY GLAND PROCEDURES EXCEPT           0.9562            26.1            21.7
                            SIALOADENECTOMY.
52                         \8\ CLEFT LIP & PALATE REPAIR........          0.9562            26.1            21.7
53                         \2\ SINUS & MASTOID PROCEDURES AGE             0.7372            23.5            19.5
                            17.
54                         \8\ SINUS & MASTOID PROCEDURES AGE 0-          0.9562            26.1            21.7
                            17.
55                         \8\ MISCELLANEOUS EAR, NOSE, MOUTH &           0.9562            26.1            21.7
                            THROAT PROCEDURES.
56                         \8\ RHINOPLASTY......................          0.7372            23.5            19.5
57                         \8\ T&A PROC, EXCEPT TONSILLECTOMY &/          0.9562            26.1            21.7
                            OR ADENOIDECTOMY ONLY, AGE 17.
58                         \8\ T&A PROC, EXCEPT TONSILLECTOMY &/          0.9562            26.1            21.7
                            OR ADENOIDECTOMY ONLY, AGE 0-17.
59                         \8\ TONSILLECTOMY &/OR ADENOIDECTOMY           0.9562            26.1            21.7
                            ONLY, AGE 17.
60                         \8\ TONSILLECTOMY &/OR ADENOIDECTOMY           0.9562            26.1            21.7
                            ONLY, AGE 0-17.
61                         \2\ MYRINGOTOMY W TUBE INSERTION AGE           0.7372            23.5            19.5
                            17.
62                         \8\ MYRINGOTOMY W TUBE INSERTION AGE           0.9562            26.1            21.7
                            0-17.
63                         \3\ OTHER EAR, NOSE, MOUTH & THROAT            0.9562            26.1            21.7
                            O.R. PROCEDURES.
64                         EAR, NOSE, MOUTH & THROAT MALIGNANCY.          1.2540            27.5            22.9
65                         \1\ DYSEQUILIBRIUM...................          0.4964            18.5            15.4
66                         \1\ EPISTAXIS........................          0.4964            18.5            15.4
67                         \8\ EPIGLOTTITIS.....................          0.9562            26.1            21.7
68                         OTITIS MEDIA & URI AGE >17 W CC...          0.8243            21.9            18.2
69                         \1\ OTITIS MEDIA & URI AGE >17 W/O          0.4964            18.5            15.4
                            CC.
70                         \8\ OTITIS MEDIA & URI AGE 0-17......          0.4964            18.5            15.4
71                         \8\ LARYNGOTRACHEITIS................          0.4964            18.5            15.4
72                         \2\ NASAL TRAUMA & DEFORMITY.........          0.7372            23.5            19.5
73                         OTHER EAR, NOSE, MOUTH & THROAT                0.7215            20.3            16.9
                            DIAGNOSES AGE 17.
74                         \8\ OTHER EAR, NOSE, MOUTH & THROAT            0.4964            18.5            15.4
                            DIAGNOSES AGE 0-17.
75                         \5\ MAJOR CHEST PROCEDURES...........          2.0841            40.0            33.3
76                         OTHER RESP SYSTEM O.R. PROCEDURES W            2.4382            43.9            36.5
                            CC.
77                         \5\ OTHER RESP SYSTEM O.R. PROCEDURES          2.0841            40.0            33.3
                            W/O CC.
78                         PULMONARY EMBOLISM...................          0.8896            24.2            20.1
79                         RESPIRATORY INFECTIONS &                       0.8985            22.6            18.8
                            INFLAMMATIONS AGE 17 W CC.
80                         RESPIRATORY INFECTIONS &                       0.7645            22.3            18.5
                            INFLAMMATIONS AGE 17 W/O
                            CC.
81                         \8\ RESPIRATORY INFECTIONS &                   0.4964            18.5            15.4
                            INFLAMMATIONS AGE 0-17.
82                         RESPIRATORY NEOPLASMS................          0.7480            20.3            16.9
83                         \3\ MAJOR CHEST TRAUMA W CC..........          0.9562            26.1            21.7
84                         \2\ MAJOR CHEST TRAUMA W/O CC........          0.7372            23.5            19.5
85                         PLEURAL EFFUSION W CC................          0.8514            23.5            19.5
86                         PLEURAL EFFUSION W/O CC..............          0.6540            22.4            18.6
87                         PULMONARY EDEMA & RESPIRATORY FAILURE          1.6513            31.9            26.5
88                         CHRONIC OBSTRUCTIVE PULMONARY DISEASE          0.7653            20.7            17.2
89                         SIMPLE PNEUMONIA & PLEURISY AGE 17 W CC.
90                         SIMPLE PNEUMONIA & PLEURISY AGE 17 W/O CC.
91                         \8\ SIMPLE PNEUMONIA & PLEURISY AGE 0-         0.7372            23.5            19.5
                            17.
92                         INTERSTITIAL LUNG DISEASE W CC.......          0.7702            20.4            17.0
93                         \1\ INTERSTITIAL LUNG DISEASE W/O CC.          0.4964            18.5            15.4
94                         PNEUMOTHORAX W CC....................          0.6571            18.9            15.7
95                         \1\ PNEUMOTHORAX W/O CC..............          0.4964            18.5            15.4
96                         BRONCHITIS & ASTHMA AGE 17          0.7381            20.5            17.0
                            W CC.
97                         BRONCHITIS & ASTHMA AGE 17          0.5296            18.7            15.5
                            W/O CC.
98                         \8\ BRONCHITIS & ASTHMA AGE 0-17.....          0.4964            18.5            15.4

[[Page 45652]]

 
99                         RESPIRATORY SIGNS & SYMPTOMS W CC....          1.0622            26.6            22.1
100                        RESPIRATORY SIGNS & SYMPTOMS W/O CC..          1.0579            26.1            21.7
101                        OTHER RESPIRATORY SYSTEM DIAGNOSES W           0.9009            22.6            18.8
                            CC.
102                        OTHER RESPIRATORY SYSTEM DIAGNOSES W/          0.7011            21.0            17.5
                            O CC.
103                        \6\ HEART TRANSPLANT.................          0.0000             0.0             0.0
104                        \8\ CARDIAC VALVE & OTHER MAJOR                2.0841            40.0            33.3
                            CARDIOTHORACIC PROC W CARDIAC CATH.
105                        \8\ CARDIAC VALVE & OTHER MAJOR                2.0841            40.0            33.3
                            CARDIOTHORACIC PROC W/O CARDIAC CATH.
106                        \8\ CORONARY BYPASS W PTCA...........          2.0841            40.0            33.3
107                        \8\ CORONARY BYPASS W CARDIAC CATH...          2.0841            40.0            33.3
108                        \5\ OTHER CARDIOTHORACIC PROCEDURES..          2.0841            40.0            33.3
109                        \8\ CORONARY BYPASS W/O PTCA OR                2.0841            40.0            33.3
                            CARDIAC CATH.
110                        \5\ MAJOR CARDIOVASCULAR PROCEDURES W          2.0841            40.0            33.3
                            CC.
111                        \8\ MAJOR CARDIOVASCULAR PROCEDURES W/         2.0841            40.0            33.3
                            O CC.
113                        AMPUTATION FOR CIRC SYSTEM DISORDERS           1.5629            38.7            32.2
                            EXCEPT UPPER LIMB & TOE.
114                        UPPER LIMB & TOE AMPUTATION FOR CIRC           1.3604            38.3            31.9
                            SYSTEM DISORDERS.
115                        \5\ PRM CARD PACEM IMPL W AMI,HRT              2.0841            40.0            33.3
                            FAIL OR SHK,OR AICD LEAD OR GNRTR P.
116                        \5\ OTH PERM CARD PACEMAK IMPL OR              2.0841            40.0            33.3
                            PTCA W CORONARY ARTERY STENT IMPLNT.
117                        \3\ CARDIAC PACEMAKER REVISION EXCEPT          0.9562            26.1            21.7
                            DEVICE REPLACEMENT.
118                        \5\ CARDIAC PACEMAKER DEVICE                   2.0841            40.0            33.3
                            REPLACEMENT.
119                        \4\ VEIN LIGATION & STRIPPING........          1.3569            32.5            27.0
120                        OTHER CIRCULATORY SYSTEM O.R.                  1.2435            34.4            28.6
                            PROCEDURES.
121                        CIRCULATORY DISORDERS W AMI & MAJOR            0.7467            22.1            18.4
                            COMP, DISCHARGED ALIVE.
122                        CIRCULATORY DISORDERS W AMI W/O MAJOR          0.6440            18.8            15.6
                            COMP, DISCHARGED ALIVE.
123                        CIRCULATORY DISORDERS W AMI, EXPIRED.          0.8527            18.8            15.6
124                        \4\ CIRCULATORY DISORDERS EXCEPT AMI,          1.3569            32.5            27.0
                            W CARD CATH & COMPLEX DIAG.
125                        \4\ CIRCULATORY DISORDERS EXCEPT AMI,          1.3569            32.5            27.0
                            W CARD CATH W/O COMPLEX DIAG.
126                        ACUTE & SUBACUTE ENDOCARDITIS........          0.8706            25.6            21.3
127                        HEART FAILURE & SHOCK................          0.7719            22.1            18.4
128                        \2\ DEEP VEIN THROMBOPHLEBITIS.......          0.7372            23.5            19.5
129                        \3\ CARDIAC ARREST, UNEXPLAINED......          0.9562            26.1            21.7
130                        PERIPHERAL VASCULAR DISORDERS W CC...          0.7712            24.4            20.3
131                        PERIPHERAL VASCULAR DISORDERS W/O CC.          0.6398            23.1            19.2
132                        ATHEROSCLEROSIS W CC.................          0.8092            22.4            18.6
133                        ATHEROSCLEROSIS W/O CC...............          0.7044            21.9            18.2
134                        HYPERTENSION.........................          0.9154            27.9            23.2
135                        CARDIAC CONGENITAL & VALVULAR                  0.9039            23.1            19.2
                            DISORDERS AGE 17 W CC.
136                        CARDIAC CONGENITAL & VALVULAR                  0.7186            22.4            18.6
                            DISORDERS AGE 17 W/O CC.
137                        \8\ CARDIAC CONGENITAL & VALVULAR              0.7372            23.5            19.5
                            DISORDERS AGE 0-17.
138                        CARDIAC ARRHYTHMIA & CONDUCTION                0.7430            22.7            18.9
                            DISORDERS W CC.
139                        CARDIAC ARRHYTHMIA & CONDUCTION                0.6032            20.3            16.9
                            DISORDERS W/O CC.
140                        ANGINA PECTORIS......................          0.6094            19.3            16.0
141                        SYNCOPE & COLLAPSE W CC..............          0.6453            22.9            19.0
142                        SYNCOPE & COLLAPSE W/O CC............          0.5041            20.3            16.9
143                        CHEST PAIN...........................          0.7314            21.8            18.1
144                        OTHER CIRCULATORY SYSTEM DIAGNOSES W           0.7921            22.2            18.5
                            CC.
145                        OTHER CIRCULATORY SYSTEM DIAGNOSES W/          0.6983            20.7            17.2
                            O CC.
146                        \8\ RECTAL RESECTION W CC............          2.0841            40.0            33.3
147                        \8\ RECTAL RESECTION W/O CC..........          2.0841            40.0            33.3
148                        \5\ MAJOR SMALL & LARGE BOWEL                  2.0841            40.0            33.3
                            PROCEDURES W CC.
149                        \1\ MAJOR SMALL & LARGE BOWEL                  0.4964            18.5            15.4
                            PROCEDURES W/O CC.
150                        \4\ PERITONEAL ADHESIOLYSIS W CC.....          1.3569            32.5            27.0
151                        \8\ PERITONEAL ADHESIOLYSIS W/O CC...          1.3569            32.5            27.0
152                        \4\ MINOR SMALL & LARGE BOWEL                  1.3569            32.5            27.0
                            PROCEDURES W CC.
153                        \8\ MINOR SMALL & LARGE BOWEL                  1.3569            32.5            27.0
                            PROCEDURES W/O CC.
154                        \5\ STOMACH, ESOPHAGEAL & DUODENAL             2.0841            40.0            33.3
                            PROCEDURES AGE 17 W CC.
155                        \8\ STOMACH, ESOPHAGEAL & DUODENAL             1.3569            32.5            27.0
                            PROCEDURES AGE 17 W/O CC.
156                        \8\ STOMACH, ESOPHAGEAL & DUODENAL             1.3569            32.5            27.0
                            PROCEDURES AGE 0-17.
157                        \4\ ANAL & STOMAL PROCEDURES W CC....          1.3569            32.5            27.0
158                        \3\ ANAL & STOMAL PROCEDURES W/O CC..          0.9562            26.1            21.7
159                        \8\ HERNIA PROCEDURES EXCEPT INGUINAL          1.3569            32.5            27.0
                            & FEMORAL AGE 17 W CC.
160                        \8\ HERNIA PROCEDURES EXCEPT INGUINAL          1.3569            32.5            27.0
                            & FEMORAL AGE 17 W/O CC.
161                        \4\ INGUINAL & FEMORAL HERNIA                  1.3569            32.5            27.0
                            PROCEDURES AGE 17 W CC.
162                        \8\ INGUINAL & FEMORAL HERNIA                  0.4964            18.5            15.4
                            PROCEDURES AGE 17 W/O CC.
163                        \8\ HERNIA PROCEDURES AGE 0-17.......          0.4964            18.5            15.4

[[Page 45653]]

 
164                        \8\ APPENDECTOMY W COMPLICATED                 2.0841            40.0            33.3
                            PRINCIPAL DIAG W CC.
165                        \8\ APPENDECTOMY W COMPLICATED                 0.4964            18.5            15.4
                            PRINCIPAL DIAG W/O CC.
166                        \8\ APPENDECTOMY W/O COMPLICATED               2.0841            40.0            33.3
                            PRINCIPAL DIAG W CC.
167                        \8\ APPENDECTOMY W/O COMPLICATED               0.4964            18.5            15.4
                            PRINCIPAL DIAG W/O CC.
168                        \5\ MOUTH PROCEDURES W CC............          2.0841            40.0            33.3
169                        \8\ MOUTH PROCEDURES W/O CC..........          0.7372            23.5            19.5
170                        OTHER DIGESTIVE SYSTEM O.R.                    1.7006            40.3            33.5
                            PROCEDURES W CC.
171                        \4\ OTHER DIGESTIVE SYSTEM O.R.                1.3569            32.5            27.0
                            PROCEDURES W/O CC.
172                        DIGESTIVE MALIGNANCY W CC............          0.8702            22.5            18.7
173                        DIGESTIVE MALIGNANCY W/O CC..........          0.7092            20.2            16.8
174                        G.I. HEMORRHAGE W CC.................          0.7874            23.7            19.7
175                        G.I. HEMORRHAGE W/O CC...............          0.6345            21.1            17.5
176                        COMPLICATED PEPTIC ULCER.............          0.7728            21.2            17.6
177                        \2\ UNCOMPLICATED PEPTIC ULCER W CC..          0.7372            23.5            19.5
178                        \1\ UNCOMPLICATED PEPTIC ULCER W/O CC          0.4964            18.5            15.4
179                        INFLAMMATORY BOWEL DISEASE...........          1.0023            25.2            21.0
180                        \7\ G.I. OBSTRUCTION W CC............          0.8222            22.9            19.0
181                        \7\ G.I. OBSTRUCTION W/O CC..........          0.8222            22.9            19.0
182                        ESOPHAGITIS, GASTROENT & MISC DIGEST           0.8449            23.5            19.5
                            DISORDERS AGE 17 W CC.
183                        ESOPHAGITIS, GASTROENT & MISC DIGEST           0.6362            20.3            16.9
                            DISORDERS AGE 17 W/O CC.
184                        \8\ ESOPHAGITIS, GASTROENT & MISC              0.7372            23.5            19.5
                            DIGEST DISORDERS AGE 0-17.
185                        \2\ DENTAL & ORAL DIS EXCEPT                   0.7372            23.5            19.5
                            EXTRACTIONS & RESTORATIONS, AGE 17.
186                        \8\ DENTAL & ORAL DIS EXCEPT                   0.7372            23.5            19.5
                            EXTRACTIONS & RESTORATIONS, AGE 0-17.
187                        \8\ DENTAL EXTRACTIONS & RESTORATIONS          0.7372            23.5            19.5
188                        OTHER DIGESTIVE SYSTEM DIAGNOSES AGE           1.0308            25.3            21.0
                            17 W CC.
189                        OTHER DIGESTIVE SYSTEM DIAGNOSES AGE           0.7826            21.8            18.1
                            17 W/O CC.
190                        \8\ OTHER DIGESTIVE SYSTEM DIAGNOSES           0.7372            23.5            19.5
                            AGE 0-17.
191                        \4\ PANCREAS, LIVER & SHUNT                    1.3569            32.5            27.0
                            PROCEDURES W CC.
192                        \1\ PANCREAS, LIVER & SHUNT                    0.4964            18.5            15.4
                            PROCEDURES W/O CC.
193                        \2\ BILIARY TRACT PROC EXCEPT ONLY             0.7372            23.5            19.5
                            CHOLECYST W OR W/O C.D.E. W CC.
194                        \3\ BILIARY TRACT PROC EXCEPT ONLY             0.7372            23.5            19.5
                            CHOLECYST W OR W/O C.D.E. W/O CC.
195                        \4\ CHOLECYSTECTOMY W C.D.E. W CC....          1.3569            32.5            27.0
196                        \8\ CHOLECYSTECTOMY W C.D.E. W/O CC..          0.9562            26.1            21.7
197                        \3\ CHOLECYSTECTOMY EXCEPT BY                  0.9562            26.1            21.7
                            LAPAROSCOPE W/O C.D.E. W CC.
198                        \8\ CHOLECYSTECTOMY EXCEPT BY                  0.9562            26.1            21.7
                            LAPAROSCOPE W/O C.D.E. W/O CC.
199                        \8\ HEPATOBILIARY DIAGNOSTIC                   0.7372            23.5            19.5
                            PROCEDURE FOR MALIGNANCY.
200                        \2\ HEPATOBILIARY DIAGNOSTIC                   0.7372            23.5            19.5
                            PROCEDURE FOR NON-MALIGNANCY.
201                        \5\ OTHER HEPATOBILIARY OR PANCREAS            2.0841            40.0            33.3
                            O.R. PROCEDURES.
202                        CIRRHOSIS & ALCOHOLIC HEPATITIS......          0.7254            22.3            18.5
203                        MALIGNANCY OF HEPATOBILIARY SYSTEM OR          0.6758            18.9            15.7
                            PANCREAS.
204                        DISORDERS OF PANCREAS EXCEPT                   0.9986            23.4            19.5
                            MALIGNANCY.
205                        \7\ DISORDERS OF LIVER EXCEPT                  0.7029            22.1            18.4
                            MALIG,CIRR,ALC HEPA W CC.
206                        \7\ DISORDERS OF LIVER EXCEPT                  0.7029            22.1            18.4
                            MALIG,CIRR,ALC HEPA W/O CC.
207                        \7\ DISORDERS OF THE BILIARY TRACT W           0.6671            20.5            17.0
                            CC.
208                        \7\ DISORDERS OF THE BILIARY TRACT W/          0.6671            20.5            17.0
                            O CC.
209                        \4\ MAJOR JOINT & LIMB REATTACHMENT            1.3569            32.5            27.0
                            PROCEDURES OF LOWER EXTREMITY.
210                        \4\ HIP & FEMUR PROCEDURES EXCEPT              1.3569            32.5            27.0
                            MAJOR JOINT AGE 17 W CC.
211                        \2\ HIP & FEMUR PROCEDURES EXCEPT              0.7372            23.5            19.5
                            MAJOR JOINT AGE 17 W/O CC.
212                        \8\ HIP & FEMUR PROCEDURES EXCEPT              0.7372            23.5            19.5
                            MAJOR JOINT AGE 0-17.
213                        AMPUTATION FOR MUSCULOSKELETAL SYSTEM          1.3851            33.8            28.1
                            & CONN TISSUE DISORDERS.
216                        \4\ BIOPSIES OF MUSCULOSKELETAL                1.3569            32.5            27.0
                            SYSTEM & CONNECTIVE TISSUE.
217                        WND DEBRID & SKN GRFT EXCEPT HAND,FOR          1.4038            39.3            32.7
                            MUSCSKELET & CONN TISS DIS.
218                        \3\ LOWER EXTREM & HUMER PROC EXCEPT           0.9562            26.1            21.7
                            HIP,FOOT,FEMUR AGE 17 W
                            CC.
219                        \8\ LOWER EXTREM & HUMER PROC EXCEPT           0.9562            26.1            21.7
                            HIP,FOOT,FEMUR AGE 17 W/O
                            CC.
220                        \8\ LOWER EXTREM & HUMER PROC EXCEPT           0.9562            26.1            21.7
                            HIP,FOOT,FEMUR AGE 0-17.
223                        \3\ MAJOR SHOULDER/ELBOW PROC, OR              0.9562            26.1            21.7
                            OTHER UPPER EXTREMITY PROC W CC.
224                        \8\ SHOULDER,ELBOW OR FOREARM                  0.9562            26.1            21.7
                            PROC,EXC MAJOR JOINT PROC, W/O CC.
225                        \3\ FOOT PROCEDURES..................          0.9562            26.1            21.7
226                        \7\ SOFT TISSUE PROCEDURES W CC......          1.3569            32.5            27.0
227                        \7\ SOFT TISSUE PROCEDURES W/O CC....          1.3569            32.5            27.0
228                        \4\ MAJOR THUMB OR JOINT PROC,OR OTH           1.3569            32.5            27.0
                            HAND OR WRIST PROC W CC.
229                        \8\ HAND OR WRIST PROC, EXCEPT MAJOR           0.9562            26.1            21.7
                            JOINT PROC, W/O CC.

[[Page 45654]]

 
230                        \4\ LOCAL EXCISION & REMOVAL OF INT            1.3569            32.5            27.0
                            FIX DEVICES OF HIP & FEMUR.
232                        \2\ ARTHROSCOPY......................          0.7372            23.5            19.5
233                        \3\ OTHER MUSCULOSKELET SYS & CONN             0.9562            26.1            21.7
                            TISS O.R. PROC W CC.
234                        \3\ OTHER MUSCULOSKELET SYS & CONN             0.9562            26.1            21.7
                            TISS O.R. PROC W/O CC.
235                        FRACTURES OF FEMUR...................          0.8396            29.6            24.6
236                        FRACTURES OF HIP & PELVIS............          0.7368            27.1            22.5
237                        \2\ SPRAINS, STRAINS, & DISLOCATIONS           0.7372            23.5            19.5
                            OF HIP, PELVIS & THIGH.
238                        OSTEOMYELITIS........................          0.8432            27.9            23.2
239                        PATHOLOGICAL FRACTURES &                       0.6610            22.0            18.3
                            MUSCULOSKELETAL & CONN TISS
                            MALIGNANCY.
240                        CONNECTIVE TISSUE DISORDERS W CC.....          0.6685            21.2            17.6
241                        CONNECTIVE TISSUE DISORDERS W/O CC...          0.4538            18.7            15.5
242                        SEPTIC ARTHRITIS.....................          0.7721            26.4            22.0
243                        MEDICAL BACK PROBLEMS................          0.6616            23.2            19.3
244                        BONE DISEASES & SPECIFIC                       0.5563            20.0            16.6
                            ARTHROPATHIES W CC.
245                        BONE DISEASES & SPECIFIC                       0.4721            18.5            15.4
                            ARTHROPATHIES W/O CC.
246                        NON-SPECIFIC ARTHROPATHIES...........          0.5128            22.2            18.5
247                        SIGNS & SYMPTOMS OF MUSCULOSKELETAL            0.5536            20.2            16.8
                            SYSTEM & CONN TISSUE.
248                        TENDONITIS, MYOSITIS & BURSITIS......          0.7274            24.5            20.4
249                        AFTERCARE, MUSCULOSKELETAL SYSTEM &            0.7829            27.0            22.5
                            CONNECTIVE TISSUE.
250                        FX, SPRN, STRN & DISL OF FOREARM,              0.8206            29.9            24.9
                            HAND, FOOT AGE 17 W CC.
251                        FX, SPRN, STRN & DISL OF FOREARM,              0.6009            27.3            22.7
                            HAND, FOOT AGE 17 W/O CC.
252                        \8\ FX, SPRN, STRN & DISL OF FOREARM,          0.9562            26.1            21.7
                            HAND, FOOT AGE 0-17.
253                        FX, SPRN, STRN & DISL OF UPARM,LOWLEG          0.8176            27.6            23.0
                            EX FOOT AGE 17 W CC.
254                        FX, SPRN, STRN & DISL OF UPARM,LOWLEG          0.6691            25.1            20.9
                            EX FOOT AGE 17 W/O CC.
255                        \8\ FX, SPRN, STRN & DISL OF                   0.9562            26.1            21.7
                            UPARM,LOWLEG EX FOOT AGE 0-17.
256                        OTHER MUSCULOSKELETAL SYSTEM &                 0.8294            25.9            21.5
                            CONNECTIVE TISSUE DIAGNOSES.
257                        \3\ TOTAL MASTECTOMY FOR MALIGNANCY W          0.9562            26.1            21.7
                            CC.
258                        \8\ TOTAL MASTECTOMY FOR MALIGNANCY W/         0.9562            26.1            21.7
                            O CC.
259                        \8\ SUBTOTAL MASTECTOMY FOR                    0.9562            26.1            21.7
                            MALIGNANCY W CC.
260                        \8\ SUBTOTAL MASTECTOMY FOR                    0.9562            26.1            21.7
                            MALIGNANCY W/O CC.
261                        \5\ BREAST PROC FOR NON-MALIGNANCY             2.0841            40.0            33.3
                            EXCEPT BIOPSY & LOCAL EXCISION.
262                        \3\ BREAST BIOPSY & LOCAL EXCISION             0.9562            26.1            21.7
                            FOR NON-MALIGNANCY.
263                        SKIN GRAFT &/OR DEBRID FOR SKN ULCER           1.4522            42.4            35.3
                            OR CELLULITIS W CC.
264                        SKIN GRAFT &/OR DEBRID FOR SKN ULCER           1.2892            44.1            36.7
                            OR CELLULITIS W/O CC.
265                        \7\ SKIN GRAFT &/OR DEBRID EXCEPT FOR          1.2215            34.8            29.0
                            SKIN ULCER OR CELLULITIS W CC.
266                        \7\ SKIN GRAFT &/OR DEBRID EXCEPT FOR          1.2215            34.8            29.0
                            SKIN ULCER OR CELLULITIS W/O CC.
267                        \8\ PERIANAL & PILONIDAL PROCEDURES..          0.9562            26.1            21.7
268                        \5\ SKIN, SUBCUTANEOUS TISSUE &                2.0841            40.0            33.3
                            BREAST PLASTIC PROCEDURES.
269                        OTHER SKIN, SUBCUT TISS & BREAST PROC          1.4466            43.0            35.8
                            W CC.
270                        OTHER SKIN, SUBCUT TISS & BREAST PROC          0.9916            33.9            28.2
                            W/O CC.
271                        SKIN ULCERS..........................          0.9620            30.4            25.3
272                        MAJOR SKIN DISORDERS W CC............          0.7121            22.8            19.0
273                        \1\ MAJOR SKIN DISORDERS W/O CC......          0.4964            18.5            15.4
274                        MALIGNANT BREAST DISORDERS W CC......          0.9072            24.9            20.7
275                        \2\ MALIGNANT BREAST DISORDERS W/O CC          0.7372            23.5            19.5
276                        \1\ NON-MALIGANT BREAST DISORDERS....          0.4964            18.5            15.4
277                        CELLULITIS AGE 17 W CC....          0.7409            23.6            19.6
278                        CELLULITIS AGE 17 W/O CC..          0.5982            20.7            17.2
279                        \8\ CELLULITIS AGE 0-17..............          0.9562            26.1            21.7
280                        TRAUMA TO THE SKIN, SUBCUT TISS &              0.9724            29.5            24.5
                            BREAST AGE 17 W CC.
281                        TRAUMA TO THE SKIN, SUBCUT TISS &              0.7386            26.4            22.0
                            BREAST AGE 17 W/O CC.
282                        \8\ TRAUMA TO THE SKIN, SUBCUT TISS &          0.7372            23.5            19.5
                            BREAST AGE 0-17.
283                        MINOR SKIN DISORDERS W CC............          0.6508            19.3            16.0
284                        \1\ MINOR SKIN DISORDERS W/O CC......          0.4964            18.5            15.4
285                        AMPUTAT OF LOWER LIMB FOR                      1.5176            37.4            31.1
                            ENDOCRINE,NUTRIT,& METABOL DISORDERS.
286                        \8\ ADRENAL & PITUITARY PROCEDURES...          0.7372            23.5            19.5
287                        SKIN GRAFTS & WOUND DEBRID FOR ENDOC,          1.3982            39.7            33.0
                            NUTRIT & METAB DISORDERS.
288                        \5\ O.R. PROCEDURES FOR OBESITY......          2.0841            40.0            33.3
289                        \8\ PARATHYROID PROCEDURES...........          0.7372            23.5            19.5
290                        \8\ THYROID PROCEDURES...............          0.7372            23.5            19.5
291                        \8\ THYROGLOSSAL PROCEDURES..........          0.7372            23.5            19.5
292                        \4\ OTHER ENDOCRINE, NUTRIT & METAB            1.3569            32.5            27.0
                            O.R. PROC W CC.
293                        \8\ OTHER ENDOCRINE, NUTRIT & METAB            0.9562            26.1            21.7
                            O.R. PROC W/O CC.
294                        DIABETES AGE 35...........          0.8061            25.9            21.5

[[Page 45655]]

 
295                        \3\ DIABETES AGE 0-35................          0.9562            26.1            21.7
296                        NUTRITIONAL & MISC METABOLIC                   0.8207            24.1            20.0
                            DISORDERS AGE 17 W CC.
297                        NUTRITIONAL & MISC METABOLIC                   0.6524            24.5            20.4
                            DISORDERS AGE 17 W/O CC.
298                        \8\ NUTRITIONAL & MISC METABOLIC               0.7372            23.5            19.5
                            DISORDERS AGE 0-17.
299                        \3\ UNBORN ERRORS OF METABOLISM......          0.9562            26.1            21.7
300                        ENDOCRINE DISORDERS W CC.............          0.7704            22.3            18.5
301                        \2\ ENDOCRINE DISORDERS W/O CC.......          0.7372            23.5            19.5
302                        \6\ KIDNEY TRANSPLANT................          0.0000             0.0             0.0
303                        \8\ KIDNEY,URETER & MAJOR BLADDER              2.0841            40.0            33.3
                            PROCEDURES FOR NEOPLASM.
304                        \5\ KIDNEY,URETER & MAJOR BLADDER              2.0841            40.0            33.3
                            PROC FOR NON-NEOPL W CC.
305                        \1\ KIDNEY,URETER & MAJOR BLADDER              0.4964            18.5            15.4
                            PROC FOR NON-NEOPL W/O CC.
306                        \8\ PROSTATECTOMY W CC...............          1.3569            32.5            27.0
307                        \8\ PROSTATECTOMY W/O CC.............          1.3569            32.5            27.0
308                        \4\ MINOR BLADDER PROCEDURES W CC....          1.3569            32.5            27.0
309                        \2\ MINOR BLADDER PROCEDURES W/O CC..          0.7372            23.5            19.5
310                        \4\ TRANSURETHRAL PROCEDURES W CC....          1.3569            32.5            27.0
311                        \1\ TRANSURETHRAL PROCEDURES W/O CC..          0.4964            18.5            15.4
312                        \4\ URETHRAL PROCEDURES, AGE 17 W CC.
313                        \8\ URETHRAL PROCEDURES, AGE 17 W/O CC.
314                        \8\ URETHRAL PROCEDURES, AGE 0-17....          0.4964            18.5            15.4
315                        OTHER KIDNEY & URINARY TRACT O.R.              1.5070            36.8            30.6
                            PROCEDURES.
316                        RENAL FAILURE........................          0.9214            23.8            19.8
317                        \3\ ADMIT FOR RENAL DIALYSIS.........          0.9562            26.1            21.7
318                        KIDNEY & URINARY TRACT NEOPLASMS W CC          0.7048            21.1            17.5
319                        \1\ KIDNEY & URINARY TRACT NEOPLASMS           0.4964            18.5            15.4
                            W/O CC.
320                        KIDNEY & URINARY TRACT INFECTIONS AGE          0.7223            23.0            19.1
                            17 W CC.
321                        KIDNEY & URINARY TRACT INFECTIONS AGE          0.6260            23.2            19.3
                            17 W/O CC.
322                        \8\ KIDNEY & URINARY TRACT INFECTIONS          0.4964            18.5            15.4
                            AGE 0-17.
323                        \2\ URINARY STONES W CC, &/OR ESW              0.7372            23.5            19.5
                            LITHOTRIPSY.
324                        \2\ URINARY STONES W/O CC............          0.7372            23.5            19.5
325                        \3\ KIDNEY & URINARY TRACT SIGNS &             0.9562            26.1            21.7
                            SYMPTOMS AGE 17 W CC.
326                        \1\ KIDNEY & URINARY TRACT SIGNS &             0.4964            18.5            15.4
                            SYMPTOMS AGE 17 W/O CC.
327                        \8\ KIDNEY & URINARY TRACT SIGNS &             0.4964            18.5            15.4
                            SYMPTOMS AGE 0-17.
328                        \8\ URETHRAL STRICTURE AGE 17 W CC.
329                        \8\ URETHRAL STRICTURE AGE 17 W/O CC.
330                        \8\ URETHRAL STRICTURE AGE 0-17......          0.4964            18.5            15.4
331                        OTHER KIDNEY & URINARY TRACT                   0.8473            23.2            19.3
                            DIAGNOSES AGE 17 W CC.
332                        OTHER KIDNEY & URINARY TRACT                   0.5722            21.1            17.5
                            DIAGNOSES AGE 17 W/O CC.
333                        \8\ OTHER KIDNEY & URINARY TRACT               0.4964            18.5            15.4
                            DIAGNOSES AGE 0-17.
334                        \8\ MAJOR MALE PELVIC PROCEDURES W CC          2.0841            40.0            33.3
335                        \8\ MAJOR MALE PELVIC PROCEDURES W/O           2.0841            40.0            33.3
                            CC.
336                        \8\ TRANSURETHRAL PROSTATECTOMY W CC.          0.7372            23.5            19.5
337                        \8\ TRANSURETHRAL PROSTATECTOMY W/O            0.7372            23.5            19.5
                            CC.
338                        \8\ TESTES PROCEDURES, FOR MALIGNANCY          0.7372            23.5            19.5
339                        \2\ TESTES PROCEDURES, NON-MALIGNANCY          0.7372            23.5            19.5
                            AGE 17.
340                        \8\ TESTES PROCEDURES, NON-MALIGNANCY          0.7372            23.5            19.5
                            AGE 0-17.
341                        \2\ PENIS PROCEDURES.................          0.7372            23.5            19.5
342                        \1\ CIRCUMCISION AGE 17...          0.4964            18.5            15.4
343                        \8\ CIRCUMCISION AGE 0-17............          0.7372            23.5            19.5
344                        \1\ OTHER MALE REPRODUCTIVE SYSTEM             0.4964            18.5            15.4
                            O.R. PROCEDURES FOR MALIGNANCY.
345                        \5\ OTHER MALE REPRODUCTIVE SYSTEM             2.0841            40.0            33.3
                            O.R. PROC EXCEPT FOR MALIGNANCY.
346                        \7\ MALIGNANCY, MALE REPRODUCTIVE              0.7150            22.3            18.5
                            SYSTEM, W CC.
347                        \7\ MALIGNANCY, MALE REPRODUCTIVE              0.7150            22.3            18.5
                            SYSTEM, W/O CC.
348                        \1\ BENIGN PROSTATIC HYPERTROPHY W CC          0.4964            18.5            15.4
349                        \1\ BENIGN PROSTATIC HYPERTROPHY W/O           0.4964            18.5            15.4
                            CC.
350                        INFLAMMATION OF THE MALE REPRODUCTIVE          1.1820            26.6            22.1
                            SYSTEM.
351                        \8\ STERILIZATION, MALE..............          0.7372            23.5            19.5
352                        \3\ OTHER MALE REPRODUCTIVE SYSTEM             0.9562            26.1            21.7
                            DIAGNOSES.
353                        \8\ PELVIC EVISCERATION, RADICAL               2.0841            40.0            33.3
                            HYSTERECTOMY & RADICAL VULVECTOMY.
354                        \8\ UTERINE,ADNEXA PROC FOR NON-               2.0841            40.0            33.3
                            OVARIAN/ADNEXAL MALIG W CC.
355                        \8\ UTERINE,ADNEXA PROC FOR NON-               2.0841            40.0            33.3
                            OVARIAN/ADNEXAL MALIG W/O CC.
356                        \8\ FEMALE REPRODUCTIVE SYSTEM                 1.3569            32.5            27.0
                            RECONSTRUCTIVE PROCEDURES.
357                        \8\ UTERINE & ADNEXA PROC FOR OVARIAN          1.3569            32.5            27.0
                            OR ADNEXAL MALIGNANCY.
358                        \8\ UTERINE & ADNEXA PROC FOR NON-             1.3569            32.5            27.0
                            MALIGNANCY W CC.
359                        \8\ UTERINE & ADNEXA PROC FOR NON-             1.3569            32.5            27.0
                            MALIGNANCY W/O CC.
360                        \4\ VAGINA, CERVIX & VULVA PROCEDURES          1.3569            32.5            27.0

[[Page 45656]]

 
361                        \8\ LAPAROSCOPY & INCISIONAL TUBAL             0.4964            18.5            15.4
                            INTERRUPTION.
362                        \8\ ENDOSCOPIC TUBAL INTERRUPTION....          0.4964            18.5            15.4
363                        \8\ D&C, CONIZATION & RADIO-IMPLANT,           0.4964            18.5            15.4
                            FOR MALIGNANCY.
364                        \8\ D&C, CONIZATION EXCEPT FOR                 0.4964            18.5            15.4
                            MALIGNANCY.
365                        \5\ OTHER FEMALE REPRODUCTIVE SYSTEM           2.0841            40.0            33.3
                            O.R. PROCEDURES.
366                        MALIGNANCY, FEMALE REPRODUCTIVE                0.8139            23.1            19.2
                            SYSTEM W CC.
367                        \1\ MALIGNANCY, FEMALE REPRODUCTIVE            0.4964            18.5            15.4
                            SYSTEM W/O CC.
368                        INFECTIONS, FEMALE REPRODUCTIVE                0.6963            19.3            16.0
                            SYSTEM.
369                        \3\ MENSTRUAL & OTHER FEMALE                   0.9562            26.1            21.7
                            REPRODUCTIVE SYSTEM DISORDERS.
370                        \8\ CESAREAN SECTION W CC............          0.9562            26.1            21.7
371                        \8\ CESAREAN SECTION W/O CC..........          0.4964            18.5            15.4
372                        \8\ VAGINAL DELIVERY W COMPLICATING            0.4964            18.5            15.4
                            DIAGNOSES.
373                        \8\ VAGINAL DELIVERY W/O COMPLICATING          0.4964            18.5            15.4
                            DIAGNOSES.
374                        \8\ VAGINAL DELIVERY W STERILIZATION           0.4964            18.5            15.4
                            &/OR D&C.
375                        \8\ VAGINAL DELIVERY W O.R. PROC               0.4964            18.5            15.4
                            EXCEPT STERIL &/OR D&C.
376                        \1\ POSTPARTUM & POST ABORTION                 0.4964            18.5            15.4
                            DIAGNOSES W/O O.R. PROCEDURE.
377                        \8\ POSTPARTUM & POST ABORTION                 0.4964            18.5            15.4
                            DIAGNOSES W O.R. PROCEDURE.
378                        \8\ ECTOPIC PREGNANCY................          0.9562            26.1            21.7
379                        \8\ THREATENED ABORTION..............          0.4964            18.5            15.4
380                        \8\ ABORTION W/O D&C.................          0.4964            18.5            15.4
381                        \8\ ABORTION W D&C, ASPIRATION                 0.4964            18.5            15.4
                            CURETTAGE OR HYSTEROTOMY.
382                        \8\ FALSE LABOR......................          0.4964            18.5            15.4
383                        \8\ OTHER ANTEPARTUM DIAGNOSES W               0.4964            18.5            15.4
                            MEDICAL COMPLICATIONS.
384                        \8\ OTHER ANTEPARTUM DIAGNOSES W/O             0.4964            18.5            15.4
                            MEDICAL COMPLICATIONS.
385                        \8\ NEONATES, DIED OR TRANSFERRED TO           0.4964            18.5            15.4
                            ANOTHER ACUTE CARE FACILITY.
386                        \8\ EXTREME IMMATURITY...............          0.4964            18.5            15.4
387                        \8\ PREMATURITY W MAJOR PROBLEMS.....          0.4964            18.5            15.4
388                        \8\ PREMATURITY W/O MAJOR PROBLEMS...          0.4964            18.5            15.4
389                        \8\ FULL TERM NEONATE W MAJOR                  0.4964            18.5            15.4
                            PROBLEMS.
390                        \8\ NEONATE W OTHER SIGNIFICANT                0.4964            18.5            15.4
                            PROBLEMS.
391                        \8\ NORMAL NEWBORN...................          0.4964            18.5            15.4
392                        \8\ SPLENECTOMY AGE 17....          0.7372            23.5            19.5
393                        \8\ SPLENECTOMY AGE 0-17.............          0.7372            23.5            19.5
394                        \3\ OTHER O.R. PROCEDURES OF THE               0.9562            26.1            21.7
                            BLOOD AND BLOOD FORMING ORGANS.
395                        RED BLOOD CELL DISORDERS AGE 17.
396                        \8\ RED BLOOD CELL DISORDERS AGE 0-17          0.4964            18.5            15.4
397                        COAGULATION DISORDERS................          0.9454            23.5            19.5
398                        RETICULOENDOTHELIAL & IMMUNITY                 0.8372            22.0            18.3
                            DISORDERS W CC.
399                        \1\ RETICULOENDOTHELIAL & IMMUNITY             0.4964            18.5            15.4
                            DISORDERS W/O CC.
401                        \5\ LYMPHOMA & NON-ACUTE LEUKEMIA W            2.0841            40.0            33.3
                            OTHER O.R. PROC W CC.
402                        \3\ LYMPHOMA & NON-ACUTE LEUKEMIA W            0.9562            26.1            21.7
                            OTHER O.R. PROC W/O CC.
403                        LYMPHOMA & NON-ACUTE LEUKEMIA W CC...          0.8941            22.4            18.6
404                        LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC.          0.7394            18.0            15.0
405                        \8\ ACUTE LEUKEMIA W/O MAJOR O.R.              0.7372            23.5            19.5
                            PROCEDURE AGE 0-17.
406                        \5\ MYELOPROLIF DISORD OR POORLY DIFF          2.0841            40.0            33.3
                            NEOPL W MAJ O.R.PROC W CC.
407                        \8\ MYELOPROLIF DISORD OR POORLY DIFF          0.9562            26.1            21.7
                            NEOPL W MAJ O.R.PROC W/O CC.
408                        \3\ MYELOPROLIF DISORD OR POORLY DIFF          0.9562            26.1            21.7
                            NEOPL W OTHER O.R.PROC.
409                        RADIOTHERAPY.........................          0.8871            25.1            20.9
410                        \3\ CHEMOTHERAPY W/O ACUTE LEUKEMIA            0.9562            26.1            21.7
                            AS SECONDARY DIAGNOSIS.
411                        \8\ HISTORY OF MALIGNANCY W/O                  0.4964            18.5            15.4
                            ENDOSCOPY.
412                        \8\ HISTORY OF MALIGNANCY W ENDOSCOPY          0.4964            18.5            15.4
413                        OTHER MYELOPROLIF DIS OR POORLY DIFF           0.9541            25.5            21.2
                            NEOPL DIAG W CC.
414                        \1\ OTHER MYELOPROLIF DIS OR POORLY            0.4964            18.5            15.4
                            DIFF NEOPL DIAG W/O CC.
415                        O.R. PROCEDURE FOR INFECTIOUS &                1.6849            40.1            33.4
                            PARASITIC DISEASES.
416                        SEPTICEMIA AGE 17.........          0.9191            24.9            20.7
417                        \8\ SEPTICEMIA AGE 0-17..............          0.9562            26.1            21.7
418                        POSTOPERATIVE & POST-TRAUMATIC                 0.8304            25.2            21.0
                            INFECTIONS.
419                        \3\ FEVER OF UNKNOWN ORIGIN AGE 17 W CC.
420                        \2\ FEVER OF UNKNOWN ORIGIN AGE 17 W/O CC.
421                        \2\ VIRAL ILLNESS AGE 17..          0.7372            23.5            19.5
422                        \8\ VIRAL ILLNESS & FEVER OF UNKNOWN           0.7372            23.5            19.5
                            ORIGIN AGE 0-17.
423                        OTHER INFECTIOUS & PARASITIC DISEASES          0.9024            23.1            19.2
                            DIAGNOSES.
424                        \4\ O.R. PROCEDURE W PRINCIPAL                 1.3569            32.5            27.0
                            DIAGNOSES OF MENTAL ILLNESS.
425                        ACUTE ADJUSTMENT REACTION &                    0.5981            27.5            22.9
                            PSYCHOLOGICAL DYSFUNCTION.
426                        DEPRESSIVE NEUROSES..................          0.4660            22.3            18.5
427                        \4\ NEUROSES EXCEPT DEPRESSIVE.......          1.3569            32.5            27.0
428                        \1\ DISORDERS OF PERSONALITY &                 0.4964            18.5            15.4
                            IMPULSE CONTROL.
429                        ORGANIC DISTURBANCES & MENTAL                  0.6438            27.4            22.8
                            RETARDATION.

[[Page 45657]]

 
430                        PSYCHOSES............................          0.4689            22.7            18.9
431                        \1\ CHILDHOOD MENTAL DISORDERS.......          0.4964            18.5            15.4
432                        \1\ OTHER MENTAL DISORDER DIAGNOSES..          0.4964            18.5            15.4
433                        \1\ ALCOHOL/DRUG ABUSE OR DEPENDENCE,          0.4964            18.5            15.4
                            LEFT AMA.
439                        SKIN GRAFTS FOR INJURIES.............          1.3663            40.5            33.7
440                        WOUND DEBRIDEMENTS FOR INJURIES......          1.5854            40.0            33.3
441                        \5\ HAND PROCEDURES FOR INJURIES.....          2.0841            40.0            33.3
442                        OTHER O.R. PROCEDURES FOR INJURIES W           1.4971            44.6            37.1
                            CC.
443                        \4\ OTHER O.R. PROCEDURES FOR                  1.3569            32.5            27.0
                            INJURIES W/O CC.
444                        TRAUMATIC INJURY AGE 17 W           0.9609            30.6            25.5
                            CC.
445                        TRAUMATIC INJURY AGE 17 W/          0.7552            26.6            22.1
                            O CC.
446                        \8\ TRAUMATIC INJURY AGE 0-17........          0.7372            23.5            19.5
447                        \3\ ALLERGIC REACTIONS AGE 17.
448                        \8\ ALLERGIC REACTIONS AGE 0-17......          0.7372            23.5            19.5
449                        \7\ POISONING & TOXIC EFFECTS OF               0.9562            26.1            21.7
                            DRUGS AGE 17 W CC.
450                        \7\ POISONING & TOXIC EFFECTS OF               0.9562            26.1            21.7
                            DRUGS AGE 17 W/O CC.
451                        \8\ POISONING & TOXIC EFFECTS OF               0.7372            23.5            19.5
                            DRUGS AGE 0-17.
452                        COMPLICATIONS OF TREATMENT W CC......          0.9692            24.9            20.7
453                        COMPLICATIONS OF TREATMENT W/O CC....          0.8633            24.2            20.1
454                        \2\ OTHER INJURY, POISONING & TOXIC            0.7372            23.5            19.5
                            EFFECT DIAG W CC.
455                        \2\ OTHER INJURY, POISONING & TOXIC            0.7372            23.5            19.5
                            EFFECT DIAG W/O CC.
461                        O.R. PROC W DIAGNOSES OF OTHER                 1.3216            36.5            30.4
                            CONTACT W HEALTH SERVICES.
462                        REHABILITATION.......................          0.6471            23.2            19.3
463                        SIGNS & SYMPTOMS W CC................          0.7541            26.8            22.3
464                        SIGNS & SYMPTOMS W/O CC..............          0.6170            25.5            21.2
465                        \2\ AFTERCARE W HISTORY OF MALIGNANCY          0.7372            23.5            19.5
                            AS SECONDARY DIAGNOSIS.
466                        AFTERCARE W/O HISTORY OF MALIGNANCY            0.7365            22.0            18.3
                            AS SECONDARY DIAGNOSIS.
467                        \1\ OTHER FACTORS INFLUENCING HEALTH           0.4964            18.5            15.4
                            STATUS.
468                        EXTENSIVE O.R. PROCEDURE UNRELATED TO          2.0686            42.5            35.4
                            PRINCIPAL DIAGNOSIS.
469                        \6\ PRINCIPAL DIAGNOSIS INVALID AS             0.0000             0.0             0.0
                            DISCHARGE DIAGNOSIS.
470                        \6\ UNGROUPABLE......................          0.0000             0.0             0.0
471                        \5\ BILATERAL OR MULTIPLE MAJOR JOINT          2.0841            40.0            33.3
                            PROCS OF LOWER EXTREMITY.
473                        \3\ ACUTE LEUKEMIA W/O MAJOR O.R.              0.9562            26.1            21.7
                            PROCEDURE AGE 17.
475                        RESPIRATORY SYSTEM DIAGNOSIS WITH              2.1358            35.2            29.3
                            VENTILATOR SUPPORT.
476                        PROSTATIC O.R. PROCEDURE UNRELATED TO          1.0032            31.9            26.5
                            PRINCIPAL DIAGNOSIS.
477                        NON-EXTENSIVE O.R. PROCEDURE                   1.8998            40.0            33.3
                            UNRELATED TO PRINCIPAL DIAGNOSIS.
478                        \7\ OTHER VASCULAR PROCEDURES W CC...          1.2567            34.2            28.5
479                        \7\ OTHER VASCULAR PROCEDURES W/O CC.          1.2567            34.2            28.5
480                        \6\ LIVER TRANSPLANT.................          0.0000             0.0             0.0
481                        \8\ BONE MARROW TRANSPLANT...........          0.9562            26.1            21.7
482                        \5\ TRACHEOSTOMY FOR FACE,MOUTH &              2.0841            40.0            33.3
                            NECK DIAGNOSES.
483                        TRACH W MECH VENT 96+ HRS OR PDX               3.2131            55.7            46.4
                            EXCEPT FACE,MOUTH & NECK DIAG.
484                        \8\ CRANIOTOMY FOR MULTIPLE                    2.0841            40.0            33.3
                            SIGNIFICANT TRAUMA.
485                        \8\ LIMB REATTACHMENT, HIP AND FEMUR           1.3569            32.5            27.0
                            PROC FOR MULTIPLE SIGNIFICANT TR.
486                        \4\ OTHER O.R. PROCEDURES FOR                  1.3569            32.5            27.0
                            MULTIPLE SIGNIFICANT TRAUMA.
487                        OTHER MULTIPLE SIGNIFICANT TRAUMA....          1.2484            32.7            27.2
488                        \5\ HIV W EXTENSIVE O.R. PROCEDURE...          2.0841            40.0            33.3
489                        HIV W MAJOR RELATED CONDITION........          0.9254            21.3            17.7
490                        HIV W OR W/O OTHER RELATED CONDITION.          0.7361            19.6            16.3
491                        \8\ MAJOR JOINT & LIMB REATTACHMENT            1.3569            32.5            27.0
                            PROCEDURES OF UPPER EXTREMITY.
492                        \8\ CHEMOTHERAPY W ACUTE LEUKEMIA AS           0.9562            26.1            21.7
                            SECONDARY DIAGNOSIS OR W USE HIGH
                            DOSE CHEMOTHERAPY AGENT.
493                        \7\ LAPAROSCOPIC CHOLECYSTECTOMY W/O           1.3569            32.5            27.0
                            C.D.E. W CC.
494                        \7\ LAPAROSCOPIC CHOLECYSTECTOMY W/O           2.0841            40.0            33.3
                            C.D.E. W/O CC.
495                        \6\ LUNG TRANSPLANT..................          0.0000             0.0             0.0
496                        \8\ COMBINED ANTERIOR/POSTERIOR                1.3569            32.5            27.0
                            SPINAL FUSION.
497                        \7\ SPINAL FUSION W CC...............          0.9562            26.1            21.7
498                        \7\ SPINAL FUSION W/O CC4............          0.9562            26.1            21.7
499                        \5\ BACK & NECK PROCEDURES EXCEPT              2.0841            40.0            33.3
                            SPINAL FUSION W CC.
500                        \4\ BACK & NECK PROCEDURES EXCEPT              1.3569            32.5            27.0
                            SPINAL FUSION W/O CC.
501                        \5\ KNEE PROCEDURES W PDX OF                   2.0841            40.0            33.3
                            INFECTION W CC.
502                        \2\ KNEE PROCEDURES W PDX OF                   0.7372            23.5            19.5
                            INFECTION W/O CC.
503                        \3\ KNEE PROCEDURES W/O PDX OF                 0.9562            26.1            21.7
                            INFECTION.
504                        \8\ EXTENSIVE 3RD DEGREE BURNS W SKIN          2.0841            40.0            33.3
                            GRAFT.
505                        \4\ EXTENSIVE 3RD DEGREE BURNS W/O             1.3569            32.5            27.0
                            SKIN GRAFT.

[[Page 45658]]

 
506                        \7\ FULL THICKNESS BURN W SKIN GRAFT           0.7372            23.5            19.5
                            OR INHAL INJ W CC OR SIG TRAUMA.
507                        \7\ FULL THICKNESS BURN W SKIN GRFT            0.7372            23.5            19.5
                            OR INHAL INJ W/O CC OR SIG TRAUMA.
508                        \2\ FULL THICKNESS BURN W/O SKIN GRFT          0.7372            23.5            19.5
                            OR INHAL INJ W CC OR SIG TRAUMA.
509                        \2\ FULL THICKNESS BURN W/O SKIN GRFT          0.7372            23.5            19.5
                            OR INH INJ W/O CC OR SIG TRAUMA.
510                        \2\ NON-EXTENSIVE BURNS W CC OR                0.7372            23.5            19.5
                            SIGNIFICANT TRAUMA.
511                        \1\ NON-EXTENSIVE BURNS W/O CC OR              0.4964            18.5            15.4
                            SIGNIFICANT TRAUMA.
512                        \6\ SIMULTANEOUS PANCREAS/KIDNEY               0.0000             0.0             0.0
                            TRANSPLANT.
513                        \6\ PANCREAS TRANSPLANT..............          0.0000             0.0             0.0
515                        \5\ CARDIAC DEFIBRILATOR IMPLANT W/O           2.0841            40.0            33.3
                            CARDIAC CATH.
516                        \8\ PERCUTANEOUS CARDIVASCULAR                 0.9562            26.1            21.7
                            PROCEDURE W AMI.
517                        \4\ PERCUTANEOUS CARDIVASCULAR PROC W          1.3569            32.5            27.0
                            NON-DRUG ELUTING STENT W/O AMI.
518                        \3\ PERCUTANEOUS CARDIVASCULAR PROC W/         0.9562            26.1            21.7
                            O CORONARY ARTERY STENT OR AMI.
519                        \4\ CERVICAL SPINAL FUSION W CC......          1.3569            32.5            27.0
520                        \8\ CERVICAL SPINAL FUSION W/O CC....          0.9562            26.1            21.7
521                        ALCOHOL/DRUG ABUSE OR DEPENDENCE W CC          0.4753            20.5            17.0
522                        ALCOHOL/DRUG ABUSE OR DEPENDENCE W             0.4061            20.4            17.0
                            REHABILITATION THERAPY W/O CC.
523                        ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O           0.4214            19.8            16.5
                            REHABILITATION THERAPY W/O CC.
524                        TRANSIENT ISCHEMIA...................          0.5885            22.9            19.0
525                        \8\ HEART ASSIST SYSTEM IMPLANT......          2.0841            40.0            33.3
526                        \8\ PERCUTANEOUS CARVIOVASCULAR PROC           1.3569            32.5            27.0
                            W DRUG-ELUTING STENT W AMI.
527                        \8\ PERCUTANEOUS CARVIOVASCULAR PROC           1.3569            32.5            27.0
                            W DRUG-ELUTING STENT W/O AMI.
528                        \8\ INTRACRANIAL VASCLUAR PROCEDURES           2.0841            40.0            33.3
                            WITH PDX HEMORRHAGE.
529                        \2\ VENTRICULAR SHUNT PROCEDURES WITH          0.7372            23.5            19.5
                            CC.
530                        \8\ VENTRICULAR SHUNT PROCEDURES               0.7372            23.5            19.5
                            WITHOUT CC.
531                        \4\ SPINAL PROCEDURES WITH CC........          1.3569            32.5            27.0
532                        \3\ SPINAL PROCEDURES WITHOUT CC.....          0.9562            26.1            21.7
533                        \5\ EXTRACRANIAL VASCULAR PROCEDURES           2.0841            40.0            33.3
                            WITH CC.
534                        \8\ EXTRACRANIAL VASCULAR PROCEDURES           1.3569            32.5            27.0
                            WITHOUT CC.
535                        \8\ CARDIAC DEFIB IMPLANT WITH                 2.0841            40.0            33.3
                            CARDIAC CATH WITH AMI/HF/SHOCK.
536                        \5\ CARDIAC DEFIB IMPLANT WITH                 2.0841            40.0            33.3
                            CARDIAC CATH WITHOUT AMI/HF/SHOCK.
537                        \4\ LOCAL EXCISION AND REMOVAL OF              1.3569            32.5            27.0
                            INTERNAL FIXATION DEVICES EXCEPT HIP
                            AND FEMUR WITH CC.
538                        \1\ LOCAL EXCISION AND REMOVAL OF              0.4964            18.5            15.4
                            INTERNAL FIXATION DEVICES EXCEPT HIP
                            AND FEMUR WITHOUT CC.
539                        \8\ LYMPHOMA AND LEUKEMIA WITH MAJOR           2.0841            40.0            33.3
                            O.R. PROCEDURE WITH CC.
540                        \1\ LYMPHOMA AND LEUKEMIA WITH MAJOR           0.4964            18.5           15.4
                            O.R. PROCEDURE WITHOUT CC.
----------------------------------------------------------------------------------------------------------------
\1\ Relative weights for these LTC-DRGs were determined by assigning these cases to low volume quintile 1.
\2\ Relative weights for these LTC-DRGs were determined by assigning these cases to low volume quintile 2.
\3\ Relative weights for these LTC-DRGs were determined by assigning these cases to low volume quintile 3.
\4\ Relative weights for these LTC-DRGs were determined by assigning these cases to low volume quintile 4.
\5\ Relative weights for these LTC-DRGs were determined by assigning these cases to low volume quintile 5.
\6\ Relative weights for these LTC-DRGs were assigned a value of 0.0000.
\7\ Relative weights for these LTC-DRGs were determined after adjusting to account for nonmonotonicity (see step
  5 above).
\8\ Relative weights for these LTC-DRGs were determined by assigning these cases to the appropriate 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 final 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 final 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 
1.8 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 $1.8 billion increase. This amount does not 
reflect changes in hospital admissions or case-mix intensity, which 
would also affect overall payment changes.

[[Page 45659]]

    The RFA requires agencies to analyze options for regulatory 
relief of small businesses. For purposes of the RFA, small entities 
include small businesses, nonprofit organizations, and government 
agencies. Most hospitals and most other providers and suppliers are 
small entities, either by nonprofit status or by having revenues of 
$5 million to $25 million in any 1 year. For purposes of the RFA, 
all hospitals and other providers and suppliers are considered to be 
small entities. Individuals and States are not included in the 
definition of a small entity.
    In addition, section 1102(b) of the Act requires us to prepare a 
regulatory impact analysis for any final rule that may have a 
significant impact on the operations of a substantial number of 
small rural hospitals. This analysis must conform to the provisions 
of section 603 of the RFA. With the exception of hospitals located 
in certain New England counties, for purposes of section 1102(b) of 
the Act, we define a small rural hospital as a hospital with fewer 
than 100 beds that is located outside of a Metropolitan Statistical 
Area (MSA) or New England County Metropolitan Area (NECMA). Section 
601(g) of the Social Security Amendments of 1983 (Pub. L. 98-21) 
designated hospitals in certain New England counties as belonging to 
the adjacent NECMA. Thus, for purposes of the IPPS, 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 a final rule that has been preceded by a 
proposed rule that may result in an expenditure in any one year by 
State, local, or tribal governments, in the aggregate, or by the 
private sector, of $110 million. This final rule will not mandate 
any requirements for State, local, or tribal governments.
    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule (and subsequent 
final rule) that imposes substantial direct requirement costs on 
State and local governments, preempts State law, or otherwise has 
Federalism implications. We have reviewed this final rule in light 
of Executive Order 13132 and have determined that it will not have 
any negative impact on the rights, roles, and responsibilities of 
State, local, or tribal governments.
    In accordance with the provisions of Executive Order 12866, this 
final rule was reviewed by the Office of Management and Budget.
    The following analysis, in conjunction with the remainder of 
this document, demonstrates that this final rule is consistent with 
the regulatory philosophy and principles identified in Executive 
Order 12866, the RFA, and section 1102(b) of the Act. The final rule 
will 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 final rule will further each of 
these goals while maintaining the financial viability of the 
hospital industry and ensuring access to high quality health care 
for Medicare beneficiaries. We expect that these changes will ensure 
that the outcomes of this payment system are reasonable and 
equitable while avoiding or minimizing unintended adverse 
consequences.

III. Limitations of Our Analysis

    The following quantitative analysis presents the projected 
effects of our policy changes, as well as statutory changes 
effective for FY 2004, on various hospital groups. We estimate the 
effects of individual policy changes by estimating payments per case 
while holding all other payment policies constant. We use the best 
data available, but we do not attempt to predict behavioral 
responses to our policy changes, and we do not make adjustments for 
future changes in such variables as admissions, lengths of stay, or 
case-mix. In the May 19, 2003 proposed rule, we solicited comments 
and information about the anticipated effects of the changes on 
hospitals that we had proposed and our methodology for estimating 
them. Any comments that we received in response to the proposed rule 
are addressed in the appropriate sections throughout this final 
rule.

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 42 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 47 such hospitals in Maryland 
remain excluded from the IPPS under the waiver at section 1814(b)(3) 
of the Act.
    There are approximately 768 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 
policy changes on these hospitals are discussed below.
    Thus, as of April 2003, we have included 4,049 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 July 2003, there were 1,086 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 478 psychiatric, 216 rehabilitation, 
300 long-term care, 81 children's, and 11 cancer hospitals. In 
addition, there were 1,405 psychiatric units and 985 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 47 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 update is the percentage increase in the excluded 
hospital market basket, 3.4 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 are not impacted by this final 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 excluded hospital market basket (or 3.4 percent).
    The impact on excluded hospitals and hospital units of the 
update in the rate-of-increase limit depends on the cumulative cost 
increases experienced by each excluded hospital or unit since its 
applicable base period. For excluded hospitals and units that have 
maintained their cost increases at a level below the rate-of-
increase limits since their base period, the major effect is 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 is the amount of excess costs 
that will 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

[[Page 45660]]

addition, under the various provisions set forth in Sec.  413.40, 
certain excluded hospitals and hospital units can obtain payment 
adjustments for justifiable increases in operating costs that exceed 
the limit. At the same time, however, by generally limiting payment 
increases, we continue to provide an incentive for excluded 
hospitals and hospital units to restrain the growth in their 
spending for patient services.

VI. Quantitative Impact Analysis of the Policy Changes Under the IPPS 
for Operating Costs

A. Basis and Methodology of Estimates

    In this final 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 1.8 percent 
increase), we estimate the total impact of these changes for FY 2004 
payments compared to FY 2003 payments to be approximately a $1.8 
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 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 making in this final rule. However, there are 
other changes we have made, but for which we do not have data 
available that would allow us to estimate the payment impacts using 
this model. For those changes, we have attempted to predict the 
payment impacts of those 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 final 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 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 final FY 2004 changes to the capital 
IPPS are discussed in section VIII. of this Appendix.
    The final changes discussed separately below are the following:
    [sbull] The effects of expanding the postacute care transfer 
policy to 21 additional DRGs.
    [sbull] The effects of the annual reclassification of diagnoses 
and procedures and the recalibration of the DRG relative weights 
required by section 1886(d)(4)(C) of the Act.
    [sbull] The effects of the final 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 effects on FY 2004 outlier payments of the policy 
changes implemented in the June 9, 2003 final rule on high-cost 
outlier payments.
    [sbull] The total change in payments based on final FY 2004 
policies relative to payments based on FY 2003 policies.
    To illustrate the impacts of the final 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 final and statutory policy change is then added 
incrementally to this baseline model, finally arriving at an FY 2004 
model incorporating all of the final changes. This allows us to 
isolate the effects of each change.
    Our final comparison illustrates the percent change in payments 
per case from FY 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 have 
updated 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 3.4 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 3.4 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 6.5 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 final 
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 have expanded the postacute care transfer policy to 
21 additional DRGs and dropped 2 DRGs from the original policy. This 
makes a total of 29 DRGs that will be subject to the postacute care 
transfer policy. This expansion is estimated to result in Medicare 
savings of $205 million because we will no longer pay a full DRG 
payment for these cases. As a result, there will 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 4,049 hospitals included in the analysis. This number 
is 181 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 2,564 
hospitals located in urban areas (MSAs or NECMAs) included in our 
analysis. Among these, there are 1,488 hospitals located in large 
urban areas (populations over 1 million), and 1,076 hospitals in 
other urban areas (populations of 1 million or fewer). In addition, 
there are 1,485 hospitals in rural areas. The next two groupings are 
by bed-size categories, shown

[[Page 45661]]

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 2,605, 
1,582, 1,023, and 1,444, respectively.
    The next three groupings examine the impacts of the final 
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 2,932 nonteaching hospitals in our 
analysis, 880 teaching hospitals with fewer than 100 residents, and 
237 teaching hospitals with 100 or more residents.
    In the DSH categories, hospitals are grouped according to their 
DSH payment status, and whether they are considered urban or rural 
after MGCRB reclassifications. 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 final changes on 
rural hospitals by special payment groups (SCHs, rural referral 
centers (RRCs), and MDHs), as well as rural hospitals not receiving 
a special payment designation. The RRCs (148), SCHs (497), MDHs 
(250), and hospitals that are both SCH and RRC (75) 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 122 hospitals. Similarly, the data needed to determine Medicare 
utilization were unavailable for 106 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 Final Changes for FY 2004 Operating Prospective Payment System [Percent Changes in Payments Per Case]
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                     New wage                                                           All FY
                                                                                                         New wage      index                DRG & Wage                      All FY       2004
                                                         Number of    Revised    Transfer    New wage      index      without    DRG Recal     index          MCGRB          2004     changes w/
                                                         hosps.\1\    outlier     changes    data \4\     without     CAHS &        \7\       changes   reclassification    changes    o FY 2003
                                                                    policy \2\      \3\                  CAHS \5\     NPHYS.                    \8\            \9\           \10\      outliers
                                                                                                                    part B \6\                                                           \11\
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                               (1)         (2)         (3)         (4)         (5)         (6)         (7)         (8)            (9)           (10)        (11)
-------------------------------------------------------
By Geographic Location:
    All hospitals.....................................       4,049         0.0        -0.2        -0.3        -0.2         0.0         0.0         0.0            0.0            1.8         3.2
    Urban hospitals...................................       2,564        -0.1        -0.3        -0.3        -0.2         0.0         0.0         0.0           -0.3            1.2         2.9
    Large urban areas (populations over 1 million)....       1,488        -0.4        -0.3        -0.3        -0.2         0.0         0.0         0.0           -0.4            1.1         3.2
    Other urban areas (populations of 1 million or           1,076         0.3        -0.2        -0.3        -0.2         0.0         0.0         0.0           -0.3            1.4         2.4
     fewer)...........................................
    Rural hospitals...................................       1,485         0.7        -0.2        -0.3         0.2         0.1         0.0         0.5            2.2            5.8         5.5
Bed Size (Urban):
    0-99 beds.........................................         614        -0.1        -0.4         0.0        -0.2         0.0        -0.1         0.5           -0.6            2.1         3.1
    100-199 beds......................................         914        -0.6        -0.5        -0.3        -0.2         0.0         0.0         0.1           -0.4            1.2         2.9
    200-299 beds......................................         508         0.0        -0.4        -0.3        -0.2         0.0         0.0         0.0           -0.3            1.4         2.9
    300-499 beds......................................         372        -0.5        -0.2        -0.1        -0.2         0.0        -0.1         0.2           -0.3            0.8         3.1
    500 or more beds..................................         156         0.5         0.0        -0.7        -0.2         0.0         0.1        -0.4           -0.4            1.4         2.6
Bed Size (Rural):
    0-49 beds.........................................         671         0.2        -0.3        -0.4         0.2         0.1         0.0         0.7            0.5            6.0         5.9
    50-99 beds........................................         474         0.4        -0.2        -0.3         0.1         0.0         0.0         0.4            0.9            6.2         6.1
    100-149 beds......................................         203         0.8        -0.2        -0.4         0.2         0.1         0.0         0.3            2.8            6.0         5.6
    150-199 beds......................................          70         1.1         0.0        -0.2         0.3         0.0        -0.1         0.6            4.2            4.4         3.9
    200 or more beds..................................          67         1.1         0.0        -0.1         0.1         0.0        -0.1         0.4            3.5            5.7         5.1
Urban by Region:
    New England.......................................         132         1.2        -0.4        -0.3        -0.6         0.0         0.0         0.5            0.1            2.8         2.5
    Middle Atlantic...................................         395        -3.1        -0.3        -0.9        -0.2         0.0         0.0        -0.6            0.2           -2.8         2.3
    South Atlantic....................................         370         1.1        -0.3        -0.1        -0.2         0.0         0.0         0.2           -0.5            2.7         3.0
    East North Central................................         422         1.3         0.0        -0.6        -0.2         0.0         0.0        -0.3           -0.3            2.7         2.6
    East South Central................................         154         1.0         0.0         0.1        -0.2         0.0        -0.1         0.3           -0.6            2.9         3.1
    West North Central................................         175         1.6        -0.5         0.0        -0.2         0.0        -0.1         0.2           -0.7            3.1         2.9
    West South Central................................         327        -0.1        -0.2        -0.1        -0.2         0.0         0.0         0.2           -0.6            1.6         3.2
    Mountain..........................................         130         1.5        -0.2         0.5         0.0         0.0        -0.1         0.8           -0.5            4.4         4.1
    Pacific...........................................         413        -2.0        -0.5        -0.1        -0.2         0.0         0.0         0.2           -0.4           -0.6         3.3
    Puerto Rico.......................................          46         0.3         0.1        -0.3        -0.1         0.0        -0.2        -0.1           -0.7            2.8         2.9
Rural by Region:
    New England.......................................          37         0.7        -0.1        -0.2         0.1         0.0        -0.1         0.3            2.6            6.8         6.6
    Middle Atlantic...................................          66         0.7        -0.2        -0.4         0.0         0.0         0.0         0.1            2.6            4.1         3.6
    South Atlantic....................................         222         1.0        -0.2        -0.1         0.1         0.0        -0.1         0.5            2.3            5.3         4.8
    East North Central................................         193         0.7        -0.2         0.1         0.2         0.0        -0.1         0.7            1.5            4.5         4.1
    East South Central................................         231         0.7        -0.2        -0.4         0.0         0.0         0.0         0.2            2.6            4.7         4.4
    West North Central................................         247         0.4        -0.1        -0.1         0.6         0.1        -0.1         0.9            1.3            7.9         7.8
    West South Central................................         273         0.6        -0.2        -0.6         0.0         0.2         0.0         0.3            3.6            5.8         5.5
    Mountain..........................................         121         0.3         0.0        -0.3         0.2         0.0         0.0         0.2            1.5            7.1         6.9
    Pacific...........................................          90         0.7        -0.1        -0.6         0.3         0.1         0.0         0.2            2.3            8.7         8.4
    Puerto Rico.......................................           5         0.1        -0.1        -4.2        -0.1         0.0        -0.1        -4.1            0.4           -0.3        -0.5
By Payment Classification:
    Urban hospitals...................................       2,605        -0.1        -0.3        -0.3        -0.2         0.0         0.0         0.0           -0.3            1.2         2.9
    Large urban areas (populations over 1 million)....       1,582        -0.3        -0.3        -0.3        -0.2         0.0         0.0         0.0           -0.2            1.2         3.1
    Other urban areas (populations of 1 million or           1,023         0.2        -0.2        -0.3        -0.2         0.0         0.0         0.0           -0.4            1.3         2.4
     fewer)...........................................
    Rural areas.......................................       1,444         0.6        -0.2        -0.3         0.2         0.1         0.0         0.4            2.1            5.9         5.7
Teaching Status:
    Non-teaching......................................       2,932        -0.1        -0.3        -0.2        -0.1         0.0         0.0         0.3            0.3            2.6         3.7
    Fewer than 100 Residents..........................         880        -0.2        -0.1        -0.2        -0.2         0.0         0.0         0.2           -0.2            1.3         3.1
    100 or more Residents.............................         237         0.4        -0.2        -0.7        -0.2         0.0         0.0        -0.4           -0.1            1.2         2.4
Urban DSH:
    Non-DSH...........................................       1,349         0.5        -0.2        -0.2        -0.1         0.0         0.0         0.2            0.0            2.5         3.3
    100 or more beds..................................       1,399        -0.3        -0.3        -0.4        -0.2         0.0         0.0         0.0           -0.3            0.9         2.8

[[Page 45662]]

 
    Less than 100 beds................................         282        -1.1        -0.5        -0.1        -0.2         0.0        -0.1         0.4           -0.5            0.9         3.1
Rural DSH:
    Sole Community (SCH)..............................         493         0.2        -0.1        -0.2         0.1         0.0         0.0         0.5            0.3           10.0         9.9
    Referral Center (RRC).............................         156         1.1        -0.1        -0.3         0.2         0.1        -0.1         0.4            4.5            4.5         4.0
    Other Rural: 100 or more beds.....................          71         0.9        -0.3        -0.7         0.0         0.1         0.0         0.0            1.3            2.5         2.0
    Less than 100 beds................................         299         0.5        -0.4        -0.6         0.0         0.1         0.0         0.3            1.2            2.8         2.6
Urban teaching and DSH:
    DSH...............................................         775        -0.3        -0.2        -0.4        -0.2         0.0         0.0        -0.1           -0.3            0.9         2.8
    Teaching and no DSH...............................         274         0.8        -0.1        -0.3        -0.2         0.0         0.0         0.0           -0.2            2.1         2.9
    No teaching and DSH...............................         906        -0.6        -0.5        -0.3        -0.2         0.0         0.0         0.1           -0.3            1.0         2.8
    No teaching and no DSH............................         650         0.2        -0.3        -0.1        -0.2         0.0         0.0         0.3           -0.3            1.8         3.1
Rural Hospital Types:
    Non special status hospitals......................         474         0.7        -0.4        -0.5         0.1         0.1         0.0         0.3            1.3            2.7         2.4
    RRC...............................................         148         1.5        -0.2        -0.2         0.3         0.1        -0.1         0.6            5.8            3.5         2.9
    SCH...............................................         497         0.1        -0.1        -0.1         0.1         0.0         0.0         0.5            0.2           10.8        10.8
    Medicare-dependent hospitals (MDH)................         250         0.3        -0.3        -0.5         0.3         0.1        -0.1         0.7            0.8            3.3         3.2
    SCH and RRC.......................................          75         0.2         0.0        -0.2         0.1         0.0         0.0         0.2            1.2            7.4         7.3
Type of Ownership:
    Voluntary.........................................       2,411         0.4        -0.1        -0.3        -0.2         0.0         0.0         0.0            0.0            2.2         3.1
    Proprietary.......................................         698        -3.7        -1.0         0.0        -0.2         0.0        -0.1         0.4           -0.1           -2.1         3.6
    Government........................................         818         1.2        -0.3        -0.4        -0.1         0.0         0.0         0.0            0.2            4.0         3.8
    Unknown...........................................         122         2.4         0.0        -1.0        -0.1         0.0         0.1        -0.6           -0.4            3.5         2.2
Medicare Utilization as a Percent of Inpatient Days:
    0-25..............................................         303         0.5         0.0         0.1        -0.2         0.0        -0.1         0.3           -0.2            2.5         3.4
    25-50.............................................       1,533        -0.2        -0.3        -0.4        -0.2         0.0         0.0         0.0           -0.2            1.2         3.0
    50-65.............................................       1,651         0.4        -0.2        -0.3        -0.1         0.0         0.0         0.1            0.3            2.8         3.4
    Over 65...........................................         456        -1.2        -0.2        -0.2        -0.1         0.0         0.0         0.4            0.7            1.1         3.6
    Unknown...........................................         106        -0.6        -0.1         0.1        -0.2         0.0        -0.1         0.4           -0.6            1.7         3.4
Hospitals Reclassified by the Medicare Geographic
 Classification Review Board: FY 2004
 Reclassifications:
    All Reclassified Hospitals........................         616        -0.7        -0.1        -0.3         0.0         0.0         0.0         0.3            4.3            2.6         4.3
    Standardized Amount Only..........................          22         0.9         0.0        -0.8         0.0         0.1         0.0        -0.1            3.4            5.4         5.6
    Wage Index Only...................................         554        -1.0        -0.1        -0.3         0.0         0.0         0.0         0.3            4.2            1.9         3.7
    Both..............................................          33         1.7         0.1        -0.3         0.0         0.0         0.0         0.2            4.1            4.1         3.3
Nonreclassified Hospitals.............................       3,407         0.1        -0.3        -0.3        -0.2         0.0         0.0         0.1           -0.6            1.8         3.2
All Reclassified Urban Hospitals......................         125        -3.3        -0.2        -0.3        -0.3         0.0         0.0         0.1            4.6           -1.8         3.0
    Standardized Amount Only..........................          15         2.5        -1.3        -0.9        -0.1         0.0         0.0        -0.6            0.8           -4.6         3.2
    Wage Index Only...................................          71        -5.4         0.0        -0.3        -0.4         0.0         0.0         0.0            5.1           -4.1         2.9
    Both..............................................          39         1.8        -0.3         0.1        -0.2         0.0        -0.1         0.4            4.6            4.1         3.3
    Urban Nonreclassified Hospitals...................       2,408         0.1        -0.3        -0.3        -0.2         0.0         0.0         0.0           -0.6            1.4         2.9
All Reclassified Rural Hospitals......................         491         0.9        -0.1        -0.2         0.2         0.1        -0.1         0.4            4.0            5.5         5.1
    Standardized Amount Only..........................          27         1.6         0.0        -0.1         0.2         0.0        -0.1         0.6            3.1            2.3         1.3
    Wage Index Only...................................         451         0.8        -0.1        -0.3         0.2         0.1        -0.1         0.4            4.0            5.7         5.4
    Both..............................................          13         1.8         0.0         0.0         0.2         0.0        -0.1         0.8            7.1            5.4         4.6
Rural Nonreclassified Hospitals.......................         992         0.3        -0.2        -0.3         0.1         0.1         0.0         0.5           -0.4            6.2         6.1
Other Reclassified Hospitals (Section 1886(D)(8)(B))..          33         0.6        -0.2         0.0        -0.2         0.0         0.0         0.5           -1.5            3.0        2.8
\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 outlier policy that were published in the June 9, 2003 Federal Register.
\3\ This column displays the payment impact of the expanded postacute care transfer policy.
\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 CAHs from the wage index.
\6\ This column displays the impact of the revised wage data used to calculate the wage index from removal of nonphysician Part B costs and hours from cost report data (Worksheet S-3, Part II,
  Line 5.01).
\7\ 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.
\8\ This column shows the payment impact of 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 4, 5, 6 and 7, and the final FY 2004 budget neutrality factor of 1.005522.
\9\ 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.
\10\ This column shows changes in payments from FY 2003 to FY 2004. It incorporates all of the changes displayed in columns 2, 3, and 8 (the changes displayed in columns 4, 5, and 6 are
  included in column 8). 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.
\11\ This column shows changes in payments from FY 2003 to FY 2004, similar to column 10. However, this simulation assumes FY 2003 outlier payments will be at the same percentage level as FY
  2004. This effectively reduces FY 2003 outlier payments from 6.5 percent of total DRG payments to 5.1 percent of total DRG payments, thereby reducing FY 2003 payments and increasing the
  percent changes from FY 2003 to FY 2004.

C. Impact of the Changes to the Outlier Policy (Column 2)

    In the proposed rule, we estimated the FY 2004 outlier threshold 
to be $50,645. We also noted that the final outlier threshold was 
likely to be different from the proposed threshold after taking into 
account changes implemented by the final outlier rule. Since the 
publication of the proposed IPPS rule, we published a final outlier 
rule on June 9, 2003 (68 FR 34494).
    We published three central changes to our outlier policy in the 
June 9, 2003 final rule. First, fiscal intermediaries will use 
either the most recent settled or the most recent tentative settled 
cost report, whichever is from the latest reporting period when 
determining the cost-to-charge ratio for each hospital. Second, we 
removed the requirement in our regulations that specified 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. Third, outlier payments for 
some hospitals will become subject to reconciliation when the 
hospitals' cost reports are settled.
    Column 2 shows the effects of these changes. This column 
displays the effects of moving from our policy prior to the changes 
in the June 9 final rule, that hospitals' cost-to-charge ratios are 
based on their latest settled cost reports, and if the ratio falls 
below 3 standard deviations from the mean, the statewide average is 
assigned, to the new

[[Page 45663]]

policy where the cost-to-charge ratio is based on the latest 
tentatively settled cost report, there is no minimum ratio, and 
outlier payments may be subject to reconciliation when the cost 
report is settled. As a result of these changes, the outlier 
threshold falls from $50,200 (this represents what the FY 2004 
threshold would be absent the policy changes to $31,000).
    The top row in this column indicates these changes have no 
impact on overall spending. However, the changes among specific 
categories of hospitals are quite dramatic. Hospital categories 
negatively impacted in this column are those groups expected to have 
dramatic reduction in their cost-to-charge ratios as a result of the 
new policies. On the other hand, hospitals that are not expected to 
experience dramatic changes in their cost-to-charge ratios benefit 
from the decline in the threshold.
    Rural hospitals overall experience a 0.7 percent increase in 
their outlier payments as a result of this change. On the other 
hand, urban hospitals in the Middle Atlantic census division 
experience a 3.1 percent decrease. The largest negative impacts are 
among proprietary hospitals, with a 3.7 percent decrease and among 
urban hospitals that reclassified for the purposes of wage index 
only, with a decrease of 5.4 percent.

D. Impact of the Changes to the Postacute Care Transfer Policy 
(Column 3)

    In column 3 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 final 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 expanded postacute care transfer policy (with the additional 21 
DRGs). The changes we are making are estimated to result in 0.2 
percent lower payments to hospitals overall. We estimate the total 
savings at approximately $205 million.
    To simulate the impact of this final policy, we calculated 
hospitals' transfer-adjusted discharges and case-mix index values, 
including the additional 21 DRGs, minus 2 of the current 10 DRGs. 
The transfer-adjusted discharge fraction is calculated in one of two 
ways, depending on the transfer payment methodology. Under our 
previous 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 21 additional DRGs qualify 
to 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 change to the 
transfer policy.
    This 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 original 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 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-1990s 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.

E. Impact of Wage Index Changes (Columns 4, 5, and 6)

    Section 1886(d)(3)(E) of the Act requires that, beginning 
October 1, 1993, we annually update the wage data used to calculate 
the wage index. In accordance with this requirement, the final wage 
index for FY 2004 is based on data submitted for hospital cost 
reporting periods beginning on or after October 1, 1999 and before 
October 1, 2000. 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 the preamble of this final rule, 
the final FY 2004 wage index is calculated by removing CAHs, shown 
in column 5, and the removal of nonphysician Part B costs and hours 
of RHCs and FQHCs, shown in column 6.
    Column 4 shows the impacts of updating the wage data using FY 
2000 cost reports. Overall, the new wage data would lead to a 0.3 
percent reduction, but this reduction is offset by the budget 
neutrality factor. Urban hospitals' wage indexes would decline by 
0.3 percent, and rural hospitals' wage indexes would decline by 0.3 
percent. Among regions, the largest impact of updating the wage data 
is seen in rural Puerto Rico (a 4.2 percent decrease). Rural 
hospitals in the West South Central and Pacific regions would 
experience the next largest impact, with a 0.6 percent decrease for 
each. The rural East North Central region would experience an 
increase of 0.1.
    The national average hourly wage increased 6.79 percent compared 
to last year. Therefore, the only manner in which to maintain or 
exceed the previous year's wage index was to match the national 6.79 
increase in average hourly wage. Of the 4,018 hospitals with wage 
index values in both FYs 2003 and 2004, 1,753, or 43.6 percent, also 
experienced an average hourly wage increase of 6.79 percent or more.
    In order to confirm the -0.3 percent, we compared FY 2003 
prereclassified wage indexes to those of FY 2004, which yielded a 
percent change of -0.62 percent per MSA. We weighted this value 
based on the frequency of hospitals in each MSA, which produced an 
overall reduction of 0.4 percent. When we multiplied this value by 
the 71.1 percent labor share representing the proportion of IPPS 
payments affected by the wage index, we found that the overall wage 
index values dropped 0.29 percent, essentially equaling the overall 
change in column 4.
    Among urban hospitals, the Middle Atlantic and East North 
Central regions would experience 0.9 and 0.6 percent decreases, 
respectively. These impacts result, respectively from a 4.9 percent 
fall in the FY 2004 final wage index for Pittsburgh, Pennsylvania, 
and a 5.7 percent decrease in Janesville-Beloit, Wisconsin, as well 
as a 5.4 percent decrease in the Muncie and Lafayette, Indiana wage 
indexes. The Mountain and East South Central regions would 
experience increases of 0.5 percent and 0.1 percent, respectively.
    The next column (5) shows the impacts on the calculation of the 
FY 2004 wage index of removing CAHs. The effects of this change are 
relatively small with the exception of urban New England, which 
would experience a 0.6 percent decrease, due primarily to the 
Pittsfield, Springfield, and rural Massachusetts wage indexes, each 
falling 7.5 percent. The rural West North Central region would 
experience an increase of 0.6 percent.
    Column 6 shows the impacts of removing nonphysician Part B costs 
for RHCs and FQHCs. The effects of this change are relatively small.
    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

[[Page 45664]]

the final FY 2004 wage index, including updating to FY 2000 wage 
data. The majority of labor market areas (336) would experience less 
than a 5-percent change. A total of 9 labor market areas would 
experience an increase of more than 5 percent and less than 10 
percent. One area would experience an increase greater than 10 
percent. A total of 25 areas would experience decreases of more than 
5 percent and less than 10 percent. Finally, 2 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               1
Increase more than 5 percent and less                 11               9
 than 10 percent........................
Increase or decrease less than 5 percent             343             336
Decrease more than 5 percent and less                 15              25
 than 10 percent........................
Decrease more than 10 percent...........               1               2
------------------------------------------------------------------------

    Among urban hospitals, 35 would experience an increase of 
between 5 and 10 percent and 5 more than 10 percent. A total of 37 
rural hospitals would experience increases greater than 5 percent, 
but none would experience increases of greater than 10 percent. On 
the negative side, 107 urban hospitals would experience decreases in 
their wage index values of at least 5 percent but less than 10 
percent. Seven urban hospitals would experience decreases in their 
wage index values greater than 10 percent. There are 27 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...........               5               0
Increase more than 5 percent and less                 35              37
 than 10 percent........................
Increase or decrease less than 5 percent           2,443           1,754
Decrease more than 5 percent and less                107              27
 than 10 percent........................
Decrease more than 10 percent...........               7               0
------------------------------------------------------------------------

F. Impact of the Changes to the DRG Reclassifications and 
Recalibration of Relative Weights (Column 7)

    In column 7 of Table I, we present the combined effects of the 
DRG reclassifications and recalibration, as discussed in section II. 
of the preamble to this final rule. Section 1886(d)(4)(C)(i) of the 
Act requires us 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 final 
FY 2004 DRG relative weights (GROUPER version 21.0). Both 
simulations reflected the 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 budget neutrality factor 
of 1.005522 is applied to payments in Column 8. 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 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 changes 
will result in 0.0 percent change in overall payments to hospitals. 
The impacts of these changes on any particular hospital group are 
very small.

G. Combined Impact of DRG and Wage Index Changes, Including Budget 
Neutrality Adjustment (Column 8)

    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 final rule, 
we compared simulated aggregate payments using the FY 2003 DRG 
relative weights and wage index to simulated aggregate payments 
using the 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 final 
rule, we have maintained the new technology status of the drug 
Xigris[reg] for the treatment of severe sepsis (approved in last 
year's final rule at 67 FR 50013). We estimate the total add-on 
payments for this new technology for FY 2004 will be $10 million.
    We also approved a second new technology for add-on payments. 
For FY 2004, the InFUSETM Bone Graft/LT-CAGETM 
Lumbar Tapered Fusion Device for spinal fusions will be eligible to 
receive add-on payments. We estimate the total add-on payments 
associated with cases involving this new device for FY 2004 will be 
$4.4 million.
    We computed a final wage and recalibration budget neutrality 
factor of 1.005522. The 0.0 percent impact for all hospitals 
demonstrates that these changes, in combination with the budget 
neutrality factor, are budget neutral. In Table I, the combined 
overall impacts of the effects of both the DRG reclassifications and 
recalibration and the updated wage index are shown in column 8. The 
changes in this column are the sum of the final changes in columns 
4, 5, 6, and 7, 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.

H. Impact of MGCRB Reclassifications (Column 9)

    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 9 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 final FY 2004 
wage index values incorporate all of the MGCRB's

[[Page 45665]]

reclassification decisions for FY 2004. The wage index values also 
reflect any decisions made by the CMS Administrator through the 
appeals and review process.
    The overall effect of geographic reclassification is required by 
section 1886(d)(8)(D) of the Act to be budget neutral. Therefore, we 
applied an adjustment of 0.992026 to ensure that the effects of 
reclassification are budget neutral. (See section II.A.4.b. of the 
Addendum to this final rule.)
    As a group, rural hospitals benefit from geographic 
reclassification. Their payments would rise 2.2 percent in column 9. 
Payments to urban hospitals would decline 0.3 percent. Hospitals in 
other urban areas would experience an overall decrease in payments 
of 0.3 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 for Puerto Rico and 1.3 percent for the West North Central 
region. The largest increases are in the rural Middle Atlantic, New 
England, and East South Central with increases of 2.6 percent and in 
the West South Central region which would experience an increase of 
3.6 percent.
    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 4.6 percent, while rural reclassified hospitals are 
expected to benefit from the MGCRB changes with a 4.0 percent 
increase in payments. Overall, among hospitals that were 
reclassified for purposes of the standardized amount only, a payment 
increase of 3.4 percent is expected, while those reclassified for 
purposes of the wage index only show a 4.2 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 0.4 
percent for rural hospitals.

I. All Changes (Columns 10 and 11)

    Column 10 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 final policy 
changes. Because the reclassifications shown in column 9 do not 
reflect FY 2003 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 10 includes the effects of the 3.4 percent update to the 
standardized amounts and the hospital-specific rates for MDHs and 
SCHs. It also reflects the 1.4 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 (6.5 percent), as described in the 
introduction to this Appendix and the Addendum to this final rule. 
As a result, payments are projected to be 1.4 percent higher in FY 
2003 than originally estimated, resulting in a 1.4 percent smaller 
increase than would otherwise occur. (Column 11, as discussed below, 
displays the changes from FY 2003 to 2004 after adjusting for the 
higher than expected FY 2003 outlier payments.)
    Section 213 of Pub. L. 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 10 as well.
    The expansion of the postacute care transfer policy also reduces 
payments by paying for discharges to postacute care in 21 additional 
DRGs as transfers and dropping 2 DRGs from the original list of 
affected DRGs. Because FY 2003 payments reflect full DRG payments 
for all cases in these 29 DRGs, there is a negative impact due to 
the expansion of this policy compared to FY 2003. The net effect of 
this expanded policy, as displayed in column 3, is also seen in the 
lower overall percent change shown in column 10 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 Pub. L. 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 10 may not equal 
the sum of the changes described above.
    The overall change in payments per case for hospitals in FY 2004 
would increase by 1.8 percent. Hospitals in urban areas would 
experience a 1.2 percent increase in payments per case compared to 
FY 2003. Hospitals in rural areas, meanwhile, would experience a 5.8 
percent payment increase. Hospitals in large urban areas would 
experience a 1.1 percent increase in payments.
    Among urban census divisions, the largest payment increase was 
4.4 percent in the Mountain region. Hospitals in the urban East 
South Central region and in Puerto Rico would experience an overall 
increase of 2.9 percent and 2.8 percent, respectively. The smallest 
increase would occur in the West South Central region, with an 
increase of 1.6 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.
    The effect of outlier payments is illustrated in column 11, 
which sets each hospital's outlier percentage equal to their 
projected percentage for FY 2004. In this way, we are able to model 
FY 2003 payments as if outlier payments were on a par with projected 
FY 2004 outlier payments. The results illustrate the dampening 
effect the high FY 2003 outliers have on column 10. After removing 
this effect, the impact for all hospitals in FY 2004 is a 3.2 
percent increase, equal to the 3.4 percent update minus 0.2 percent 
for the impact of the expanded postacute transfer policy. For the 
most part (except for the 0.5 percent decrease in the rural Puerto 
Rico category), this reverses any negative overall impacts observed 
in column 10.
    Among rural regions in column 10, the only hospital category 
that would experience overall payment decreases is Puerto Rico, 
where payments would decrease by 0.3 percent, largely due to the 
updated wage data. The West North Central and Pacific regions would 
benefit the most, with 7.9 and 8.7 percent increases, respectively.
    Among special categories of rural hospitals in column 10, those 
hospitals receiving payment under the hospital-specific methodology 
(SCHs, MDHs, and SCH/RRCs) would experience payment increases of 
10.8 percent, 3.3 percent, and 7.4 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. The 10.8 percent increase for 
SCHs is due to the increase in percentage of the 1996 hospital-
specific rate percentage from 75 percent in FY 3003 to 100 percent 
in FY 2004.
    Hospitals that were reclassified for FY 2004 are estimated to 
receive a 2.6 percent increase in payments. Urban hospitals 
reclassified for FY 2004 are anticipated to receive a decrease of 
1.8 percent, while rural reclassified hospitals are expected to 
benefit from reclassification with a 5.5 percent increase in 
payments. Overall, among hospitals reclassified for purposes of the 
standardized amount, a payment increase of 5.4 percent is expected, 
while those hospitals reclassified for purposes of the wage index 
only would show an expected 1.9 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 3.0 percent.

[[Page 45666]]



   Table II.--Impact Analysis of 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...............................           4,049           7,512           7,651             1.8
    Urban hospitals.............................           2,564           7,976           8,073             1.2
    Large urban areas (populations over 1                  1,488           8,466           8,557             1.1
     million)...................................
    Other urban areas (populations of 1 million            1,076           7,324           7,429             1.4
     or fewer)..................................
    Rural hospitals.............................           1,485           5,506           5,825             5.8
Bed Size (Urban):
    0-99 beds...................................             614           5,539           5,654             2.1
    100-199 beds................................             914           6,691           6,772             1.2
    200-299 beds................................             508           7,653           7,763             1.4
    300-499 beds................................             372           8,568           8,635             0.8
    500 or more beds............................             156          10,199          10,339             1.4
Bed Size (Rural):
    0-49 beds...................................             671           4,526           4,796             6.0
    50-99 beds..................................             474           5,113           5,431             6.2
    100-149 beds................................             203           5,519           5,851             6.0
    150-199 beds................................              70           5,845           6,101             4.4
    200 or more beds............................              67           7,051           7,453             5.7
Urban by Region:
    New England.................................             132           8,390           8,623             2.8
    Middle Atlantic.............................             395           9,010           8,757            -2.8
    South Atlantic..............................             370           7,538           7,739             2.7
    East North Central..........................             422           7,509           7,708             2.7
    East South Central..........................             154           7,201           7,407             2.9
    West North Central..........................             175           7,639           7,877             3.1
    West South Central..........................             327           7,432           7,549             1.6
    Mountain....................................             130           7,770           8,110             4.4
    Pacific.....................................             413           9,774           9,718            -0.6
    Puerto Rico.................................              46           3,346           3,438             2.8
Rural by Region:
    New England.................................              37           6,932           7,404             6.8
    Middle Atlantic.............................              66           5,581           5,809             4.1
    South Atlantic..............................             222           5,596           5,890             5.3
    East North Central..........................             193           5,479           5,726             4.5
    East South Central..........................             231           4,957           5,191             4.7
    West North Central..........................             247           5,728           6,183             7.9
    West South Central..........................             273           4,733           5,005             5.8
    Mountain....................................             121           6,266           6,710             7.1
    Pacific.....................................              90           7,231           7,861             8.7
    Puerto Rico.................................               5           2,621           2,613            -0.3
By Payment Classification:
    Urban hospitals.............................           2,605           7,953           8,052             1.2
    Large urban areas (populations over 1                  1,582           8,362           8,463             1.2
     million)...................................
    Other urban areas (populations of 1 million            1,023           7,350           7,445             1.3
     or fewer)..................................
    Rural areas.................................           1,444           5,483           5,809             5.9
Teaching Status:
    Non-teaching................................           2,932           6,189           6,351             2.6
    Fewer than 100 Residents....................             880           7,768           7,871             1.3
    100 or more Residents.......................             237          11,499          11,642             1.2
Urban DSH:
    Non-DSH.....................................           1,349           6,736           6,902             2.5
    100 or more beds............................           1,399           8,575           8,656             0.9
    Less than 100 beds..........................             282           5,425           5,472             0.9
Rural DSH:
    Sole Community (SCH)........................             493           5,589           6,146            10.0
    Referral Center (RRC).......................             156           6,053           6,326             4.5
    Other Rural: 100 or more beds...............              71           4,647           4,762             2.5
    Less than 100 beds..........................             299           4,286           4,404             2.8
Urban teaching and DSH:
    Both teaching and DSH.......................             775           9,435           9,523             0.9
    Teaching and no DSH.........................             274           7,704           7,865             2.1
    No teaching and DSH.........................             906           6,814           6,881             1.0
    No teaching and no DSH......................             650           6,265           6,380             1.8
Rural Hospital Types:
    Non special status hospitals................             474           4,441           4,559             2.7
    RRC.........................................             148           5,868           6,072             3.5
    SCH.........................................             497           6,022           6,673            10.8

[[Page 45667]]

 
    Medicare-dependent hospitals (MDH)..........             250           4,162           4,301             3.3
    SCH and RRC.................................              75           6,805           7,312             7.4
Type of Ownership:
    Voluntary...................................           2,411           7,617           7,784             2.2
    Proprietary.................................             698           7,189           7,035            -2.1
    Government..................................             818           7,264           7,557             4.0
    Unknown.....................................             122           7,528           7,794             3.5
Medicare Utilization as a Percent of Inpatient
 Days:
    0-25........................................             303          10,131          10,383             2.5
    25-50.......................................           1,533           8,568           8,669             1.2
    50-65.......................................           1,651           6,505           6,686             2.8
    Over 65.....................................             456           5,824           5,891             1.1
    Unknown.....................................             106           6,766           6,884             1.7
Hospitals Reclassified by the Medicare
 Geographic Classification Review Board: FY 2004
 Reclassifications:
    All Reclassified Hospitals..................             616           6,892           7,071             2.6
        Standardized Amount Only................              22           5,672           5,980             5.4
        Wage Index Only.........................             554           6,952           7,082             1.9
        Both....................................              33           6,146           6,398             4.1
    All Nonreclassified Hospitals...............           3,407           7,639           7,777             1.8
    All Urban Reclassified Hospitals............             125           8,779           8,619            -1.8
    Urban Nonreclassified Hospitals.............              15           6,352           6,646             4.6
        Standardized Amount Only................              71           9,881           9,471            -4.1
        Wage Index Only.........................              39           7,018           7,304             4.1
        Both....................................           2,408           7,946           8,059             1.4
    All Reclassified Rural Hospitals............             491           6,040           6,372             5.5
        Standardized Amount Only................              27           6,218           6,363             2.3
        Wage Index Only.........................             451           6,047           6,393             5.7
        Both....................................              13           5,345           5,632             5.4
    Rural Nonreclassified Hospitals.............             992           4,863           5,166             6.2
    Other Reclassified Hospitals (Section                     33           5,087           5,241            3.0
     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 final 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 10 of Table 
I.

VII. Impact of Other Policy Changes

    In addition to those changes discussed above that we are able to 
model using our IPPS payment simulation model, we are implementing 
various other changes in this final rule. Generally, we have limited 
or no specific data available with which to estimate the impacts of 
these changes. Our estimates of the likely impacts associated with 
these other 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. Nonacute Care Beds and Days

    The rule clarifies 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 final rule 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 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 provision 
would reduce Medicare DSH payments to Alaska's hospitals by 
$662,097.
    We are unable to estimate the effect of this 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

[[Page 45668]]

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.

3. Observation and Swing-Beds

    We are revising 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 clarification reflects our current 
policy, despite the fact 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.

4. Labor, Delivery, and Postpartum Beds and Days

    Similarly, in the case of labor, delivery, and postpartum rooms, 
we are clarifying 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 change will have a 
significant payment impact. However, we do not have data available 
to enable us to identify those hospitals that have not been applying 
this policy and, therefore, will be required to change their policy. 
Consequently, we are unable to quantify the impacts of this 
clarification.

5. 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 
final rule, we also 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 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.

B. Costs of Approved Nursing and Allied Health Education Activities

1. Continuing Education

    In section IV.E. of the preamble of this final rule, we are 
clarifying 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. Effective October 1, 
2003, we are clarifying 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 are inappropriately receiving pass-through 
payment.
    To the extent that Medicare would no longer pay for such 
programs, Medicare payments would be reduced. We believe that these 
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 final rule, we are 
finalizing the proposal 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 for costs of nursing or allied health education 
program(s) where the program(s) had originally been operated by the 
hospital, and then operation 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 will 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 finalizing the proposal 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 also finalizing 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

[[Page 45669]]

costs to the Medicare program for this provision will 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 final 
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 redistribution of costs and 
community support principles, which state that Medicare will not 
share in the costs of educational activities of a hospital that 
represent a redistribution of costs from a university or the 
community to the hospital. Accordingly, we are revising our policy 
concerning counting residents to ensure that, effective for portions 
of cost reporting periods occurring on or after October 1, 2003, 
Medicare GME payments are not made to hospitals for training that 
had already been in place in the absence of the hospital's financial 
support. However, we also are providing that, for an FTE resident 
who began training in a residency program on or before October 1, 
2003, and with respect to whom there has been a redistribution of 
costs or community support, the resident may continue to be counted 
by a hospital as an FTE resident until the resident has completed 
training in that program, or until 3 years after the date the 
resident began training in that program, whichever comes first.
    By prohibiting payment for residency training that had been 
previously supported by nonhospital institutions, this change will 
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. 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 final 
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 revising 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 provision will 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 final 
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 making this technical clarification to the 
regulations. We believe that this provision will not have a budget 
impact because it is a clarification of existing policy.

D. Impact of Application of RCE Limits

    As discussed in section IV.G. of this final rule, we are 
updating the RCE limits by applying the most recent economic index. 
In this final rule, we are announcing an update of the limits, as 
required by Sec.  415.70(f)(3) and does not alter any regulations or 
policy. The RCE limits apply only to providers paid on a reasonable 
cost basis and to compensation a physician receives from a provider 
for services that benefit patients generally or otherwise but that 
are not eligible for payment under the physician fee schedule. Also, 
the limits do not apply to costs of physician compensation that are 
attributable to furnishing inpatient hospital services paid under 
the IPPS or that are attributable to GME costs. In addition, RCE 
limits do not apply to the costs CAHs incur in compensating 
physicians for services. As a result of the application of the RCE 
limits, we estimate the costs associated with the updated limits for 
calendar year 2004 to be approximately $11 million.

VIII. Impact of 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 capital 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 capital 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 capital Federal rate (see Sec.  
412.344). As we state in section V. of the preamble of this final 
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 capital 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 March 2003 update of the FY 2002 MedPAR file and 
the March 2003 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 2001) to categorize hospitals. Our 
analysis has several qualifications. First, we do not make 
adjustments for behavioral changes that hospitals may adopt in 
response to policy changes. Second, due to the interdependent nature 
of the prospective payment system, it is very difficult to precisely 
quantify the impact associated with each change. Third, we draw upon 
various sources for the data used to categorize hospitals in the 
tables. In some cases (for instance, the number of beds), there is a 
fair degree of variation in the data from different sources. We have 
attempted to construct these variables with the best available 
sources overall. However, for individual hospitals, some 
miscategorizations are possible.
    Using cases from the March 2003 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.

[[Page 45670]]

    As we explain in section III.A.4. of the Addendum of this final 
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 capital 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 1.01 percent in both FY 2003 and FY 2004.
    [sbull] We estimate that the Medicare discharges will be 14.3 
million in FY 2003 and 14.5 million in FY 2004 for a 1.5 percent 
increase from FY 2003 to FY 2004.
    [sbull] The capital Federal rate was updated beginning in FY 
1996 by an analytical framework that considers changes in the prices 
associated with capital-related costs and adjustments to account for 
forecast error, changes in the case-mix index, allowable changes in 
intensity, and other factors. The FY 2004 update is 0.7 percent (see 
section III.A.1.a. of the Addendum to this final rule).
    [sbull] In addition to the FY 2004 update factor, the FY 2004 
capital Federal rate was calculated based on a GAF/DRG budget 
neutrality factor of 1.0059, an outlier adjustment factor of 0.9522, 
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 capital Federal rate in FY 2004.
    We used the actuarial model described above to estimate the 
potential impact of our changes for FY 2004 on total capital 
payments per case, using a universe of 3,929 hospitals. As described 
above, the individual hospital payment parameters are taken from the 
best available data, including the March 2003 update of the FY 2002 
MedPAR file, the March 2003 update to the Provider-Specific File, 
and the most recent cost report data from the March 2003 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 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 capital Federal 
rate, a 1.01 percent increase in case-mix, changes in the 
adjustments to the capital 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 decrease slightly -0.2 percent) in FY 
2004. This projected decrease in capital payments per case is mostly 
due to the estimated decrease in outlier payments in FY 2004 as a 
result of the changes to the outlier policy established in the June 
9, 2003 high-cost outlier final rule (68 FR 34494). Our comparison 
by geographic location shows that urban hospitals are expected to 
experience a slight decrease in capital payments per case (-0.6 
percent), while rural hospitals are expected to experience an 
increase in capital payments per case (2.5 percent). This difference 
is mostly due to a projection that urban hospitals will experience a 
larger decrease in outlier payments from FY 2003 to FY 2004 due to 
the changes in the outlier policy established in the June 9, 2003 
high-cost outlier final rule compared to rural hospitals.
    Most regions are estimated to receive an increase in total 
capital payments per case. Changes by region vary from a maximum 
decrease of 4.1 percent (Middle Atlantic urban region) to a maximum 
increase of 3.3 percent (West North Central rural region). Hospitals 
located in Puerto Rico are expected to experience an increase in 
total capital payments per case of 0.4 percent.
    By type of ownership, government hospitals are projected to have 
the largest rate of increase of total payment changes (2.0 percent). 
Similarly, payments to voluntary hospitals are expected to increase 
0.7 percent, while payments to proprietary hospitals are expected to 
decrease 6.9 percent. As noted above, this projected decrease in 
capital payments per case for proprietary hospitals is mostly due to 
the estimated decrease in outlier payments in FY 2004 as a result of 
the changes to the outlier policy established in the June 9, 2003 
high-cost outlier final rule.
    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 capital Federal 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 0.3 percent increase in payments. Payments to 
nonreclassified hospitals in FY 2004 are expected to decrease 0.3 
percent. Hospitals reclassified during both FY 2003 and FY 2004 are 
projected to experience a slight decrease in payments of 0.2 
percent. Hospitals reclassified during FY 2004 only are projected to 
receive an increase in payments of 5.7 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 FY 2004 Payments)
----------------------------------------------------------------------------------------------------------------
                                                                            Average FY   Average FY
                                                               Number of       2003         2004
                                                               hospitals    payments/    payments/      Change
                                                                               case         case
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
    All hospitals...........................................        3,929          715          714         -0.2
    Large urban areas (populations over 1 million)..........        1,436          820          813         -0.8
    Other urban areas (populations of 1 million of fewer)...        1,035          703          701         -0.3
    Rural areas.............................................        1,458          479          491          2.5
    Urban hospitals.........................................        2,471          770          765         -0.6
        0-99 beds...........................................          549          545          545         -0.1
        100-199 beds........................................          895          647          646         -0.1
        200-299 beds........................................          503          738          734         -0.6
        300-499 beds........................................          369          823          814         -1.0
        500 or more beds....................................          155          980          976         -0.5
    Rural hospitals.........................................        1,458          479          491          2.5
        0-49 beds...........................................          650          391          402          2.9
        50-99 beds..........................................          468          442          453          2.5

[[Page 45671]]

 
        100-149 beds........................................          203          484          496          2.5
        150-199 beds........................................           70          526          538          2.3
        200 or more beds....................................           67          599          612          2.2
By Region:
    Urban by Region.........................................        2,471          770          765         -0.6
        New England.........................................          129          816          827          1.4
        Middle Atlantic.....................................          389          865          830         -4.1
        South Atlantic......................................          359          733          734          0.1
        East North Central..................................          403          736          748          1.6
        East South Central..................................          151          691          698          1.0
        West North Central..................................          168          754          761          0.9
        West South Central..................................          307          721          710         -1.5
        Mountain............................................          121          746          768          2.9
        Pacific.............................................          400          907          886         -2.3
        Puerto Rico.........................................           44          320          321          0.4
    Rural by Region.........................................        1,458          479          491          2.5
        New England.........................................           37          597          593         -0.6
        Middle Atlantic.....................................           65          503          514          2.2
        South Atlantic......................................          220          492          504          2.4
        East North Central..................................          191          492          504          2.3
        East South Central..................................          228          437          448          2.5
        West North Central..................................          242          478          493          3.3
        West South Central..................................          268          426          439          3.1
        Mountain............................................          116          508          519          2.1
        Pacific.............................................           86          566          580          2.5
By Payment Classification:
    All hospitals...........................................        3,929          715          714         -0.2
        Large urban areas (populations over 1 million)......        1,529          809          804         -0.6
        Other urban areas (populations of 1 million of                983          705          702         -0.5
         fewer).............................................
        Rural areas.........................................        1,417          476          487          2.5
    Teaching Status:
        Non-teaching........................................        2,821          585          586          0.1
        Fewer than 100 Residents............................          872          742          742          0.1
        100 or more Residents...............................          236        1,097        1,085         -1.1
        Urban DSH:
            100 or more beds................................        1,383          809          804         -0.7
            Less than 100 beds..............................          269          530          518         -2.4
        Rural DSH:
            Sole Community (SCH/EACH).......................          491          419          431          2.7
            Referral Center (RRC/EACH)......................          156          544          557          2.4
            Other Rural:
                100 or more beds............................           71          440          448          1.9
                Less than 100 beds..........................          291          407          417          2.4
    Urban teaching and DSH:
        Both teaching and DSH...............................          769          890          885         -0.6
        Teaching and no DSH.................................          271          774          775          0.1
        No teaching and DSH.................................          883          645          638         -1.1
        No teaching and no DSH..............................          589          639          637         -0.3
    Rural Hospital Types:
        Non special status hospitals........................          453          425          435          2.3
        RRC/EACH............................................          148          556          570          2.4
        SCH/EACH............................................          492          441          453          2.6
        Medicare-dependent hospitals (MDH)..................          249          395          406          2.9
        SCH, RRC and EACH...................................           75          542          555          2.5
Hospitals Reclassified by the Medicare Geographic
 Classification Review Board:
    Reclassification Status During FY2003 and FY2004:
        Reclassified During Both FY2003 and FY2004..........          556          628          626         -0.2
        Reclassified During FY2004 Only.....................           58          618          654          5.7
        Reclassified During FY2003 Only.....................           55          580          557         -4.1
        FY2004 Reclassifications:
            All Reclassified Hospitals......................          614          627          629          0.3
            All Nonreclassified Hospitals...................        3,283          732          730         -0.3
            All Urban Reclassified Hospitals................          124          835          811         -3.0
            Urban Nonreclassified Hospitals.................        2,317          768          764         -0.4
            All Reclassified Rural Hospitals................          490          532          546          2.6
            Rural Nonreclassified Hospitals.................          966          413          423          2.3
        Other Reclassified Hospitals (Section 1886(D)(8)(B))           32          490          502          2.5
    Type of Ownership:
        Voluntary...........................................        2,399          728          733          0.7

[[Page 45672]]

 
        Proprietary.........................................          685          704          656         -6.9
        Government..........................................          811          651          665          2.0
    Medicare Utilization as a Percent of Inpatient Days:
        0-25................................................          298          917          925          0.8
        25-50...............................................        1,523          817          810         -0.9
        50-65...............................................        1,641          619          624          0.8
        Over 65.............................................          451          566          560         -1.1
----------------------------------------------------------------------------------------------------------------

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 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 Final Recommendations for Updating the Prospective 
Payment System Standardized Amounts

    In recommending an update, the Secretary takes into account the 
factors in the update framework, as well as other factors, such as 
the recommendations of MedPAC, the long-term solvency of the 
Medicare Trust Funds, and the capacity of the hospital industry to 
continually provide access to high quality care to Medicare 
beneficiaries through adequate payment to health care providers.
    Comment: One commenter noted that overall Medicare payments are 
less than the costs associated with providing care to Medicare 
beneficiaries. The commenter indicated its organization will 
continue to urge Congress to provide adequate Medicare reimbursement 
to hospitals.
    Response: As noted above, the Secretary's update recommendation 
for FY 2004 is consistent with current law. Therefore, Congress is 
the appropriate body to address the issue of adequate Medicare 
reimbursement that was raised by the commenter.

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

    We did not receive any comments concerning our proposed 
recommendation for updating the rate-of-increase for excluded 
hospitals and hospital units. Our final recommendation does not 
differ from the proposed recommendation. However, the second quarter 
forecast of the market basket percentage increase is 3.4 for 
excluded hospitals and hospital units (compared to the 3.5 percent 
estimated in the proposed rule). Thus, the policy finalized in this 
final rule is that the update for the remaining hospitals and 
hospital units excluded from the IPPS is 3.4 percent.
[FR Doc. 03-19363 Filed 7-31-03; 8:45 am]
BILLING CODE 4120-01-P