[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]
[[Page 45345]]
-----------------------------------------------------------------------
Part III
Department of Health and Human Services
-----------------------------------------------------------------------
Centers of Medicare & Medicaid Services
-----------------------------------------------------------------------
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]]
-----------------------------------------------------------------------
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.
-----------------------------------------------------------------------
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:
Availability of Copies and Electronic Access
Copies: To order copies of the Federal Register containing this
document, send your request to: New Orders, Superintendent of
Documents, PO Box 371954, Pittsburgh, PA 15250-7954. Specify the date
of the issue requested and enclose a check or money order payable to
the Superintendent of Documents, or enclose your Visa or Master Card
number and expiration date. Credit card orders can also be placed by
calling the order desk at (202) 512-1800 or by faxing to (202) 512-
2250. The cost for each copy is $10.00. As an alternative, you can view
and photocopy the Federal Register document at most libraries
designated as Federal Depository Libraries and at many other public and
academic libraries throughout the country that receive the Federal
Register.
This Federal Register document is also available from the Federal
Register online database through GPO Access, a service of the U.S.
Government Printing Office. Free public access is available on a Wide
Area Information Server (WAIS) through the Internet and via
asynchronous dial-in. Internet users can access the database by using
the World Wide Web; the Superintendent of Documents Home page address
is http://www.access.gpo.gov/nara_docs/, by using local WAIS client
software, or by telnet to swais.access.gpo.gov, then login as guest (no
password required). Dial-in users should use communications software
and modem to call (202) 512-1661; type swais, then login as guest (no
password required).
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
[[Page 45347]]
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
[[Page 45348]]
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
[[Page 45349]]
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
----------------------------------------------------------------------------------------------------------------
[[Page 45599]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.017
[[Page 45600]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.018
[[Page 45601]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.019
[[Page 45602]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.020
[[Page 45603]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.021
[[Page 45604]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.022
[[Page 45605]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.023
[[Page 45606]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.024
[[Page 45607]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.025
[[Page 45608]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.026
[[Page 45609]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.027
[[Page 45610]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.028
[[Page 45611]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.029
[[Page 45612]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.030
[[Page 45613]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.031
[[Page 45614]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.032
[[Page 45615]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.033
[[Page 45616]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.034
[[Page 45617]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.035
[[Page 45618]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.036
[[Page 45619]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.037
[[Page 45620]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.038
[[Page 45621]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.039
[[Page 45622]]
[GRAPHIC] [TIFF OMITTED] TR01AU03.040
[[Page 45623]]
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