[Federal Register Volume 70, Number 85 (Wednesday, May 4, 2005)]
[Proposed Rules]
[Pages 23306-23673]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 05-8507]



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Part II





Department of Health and Human Services





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Centers for Medicare & Medicaid Services



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42 CFR Parts 405, 412, et al.



Medicare Program; Proposed Changes to the Hospital Inpatient 
Prospective Payment Systems and Fiscal Year 2006 Rates; Proposed Rule

  Federal Register / Vol. 70, No. 85 / Wednesday, May 4, 2005 / 
Proposed Rules  

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 405, 412, 413, 415, 419, 422, and 485

[CMS-1500-P]
RIN 0938-AN57


Medicare Program; Proposed Changes to the Hospital Inpatient 
Prospective Payment Systems and Fiscal Year 2006 Rates

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

ACTION: Proposed rule.

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SUMMARY: We are proposing to revise the Medicare hospital inpatient 
prospective payment systems (IPPS) for operating and capital-related 
costs to implement changes arising from our continuing experience with 
these systems. In addition, in the Addendum to this proposed rule, we 
describe the proposed changes to the amounts and factors used to 
determine the rates for Medicare hospital inpatient services for 
operating costs and capital-related costs. We also are setting forth 
proposed rate-of-increase limits as well as proposed policy changes for 
hospitals and hospital units excluded from the IPPS that are paid in 
full or in part on a reasonable cost basis subject to these limits. 
These proposed changes would be applicable to discharges occurring on 
or after October 1, 2005, with one exception: The proposed changes 
relating to submittal of hospital wage data by a campus or campuses of 
a multicampus hospital system (that is, the proposed changes to Sec.  
412.230(d)(2) of the regulations) would be effective upon publication 
of the final rule.
    Among the policy changes that we are proposing to make are changes 
relating to: the classification of cases to the diagnosis-related 
groups (DRGs); the long-term care (LTC)-DRGs and relative weights; the 
wage data, including the occupational mix data, used to compute the 
wage index; rebasing and revision of the hospital market basket; 
applications for new technologies and medical services add-on payments; 
policies governing postacute care transfers, payments to hospitals for 
the direct and indirect costs of graduate medical education, submission 
of hospital quality data, payment adjustment for low-volume hospitals, 
changes in the requirements for provider-based facilities; and changes 
in the requirements for critical access hospitals (CAHs).

DATES: Comments will be considered if received at the appropriate 
address, as provided in the ADDRESSES section, no later than 5 p.m. on 
June 24, 2005.

ADDRESSES: In commenting, please refer to file code CMS-1500-P. Because 
of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission.
    You may submit comments in one of three ways (no duplicates, 
please):

1. Electronically

    You may submit electronic comments to http://www.cms.hhs.gov/regulations/ecomments (attachments should be in Microsoft Word, 
WordPerfect, or Excel; however, we prefer Microsoft Word).

2. By Mail

    You may mail written comments (one original and two copies) to the 
following address only: Centers for Medicare & Medicaid Services, 
Department of Health and Human Services, Attention: CMS-1500-P, P.O. 
Box 8011, Baltimore, MD 21244-1850.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.

3. By Hand or Courier

    If you prefer, you may deliver (by hand or courier) your written 
comments (one original and two copies) before the close of the comment 
period to one of the following addresses. If you intend to deliver your 
comments to the Baltimore address, please call telephone number (410) 
786-7195 in advance to schedule your arrival with one of our staff 
members.
    Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, 
SW., Washington, DC 20201, or 7500 Security Boulevard, Baltimore, MD 
21244-1850.
    (Because access to the interior of the Hubert H. Humphrey Building 
is not readily available to persons without Federal Government 
identification, commenters are encouraged to leave their comments in 
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain proof of filing by 
stamping in and retaining an extra copy of the comments being filed.)
    Comments mailed to the addresses indicated as appropriate for hand 
or courier delivery may be delayed and received after the comment 
period.
    Inspection of Public Comments: All comments received before the 
close of the comment period are available for viewing by the public, 
including any personally identifiable or confidential business 
information that is included in a comment. After the close of the 
comment period, CMS posts all electronic comments received before the 
close of the comment period on its public Web site. Written comments 
received timely will be available for public inspection as they are 
received, generally beginning approximately 4 weeks after publication 
of a document, at the headquarters of the Centers for Medicare & 
Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244, Monday 
through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an 
appointment to view public comments, phone 1-800-743-3951.
    For comments that relate to information collection requirements, 
mail a copy of comments to the following addresses:

Centers for Medicare & Medicaid Services, Office of Strategic 
Operations and Regulatory Affairs, Security and Standards Group, Office 
of Regulations Development and Issuances, Room C4-24-02 7500 Security 
Boulevard, Baltimore, Maryland 21244-1850, Attn: James Wickliffe, CMS-
1500-P; and
Office of Information and Regulatory Affairs, Office of Management and 
Budget, Room 3001, New Executive Office Building, Washington, DC 20503, 
Attn: Christopher Martin, CMS Desk Officer, CMS-1500-P, [email protected]. Fax (202) 395-6974.

FOR FURTHER INFORMATION CONTACT:

Marc Harstein, (410) 786-4539, Operating Prospective Payment, 
Diagnosis-Related Groups (DRGs), Wage Index, New Medical Services and 
Technology Add-On Payments, Hospital Geographic Reclassifications, 
Postacute Care Transfers, and Disproportionate Share Hospital Issues.
Tzvi Hefter, (410) 786-4487, Capital Prospective Payment, Excluded 
Hospitals, Graduate Medical Education, Critical Access Hospitals, and 
Long-Term Care (LTC)-DRGs, and Provider-Based Facilities Issues.
Steve Heffler, (410) 786-1211, Hospital Market Basket Revision and 
Rebasing.
Siddhartha Mazumdar, (410) 786-6673, Rural Hospital Community 
Demonstration Project Issues.
Mary Collins, (410) 786-3189, Critical Access Hospitals (CAHs) Issues.
Dr. Mark Krushat, (410) 786-6809, Quality Data for Annual Payment 
Update Issues.
Martha Kuespert, (410) 786-4605 Specialty Hospitals Definition Issues.

SUPPLEMENTARY INFORMATION: 

Electronic Access

    This Federal Register document is also available from the Federal 
Register

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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 
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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

AAOS American Association of Orthopedic Surgeons
ACGME Accreditation Council on Graduate Medical Education
AHIMA American Health Information Management Association
AHA American Hospital Association
AICD Automatic cardioverter defibrillator
AMI Acute myocardial infarction
AOA American Osteopathic Association
ASC Ambulatory Surgical Center
ASP Average sales price
AWP Average wholesale price
BBA Balanced Budget Act of 1997, Pub. L. 105-33
BES Business Expenses Survey
BIPA Medicare, Medicaid, and SCHIP [State Children's Health 
Insurance Program] Benefits Improvement and Protection Act of 2000, 
Pub. L. 106-554
BLS Bureau of Labor Statistics
CAH Critical access hospital
CBSAs Core-Based Statistical Areas
CC Complication or comorbidity
CIPI Capital Input Price Index
CMS Centers for Medicare & Medicaid Services
CMSA Consolidated Metropolitan Statistical Area
COBRA Consolidated Omnibus Reconciliation Act of 1985, Pub. L. 99-
272
CoP Condition of Participation
CPI Consumer Price Index
CRNA Certified registered nurse anesthetist
CRT Cardiac Resynchronization Therapy
DRG Diagnosis-related group
DSH Disproportionate share hospital
ECI Employment Cost Index
FDA Food and Drug Administration
FIPS Federal Information Processing Standards
FQHC Federally qualified health center
FTE Full-time equivalent
FY Federal fiscal year
GAAP Generally accepted accounting principles
GAF Geographic adjustment factor
HIC Health Insurance Card
HIS Health Information System
GME Graduate medical education
HCRIS Hospital Cost Report Information System
HIPC Health Information Policy Council
HIPAA Health Insurance Portability and Accountability Act of 1996, 
Pub. L. 104-191
HHA Home health agency
HHS Department of Health and Human Services
HPSA Health Professions Shortage Area
HQA Hospital Quality Alliance
ICD-9-CM International Classification of Diseases, Ninth Revision, 
Clinical Modification
ICD-10-PCS International Classification of Diseases, Tenth Edition, 
Procedure Coding System
ICF/MRs Intermediate care facilities for the mentally retarded
ICU Intensive Care Unit
IHS Indian Health Service
IME Indirect medical education
IPPS Acute care hospital inpatient prospective payment system
IPF Inpatient psychiatric facility
IRF Inpatient rehabilitation facility
IRP Initial residency period
JCAHO Joint Commission on Accreditation of Healthcare Organizations
LAMCs Large area metropolitan counties
LTC-DRG Long-term care diagnosis-related group
LTCH Long-term care hospital
MCE Medicare Code Editor
MCO Managed care organization
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
MMA Medicare Prescription Drug, Improvement, and Modernization Act 
of 2003, Pub. L. 108-173
MRHFP Medicare Rural Hospital Flexibility Program
MSA Metropolitan Statistical Area
NAICS North American Industrial Classification System
NCD National coverage determination
NCHS National Center for Health Statistics
NCVHS National Committee on Vital and Health Statistics
NECMA New England County Metropolitan Areas
NICU Neonatal intensive care unit
NQF National Quality Forum
NTIS National Technical Information Service
NVHRI National Voluntary Hospital Reporting Initiative
OES Occupational Employment Statistics
OIG Office of the Inspector General
OMB Executive Office of Management and Budget
O.R. Operating room
OSCAR Online Survey Certification and Reporting (System)
OSHA Occupational Safety and Health Act
PRM Provider Reimbursement Manual
PPI Producer Price Index
PMS Performance Measurement System
PMSAs Primary Metropolitan Statistical Areas
PPS Prospective payment system
PRA Per resident amount
ProPAC Prospective Payment Assessment Commission
PRRB Provider Reimbursement Review Board
PS&R Provider Statistical and Reimbursement System
QIA Quality Improvement Organizations
RHC Rural health clinic
RHQDAPU Reporting Hospital Quality Data for Annual Payment Update
RNHCI Religious nonmedical health care institution
RRC Rural referral center
RUCAs Rural-Urban Commuting Area Codes
SCH Sole community hospital
SDP Single Drug Pricer
SIC Standard Industrial Codes
SNF Skilled nursing facility
SOCs Standard occupational classifications
SOM State Operations Manual
SSA Social Security Administration
SSI Supplemental Security Income
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
    1. Acute Care Hospital Inpatient Prospective Payment System 
(IPPS)
    2. Hospitals and Hospital Units Excluded from the IPPS
    a. IRFs
    b. LTCH
    c. IPFs
    3. Critical Access Hospitals (CAHs)
    4. Payments for Graduate Medical Education (GME)
    B. Major Contents of this Proposed Rule
    1. Proposed Changes to the DRG Reclassifications and 
Recalibrations of Relative Weights
    2. Proposed Changes to the Hospital Wage Index
    3. Proposed Revision and Rebasing of the Hospital Market Basket
    4. Other Decisions and Proposed Changes to the PPS for Inpatient 
Operating and GME Costs
    5. PPS for Capital-Related Costs
    6. Proposed Changes for Hospitals and Hospital Units Excluded 
from the IPPS
    7. Proposed Payment for Blood Clotting Factors for Inpatients 
with Hemophilia
    8. Determining Proposed Prospective Payment Operating and 
Capital Rates and Rate-of-Increase Limits
    9. Impact Analysis
    10. Recommendation of Update Factor for Hospital Inpatient 
Operating Costs
    11. Discussion of Medicare Payment Advisory Commission 
Recommendations
II. Proposed Changes to DRG Classifications and Relative Weights
    A. Background
    B. DRG Reclassifications
    1. General
    2. Pre-MDC: Intestinal Transplantation
    3. MDC 1 (Diseases and Disorders of the Nervous System)
    a. Strokes
    b. Unruptured Cerebral Aneurysms
    4. MDC 5 (Diseases and Disorders of the Circulatory System)
    a. Automatic Implantable Cardioverter/Defibrillator

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    b. Coronary Artery Stents
    c. Insertion of Left Atrial Appendage Device
    d. External Heart Assist System Implant
    e. Carotid Artery Stent
    f. Extracorporeal Membrane Oxygenation (ECMO)
    5. MDC 6 (Diseases and Disorders of the Digestive System): 
Artificial Anal Sphincter
    6. MDC 8 (Diseases and Disorders of the Musculoskeletal System 
and Connective Tissue)
    a. Hip and Knee Replacements
    b. Kyphoplasty
    c. Multiple Level Spinal Fusion
    7. MDC 18 (Infectious and Parasitic Diseases (Systemic or 
Unspecified Sites)): Severe Sepsis
    8. MDC 20 (Alcohol/Drug Use and Alcohol/Drug Induced Organic 
Mental Disorders): Drug-Induced Dementia
    9. Medicare Code Editor (MCE) Changes
    a. Newborn Age Edit
    b. Newborn Diagnoses Edit
    c. Diagnoses Allowed for ``Males Only'' Edit
    d. Tobacco Use Disorder Edit
    e. Noncovered Procedure Edit
    10. Surgical Hierarchies
    11. Refinement of Complications and Comorbidities (CC) List
    a. Background
    b. Comprehensive Review of the CC List
    c. CC Exclusion List for FY 2006
    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 or Procedure Codes to MDCs
    13. Changes to the ICD-9-CM Coding System
    14. Other Issues: Acute Intermittent Porphyria
    C. Proposed Recalibration of DRG Weights
    D. Proposed LTC-DRG Reclassifications and Relative Weights for 
LTCHs for FY 2006
    1. Background
    2. Proposed Changes in the LTC-DRG Classifications
    a. Background
    b. Patient Classifications into DRGs
    3. Development of the Proposed FY 2006 LTC-DRG Relative Weights
    a. General Overview of Development of the LTC-DRG Relative 
Weights
    b. Data
    c. Hospital-Specific Relative Value Methodology
    d. Proposed Low-Volume LTC-DRGs
    4. Steps for Determining the Proposed FY 2006 LTC-DRG Relative 
Weights
    E. Proposed Add-On Payments for New Services and Technologies
    1. Background
    2. FY 2006 Status of Technology Approved for FY 2005 Add-On 
Payments
    3. Reevaluation of FY 2005 Applications That Were Not Approved
    4. FY 2006 Applicants for New Technology Add-On Payments
III. Proposed Changes to the Hospital Wage Index
    A. Background
    B. Core-Based Statistical Areas for the Proposed Hospital Wage 
Index
    C. Proposed Occupational Mix Adjustment to FY 2006 Index
    1. Development of Data for the Proposed Occupational Mix 
Adjustment
    2. Calculation of the Proposed Occupational Mix Adjustment 
Factor and the Proposed Occupational Mix Adjusted Wage Index
    D. Worksheet S-3 Wage Data for the Proposed FY 2006 Wage Index 
Update
    E. Verification of Worksheet S-3 Wage Data
    F. Computation of the Proposed FY 2006 Unadjusted Wage Index
    G. Computation of the Proposed FY 2006 Blended Wage Index
    H. Proposed Revisions to the Wage Index Based on Hospital 
Redesignation
    1. General
    2. Effects of Reclassification
    3. Proposed Application of Hold Harmless Protection for Certain 
Urban Hospitals Redesignated as Rural
    4. FY 2006 MGCRB Reclassifications
    5. Proposed FY 2006 Redesignations under Section 1886(d)(8)(B) 
of the Act
    6. Reclassifications under Section 508 of Pub. L. 108-173
    I. Proposed FY 2006 Wage Index Adjustment Based on Commuting 
Patterns of Hospital Employees
    J. Process for Requests for Wage Index Data Corrections
IV. Proposed Rebasing and Revision of the Hospital Market Baskets
    A. Background
    B. Rebasing and Revising the Hospital Market Basket
    1. Development of Cost Categories and Weights
    2. PPS--Selection of Price Proxies
    3. Labor-Related Share
    C. Separate Market Basket for Hospitals and Hospital Units 
Excluded from the IPPS
    1. Hospitals Paid Based on Their Reasonable Costs
    2. Excluded Hospitals Paid Under Blend Methodology
    3. Development of Cost Categories and Weights for the Proposed 
2002-Based Excluded Hospital Market Basket
    D. Frequency of Updates of Weights in IPPS Hospital Market 
Basket
    E. Capital Input Price Index Section
V. Other Decisions and Proposed Changes to the IPPS for Operating 
Costs and GME Costs
    A. Postacute Care Transfer Payment Policy
    1. Background
    2. Changes to DRGs Subject to the Postacute Care Transfer Policy
    B. Reporting of Hospital Quality Data for Annual Hospital 
Payment Update
    1. Background
    2. Requirements for Hospital Reporting of Quality Data
    C. Sole Community Hospitals and Medicare Dependent Hospitals
    1. Background
    2. Budget Neutrality Adjustment to Hospital Payments Based on 
Hospital-Specific Rate
    3. Technical Change
    D. Rural Referral Centers
    1. Case-Mix Index
    2. Discharges
    3. Technical Change
    E. Payment Adjustment for Low-Volume Hospitals
    F. Indirect Medical Education (IME) Adjustment
    1. Background
    2. IME Adjustment for TEFRA Hospitals Converting to IPPS 
Hospitals
    3. Section 1886(d)(3)(E) Teaching Hospitals That Withdraw Rural 
Reclassification
    G. Payment to Disproportionate Share Hospitals (DSHs)
    1. Background
    2. Implementation of Section 951 of Pub. L. 108-173
    H. Geographic Reclassifications
    1. Background
    2. Multicampus Hospitals
    3. Urban Group Hospital Reclassifications
    4. Clarification of Goldsmith Modification Criterion for Urban 
Hospitals Seeking Reclassification as Rural
    I. Payment for Direct Graduate Medical Education
    1. Background
    2. Direct GME Initial Residency Period
    a. Background
    b. Direct GME Initial Residency Period Limitation: Simultaneous 
Match
    3. New Teaching Hospitals' Participation in Medicare GME 
Affiliated Groups
    4. GME FTE Cap Adjustments for Rural Hospitals
    5. Technical Changes: Cross-References
    J. Provider-Based Status of Facilities under Medicare
    1. Background
    2. Limits on Scope of Provider-Based Regulations--Facilities for 
Which Provider-Based Determinations Will Not Be Made
    3. Location Requirement for Off-Campus Facilities: Application 
to Certain Neonatal Intensive Care Units
    4. Technical and Clarifying Changes
    K. Rural Community Hospital Demonstration Program
    L. Definition of a Hospital in Connection with Specialty 
Hospitals
VI. PPS for Capital-Related Costs
VII. Proposed Changes for Hospitals and Hospital Units Excluded from 
the IPPS
    A. Payments to Excluded Hospitals and Hospital Units
    1. Payments to Existing Excluded Hospitals and Hospital Units
    2. Updated Caps for New Excluded Hospitals and Units
    3. Implementation of a PPS for IRFs
    4. Implementation of a PPS for LTCHs
    5. Implementation of a PPS for IPFs
    B. Critical Access Hospitals (CAHs)
    1. Background
    2. Proposed Policy Change Relating to Continued Participation by 
CAHs in Lugar Counties
    3. Proposed Policy Change Relating to Designation of CAHs as 
Necessary Providers
    a. Determination of the Relocation Status of a CAH
    b. Relocation of a CAH Using a Waiver to Meet the CoP for 
Distance

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VIII. Payment for Blood Clotting Factor Administered to Hemophilia 
Inpatients
IX. MedPAC Recommendations
    A. Medicare Payment Policy
    B. Physician-Owned Specialty Hospitals
    C. Other MedPAC Recommendations
X. Other Required Information
    A. Requests for Data from the Public
    B. Collection of Information Requirements
    C. Public Comments

Regulation Text

Addendum--Proposed Schedule of Standardized Amounts Effective with 
Discharges Occurring On or After October 1, 2004 and Update Factors 
and Rate-of-Increase Percentages Effective With Cost Reporting 
Periods Beginning On or After October 1, 2004
I. Summary and Background
II. Proposed Changes to Prospective Payment Rates for Hospital 
Inpatient Operating Costs for FY 2006
    A. Calculation of the Adjusted Standardized Amount
    1. Standardization of Base-Year Costs or Target Amounts
    2. Computing the Average Standardized Amount
    3. Updating the Average Standardized Amount
    4. Other Adjustments to the Average Standardized Amount
    a. Recalibration of DRG Weights and Updated Wage Index--Budget 
Neutrality Adjustment
    b. Reclassified Hospitals--Budget Neutrality Adjustment
    c. Outliers
    d. Rural Community Hospital Demonstration Program Adjustment 
(Section 410A of Pub. L. 108-173)
    5. Proposed FY 2006 Standardized Amount
    B. Adjustments for Area Wage Levels and Cost-of-Living
    1. Adjustment for Area Wage Levels
    2. Adjustment for Cost-of-Living in Alaska and Hawaii
    C. DRG Relative Weights
    D. Calculation of Proposed Prospective Payment Rates for FY 2006
    1. Federal Rate
    2. Hospital-Specific Rate (Applicable Only to SCHs and MDHs)
    a. Calculation of Hospital-Specific Rate
    b. Updating the FY 1982, FY 1987, and FY 1996 Hospital-Specific 
Rates for FY 2006
    3. General Formula for Calculation of Proposed Prospective 
Payment Rates for Hospitals Located in Puerto Rico Beginning On or 
After October 1, 2005 and Before October 1, 2006
    a. Puerto Rico Rate
    b. National Rate
III. Proposed Changes to Payment Rates for Acute Care Hospital 
Inpatient Capital-Related Costs for FY 2006
    A. Determination of Proposed Federal Hospital Inpatient Capital-
Related Prospective Payment Rate Update
    1. Proposed Capital Standard Federal Rate Update
    a. Description of the Update Framework
    b. Comparison of CMS and MedPAC Update Recommendation
    2. Proposed Outlier Payment Adjustment Factor
    3. Proposed Budget Neutrality Adjustment Factor for Changes in 
DRG Classifications and Weights and the Geographic Adjustment Factor
    4. Proposed Exceptions Payment Adjustment Factor
    5. Proposed Capital Standard Federal Rate for FY 2006
    6. Proposed Special Capital Rate for Puerto Rico Hospitals
    B. Calculation of Proposed Inpatient Capital-Related Prospective 
Payments for FY 2006
    C. Capital Input Price Index
    1. Background
    2. Forecast of the CIPI for FY 2006
IV. Proposed Changes to Payment Rates for Excluded Hospitals and 
Hospital Units: Rate-of-Increase Percentages
    A. Payments to Existing Excluded Hospitals and Units
    B. Updated Caps for New Excluded Hospitals and Units
V. Payment for Blood Clotting Factor Administered to Hemophilia 
Inpatients

Tables

Table 1A--National Adjusted Operating Standardized Amounts, Labor/
Nonlabor (69.7 Percent Labor Share/30.3 Percent Nonlabor Share If 
Wage Index Is Greater Than 1)
Table 1B--National Adjusted Operating Standardized Amounts, Labor/
Nonlabor (62 Percent Labor Share/38 Percent Nonlabor Share If Wage 
Index Is Less Than or Equal to 1)
Table 1C--Adjusted Operating Standardized Amounts for Puerto Rico, 
Labor/Nonlabor
Table 1D--Capital Standard Federal Payment Rate
Table 2--Hospital Case-Mix Indexes for Discharges Occurring in 
Federal Fiscal Year 2004; Hospital Average Hourly Wage for Federal 
Fiscal Years 2004 (2000 Wage Data), 2005 (2001 Wage Data), and 2006 
(2002 Wage Data) Wage Indexes and 3-Year Average of Hospital Average 
Hourly Wages
Table 3A--FY 2006 and 3-Year Average Hourly Wage for Urban Areas
Table 3B--FY 2006 and 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 4J--Out-Migration Adjustment--FY 2006
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 2004 MedPAR Update December 2004 GROUPER V22.0
Table 7B--Medicare Prospective Payment System Selected Percentile 
Lengths of Stay: FY 2004 MedPAR Update December 2004 GROUPER V23.0
Table 8A--Statewide Average Operating Cost-to-Charge Ratios--March 
2005
Table 8B--Statewide Average Capital Cost-to-Charge Ratios--March 
2005
Table 9A--Hospital Reclassifications and Redesignations by 
Individual Hospital--FY 2006
Table 9B--Hospital Reclassifications and Redesignation by Individual 
Hospital Under Section 508 of Pub. L. 108-173--FY 2005
Table 9C--Hospitals Redesignated as Rural under Section 
1886(d)(8)(E) of the Act--FY 2006
Table 10--Geometric Mean Plus the Lesser of .75 of the National 
Adjusted Operating Standardized Payment Amount (Increased to Reflect 
the Difference Between Costs and Charges) or .75 of One Standard 
Deviation of Mean Charges by Diagnosis-Related Groups (DRGs)--March 
2005
Table 11--Proposed FY 2006 LTC-DRGs, Relative Weights, Geometric 
Average Length of Stay, and 5/6ths of the Geometric Average Length 
of Stay
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

[[Page 23310]]

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 or medical services that have been approved for special 
add-on payments. To qualify, a new technology or medical service must 
demonstrate that it is a substantial clinical improvement over 
technologies or services 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 or medical service 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. (An MDH receives only 50 
percent of the difference between the IPPS rate and its hospital-
specific rates if the hospital-specific rate is higher than the IPPS 
rate. In addition, an MDH does not have the option of using FY 1996 as 
the base year for its hospital-specific 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 facilities 
(IRFs)), psychiatric hospitals and units (referred to as inpatient 
psychiatric facilities (IPFs)), 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. IRFs
    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 the adjusted facility 
Federal prospective payment rate for cost reporting periods beginning 
January 1, 2002 through September 30, 2002, to payment at 100 percent 
of the Federal rate effective for cost reporting periods beginning on 
or after October 1, 2002 (66 FR 41316, August 7, 2001; 67 FR 49982, 
August 1, 2002; and 68 FR 45674, August 1, 2003). The existing 
regulations governing payments under the IRF PPS are located in 42 CFR 
Part 412, Subpart P.
b. LTCHs
    Under the authority of sections 123(a) and (c) of Pub. L. 106-113 
and section 307(b)(1) of Pub. L. 106-554, LTCHs are being transitioned 
from being paid for inpatient hospital services based on a blend of 
reasonable cost-based reimbursement under section 1886(b) of the Act to 
100 percent of the Federal rate 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 100 percent of the Federal rate (May 7, 2004 LTCH PPS final rule 
(69 FR 25674)). LTCHs may elect to be paid based on 100 percent of the 
Federal rate 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. IPFs
    Under the authority of sections 124(a) and (c) of Pub. L. 106-113, 
inpatient psychiatric facilities (IPFs) (formerly psychiatric hospitals 
and psychiatric units of acute care hospitals) are paid under the new 
IPF PPS. Under the IPF PPS, some IPFs are transitioning from being paid 
for inpatient hospital services based on a blend of reasonable cost-
based payment and a Federal per diem payment rate, effective for cost 
reporting periods beginning on or after January 1, 2005 (November 15, 
2004 IPF PPS final rule (69 FR 66921)). For cost reporting periods 
beginning on or after July 1, 2008, IPFs will be paid 100 percent of 
the Federal per diem payment amount. The existing regulations governing 
payment under the IPF PPS are located in 42 CFR part 412, subpart N.
3. Critical Access Hospitals (CAHs)
    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 based

[[Page 23311]]

on 101 percent of reasonable cost. 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 (GME)
    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.
    On August 11, 2004, we published a final rule in the Federal 
Register (69 FR 48916) that implemented changes to the Medicare 
hospital inpatient prospective payment systems for both operating cost 
and capital-related costs, as well as changes addressing payments for 
excluded hospitals and payments for GME costs. Generally these changes 
were effective for discharges occurring on or after October 1, 2004. On 
October 7, 2004, we published a document in the Federal Register (69 FR 
60242) that corrected technical errors made in the August 11, 2004 
final rule. On December 30, 2004, we published another document in the 
Federal Register (69 FR 78525) that further corrected the August 11, 
2004 final rule and the October 7, 2004 correction to that rule, 
effective January 1, 2005.

B. Major Contents of This Proposed Rule

    In this proposed rule, we are setting forth proposed changes to the 
Medicare IPPS for operating costs and for capital-related costs in FY 
2006. We also are setting forth proposed changes relating to payments 
for GME costs, payments to certain hospitals and units that continue to 
be excluded from the IPPS and paid on a reasonable cost basis, payments 
for DSHs, and requirements and payments for CAHs. The changes being 
proposed would be effective for discharges occurring on or after 
October 1, 2005, unless otherwise noted.
    The following is a summary of the major changes that we are 
proposing to make:
1. Proposed Changes to the DRG Reclassifications and Recalibrations of 
Relative Weights
    As required by section 1886(d)(4)(C) of the Act, in section II. of 
this proposed rule, we are proposing annual adjustments to the DRG 
classifications and relative weights. Based on analyses of Medicare 
claims data, we are proposing to establish a number of new DRGs and 
make changes to the designation of diagnosis and procedure codes under 
other existing DRGs.
    The major DRG classification changes we are proposing include:
     Reassigning procedure code 35.52 (Repair of atrial septal 
defect with prosthesis, closed technique) from DRG 108 to DRG 518 
(Percutaneous Cardiovascular Procedure Without Coronary Artery Stent or 
AMI);
     Reassigning procedure code 37.26 (Cardiac 
electrophysiologic stimulation and recording studies) from DRGs 535 and 
536 to DRGs 515 (Cardiac Defibrillator Implant Without Cardiac 
Catheterization);
     Splitting DRG 209 into two new DRGs based on the presence 
or absence of the procedure codes for major joint replacement or 
reattachment of lower extremity and revision of hip or knee 
replacement, DRG 545 (Revision of Hip or Knee Replacement) and DRG 544 
(Major Joint Replacement or Reattachment of Lower Extremity);
     Reassigning procedure code 26.12 (Open biopsy of salivary 
gland or duct) from DRG 468 to DRG 477 (Nonextensive O.R. Procedure 
Unrelated To Principal Diagnosis);
     Reassigning the principal diagnosis codes for curvature of 
the spine or malignancy from DRGs 497 and 498 to proposed new DRG 546 
(Spinal Fusion Except Cervical with PDX of Curvature of the Spine or 
Malignancy);
     Splitting DRGs 516 and 526 into four new DRGs based on the 
presence or absence of a CC;
     Reassigning procedure code 39.65 (Extracorporeal membrane 
oxygenation [ECMO]) from DRGs 104 and 105 to DRG 541 (ECMO or 
Tracheostomy with Mechanical Ventilation 96+ Hours or Principal 
Diagnosis Except Face, Mouth and Neck Diagnoses With Major Operating 
Room Procedure).
    We also are presenting our reevaluation of certain FY 2005 
applicants for add-on payments for high-cost new medical services and 
technologies, and our analysis of FY 2006 applicants (including public 
input, as directed by Pub. L. 108-173, obtained in a town hall 
meeting).
    We are proposing the annual update of the long-term care diagnosis-
related group (LTC-DRG) classifications and relative weights for use 
under the LTCH PPS for FY 2006.
2. Proposed Changes to the Hospital Wage Index
    In section III. of this preamble, we are proposing revisions to the 
wage index and the annual update of the wage data. Specific issues 
addressed include the following:
     The FY 2006 wage index update, using wage data from cost 
reporting periods that began during FY 2002.
     The proposed occupational mix adjustment to the wage index 
that we began to apply effective October 1, 2004.
     The proposed revisions to the wage index based on hospital 
redesignations and reclassifications.
     The proposed adjustment to the wage index for FY 2006 
based on commuting patterns of hospital employees who reside in a 
county and work in a different area with a higher wage index.
     The timetable for reviewing and verifying the wage data 
that will be in effect for the proposed FY 2006 wage index.
3. Proposed Revision and Rebasing of the Hospital Market Baskets
    In section IV. of this proposed rule, we are proposing rebasing and 
revising the hospital operating and capital market baskets to be used 
in developing the FY 2006 update factor for the operating prospective 
payment rates and the excluded hospital market basket to be used in 
developing the FY 2006 update factor for the excluded hospital rate-of-
increase limits. We are also setting forth the data sources used to 
determine the revised market basket relative weights and choice of 
price proxies.
4. Other Decisions and Proposed Changes to the PPS for Inpatient 
Operating and GME Costs
    In section V. of this proposed rule, we discuss a number of 
provisions of the regulations in 42 CFR Parts 412 and 413 and set forth 
proposed changes concerning the following:
     Solicitation of public comments on two options for 
possible expansion of the current postacute care transfer policy.
     The reporting of hospital quality data as a condition for 
receiving the full annual payment update increase.
     Proposed changes in the payment adjustment for low-volume 
hospitals.
     Proposed IME adjustment for TEFRA hospitals that are 
converting to IPPS hospitals, and IME FTE resident caps for urban 
hospitals that are granted

[[Page 23312]]

rural reclassification and then withdraw that rural classification.
     Proposed changes to implement section 951 of Pub. L. 108-
173 relating to the provision of patient stay/SSI days data maintained 
by CMS to hospitals for the purpose of determining their DSH 
percentage.
     Proposed changes relating to hospitals' geographic 
classifications, including multicampus hospitals and urban group 
hospital reclassifications.
     Proposed changes and clarifications relating to GME, 
including GME initial residency period limitation, new teaching 
hospitals' participation in Medicare GME affiliated groups, and the GME 
FTE cap adjustment for rural hospitals;
     Solicitation of public comments on possible changes in 
requirements for provider-based entities relating to entities the 
location requirements for certain neonatal intensive care units as off-
campus facilities;
     Discussion of the second year of implementation of the 
Rural Community Hospital Demonstration Program; and
     Clarification of the definition of a hospital as it 
relates to ``specialty hospitals'' participating in the Medicare 
program.
5. PPS for Capital-Related Costs
    In section VI. of this proposed rule, we are not proposing any 
policy changes to the capital-related prospective payment system. For 
the readers' benefit, we discuss the payment policy requirements for 
capital-related costs and capital payments to hospitals.
6. Proposed Changes for Hospitals and Hospital Units Excluded From the 
IPPS
    In section VII. of this proposed rule, we discuss the proposed 
revisions and clarifications concerning excluded hospitals and hospital 
units, proposed policy changes relating to continued participation by 
CAHs located in counties redesignated under section 1886(d)(8)(B) of 
the Act (Lugar counties), and proposed policy changes relating to 
designation of CAHs as necessary providers.
7. Proposed Changes in Payment for Blood Clotting Factor
    In section VIII of this proposed rule, we discuss the proposed 
change in payment for blood clotting factor administered to inpatients 
with hemophilia for FY 2006.
8. Determining Prospective Payment Operating and Capital Rates and 
Rate-of-Increase Limits
    In the Addendum to this proposed rule, we set forth proposed 
changes to the amounts and factors for determining the FY 2006 
prospective payment rates for operating costs and capital-related 
costs. We also establish the proposed threshold amounts for outlier 
cases. In addition, we address the proposed update factors for 
determining the rate-of-increase limits for cost reporting periods 
beginning in FY 2006 for hospitals and hospital units excluded from the 
PPS.
9. Impact Analysis
    In Appendix A of this proposed rule, we set forth an analysis of 
the impact that the proposed changes would have on affected hospitals.
10. Recommendation of Update Factor for Hospital Inpatient Operating 
Costs
    In Appendix B of this 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 2006 for the following:
     A single average standardized amount for all areas for 
hospital inpatient services paid under the IPPS for operating costs 
(and hospital-specific rates applicable to SCHs and MDHs).
     Target rate-of-increase limits to the allowable operating 
costs of hospital inpatient services furnished by hospitals and 
hospital units excluded from the IPPS.
11. Discussion of Medicare Payment Advisory Commission Recommendations
    Under section 1805(b) of the Act, the Medicare Payment Advisory 
Commission (MedPAC) is required to submit a report to Congress, no 
later than March 1 of each year, in which MedPAC reviews and makes 
recommendations on Medicare payment policies. MedPAC's March 2005 
recommendation concerning hospital inpatient payment policies addressed 
only the update factor for inpatient hospital operating costs and 
capital-related costs under the IPPS and for hospitals and distinct 
part hospital units excluded from the IPPS. This recommendation is 
addressed in Appendix B of this proposed rule. MedPAC issued a second 
Report to Congress: Physician-Owned Specialty Hospitals, March 2005, 
which addressed other issues relating to Medicare payments to hospitals 
for inpatient services. The recommendations on these issues from this 
second report are addressed in section IX. of this preamble. For 
further information relating specifically to the MedPAC March 2005 
reports or to obtain a copy of the reports, contact MedPAC at (202) 
220-3700 or visit MedPAC's Web site at: http://www.medpac.gov.

II. Proposed Changes to DRG Classifications and Relative Weights

A. Background

    Section 1886(d) of the Act specifies that the Secretary shall 
establish a classification system (referred to as DRGs) for inpatient 
discharges and adjust payments under the IPPS based on appropriate 
weighting factors assigned to each DRG. Therefore, under the IPPS, we 
pay for inpatient hospital services on a rate per discharge basis that 
varies according to the DRG to which a beneficiary's stay is assigned. 
The formula used to calculate payment for a specific case multiplies an 
individual hospital's payment rate per case by the weight of the DRG to 
which the case is assigned. Each DRG weight represents the average 
resources required to care for cases in that particular DRG, relative 
to the average resources used to treat cases in all DRGs.
    Congress recognized that it would be necessary to recalculate the 
DRG relative weights periodically to account for changes in resource 
consumption. Accordingly, section 1886(d)(4)(C) of the Act requires 
that the Secretary adjust the DRG classifications and relative weights 
at least annually. These adjustments are made to reflect changes in 
treatment patterns, technology, and any other factors that may change 
the relative use of hospital resources. The proposed changes to the DRG 
classification system and the recalibration of the DRG weights for 
discharges occurring on or after October 1, 2005, are discussed below.

B. DRG Reclassifications

    (If you choose to comment on issues in this section, please include 
the caption ``DRG Reclassifications'' at the beginning of your 
comment.)
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

[[Page 23313]]

Classification of Diseases, Ninth Revision, Clinical Modification (ICD-
9-CM).
    The process of forming the DRGs was begun by dividing all possible 
principal diagnoses into mutually exclusive principal diagnosis areas 
referred to as Major Diagnostic Categories (MDCs). The MDCs were formed 
by physician panels as the first step toward ensuring that the DRGs 
would be clinically coherent. The diagnoses in each MDC correspond to a 
single organ system or etiology and, in general, are associated with a 
particular medical specialty. Thus, in order to maintain the 
requirement of clinical coherence, no final DRG could contain patients 
in different 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)). For FY 2005, cases are 
assigned to one of 519 DRGs in 25 MDCs. The table below lists the 25 
MDCs.
[GRAPHIC] [TIFF OMITTED] TP04MY05.000

    In general, cases are assigned to an MDC based on the patient's 
principal diagnosis before assignment to a DRG. However, for FY 2005, 
there are nine DRGs to which cases are directly assigned on the basis 
of ICD-9-CM procedure codes. These DRGs are for heart transplant or 
implant of heart assist systems, liver and/or intestinal transplants, 
bone marrow, lung, simultaneous pancreas/kidney, and pancreas 
transplants and for tracheostomies. Cases are assigned to these DRGs 
before they are classified to an MDC. The table below lists the current 
nine pre-MDCs.

[[Page 23314]]

[GRAPHIC] [TIFF OMITTED] TP04MY05.001

    Once the MDCs were defined, each MDC was evaluated to identify 
those additional patient characteristics that would have a consistent 
effect on the consumption of hospital resources. Since the presence of 
a surgical procedure that required the use of the operating room would 
have a significant effect on the type of hospital resources used by a 
patient, most MDCs were initially 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 urinary stones.
    Once the medical and surgical classes for an MDC were formed, each 
class of patients was evaluated to determine if complications, 
comorbidities, or the patient's age would consistently affect the 
consumption of hospital resources. Physician panels classified each 
diagnosis code based on whether the diagnosis, when present as a 
secondary condition, would be considered a substantial complication or 
comorbidity.
    A substantial complication or comorbidity was defined as a 
condition, which because of its presence with a specific principal 
diagnosis, would cause an increase in the length of stay by at least 
one day in at least 75 percent of the patients. Each medical and 
surgical class within an MDC was tested to determine if the presence of 
any substantial comorbidities or complications would consistently 
affect the consumption of hospital resources.
    The actual process of forming the DRGs was, and continues to be, 
highly iterative, involving a combination of statistical results from 
test data combined with clinical judgment. In deciding whether to 
create a separate DRG, we consider whether the resource consumption and 
clinical characteristics of the patients with a given set of conditions 
are significantly different than the remaining patients in the DRG. We 
evaluate patient care costs using average charges and length of stay as 
proxies for costs and rely on the judgment of our medical officers to 
decide whether patients are distinct or clinically similar to other 
patients in the DRG. In evaluating resource costs, we consider both the 
absolute and percentage differences in average charges between the 
cases we are selecting for review and the remainder of cases in the 
DRG. We also consider variation in charges within these groups; that 
is, whether observed average differences are consistent across patients 
or attributable to cases that are extreme in terms of charges or length 
of stay, or both. Further, we also consider the number of patients who 
will have a given set of characteristics and generally prefer not to 
create a new DRG unless it will include a substantial number of cases. 
As we explain in more detail in section IX. of this preamble, MedPAC 
has made a number of recommendations regarding the DRG system. As part 
of our review and analysis of MedPAC's recommendations, we will 
consider whether to establish guidelines for making DRG 
reclassification decisions.
    A 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, the cases are classified 
into the appropriate DRG by the Medicare GROUPER software program. The 
GROUPER program was developed as a means of classifying each case into 
a DRG on the basis of the diagnosis and procedure codes and, for a 
limited number of DRGs, demographic information (that is, sex, age, and 
discharge status).
    After cases are screened through the MCE and assigned to a DRG by 
the GROUPER, the PRICER software calculates a base DRG payment. 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

[[Page 23315]]

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 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 if included, may be subjected to public review and comment. 
Therefore, similar to the timetable for interested parties to submit 
non-MedPAR data for consideration in the DRG recalibration process, 
concerns about DRG classification issues should be brought to our 
attention no later than early December in order to be considered and 
possibly included in the next annual proposed rule updating the IPPS.
    The changes we are proposing to the DRG classification system for 
FY 2006 for the FY 2006 GROUPER, version 23.0 and to the methodology 
used to recalibrate the DRG weights are set forth below. Unless 
otherwise noted in this proposed rule, our DRG analysis is based on 
data from the December 2004 update of the FY 2004 MedPAR file, which 
contains hospital bills received through December 31, 2004 for 
discharges in FY 2004.
2. Pre-MDC: Intestinal Transplantation
    In the FY 2005 IPPS final rule (69 FR 48976), we moved intestinal 
transplantation cases that were assigned to ICD-9-CM procedure code 
46.97 (Transplant of intestine) out of DRG 148 (Major Small and Large 
Bowel Procedures with CC) and DRG 149 (Major Small and Large Bowel 
Procedures Without CC) and into DRG 480 (Liver Transplant). We also 
changed the title for DRG 480 to ``Liver Transplant and/or Intestinal 
Transplant.'' We moved these cases out of DRGs 148 and 149 because our 
analysis demonstrated that the average charges for intestinal 
transplants are significantly higher than the average charges for other 
cases in these DRGs. We stated at that time that we would continue to 
monitor these cases.
    Based on our review of the FY 2004 MedPAR data, we found 959 cases 
assigned to DRG 480 with overall average charges of approximately 
$165,622. There were only three cases involving an intestinal 
transplant alone and one case in which both an intestinal transplant 
and a liver transplant were performed. The average charges for the 
intestinal transplant cases ($138,922) were comparable to the average 
charges for the liver transplant cases ($165,314), while the remaining 
combination of an intestinal transplant and a liver transplant case had 
much higher charges ($539,841), and would be paid as an outlier case. 
Therefore, we are not proposing any DRG modification for intestinal 
transplantation cases at this time.
    We note that an institution that performs intestinal 
transplantation, in correspondence to us written following the 
publication of the FY 2005 IPPS final rule, agreed with our decision to 
move cases assigned to code 46.97 to DRG 480.
3. MDC 1 (Diseases and Disorders of the Nervous System)
a. Strokes
    In 1996, the Food and Drug Administration (FDA) approved the use of 
tissue plasminogen activator (tPA), one type of thrombolytic agent that 
dissolves blood clots. In 1998, the ICD-9-CM Coordination and 
Maintenance Committee created code 99.10 (Injection or infusion of 
thrombolytic agent) in order to be able to uniquely identify the 
administration of thrombolytic agents. Studies have shown that tPA can 
be effective in reducing the amount of damage the brain sustains during 
an ischemic stroke, which is caused by blood clots that block blood 
flow to the brain. The use of tPA is approved for patients who have 
blood clots in the brain, but not for patients who have a bleeding or 
hemorrhagic stroke. Thrombolytic therapy has been shown to be most 
effective when used within the first 3 hours after the onset of a 
stroke, and it is contraindicated in hemorrhagic stroke. The presence 
or absence of code 99.10 does not currently influence DRG assignment. 
Since code 99.10 became effective, we have been monitoring the DRGs and 
cases in which this code can be found, particularly with respect to 
cardiac and stroke DRGs.
    Last year, we met with representatives from several hospital stroke 
centers who recommended modification of the existing stroke DRGs 14 
(Intracranial Hemorrhage or Cerebral Infarction) and 15 (Nonspecific 
CVA and Precerebral Occlusion Without Infarction) by using the 
administration of tPA as a proxy to identify patients who have severe 
strokes. The representatives stated that using tPA as a proxy for the 
more severely ill stroke patient would recognize the higher charges 
these cases generate because of their higher hospital resource 
utilization.
    The stroke representatives made two suggestions concerning DRGs 14 
and 15. First, they proposed modifying DRG 14 by renaming it ``Ischemic 
Stroke Treatment with a Reperfusion Agent,'' and including only those 
cases containing code 99.10. The remainder of stroke cases where the 
patient was not treated with a reperfusion agent would be included in 
DRG 15, which would be renamed ``Hemorrhagic Stroke or Ischemic Stroke 
without a Reperfusion Agent.'' Hemorrhagic stroke cases now found in 
DRG 14 that are not treated with a reperfusion agent would migrate to 
DRG 15.
    The second suggestion was to leave DRGs 14 and 15 as they currently 
exist, and create a new DRG, with a recommended title ``Ischemic Stroke 
Treatment with a Reperfusion Agent.'' This suggested DRG would only 
include strokes caused by clots, not by hemorrhages, and would include 
the administration of tPA, identified by procedure code 99.10.
    We have examined the MedPAR data for the cases in DRGs 14 and 15, 
and have divided the cases based on the presence of a principal 
diagnosis of hemorrhage or occlusive ischemia, and the presence of 
procedure code 99.10. The following table displays the results:

[[Page 23316]]

[GRAPHIC] [TIFF OMITTED] TP04MY05.002

    The above table shows that the average standardized charges for 
cases treated with a reperfusion agent are more than $16,000 and 
$10,000 higher than all other cases in DRGs 14 and 15, respectively. 
While these data suggest that patients treated with a reperfusion agent 
are more expensive than all other stroke patients, this conclusion is 
based on a small number of cases. At this time, we are not proposing a 
change to the stroke DRGs because of this concern. However, we believe 
it is possible that more patients are being treated with a reperfusion 
agent than indicated by our data because the presence of code 99.10 
does not affect DRG assignment and may be underreported.
    We invite public comment on the changes to DRGs 14 and 15 suggested 
by the hospital representatives. In addition, we are interested in 
public comment on the number of patients currently being treated with a 
reperfusion agent as well as the potential costs of these patients 
relative to others with strokes that are also included in DRGs 14 and 
15.
b. Unruptured Cerebral Aneurysms
    In the FY 2004 IPPS final rule (68 FR 45353), we created DRG 528 
(Intracranial Vascular Procedures With a Principal Diagnosis of 
Hemorrhage) in MDC 1. We received a comment at that time that suggested 
we create another DRG for intracranial vascular procedures for 
unruptured cerebral aneurysms. For the FY 2004 IPPS final rule (68 FR 
45353) and the FY 2005 IPPS final rule (69 FR 48957), we evaluated the 
data for cases in the MedPAR file involving unruptured cerebral 
aneurysms assigned to DRG 1 (Craniotomy Age >17 With CC) and DRG 2 
(Craniotomy Age >17 Without CC) and concluded that the average charges 
were consistent with those for other cases found in DRGs 1 and 2. 
Therefore, we did not propose a change to the DRG assignment for 
unruptured cerebral aneurysms.
    We have reviewed the latest data for unruptured cerebral aneurysms 
cases. In our analysis of the FY 2004 MedPAR data, we found 1,136 
unruptured cerebral aneurysm cases assigned to DRG 1 and 964 unruptured 
cerebral aneurysm cases assigned to DRG 2. Although the average charges 
for the unruptured cerebral aneurysm cases in DRG 1 ($53,455) and DRG 2 
($34,028) were slightly higher than the average charges for all cases 
in DRG 1 ($51,466) and DRG 2 ($30,346), we do not believe these 
differences are significant enough to warrant a change in these two 
DRGs at this time. Therefore, we are not proposing a change in the 
structure of these DRGs relating to unruptured cerebral aneurysm cases 
for FY 2006.
4. MDC 5 (Diseases and Disorders of the Circulatory System)
a. Automatic Implantable Cardioverter/Defibrillator
    As part of our annual review of DRGs, for FY 2006, we performed a 
review of cases in the FY 2004 MedPAR file involving the implantation 
of a defibrillator in the following DRGs:
    DRG 515 (Cardiac Defibrillator Implant Without Cardiac 
Catheterization).
    DRG 535 (Cardiac Defibrillator Implant With Cardiac Catheterization 
With Acute Myocardial Infarction, Heart Failure, or Shock).
    DRG 536 (Cardiac Defibrillator Implant With Cardiac Catheterization 
Without Acute Myocardial Infarction, Heart Failure, or Shock).
    While conducting our review, we noted that there had been 
considerable comments from hospital coders on code 37.26 (Cardiac 
electrophysiologic stimulation and recording studies (EPS)), which is 
included in these DRGs. These comments from hospital coders were 
directed at both CMS and the American Hospital Association. The 
procedure codes for these three DRGs describe the procedures that are 
considered to be a cardiac catheterization. Code 37.26 is classified as 
a cardiac catheterization within these DRGs. Therefore, the submission 
of code

[[Page 23317]]

37.26 affects the DRG assignment for defibrillator cases and leads to 
the assignment of DRGs 535 or 536. When a cardiac catheterization is 
performed, the case is assigned to DRGs 535 or 536, depending on 
whether or not the patient also had an acute myocardial infarction, 
heart failure, or shock. The following chart shows the number of cases 
in each DRG, along with their average length of stay and average 
charges, found in the data:
[GRAPHIC] [TIFF OMITTED] TP04MY05.003

    We have received a number of questions from hospital coders 
regarding the correct use of code 37.26. There is considerable 
confusion about whether or not code 37.26 should be reported when the 
procedure is performed as part of the defibrillator implantation. 
Currently, the ICD-9-CM instructs the coder not to report code 37.26 
when a defibrillator is inserted. There is an inclusion term under the 
defibrillator code 37.94 (Implantation or replacement of automatic 
cardioverter/defibrillator, total system [AICD]) which states that EPS 
is included in code 37.94. We discussed modifying this instruction at 
the October 7-8, 2004 meeting of the ICD-9-CM Coordination and 
Maintenance Committee. We received a number of comments opposing a 
modification to the use of code 37.26 to also allow it to be reported 
with an AICD insertion. A report of this meeting can be found on the 
Web site: http://www.cms.hhs.gov/paymentsystem/icd9.
    We performed an analysis of cases within DRGs 535 and 536 with 
cardiac catheterization and with and without code 37.26 and with code 
37.26 only reported without cardiac catheterization and found the 
following:
[GRAPHIC] [TIFF OMITTED] TP04MY05.004

    The data show that when code 37.26 is the only procedure reported 
from the list of cardiac catheterizations, the average charges and the 
average length of stay are considerably lower. For example, the average 
standardized charges for a defibrillator implant with only an EPS are 
$85,390.88 in DRG 536, while the average standardized charges for DRG 
536 with a cardiac catheterization, but not an EPS, are $110,493.86. 
The average standardized charges for all cases in DRG 536 are 
$94,453.62. The data show similar findings for DRG 535, with lower 
lengths of stay and average charges when the only code reported from 
the cardiac catheterization list is an EPS. When we also consider that 
there may be some coding problems in the use of code 37.26, we believe 
it is appropriate to propose a modification to these DRGs.
    Data reflected in the chart above show that the average 
standardized charges for DRG 515 were $83,659.76. These average charges 
are closer to those in DRG 536 with code 37.26 and without any other 
cardiac catheterization code reported. While the cases in DRG 535 with 
code 37.26 and without a cardiac catheterization have higher average 
charges than the average charges for cases in DRG 515, these cases have 
much lower average charges than the average charges for overall cases 
in DRG 535. For these reasons, we are proposing to remove code 37.26 
from the list of cardiac catheterizations for DRGs 535 and 536. If a 
defibrillator is implanted and an EPS is performed with no other type 
of cardiac catheterization, the case would be assigned to DRG 515.
    CMS issued a National Coverage Determination for implantable 
cardioverter defibrillators, effective January 27, 2005, that expands 
coverage and requires, in certain cases, that patient data be reported 
when the defibrillator is implanted for the clinical indication of 
primary prevention of sudden cardiac death. The submission of data on 
patients receiving an implantable cardioverter defibrillator for 
primary prevention to a data collection system is needed for the 
determination that the implantable cardioverter

[[Page 23318]]

defibrillator is reasonable and necessary and for quality improvement. 
These data will be made available in some form to providers and 
practitioners to inform their decisions, monitor performance quality, 
and benchmark and identify best practices. We made a temporary registry 
available for use when the policy became effective and used the Quality 
Net Exchange for data submission because Medicare-participating 
hospitals already use the Exchange to report data.
    We intend to transition from the temporary registry using the 
Quality Net Exchange to a more sophisticated follow-on registry that 
will have the ability to collect longitudinal data. Some providers have 
suggested that CMS increase reimbursement for implantable cardioverter 
defibrillators to compensate the provider for reporting data. ICD data 
reporting includes elements of patient demographics, clinical 
characteristics and indications, medications, provider information, and 
complications. Since these data elements are commonly found in patient 
medical records, it is CMS' expectation that these data are readily 
available to the individuals abstracting and reporting data. Therefore, 
we believe that increased reimbursement is not needed at this time.
b. Coronary Artery Stents
    In the FY 2005 IPPS final rule (69 FR 48971 through 48974), we 
addressed two comments from industry representatives about the DRG 
assignments for coronary artery stents. These commenters had expressed 
concern about whether the reimbursement for stents is adequate, 
especially for insertion of multiple stents. They also expressed 
concern about whether the current DRG structure represents the most 
clinically coherent classification of stent cases.
    The current DRG structure incorporates stent cases into the 
following two pairs of DRGs, depending on whether bare metal or drug-
eluting stents are used and whether acute myocardial infarction (AMI) 
is present:
     DRG 516 (Percutaneous Cardiovascular Procedures with AMI).
     DRG 517 (Percutaneous Cardiovascular Procedures with 
Nondrug-Eluting Stent without AMI).
     DRG 526 (Percutaneous Cardiovascular Procedures with Drug-
Eluting Stent with AMI).
     DRG 527 (Percutaneous Cardiovascular Procedures with Drug-
Eluting Stent without AMI).
    The commenters presented two recommendations for refinement and 
restructuring of the current coronary stent DRGs. One of the 
recommendations involved restructuring these DRGs to create two 
additional stent DRGs that are closely patterned after the existing 
pairs, and would reflect insertion of multiple stents with and without 
AMI. The commenters recommended incorporating either stenting code 
36.06 (Insertion of nondrug-eluting coronary artery stent(s)) or code 
36.07 (Insertion of drug-eluting coronary artery stent(s)) when they 
are reported along with code 36.05 (Multiple vessel percutaneous 
transluminal coronary angioplasty [PTCA] or coronary atherectomy 
performed during the same operation, with or without mention of 
thrombolytic agent). The commenter's first concern was that hospitals 
may be steering patients toward coronary artery bypass graft surgery in 
place of stenting in order to avoid significant financial losses due to 
what it considered the inadequate reimbursement for inserting multiple 
stents.
    In our response to comments in the FY 2005 IPPS final rule, we 
indicated that it was premature to act on this recommendation because 
the current coding structure for coronary artery stents cannot 
distinguish cases in which multiple stents are inserted from those in 
which only a single stent is inserted. Current codes are able to 
identify performance of PTCA in more than one vessel by use of code 
36.05. However, while this code indicates that PTCA was performed in 
more than one vessel, its use does not reflect the exact number of 
procedures performed or the exact number of vessels treated. Similarly, 
when codes 36.06 and 36.07 are used, they document the insertion of at 
least one stent. However, these stenting codes do not identify how many 
stents were inserted in a procedure, nor distinguish insertion of a 
single stent from insertion of multiple stents. Even the use of one of 
the stenting codes in conjunction with multiple-PTCA code 36.05 does 
not distinguish insertion of a single stent from multiple stents. The 
use of code 36.05 in conjunction with code 36.06 or code 36.07 
indicates only performance of PTCA in more than one vessel, along with 
insertion of at least one stent. The precise numbers of PTCA-treated 
vessels, the number of vessels into which stents were inserted, and the 
total number of stents inserted in all treated vessels cannot be 
determined. Therefore, the capabilities of the current coding structure 
do not permit the distinction between single and multiple vessel 
stenting that would be required under the recommended restructuring of 
the coronary stent DRGs.
    We agree that the DRG classification of cases involving coronary 
stents must be clinically coherent and provide for adequate 
reimbursement, including those cases requiring multiple stents. For 
this reason, we created four new ICD-9-CM codes identifying multiple 
stent insertion (codes 00.45, 00.46, 00.47, and 00.48) and four new 
codes identifying multiple vessel treatment (codes 00.40, 00.41, 00.42, 
and 00.43) at the October 7, 2004 ICD-9-CM Coordination and Maintenance 
Committee Meeting. These eight new codes can be found in Table 6B of 
this proposed rule. We have worked closely with the coronary stent 
industry and the clinical community to identify the most logical code 
structure to identify new codes for both multiple vessel and multiple 
stent use. Effective October 1, 2005, code 36.05 will be deleted and 
the eight new codes will be used in its place. Coders are encouraged to 
use as many codes as necessary to describe each case, using one code to 
describe the angioplasty or atherectomy, and one code each for the 
number of vessels treated and the number of stents inserted. Coders are 
encouraged to record codes accurately, as these data will potentially 
be the basis for future DRG restructuring. While we agree that use of 
multiple vessel and stent codes will provide useful information in the 
future on hospital costs associated with percutaneous coronary 
procedures, we believe it remains premature to proceed with a 
restructuring of the current coronary stent DRGs on the basis of the 
number of vessels treated or the number of stents inserted, or both, in 
the absence of data reflecting use of this new coding structure.
    The commenter's second recommendation was that we distinguish 
``complex'' from ``noncomplex'' cases in the stent DRGs by expanding 
the higher weighted DRGs (516 and 526) to include conditions other than 
AMI. The commenter recommended recognizing certain comorbid and 
complicating conditions, including hypertensive renal failure, 
congestive heart failure, diabetes, arteriosclerotic cardiovascular 
disease, cerebrovascular disease, and certain procedures such as 
multiple vessel angioplasty or atherectomy (as evidenced by the 
presence of procedure code 36.05), as indicators of complex cases for 
this purpose. Specifically, the commenters recommended replacing the 
current structure with the following four DRGs:
     Recommended restructured DRG 516 (Complex percutaneous

[[Page 23319]]

cardiovascular procedures with non-drug-eluting stents).
     Recommended restructured DRG 517 (Noncomplex percutaneous 
cardiovascular procedures with non-drug-eluting stents).
     Recommended restructured DRG 526 (Complex percutaneous 
cardiovascular procedures with drug-eluting stents).
     Recommended restructured DRG 527 (Noncomplex percutaneous 
cardiovascular procedures with drug-eluting stents).
    The commenter argued that this structure would provide an 
improvement in both clinical and resource coherence over the current 
structure that classifies cases according to the type of stent inserted 
and the presence or absence of AMI alone, without considering other 
complicating conditions. The commenter also presented an analysis, 
based on previous MedPAR data, that evaluated charges and lengths of 
stay for cases with expected high resource use and reclassified cases 
into its recommended new structure of paired ``complex'' and 
``noncomplex'' DRGs. The commenter's analysis showed some evidence of 
clinical and resource coherence in the recommended DRG structure. 
However, we did not adopt the proposal in the FY 2005 IPPS final rule. 
First, the data presented by the commenter still represented 
preliminary experience under a relatively new DRG structure. Second, 
the analysis did not reveal significant gains in resource coherence 
compared to existing DRGs for stenting cases. Therefore, we were 
reluctant to adopt this approach because of comments and concern about 
whether the overall level of payment in the coronary stent DRGs was 
adequate. However, we indicated that this issue deserved further study 
and consideration, and that we would conduct an analysis of this 
recommendation and other approaches to restructuring these DRGs with 
updated data in the FY 2006 proposed rule.
    This year, we have analyzed the MedPAR data to determine the impact 
of certain secondary diagnoses or complicating conditions on the four 
DRGs cited above. Specifically, we examined the data in DRGs 516, 517, 
526, and 527, based on the presence of coronary stents (codes 36.06 and 
36.07) and the following additional diagnoses:
     Congestive heart failure (represented by codes 398.91 
(Rheumatic heart failure (congestive)), 402.01 (Hypertensive heart 
disease, malignant, with heart failure), 402.11, (Hypertensive heart 
disease, benign, with heart failure), 402.91 (Hypertensive heart 
disease, unspecified, with heart failure), 404.01 (Hypertensive heart 
and renal disease, malignant, with heart failure), 404.03 (Hypertensive 
heart and renal disease, malignant, with heart failure and renal 
failure), 404.11 (Hypertensive heart and renal disease, benign, with 
heart failure), 404.13 (Hypertensive heart and renal disease, benign, 
with heart failure and renal failure), 404.91 (Hypertensive heart and 
renal disease, unspecified, with heart failure), 404.93 (Hypertensive 
heart and renal disease, unspecified, with heart failure and renal 
failure), 428.0 (Congestive heart failure, unspecified), and 428.1 
(Left heart failure)).
     Arteriosclerotic cardiovascular disease (represented by 
code 429.2 (Cardiovascular disease, unspecified)).
     Cerebrovascular disease (represented by codes 430.0 
(Subarachnoid hemorrhage), 431.0 (Intracerebral hemorrhage), 432.0 
(Nontraumatic extradural hemorrhage), 432.1, Subdural hemorrhage, 
432.9, (Unspecified intracranial hemorrhage), 433.01 (Occlusion and 
stenosis of basilar artery, with cerebral infarction), 433.11 
(Occlusion and stenosis of carotid artery, with cerebral infarction), 
433.21 (Occlusion and stenosis of vertebral artery, with cerebral 
infarction), 433.31 (Occlusion and stenosis of multiple and bilateral 
precerebral arteries, with cerebral infarction), 433.81 (Occlusion and 
stenosis of other specified precerebral artery, with cerebral 
infarction), 434.01 (Cerebral thrombosis with cerebral infarction), 
434.11 (Cerebral embolism with cerebral infarction), 434.91 (Cerebral 
artery occlusion with cerebral infarction, unspecified), 436.0 (Acute, 
but ill-defined, cerebrovascular disease)).
     Secondary diagnosis of acute myocardial infarction 
(represented by codes 410.01 (Acute myocardial infarction of 
anterolateral wall, initial episode of care), 410.11 (Acute myocardial 
infarction of other anterior wall, initial episode of care), 410.21 
(Acute myocardial infarction of inferolateral wall, initial episode of 
care), 410.31 (Acute myocardial infarction of inferoposterior wall, 
initial episode of care), 410.41 (Acute myocardial infarction of other 
inferior wall, initial episode of care), 410.51 (Acute myocardial 
infarction of other lateral wall, initial episode of care), 410.61 
(True posterior wall infarction, initial episode of care), 410.71 
(Subendocardial infarction, initial episode of care), 410.81 (Acute 
myocardial infarction of other specified sites, initial episode of 
care), 410.91 (Acute myocardial infarction of unspecified site, initial 
episode of care)).
     Renal failure (represented by codes 403.01 (Hypertensive 
renal disease, malignant, with renal failure), 403.11 (Hypertensive 
renal disease, benign, with renal failure), 403.91 (Hypertensive renal 
disease, unspecified, with renal failure), 585.0 (Chronic renal 
failure), V42.0 (Organ or tissue replaced by transplant, kidney), V45.1 
(Renal dialysis status), V56.0 (Extracorporeal dialysis), V56.1 
(Fitting and adjustment of extracorporeal dialysis catheter), V56.2 
(Fitting and adjustment of peritoneal dialysis catheter)). Any renal 
failure with congestive heart failure will be captured in the 404.xx 
codes listed above.
    We reviewed the cases in the four coronary stent DRGs and found 
that most of the additional or ``complicated'' cases did, in fact, have 
higher average charges in most instances. However, these results could 
potentially be duplicated for many DRGs, or sets of DRGs, within the 
PPS structure. That is, cases with selected complicating factors will 
tend to have higher average lengths of stay and average charges than 
cases without those complicating factors. Since cases with the selected 
complicating factors necessarily contain sicker patients, longer 
lengths of stay and higher average charges are to be expected. For 
example, cases in which patients with a cardiac condition also have 
renal failure are quite likely to consume higher resources than 
patients only with a cardiac condition. In addition, selectively 
recognizing the recommended secondary diagnoses or complicating 
conditions raises some issues related to the logic and structural 
integrity of the DRG system. Generally, we have taken into account the 
higher costs of cases with complications by maintaining a general list 
of comorbidities and complications (the CC) list), and, where 
appropriate, distinguishing pairs of DRGs by ``with and without CCs.'' 
(This system also specifies exclusions from each pair, to account for 
cases where a condition on the CC list is an expected and normal 
constituent of the diagnoses reflected in the paired DRGs.) In order to 
maintain the basic DRG body-system structure, we have not employed 
special lists of procedures and diagnoses from one MDC to make 
determinations about the structure of DRGs in another MDC. The 
recommended restructuring of the coronary stent DRGs is inconsistent 
with this principle and may create a new precedent of selecting 
specific comorbidities and complications to restructure DRGs. For 
example, the

[[Page 23320]]

presence of code 403.11 (Hypertensive renal disease, malignant, with 
renal failure) may distinguish cases with higher average charges, but 
the same argument could be raised for many other procedures across 
other MDCs.
    Rather than establishing such a precedent, we are proposing to 
restructure the coronary stent DRGs on the basis of the standard CC 
list to differentiate cases that require greater resources. We believe 
this list to be more inclusive of true comorbid or complicating 
conditions than selection of specific secondary diagnosis codes. 
Therefore, restructuring these DRGs on this basis would result in a 
logical arrangement of cases with regard to both clinical coherence and 
resource consumption. We have compared the existing CC list with the 
list of the codes recommended by the commenter as secondary diagnoses. 
All of the recommended codes already appear on the CC list except for 
codes 429.2, 432.9, V56.1, and V56.2. Code 429.2 represents a very 
vague diagnosis (arteriosclerotic cardiovascular disease (ASCVD)). Code 
432.9 represents a nonspecific principal diagnosis that is rejected by 
the MCE when reported as the principal diagnosis. Codes V56.1 and V56.2 
describe conditions relating to dialysis for renal failure. Therefore, 
we believe that our proposal to utilize the existing CC list would 
encompass most of the cases on the recommended list, as well as other 
cases with additional CCs requiring additional resources. We have 
examined the MedPAR data for the cases in the coronary stent DRGs, 
distinguishing cases that include CCs and those that do not. The 
following table displays the results:
[GRAPHIC] [TIFF OMITTED] TP04MY05.005

    The data show a clear differentiation in average charges between 
the cases in DRG 516 and 526 ``with CC'' and those ``without CC.'' 
Therefore, the data suggest that a ``with and without CC'' split in DRG 
516 and 526 is warranted. At the same time, the data do not show such a 
clear differentiation, in either average charges or lengths of stay, 
among the cases in DRGs 517 and 527.
    Therefore, we are proposing to delete DRGs 516 and 526, and to 
substitute four new DRGs in their place. These new DRGs would be 
patterned after existing DRGs 516 and 526, except that they would be 
split based on the presence or absence of a secondary diagnosis on the 
existing CC list. Specifically, we are proposing to create DRG 547 
(Percutaneous Cardiovascular Procedure with AMI with CC), DRG 548 
(Percutaneous Cardiovascular Procedure with AMI without CC), DRG 549 
(Percutaneous Cardiovascular Procedure with Drug-Eluting Stent with AMI 
with CC), and DRG 550 (Percutaneous Cardiovascular Procedure with Drug-
Eluting Stent with AMI without CC). As we noted above, the MedPAR data 
do not support restructuring DRGs 517 and 527 based on the presence or 
absence of a CC. Therefore, we are proposing to retain these two DRGs 
in their current forms. We believe this revised structure will result 
in a more inclusive and comprehensive array of cases within MDC 5 
without selectively recognizing certain secondary diagnoses as 
``complex.''
    While we are proposing some restructuring of the coronary stent 
DRGs for FY 2006, it is important to note that we will continue to 
monitor and analyze clinical and resource trends in this area. For 
example, we have found indications in the current data that treatment 
may be moving toward use of drug-eluting stents, and away from use of 
bare metal stents. Specifically, cases in DRGs 516 and 517, which 
utilize bare metal stents, comprise only 44.4 percent, or less than 
half, of the cases in the four coronary stent DRGs in the MedPAR data 
we analyzed. As use of drug-eluting stents becomes the standard of 
treatment, we may consider over time whether to dispense with the 
distinction between these stents and the older bare metal stent 
technology in the structure of the coronary stent DRGs. In addition, we 
will continue to consider whether the structure of these DRGs ought to 
reflect differences in the number of vessels treated or the number of 
stents inserted, or both. As we discussed above, a new coding structure 
capable of identifying multiple vessel treatment and the insertion of 
multiple stents will go into effect on October 1, 2005. It remains 
premature to restructure the coronary stent DRGs on the basis of the 
number of vessels treated or the number of stents inserted, or both, 
until data reflecting the use of these new codes become available. 
However, we will analyze those data when they become available in order 
to determine whether a restructuring based on multiple vessel treatment 
or insertion of multiple stents, or both, is warranted. Our proposal to 
restructure two of the current coronary stent DRGs into paired ``with 
and without CC'' DRGs for FY 2006 does not preclude proposals in 
subsequent years to restructure the coronary stent DRGs in one or both 
of these ways.

[[Page 23321]]

c. Insertion of Left Atrial Appendage Device
    Atrial fibrillation is a common heart rhythm disorder that can lead 
to a cardiovascular blood clot formation leading to increased risk of 
stroke. According to product literature, nearly all strokes are from 
embolic clots arising in the left atrial appendage of the heart: an 
appendage for which there is no useful function. Standard therapy uses 
anticoagulation drugs. However, these drugs may be contraindicated in 
certain patients and may cause complications such as bleeding. The 
underlying concept behind the left atrial appendage device is to block 
off the left atrial appendage, so that the blood clots formed therein 
cannot travel to other sites in the vascular system. The device is 
implanted using a percutaneous catheter procedure under fluoroscopy 
through the femoral vein. Implantation is performed in a hospital 
catheterization laboratory using standard transseptal technique, with 
the patient generally under local anesthesia. The procedure takes 
approximately 1 hour, and most patients stay overnight in the hospital.
    In the FY 2005 IPPS final rule (69 FR 48978, August 11, 2004), we 
discussed the DRG assignment of new ICD-9-CM procedure code 37.90 
(Insertion of left atrial appendage device) for clinical trials, 
effective for discharges occurring on or after October 1, 2004, to DRG 
518 (Percutaneous Cardiovascular Procedure without Coronary Artery 
Stent or Acute Myocardial Infarction)). In that final rule, we 
addressed the DRG assignment of procedure code 37.90 in response to a 
comment from a manufacturer who suggested that placement of the code in 
DRG 108 (Other Cardiothoracic Procedures) was more representative of 
the complexity of the procedure than placement in DRG 518. The 
manufacturer indicated that the suggested placement of procedure code 
37.90 in DRG 108 was justified because another percutaneous procedure, 
described by ICD-9-CM procedure code 35.52 (Repair of atrial septal 
defect with prosthesis, closed technique), was assigned to DRG 108. As 
we indicated in the FY 2005 final rule (69 FR 48978), this comment 
prompted us to examine data in the FY 2003 MedPAR file for cases of 
code 35.52 assigned to DRG 108 and DRG 518 in comparison to all cases 
assigned to DRG 108. We found the following:
[GRAPHIC] [TIFF OMITTED] TP04MY05.006

    Therefore, we concluded that procedure code 35.52 showed a decided 
similarity to the cases found in DRG 518, not DRG 108. At that time, we 
determined that we would analyze the cases for both clinical coherence 
and charge data as part of the IPPS FY 2006 process of identifying the 
most appropriate DRG assignment for procedure code 35.52.
    We have now examined data from the FY 2004 MedPAR file and found 
results for cases assigned to DRG 108 and DRG 518 that are similar to 
last year's findings as indicated in the chart below:
[GRAPHIC] [TIFF OMITTED] TP04MY05.007

    From this comparison, we found that when an atrial septal defect is 
percutaneously repaired, and procedure code 35.52 is the only code 
reported in DRG 108, there is a significant discrepancy in both the 
average charges and the average length of stay between the cases with 
procedure code 35.52 reported in DRG 108 and the total cases in DRG 
108. The total cases in DRG 108 have average charges of $51,744 greater 
than the 872 cases in DRG 108 reporting procedure code 35.52 as the 
only procedure. The total cases in DRG 108 also have an average length 
of stay of 7.39 days greater than the average length of stay for cases 
in DRG 108 with procedure code 35.52 reported. In comparison, the total 
cases in DRG 518 have average charges of only $1,988 lower than the 
cases in DRG 108 with only procedure code 35.52 reported. In addition, 
the length of stay in total cases in DRG 518 is more closely related to 
cases in DRG 108 with only procedure code 35.52 reported.
    Based on our analysis of these data, we are proposing to move 
procedure code 35.52 out of DRG 108 and place it in DRG 518. We believe 
that this proposal would result in a more coherent group of cases in 
DRG 518 that reflect all percutaneous procedures.
d. External Heart Assist System Implant
    In the August 1, 2002, final rule (67 FR 49989), we attempted to 
clinically and financially align ventricular assist device (VAD) 
procedures by creating DRG 525 (Heart Assist System Implant). We also 
noted that cases in which a heart transplant also occurred during the 
same hospitalization episode would continue to be assigned to DRG 103 
(Heart Transplant).
    After further data review during the next 2 years, we decided to 
realign the

[[Page 23322]]

DRGs containing VAD codes for FY 2005. In the August 11, 2004 final 
rule (69 FR 48927), we announced changes to DRG 103, DRG 104 (Cardiac 
Valve and Other Major Cardiothoracic Procedure with Cardiac 
Catheterization), DRG 105 (Cardiac Valve and Other Major Cardiothoracic 
Procedures Without Cardiac Catheterization), and DRG 525.
    In summary, these changes included--
     Moving code 37.66 (Insertion of implantable heart assist 
system) out of DRG 525 and into DRG 103.
     Renaming DRG 525 as ``Other Heart Assist System Implant.''
     Moving code 37.62 (Insertion of non-implantable heart 
assist system) out of DRGs 104 and 105 and back into DRG 525.
    DRG 525 currently consists of any principal diagnosis in MDC 5, 
plus the following surgical procedure codes:
     37.52, Implantation of total replacement heart system *.
     37.53, Replacement or repair of thoracic unit of total 
replacement heart system *.
     37.54, Replacement or repair of other implantable 
component of total replacement heart system *.
     37.62, Insertion of non-implantable heart assist system.
     37.63, Repair of heart assist system.
     37.65, Implant of external heart assist system.

    * These codes represent noncovered services for Medicare 
beneficiaries. However, it is our longstanding practice to assign 
every code in the ICD-9-CM classification to a DRG. Therefore, they 
have been assigned to DRG 525.

    Since that decision, we have been encouraged by a manufacturer to 
reevaluate DRG 525 for FY 2006. The manufacturer requested that we 
again review the data surrounding cases reporting code 37.65 and has 
suggested moving these cases into DRG 103. The manufacturer pointed out 
the following: Code 37.65 describes the implantation of an external 
heart assist system and is currently approved by the FDA as a bridge-
to-recovery device. From the standpoint of clinical status, the 
patients in DRG 103 and receiving an external heart assist system are 
similar because their native hearts cannot support circulation, and 
absent a heart transplant, a mechanical pump is needed for patient 
survival. The surgical procedures for implantation of both an internal 
VAD and an external VAD are very similar. However, the external heart 
assist system (code 37.65) is a less expensive device than the 
implantable heart assist system (code 37.66). The manufacturer 
suggested that the payment differential between DRGs 103 and 525 is an 
incentive to choose the higher paying device, and asserted that only a 
subset of patients receiving an implantable heart assist system are 
best served by this device. The manufacturer also suggested that the 
initial use of the least expensive therapeutically appropriate device 
yields both the best clinical outcomes and the lowest total system 
costs.
    We note that, under the DRG system, our intent is to create 
payments that are reflective of the average resources required to treat 
a particular case. Our goal is that physicians and hospitals should 
make treatment decisions based on the clinical needs of the patient and 
not financial incentives.
    When we reviewed the FY 2004 MedPAR data, we were able to 
demonstrate the following comparisons:
[GRAPHIC] [TIFF OMITTED] TP04MY05.008

    The above table shows that the 37.8 percent of cases in DRG 525 
that reported code 37.65 have average charges that are nearly $33,000 
higher than the average charges for all cases in the DRG. However, the 
average charges for the subset of cases with code 37.65 in DRG 525 
($206,497) are more than $107,086 lower than the average charges for 
all cases in DRG 103 ($313,583). Furthermore, the average length of 
stay for the subset of patients in DRG 525 receiving an external heart 
assist system was 9.26 days compared to 37.5 days for the 633 cases in 
DRG 103.
    We note that the analysis above presents the difference in average 
charges, not costs. Because hospitals' charges are higher than costs, 
the difference in hospital costs will be less than the figures shown 
here. Moving cases containing code 37.65 from DRG 525 to DRG 103 would 
have two consequences. The cases in DRG 103 reporting code 37.65 would 
be appreciably overreimbursed, which would be inconsistent with our 
goal of coherent reimbursement structure within the DRGs. In addition, 
the relative weight of DRG 103 would decrease by moving the less 
resource-intensive external heart procedures into the same DRG with the 
more expensive heart transplant cases. The net effect would be an 
underpayment for heart transplant cases. Alternatively, we also 
reconsidered our position on moving the insertion of an implantable 
heart assist system (code 37.66) back into

[[Page 23323]]

DRG 525. However, as shown in the FY 2005 IPPS final rule (69 FR 
48929), the resource costs associated with caring for a patient 
receiving an implantable heart assist system are far more similar to 
those cases receiving a heart transplant in DRG 103 than they are to 
cases in DRG 525. For these reasons, we are not proposing to make any 
changes to the structure of either DRG 103 or DRG 525 in this proposed 
rule.
e. Carotid Artery Stent
    Stroke is the third leading cause of death in the United States and 
the leading cause of serious, long-term disability. Approximately 70 
percent of all strokes occur in people age 65 and older. The carotid 
artery, located in the neck, is the principal artery supplying the head 
and neck with blood. Accumulation of plaque in the carotid artery can 
lead to stroke either by decreasing the blood flow to the brain or by 
having plaque break free and lodge in the brain or in other arteries to 
the head. The percutaneous transluminal angioplasty (PTA) procedure 
involves inflating a balloon-like device in the narrowed section of the 
carotid artery to reopen the vessel. A carotid stent is then deployed 
in the artery to prevent the vessel from closing or restenosing. A 
distal filter device (embolic protection device) may also be present, 
which is intended to prevent pieces of plaque from entering the 
bloodstream.
    Effective July 1, 2001, Medicare covers PTA of the carotid artery 
concurrent with carotid stent placement when furnished in accordance 
with the FDA-approved protocols governing Category B Investigational 
Device Exemption (IDE) clinical trials. PTA of the carotid artery, when 
provided solely for the purpose of carotid artery dilation concurrent 
with carotid stent placement, is considered to be a reasonable and 
necessary service only when provided in the context of such clinical 
trials and, therefore, is considered a covered service for the purposes 
of these trials. Performance of PTA in the carotid artery when used to 
treat obstructive lesions outside of approved protocols governing 
Category B IDE clinical trials remains a noncovered service.
    At the April 1, 2004 ICD-9-CM Coordination and Maintenance 
Committee meeting, we discussed creation of a new code or codes to 
identify carotid artery stenting, along with a concomitant percutaneous 
angioplasty or atherectomy (PTA) code for delivery of the stent(s). 
This subject was addressed in response to the need to identify carotid 
artery stenting for use in clinical trials in the upcoming fiscal year. 
Public comment confirmed the need for specific codes for this 
procedure. We established codes for carotid artery stenting procedures 
effective October 1, 2004, for patients who are enrolled in an FDA-
approved clinical trial and are using on-label FDA approved stents and 
embolic protection devices.
    New procedure codes 00.61 (Percutaneous angioplasty or atherectomy 
of precerebral (extracranial vessel(s)) and 00.63 (Percutaneous 
insertion of carotid artery stent(s)) were published in Table 6B, New 
Procedure Codes in the FY 2005 IPPS final rule (69 FR 49624).
    Procedure code 00.61 was assigned to four MDCs and seven DRGs. The 
most likely scenario is that in which cases are assigned to MDC 1 
(Diseases and Disorders of the Nervous System in DRGs 533 (Extracranial 
Procedures with CC) and 534 (Extracranial Procedures without CC). Cases 
may also be assigned to MDC 5 (Diseases and Disorders of the 
Circulatory System), MDC 21 (Injuries, Poisoning, and Toxic Effects of 
Drugs), and MDC 24 (Multiple Significant Trauma). Other less likely DRG 
assignments can be found in Table 6B in the Addendum to the FY 2005 
IPPS final rule (69 FR 49624).
    In the FY 2005 final rule, we indicated that we would continue to 
monitor DRGs 533 and 534 and procedure code 00.61 in combination with 
procedure code 00.63 in upcoming annual DRG reviews. For this proposed 
rule, we are using proxy codes to evaluate the costs and DRG 
assignments for carotid artery stenting because codes 00.61 and 00.63 
were only approved for use beginning October 1, 2004, and because 
MedPAR data for this period are not yet available. We used procedure 
code 39.50 (Angioplasty or atherectomy of other noncoronary vessel(s)) 
in combination with procedure code 39.90 (Insertion of nondrug-eluting 
peripheral vessel stent(s)) in DRGs 533 and 534 as the proxy codes for 
coronary artery stenting. For this evaluation, we used principal 
diagnosis code 433.10 (Occlusion and stenosis of carotid artery, 
without mention of cerebral infarction) because this diagnosis most 
closely reflects the clinical trial criteria.
    The following chart shows our findings:
    [GRAPHIC] [TIFF OMITTED] TP04MY05.009
    
    The patients receiving a carotid stent (codes 39.50 and 39.90) 
represented 3.5 percent of all cases in DRG 534. On average, patients 
receiving a carotid stent had slightly shorter average lengths of stay 
than other patients in DRGs 533 and 534. While the average charges for 
patients receiving a carotid artery stent were higher than for other 
patients in DRG 534, in our view, the small number of cases and the 
magnitude of the difference in average charges are not sufficient to 
justify a change in the DRGs.
    Because we have a paucity of data for the carotid stent device and 
its insertion, and no data utilizing procedure codes 00.61 and 00.63 in 
a clinical trial setting, we believe it is premature to revise the DRG 
structure at this time. We expect to revisit this analysis once data 
become available on the new codes for carotid artery stents.

[[Page 23324]]

f. Extracorporeal Membrane Oxygenation (ECMO)
    Extracorporeal membrane oxygenation (ECMO) is a procedure to create 
a closed chest, heart-lung bypass system by insertion of vascular 
catheters. Patients receiving this procedure require mechanical 
ventilation. ECMO is performed for a small number of severely ill 
patients who are at high risk of dying without this procedure. Most 
often it is done for neonates with persistent pulmonary hypertension 
and respiratory failure for whom other treatments have failed, certain 
severely ill neonates receiving major cardiac procedures or 
diaphragmatic hernia repair, and certain older children and adults, 
most of whom are receiving major cardiac procedures.
    We received several letters from institutions that perform ECMO. 
The commenters stated that, in the CMS GROUPER logic, this procedure 
has little or no impact on the DRG assignment in the newborn, 
pediatric, and adult population. According to these letters, patients 
receiving ECMO are highly resource intensive and should have a unique 
DRG that reflects the costs of these resources. The commenters 
recommended the creation of a new DRG for ECMO with a DRG weight equal 
to or greater than the DRG weight for tracheostomy.
    ECMO is assigned to procedure code 39.65 (Extracorporeal membrane 
oxygenation). This code is classified as an O.R. procedure and is 
assigned to DRG 104 (Cardiac Valve and Other Major Cardiothoracic 
Procedure With Cardiac Catheterization) and DRG 105 (Cardiac Valve and 
Other Major Cardiothoracic Procedure Without Cardiac Catheterization). 
When ECMO is performed with other O.R. procedures, the case is assigned 
to the higher weighted DRG. For example, when ECMO and a tracheostomy 
are performed during the same admission, the case would be assigned to 
DRG 541 (Tracheostomy with Mechanical Ventilation 96+ Hours or 
Principal Diagnosis Except Face, Mouth, and Neck Diagnoses With Major 
O.R.).
    We note that the primary focus of updates to the Medicare DRG 
classification system is changes relating to the Medicare patient 
population, not the pediatric patient population. Because ECMO is 
primarily a pediatric procedure and rarely performed in an adult 
population, we have few cases in our data to use to evaluate resource 
costs. We are aware that other insurers sometimes use Medicare's rates 
to make payments. We advise private insurers to make appropriate 
modifications to our payment system when it is being used for children 
or other patients who are not generally found in the Medicare 
population.
    To evaluate the appropriateness of payment under the current DRG 
assignment, we have reviewed the FY 2004 MedPAR data and found 78 ECMO 
cases in 13 DRGs. The following table illustrates the results of our 
findings:
[GRAPHIC] [TIFF OMITTED] TP04MY05.010

    The average charges for all ECMO cases were approximately $258,821, 
and the average length of stay was approximately 20.7 days. The average 
charges for the ECMO cases are closer to the average charges for DRG 
541 ($273,656) than to the average charges of DRG 104 ($147,766) and 
DRG 105 ($131,700). Of the 78 ECMO cases, 14 cases are already assigned 
to DRG 541. We believe that the data indicate that DRG 541 would be a 
more appropriate DRG assignment for cases where ECMO is performed. We 
further note that under the All Payer DRG System used in New York 
State, cases involving ECMO are assigned to the tracheostomy DRG. Thus, 
the assignment of ECMO cases to the tracheostomy DRG for Medicare would 
be similar to how these cases are grouped in another DRG system. For 
these reasons, we are proposing to reassign ECMO cases reporting code 
39.65 to DRG 541. We are also proposing to change the title of DRG 541 
to: ``ECMO or Tracheostomy With Mechanical Ventilation 96+ Hours or 
Principal Diagnosis Except Face, Mouth and Neck Diagnoses With Major 
O.R.''
5. MDC 6 (Diseases and Disorders of the Digestive System): Artificial 
Anal Sphincter
    In the FY 2003 IPPS final rule (67 FR 50242), we created two new 
codes for procedures involving an artificial anal sphincter, effective 
for discharges occurring on or after October 1, 2002: code 49.75 
(Implantation or revision of artificial anal sphincter) is used to 
identify cases involving implantation or revision of an artificial anal 
sphincter and code 49.76 (Removal of artificial anal sphincter) is used 
to identify cases involving the removal of the device. In Table 6B of 
that final rule, we assigned both codes to one of four MDCs, based on 
principal diagnosis, and one of six DRGs within those MDCs: MDC 6 
(Diseases and Disorders of the Digestive System), DRGs 157 and 158 
(Anal and Stomal Procedures With and Without CC, respectively); MDC 9 
(Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast), 
DRG 267 (Perianal and Pilonidal Procedures); MDC 21 (Injuries, 
Poisonings, and Toxic Effects of Drugs), DRGs 442 and 443 (Other O.R. 
Procedures for Injuries With and without CC, respectively); and MDC 24 
(Multiple Significant Trauma), DRG 486 (Other O.R. Procedures for 
Multiple Significant Trauma).
    In the FY 2004 IPPS final rule (68 FR 45372), we discussed the 
assignment of these codes in response to a request we had received to 
consider reassignment of these two codes to different MDCs and DRGs. 
The requester believed that the average charges ($44,000) for these 
codes warranted reassignment. In the FY 2004 IPPS final rule, we stated 
that we did not have sufficient MedPAR data available on the reporting 
of codes 49.75 and 49.76 to make a determination on

[[Page 23325]]

DRG reassignment of these codes. We agreed that, if warranted, we would 
give further consideration to the DRG assignments of these codes 
because it is our customary practice to review DRG assignment(s) for 
newly created codes to determine clinical coherence and similar 
resource consumption after we have had the opportunity to collect 
MedPAR data on utilization, average lengths of stay, average charges, 
and distribution throughout the system. In the FY 2005 IPPS final rule, 
we reviewed the FY 2003 MedPAR data for the presence of codes 49.75 and 
49.76 and determined that these procedures were not a clinical match 
with the other procedures in DRGs 157 and 158. Therefore, for FY 2005, 
we moved procedure codes 49.75 and 49.76 out of DRGs 157 and 158 and 
into DRGs 146 and 147 (Rectal Resection With and Without CC, 
respectively). This change had the effect of doubling the payment for 
the cases with procedure codes 49.75 and 49.76 assigned to DRGs 146 and 
147 based on increases in the relative weights. One commenter had 
suggested that we create a new DRG for ``Complex Anal/Rectal Procedure 
with Implant.'' However, we noted that the DRG structure is a system of 
averages and is based on groups of patients with similar 
characteristics. At that time, we indicated that we would continue to 
monitor procedure codes 49.75 and 49.76 and the DRGs to which they are 
assigned.
    For this FY 2006 proposed rule, we reviewed the FY 2004 MedPAR data 
for the presence of codes 49.75 and 49.76. We found that these two 
procedures are still of low incidence. Among the six possible DRG 
assignments, we found a total of 18 cases reported with codes 49.75 and 
49.76 for the implant, revision, or removal of the artificial anal 
sphincter. We found 13 of these cases in DRGs 146 and 147 (compared to 
12,558 total cases in these DRGs), and the remaining 5 cases in DRGs 
442 and 443 (compared to 19,701 total cases in these DRGs).
    We believe the number of cases with codes 49.75 and 49.76 in these 
DRGs is too low to provide meaningful data of statistical significance. 
Therefore, we are not proposing any further changes to the DRGs for 
these procedures at this time. Neither are we proposing to change the 
structure of DRGs 146 or 147 at this time.
6. MDC 8 (Diseases and Disorders of the Musculoskeletal System and 
Connective Tissue)
a. Hip and Knee Replacements
    Orthopedic surgeons representing the American Association of 
Orthopaedic Surgeons (AAOS) requested that we subdivide DRG 209 (Major 
Joint and Limb Reattachment Procedures of Lower Extremity) in MDC 8 by 
creating a new DRG for revision of lower joint procedures. The AAOS 
made a presentation at the October 7-8, 2004 meeting of the ICD-9-CM 
Coordination and Maintenance Committee meeting. A summary report of 
this meeting can be found at the CMS Web site: http://www.cms.hhs.gov/paymentsystems/icd9/. We also received written comments on this 
request.
    The AAOS surgeons stated that cases involving patients who require 
a revision of a prior replacement of a knee or hip require 
significantly more resources than cases in which patients receive an 
initial joint replacement. They pointed out that total joint 
replacement is one of the most commonly performed and successful 
operations in orthopedic surgery. The surgeons mentioned that, in 2002, 
over 300,000 hip replacement and 350,000 knee replacement procedures 
were performed in the United States. They also pointed out that these 
procedures are a frequent reason for Medicare hospitalization. The 
surgeons stated that total joint replacements have been shown to be 
highly cost-effective procedures, resulting in dramatic improvements in 
quality of life for patients suffering from disabling arthritic 
conditions involving the hip or knee. In addition, they reported that 
the medical literature indicates success rates of greater than 90 
percent for implant survivorship, reduction in pain, and improvement in 
function at a 10-year to 15-year followup. However, despite these 
excellent results with primary total joint replacement, factors related 
to implant longevity and evolving patient demographics have led to an 
increase in the volume of revision total joint procedures performed in 
the United States over the past decade.
    Total hip replacement is an operation that is intended to reduce 
pain and restore function in the hip joint by replacing the arthritic 
hip joint with a prosthetic ball and socket joint. The prosthetic hip 
joint consists of a metal alloy femoral component with a modular 
femoral head made of either metal or ceramic (the ``ball'') that 
articulates with a metal acetabular component with a modular liner made 
of either metal, ceramic, or high-density polyethylene (the 
``socket'').
    The AAOS surgeons stated that in a normal knee, four ligaments help 
hold the bones in place so that the joint works properly. When a knee 
becomes arthritic, these ligaments can become scarred or damaged. 
During knee replacement surgery, some of these ligaments, as well as 
the joint surfaces, are substituted or replaced by the new artificial 
prostheses. Two types of fixation are used to hold the prostheses in 
place. Cemented designs use polymethyl methacrylate to hold the 
prostheses in place. Cementless designs rely on bone growing into the 
surface of the implant for fixation.
    The surgeons stated that all hip and knee replacements have an 
articular bearing surface that is subject to wear (the acetabular 
bearing surface in the hip and the tibial bearing surface in the knee). 
Traditionally, these bearing surfaces have been made of metal-on-metal 
or metal-on-polyethylene, although newer materials (both metals and 
ceramics) have been used more recently. Earlier hip and knee implant 
designs had nonmodular bearing surfaces, but later designs included 
modular articular bearing surfaces to reduce inventory and potentially 
simplify revision surgery. Wear of the articular bearing surface occurs 
over time and has been found to be related to many factors, including 
the age and activity level of the patient. In some cases, wear of the 
articular bearing surface can produce significant debris particles that 
can cause peri-prosthetic bone resorption (also known and osteolysis) 
and mechanical loosening of the prosthesis. Wear of the bearing surface 
can also lead to instability or prosthetic dislocation, or both, and is 
a common cause of revision hip or knee replacement surgery.
    Depending on the cause of failure of the hip replacement, the type 
of implants used in the previous surgery, the amount and quality of the 
patient's remaining bone stock, and factors related to the patient's 
overall health and anatomy, revision hip replacement surgery can be 
relatively straightforward or extremely complex. Revision hip 
replacement can involve replacing any part or all of the implant, 
including the femoral or acetabular components, and the bearing surface 
(the femoral head and acetabular liner), and may involve major 
reconstruction of the bones and soft tissues around the hip. All of 
these procedures differ significantly in their clinical indications, 
outcomes, and resource intensity.
    The AAOS surgeons provided the following summary of the types of

[[Page 23326]]

revision knee replacement procedures: Among revision knee replacement 
procedures, patients who underwent complete revision of all components 
had longer operative times, higher complication rates, longer lengths 
of stay, and significantly higher resource utilization, according to 
studies conducted by the AAOS. Revision of the isolated modular tibial 
insert component was the next most resource-intensive procedure, and 
primary total knee replacement was the least resource-intensive of all 
the procedures studied.
     Isolated Modular Tibial Insert Exchange. Isolated removal 
and exchange of the modular tibial bearing surface involves replacing 
the modular polyethylene bearing surface without removing the femoral, 
tibial, or patellar components of the prosthetic joint. Common 
indications for this procedure include wear of the polyethylene bearing 
surface or instability (for example, looseness) of the prosthetic knee 
joint. Patient recovery times are much shorter with this procedure than 
with removal and exchange of either the tibial, femoral, or patellar 
components.
     Revision of the Tibial Component. Revision of the tibial 
component involves removal and exchange of the entire tibial component, 
including both the metal base plate and the modular polyethylene 
bearing surface. Common indications for tibial component revision are 
wear of the modular bearing surface, aseptic loosening (often 
associated with osteolysis), or infection. Depending on the amount of 
associated bone loss and the integrity of the ligaments around the 
knee, tibial component revision may require the use of specialized 
implants with stems that extend into the tibial canal and/or the use of 
metal augments or bone graft to fill bony defects.
     Revision of the Femoral Component. Revision of the femoral 
component involves removal and exchange of the metal implant that 
covers the end of the thigh-bone (the distal femur). Common indications 
for femoral component revision are aseptic loosening with or without 
associated osteolysis/bone loss, or infection. Similar to tibial 
revision, femoral component revision that is associated with extensive 
bone loss often involves the use of specialized implants with stems 
that extend into the femoral canal and/or the use of metal augments or 
bone graft to fill bony defects.
     Revision of the Patellar Component. Complications related 
to the patella-femoral joint are one of the most common indications for 
revision knee replacement surgery. Early patellar implant designs had a 
metal backing covered by high-density polyethylene; these implants were 
associated with a high rate of failure due to fracture of the 
relatively thin polyethylene bearing surface. Other common reasons for 
isolated patellar component revision include poor tracking of the 
patella in the femoral groove leading to wear and breakage of the 
implant, fracture of the patella with or without loosening of the 
patellar implant, rupture of the quadriceps or patellar tendon, and 
infection.
     Revision of All Components (Tibial, Femoral, and 
Patellar). The most common type of revision knee replacement procedure 
is a complete total knee revision. A complete revision of all implants 
is more common in knee replacements than hip replacements because the 
components of an artificial knee are not compatible across vendors or 
types of prostheses. Therefore, even if only one of the implants is 
loose or broken, a complete revision of all components is often 
required in order to ensure that the implants are compatible. Complete 
total knee revision often involves extensive surgical approaches, 
including osteotomizing (for example, cutting) the tibia bone in order 
to adequately expose the knee joint and gain access to the implants. 
These procedures often involve extensive bone loss, requiring 
reconstruction with specialized implants with long stems and metal 
augments or bone graft to fill bony defects. Depending on the status of 
the ligaments in the knee, complete total knee revision at times 
requires implantation of a highly constrained or ``hinged'' knee 
replacement in order to ensure stability of the knee joint.
     Reimplantation from previous resection or cement spacer. 
In cases of deep infection of a prosthetic knee, removal of the 
implants with implantation of an antibiotic-impregnated cement spacer, 
followed by 6 weeks of intravenous antibiotics is often required in 
order to clear the infection. Revision knee replacement from an 
antibiotic impregnated cement spacer often involves complex bony 
reconstruction due to extensive bone loss that occurs as a result of 
the infection and removal of the often well-fixed implants. As noted 
above, the clinical outcomes following revision from a spacer are often 
poor due to limited functional capacity while the spacer is in place, 
prolonged periods of protected weight bearing (following reconstruction 
of extensive bony defects), and the possibility of chronic infection.
    The surgeons stated that the current ICD-9-CM codes did not 
adequately capture the complex nature of revisions of hip and knee 
replacements. Currently, code 81.53 (Revision of hip replacement) 
captures all ``partial'' and ``total'' revision hip replacement 
procedures. Code 81.55 (Revision of knee replacement) captures all 
revision knee replacement procedures. These two codes currently capture 
a wide variety of procedures that differ in their clinical indications, 
resource intensity, and clinical outcomes.
    An AAOS representative made a presentation at the October 7-8, 2004 
ICD-9-CM Coordination and Maintenance Committee. Based on the comments 
received at the October 7-8, 2004 meeting and subsequent written 
comments, new ICD-9-CM procedure codes were developed to better capture 
the variety of ways that revision of hip and knee replacements can be 
performed: codes 00.70 through 00.73 and code 81.53 for revisions of 
hip replacements and codes 00.80 through 00.84 and code 81.55 for 
revisions of knee replacements. These new and revised procedure codes, 
which will be effective on October 1, 2005, can be found in Table 6B 
and Table 6F of this proposed rule. The commenters stated that claims 
data using these new and specific codes should provide improved data on 
these procedures for future DRG modifications.
    However, the commenters requested that CMS consider DRG 
modifications based on current data using the existing revision codes. 
The commenters reported on a recently completed study comparing 
detailed hospital resource utilization and clinical characteristics in 
over 10,000 primary and revision hip and knee replacement procedures at 
3 high volume institutions: The Massachusetts General Hospital, the 
Mayo Clinic, and the University of California at San Francisco. The 
purpose of this study was to evaluate differences in clinical outcomes 
and resource utilization among patients who underwent different types 
of primary and revision hip or knee replacement procedures. The study 
found significant differences in operative time, complication rates, 
hospital length of stay, discharge disposition, and resource 
utilization among patients who underwent different types of revision 
hip or knee replacement procedures.
    Among revision hip replacement procedures, patients who underwent 
both femoral and acetabular component revision had longer operative 
times, higher complication rates, longer lengths of stay, significantly 
higher resource utilization, and were more likely to be discharged to a 
subacute care facility. Isolated femoral

[[Page 23327]]

component revision was the next most resource-intensive procedure, 
followed by isolated acetabular revision. Primary hip replacement was 
the least resource intensive of all the procedures studied. Similarly, 
among revision knee replacement procedures, patients who underwent 
complete revision of all components had longer operative times, higher 
complication rates, longer lengths of stay, and significantly higher 
resource utilization. Revision of one component was the next most 
resource-intensive procedure. Primary total knee replacement was the 
least resource intensive of all the procedures studied.
    In addition, the commenters indicated that the data showed that 
extensive bone loss around the implants and the presence of a peri-
prosthetic fracture were the most significant predictors of higher 
resource utilization among all revision hip and knee replacement 
procedures, even when controlling for other significant patient and 
procedural characteristics.
    For this proposed rule, we examined data in the FY 2004 MedPAR file 
on the current hip replacement procedures (codes 81.51, 81.52, 81.53) 
as well as the replacements and revisions of knee replacement 
procedures (codes 81.54 and 81.55) in DRG 209. We found that revisions 
were significantly more resource intensive than the original hip and 
knee replacements. We found average charges for revisions of hip and 
knee replacements were approximately $7,000 higher than average charges 
for the original joint replacements, as shown in the following charts. 
The average charges for revisions of hip replacements were 21 percent 
higher than the average charges for initial hip replacements. The 
average charges for revisions of knee replacements were 25 percent 
higher than for initial knee replacements.
[GRAPHIC] [TIFF OMITTED] TP04MY05.011

    We note that there were no cases in DRG 209 for reattachment of the 
foot, lower leg, or thigh (codes 84.29, 84.27, and 84.28).
    To address the higher resource costs associated with hip and knee 
revisions relative to the initial joint replacement procedure, we are 
proposing to delete DRG 209, create a proposed new DRG 544 (Major Joint 
Replacement or Reattachment of Lower Extremity), and create a proposed 
new DRG 545 (Revision of Hip or Knee Replacement).
    We are proposing to assign the following codes to the new proposed 
DRG 544:
     81.51, Total hip replacement.
     81.52, Partial hip replacement.
     81.54, Total knee replacement.
     81.56, Total ankle replacement.
     84.26, Foot reattachment.
     84.27, Lower leg/ankle reattach.
     84.28, Thigh reattachment.
    We are proposing to assign the following codes to the proposed new 
DRG 545:
     00.70, Revision of hip replacement, both acetabular and 
femoral components.
     00.71, Revision of hip replacement, acetabular component.
     00.72, Revision of hip replacement, femoral component.
     00.73, Revision of hip replacement, acetabular liner and/
or femoral head only.
     00.80, Revision of knee replacement, total (all 
components).
     00.81, Revision of knee replacement, tibial component.
     00.82, Revision of knee replacement, femoral component.
     00.83, Revision of knee replacement, patellar component.
     00.84, Revision of knee replacement, tibial insert 
(liner).
     81.53, Revision of hip replacement, not otherwise 
specified.
     81.55, Revision of knee replacement, not otherwise 
specified.
    We agree with the commenters and the AAOS that the creation of a 
new DRG for revisions of hip and knee replacements should resolve 
payment issues for hospitals that perform the more difficult revisions 
of joint replacements. In addition, as stated earlier, we have worked 
with the orthopedic community to develop new procedure codes that 
better capture data on the types of revisions of hip and knee 
replacements. These new codes will be implemented on October 1, 2005. 
Once we receive claims data using these new codes, we will review data 
to determine if additional DRG modifications are needed. This effort 
may include assigning some of the revision codes, such as 00.83 and 
00.84 to a separate DRG. As stated earlier, the AAOS has found that 
some of the procedures may not be as resource intensive. Therefore, the 
AAOS has requested that CMS closely examine data from the use of the 
new codes and consider future revisions.
b. Kyphoplasty
    In the FY 2005 IPPS final rule (69 FR 48938), we discussed the 
creation of new codes for vertebroplasty (81.65) and kyphoplasty 
(81.66), which went into effect on October 1, 2004. Prior to October 1, 
2004, both of these surgical procedures were assigned to code 78.49 
(Other repair or plastic operation on bone). For FY 2005, we assigned 
these codes to DRGs 233 and 234 (Other Musculoskeletal System and 
Connective Tissue O.R. Procedure With and Without CC, respectively) in 
MDC 8 (Table 6B of the FY 2005 final rule). (In the FY 2005 IPPS final 
rule (69 FR 48938), we indicated that new codes 81.65 and 81.66 were 
assigned to DRGs 223 and 234. We made a typographical error when 
indicating that these codes were assigned to DRG 223. Codes 81.65 and 
81.66 have been assigned to DRGs

[[Page 23328]]

233 and 234.) Last year, we received comments opposing the assignment 
of code 81.66 to DRGs 233 and 234. The commenters supported the 
creation of the codes for kyphoplasty and vertebroplasty but 
recommended that code 81.66 be assigned to DRGs 497 and 498 (Spinal 
Fusion Except Cervical With and Without CC, respectively). The 
commenters stated that kyphoplasty requires special inflatable bone 
tamps and bone cement and is a significantly more resource intensive 
procedure than vertebroplasty. The commenters further stated that, 
while kyphoplasty involves internal fixation of the spinal fracture and 
restoration of vertebral heights, vertebroplasty involves only 
fixation. The commenters indicated that hospital costs for kyphoplasty 
procedures are more similar to resources used in a spinal fusion.
    We stated in the FY 2005 IPPS final rule that we did not have data 
in the MedPAR file on kyphoplasty and vertebroplasty. Prior to October 
1, 2004, both procedures were assigned in code 78.49, which was 
assigned to DRGs 233 and 234 in MDC 8. We stated that we would continue 
to review this area as part of our annual review of MedPAR data. While 
we do not have separate data for kyphoplasty because code 81.66 was not 
established until October 1, 2004, for this proposed rule, we did 
examine data on code 78.49, which includes both kyphoplasty and 
vertebroplasty procedures reported in DRGs 233 and 234. The following 
chart illustrates our findings:
[GRAPHIC] [TIFF OMITTED] TP04MY05.012

    We do not believe these data findings support moving cases 
represented by code 78.49 out of DRGs 233 and 234. While we cannot 
distinguish cases that are kyphoplasty from cases that are 
vertebroplasty, cases represented by code 78.49 have lower charges than 
do other cases within DRGs 233 and 234. Therefore, we are not proposing 
to change the DRG assignment of code 81.66 to DRGs 233 and 234 at this 
time. However, once specific charge data are available, we will 
consider whether further changes are warranted.
c. Multiple Level Spinal Fusion
    On October 1, 2003, the following ICD-9-CM codes were created to 
identify the number of levels of vertebra fused during a spinal fusion 
procedure:
     81.62, Fusion or refusion of 2-3 vertebrae.
     81.63, Fusion or refusion of 4-8 vertebrae.
     81.64, Fusion or refusion of 9 or more vertebrae.
    Prior to the creation of these codes, we received a comment 
recommending the establishment of new DRGs that would be differentiated 
based on the number of vertebrae fused. In the FY 2005 IPPS final rule 
(69 FR 48936), we stated that we did not yet have any reported cases 
utilizing these multiple level spinal fusion codes. We stated that we 
would wait until sufficient data were available prior to making a final 
determination on whether to create separate DRGs based on the number of 
vertebrae fused. We also stated that spinal fusion surgery was an area 
undergoing rapid changes.
    Effective October 1, 2004, we created a series of codes that 
describe a new type of spinal surgery, spinal disc replacement. Our 
medical advisors describe these procedures as a more conservative 
approach for back pain than the spinal fusion surgical procedure. These 
codes are as follows:
     84.60, Insertion of spinal disc prosthesis, not otherwise 
specified.
     84.61, Insertion of partial spinal disc prosthesis, 
cervical.
     84.62, Insertion of total spinal disc prosthesis, 
cervical.
     84.63, Insertion of spinal disc prosthesis, thoracic.
     84.64, Insertion of partial spinal disc prosthesis, 
lumbosacral.
     84.65, Insertion of total spinal disc prosthesis, 
lumbosacral.
     84.66, Revision or replacement of artificial spinal disc 
prosthesis, cervical.
     84.67, Revision or replacement of artificial spinal disc 
prosthesis, thoracic.
     84.68, Revision or replacement of artificial spinal disc 
prosthesis, lumbosacral.
     84.69, Revision or replacement of artificial spinal disc 
prosthesis, not otherwise specified.
    We also created the following two codes effective October 1, 2004, 
for these new types of spinal surgery that are also a more conservative 
approach to back pain than is spinal fusion:
     81.65 Vertebroplasty.
     81.66 Kyphoplasty.
    We do not yet have data in the MedPAR file on these new types of 
procedures. Therefore, we cannot yet determine what effect these new 
types of procedures will have on the frequency of spinal fusion 
procedures.
    However, we do have data in the MedPAR file on multiple level 
spinal procedures for analysis for this year's proposed rule. We 
examined data in the FY 2004 MedPAR file on spinal fusion cases in the 
following DRGs:
     DRG 496 (Combined Anterior/Posterior Spinal Fusion).
     DRG 497 (Spinal Fusion Except Cervical With CC).
     DRG 498 (Spinal Fusion Except Cervical Without CC).
     DRG 519 (Cervical Spinal Fusion With CC).
     DRG 520 (Cervical Spinal Fusion Without CC).
    Multiple level spinal fusion is captured by code 81.63 (Fusion or 
refusion of 4-8 vertebrae) and code 81.64 (Fusion or refusion of 9 or 
more vertebrae). Code 81.62 includes the fusion of 2-3 vertebrae and is 
not considered a multiple level spinal fusion. Orthopedic surgeons 
stated at the October 7-8, 2004 ICD-9-CM Coordination and Maintenance 
Committee meeting that the most simple and common type of spinal fusion 
involves fusing either 2 or 3 vertebrae. These surgeons stated that 
there was not

[[Page 23329]]

a significant difference in resource utilization for cases involving 
the fusion of 2 versus 3 vertebrae. For this reason, the orthopedic 
surgeons recommended that fusion of 2 and 3 vertebrae be grouped into 
one ICD-9-CM code.
    We reviewed the Medicare charge data to determine whether the 
number of vertebrae fused or specific diagnoses have an effect on 
average length of stay and resource use for a patient. We found that, 
while fusing 4 or more levels of the spine results in a small increase 
in the average length of stay and a somewhat larger increase in average 
charges for spinal fusion patients, an even greater impact was made by 
the presence of a principal diagnosis of curvature of the spine or 
malignancy. The following list of diagnoses describes conditions that 
have a significant impact on resource use for spinal fusion patients:
     170.2, Malignant neoplasm of vertebral column, excluding 
sacrum and coccyx.
     198.5, Secondary malignant neoplasm of bone and bone 
marrow.
     732.0, Juvenile osteochondrosis of spine.
     733.13, Pathologic fracture of vertebrae.
     737.0, Adolescent postural kyphosis.
     737.10, Kyphosis (acquired) (postural).
     737.11, Kyphosis due to radiation.
     737.12, Kyphosis, postlaminectomy.
     737.19, Kyphosis (acquired), other.
     737.20, Lordosis (acquired) (postural).
     737.21, Lordosis, postlaminectomy
     737.22, Other postsurgical lordosis.
     737.29, Lordosis (acquired), other.
     737.30, Scoliosis [and kyphoscoliosis], idiopathic.
     737.31, Resolving infantile idiopathic scoliosis.
     737.32, Progressive infantile idiopathic scoliosis.
     737.33, Scoliosis due to radiation.
     737.34, Thoracogenic scoliosis.
     737.39, Other kyphoscoliosis and scoliosis.
     737.40, Curvature of spine, unspecified.
     737.41, Curvature of spine associated with other 
conditions, kyphosis.
     737.42, Curvature of spine associated with other 
conditions, lordosis.
     737.43, Curvature of spine associated with other 
conditions, scoliosis.
     737.8, Other curvatures of spine.
     737.9, Unspecified curvature of spine.
     754.2, Congenital scoliosis.
     756.51, Osteogenesis imperfecta.
    The majority of fusion patients with these diagnoses were in DRGs 
497 and 498. The chart below reflects our findings. We also include in 
the chart statistics for cases in DRGs 497 and 498 with spinal fusion 
of 4 or more vertebrae and cases with a principal diagnosis of 
curvature of the spine or bone malignancy.
[GRAPHIC] [TIFF OMITTED] TP04MY05.013

    Thus, these diagnoses result in a significant increase in resource 
use. While the fusing of 4 or more vertebrae resulted in average 
charges of $77,352, the impact of a principal diagnosis of curvature of 
the spine or bone malignancy was substantially greater with average 
charges of $95,315.
    Based on this analysis, we are proposing to create a new DRG for 
noncervical spinal fusions with a principal diagnosis of curvature of 
the spine and malignancies. The proposed new DRG would be: proposed new 
DRG 546 (Spinal Fusions Except Cervical With Principal Diagnosis of 
Curvature of the Spine or Malignancy). Cases included in this proposed 
new DRG would include all noncervical spinal fusions previously 
assigned to DRGs 497 and 498 that have a principal diagnosis of 
curvature of the spine or malignancy and would include the following 
codes listed above: 170.2, 198.5, 732.0, 733.13, 737.0, 737.10, 737.11, 
737.12, 737.19, 737.20, 737.21, 737.22, 737.29, 737.30, 737.31, 737.32, 
737.33, 737.34, 737.39, 737.40, 737.41, 737.42, 737.43, 737.8, 737.9, 
754.2, and 756.51. The proposed DRG 546 would not include cases 
currently assigned to DRGs 496, 519, or 520 that have a principal 
diagnosis of curvature of the spine or malignancy. The structure of 
DRGs 496, 519, and 520 would remain the same.
    As part of our meeting with the AAOS on DRG 209 in February 2005 
(discussed under section II.B.6.a. of this preamble), the AAOS offered 
to work with CMS to analyze clinical issues and make revisions to the 
spinal fusion DRGs (DRGs 496 through 498 and 519 and 520). At this 
time, we are limiting our proposed changes to the spinal fusion DRGs 
for FY 2006 to the creation of the proposed DRG 546 discussed above. 
However, we look forward to working with the AAOS to obtain its 
clinical recommendations concerning our proposed changes and potential 
additional modifications to the spinal fusion DRGs. We are also 
soliciting comments from the public on our proposed changes and how to 
incorporate new types of spinal procedures such as kyphoplasty and 
spinal disc prostheses into the spinal fusion DRGs.
7. MDC 18 (Infectious and Parasitic Diseases (Systemic or Unspecified 
Sites)): Severe Sepsis
    As we did for FY 2005, we received a request to consider the 
creation of a separate DRG for the diagnosis of severe sepsis for FY 
2006. Severe sepsis is described by ICD-9-CM code 995.92 (Systemic 
inflammatory response syndrome due to infection with organ 
dysfunction). Patients admitted with sepsis currently are assigned to 
DRG 416 (Septicemia Age > 17) and DRG 417

[[Page 23330]]

(Septicemia Age 0-17) in MDC 18 (Infectious and Parasitic Diseases, 
Systemic or Unspecified Sites). The commenter requested that all cases 
in which severe sepsis is present on admission, as well as those cases 
in which it develops after admission (which are currently classified 
elsewhere), be included in this new DRG. We addressed this issue in the 
FY 2005 IPPS final rule (69 FR 48975). As indicated last year, we do 
not feel the current clinical definition of severe sepsis is specific 
enough to identify a meaningful cohort of patients in terms of clinical 
coherence and resource utilization to warrant a separate DRG. Sepsis is 
found across hundreds of medical and surgical DRGs, and the term 
``organ dysfunction'' implicates numerous currently existing diagnosis 
codes. While we recognize that Medicare beneficiaries with severe 
sepsis are quite ill and require extensive hospital resources, we do 
not believe that they can be identified adequately to justify removing 
them from all of the other DRGs in which they appear. We are not 
proposing a new DRG for severe sepsis at this time.
8. MDC 20 (Alcohol/Drug Use and Alcohol/Drug Induced Organic Mental 
Disorders): Drug-Induced Dementia
    In the FY 2005 IPPS final rule (69 FR 48939, August 11, 2004), we 
discussed a request that CMS modify DRGs 521 through 523 by removing 
the principal diagnosis code 292.82 (Drug-induced dementia) from these 
alcohol and drug abuse DRGs. These DRGs are as follows:
     DRG 521 (Alcohol/Drug Abuse or Dependence With CC).
     DRG 522 (Alcohol/Drug Abuse or Dependence With 
Rehabilitation Therapy Without CC).
     DRG 523 (Alcohol/Drug Abuse or Dependence Without 
Rehabilitation Therapy Without CC).
    The commenter indicated that a patient who has a drug-induced 
dementia should not be classified to an alcohol/drug DRG. However, the 
commenter did not propose a new DRG assignment for code 292.82. Our 
medical advisors evaluated the request and determined that the most 
appropriate DRG classification for a patient with drug-induced dementia 
was within MDC 20. The medical advisors indicated that because the 
dementia is drug induced, it is appropriately classified to DRGs 521 
through 523 in MDC 20. Therefore, we did not propose a new DRG 
classification for the principal diagnosis code 292.82.
    In the FY 2005 IPPS final rule, we addressed a comment from an 
organization representing hospital coders that disagreed with our 
decision to keep code 292.82 in DRGs 521 through 523. The commenter 
stated that DRGs 521 through 523 are described as alcohol/drug abuse 
and dependence DRGs, and that drug-induced dementia can be caused by an 
adverse effect of a prescribed medication or a poisoning. The commenter 
did not believe that assignment to DRGs 521 through 523 was appropriate 
if the drug-induced dementia is due to one of these events and the 
patient is not alcohol or drug dependent. The commenter recommended 
that admissions for drug-induced dementia be classified to DRGs 521 
through 523 only if there is a secondary diagnosis indicating alcohol/
drug abuse or dependence.
    The commenter recommended that drug-induced dementia that is due to 
the adverse effect of a drug or poisoning be classified to the same 
DRGs as other types of dementia, such as DRG 429 (Organic Disturbances 
and Mental Retardation). The commenter believed that when drug-induced 
dementia is caused by a poisoning, either accidental or intentional, 
the appropriate poisoning code would be sequenced as the principal 
diagnosis and, therefore, these cases would likely already be assigned 
to DRGs 449 and 450 (Poisoning and Toxic Effects of Drugs, Age Greater 
than 17, With and Without CC, respectively) and DRG 451 (Poisoning and 
Toxic Effects of Drugs, Age 0-17). The commenter stated that these 
would be the appropriate DRG assignments for drug-induced dementia due 
to a poisoning. We received a similar comment from a hospital 
organization.
    In the FY 2005 IPPS final rule, we acknowledged that the commenters 
raised additional issues surrounding the DRG assignment for code 292.82 
that should be considered. The commenters provided alternatives for DRG 
assignment based on sequencing of the principal diagnosis and reporting 
of additional secondary diagnoses. We recognized that patients may 
develop drug-induced dementia from drugs that are prescribed, as well 
as from drugs that are not prescribed. However, because dementia 
develops as a result of use of a drug, we believed the current DRG 
assignment to DRGs 521 through 523 remained appropriate. Some 
commenters have agreed with the current DRG assignment of code 292.82 
since the dementia was caused by use of a drug. We agree that if either 
accidental or intentional poisoning caused the drug-induced dementia, 
the appropriate poisoning code should be sequenced as the principal 
diagnosis. As one commenter stated, these cases would be assigned to 
DRGs 449 through 451. We encouraged hospitals to examine the coding for 
these types of cases to determine if there were any coding or 
sequencing errors. As suggested by the commenter, if code 292.82 were 
reported as a secondary diagnosis and not a principal diagnosis in 
cases of poisoning or adverse drug reactions, the number of cases on 
DRGs 521 through 523 would decline.
    In the FY 2005 IPPS final rule, we agreed to analyze this area for 
FY 2006 and to look at the alternative DRG assignments suggested by the 
commenters. For this proposed rule, we examined data from the FY 2004 
MedPAR file on cases in DRGs 521 through 523 with a principal diagnosis 
of code 292.82. We found that there were only 134 cases reported with 
the principal diagnosis code 292.82 in DRGs 521 through 523 without a 
diagnosis of drug and alcohol abuse. The average standardized charges 
for cases with a principal diagnosis of code 292.82 that did not have a 
secondary diagnosis of drug/alcohol abuse or dependence were 
$12,244.35, compared to the average standardized charges for all cases 
in DRG 521, which were $10,543.69. There were no cases in DRG 522 with 
a principal diagnosis of code 292.82. We found only 24 cases in DRG 523 
with a principal diagnosis of code 292.82. Given the small number of 
cases in DRG 522 and 523, and the similarity in average standardized 
charges between those cases in DRG 521 with a principal diagnosis of 
code 292.82 and without a secondary diagnosis of drug/alcohol abuse or 
dependence to the overall average for all cases in the DRG, we do not 
believe the data suggest that a modification to DRGs 521 through 523 is 
warranted. Therefore, we are not proposing changes to the current 
structure of DRGs 521 through 523 for FY 2006.
9. Medicare Code Editor (MCE) Changes
    (If you choose to comment on issues in this section, please include 
the caption ``Medicare Code Editor'' at the beginning of your comment.)
    As explained under section II.B.1. of this preamble, the Medicare 
Code Editor (MCE) is a software program that detects and reports errors 
in the coding of Medicare claims data. Patient diagnoses, procedure(s), 
discharge status, and demographic information go into the Medicare 
claims processing systems and are subjected to a series of automated 
screens. The MCE screens are designed to identify cases that require 
further review before classification into a DRG.

[[Page 23331]]

a. Newborn Age Edit
    In the past, we have discussed and received comments concerning 
revision of the pediatric portions of the Medicare IPPS DRG 
classification system, that is, MDC 15 (Newborns and Other Neonates 
With Conditions Originating in the Perinatal Period). Most recently, we 
addressed these comments in both the FY 2005 proposed rule (69 FR 
28210) and the FY 2005 IPPS final rule (69 FR 48938). In those rules, 
we indicated that we would be responsive to specific requests for 
updating MDC 15 on a limited, case-by-case basis.
    We have recently received a request through the Open Door Forum to 
revise the MCE ``newborn age edit'' by removing over 100 codes located 
in Chapter 15 of ICD-9-CM that are identified as ``newborn'' codes. 
This request was made because these codes usually cause an edit or 
denial to be triggered when they are used on children greater than 1 
year of age. However, the underlying issue with these particular edits 
is that other payers have adopted the CMS Medicare Code Editor in a 
wholesale manner, instead of adapting it for use in their own patient 
populations.
    We acknowledge that Medicare DRGs are sometimes used to classify 
other patient groups. However, CMS' primary focus of updates to the 
Medicare DRG classification system is on changes relating to the 
Medicare patient population, not the pediatric or neonatal patient 
populations.
    There are practical considerations regarding the assumption of a 
larger role for the Medicare DRG in the pediatric or neonatal areas, 
given the difference between the Medicare population and that of 
newborns and children. There are also challenges surrounding the 
development of DRG classification systems and applications appropriate 
to children. We do not have the clinical expertise to make decisions 
about these patients, and must rely on outside clinicians for advice. 
In addition, because newborns and other children are generally not 
eligible for Medicare, we must rely on outside data to make decisions. 
We recognize that there are evolving alternative classification systems 
for children and encourage payers to use the CMS MCE as a template 
while making modifications appropriate for pediatric patients.
    Therefore, we would encourage those non-Medicare systems needing a 
more comprehensive pediatric system of edits to update their systems by 
choosing from other existing systems or programs that are currently in 
use. Because of our reluctance to assume expertise in the pediatric 
arena, we are not proposing to make the commenter's suggested changes 
to the MCE ``newborn age edit'' for FY 2006.
b. Newborn Diagnoses Edit
    Last year, in our changes to the MCE, we inadvertently added code 
796.6 (Abnormal findings on neonatal screening) to both the MCE edit 
for ``Maternity Diagnoses--age 12 through 55'', and the MCE edit for 
``Diagnoses Allowed for Females Only''. We are proposing to remove code 
796.6 from these two edits and add it to the ``Newborn Diagnoses'' 
edit.
c. Diagnoses Allowed for ``Males Only'' Edit
    We have received a request to remove two codes from the ``Diagnoses 
Allowed for Males Only'' edit, related to androgen insensitivity 
syndrome (AIS). AIS is a new term for testicular feminization. Code 
257.8 (Other testicular dysfunction) is used to describe individuals 
who, despite having XY chromosomes, develop as females with normal 
female genitalia and mammary glands. Testicles are present in the same 
general area as the ovaries, but are undescended and are at risk for 
development of testicular cancer, so are generally surgically removed. 
These individuals have been raised as females, and would continue to be 
considered female, despite their XY chromosome makeup. Therefore, as 
AIS is coded to 257.8, and has posed a problem associated with the 
gender edit, we are proposing to remove this code from the ``Males 
Only'' edit in the MCE.
    A similar clinical scenario can occur with certain disorders that 
cause a defective biosynthesis of testicular androgen. This disorder is 
included in code 257.2 (Other testicular hypofunction). Therefore, we 
also are proposing to remove code 257.2 from the ``Male Only'' gender 
edit in the MCE.
d. Tobacco Use Disorder Edit
    We have become aware of the possible need to add code 305.1 
(Tobacco use disorder) to the MCE in order to make admissions for 
tobacco use disorder a noncovered Medicare service when code 305.1 is 
reported as the principal diagnosis. On March 22, 2005, CMS published a 
final decision memorandum and related national coverage determination 
(NCD) on smoking cessation counseling services on its Web site: (http://www.cms.hhs.gov/coverage/ coverage/). Among other things, this NCD provides 
that: ``Inpatient hospital stays with the principal diagnosis of 305.1, 
Tobacco Use Disorder, are not reasonable and necessary for the 
effective delivery of tobacco cessation counseling services. Therefore, 
we will not cover tobacco cessation services if tobacco cessation is 
the primary reason for the patient's hospital stay.'' Therefore, in 
order to maintain internal consistency with CMS programs and decisions, 
we are proposing to add code 305.1 to the MCE edit ``Questionable 
Admission-Principal Diagnosis Only'' in order to make tobacco use 
disorder a noncovered admission.
e. Noncovered Procedure Edit
    Effective October 1, 2004, CMS adopted the use of code 00.61 
(Percutaneous angioplasty or atherectomey of precerebral (extracranial) 
vessel(s) (PTA)) and code 00.63 (Percutaneous insertion of carotid 
artery stent(s). Both codes are to be recorded to indicate the 
insertion of a carotid artery stent or stents. At the time of the 
creation of the codes, the coverage indication for carotid artery 
stenting was only for patients in a clinical trial setting, and 
diagnostic code V70.7 (Examination of participation in a clinical 
trial) was required for payment of these cases. However, effective 
October 12, 2004, Medicare covers PTA of the carotid artery concurrent 
with the placement of an FDA-approved carotid stent for an FDA-approved 
indication when furnished in accordance with FDA-approved protocols 
governing post-approval studies. Therefore, as the coverage indication 
has changed, we are proposing to remove codes 00.61, 00.63, and V70.7 
from the MCE noncovered procedure edit.
10. Surgical Hierarchies
    (If you choose to comment on issues in this section, please include 
the caption ``Surgical Hierarchy'' at the beginning of your comment.)
    Some inpatient stays entail multiple surgical procedures, each one 
of which, occurring by itself, could result in assignment of the case 
to a different DRG within the MDC to which the principal diagnosis is 
assigned. Therefore, it is necessary to have a decision rule within the 
GROUPER by which these cases are assigned to a single DRG. The surgical 
hierarchy, an ordering of surgical classes from most resource-intensive 
to least resource-intensive, performs that function. Application of 
this hierarchy ensures that cases involving multiple surgical 
procedures are assigned to the DRG associated with the most resource-
intensive surgical class.
    Because the relative resource intensity of surgical classes can 
shift as a function of DRG reclassification and recalibrations, we 
reviewed the surgical

[[Page 23332]]

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, in cases involving multiple 
procedures, this result is sometimes unavoidable.
    We note that, notwithstanding the foregoing discussion, there are a 
few instances when a surgical class with a lower average charge is 
ordered above a surgical class with a higher average charge. For 
example, the ``other O.R. procedures'' surgical class is uniformly 
ordered last in the surgical hierarchy of each MDC in which it occurs, 
regardless of the fact that the average charge for the DRG or DRGs in 
that surgical class may be higher than that for other surgical classes 
in the MDC. The ``other O.R. procedures'' class is a group of 
procedures that are only infrequently related to the diagnoses in the 
MDC, but are still occasionally performed on patients in the MDC with 
these diagnoses. Therefore, assignment to these surgical classes should 
only occur if no other surgical class more closely related to the 
diagnoses in the MDC is appropriate.
    A second example occurs when the difference between the average 
charges for two surgical classes is very small. We have found that 
small differences generally do not warrant reordering of the hierarchy 
because, as a result of reassigning cases on the basis of the hierarchy 
change, the average charges are likely to shift such that the higher-
ordered surgical class has a lower average charge than the class 
ordered below it.
    Based on the preliminary recalibration of the DRGs, we are 
proposing to revise the surgical hierarchy for MDC 5 (Diseases and 
Disorders of the Circulatory System) and MDC 8 (Diseases and Disorders 
of the Musculoskeletal System and Connective Tissue) as follows:
    In MDC 5, we are proposing to reorder--
     DRG 116 (Other Permanent Cardiac Pacemaker Implant) above 
DRG 549 (Percutaneous Cardiovascular Procedure With Drug-Eluting Stent 
With AMI With CC).
     DRG 549 above DRG 550 (Percutaneous Cardiovascular 
Procedure With Drug-Eluting Stent With AMI Without CC).
     DRG 550 above DRG 547 (Percutaneous Cardiovascular 
Procedure With AMI With CC).
     DRG 547 above DRG 548 (Percutaneous Cardiovascular 
Procedure With AMI Without CC).
     DRG 548 above DRG 527 (Percutaneous Cardiovascular 
Procedure With Drug-Eluting Stent Without AMI).
     DRG 527 above DRG 517 (Percutaneous Cardiovascular 
Procedure With Non-Drug Eluting Stent Without AMI).
     DRG 517 above DRG 518 (Percutaneous Cardiovascular 
Procedure Without Coronary Artery Stent or AMI).
     DRG 518 above DRGs 478 and 479 (Other Vascular Procedures 
With and Without CC, respectively).
    In MDC 8, we are proposing to reorder--
     DRG 496 (Combined Anterior/Posterior Spinal Fusion) above 
DRG 546 (Spinal Fusion Except Cervical With Principal Diagnosis of 
Curvature of the Spine or Malignancy).
     DRG 546 above DRGs 497 and 498 (Spinal Fusion Except 
Cervical With and Without CC, respectively).
     DRG 217 (Wound Debridement and Skin Graft Except Hand, For 
Musculoskeletal and Connective Tissue Disease) above DRG 545 (Revision 
of Hip or Knee Replacement).
     DRG 545 above DRG 544 (Major Joint Replacement or 
Reattachment).
     DRG 544 above DRGs 519 and 520 (Cervical Spinal Fusion 
With and Without CC, respectively).
11. Refinement of Complications and Comorbidities (CC) List
    (If you choose to comment on issues in this section, please include 
the caption ``CC List'' at the beginning of your comment.)
a. Background
    As indicated earlier in this preamble, under the IPPS DRG 
classification system, we have developed a standard list of diagnoses 
that are considered complications or comorbidities (CCs). Historically, 
we developed this list using physician panels that classified each 
diagnosis code based on whether the diagnosis, when present as a 
secondary condition, would be considered a substantial complication or 
comorbidity. A substantial complication or comorbidity was defined as a 
condition that, because of its presence with a specific principal 
diagnosis, would cause an increase in the length of stay by at least 1 
day in at least 75 percent of the patients.
b. Comprehensive Review of the CC List
    In previous years, we have made changes to the standard list of 
CCs, either by adding new CCs or deleting CCs already on the list, but 
we have never conducted a comprehensive review of the list. There are 
currently 3,285 diagnosis codes on the CC list. There are 121-paired 
DRGs that are split on the presence or absence of a CC.
    We have reviewed these paired DRGs and found that the majority of 
cases that are assigned to DRGs that have a CC split fall into the DRG 
with CC. While this fact is not new, we have found that a much higher 
proportion of cases are being grouped to the DRG with a CC than had 
occurred in the past. In our review of the DRGs included in Table 7b of 
the September 1, 1987 Federal Register rule (52 FR 33125), we found the 
following percentages of cases assigned a CC in those DRGs that had a 
CC split (DRG Definitions Manual, GROUPER Version 5.0 (1986 data)):
     Cases with CC: 61.9 percent.
     Cases without CC: 38.1 percent.
    When we compared the above DRG 1986 data to the DRG 2004 data that 
were included in the DRGs Definitions Manual, GROUPER Version 22.0, we 
found the following:
     Cases with CC: 79.9 percent.

[[Page 23333]]

     Cases without CC: 20.1 percent.
    (We used DRGs Definitions Manual, GROUPER Version 5.0, for this 
analysis because prior versions of the DRGs Definitions Manual used age 
as a surrogate for a CC and the split was ``CC and/or age greater than 
69''.)
    The vast majority of patients being treated in inpatient settings 
have a CC as currently defined, and we believe that it is possible that 
the CC distinction has lost much of its ability to differentiate the 
resource needs of patients. The original definition used to develop the 
CC list (the presence of a CC would be expected to extend the length of 
stay of at least 75 percent of the patients who had the CC by at least 
one day) was used beginning in 1981 and has been part of the IPPS since 
its inception in 1983. There has been no substantive review of the CC 
list since its original development. In reviewing this issue, our 
clinical experts found several diseases that appear to be obvious 
candidates to be on the CC list, but currently are not:
[GRAPHIC] [TIFF OMITTED] TP04MY05.014

    Conversely, our medical experts believe the following conditions 
are examples of common conditions that are on the CC list, but are not 
likely to lead to higher treatment costs when present as a secondary 
diagnosis:
[GRAPHIC] [TIFF OMITTED] TP04MY05.015

    We note that the above conditions are examples only of why we 
believe the CC list needs a comprehensive review. In addition to this 
review, we note that these conditions may be treated differently under 
several DRG systems currently in use. For instance, ICD-9-CM code 
414.12 (Dissection of coronary artery) is listed as a ``Major CC'' 
under the All Patient (AP) DRGs, GROUPER Version 21.0 and an 
``Extreme'' CC under the All Patient Refined (APR) DRGs, GROUPER 
Version 20.0, but is not listed as a CC at all in GROUPER Version 22.0 
of the DRGs Definitions Manual used by Medicare. Similarly, ICD-9-CM 
code 424.0 (Mitral valve disorder) is a CC under GROUPER Version 22.0 
of the DRGs Definitions Manual for Medicare's DRG system, a minor CC 
under the GROUPER Version 20.0 of the APR-DRGs, and not a CC at all 
under GROUPER Version 21.0 of the AP-DRGs.
    Given the long period of time that has elapsed since the original 
CC list was developed, the incremental nature of changes to it, and 
changes in the way inpatient care is delivered, we are planning a 
comprehensive and systematic review of the CC list for the IPPS rule 
for FY 2007. As part of this process, we plan to consider revising the 
standard for determining when a condition is a CC. For instance, we may 
use an alternative to classifying a condition as a CC based on how it 
affects the length of stay of a case. Similar to other aspects of the 
DRG system, we may consider the effect of a specific secondary 
diagnosis on the charges or costs of a case to evaluate whether to 
include the condition on the CC list. Using a statistical algorithm, we 
may classify each diagnosis based on its effect on hospital charges (or 
costs) relative to other cases when present as a secondary diagnosis to 
obtain better information on when a particular condition is likely to 
increase hospital costs. For example, Code 293.84 (Anxiety disorder in 
conditions classified elsewhere), which is currently listed as a CC, 
might be removed from the CC list if analysis of the data do not 
support the fact that it represents a significant increase in resource 
utilization, and a code such as 359.4 (Toxic myopathy), which is 
currently not listed as a CC, could be added to the CC list if the data 
support it. In addition to using hospital charge data as a basis for a 
review, we would expect to supplement the process with review by our 
medical experts. Further, we may also consider doing a comparison of 
the Medicare DRG CC list with other DRG systems such as the AP-DRGs and 
the APR-DRGs to determine how the same secondary diagnoses are treated 
under these systems.

[[Page 23334]]

    By performing a comprehensive review of the CC list, we expect to 
revise the DRG classification system to better reflect resource 
utilization and remove conditions from the CC list that only have a 
marginal impact on a hospital's costs. We believe that a comprehensive 
review of the CC list would be consistent with MedPAC's recommendation 
that we improve the DRG system to better recognize severity. We will 
provide more detail about how we expect to undertake this analysis in 
the future, and any changes to the CC list will only be adopted after a 
notice and comment rulemaking that fully explains the methodology we 
plan to use in conducting this review. We encourage comment at this 
time regarding possible ways that more meaningful indicators of 
clinical severity and their implications for resource use can be 
incorporated into our comprehensive review and possible restructuring 
of the CC list.
c. CC Exclusions List for FY 2006
    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. As we indicated above, 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. At this time, we are not 
proposing to delete any of the diagnosis codes on the CC list for FY 
2006.
    In the May 19, 1987 proposed notice (52 FR 18877) and the September 
1, 1987 final notice (52 FR 33154), we explained that the excluded 
secondary diagnoses were established using the following five 
principles:
     Chronic and acute manifestations of the same condition 
should not be considered CCs for one another.
     Specific and nonspecific (that is, not otherwise specified 
(NOS)) diagnosis codes for the same condition should not be considered 
CCs for one another.
     Codes for the same condition that cannot coexist, such as 
partial/total, unilateral/bilateral, obstructed/unobstructed, and 
benign/malignant, should not be considered CCs for one another.
     Codes for the same condition in anatomically proximal 
sites should not be considered CCs for one another.
     Closely related conditions should not be considered CCs 
for one another.
    The creation of the CC Exclusions List was a major project 
involving hundreds of codes. 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.\1\
---------------------------------------------------------------------------

    \1\ See the FY 1989 final rule (53 FR 38485) [September 30, 
1988] for the revision made for the discharges occurring in FY 1989; 
the FY 1990 final rule (54 FR 36552) [September 1, 1989] for the FY 
1990 revision; the FY 1991 final rule (55 FR 36126) [September 4, 
1990] for the FY 1991 revision; the FY 1992 final rule (56 FR 43209) 
[August 30, 1991] for the FY 1992 revision; the FY 1993 final rule 
(57 FR 39753) [September 1, 1992] for the FY 1993 revision; the FY 
1994 final rule (58 FR 46278) [September 1, 1993] for the FY 1994 
revisions; the FY 1995 final rule (59 FR 45334) [September 1, 1994] 
for the FY 1995 revisions; the FY 1996 final rule (60 FR 45782) 
[September 1, 1995] for the FY 1996 revisions; the FY 1997 final 
rule (61 FR 46171) [August 30, 1996] for the FY 1997 revisions; the 
FY 1998 final rule (62 FR 45966) [August 29, 1997] for the FY 1998 
revisions; the FY 1999 final rule (63 FR 40954) [July 31, 1998] for 
the FY 1999 revisions; the FY 2001 final rule (65 FR 47064) [August 
1, 2000] for the FY 2001 revisions; the FY 2002 final rule (66 FR 
39851) [August 1, 2001] for the FY 2002 revisions; the FY 2003 final 
rule (67 FR 49998) [August 1, 2002] for the FY 2003 revisions; the 
FY 2004 final rule (68 FR 45364) [August 1, 2003] for the FY 2004 
revisions; and the FY 2005 final rule (69 FR 49848) [August 11, 
2004] for the FY 2005 revisions. In the FY 2000 final rule (64 FR 
41490) [July 30, 1999], we did not modify the CC Exclusions List 
because we did not make any changes to the ICD-9-CM codes for FY 
2000.
---------------------------------------------------------------------------

    We are proposing a limited revision of the CC Exclusions List to 
take into account the proposed changes that will be made in the ICD-9-
CM diagnosis coding system effective October 1, 2004. (See section 
II.B.13. of this preamble for a discussion of ICD-9-CM changes.) We are 
proposing these changes in accordance with the principles established 
when we created the CC Exclusions List in 1987.
    Tables 6G and 6H in the Addendum to this proposed rule contain the 
revisions to the CC Exclusions List that would be effective for 
discharges occurring on or after October 1, 2005. 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, 2005, 
the indented diagnoses would not be recognized by the GROUPER as valid 
CCs for the asterisked principal diagnosis.
    CCs that are deleted from the list are in Table 6H--Deletions from 
the CC Exclusions List. Beginning with discharges on or after October 
1, 2005, the indented diagnoses would be recognized by the GROUPER as 
valid CCs for the asterisked principal diagnosis.
    Copies of the original CC Exclusions List applicable to FY 1988 can 
be obtained from the National Technical Information Service (NTIS) of 
the Department of Commerce. It is available in hard copy for $152.50 
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, 2001, 2002, 2003, 2004, and 2005) and those in Tables 
6G and 6H of this proposed rule for FY 2006 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, 2005. (Note: 
There was no CC Exclusions List in FY 2000 because we did not make 
changes to the ICD-9-CM codes for FY 2000.)
    Alternatively, the complete documentation of the GROUPER logic, 
including the current CC Exclusions List, is available from 3M/Health 
Information Systems (HIS), which, under contract with CMS, is 
responsible for updating and maintaining the GROUPER program. The 
current DRG Definitions Manual, Version 22.0, is available for $225.00, 
which includes $15.00 for shipping and handling. Version 23.0 of this 
manual, which will include the final FY 2006 DRG changes, will be 
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.

[[Page 23335]]

12. Review of Procedure Codes in DRGs 468, 476, and 477
    (If you choose to comment on issues in this section, please include 
the caption ``DRGs 468, 476, and 477'' at the beginning of your 
comment.)
    Each year, we review cases assigned to DRG 468 (Extensive O.R. 
Procedure Unrelated to Principal Diagnosis), DRG 476 (Prostatic O.R. 
Procedure Unrelated to Principal Diagnosis), and DRG 477 (Nonextensive 
O.R. Procedure Unrelated to Principal Diagnosis) to determine whether 
it would be appropriate to change the procedures assigned among these 
DRGs.
    DRGs 468, 476, and 477 are reserved for those cases in which none 
of the O.R. procedures performed are related to the principal 
diagnosis. These DRGs are intended to capture atypical cases, that is, 
those cases not occurring with sufficient frequency to represent a 
distinct, recognizable clinical group. DRG 476 is assigned to those 
discharges in which one or more of the following prostatic procedures 
are performed and are unrelated to the principal diagnosis:
     60.0, Incision of prostate.
     60.12, Open biopsy of prostate.
     60.15, Biopsy of periprostatic tissue.
     60.18, Other diagnostic procedures on prostate and 
periprostatic tissue.
     60.21, Transurethral prostatectomy.
     60.29, Other transurethral prostatectomy.
     60.61, Local excision of lesion of prostate.
     60.69, Prostatectomy, not elsewhere classified.
     60.81, Incision of periprostatic tissue.
     60.82, Excision of periprostatic tissue.
     60.93, Repair of prostate.
     60.94, Control of (postoperative) hemorrhage of prostate.
     60.95, Transurethral balloon dilation of the prostatic 
urethra.
     60.96, Transurethral destruction of prostate tissue by 
microwave thermotherapy.
     60.97, Other transurethral destruction of prostate tissue 
by other thermotherapy.
     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.\2\
---------------------------------------------------------------------------

    \2\ 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 FY 1989 final rule (53 FR 38591). As part 
of the FY 1991 final rule (55 FR 36135), the FY 1992 final rule (56 
FR 43212), the FY 1993 final rule (57 FR 23625), the FY 1994 final 
rule (58 FR 46279), the FY 1995 final rule (59 FR 45336), the FY 
1996 final rule (60 FR 45783), the FY 1997 final rule (61 FR 46173), 
and the FY 1998 final rule (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 
final rule (63 FR 40962); in FY 2000 (64 FR 41496); in FY 2001 (65 
FR 47064); or in FY 2002 (66 FR 39852). In the FY 2003 final rule 
(67 FR 49999) we did not move any procedures from DRG 477. However, 
we did move procedure codes from DRG 468 and placed them in more 
clinically coherent DRGs. In the FY 2004 final rule (68 FR 45365), 
we moved several procedures from DRG 468 to DRGs 476 and 477 because 
the procedures are nonextensive. In the FY 2005 final rule (69 FR 
48950), we moved one procedure from DRG 468 to 477. In addition, we 
added several existing procedures to DRGs 476 and 477.
---------------------------------------------------------------------------

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 procedures in DRGs 
468 or 477 that should be removed to one of the surgical DRGs. 
Therefore, in this proposed rule, we are not proposing any changes for 
FY 2006.
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.
    It has come to our attention that procedure code 26.12 (Open biopsy 
of salivary gland or duct) is assigned to DRG 468 (Extensive O.R. 
Procedure Unrelated to Principal Diagnosis). We believe this to be an 
error, as code 26.31 (Partial sialoadenectomy), which is a more 
extensive procedure than code 26.12, is assigned to DRG 477. Therefore, 
we are proposing to correct this error by moving code 26.12 out of DRG 
468 and reassigning it to DRG 477.
    We are not proposing to move any procedure codes from DRG 476 to 
DRGs 468 or 477, or from DRG 477 to DRGs 468 or 476.
c. Adding Diagnosis or Procedure Codes to MDCs
    Based on our review this year, we are not proposing to add any 
diagnosis codes to MDCs.
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 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 Official Version of the ICD-9-CM contains the list of valid 
diagnosis and procedure codes. (The Official Version of the ICD-9-CM is 
available from the Government Printing Office on CD-ROM for $25.00 by 
calling (202) 512-1800.) The Official Version of the ICD-9-CM is no 
longer available in printed manual form from the Federal Government; it 
is only available on CD-ROM. Users who need a paper version are 
referred to one of the many products available from publishing houses.
    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

[[Page 23336]]

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 2006 at a public meeting held on October 7-8, 
2004, and finalized the coding changes after consideration of comments 
received at the meetings and in writing by January 12, 2005. Those 
coding changes are announced in Tables 6A through 6F of the Addendum to 
this proposed rule. The Committee held its 2005 meeting on March 31-
April l, 2005. Proposed new codes for which there was a consensus of 
public support and for which complete tabular and indexing charges can 
be made by May 2005 will be included in the October 1, 2005 update to 
ICD-9-CM. These additional codes will be included in Tables 6A through 
6F of the final rule.
    Copies of the minutes of the procedure codes discussions at the 
Committee's October 7-8, 2004 meeting can be obtained from the CMS Web 
site: http://www.cms.hhs.gov/paymentsystems/icd9/. The minutes of the 
diagnoses codes discussions at the October 7-8, 2004 meeting 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. These 
Web sites also provide detailed information about the Committee, 
including information on requesting a new code, attending a Committee 
meeting, and timeline requirements and meeting dates.
    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 2402, 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, 2005. The new ICD-9-CM codes are listed, along 
with their DRG classifications, in Tables 6A and 6B (New Diagnosis 
Codes and New Procedure Codes, respectively) in the Addendum to this 
proposed rule. As we stated above, the code numbers and their titles 
were presented for public comment at the ICD-9-CM Coordination and 
Maintenance Committee meetings. Both oral and written comments were 
considered before the codes were approved. In this proposed rule, we 
are only soliciting comments on the proposed classification of these 
new codes.
    For codes that have been replaced by new or expanded codes, the 
corresponding new or expanded diagnosis codes are included in Table 6A. 
New procedure codes are shown in Table 6B. Diagnosis codes that have 
been replaced by expanded codes or other codes or have been deleted are 
in Table 6C (Invalid Diagnosis Codes). These invalid diagnosis codes 
will not be recognized by the GROUPER beginning with discharges 
occurring on or after October 1, 2005. Table 6D contains invalid 
procedure codes. These invalid procedure codes will not be recognized 
by the GROUPER beginning with discharges occurring on or after October 
1, 2005. 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 2006.
    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 proposals for procedure codes that would describe new 
technology discussed and approved at the April meeting as part of the 
code revisions effective the following October. As stated previously, 
ICD-9-CM codes discussed at the March 31-April 1, 2005 Committee 
meeting that receive consensus and that can be finalized by May 2005 
will be included in Tables 6A through 6F of the final rule.
    Section 503(a) of Pub. L. 108-173 included a requirement for 
updating ICD-9-CM codes twice a year instead of a single update on 
October 1 of each year. This requirement was included as part of the 
amendments to the Act relating to recognition of new technology under 
the IPPS. Section 503(a) amended section 1886(d)(5)(K) of the Act by 
adding a clause (vii) which states that the ``Secretary shall provide 
for the addition of new diagnosis and procedure codes in April 1 of 
each year, but the addition of such codes shall not require the 
Secretary to adjust the payment (or diagnosis-related group 
classification) * * * until the fiscal year that begins after such 
date.'' This requirement improves the recognition of new technologies 
under the IPPS system by providing information on these new 
technologies at an earlier date. Data will be available 6 months 
earlier than would be possible with updates occurring only once a year 
on October 1.
    While section 503(a) states that the addition of new diagnosis and 
procedure codes on April 1 of each year shall not require the Secretary 
to adjust the payment, or DRG classification under section 1886(d) of 
the Act until the fiscal year that begins after such date, we have to 
update the DRG software and other systems in order to recognize and 
accept the new codes. We also publicize the code changes and the need 
for a mid-year systems update by providers to capture the new codes. 
Hospitals also have to obtain the new code books and encoder updates, 
and make other system changes in order to capture and report the new 
codes.
    The ICD-9-CM Coordination and Maintenance Committee holds its 
meetings in the Spring and Fall, usually in April and September, in 
order to update the codes and the applicable payment and reporting 
systems by October 1 of each year. Items are placed on the agenda for 
the ICD-9-CM Coordination and Maintenance Committee meeting if the 
request is received at least 2 months prior to the meeting. This 
requirement allows time for staff to review and research the coding 
issues and prepare material for discussion at the meeting. It also 
allows time for the topic to be publicized in meeting announcements in 
the Federal Register as well as on the CMS Web site. The public decides 
whether or not to attend the meeting based on the topics listed on the 
agenda. Final decisions on code title revisions are currently made by 
March 1 so that these titles can be included in the IPPS proposed rule. 
A

[[Page 23337]]

complete addendum describing details of all changes to ICD-9-CM, both 
tabular and index, are publicized on CMS and NCHS Web pages in May of 
each year. Publishers of coding books and software use this information 
to modify their products that are used by health care providers. This 
5-month time period has proved to be necessary for hospitals and other 
providers to update their systems.
    A discussion of this timeline and the need for changes are included 
in the December 4-5, 2003 ICD-9-CM Coordination and Maintenance 
Committee minutes. The public agreed that there was a need to hold the 
fall meetings earlier, in September or October, in order to meet the 
new implementation dates. The public provided comment that additional 
time would be needed to update hospital systems and obtain new code 
books and coding software. There was considerable concern expressed 
about the impact this new April update would have on providers.
    In the FY 2005 IPPS final rule, we implemented section 503(a) by 
developing a mechanism for approving, in time for the April update, 
diagnoses and procedure code revisions needed to describe new 
technologies and medical services for purposes of the new technology 
add-on payment process. We also established the following process for 
making these determinations. Topics considered during the Fall ICD-9-CM 
Coordination and Maintenance Committee meeting are considered for an 
April 1 update if a strong and convincing case is made by the requester 
at the Committee's public meeting. The request must identify the reason 
why a new code is needed in April for purposes of the new technology 
process. The participants at the meeting and those reviewing the 
Committee meeting summary report are provided the opportunity to 
comment on this expedited request. All other topics are considered for 
the October 1 update. Participants at the Committee meeting are 
encouraged to comment on all such requests. There were no requests for 
an expedited April l, 2005 implementation of an ICD-9-CM code at the 
October 7-8, 2004 Committee meeting. Therefore, there were no new ICD-
9-CM codes implemented on April 1, 2005.
    We believe that this process captures the intent of section 503(a). 
This requirement was included in the provision revising the standards 
and process for recognizing new technology under the IPPS. In addition, 
the need for approval of new codes outside the existing cycle (October 
1) arises most frequently and most acutely where the new codes will 
capture new technologies that are (or will be) under consideration for 
new technology add-on payments. Thus, we believe this provision was 
intended to expedite data collection through the assignment of new ICD-
9-CM codes for new technologies seeking higher payments.
    Current addendum and code title information is published on the CMS 
Web page at: http://www.cms.hhs.gov/paymentsystems/icd9. Summary tables 
showing new, revised, and deleted code titles are also posted on the 
following CMS Web page: http://www.cms.hhs.gov/medlearn/icd9code.asp. 
Information on ICD-9-CM diagnosis codes, along with the Official ICD-9-
CM Coding Guidelines, can be found on the Wep page at: http://www.cdc.gov/nchs/icd9.htm. Information on new, revised, and deleted 
ICD-9-CM codes is also provided to the AHA for publication in the 
Coding Clinic for ICD-9-CM. AHA also distributes information to 
publishers and software vendors.
    CMS also sends copies of all ICD-9-CM coding changes to its 
contractors for use in updating their systems and providing education 
to providers.
    These same means of disseminating information on new, revised, and 
deleted ICD-9-CM codes will be used to notify providers, publishers, 
software vendors, contractors, and others of any changes to the ICD-9-
CM codes that are implemented in April. Currently, code titles are also 
published in the IPPS proposed and final rules. The code titles are 
adopted as part of the ICD-9-CM Coordination and Maintenance Committee 
process. The code titles are not subject to comment in the proposed or 
final rules. We will continue to publish the October code updates in 
this manner within the IPPS proposed and final rules. For codes that 
are implemented in April, we will assign the new procedure code to the 
same DRG in which its predecessor code was assigned so there will be no 
DRG impact as far as DRG assignment. This mapping was specified by Pub. 
L. 108-173. Any midyear coding updates will be available through the 
websites indicated above and through the Coding Clinic for ICD-9-CM. 
Publishers and software vendors currently obtain code changes through 
these sources in order to update their code books and software systems. 
We will strive to have the April 1 updates available through these 
websites 5 months prior to implementation (that is, early November of 
the previous year), as is the case for the October 1 updates. Codebook 
publishers are evaluating how they will provide any code updates to 
their subscribers. Some publishers may decide to publish mid-year book 
updates. Others may decide to sell an addendum that lists the changes 
to the October 1 code book. Coding personnel should contact publishers 
to determine how they will update their books. CMS and its contractors 
will also consider developing provider education articles concerning 
this change to the effective date of certain ICD-9-CM codes.
14. Other Issues: Acute Intermittent Porphyria
    Acute intermittent porphyria is a rare metabolic disorder. The 
condition is described by code 277.1 (Disorders of porphyrin 
metabolism). Code 277.1 is assigned to DRG 299 (Inborn Errors of 
Metabolism) under MDC 10 (Endocrine, Nutritional, and Metabolic 
Diseases and Disorders).
    In the FY 2005 final rule (69 FR 48981), we discussed the DRG 
assignment of acute intermittent porphyria. This discussion was a 
result of correspondence that we received during the comment period for 
the FY 2005 proposed rule in which the commenter suggested that 
Medicare hospitalization payments do not accurately reflect the cost of 
treatment. At that time, we indicated that we would take this comment 
into consideration when we analyzed the MedPAR data for this proposed 
rule for FY 2006.
    Our review of the most recent MedPAR data shows a total of 1,370 
cases overall in DRG 299, of which 471 had a principal diagnosis coded 
as 277.1. The average length of stay for all cases in DRG 299 was 5.17 
days, while the average length of stay for porphyria cases with code 
277.1 was 6.0 days. The average charges for all cases in DRG 299 were 
$15,891, while the average changes for porphyria cases with code 277.1 
were $21,920. Based on our analysis of these data, we do not believe 
that there is a sufficient difference between the average charges and 
average length of stay for these cases to justify a change to the DRG 
assignment for treating this condition.

C. Proposed Recalibration of DRG Weights

    (If you choose to comment on issues in this section, please include 
the caption ``DRG Weights'' at the beginning of your comment.)
    We are proposing to use the same basic methodology for the FY 2006 
recalibration as we did for FY 2005 (FY 2005 IPPS final rule (69 FR 
48981)). That is, we have recalibrated the DRG weights based on charge 
data for

[[Page 23338]]

Medicare discharges using the most current charge information available 
(the FY 2004 MedPAR file).
    The MedPAR file is based on fully coded diagnostic and procedure 
data for all Medicare inpatient hospital bills. The FY 2004 MedPAR data 
used in this final rule include discharges occurring between October 1, 
2003 and September 30, 2004, based on bills received by CMS through 
December 31, 2004, from all hospitals subject to the IPPS and short-
term acute care hospitals in Maryland (which are under a waiver from 
the IPPS under section 1814(b)(3) of the Act). The FY 2004 MedPAR file 
includes data for approximately 11,910,025 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.
    The proposed methodology used to calculate the DRG relative weights 
from the FY 2004 MedPAR file is as follows:
     To the extent possible, all the claims were regrouped 
using the DRG classification revisions discussed in section II.B. of 
this preamble.
     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 2004 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.)
     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.
     Charges were standardized to remove the effects of 
differences in area wage levels, indirect medical education and 
disproportionate share payments, and, for hospitals in Alaska and 
Hawaii, the applicable cost-of-living adjustment.
     The average standardized charge per DRG was calculated by 
summing the standardized charges for all cases in the DRG and dividing 
that amount by the number of cases classified in the DRG. A transfer 
case is counted as a fraction of a case based on the ratio of its 
transfer payment under the per diem payment methodology to the full DRG 
payment for nontransfer cases. That is, 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.
     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.
     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 proposed new weights are normalized by an adjustment factor of 
1.47263 so that the average case weight after recalibration is equal to 
the average case weight before recalibration. This proposed adjustment 
is intended to ensure that recalibration by itself neither increases 
nor decreases total payments under the IPPS.
    When we recalibrated the DRG weights for previous years, we set a 
threshold of 10 cases as the minimum number of cases required to 
compute a reasonable weight. We used that same case threshold in 
recalibrating the proposed DRG weights for FY 2006. Using the FY 2004 
MedPAR data set, there are 41 DRGs that contain fewer than 10 cases. We 
are proposing to compute the weights for these low-volume DRGs by 
adjusting the FY 2005 weights of these DRGs by the percentage change in 
the average weight of the cases in the other DRGs.
    Section 1886(d)(4)(C)(iii) of the Act requires that, beginning with 
FY 1991, reclassification and recalibration changes be made in a manner 
that assures that the aggregate payments are neither greater than nor 
less than the aggregate payments that would have been made without the 
changes. Although normalization is intended to achieve this effect, 
equating the average case weight after recalibration to the average 
case weight before recalibration does not necessarily achieve budget 
neutrality with respect to aggregate payments to hospitals because 
payments to hospitals are affected by factors other than average case 
weight. Therefore, as we have done in past years and as discussed in 
section II.A.4.a. of the Addendum to this proposed rule, we are making 
a budget neutrality adjustment to ensure that the requirement of 
section 1886(d)(4)(C)(iii) of the Act is met.

D. Proposed LTC-DRG Reclassifications and Relative Weights for LTCHs 
for FY 2006

    (If you choose to comment on issues in this section, please include 
the caption ``LTC-DRGs'' at the beginning of your comment.)
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, 
because 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 used under the IPPS. 
In that same final rule, 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.
    In the past, the annual update to the IPPS DRGs has been based on 
the annual revisions to the ICD-9-CM codes and was effective each 
October 1. As discussed in the FY 2005 IPPS final rule (69 FR 48954 
through 48957) and in the February 3, 2005 LTCH PPS proposed rule (70 
FR 5729 through 5733), with the implementation of section 503 (a) of 
Pub. L. 108-173, there is the possibility that one feature of the 
GROUPER software program may be updated twice during a Federal fiscal 
year (October 1 and April 1) as required by the statute for the IPPS. 
Specifically, ICD-9-CM diagnosis and procedure codes for new medical 
technology may be created and added to existing DRGs in the middle of 
the Federal fiscal year on April 1. This policy change will have no 
effect, however, on the LTC-DRG relative weights which will continue to 
be updated only once a year (October 1), nor will there be any impact 
on Medicare payments under the LTCH PPS. The use of the ICD-9-CM code 
set is also compliant with the current requirements of the Transactions 
and Code Sets Standards regulations at 45 CFR Parts 160 and 162, 
promulgated in accordance with the Health Insurance Portability and 
Accountability Act of 1996 (HIPAA), Pub. L. 104-191.

[[Page 23339]]

    In the health care industry, historically annual changes to the 
ICD-9-CM codes were effective for discharges occurring on or after 
October 1 each year. Thus, the manual and electronic versions of the 
GROUPER software, which are based on the ICD-9-CM codes, were also 
revised annually and effective for discharges occurring on or after 
October 1 each year. As noted above, the patient classification system 
used under the LTCH PPS (LTC-DRGs) is based on the patient 
classification system used under the IPPS (CMS-DRGs), which 
historically had been updated annually and effective for discharges 
occurring on or after October 1 through September 30 each year. As 
mentioned above, the ICD-9-CM coding update process has been revised, 
as discussed in greater detail in the FY 2005 IPPS final rule (69 FR 
48954 through 48957). Specifically, section 503(a) of Pub. L. 108-173 
includes a requirement for updating ICD-9-CM codes as often as twice a 
year instead of the current process of annual updates on October 1 of 
each year. This requirement is included as part of the amendments to 
the Act relating to recognition of new medical technology under the 
IPPS. Section 503(a) of Pub L. 108-173 amended section 1886(d)(5)(K) of 
the Act by adding a new clause (vii) which states that ``the Secretary 
shall provide for the addition of new diagnosis and procedure codes in 
[sic] April 1 of each year, but the addition of such codes shall not 
require the Secretary to adjust the payment (or diagnosis-related group 
classification) * * * until the fiscal year that begins after such 
date.'' This requirement will improve the recognition of new 
technologies under the IPPS by accounting for those ICD-9-CM codes in 
the MedPAR claims data at an earlier date. Despite the fact that 
aspects of the GROUPER software may be updated to recognize any new 
technology ICD-9-CM codes, as discussed in the February 3, 2005 LTCH 
PPS proposed rule (70 FR 5730 through 5733), there will be no impact on 
either LTC-DRG assignments or payments under the LTCH PPS at that time. 
That is, changes to the LTC-DRGs (such as the creation or deletion of 
LTC-DRGs) and the relative weights will continue to be updated in the 
manner and timing (October 1) as they are now.
    As noted above and as described in the February 3, 2005 LTCH PPS 
proposed rule (70 FR 5730), updates to the GROUPER for both the IPPS 
and the LTCH PPS (with respect to relative weights and the creation or 
deletion of DRGs) are made in the annual IPPS proposed and final rules 
and are effective each October 1. We explained in the FY 2005 IPPS 
final rule (69 FR 48955 and 48956), that since we do not publish a 
midyear IPPS rule, April 1 code updates discussed above will not be 
published in a midyear IPPS rule. Rather, we will assign any new 
diagnostic or procedure codes to the same DRG in which its predecessor 
code was assigned, so that there will be no impact on the DRG 
assignments. Any proposed coding updates will be available through the 
websites indicated in the same rule and provided above in section II.B. 
of this preamble and through the Coding Clinic for ICD-9-CM. Publishers 
and software vendors currently obtain code changes through these 
sources in order to update their code books and software system. If new 
codes are implemented on April 1, revised code books and software 
systems, including the GROUPER software program, will be necessary 
because we must use current ICD-9-CM codes. Therefore, for purposes of 
the LTCH PPS, since each ICD-9-CM code must be included in the GROUPER 
algorithm to classify each case into a LTC-DRG, the GROUPER software 
program used under the LTCH PPS would need to be revised to accommodate 
any new codes.
    As we discussed in the FY 2005 IPPS final rule (69 FR 48956), in 
implementing section 503(a) of Pub. L. 108-173, there will only be an 
April 1 update if new technology codes are requested and approved. It 
should be noted that any new codes created for April 1 implementation 
will be limited to those diagnosis and procedure code revisions 
primarily needed to describe new technologies and medical services. 
However, we reiterate that the process of discussing updates to the 
ICD-9-CM has been an open process through the ICD-9-CM C&M Committee 
since 1995. Requestors will be given the opportunity to present the 
merits of their proposed new code and make a clear and convincing case 
for the need to update ICD-9-CM codes for purposes of the IPPS new 
technology add-on payment process through an April 1 update.
    In addition, in the FY 2005 IPPS final rule (69 FR 48956), we 
stated that at the October 2004 ICD-9-CM Coordination and Maintenance 
Committee meeting, no new codes were proposed for an April 1, 2005 
implementation, and the next update to the ICD-9-CM coding system would 
not occur until October 1, 2005 (FY 2006). Presently, as there were no 
coding changes suggested for an April 1, 2005 update, the ICD-9-CM 
coding set implemented on October 1, 2004 will continue through 
September 30, 2005 (FY 2005). The proposed update to the ICD-9-CM 
coding system for FY 2006 is discussed above in section II.B. of this 
preamble.
    In this proposed rule, we are proposing revisions to the LTC-DRG 
classifications and relative weights and, to the extent that they are 
finalized, we will publish them in the corresponding IPPS final rule, 
to be effective October 1, 2005 through September 30, 2006 (FY 2006), 
using the latest available data. The proposed LTC-DRGs and relative 
weights for FY 2006 in this proposed rule are based on the proposed 
IPPS DRGs (GROUPER Version 23.0) discussed in section II. of this 
proposed rule.
2. Proposed Changes in the LTC-DRG Classifications
a. Background
    Section 123 of Pub. L. 106-113 specifically requires that the PPS 
for LTCHs be a per discharge system with a DRG-based patient 
classification system reflecting the differences in patient resources 
and costs in LTCHs while maintaining budget neutrality. Section 
307(b)(1) of Pub. 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, 
in this proposed rule, we are proposing to use the IPPS GROUPER Version 
23.0 for FY 2006 to process LTCH PPS claims for LTCH occurring from 
October 1, 2005 through September 30, 2006. The proposed changes to the 
CMS DRG classification system used under the IPPS for FY 2006 (GROUPER 
Version 23.0) are discussed in section II.B. of the preamble to this 
proposed rule.
    Under the LTCH PPS, we determine relative weights for each of the 
CMS DRGs to account for the difference in resource use by patients 
exhibiting the

[[Page 23340]]

case complexity and multiple medical problems characteristic of LTCH 
patients. In a departure from the IPPS, as we discussed in the August 
30, 2002 LTCH PPS final rule (67 FR 55985), which implemented the LTCH 
PPS, and the FY 2004 IPPS final rule (68 FR 45374), we use low-volume 
quintiles in determining the LTC-DRG weights for LTC-DRGs with less 
than 25 LTCH cases, because LTCHs do not typically treat the full range 
of diagnoses as do acute care hospitals. Specifically, we group those 
low-volume LTC-DRGs (LTC-DRGs with fewer than 25 cases) into 5 
quintiles based on average charge per discharge. (A listing of the 
composition of low-volume quintiles for the FY 2005 LTC-DRGs (based on 
FY 2003 MedPAR data) appears in section II.D.3. of the FY 2005 IPPS 
final rule (69 FR 48985 through 48989).) 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 below 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 in section II.B. of this preamble, the CMS 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 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 Transactions and Code 
Sets Standards under 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. Completed 
claim forms are to be submitted electronically 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 an 
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 
LTCH PPS 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 relative weights are based on data for the population of LTCH 
discharges, reflecting the fact that LTCH patients represent a 
different patient mix than patients in short-term acute care hospitals.
3. Development of the Proposed FY 2006 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 applicable LTC-DRG relative weight 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 an LTC-DRG with a relative weight 
of 2 will, on average, cost twice as much as cases in an LTC-DRG with a 
weight of 1.

[[Page 23341]]

b. Data
    To calculate the proposed LTC-DRG relative weights for FY 2006 in 
this proposed rule, we obtained total Medicare allowable charges from 
FY 2004 Medicare hospital bill data from the December 2004 update of 
the MedPAR file, and we used the proposed Version 23.0 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 are 
proposing to recalculate the FY 2006 LTC-DRG relative weights based on 
the best available data for this proposed rule.
    As we discussed in the FY 2005 IPPS final rule (69 FR 48984), 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 proposed FY 2006 LTC-DRG relative weights, we 
have excluded the data of the 19 all-inclusive rate providers and the 3 
LTCHs that are paid in accordance with demonstration projects that had 
claims in the FY 2003 MedPAR file.
    In the FY 2005 IPPS final rule (6 FR 48984), we discussed coding 
inaccuracies that were found in the claims data for a large chain of 
LTCHs in the FY 2002 MedPAR file, which were used to determine the LTC-
DRG relative weights for FY 2004. As we discussed in the same final 
rule, after notifying the large chain of LTCHs whose claims contained 
the coding inaccuracies to request that they resubmit those claims with 
the correct diagnosis, from an analysis of LTCH claims data from the 
December 2003 update of the FY 2003 MedPAR file, it appeared that such 
claims data no longer contain coding errors. Therefore, it was not 
necessary to correct the FY 2003 MedPAR data for the development of the 
FY 2005 LTC-DRGs and relative weights established in the same final 
rule.
    As stated above, in this proposed rule, we are proposing to use the 
December 2004 update of the FY 2004 MedPAR file for the determination 
of the proposed FY 2006 LTC-DRG relative weights as these are the best 
available data. Based on an analysis of LTCH claims data from the 
December 2004 update of the FY 2004 MedPAR file, it appears that such 
claims data do not contain coding inaccuracies found previously in LTCH 
claims data. Therefore, it was not necessary to correct the FY 2004 
MedPAR data for the development of the proposed FY 2006 LTC-DRGs and 
relative weights presented in this proposed rule.
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. 
This 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. Proposed 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 
established in the August 30, 2002 LTCH PPS final rule (67 FR 55984), 
we group those low-volume LTC-DRGs into one of five categories 
(quintiles) based on average charges, for the purposes of determining 
relative weights. For this proposed rule, using LTCH cases from the 
December 2004 update of the FY 2004 MedPAR file, we identified 172 LTC-
DRGs that contained between 1 and 24 cases. This list of proposed LTC-
DRGs was then divided into one of the 5 low-volume quintiles, each 
containing a minimum of 34 LTC-DRGs (172/5 = 34 with 2 LTC-DRGs as the 
remainder). For FY 2006, we are proposing to make an assignment to a 
specific low-volume quintile by sorting the low-volume proposed LTC-
DRGs in ascending order by average charge. For this proposed rule, this 
results in an assignment to a specific low volume quintile of the 
sorted 172 low-volume proposed LTC-DRGs by ascending order by average 
charge. Because the number of LTC-DRGs with less than 25 LTCH cases is 
not evenly divisible by five, the average charge of the low-volume 
proposed LTC-DRG was used to determine which low-

[[Page 23342]]

volume quintile received the additional proposed LTC-DRG. After sorting 
the 172 low-volume LTC-DRGs in ascending order, we are proposing that 
the first fifth of low-volume LTC-DRGs with the lowest average charge 
would be grouped into Quintile 1. The highest average charge cases 
would be grouped into Quintile 5. Since the average charge of the 
proposed 35th LTC-DRG in the sorted list is closer to the proposed 34th 
LTC-DRG's average charge (assigned to Quintile 1) than to the average 
charge of the proposed 36th LTC-DRG in the sorted list (to be assigned 
to Quintile 2), we are proposing to place it into Quintile 1. This 
process was repeated through the remaining low-volume proposed LTC-DRGs 
so that 2 proposed low-volume quintiles contain 35 proposed LTC-DRGs 
and 3 proposed low-volume quintiles contain 34 proposed LTC-DRGs.
    In order to determine the proposed relative weights for the 
proposed LTC-DRGs with low volume for FY 2006, in accordance with the 
methodology established in the August 30, 2002 LTCH PPS final rule (67 
FR 55984), we are proposing to use the proposed five low-volume 
quintiles described above. The composition of each of the proposed five 
low-volume quintiles shown in the chart below would be used in 
determining the proposed LTC-DRG relative weights for FY 2006. We would 
determine a proposed relative weight and (geometric) average length of 
stay for each of the proposed five low-volume quintiles using the 
formula that we apply to the regular proposed LTC-DRGs (25 or more 
cases), as described below in section II.D.4. of this preamble. We are 
proposing to assign the same relative weight and average length of stay 
to each of the proposed LTC-DRGs that make up that proposed low-volume 
quintile. We note that, as this system is dynamic, it is possible that 
the number and specific type of LTC-DRGs with a low volume of LTCH 
cases will vary in the future. We use the best available claims data in 
the MedPAR file to identify low-volume LTC-DRGs and to calculate the 
relative weights based on our methodology.
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4. Steps for Determining the Proposed FY 2006 LTC-DRG Relative Weights
    As we noted previously, the proposed FY 2006 LTC-DRG relative 
weights are determined in accordance with the methodology established 
in the August 1, 2003 IPPS final rule (68 FR 45367). In summary, LTCH 
cases must be grouped in the appropriate LTC-DRG, while taking into 
account the low-volume proposed LTC-DRGs as described above, before the 
proposed FY 2006 LTC-DRG relative weights can be determined. After 
grouping the cases in the appropriate proposed LTC-DRG, we are 
proposing to calculate the proposed relative weights for FY 2006 in 
this proposed rule by first removing statistical outliers and cases 
with a length of stay of 7 days or less, as discussed in greater detail 
below. Next, we are proposing to adjust the number of cases in each 
proposed LTC-DRG for the effect of short-stay outlier cases under Sec.  
412.529, as also discussed in greater detail below. The short-stay 
adjusted discharges and corresponding charges are used to calculate 
``relative adjusted weights'' in each proposed LTC-DRG using the 
hospital-specific relative value method described above.
    Below we discuss in detail the steps for calculating the proposed 
FY 2006 LTC-DRG relative weights.
    Step 1--Remove statistical outliers.
    The first step in the calculation of the proposed FY 2006 LTC-DRG 
relative weights is to remove statistical outlier cases. We define 
statistical outliers as cases that are outside of 3.0 standard 
deviations from the mean of the log distribution of both charges per 
case and the charges per day for each LTC-DRG. These statistical 
outliers are removed prior to calculating the proposed relative 
weights. We believe that they may represent aberrations in the data 
that distort the measure of average resource use. Including those LTCH 
cases in the calculation of the proposed relative weights could result 
in an inaccurate proposed relative weight that does not truly reflect 
relative resource use among the proposed LTC-DRGs.
    Step 2--Remove cases with a length of stay of 7 days or less.
    The proposed FY 2006 LTC-DRG relative weights reflect the average 
of resources used on representative cases of a specific type. 
Generally, cases with a length of stay 7 days or less do not belong in 
a LTCH because these stays do not fully receive or benefit from 
treatment that is typical in a LTCH stay, and full resources are often 
not used in the earlier stages of admission to a LTCH. If we were to 
include stays of 7 days or less in the computation of the proposed FY 
2006 LTC-DRG relative weights, the value of many proposed relative 
weights would decrease and, therefore, payments would decrease to a 
level that may no longer be appropriate.
    We do not believe that it would be appropriate to compromise the 
integrity of the payment determination for those LTCH cases that 
actually benefit from and receive a full course of treatment at a LTCH, 
in order to include data from these very short-stays. Thus, in 
determining the proposed FY 2006 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.
    After removing cases with a length of stay of 7 days or less, we 
are left with cases that have a length of stay of greater than or equal 
to 8 days. The next step in the calculation of the proposed FY 2006 
LTC-DRG relative weights is to adjust each LTCH's charges per discharge 
for those remaining cases for the effects of short-stay outliers as 
defined in Sec.  412.529(a). (However, we note that even if a case was 
removed in Step 2 (that is, cases with a length of stay of 7 days or 
less), it was paid as a short-stay outlier if its length of stay was 
less than or equal to five-sixths of the average length of stay of the 
LTC-DRG, in accordance with Sec.  412.529.)
    We make this adjustment by counting a short-stay outlier as a 
fraction of a discharge based on the ratio of the length of stay of the 
case to the average length of stay for the proposed LTC-DRG for 
nonshort-stay outlier cases. This has the effect of proportionately 
reducing the impact of the lower charges for the short-stay outlier 
cases in calculating the average charge for the proposed LTC-DRG. This 
process produces the same result as if the actual charges per discharge 
of a short-stay outlier case were adjusted to what they would have been 
had the patient's length of stay been equal to the average length of 
stay of the proposed LTC-DRG.
    As we explained in the FY 2005 IPPS final rule (69 FR 48991), 
counting short-

[[Page 23347]]

stay outlier cases as full discharges with no adjustment in determining 
the proposed LTC-DRG relative weights would lower the proposed LTC-DRG 
relative weight for affected proposed LTC-DRGs because the relatively 
lower charges of the short-stay outlier cases would bring down the 
average charge for all cases within a proposed LTC-DRG. This would 
result in an ``underpayment'' to nonshort-stay outlier cases and an 
``overpayment'' to short-stay outlier cases. Therefore, in this 
proposed rule, we adjust for short-stay outlier cases under Sec.  
412.529 in this manner because it results in more appropriate payments 
for all LTCH cases.
    Step 4--Calculate the Proposed FY 2006 LTC-DRG relative weights on 
an iterative basis.
    The process of calculating the proposed LTC-DRG relative weights 
using the hospital specific relative value methodology is iterative. 
First, for each LTCH case, we calculate a hospital-specific relative 
charge value by dividing the short-stay outlier adjusted charge per 
discharge (see step 3) of the LTCH case (after removing the statistical 
outliers (see step 1)) and LTCH cases with a length of stay of 7 days 
or less (see step 2) by the average charge per discharge for the LTCH 
in which the case occurred. The resulting ratio is then multiplied by 
the LTCH's case-mix index to produce an adjusted hospital-specific 
relative charge value for the case. An initial case-mix index value of 
1.0 is used for each LTCH.
    For each proposed LTC-DRG, the proposed FY 2006 LTC-DRG relative 
weight is calculated by dividing the average of the adjusted hospital-
specific relative charge values (from above) for the proposed LTC-DRG 
by the overall average hospital-specific relative charge value across 
all cases for all LTCHs. Using these recalculated proposed LTC-DRG 
relative weights, each proposed LTCH's average relative weight for all 
of its cases (case-mix) is calculated by dividing the sum of all the 
proposed 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 proposed LTC-DRG relative weights across all 
LTCHs. In this proposed rule, this iterative process is continued until 
there is convergence between the weights produced at adjacent steps, 
for example, when the maximum difference is less than 0.0001.
    Step 5-Adjust the proposed FY 2006 LTC-DRG relative weights to 
account for nonmonotonically increasing relative weights.
    As explained in section II.B. of this preamble, the proposed FY 
2006 CMS DRGs, which the proposed FY 2006 LTC-DRGs are based, contain 
``pairs'' that are differentiated based on the presence or absence of 
CCs. The proposed LTC-DRGs with CCs are defined by certain secondary 
diagnoses not related to or inherently a part of the disease process 
identified by the principal diagnosis, but the presence of additional 
diagnoses does not automatically generate a CC. As we discussed in the 
FY 2005 IPPS final rule (69 FR 48991), the value of monotonically 
increasing relative weights rises as the resource use increases (for 
example, from uncomplicated to more complicated). The presence of CCs 
in a proposed LTC-DRG means that cases classified into a ``without CC'' 
proposed LTC-DRG are expected to have lower resource use (and lower 
costs). In other words, resource use (and costs) are expected to 
decrease across ``with CC''/``without CC'' pairs of proposed LTC-DRGs.
    For a case to be assigned to a proposed LTC-DRG with CCs, more 
coded information is called for (that is, at least one relevant 
secondary diagnosis), than for a case to be assigned to a proposed LTC-
DRG ``without CCs'' (which is based on only one principal diagnosis and 
no relevant secondary diagnoses). Currently, the LTCH claims data 
include both accurately coded cases without complications and cases 
that have complications (and cost more), but were not coded completely. 
Both types of cases are grouped to a proposed LTC-DRG ``without CCs'' 
because only one principal diagnosis was coded. Since the LTCH PPS was 
only implemented for cost reporting periods beginning on or after 
October 1, 2002 (FY 2003) and 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, as discussed in the 
FY 2005 IPPS final rule (69 FR 48991 through 48992), based on FY 2003 
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 the FY 2005 LTC-DRG relative weights.
    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 because, in general, cases 
classified into a ``with CC'' LTC-DRG are expected to have higher 
resource use (and higher cost) as discussed above. Therefore, 
previously when we determined the LTC-DRG relative weights in 
accordance with the methodology established in the August 30, 2002 LTCH 
PPS final rule (67 FR 55990), we grouped both the cases ``with CCs'' 
and ``without CCs'' together for the purpose of calculating the LTC-DRG 
relative weights for FYs 2003 through 2005. As we stated in that same 
final rule, we will 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'' proposed LTC-
DRG would have a higher average charge than the ``with CC'' proposed 
LTC-DRG. For this proposed rule, using the LTCH cases in the December 
2004 update of the FY 2004 MedPAR file (the best available data at this 
time), we identified one of the three types of nonmonotonic LTC-DRG 
pairs.
    The first category of nonmonotonically increasing proposed relative 
weights for FY 2006 proposed LTC-DRG pairs ``with and without CCs'' 
contains zero pairs of proposed LTC-DRGs in which both the proposed 
LTC-DRG ``with CCs'' and the proposed LTC-DRG ``without CCs'' had 25 or 
more LTCH cases and, therefore, did not fall into one of the 5 low-
volume quintiles. For those nonmonotonic proposed LTC-DRG pairs, we 
would combine the LTCH cases and compute a new proposed relative weight 
based on the case-weighted average of the combined LTCH cases of the 
proposed LTC-DRGs.

[[Page 23348]]

The case-weighted average charge is determined by dividing the total 
charges for all LTCH cases by the total number of LTCH cases for the 
combined proposed LTC-DRG. This new proposed relative weight would then 
be assigned to both of the proposed LTC-DRGs in the pair. In this 
proposed rule, for FY 2006, there are no proposed LTC-DRGs that fall 
into this category.
    The second category of nonmonotonically increasing relative weights 
for proposed LTC-DRG pairs ``with and without CCs'' consists of one 
pair of proposed LTC-DRGs that has fewer than 25 cases, and each 
proposed LTC-DRG would be grouped to different proposed low-volume 
quintiles in which the ``without CC'' proposed LTC-DRG is in a higher-
weighted proposed low-volume quintile than the ``with CC'' proposed 
LTC-DRG. For those pairs, we would combine the LTCH cases and determine 
the case-weighted average charge for all LTCH cases. The case-weighted 
average charge is determined by dividing the total charges for all LTCH 
cases by the total number of LTCH cases for the combined proposed LTC-
DRG. Based on the case-weighted average LTCH charge, we determine 
within which low-volume quintile the ``combined LTC-DRG'' is grouped. 
Both proposed LTC-DRGs in the pair are then grouped into the same 
proposed low-volume quintile, and thus have the same proposed relative 
weight. In this proposed rule, for FY 2006, proposed LTC-DRGs 531 and 
532 fall into this category.
    The third category of nonmonotonically increasing relative weights 
for proposed LTC-DRG pairs ``with and without CCs'' consists of zero 
pairs of proposed LTC-DRGs where one of the proposed LTC-DRGs has fewer 
than 25 LTCH cases and is grouped to a proposed low-volume quintile and 
the other proposed LTC-DRG has 25 or more LTCH cases and has its own 
proposed LTC-DRG relative weight, and the proposed LTC-DRG ``without 
CCs'' has the higher proposed relative weight. We remove the proposed 
low-volume LTC-DRG from the proposed low-volume quintile and combine it 
with the other proposed LTC-DRG for the computation of a new proposed 
relative weight for each of these proposed LTC-DRGs. This new proposed 
relative weight is assigned to both proposed LTC-DRGs, so they each 
have the same proposed relative weight. In this proposed rule, for FY 
2006, there are no proposed LTC-DRGs that fall into this category.
    Step 6-Determine a proposed FY 2006 LTC-DRG relative weight for 
proposed LTC-DRGs with no LTCH cases.
    As we stated above, we determine the proposed relative weight for 
each proposed LTC-DRG using charges reported in the December 2004 
update of the FY 2004 MedPAR file. Of the 526 proposed LTC-DRGs for FY 
2006, we identified 194 proposed LTC-DRGs for which there were no LTCH 
cases in the database. That is, based on data from the FY 2004 MedPAR 
file used in this proposed rule, no patients who would have been 
classified to those LTC-DRGs were treated in LTCHs during FY 2004 and, 
therefore, no charge data were reported for those proposed LTC-DRGs. 
Thus, in the process of determining the proposed LTC-DRG relative 
weights, we are unable to determine weights for these 194 proposed LTC-
DRGs using the methodology described in steps 1 through 5 above. 
However, because patients with a number of the diagnoses under these 
proposed LTC-DRGs may be treated at LTCHs beginning in FY 2006, we 
assign proposed relative weights to each of the 194 ``no volume'' 
proposed LTC-DRGs based on clinical similarity and relative costliness 
to one of the remaining 332 (156--194 = 332) proposed LTC-DRGs for 
which we are able to determine proposed relative weights, based on FY 
2004 claims data.
    As there are currently no LTCH cases in these ``no volume'' 
proposed LTC-DRGs, we determine proposed relative weights for the 194 
proposed LTC-DRGs with no LTCH cases in the FY 2004 MedPAR file used in 
this proposed rule by grouping them to the appropriate proposed low-
volume quintile. This methodology is consistent with our methodology 
used in determining proposed relative weights to account for the 
proposed low-volume LTC-DRGs described above.
    Our methodology for determining proposed relative weights for the 
proposed ``no volume'' LTC-DRGs is as follows: We crosswalk the 
proposed no volume LTC-DRGs by matching them to other similar proposed 
LTC-DRGs for which there were LTCH cases in the FY 2004 MedPAR file 
based on clinical similarity and intensity of use of resources as 
determined by care provided during the period of time surrounding 
surgery, surgical approach (if applicable), length of time of surgical 
procedure, post-operative care, and length of stay. We assign the 
proposed relative weight for the applicable proposed low-volume 
quintile to the proposed no volume LTC-DRG if the proposed LTC-DRG to 
which it is crosswalked is grouped to one of the proposed low-volume 
quintiles. If the proposed LTC-DRG to which the proposed no volume LTC-
DRG is crosswalked is not one of the proposed LTC-DRGs to be grouped to 
one of the proposed low-volume quintiles, we compare the proposed 
relative weight of the proposed LTC-DRG to which the proposed no volume 
LTC-DRG is crosswalked to the proposed relative weights of each of the 
five quintiles and we assign the proposed no volume LTC-DRG the 
proposed relative weight of the proposed low-volume quintile with the 
closest weight. For this proposed rule, a list of the proposed no 
volume FY 2006 LTC-DRGs and the proposed FY 2006 LTC-DRG to which it is 
crosswalked in order to determine the appropriate proposed low-volume 
quintile for the assignment of a relative weight for FY 2006 is shown 
in the chart below.

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    To illustrate this methodology for determining the proposed 
relative weights for the 194 proposed LTC-DRGs with no LTCH cases, we 
are providing the following examples, which refer to the proposed no 
volume LTC-DRGs crosswalk information for FY 2006 provided in the chart 
above.
    Example 1:
    There were no cases in the FY 2004 MedPAR file used for this 
proposed rule for proposed LTC-DRG 163 (Hernia Procedures Age 0-17). 
Since the procedure is similar in resource use and the length and 
complexity of the procedures and the length of stay are similar, we 
determined that proposed LTC-DRG 178 (Uncomplicated Peptic Ulcer 
Without CC), which is assigned to proposed low-volume Quintile 3 for 
the purpose of determining the proposed FY 2006 relative weights, would 
display similar clinical and resource use. Therefore, we assign the 
same proposed relative weight of proposed LTC-DRG 178 of 0.7586 
(proposed Quintile 3) for FY 2006 (Table 11 in the Addendum to this 
proposed rule) to proposed LTC-DRG 163.
    Example 2:
    There were no LTCH cases in the FY 2004 MedPAR file used in this 
proposed rule for proposed LTC-DRG 91 (Simple Pneumonia and Pleurisy 
Age 0-17). Since the severity of illness in patients with bronchitis 
and asthma is similar in patients regardless of age, we determined that 
proposed LTC-DRG 90 (Simple Pneumonia and Pleurisy Age >17 Without CC) 
would display similar clinical and resource use characteristics and 
have a similar length of stay to proposed LTC-DRG 91. There were over 
25 cases in proposed LTC-DRG 90. Therefore, it would not be assigned to 
a low-volume quintile for the purpose of determining the proposed LTC-
DRG relative weights. However, under our established methodology, 
proposed LTC-DRG 91, with no LTCH cases, would need to be grouped to a 
proposed low-volume quintile. We determined that the proposed low-
volume quintile with the closest weight to proposed LTC-DRG 90 (0.5004) 
(refer to Table 11 in the Addendum to this proposed rule) would be 
proposed low-volume Quintile 1 (0. 4502) (refer to Table 11 in the 
Addendum to this proposed rule). Therefore, we assign proposed LTC-DRG 
91 a proposed relative weight of 0.4502 for FY 2006.
    Furthermore, we are proposing 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 2006 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 
would only include these six transplant LTC-DRGs in the GROUPER program 
for administrative purposes. Because 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 proposed LTC-DRGs with a zero volume of 
LTCH cases based on the system will vary in the future. We used the 
best most recent available claims data in the MedPAR file to identify 
zero volume LTC-DRGs and to determine the proposed relative weights in 
this proposed rule.
    Table 11 in the Addendum to this proposed rule lists the proposed 
LTC-DRGs and their respective proposed relative weights, geometric mean 
length of stay, and five-sixths of the geometric mean length of stay 
(to assist in the determination of short-stay outlier payments under 
Sec.  412.529) for FY 2006.
E. Proposed Add-On Payments for New Services and Technologies
    (If you choose to comment on issues in this section, please include 
the caption ``New Technology Applications'' at the beginning of your 
comment.)

[[Page 23354]]

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)(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 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.''
    The regulations implementing this provision establish three 
criteria for new medical services and techniques to receive an 
additional payment. First, Sec.  412.87(b)(2) defines when a specific 
medical service or technology will be considered new for purposes of 
new medical service or technology add-on payments. The statutory 
provision contemplated the special payment treatment for new medical 
services or technologies until such time as data are available to 
reflect the cost of the technology in the DRG weights through 
recalibration. There is a lag of 2 to 3 years from the point a new 
medical service or technology is first introduced on the market and 
when data reflecting the use of the medical service or technology are 
used to calculate the DRG weights. For example, data from discharges 
occurring during FY 2004 are used to calculate the proposed FY 2006 DRG 
weights in this proposed rule. Section 412.87(b)(2) provides that a 
``medical service or technology may be considered new within 2 or 3 
years after the point at which data begin to become available 
reflecting the ICD-9-CM code assigned to the new medical service or 
technology (depending on when a new code is assigned and data on the 
new medical service or technology become available for DRG 
recalibration). After CMS has recalibrated the DRGs, based on available 
data, to reflect the costs of an otherwise new medical service or 
technology, the medical service or technology will no longer be 
considered `new' under the criterion for this section.''
    The 2-year to 3-year period during which a technology or medical 
service can be considered new would ordinarily begin with FDA approval, 
unless there was some documented delay in bringing the product onto the 
market after that approval (for instance, component production or drug 
production had been postponed until FDA approval due to shelf life 
concerns or manufacturing issues). After the DRGs have been 
recalibrated to reflect the costs of an otherwise new medical service 
or technology, the special add-on payment for new medical services or 
technology ceases (Sec.  412.87(b)(2)). For example, an approved new 
technology that received FDA approval in October 2004 and entered the 
market at that time may be eligible to receive add-on payments as a new 
technology until FY 2007 (discharges occurring before October 1, 2006), 
when data reflecting the costs of the technology would be used to 
recalibrate the DRG weights. Because the FY 2007 DRG weights will be 
calculated using FY 2005 MedPAR data, the costs of such a new 
technology would likely be reflected in the FY 2007 DRG weights.
    Section 412.87(b)(3) further provides that, to receive special 
payment treatment, new medical services or technologies must be 
inadequately paid otherwise under the DRG system. To assess whether 
technologies would be inadequately paid under the DRGs, we establish 
thresholds to evaluate applicants for new technology add-on payments. 
In the FY 2004 IPPS final rule (68 FR 45385), we established the 
threshold at the geometric mean standardized charge for all cases in 
the DRG plus 75 percent of 1 standard deviation above the geometric 
mean standardized charge (based on the logarithmic values of the 
charges and transformed back to charges) 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). Table 10 in the Addendum to 
the FY 2004 IPPS final rule (68 FR 45648) listed the qualifying 
threshold by DRG, based on the discharge data that we used to calculate 
the FY 2004 DRG weights.
    However, section 503(b)(1) of Pub. L. 108-173 amended section 
1886(d)(5)(K)(ii)(I) of the Act to provide for ``applying a threshold* 
* *that is the lesser of 75 percent of the standardized amount 
(increased to reflect the difference between cost and charges) or 75 
percent of 1 standard deviation for the diagnosis-related group 
involved.'' The provisions of section 503(b)(1) apply to classification 
for fiscal years beginning with FY 2005. We updated Table 10 from the 
October 6, 2003 Federal Register correction document, which contains 
the thresholds that we used to evaluate applications for new service or 
technology add-on payments for FY 2005, using the section 503(b)(1) 
measures stated above, and posted these new thresholds on our Web site 
at: http://www.cms.hhs.gov/providers/hipps/newtech.asp. In the FY 2005 
IPPS final rule (in Table 10 of the Addendum), we included the final 
thresholds that are being used to evaluate applicants for new 
technology add-on payments for FY 2006. (Refer to section IV.D. of the 
preamble to the FY 2005 IPPS final rule (69 FR 49084) for a discussion 
of a revision of the regulations to incorporate the change made by 
section 503(b)(1) of Pub. L. 108-173.)
    Section 412.87(b)(1) of our existing regulations provides that a 
new technology is 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. For example, a new technology 
represents a substantial clinical improvement when it reduces 
mortality, decreases the number of hospitalizations or physician visits 
or reduces recovery time compared to the technologies previously 
available. (See the September 7, 2001 final rule (66 FR 46902) for a 
complete discussion of this criterion.)
    The new medical service or technology add-on payment policy 
provides additional payments for cases with high costs involving 
eligible new medical services or 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 medical service 
or technology. Under Sec.  412.88, Medicare pays a marginal cost factor 
of 50 percent for the costs of a new medical service or technology in 
excess of the full DRG payment. If the actual costs of a new medical 
service or technology case exceed the DRG payment by more than the 50-
percent marginal cost factor of the new medical service or 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, in

[[Page 23355]]

the past, we accounted for projected payments under the new medical 
service and technology provision during the upcoming fiscal year at the 
same time we estimated the payment effect of changes to the DRG 
classifications and recalibration. The impact of additional payments 
under this provision was then included in the budget neutrality factor, 
which was applied to the standardized amounts and the hospital-specific 
amounts.
    Section 503(d)(2) of Pub. L. 108-173 amended section 
1886(d)(5)(K)(ii)(III) of the Act to provide that there shall be no 
reduction or adjustment in aggregate payments under the IPPS due to 
add-on payments for new medical services and technologies. Therefore, 
add-on payments for new medical services or technologies for FY 2005 
and later years will not be budget neutral.
    Applicants for add-on payments for new medical services or 
technologies for FY 2007 must submit a formal request, including a full 
description of the clinical applications of the medical service or 
technology and the results of any clinical evaluations demonstrating 
that the new medical service or technology represents a substantial 
clinical improvement, along with a significant sample of data to 
demonstrate the medical service or technology meets the high-cost 
threshold, no later than October 15, 2005. Applicants must submit a 
complete database no later than December 30, 2005. Complete application 
information, along with final deadlines for submitting a full 
application, will be available after publication of the FY 2006 final 
rule at our Web site: http://www.cms.hhs.gov/providers/hipps/default.asp. To allow interested parties to identify the new medical 
services or technologies under review before the publication of the 
proposed rule for FY 2007, the website will also list the tracking 
forms completed by each applicant.
2. Public Input Before Publication of This Notice of Proposed 
Rulemaking on Add-On Payments
    Section 503(b)(2) of Pub. L. 108-173 amended section 1886(d)(5)(K) 
of the Act by adding a clause (viii) to provide for a mechanism for 
public input before publication of a notice of proposed rulemaking 
regarding whether a medical service or technology represents a 
substantial improvement or advancement. The revised process for 
evaluating new medical service and technology applications requires the 
Secretary to--
     Provide, before publication of a proposed rule, for public 
input regarding whether a new service or technology represents an 
advance in medical technology that substantially improves the diagnosis 
or treatment of Medicare beneficiaries.
     Make public and periodically update a list of the services 
and technologies for which an application for add-on payments is 
pending.
     Accept comments, recommendations, and data from the public 
regarding whether a service or technology represents a substantial 
improvement.
     Provide, before publication of a proposed rule, for a 
meeting at which organizations representing hospitals, physicians, 
manufacturers, and any other interested party may present comments, 
recommendations, and data regarding whether a new service or technology 
represents a substantial clinical improvement to the clinical staff of 
CMS.
    In order to provide an opportunity for public input regarding add-
on payments for new medical services and technologies for FY 2006 
before publication of this proposed rule, we published a notice in the 
Federal Register on December 30, 2004 (69 FR 78466) and held a town 
hall meeting at the CMS Headquarters Office in Baltimore, MD, on 
February 23, 2005. In the announcement notice for the meeting, we 
stated that the opinions and alternatives provided during the meeting 
would assist us in our evaluations of applications by allowing public 
discussions of the substantial clinical improvement criteria for each 
of the FY 2006 new medical service and technology add-on payment 
applications before the publication of this FY 2006 IPPS proposed rule.
    Approximately 45 participants registered and attended in person, 
while additional participants listened over an open telephone line. The 
participants focused on presenting data on the substantial clinical 
improvement aspect of their products, as well as the need for 
additional payments to ensure access to Medicare beneficiaries. In 
addition, we received written comments regarding the substantial 
clinical improvement criterion for the applicants. We have considered 
these comments in our evaluation of each new application for FY 2006 in 
this proposed rule. We have summarized these comments or, if 
applicable, indicated that no comments were received, at the end of the 
discussion of the individual applications.
    Section 503(c) of Pub. L. 108-173 amended section 1886(d)(5)(K) of 
the Act by adding a new clause (ix) requiring that, before establishing 
any add-on payment for a new medical service or technology, the 
Secretary shall seek to identify one or more DRGs associated with the 
new technology, based on similar clinical or anatomical characteristics 
and the costs of the technology and assign the new technology into a 
DRG where the average costs of care most closely approximate the costs 
of care using the new technology. No add-on payment shall be made with 
respect to such a new technology.
    At the time an application for new technology add-on payments is 
submitted, the DRGs associated with the new technology are identified. 
We only determine that a new technology add-on payment is appropriate 
when the reimbursement under these DRGs is not adequate for this new 
technology. The criterion for this determination is the cost threshold, 
which we discuss below. We discuss the assignments of several new 
technologies within the DRG payment system in section II.B. of this 
proposed rule.
    In this proposed rule, we evaluate whether new technology add-on 
payments will continue in FY 2006 for the three technologies that 
currently receive such payments. In addition, we present our 
evaluations of eight applications for add-on payments in FY 2006. The 
eight applications for FY 2006 include two applications for products 
that were denied new technology add-on payments for FY 2005.
3. FY 2006 Status of Technology Approved for FY 2005 Add-On Payments
a. INFUSE TM (Bone Morphogenetic Proteins (BMPs) for Spinal 
Fusions)
    INFUSE TM was approved by FDA for use on July 2, 2002, 
and became available on the market immediately thereafter. In the FY 
2004 IPPS final rule (68 FR 45388), we approved INFUSE TM 
for add-on payments under Sec.  412.88, effective for FY 2004. This 
approval was on the basis of using INFUSE TM for single-
level, lumbar spinal fusion, consistent with the FDA's approval and the 
data presented to us by the applicant. Therefore, we limited the add-on 
payment to cases using this technology for anterior lumbar fusions in 
DRGs 497 (Spinal Fusion Except Cervical With CC) and 498 (Spinal Fusion 
Except Cervical Without CC). Cases involving INFUSE TM that 
are eligible for the new technology add-on payment are identified by 
assignment to DRGs 497 and 498 as a lumbar spinal fusion, with the 
combination of ICD-9-CM procedure codes 84.51 (Insertion of

[[Page 23356]]

interbody spinal fusion device) and 84.52 (Insertion of recombinant 
bone morphogenetic protein).
    The FDA approved INFUSE TM for use on July 2, 2002. For 
FY 2005, INFUSE TM was still within the 2-year to 3-year 
period during which a technology can be considered new under the 
regulations. Therefore, in the FY 2005 IPPS final rule (69 FR 49007 
through 49009), we continued add-on payments for FY 2005 for cases 
receiving INFUSE TM for spinal fusions in DRGs 497 (Spinal 
Fusion Except Cervical With CC) and 498 (Spinal Fusion Except Cervical 
Without CC).
    As we discussed in the September 7, 2001 final rule (66 FR 46915), 
an approval of a new technology for special payment should extend to 
all technologies that are substantially similar. Otherwise, our payment 
policy would bestow an advantage to the first applicant to receive 
approval for a particular new technology. In last year's final rule (69 
FR 49008), we discussed another product, called OP-1 Putty, 
manufactured by Stryker Biotech, that promotes natural bone growth by 
using a closely related bone morphogenetic protein called rhBMP-7. 
(INFUSE TM is rhBMP-2.) We also stated in last year's final 
rule that we had determined that the costs associated with the OP-1 
Putty are similar to those associated with INFUSE TM. 
Because the OP-1 Putty became available on the market in May 2004 (when 
it received FDA approval for spinal fusions) for similar spinal fusion 
procedures and because this product also eliminates the need for the 
autograft bone surgery, we extended new technology add-on payments to 
this technology as well for FY 2005.
    As noted above, the period for which technologies are eligible to 
receive new technology add-on payments is 2 to 3 years after the 
product becomes available on the market and data reflecting the cost of 
the technology are reflected in the DRG weights. The FDA approved 
INFUSE TM bone graft on July 2, 2002. Therefore, data 
reflecting the cost of the technology are now reflected in the DRG 
weights. In addition, by the end of FY 2005, the add-on payment will 
have been made for 2 years. Therefore, we are proposing to discontinue 
new technology add-on payment for INFUSE TM for FY 2006. 
Because we apply the same policies in making new technology payment for 
OP-1 Putty as we do for INFUSE TM, we are proposing to 
discontinue new technology add-on payment for OP-1 Putty as well for FY 
2006.
b. InSync[supreg] Defibrillator System (Cardiac Resynchronization 
Therapy With Defibrillation (CRT-D))
    Cardiac Resynchronization Therapy (CRT), also known as bi-
ventricular pacing, is a therapy for chronic heart failure. A CRT 
implantable system provides electrical stimulation to the right atrium, 
right ventricle, and left ventricle to coordinate or resynchronize 
ventricular contractions and improve cardiac output.
    In the FY 2005 IPPS final rule (69 FR 49016), we determined that 
cardiac resynchronization therapy with defibrillator (CRT-D) was 
eligible for add-on payments in FY 2005. Cases involving CRT-D that are 
eligible for new technology add-on payments are identified by either 
one of the following two ICD-9-CM procedure codes: 00.51 (Implantation 
of Cardiac Resynchronization Defibrillator, Total System (CRT-D)) or 
00.54 (Implantation or Replacement of Pulse Generator Device Only (CRT-
D)). InSync[supreg] Defibrillation System received FDA approval on June 
26, 2002. However, another manufacturer, Guidant, received FDA approval 
for its CRT-D device on May 2, 2002. As we discussed in the September 
7, 2001 final rule (66 FR 46915), an approval of a new technology for 
special payment should extend to all technologies that are 
substantially similar. Otherwise, our payment policy would bestow an 
advantage to the first applicant to receive approval for a particular 
new technology. We also noted that we would extend new technology add-
on payments for the entire FY 2005 even though the 2-3 year period of 
newness ended in May 2005 for CRT-D since predictability is an 
important aspect of the prospective payment methodology and, therefore, 
we believe it is appropriate to apply a consistent payment methodology 
for new technologies throughout the fiscal year (69 FR 49016).
    As noted in the FY 2005 IPPS final rule (69 FR 49014), because CRT-
Ds were available upon the initial FDA approval in May 2002, we 
considered the technology to be new from this date. As a result, for FY 
2006, the CRT-D will be beyond the 2-3 year period during which a 
technology can be considered new. Therefore, we are proposing to 
discontinue add-on payments for the CRT-D for FY 2006.
c. Kinetra[supreg] Implantable Neurostimulator for Deep Brain 
Stimulation
    Medtronic, Inc. submitted an application for approval of the 
Kinetra[supreg] implantable neurostimulator device for new technology 
add-on payments for FY 2005. The Kinetra[supreg] device was approved by 
the FDA on December 16, 2003. The Kinetra[supreg] implantable 
neurostimulator is designed to deliver electrical stimulation to the 
subthalamic nucleus (STN) or internal globus pallidus (GPi) in order to 
ameliorate symptoms caused by abnormal neurotransmitter levels that 
lead to abnormal cell-to-cell electrical impulses in Parkinson's 
Disease and essential tremor. Before the development of 
Kinetra[supreg], treating bilateral symptoms of patients with these 
disorders required the implantation of two neurostimulators (in the 
form of a product called SoletraTM, also manufactured by 
Medtronic): one for the right side of the brain (to control symptoms on 
the left side of the body), the other for the left side of the brain 
(to control symptoms on the right side of the body). Additional 
procedures were required to create pockets in the chest cavity to place 
the two generators required to run the individual leads. The 
Kinetra[supreg] neurostimulator generator, implanted in the pectoral 
area, is designed to eliminate the need for two devices by 
accommodating two leads that are placed in both the left and right 
sides of the brain to deliver the necessary impulses. The manufacturer 
argued that the development of a single neurostimulator that treats 
bilateral symptoms provides a less invasive treatment option for 
patients, and simpler implantation, follow up, and programming 
procedures for physicians.
    In December 2003, the FDA approved the device. Therefore, for FY 
2006, Kinetra[supreg] qualifies under the newness criterion because FDA 
approval was within the statutory timeframe of 2 to 3 years and its 
costs are not yet reflected in the DRG weights. Because there were no 
data available to evaluate costs associated with Kinetra[supreg], in 
the FY 2005 IPPS final rule, we conducted the cost analysis using 
SoletraTM, the predecessor technology used to treat this 
condition, as a proxy for Kinetra[supreg]. The preexisting technology 
provided the closest means to track cases that have actually used 
similar technology and served to identify the need and use of the new 
device. The manufacturer informed us that the cost of the 
Kinetra[supreg] device is twice the price of a single 
SoletraTM device. Because most patients would receive two 
SoletraTM devices if the Kinetra[supreg] device is not 
implanted, we believed data regarding the cost of SoletraTM 
would give a good measure of the actual costs that would be incurred. 
Medtronic submitted data for 104 cases that involved the 
SoletraTM device (26 cases in DRG 1 (Craniotomy Age > 17

[[Page 23357]]

With CC), and 78 cases in DRG 2 (Craniotomy Age > 17 Without CC)). 
These cases were identified from the FY 2002 MedPAR file using 
procedure codes 02.93 (Implantation, intracranial neurostimulator) and 
86.09 (Other incision of skin and subcutaneous tissue). In the analysis 
presented by the applicant, the mean standardized charges for cases 
involving SoletraTM in DRGs 1 and 2 were $69,018 and 
$44,779, respectively. The mean standardized charge for these 
SoletraTM cases according to Medtronic's data was $50,839.
    Last year, we used the same procedure codes to identify 187 cases 
involving the SoletraTM device in DRGs 1 and 2 in the FY 
2003 MedPAR file. Similar to the Medtronic data, 53 of the cases were 
found in DRG 1, and 134 cases were found in DRG 2. The average 
standardized charges for these cases in DRGs 1 and 2 were $51,163 and 
$44,874, respectively. Therefore, the case-weighted average 
standardized charge for cases that included implantation of the 
SoletraTM device was $46,656. The new cost thresholds 
established under the revised criteria in Pub. L. 108-173 for DRGs 1 
and 2 are $43,245 and $30,129, respectively. Accordingly, the case-
weighted threshold to qualify for new technology add-on payment using 
the data we identified was determined to be $33,846. Under this 
analysis, Kinetra[supreg] met the cost threshold.
    We note that an ICD-9-CM code was approved for dual array pulse 
generator devices, effective October 1, 2004, for IPPS tracking 
purposes. The new ICD-9-CM code that will be assigned to this device is 
86.95 (Insertion or replacement of dual array neurostimulator pulse 
generator), which includes dual array and dual channel generators for 
intracranial, spinal, and peripheral neurostimulators. The code will 
not separately identify cases with the Kinetra[supreg] device and will 
only be used to distinguish single versus dual channel-pulse generator 
devices. Because the code only became effective on October 1, 2004, we 
do not have any specific data regarding the costs of cases involving 
dual array pulse generator devices.
    The manufacturer claimed that Kinetra[supreg] provides a range of 
substantial improvements beyond previously available technology. These 
include a reduced rate of device-related complications and 
hospitalizations or physician visits and less surgical trauma because 
only one generator implantation procedure is required. Kinetra[supreg] 
has a reed switch disabling function that physicians can use to prevent 
inadvertent shutoff of the device, as occurs when accidentally tripped 
by electromagnetic inference (caused by common products such as metal 
detectors and garage door openers). Kinetra[supreg] also provides 
significant patient control, allowing patients to monitor whether the 
device is on or off, to monitor battery life, and to fine-tune the 
stimulation therapy within clinician-programmed parameters. While 
Kinetra[supreg] provides the ability for patients to better control 
their symptoms and reduce the complications associated with the 
existing technology, it does not eliminate the necessity for two 
surgeries. Because the patients who receive the device are often frail, 
the implantation generally occurs in two phases: the brain leads are 
implanted in one surgery, and the generator is implanted in another 
surgery, typically on another day. However, implanting Kinetra[supreg] 
does reduce the number of potential surgeries compared to its 
predecessor (which requires two surgeries to implant the two single-
lead arrays to the brain and an additional surgery for implantation of 
the second generator). Therefore, the Kinetra[supreg] device reduces 
the number of surgeries from 3 to 2.
    Last year, we solicited comments on (1) the issue of whether the 
device is sufficiently different from the previously used technology to 
qualify as a substantially improved treatment for the same patient 
symptoms; (2) the cost of the device; and (3) the approval of the 
device for add-on payment, given the uncertainty over the frequency 
with which the patients receiving the device have the generator 
implanted in a second hospital stay, and the frequency with which this 
implantation occurs in an outpatient setting. In the response, we 
received sufficient evidence to demonstrate that Kinetra[supreg] does 
represent a substantial clinical improvement over the previous Soletra 
TM device. Specifically, the increased patient control, 
reduced surgery, fewer complications, and elimination of environmental 
interference significantly improve patient outcomes. Therefore, we 
approved Kinetra[supreg] for new technology add-on payments for FY 
2005.
    Cases receiving Kinetra[supreg] for Parkinson's disease or 
essential tremor on or after October 1, 2004, are eligible to receive 
an add-on payment of up to $8,285, or half the cost of the device, 
which is approximately $16,570. These cases are identified by the 
presence of procedure codes 02.93 (Implantation or replacement of 
intracranial neurostimulator leads) and 86.95 (Insertion or replacement 
of dual array neurostimulator pulse generator). If a claim has only the 
procedure code identifying the implantation of the intracranial leads, 
or if the claim identifies only insertion of the generator, no add-on 
payment will be made.
    This technology received FDA approval on December 16, 2003, and 
remains within the 2 to 3 year period during which it can be considered 
new. Therefore, we are proposing to continue add-on payments for 
Kinetra[supreg] Inplantable Neurostimulator for deep brain stimulation 
for FY 2006.
4. FY 2006 Applications for New Technology Add-On
a. INFUSE TM Bone Graft (Bone Morphogenetic Proteins (BMPs) 
for Tibia Fractures)
    Bone Morphogenetic Proteins (BMPs) have been shown to have the 
capacity to induce new bone formation and, therefore, to enhance the 
healing of fractures. Using recombinant techniques, some BMPs (also 
referred to as rhBMPs) can be produced in large quantities. This 
innovation has cleared the way for the potential use of BMPs in a 
variety of clinical applications such as in delayed union and nonunion 
of fractured bones and spinal fusions. One such product, rhBMP-2, is 
developed as an alternative to bone graft with spinal fusions.
    Medtronic Sofamor Danek (Medtronic) resubmitted an application 
(previously submitted for consideration for FY 2005) for a new 
technology add-on payment in FY 2006 for the use of INFUSE 
TM Bone Graft in open tibia fractures. In cases of open 
tibia fractures, INFUSE TM is applied using an absorbable 
collagen sponge, which is then applied to the fractured bone to promote 
new bone formation and improved healing. The manufacturer contends that 
patient access to this technology is restricted due to the increased 
costs of treating these cases with INFUSE TM. The FDA 
approved use of INFUSE TM for open tibia fractures on April 
30, 2004.
    Medtronic's first application for a new technology add-on payment 
for INFUSE TM Bone Graft in open tibia fractures was denied. 
As we discussed in the FY 2005 IPPS final rule (69 FR 49010), the FY 
2005 application for INFUSE TM for open tibia fractures was 
denied because a similar product, OP-1, was approved in 2001 for the 
treatment of nonunion of tibia fractures.
    Comment: In comments presented at the February 2005 new technology 
town hall meeting, Medtronic contended that there was no opportunity 
for public

[[Page 23358]]

comment on our decision regarding OP-1 Putty: ``the public had no 
opportunity to comment on whether the follow-on products were 
`substantially similar' to the primary technologies under 
consideration. The absence of such provisions led to unpredictability 
and confusion about the new-technology add-on program.''
    Response: In the FY 2005 IPPS final rule, we noted that a commenter 
brought the existence of the Stryker Biotech OP-1 product to our 
attention during the comment period on the IPPS proposed rule for FY 
2005. The commenter noted OP-1's clinical similarity to INFUSE 
TM and contended that the products should be treated the 
same with respect to new technology payments when the product is used 
for tibia fractures. At that time, we determined that, despite the 
differences in indications under the respective FDA approvals, the two 
products were in use for many of the same kinds of cases. Specifically, 
clinical studies on the safety of OP-1 included patients with 
complicated fractures of the tibia, and those cases were similar to the 
cases described in the clinical trials for INFUSE TM for 
open tibia fractures. In addition, cases involving the use of OP-1 for 
long bone union and open tibia fractures are assigned to the same DRGs 
(DRGs 218 and 219 (Lower Extremity Procedures With and Without CC, 
respectively)) as cases involving INFUSE TM. Therefore, we 
denied new technology add-on payments for INFUSE TM for open 
tibia fractures for FY 2005 on the grounds that the technology 
involving the use of bone morphogenetic proteins to treat severe long 
bone fractures (including open tibia fractures) and recalcitrant long 
bone fractures had been in use for more than 3 years.
    We note that Medtronic had ample opportunity, prior to the issuance 
of the FY 2005 IPPS final rule, to bring to our attention the fact that 
there was a similar product on the market that was being used in long 
bone fractures. We based our decision for FY 2005 on the record that 
was placed at our disposal by the applicant and by commenters during 
the comment period. Nevertheless, we have considered the issues raised 
by these two products again in the course of evaluating Medtronic's new 
application for approval of INFUSE TM for new technology 
add-on payments in FY 2006.
    As part of its FY 2006 application, Medtronic advanced several 
arguments designed to demonstrate that OP-1 and INFUSE TM 
are substantially different. The application cites data from several 
studies as evidence of the clinical superiority of INFUSE TM 
over OP-1. Medtronic presented studies at the February 2005 new 
technology town hall meeting to provide evidence that INFUSE 
TM is superior to OP-1 in the time it takes for critical-
sized defects to heal and in radiographic assessment, mechanical 
testing of the repaired bone, and histology of the union for trial 
subjects receiving INFUSE TM compared with OP-1. (Study 
subjects were canines whose ulnas had 2.5 cm each of bone removed and 
then equal amounts of OP-1 and INFUSE TM were put into the 
front legs in a head to head trial.) Medtronic has also argued that 
these studies demonstrate that OP-1 has been shown to be less effective 
than using the patient's own bone or the current standard of care (nail 
fixation with soft tissue medical management). Medtronic argued that 
the INFUSE TM product is not only superior to OP-1 for 
patients with open tibia fractures, but also that it is superior to any 
other treatment for these serious injuries.
    Medtronic also pointed out that the FDA approved OP-1 for 
Humanitarian Device Exemption (HDE) status, whereas INFUSE 
TM received a Pre-Market Approval (PMA). To receive HDE 
approval, a product only needs to meet a safety standard, while 
standards of both safety and efficacy have to be met for a PMA 
approval. Medtronic argued that, because the only point the 
manufacturer of OP-1 was able to prove was that it did not harm those 
individuals that received it, the efficacy of OP-1 not only has not 
been demonstrated for the general population, but also more 
specifically, it has not been proven in the Medicare population. 
Medtronic presented arguments that INFUSE TM is a superior 
product to OP-1 because the INFUSE TM product has 
demonstrated safety and efficacy, while the OP-1 product has merely 
demonstrated that it is safe to use in humans. Medtronic pointed to the 
labeled indications and package inserts provided with the two products, 
stating that only INFUSE TM provides a substantial clinical 
improvement to patients receiving a BMP product.
    We do not believe that the different types of FDA approvals for the 
two products are relevant to distinguish between the two products in 
determining whether either product should be considered for new 
technology add-on payments under the IPPS. Manufacturers seek different 
types of FDA approval for many different reasons, including timing, the 
availability of adequate studies, the availability of resources to 
pursue research studies, and the size of the patient population that 
may be affected. The FDA has stated that the HDE approval process was 
established to address cases involving devices used in the treatment or 
diagnosis of diseases affecting fewer than 4,000 individuals in the 
United States per year: ``A device manufacturer's research and 
development costs could exceed its market returns for diseases or 
conditions affecting small patient populations. FDA, therefore, 
developed and published [the regulation establishing the HDE process] 
to provide an incentive for the development of devices for use in the 
treatment or diagnosis of diseases affecting these populations.'' 
(http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfHDE/HDEInformation.cfm). The fact that two products received different 
types of approval does not demonstrate either that they are 
substantially different for purposes of new technology add-on payments, 
or that one is new and the other is not. Nor do the different types of 
FDA approval imply that one product could meet our substantial clinical 
improvement criterion and the other could not. Neither type of FDA 
approval requires that products establish substantial clinical 
improvement, as is required for approval of new technology add-on 
payments. Theoretically, a product that receives an FDA HDE approval 
could subsequently meet our substantial clinical improvement criterion, 
while a product that receives an FDA PMA approval could fail to do so. 
We base our substantial clinical improvement determinations on the 
evidence presented in the course of the application process, and not on 
the type of FDA approval.
    For purposes of determining whether the use of rhBMPs for open 
tibia fracture represents a new technology, the crucial consideration 
is whether the costs of this technology are represented in the weights 
of the relevant DRGs. Cases that involve treatment of non-healed and 
acute tibia fractures fall into the same DRGs. We have identified 
10,047 cases involving the use of rhBMPs in the FY 2004 MedPAR data 
file. This use includes the approved indications for INFUSE 
TM in spinal fusions (6,712 cases) and tibia DRGs (77 
cases). However, we note that an additional 3,258 cases involving the 
off-label use of rhBMPs were found in 47 DRGs in the FY 2004 MedPAR 
data. We also note that, in our analysis of the FY 2003 MedPAR data, an 
additional 890 cases of off-label use (identified by the presence of 
ICD-9-CM code 84.52) were found in 36 DRGs. Therefore, we note

[[Page 23359]]

that the use of rhBMPs, made by Medtronic or otherwise, has penetrated 
the cost data that were used to set the FY 2005 and FY 2006 DRG 
weights. Whether or not it is possible to differentiate between patient 
populations that would be eligible to receive the OP-1 Implant for 
nonunions or the INFUSE TM bone graft for open tibia 
fractures, the patient populations both fall into the same DRGs. In 
addition, we have determined that the costs associated with the two 
products are comparable (69 FR 49009). Therefore, because BMP products 
have been used in treating both types of fractures included in the same 
DRGs since 2001, we continue to believe that the hospital charge data 
used in developing the relative weights reflect the costs of these 
products.
    Comment: In our Federal Register announcement of the February 23, 
2005 new technology town hall meeting, held on February 23, 2005, we 
solicited comments on the issue of when products should be considered 
substantially similar. As a result, Medtronic recommended several 
criteria for determining whether two or more products are substantially 
similar and requested that we apply these criteria in determining 
whether OP-1 and INFUSE TM are similar for new technology 
add-on payment purposes. The three criteria recommended by Medtronic 
are:
     The technologies or services in question use the same, or 
a similar, mechanism of action to achieve the therapeutic outcome.
     The technologies or services are indicated for use in the 
same population for the same condition.
     The technologies or services achieve the same level of 
substantial improvement.
    Medtronic has also argued that, according to its proposed criteria, 
OP-1 would fail on two of the three proposed tests for substantial 
similarity:
     According to Medtronic, the OP-1 implant ``arguably'' uses 
the same or a similar mechanism of action to achieve the therapeutic 
outcome.
     OP-1 and INFUSE TM are indicated for use in 
different population and different conditions. According to Medtronic, 
INFUSE TM Bone Graft has an indication for acute, open tibia 
fractures only, used within 14 days, and is to be used with an 
intramedullary (IM) nail as part of the primary procedure. There is no 
limitation on the number of patients that can receive the technology. 
OP-1 Implant is indicated only for recalcitrant long-bone non-unions 
that have failed to heal. The HDE approval also specifies that use of 
OP-1 is limited to secondary procedures (as would be expected with 
nonunions). The number of patients able to receive the device is 
limited to 4,000 patients per year and with oversight from an 
Institutional Review Board.
     Medtronic argues the products do not achieve the same 
level of substantial improvement (as discussed above).
    Response: We agree with Medtronic that the first proposed criterion 
has some relevance in determining whether products are substantially 
similar. In evaluating the application for new technology add-on 
payments last year, we made the determination that, while these 
products are not identical chemically, the products do use the same 
mechanism of action to achieve the therapeutic outcome. However, we do 
not agree that the other two criteria recommended by Medtronic are 
relevant considerations for this purpose. As we have discussed above, 
we believe that whether cases involving different products are assigned 
to the same DRGs is a more relevant consideration than whether the 
products have the same specific indications. In addition, as we have 
already stated, we continue to believe that the hospital charge data 
used in developing the relative weights of the relevant DRGs reflect 
the costs of these products. Furthermore, we do not necessarily agree 
that considerations about the degrees of clinical improvements offered 
by different products should enter into decisions about whether 
products are new. We have always based our decisions about new 
technology add-on payments on a logical sequence of determinations, 
moving from the newness criterion to the cost criterion and finally to 
the substantial clinical improvement criterion. Specifically, we do not 
make determinations about substantial improvement unless a product has 
already been determined to be new and to meet the cost criterion. 
Therefore, we are reluctant to import substantial clinical improvement 
considerations into the logical prior decision about whether 
technologies are new. Furthermore, while we may sometimes need to make 
separate determinations about whether similar products meet the 
substantial clinical improvement criterion, we do not believe that it 
would be appropriate to make determinations about whether one product 
or another is clinically superior. However, we welcome comments while 
we continue to consider these issues.
    Comment: Medtronic suggested revisions to the application process 
that are designed to assist in identifying substantially similar 
products and provide the public with opportunity for comment on 
specific instances in which substantial similarity is an issue. The 
suggested proposed revisions are:
     After receipt of all new applications for a fiscal year, 
CMS should publish a Federal Register notice specifically asking 
manufacturers to identify if they wish to receive consideration for 
products that may be substantially similar to applications received. 
Such notice would probably occur in January. Responses would be 
required by a date certain in advance of the new technology town hall 
meeting, and would include justification of how the products meet the 
``substantial similarity'' criteria.
     The new technology town hall meeting should include a 
discussion of products identified by manufacturers as ``substantially 
similar'' to other approved products or pending applications.
     CMS should publish initial findings about ``substantial 
similarity'' in the proposed hospital inpatient rule, with opportunity 
for public comment.
     CMS should publish ultimate findings in the inpatient 
final rule.
    Alternatively, Medtronic suggested that, if a manufacturer 
identifies a product that may be substantially similar to a technology 
with an approved add-on payment, the manufacturer may choose to submit 
an application under the normal deadlines for the add-on payment 
program.
    Response: We appreciate Medtronic's suggestions for evaluating 
similar technologies for new technology add-on payment. We have stated 
on several occasions that we wish to avoid creating situations in which 
similar products receive different treatment because only one 
manufacturer has submitted an application for new technology add-on 
payments. As we discussed in the September 7, 2001 Federal Register (66 
FR 46915), an approval of a new technology for special payment should 
extend to all technologies that are substantially similar. Otherwise, 
our payment policy would bestow an advantage to the first applicant to 
receive approval for a particular new technology.
    In addition, we note that commenters on the FY 2005 proposed rule 
placed a great deal of emphasis on the fact that many manufacturers 
developing new technologies are not aware of the existence of the add-
on payment provision or lack the resources to apply for add-on payment. 
Therefore, commenters on that proposed rule argued that the regulations 
we have established are already too stringent and cumbersome, 
especially for small manufacturers to access the new

[[Page 23360]]

technology add-on payment process. The proposal by Medtronic would 
place further burden on these small manufacturers, both to know that an 
application has been made for a similar product and to make 
representations on a product that may or may not be on the market. 
Therefore, we are reluctant to adopt a process that places the formal 
burden on a competitor to seek equal treatment. However, we welcome 
comments while we continue to consider these issues.
    We note that Medtronic submitted data on 236 cases using INFUSE 
TM for open tibia fractures in the FY 2003 MedPAR data file, 
as identified by procedure code 79.36 (Reduction, fracture, open, 
internal fixation, tibia and fibula) and diagnosis codes of either 
823.30 (Fracture of tibia alone, shaft, open) or 823.32 (Fracture of 
fibula and tibia, shaft, open). Medtronic also noted that the patients 
in clinical trials with malunion fractures (diagnosis code 733.81) or 
nonunion fractures (diagnosis code 733.82) would also be likely 
candidates to receive INFUSE TM. Based on the data submitted 
by the applicant, INFUSE TM would be used primarily in two 
different DRGs: 218 and 219 (Lower Extremity and Humerus Procedures 
Except Hip, Foot, Femur Age > 17, With and Without CC, respectively). 
The analysis performed by the applicant resulted in a case-weighted 
cost threshold of $24,461 for these DRGs. The average case-weighted 
standardized charge for cases using INFUSE TM in these DRGs 
would be $39,537. Therefore, the applicant maintains that INFUSE 
TM for open tibia fractures meets the cost criterion.
    However, because the costs of INFUSE TM and OP-1 are 
already reflected in the relevant DRGs, these products cannot be 
considered new. Therefore, we are proposing to deny new technology add-
on payments for INFUSE TM bone graft for open tibia 
fractures for FY 2006.
b. AquadexTM System 100 Fluid Removal System (System 100)
    CHF Solutions, Inc. resubmitted an application (previously 
submitted for consideration for FY 2005) for the approval of the System 
100 for new technology add-on payments for FY 2006. The System 100 is 
designed to remove excess fluid (primarily excess water) from patients 
suffering from severe fluid overload through the process of 
ultrafiltration. Fluid retention, sometimes to an extreme degree, is a 
common problem for patients with chronic congestive heart failure. This 
technology removes excess fluid without causing hemodynamic 
instability. It also avoids the inherent nephrotoxicity and 
tachyphylaxis associated with aggressive diuretic therapy, the mainstay 
of current therapy for fluid overload in congestive heart failure.
    The System 100 consists of: (1) An S-100 console; (2) a UF 500 
blood circuit; (3) an extended length catheter (ELC); and (4) a 
catheter extension tubing. The System 100 is designed to monitor the 
extracorporeal blood circuit and to alert the user to abnormal 
conditions. Vascular access is established via the peripheral venous 
system, and up to 4 liters of excess fluid can be removed in an 8-hour 
period.
    On June 3, 2002, FDA approved the System 100 for use with 
peripheral venous access. On November 20, 2003, FDA approved the System 
100 for expanded use with central venous access and catheter extension 
use for infusion or withdrawal circuit line with other commercially 
applicable venous catheters. According to the applicant, although the 
FDA first approved System 100 in June 2002, it was not used by 
hospitals until August 2002 because of the substantial amount of time 
necessary to market and sell the device to hospitals. The applicant 
presented data and evidence demonstrating that the System 100 was not 
marketed until August 2002.
    We note the applicant submitted an application for FY 2005 and was 
denied new technology add-on payments. Our review indicated that the 
applicant did not present sufficient objective clinical evidence to 
determine that the System 100 meets the substantial clinical 
improvement criterion (such as a large prospective, randomized clinical 
trial) even though it is indicated for use in patients with congestive 
heart failure, a common condition in the Medicare population. However, 
for FY 2006, we are proposing to deny System 100 new technology add-on 
payments on the basis of our determination that it is no longer new. 
Technology is no longer considered new 2 to 3 years after data 
reflecting its costs begin to become available. Because data on the 
costs of the System 100 first became available in 2002, the costs are 
currently reflected in the DRG weights and the device is no longer new.
    The applicant also submitted information for the cost and 
substantial clinical improvement criteria. As stated last year, it is 
important to note at the outset of the cost analysis that the console 
is reusable and is, therefore, a capital cost. Only the circuits and 
catheters are components that represent operating expenses. Section 
1886(d)(5)(K)(i) of the Act requires that the Secretary establish a 
mechanism to recognize the costs of new medical services or 
technologies under the payment system established under subsection (d) 
of section 1886, which establishes the system for paying for the 
operating costs of inpatient hospital services. The system of payment 
for capital costs is established under section 1886(g) of the Act, 
which makes no mention of any add-on payments for a new medical service 
or technology. Therefore, it is not appropriate to include capital 
costs in the add-on payments for a new medical service or technology 
and these costs should also not be considered in evaluating whether a 
technology meets the cost criterion. The applicant has applied for add-
on payments for only the circuits and catheter, which represent the 
operating expenses of the device. However, as stated in the FY 2005 
IPPS final rule, we believe that the catheters cannot be considered new 
technology for this device. As a result, we considered only the UF 500 
disposable blood circuit as relevant to the evaluation of the cost 
criterion.
    The applicant submitted data from the FY 2003 MedPAR file in 
support of its application for new technology add-on payments for FY 
2006. The applicant used a combination of diagnosis codes to determine 
which cases could potentially use the System 100. The applicant found 
28,155 cases with the following combination of ICD-9-CM diagnosis 
codes: 428.0 through 428.9 (Heart Failure), 402.91 (Unspecified with 
Heart Failure), or 402.11 (Hypertensive Heart Disease with Heart 
Failure), in combination with 276.6 (Fluid Overload) and 782.3 (Edema). 
The 28,155 cases were found among 148 DRGs with 50.1 percent of cases 
mapped across DRGs 88, 89, 127, 277 and 316. The applicant eliminated 
those DRGs with less than 150 cases, which resulted in a total of 
22,620 cases that could potentially use the System 100. The case-
weighted average standardized charge across all DRGs was $13,619.32. 
The case-weighted threshold across all DRGs was $16,125.42. Although 
the case-weighted threshold is greater than the case-weighted 
standardized charge, it is necessary to include the standardized charge 
for the circuits used in each case. In order to establish the charge 
per circuit, the applicant submitted data regarding 76 actual cases 
that used the System 100. Based on these 76 cases, the standardized 
charge per circuit was $2,591. The applicant also stated that an 
average of two circuits are used per case. Therefore, adding $5,182 for 
the charge of the two

[[Page 23361]]

circuits to the case-weighted average standardized charge of $13,619.32 
results in a total case-weighted standardized charge of $18,801.32. 
This amount is greater than the case-weighted threshold of $16,125.42.
    The applicant contended that the System 100 represents a 
substantial clinical improvement for the following reasons: It removes 
excess fluid without the use of diuretics; it does not lead to 
electrolyte imbalance, hemodynamic instability or worsening renal 
function; it can restore diuretic responsiveness; it does not adversely 
affect the renin-angiotensin system; it reduces length of hospital stay 
for the treatment of congestive heart failure, and it requires only 
peripheral venous access. The applicant also noted that there are some 
clinical trials that have demonstrated the clinical safety and 
effectiveness as well as cost effectiveness of the System 100 in 
treating patients with fluid overload.
    However, as stated above, we are proposing to deny new technology 
add-on payments for the System 100 because it does not meet the newness 
criterion.
    We received no public comments regarding this application for add-
on payments.
c. CHARITETM Artificial Disc (CHARITETM)
    DePuy SpineTM submitted an application for new 
technology add-on payments for the CHARITETM Artificial Disc 
for FY 2006. This device is a prosthetic intervertebral disc. DePuy 
SpineTM stated that the CHARITETM Artificial Disc 
is the first artificial disc approved for use in the United States. It 
is a 3-piece articulating medical device consisting of a sliding core 
that is placed between two metal endplates. The sliding core is made 
from a medical grade plastic and the endplates are made from medical 
grade cobalt chromium alloy. The endplates support the core and have 
small teeth that are secured to the vertebrae above and below the disc 
space. The sliding core fits in between the endplates.
    On October 26, 2004, the FDA approved the CHARITETM 
Artificial Disc for single level spinal arthroplasty in skeletally 
mature patients with degenerative disc disease (DDD) between L4 and S1. 
The FDA further stated that DDD is defined as discogenic back pain with 
degeneration of the disc confirmed by patient history and radiographic 
studies. These DDD patients should have no more than 3 mm of 
spondylolisthesis at an involved level. Patients receiving the 
CHARITETM Artificial Disc should have failed at least 6 
months of conservative treatment prior to implantation of the 
CHARITETM Artificial Disc. Because the device is within the 
statutory timeframe of 2 to 3 years and data is not yet reflected 
within the DRGs, we consider the CHARITETM Artificial Disc 
to meet the newness criterion.
    We note that an ICD-9-CM code was effective October 1, 2004, for 
IPPS tracking purposes. The code assigned to the CHARITETM 
was 84.65 (Insertion of total spinal disc prosthesis, lumbosacral).
    For analysis of the cost criterion, the applicant submitted two 
sets of data: one that used actual cases and one that used FY 2003 
MedPAR cases. The applicant expects that cases using the 
CHARITETM will map to DRGs 499 and 500. The applicant 
submitted 68 actual cases from 35 hospitals that used the 
CHARITETM. Of these 68 cases, only 3 were Medicare patients; 
the remaining cases were privately insured patients or patients for 
whom the payer was unknown. Using data from the 68 actual cases, the 
average standardized charge was $40,722. The applicant maintained that 
this figure is well in excess of the thresholds for DRGs 499 and 500 
(regardless of a case weighted threshold) of $24,828 and $17,299 
respectively. Based on this analysis, the applicant maintained that the 
CHARIT[Eacute]TM meets the cost criterion because the 
average standardized charge exceeds the charge thresholds for DRGs 499 
and 500.
    In addition, as stated above, the applicant submitted cases from 
the FY 2003 MedPAR file. The applicant searched the MedPAR file for 
ICD-9-CM procedure codes 81.06, 81.07, and 81.08 in combination with 
diagnosis codes 722.10, 722.2, 722.5, 722.52, 722.6, 722.7, 722.73 and 
756.12, to identify a patient population that could be eligible for the 
CHARITETM Artificial Disc and found a total of 12,680 cases. 
However, these cases are from the FY 2003 MedPAR file and precede the 
effective date of ICD-9-CM code 84.65 that is currently used to track 
the device. Of these 12,680 cases, 55.5 percent were reported in DRG 
497, and 44.5 percent were reported in DRG 498. The applicant stated 
that cases using the CHARITETM device group to the DRGs for 
back and neck procedures that exclude spinal fusions (DRGs 499 and 
500). However, the applicant argues that the CHARITETM could 
be a substitute for spinal fusion procedures found in DRGs 497 and 498 
and, therefore, used cases from these DRGs to evaluate whether the 
CHARITETM meets the cost criterion and to argue that 
procedures using the technology should be grouped to the spinal fusion 
DRGs. The average standardized charge per case was $50,098 for DRG 497 
and $41,290 for DRG 498. Using revenue codes 272 and 278 from the 
MedPAR file, the applicant then subtracted the charges for surgical and 
medical supplies used in connection with spinal fusion procedures, 
which resulted in a standardized charge of all other charges of $24,333 
for DRG 497 and $22,183 for DRG 498. Based on the actual cases above, 
the applicant then estimated the average standardized charge for 
surgical and medical supplies per case for the CHARITETM was 
$20,033. The applicant estimated that charges have grown by 15 percent 
from FY 2003 to FY 2005 and, therefore, deflated the average 
standardized charge for surgical and medical supplies of the 
CHARITETM by 15 percent to $17,420. The applicant then added 
the average standardized charge for surgical and medical supplies of 
the CHARITETM to the standardized charge of all other 
charges for DRG 497 and 498 and also inflated the charges by 15 percent 
in order to update the data to FY 2005 charge levels. This amounted to 
a case-weighted average standardized charge of $46,256. Although the 
analysis was completed with DRGs 497 and 498, it is necessary to 
compare the average standardized charge to the thresholds of DRGs 499 
and 500 because the GROUPER maps these cases to DRGs 499 and 500. As a 
result, the case-weighted threshold was $21,480. Similar to the 
analysis above, the applicant stated that the case-weighted average 
standardized charge is greater than the case-weighted threshold and, as 
a result, the applicant maintained that the CHARITETM meets 
the cost criterion.
    The applicant also contended that the CHARITETM 
represents a substantial clinical improvement over existing technology. 
Use of the CHARITETM may eliminate the need for spinal 
fusion and the use of autogenous bone, and the applicant stated that, 
based on the Investigational Device Exemption (IDE) study, ``A 
Prospective Randomized Multicenter Comparison of Artificial Disc vs. 
Fusion for Single Level Lumbar Degenerative Disc Disease'' (Blumenthal, 
S, et al, National American Spine Society 2004 Abstract) that patients 
who received the CHARITETM Artificial Disc were discharged 
from the hospital after an average of 3.7 days compared to 4.2 days in 
the fusion group. Furthermore, the applicant stated that patients who 
received the CHARITETM Artificial Disc had a statistically 
greater improvement in Oswetry Disability Index scores and Visual 
Analog Scale Pain scores compared to the fusion group at 6 weeks

[[Page 23362]]

and 3, 6 and 12 months. The study also showed greater improvement from 
baseline compared to the fusion group on the Physical Component Score 
at 3, 6, and 23 months. In addition, the applicant states that patients 
receiving the CHARITETM Artificial Disc returned to normal 
activities in half the time, compared to patients who underwent fusion, 
and at the 2 year follow up, 15 percent of patients who underwent a 
fusion were dissatisfied with the postoperative improvements compared 
to 2 percent who received the CHARITETM Artificial Disc. 
Also, patients who received the CHARITETM Artificial Disc 
returned to work on average of 12.3 weeks after surgery compared to 
16.3 weeks after circumferential fusion and 14.4 weeks with Bagby and 
Kuslich cages. The applicant finally stated that the motion preserving 
technology of the CHARITETM Artificial Disc may reduce the 
risk of increase of degenerative disc disease (DDD). The applicant 
explained that degeneration of adjacent discs due to increased stress 
has been strongly associated with spinal fusion utilizing 
instrumentation. In a followup of 100 patients (minimum 10 years) who 
received the CHARITETM Artificial Disc, the incidence of 
adjacent level DDD was 2 percent.
    We are continuing to review the information on whether the CHARITE 
TM Artificial Disc would appear to represent a substantial 
clinical improvement over existing technology for certain patient 
populations. Based on the studies submitted to the FDA and CMS, we 
remain concerned that the information presented may not definitively 
substantiate whether the CHARITE TM Artificial Disc is a 
substantial clinical improvement over spinal fusion. In addition, we 
are concerned that the cited IDE study enrolled no patients over 60 
years of age, which excludes much of the Medicare population, and we 
are concerned that the device is contraindicated in patients with 
``significant osteoporosis,'' which is quite common in the Medicare 
population. We invite comment on both of these points and on the more 
general question of whether the device satisfies the substantial 
clinical improvement criterion.
    Despite the issues mentioned above, we are still considering 
whether it is appropriate to approve new technology add-on payment 
status for the CHARITE TM Artificial Disc for FY 2006. If 
approved for add-on payments, the device would be reimbursed up to half 
of the costs for the device. Because the manufacturer has stated that 
the cost for the CHARITE TM Artificial Disc would be 
$11,500, the maximum add-on payment for the device would be $5,750. In 
the final rule, we will make a final determination on whether the 
CHARITE TM Artificial Disc should receive new technology 
add-on payments for FY 2006 based on public comments and our continuing 
analyses.
    We finally note that the applicant requested a DRG reassignment for 
cases of the CHARITE TM Artificial Disc from DRGs 499 (Back 
and Neck Procedures Except Spinal Fusion With CC) and 500 (Back and 
Neck Procedures Except Spinal Fusion Without CC) to DRGs 497 (Spinal 
Fusion Except Cervical With CC) and 498 (Spinal Fusion Except Cervical 
Without CC). The applicant argued that the costs associated with an 
artificial disc surgery are similar to spinal fusion and inclusion in 
DRGs 497 and 498 would obviate the need to make a new technology add-on 
payment. On October 1, 2004, we created new codes for the insertion of 
spinal disc prostheses (codes 84.60 through 84.69). In the FY 2005 IPPS 
proposed rule and the final rule, we described the new DRG assignments 
for these new codes in Table 6B of the Addendum to the rules. We 
received a number of comments recommending that we change the DRG 
assignments from DRGs 499 and 500 in MDC 8 to the DRGs for spinal 
fusion (DRGs 497 and 498). In the FY 2005 IPPS final rule (69 FR 
48938), we indicated that DRGs 497 and 498 are limited to spinal fusion 
procedures. Because the surgery involving the CHARITE TM is 
not a spinal fusion, we decided not to include this procedure in these 
DRGs. However, we will continue to analyze this issue and are 
interested in public comments on both the new technology application 
for the CHARITE TM and the DRG assignment for spinal disc 
prostheses.
    We received no public comments regarding this application for new 
technology add-on payments.
d. Endovascular Graft Repair of the Thoracic Aorta
    Endovascular stent-grafting of the descending thoracic aorta (TA) 
provides a less invasive alternative to the traditional open surgical 
approach required for the management of descending thoracic aortic 
aneurysms. W.L. Gore & Associates, Inc. submitted an application for 
consideration of its Endovascular Graft Repair of the Thoracic Aorta 
(GORE TAG) for new technology add-on payments for FY 2006. The GORE TAG 
device is a tubular stent-graft mounted on a catheter-based delivery 
system, and it replaces the synthetic graft normally sutured in place 
during open surgery. The device is identified using ICD-9-CM procedure 
code 39.79 (Other endovascular repair (of aneurysm) of other vessels). 
The applicant has requested a unique ICD-9-CM procedure code.
    At this point the time of the initial application, the FDA hads not 
yet approved this technology for general use. Subsequently, however, we 
were notified that FDA approval was granted on March 23, 2005. Although 
we discuss some of the data submitted with the application for new 
technology add-on payments below, we are unable to include a detailed 
analysis of cost data and substantial clinical improvement data in this 
proposed rule because FDA approval occurred too late for us to conduct 
a complete analysis.
    The applicant submitted cost threshold information for the GORE TAG 
device. According to the manufacturer, cases using the GORE TAG device 
would fall into DRGs 110 and 111 (Major Cardiovascular Procedures With 
and Without CC, respectively). The applicant identified 185 cases in 
the FY 2003 MedPAR using procedure code 39.79 (Other endovascular 
repair (of aneurysm) of other vessels) and primary diagnosis codes 
441.2 (Thoracic aneurysm, without mention of rupture), 441.1 (Thoracic 
aneurysm, ruptured), or 441.01 (Dissection of aorta, thoracic). The 
case-weighted standardized charge for 177 of these cases was $60,905. 
According to the manufacturer, the case-weighted cost threshold for 
these DRGs is $49,817. Based on this analysis, the manufacturer 
maintained that the technology meets our cost threshold.
    The manufacturer argued that the GORE TAG represents a substantial 
clinical improvement over existing technology, primarily by avoiding 
the traditional open aneurysm repair procedure with its associated high 
morbidity and mortality. The applicant argued that a descending 
thoracic aorta aneurysm is a potentially life threatening condition 
that currently requires a major operative procedure for its treatment. 
The mortality and complication rates associated with this surgery are 
very high, and the surgery is frequently performed under urgent or 
emergent conditions. The applicant noted that such complications can 
increase the length of the hospital stay and can include neurological 
damage, paralysis, renal failure, pulmonary emboli, hemorrhage, and 
sepsis. The average time for patients undergoing surgical repair to 
return to normal activity is 3 to 4 months, but can be significantly 
longer.

[[Page 23363]]

    In comparison, the applicant argued that endovascular stent-
grafting done with the GORE TAG thoracic endoprosthesis is minimally 
invasive. The manufacturer noted that patients treated with the 
endovascular technique experience far less aneurysm-related mortality 
and morbidity, compared to those patients that receive the open 
procedure resulting in reduced overall length-of-stay, less intensive 
care unit days and less operative complications.
    We received the following public comments, in accordance with 
section 503(b)(2) of Pub. L. 108-173, regarding this application for 
add-on payments.
    Comment: Several commenters expressed support for approval of new 
technology add-on payments for the GORE TAG device. These commenters 
noted that the data presented to the FDA advisory panel for 
consideration for FDA approval of the device clearly demonstrate the 
safety and efficacy of the GORE TAG device. They also noted that nearly 
200 patients have been treated with the endografts, with a highly 
significant difference in both postoperative mortality and a reduction 
in the incidence of spinal cord ischemic complications, with some 
commenters noting the trial results, which showed a reduction in the 
rate of paraplegia from 14 percent to 3 percent, compared to open 
surgery. The commenters also stressed the rigorous nature of the open 
surgery, which requires a left lateral thoracotomy, resulting in 
significant morbidity. The commenters further argued that, since many 
of the patients with degenerative aneurysm of the thoracic aorta are 
elderly or present with significant comorbidities, or both, it is ``a 
common circumstance in clinical practice to deny repair to such 
patients because of the magnitude of the conventional open surgery.'' 
Other commenters stated that the 5-year mortality in all patients 
diagnosed with thoracic aortic aneurysm is as high as 80 percent in 
some groups of patients. Therefore, the commenters argued, the GORE TAG 
device for thoracic aortic aneurysm satisfies the criteria for 
substantial clinical improvement.
    Response: We appreciate the commenters' input on this criterion. We 
will consider these comments regarding the substantial clinical 
improvement criterion in the final rule if we determine that the 
technology meets the other two criteria.
    Comment: A representative of another device manufacturer stated at 
the town hall meeting that the manufacturer has a similar product 
awaiting FDA approval.
    Response: As we discussed in the September 7, 2001 Federal Register 
(66 FR 46915), an approval of a new technology for special payment 
should extend to all technologies that are substantially similar. 
Otherwise, our payment policy would bestow an advantage to the first 
applicant to receive approval for a particular new technology. In this 
case, we will determine whether the GORE TAG device qualifies for new 
technology add-on payments in the FY 2006 final rule. In the event that 
this technology satisfies all the criteria, we would extend new 
technology payments to any substantially similar technology that also 
receives FDA approval prior to publication of the FY 2006 final rule. 
We welcome comments regarding this technology in light of its recent 
FDA approval, particularly with regard to the cost threshold and the 
substantial clinical improvement criteria.
e. Restore[supreg] Rechargeable Implantable Neurostimulator
    Medtronic Neurological submitted an application for new technology 
add-on payments for its Restore[supreg] Rechargeable Implantable 
Neurostimulator. The Restore[supreg] Rechargeable Implantable 
Neurostimulator is designed to deliver electrical stimulation to the 
spinal cord for treatment of chronic, intractable pain.
    Neurostimulation is designed to deliver electrical stimulation to 
the spinal cord to block the sensation of pain. The current technology 
standard for neurostimulators utilizes internal sealed batteries as the 
power source to generate the electrical current. These internal 
batteries have finite lives, and require replacement when their power 
has been completely discharged. According to the manufacturer, the 
Restore[supreg] Rechargeable Implantable Neurostimulator ``represents 
the next generation of neurostimulator technology, allowing the 
physician to set the voltage parameters in such a way that fully meets 
the patient's requirements to achieve adequate pain relief without fear 
of premature depletion of the battery.'' The applicant stated that the 
expected life of the Restore[supreg] rechargeable battery is 9 years, 
compared to an average life of 3 years for conventional neurostimulator 
batteries. The applicant stated that this represents a significant 
clinical improvement because patients can use any power settings that 
are necessary to achieve pain relief with less concern for battery 
depletion and subsequent battery replacement.
    This device has not yet received approval for use by the FDA; 
however, another manufacturer has received approval for a similar 
device. (Advanced Bionics' Precision[supreg] Rechargeable 
Neurostimulator was approved by the FDA on April 27, 2004.)
    Medtronic Neurological also provided data to determine whether the 
Restore[supreg] Rechargeable Implantable Neurostimulator meets the cost 
criterion. Medtronic Neurological stated that the cases involving use 
of the device would primarily fall into DRGs 499, 500, 531 and 532, 
which have a case-weighted threshold of $24,090. The manufacturer 
stated that the anticipated average standardized charge per case 
involving the Restore[supreg] technology is $59,265. This manufacturer 
derived this estimate by identifying cases in the FY 2003 MedPAR that 
reported procedure code 03.93 (Insertion or replacement of spinal 
neurostimulators). The manufacturer then added the total cost of the 
Restore[supreg] Rechargeable Implantable Neurostimulator to the average 
standardized charges for those cases. Of the applicable charges for the 
Restore[supreg] Rechargeable Implantable Neurostimulator, only the 
components that the applicant identified as new would be eligible for 
new technology add-on payments. Medtronic Neurological submitted 
information that distinguished the old and new components of the device 
and submitted data indicating that the neurostimulator itself is 
$17,995 and the patient recharger, antenna, and belt are $3,140. Thus, 
the total cost for new components would be $21,135, with a maximum add-
on amount of $10,568 if the product were to be approved for new 
technology payments.
    We note that we reviewed a technology for add-on payments for FY 
2003 called Renew\TM\ Radio Frequency Spinal Cord Stimulation (SCS) 
Therapy, made by Advanced Neuromodulation Systems (ANS). In the FY 2003 
final rule, we discussed and subsequently denied an application for new 
technology add-on payment for Renew\TM\ SCS because ``Renew\TM\ SCS was 
introduced in July 1999 as a device for the treatment of chronic 
intractable pain of the trunk and limbs.'' (67 FR 50019) We also noted, 
``[t]his system only requires one surgical placement and does not 
require additional surgeries to replace batteries as do other internal 
SCS systems.''
    The applicant also stated in its application for Restore[supreg] 
that cases where it is used will be identified by ICD-9-CM procedure 
code 03.93 (Insertion or replacement of spinal neurostimulators). As we 
discussed in the FY 2003 final rule (67 FR 50019), the Renew\TM\ SCS is 
identified by the same ICD-9-CM procedure code. The

[[Page 23364]]

applicant has also applied for a new ICD-9-CM code for rechargeable 
neurostimulator pulse generator (We refer readers to Tables 6A through 
6H in the Addendum to this proposed rule for information regarding ICD-
9-CM codes.) Because both technologies are similar, we asked Medtronic 
to provide information that would demonstrate how the products were 
substantially different. The applicant noted that the Renew\TM\ SCS, 
while programmable and rechargeable, is not a good option for those 
patients who have high energy requirements because of chronic 
intractable pain that will result in more battery wear and subsequent 
surgery to replace the device. Both systems rely on rechargeable 
batteries, and in the case of Renew\TM\ SCS the energy is transmitted 
through the skin from a radiofrequency source for the purpose of 
recharging. The manufacturer of the Restore[supreg] device contends 
that it is superior to the Renew\TM\ device because Renew\TM\ requires 
an external component that uses a skin adhesive that is uncomfortable 
and inconvenient (causes skin irritation, is affected by moisture that 
will come from bathing, sweating, swimming, etc.), leading to patient 
noncompliance.
    Because FDA approval has not yet been received for this device, we 
are making no decision concerning the Restore[supreg] application at 
this time. We will make a formal determination if FDA approval occurs 
in sufficient time for full consideration in the final FY 2006 rule. 
However, we have reservations about whether this technology is new for 
purposes of the new technology add-on payments because of its 
similarity to other products that are also used to treat the same 
conditions. Although we recognize the benefits of a more easily 
rechargeable neurostimulator system, we believe that the 
Restore[supreg] device may not be sufficiently different from 
predecessor devices to meet the newness criterion for the new 
technology add-on payment. As we discussed above, similar products have 
been on the market since 1999. Therefore, these technologies are 
already represented in the DRG weights and are not considered new for 
the purposes of the new technology add-on payment provision. We welcome 
comments on this issue, specifically regarding how the Restore[supreg] 
device may or may not be significantly different from previous devices. 
We also seek comments on whether the product meets the cost and 
significant improvement criteria.
    We received no public comments regarding this application for add-
on payments.

f. Safe-Cross[supreg] Radio Frequency Total Occlusion Crossing System 
(Safe-Cross[supreg])

    Intraluminal Therapeutics submitted an application for the Safe 
Cross[supreg] Radio Frequency (RF) Total Occlusion Crossing System. 
This device performs the function of a guidewire during percutaneous 
transluminal angioplasty of chronic total occlusions of peripheral and 
coronary arteries. Using fiberoptic guidance and radiofrequency 
ablation, it is able to cross lesions where a standard guidewire is 
unsuccessful. On November 21, 2003, the FDA approved the Safe 
Cross[supreg] for use in iliac and superficial femoral arteries. The 
device was approved by the FDA for all native peripheral arteries 
except carotids in August 2004. In January 2004, the FDA approved the 
Safe Cross[supreg] for coronary arteries as well. Because the device is 
within the statutory timeframe of 2 to 3 years for all approved uses 
and data regarding the cost of this device are not yet reflected within 
the DRG weights, we consider the Safe Cross[supreg] to meet the newness 
criterion.
    We note that the applicant submitted an application for a 
distinctive ICD-9-CM code. The applicant noted in its application that 
the device is currently coded with ICD-9-CM procedure codes 36.09 
(Other removal of coronary artery obstruction) and 39.50 (Angioplasty 
or atherectomy of other noncoronary vessels).
    As we stated in last year's final rule, section 1886(d)(5)(K)(i) of 
the Act requires that the Secretary establish a mechanism to recognize 
the costs of new medical services or technologies under the payment 
system established under subsection (d) of section 1886, which 
establishes the system for paying for the operating costs of inpatient 
hospital services. The system of payment for capital costs is 
established under section 1886(g) of the Act, which makes no mention of 
any add-on payments for a new medical service or technology. Therefore, 
it is not appropriate to include capital costs in the add-on payments 
for a new medical service or technology, and these costs should not be 
considered in evaluating whether a technology meets the cost criterion. 
As a result, we consider only the Safe Cross[supreg] crossing wire, 
ground pad, and accessories to be operating equipment that is relevant 
to the evaluation of the cost criterion.
    The applicant submitted the following two analyses on the cost 
criterion. The first analysis contained 27 actual cases from two 
hospitals. Of these 27 cases, 25.1 percent of the cases were reported 
in DRGs 24 (Seizure and Headache Age >17 With CC), 107 (Coronary Bypass 
With Cardiac Catheterization), 125 (Circulatory Disorders Except AMI, 
With Cardiac Catheterization and Without Complex Diagnosis), 518 
(Percutaneous Cardiovascular Procedure Without Coronary Artery Stent or 
AMI), and 526 (Percutaneous Cardiovascular Procedure With Drug-Eluting 
Stent With AMI); and 74.9 percent were reported in DRG 527 
(Percutaneous Cardiovascular Procedure With Drug-Eluting Stent Without 
AMI). This resulted in a case-weighted threshold of $35,956 and a case-
weighted average standardized charge of $40,319. Because the case-
weighted average standardized charge is greater than the case-weighted 
threshold, the applicant maintained that the Safe Cross[supreg] meets 
the cost criterion.
    The applicant also submitted cases from the FY 2003 MedPAR. The 
applicant found a total of 1,274,535 cases that could be eligible for 
the Safe Cross[supreg] using diagnosis codes 411 through 411.89 (Other 
acute and subacute forms of ischemic heart disease) or 414 through 
414.19 (Other forms of chronic ischemic heart disease) in combination 
with any of the following procedure codes: 36.01 (Single vessel 
percutaneous transluminal coronary angioplasty (PTCA) or coronary 
atherectomy without mention of thrombolytic agent), 36.02 (Single 
vessel PTCA or coronary atherectomy with mention of thrombolytic 
agent), 36.05 (Multiple vessel PTCA or coronary atherectomy performed 
during the same operation with or without mention of thrombolytic 
agent), 36.06 (Insertion of nondrug-eluting coronary artery stent(s)), 
36.07 (Insertion of drug-eluting coronary artery stent(s)) and 36.09 
(Other removal of coronary artery obstruction). A total of 59.40 
percent of these cases fell into DRG 517 (Percutaneous Cardiovascular 
Procedure With Nondrug-Eluting Stent Without AMI), 16.4 percent of 
cases into DRG 516 (Percutaneous Cardiovascular Procedure With AMI), 
and 16.2 percent of cases into DRG 527, while the rest of the cases 
fell into the remaining DRGs 124, 518 and 526. The average case-
weighted standardized charge per case was $40,318. This amount included 
an extra $6,000 for the charges related to the Safe Cross[supreg]. The 
case-weighed threshold across the DRGs mentioned above was $35,955. 
Similar to the analysis above, because the case-weighted average 
standardized charge is greater than the case-weighted

[[Page 23365]]

threshold, the applicant maintained that the Safe Cross[supreg] meets 
the cost criterion.
    The applicant maintained that the device meets the substantial 
clinical improvement criterion. The applicant explained that many 
traditional guidewires fail to cross a total arterial occlusion due to 
difficulty in navigating the vessel and to the fibrotic nature of the 
obstructing plaque. By using fiberoptic guidance and radiofrequency 
ablation, the Safe Cross[supreg] succeeds where standard guidewires 
fail. The applicant further maintained that in clinical trials where 
traditional guidewires failed, the Safe Cross[supreg] succeeded in 54 
percent of cases of coronary artery chronic total occlusions (CTOs), 
and in 76 percent of cases of peripheral artery CTOs.
    However, we note that we use similar standards to evaluate 
substantial clinical improvement in the IPPS and OPPS. The IPPS 
regulations provide that technology may be approved for add-on payments 
when it ``represents an advance in medical technology that 
substantially improves, relative to technologies previously available, 
the diagnosis or treatment of Medicare beneficiaries'' (66 FR 46912). 
Under the OPPS, the standard for approval of new devices is ``a 
substantial improvement in medical benefits for Medicare beneficiaries 
compared to the benefits obtained by devices in previously established 
(that is, existing or previously existing) categories or other 
available treatments'' (67 FR 66782). Furthermore, the OPPS and IPPS 
employ identical language (for IPPS, see 66 FR 46914, and for OPPS, see 
67 FR 66782) to explain and elaborate on the kinds of considerations 
that are taken into account in determining whether a new technology 
represents substantial improvement. In both systems, we employ the 
following kinds of considerations in evaluating particular requests for 
special payment for new technology:
     The device offers a treatment option for a patient 
population unresponsive to, or ineligible for, currently available 
treatments.
     The device offers the ability to diagnose a medical 
condition in a patient population where that medical condition is 
currently undetectable or offers the ability to diagnose a medical 
condition earlier in a patient population than allowed by currently 
available methods. There must also be evidence that use of the device 
to make a diagnosis affects the management of the patient.
     Use of the device significantly improves clinical outcomes 
for a patient population as compared to currently available treatments. 
Some examples of outcomes that are frequently evaluated in studies of 
medical devices are the following:

--Reduced mortality rate with use of the device.
--Reduced rate of device-related complications.
--Decreased rate of subsequent diagnostic or therapeutic interventions 
(for example, due to reduced rate of recurrence of the disease 
process).
--Decreased number of future hospitalizations or physician visits.
--More rapid beneficial resolution of the disease process treatment 
because of the use of the device.
--Decreased pain, bleeding, or other quantifiable symptom.
--Reduced recovery time.

    In a letter to the applicant dated October 25, 2004, we denied 
approval of the Safe Cross[supreg] for pass-through payments for the 
OPPS on the basis that the technology did not meet the substantial 
clinical improvement criterion. In particular, we found that studies 
failed to show long-term or intermediate-term results, and the device 
had a relatively low rate of successfully opening occlusions. Since 
that initial determination, the applicant has requested reconsideration 
for pass-through payments under the IPPS. However, on the basis of the 
original findings under the OPPS, we do not now believe that the 
technology can qualify for new technology add-on payments under the 
IPPS. Therefore, we are proposing to deny new technology add-on payment 
for FY 2006 for Safe Cross[supreg] on the grounds that it does not 
appear to be a substantial clinical improvement over existing 
technologies. We welcome further information on whether this device 
meets the substantial clinical improvement criterion, and we will 
consider any further information prior to making our final 
determination in the final rule.
    We received no public comments regarding this application for add-
on payments.
g. Trident[supreg] Ceramic Acetabular System
    Stryker Orthopaedics submitted an application for new technology 
add-on payments for the Trident[supreg] Ceramic Acetabular System. This 
system is used to replace the ``ball and socket'' joint of a hip when a 
total hip replacement is performed for patients suffering from 
arthritis or related conditions. The applicant stated that, unlike 
conventional hip replacement systems, the Trident[supreg] system 
utilizes alumina ceramic-on-ceramic bearing surfaces rather than metal-
on-plastic or metal-on-metal. Alumina ceramic is the hardest material 
next to diamond. The Trident[supreg] System is a patented design that 
captures the ceramic insert in a titanium sleeve. This design increases 
the strength of the ceramic insert by 50 percent over other designs. 
The manufacturer stated that the alumina ceramic bearing of the device 
is a substantial clinical improvement because it is extremely hard and 
scratch resistant, has a low coefficient of friction and excellent wear 
resistance, has improved lubrication over metal or polyethylene, has no 
potential for metal ion release, and has less alumina particle debris. 
The manufacturer also stated that fewer hip revisions are needed when 
this product is used (2.7 percent of ceramic versus 7.5 percent for 
polyethylene). Stryker stated that the ceramic implant also causes less 
osteolysis (or bone loss from particulate debris). Due to these 
improvements over traditional hip implants, the manufacturer stated the 
Trident[supreg] Ceramic Acetabular System has demonstrated 
significantly lower wear versus the conventional plastic/metal system 
in the laboratory; therefore, it is anticipated that these improved 
wear characteristics will extend the life of the implant.
    The Trident[supreg] Ceramic Acetabular System received FDA approval 
in February 3, 2003. However, this product was not available on the 
market until April 2003. The period that technologies are eligible to 
receive new technology add-on payment is no less than 2 years but not 
more than 3 years from the point the product comes on the market. At 
this point, we begin to collect charges reflecting the cost of the 
device in the MedPAR data. Because the device became available on the 
market in April 2003, charges reflecting the cost of the device may 
have been included in the data used to calculate the DRG weights in FY 
2005 and the proposed DRG weights for FY 2006. Therefore, the 
technology may no longer be considered new for the purposes of new 
technology add-on payments. For this reason, we are proposing to deny 
add-on payments for the Trident[supreg] Ceramic Acetabular System for 
FY 2006.
    Although we are proposing not to approve this application because 
the Trident[supreg] Ceramic Acetabular System does not meet the newness 
criterion, we note that the applicant submitted information on the cost 
and substantial clinical improvement criteria.
    The applicant submitted cost threshold information for the 
Trident[supreg] Ceramic Acetabular System, stating that cases using the 
system would be

[[Page 23366]]

included in DRG 209 (Major Joint and Limb Reattachment Procedures of 
Lower Extremity). The manufacturer indicated that there is not an ICD-
9-CM code specific to ceramic hip arthroplasty, but it is currently 
reported using code 81.51 (Total hip replacement). Of the applicable 
charges for the Trident[supreg] Ceramic Acetabular System, only the 
components that the applicant identified as new would be eligible for 
new technology add-on payments. The estimated cost of the new portions 
of the device, according to the information provided in the 
application, is $6,009. The charge threshold for DRG 209 is $34,195. 
The data submitted by Stryker Orthopaedics showed an average 
standardized charge, assuming a 28 percent implant markup, of $34,230.
    Regarding the issue of substantial clinical improvement, we 
recognize that the Trident[supreg] Ceramic Acetabular System represents 
an incremental advance in prosthetic hip technology. However, we also 
recognize that there are a number of other new prostheses available 
that utilize a variety of bearing surface materials that also offer 
increased longevity and decreased wear. For this reason, we do not 
believe that the Trident[supreg] system has demonstrated itself to be a 
clearly superior new technology.
    We received the following public comments, in accordance with 
section 503(b)(2) of Pub. L. 108-173, regarding this application for 
add-on payments.
    Comment: One commenter noted that clinical outcomes for the 
Trident[supreg] Ceramic Acetabular System are not a significant 
clinical improvement over similar devices on the market. A member of 
the orthopedic community noted at the new technology town hall meeting 
that this system is not the only new product that promises 
significantly improved results because of enhancements to materials and 
design. This commenter suggested that it may be inappropriate to 
recognize only one of these new hip replacement products for new 
technology add-on payments.
    Response: We appreciate the commenter's input on this criterion. We 
will consider these comments regarding the substantial clinical 
improvement criterion. However, based on the observations provided at 
the town hall meeting, we are considering alternative methods of 
recognizing technological improvements in this area other than 
approving only one of these new technologies for add-on payments. For 
example, as discussed in section II.B.6.a. of the preamble to this 
proposed rule, we are proposing to split DRG 209 to create a new DRG 
for revisions of hip and knee replacements. We would leave all other 
replacements and attachment procedures in a separate, new DRG. We also 
stated that we will be reviewing these DRGs based on new procedure 
codes that will provide more detailed data on the specific nature of 
the revision procedures performed. In addition, we are creating new 
procedure codes that will identify the type of bearing surface of a hip 
replacement. As we obtain data from these new codes, we will consider 
additional DRG revisions to better capture the various types of joint 
procedures. We may consider a future restructuring of the joint 
replacement and revision DRGs that would better capture the higher 
costs of products that offer greater durability, extended life, and 
improved outcomes. In doing so, of course, we may need to create 
additional, more precise ICD-9-CM codes. We welcome comments on this 
issue, and generally on whether the Trident[supreg] Ceramic Acetabular 
System meets the criteria to qualify for new technology add-on 
payments.
h. Wingspan TM Stent System with Gateway TM PTA 
Balloon Catheter
    Boston Scientific submitted an application for the Wingspan 
TM Stent System with Gateway TM PTA Balloon 
Catheter for new technology add-on payments. The device is designed for 
the treatment of patients with intracranial atherosclerotic disease who 
suffer from recurrent stroke despite medical management. The device 
consists of the following: a self-expanding nitinol stent, a multilumen 
over the wire delivery catheter, and a Gateway PTA Balloon Catheter. 
The device is used to treat stenoses that occur in the intracranial 
vessels. Prior to stent placement, the Gateway PTA Balloon is inflated 
to dilate the target lesion, and then the stent is deployed across the 
lesion to restore and maintain luminal patency. Effective October 1, 
2004, two new ICD-9-CM procedure codes were created to code 
intracranial angioplasty and intracranial stenting procedures: 
procedure codes 00.62 (Percutaneous angioplasty or atherectomy of 
intracranial vessels) and 00.65 (Percutaneous insertion of intracranial 
vascular stents).
    On January 9, 2004, the FDA designated the Wingspan TM 
as a Humanitarian Use Designation (HUD). The manufacturer has also 
applied for Humanitarian Device Exemption (HDE) status and expects 
approval from the FDA in July 2005. It is important to note that 
currently CMS has a noncoverage policy for percutaneous transluminal 
angioplasty to treat lesions of intracranial vessels. The applicant is 
working closely with CMS to review this decision upon FDA approval. 
Because the device is neither FDA-approved nor Medicare-covered, we do 
not believe it is appropriate to present our full analysis on whether 
the technology meets the individual criteria for the new technology 
add-on payment. However, we note that the applicant did submit the 
following information below on the cost criterion and substantial 
clinical improvement criterion.
    The manufacturer submitted data from MedPAR and non-MedPAR 
databases. The non-MedPAR data was from the 2003 patient discharge data 
from California's Office of Statewide Health Planning and Development 
database for hospitals in California and from the 2003 patient data 
from Florida's Agency for Health Care Administration for hospitals in 
Florida. The applicant identified cases that had a diagnosis code of 
437.0 (Cerebral atherosclerosis), 437.1 (Other generalized ischemic 
cerebrovascular disease) or 437.9 (Unspecified) or any diagnosis code 
that begins with the prefix of 434 (Occlusion of cerebral arteries) in 
combination with procedure code 39.50 (Angioplasty or atherectomy of 
noncoronary vessel) or procedure code 39.90 (Insertion of nondrug-
eluting, noncoronary artery stents). The applicant used procedure codes 
39.50 and 39.90 because procedure codes 00.62 and 00.65 were not 
available until FY 2005. The applicant found cases in DRG 5 
(Extracranial Vascular Procedures) (which previously existed under the 
Medicare IPPS DRG system prior to a DRG split) and in DRGs 533 
(Extracranial Procedure with CC) and 534 (Extracranial Procedure 
Without CC). Even though DRG 5 was split into DRGs 533 and 534 in FY 
2003, some hospitals continued to use DRG 5 for non-Medicare cases. The 
applicant found 22 cases that had an intracranial PTA with a stent. The 
average (nonstandardized) charge per case was $78,363.
    The applicant also submitted data from the FY 2002 and FY 2003 
MedPAR files. Using the latest data from the FY 2003 MedPAR and the 
same combination of diagnosis and procedure codes mentioned above to 
identify cases of intracranial PTA with stenting, the applicant found 
116 cases in DRG 533 and 20 cases in DRG 534. The case-weighted average 
standardized charge per case was $51,173. The average case-weighted 
threshold was $25,394. Based on this analysis, the applicant maintained 
that the technology meets the cost criteria since the average case-
weighted standardized charge per case

[[Page 23367]]

is greater than the average case-weighted threshold.
    The applicant also maintained that the technology meets the 
substantial clinical improvement criterion. Currently, there is no 
available surgical or medical treatment for recurrent stroke that 
occurs despite optimal medical management. The Wingspan TM 
is the first commercially available PTA/stent system designed 
specifically for the intracranial vasculature. However, because the 
Wingspan TM does not have FDA approval or Medicare coverage, 
as stated above, we are proposing to deny add-on payment for this new 
technology.
    We received no public comments regarding this application for add-
on payments.

III. Proposed Changes to the Hospital Wage Index

A. Background

    Section 1886(d)(3)(E) of the Act requires that, as part of the 
methodology for determining prospective payments to hospitals, the 
Secretary must adjust the standardized amounts ``for area differences 
in hospital wage levels by a factor (established by the Secretary) 
reflecting the relative hospital wage level in the geographic area of 
the hospital compared to the national average hospital wage level.'' In 
accordance with the broad discretion conferred under the Act, we 
currently define hospital labor market areas based on the definitions 
of statistical areas established by the Office of Management and Budget 
(OMB). A discussion of the proposed FY 2006 hospital wage index based 
on the statistical areas, including OMB's revised definitions of 
Metropolitan Areas, appears under section III.B. of this preamble.
    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 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. The proposed adjustment for 
FY 2006 is discussed in section II.B. of the Addendum to this proposed 
rule.
    As discussed below in section III.G. of this preamble, we also take 
into account the geographic reclassification of hospitals in accordance 
with sections 1886(d)(8)(B) and 1886(d)(10) of the Act when calculating 
the wage index. 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. The proposed budget neutrality adjustment 
for FY 2006 is discussed in section II.B. of the Addendum to this 
proposed 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 short-
term, acute care hospitals participating in the Medicare program, in 
order to construct an occupational mix adjustment to the wage index. A 
discussion of the proposed occupational mix adjustment that we are 
proposing to apply beginning October 1, 2005 (the proposed FY 2006 wage 
index) appears under section III.C. of this preamble.

B. Core-Based Statistical Areas Used for the Proposed Hospital Wage 
Index

    (If you choose to comment on issues in this section, please include 
the caption ``CBSAs'' at the beginning of your comment.)
    The wage index is calculated and assigned to hospitals on the basis 
of the labor market area in which the hospital is located. In 
accordance with the broad discretion under section 1886(d)(3)(E) of the 
Act, beginning with FY 2005, we define hospital labor market areas 
based on the Core-Based Statistical Areas (CBSAs) established by OMB 
and announced in December 2003 (69 FR 49027). OMB defines a CBSA, 
beginning in 2003, as ``a geographic entity associated with at least 
one core of 10,000 or more population, plus adjacent territory that has 
a high degree of social and economic integration with the core as 
measured by commuting ties.'' The standards designate and define two 
categories of CBSAs: Metropolitan Statistical Areas (MSAs) and 
Micropolitan Statistical Areas (65 FR 82235).
    According to OMB, MSAs are based on urbanized areas of 50,000 or 
more population, and Micropolitan Statistical Areas (referred to in 
this discussion as Micropolitan Areas) are based on urban clusters with 
a population of at least 10,000 but less than 50,000. Counties that do 
not fall within CBSAs are deemed ``Outside CBSAs.'' In the past, OMB 
defined MSAs around areas with a minimum core population of 50,000, and 
smaller areas were ``Outside MSAs.''
    The general concept of the CBSAs is that of an area containing a 
recognized population nucleus and adjacent communities that have a high 
degree of integration with that nucleus. The purpose of the standards 
is to provide nationally consistent definitions for collecting, 
tabulating, and publishing Federal statistics for a set of geographic 
areas. CBSAs include adjacent counties that have a minimum of 25 
percent commuting to the central counties of the area. (This is an 
increase over the minimum commuting threshold of 15 percent for 
outlying counties applied in the previous MSA definition.)
    The new CBSAs established by OMB comprised MSAs and the new 
Micropolitan Areas based on Census 2000 data. (A copy of the 
announcement may be obtained at the following Internet address: http://www.whitehouse.gov/omb/bulletins/fy04/b04-03.html.) The definitions 
recognize 49 new MSAs and 565 new Micropolitan Areas, and extensively 
revised the composition of many of the existing MSAs.
    The new area designations resulted in a higher wage index for some 
areas and lower wage index for others. Further, some hospitals that 
were previously classified as urban are now in rural areas. Given the 
significant payment impacts upon some hospitals because of these 
changes, we provided a transition period to the new labor market areas 
in the FY 2005 IPPS final rule (69 FR 49027 through 49034). As part of 
that transition, we allowed urban hospitals that became rural under the 
new definitions to maintain their assignment to the Metropolitan 
Statistical Area (MSA) where they were previously located for the 3-
year period of FY 2005, FY 2006, and FY 2007. Specifically, these 
hospitals were assigned the wage index of the urban area to which they 
previously belonged. (For purposes of wage index computation, the wage 
data of these hospitals remained assigned to the statewide rural area 
in which they are located.) The hospitals receiving this transition 
will not be considered urban hospitals; rather they will maintain their 
status as rural hospitals. Thus, the hospital would not be eligible, 
for example, for a large urban add-on payment under the capital PPS. In 
other words, it is the wage index, but not the urban or rural status, 
of these hospitals that is being affected by this transition. The 
higher wage indices that these hospitals are receiving are also being 
taken into consideration in determining

[[Page 23368]]

whether they qualify for the out-commuting adjustment discussed in 
section III.I. of this preamble and the amount of any adjustment.
    FY 2006 will be the second year of this transition period. We will 
continue to assign the wage index for the urban area in which the 
hospital was previously located through FY 2007. In order to ensure 
this provision remains budget neutral, we will continue to adjust the 
standardized amount by a transition budget neutrality factor to account 
for these hospitals. Doing so is consistent with the requirement of 
section 1886(d)(3)(E) of the Act that any ``adjustments or updates [to 
the adjustment for different area wage levels] * * * shall be made in a 
manner that assures that aggregate payments * * * are not greater or 
less than those that would have been made in the year without such 
adjustment.''
    Beginning in FY 2008, these hospitals will receive their statewide 
rural wage index, although they will be eligible to apply for 
reclassification by the MGCRB, both during this transition period as 
well as in subsequent years.
    In addition, in the FY 2005 IPPS final rule (69 FR 49032 through 
49033), we provided a 1-year transition blend for hospitals that, due 
solely to the changes in the labor market definitions, experienced a 
decrease in their FY 2005 wage index compared to the wage index they 
would have received using the labor market areas included in 
calculating their FY 2004 wage index. Hospitals that experienced a 
decrease in their wage index as a result of adoption of the new labor 
market area changes received a wage index based on 50 percent of the 
CBSA labor market area definitions and 50 percent of the wage index 
that the provider would have received under the FY 2004 MSA boundaries 
(in both cases using the FY 2001 wage data). This blend applied to any 
provider experiencing a decrease due to the new definitions, including 
providers who were reclassifying under MGCRB requirements, section 
1886(d)(8)(B) of the Act, or section 508 of Pub. L. 108-173. In the FY 
2005 IPPS final rule (69 FR 49027 through 49033), we described the 
determination of this blend in detail. We noted that this blend would 
not prevent a decrease in wage index due to any reason other than 
adoption of CBSAs, nor did it apply to hospitals that benefited from a 
higher wage index due to the new labor market definitions.
    Consistent with the FY 2005 IPPS final rule, we are proposing that 
hospitals receive 100 percent of their wage index based upon the new 
CBSA configurations beginning in FY 2006. Specifically, we will 
determine for each hospital a new wage index employing wage index data 
from FY 2002 hospital cost reports and using the CBSA labor market 
definitions.

C. Proposed Occupational Mix Adjustment to FY 2006 Index

    (If you choose to comment on issues in this section, please include 
the caption ``Occupational Mix Adjustment'' at the beginning of your 
comment.)
    As stated earlier, section 1886(d)(3)(E) of the Act 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, for application beginning October 1, 2004 (the FY 
2005 wage index). The purpose of the occupational mix adjustment is to 
control for the effect of hospitals' employment choices on the wage 
index. For example, hospitals may choose to employ different 
combinations of registered nurses, licensed practical nurses, nursing 
aides, and medical assistants for the purpose of providing nursing care 
to their patients. The varying labor costs associated with these 
choices reflect hospital management decisions rather than geographic 
differences in the costs of labor.
1. Development of Data for the Proposed Occupational Mix Adjustment
    In the FY 2005 IPPS final rule (69 FR 49034), we discussed in 
detail the data we used to calculate the occupational mix adjustment to 
the FY 2005 wage index. For the FY 2006 wage index, we are proposing to 
use the same CMS Wage Index Occupational Mix Survey and Bureau of Labor 
Statistics (BLS) data that we used for the FY 2005 wage index, with two 
exceptions. The CMS survey requires hospitals to report the number of 
total paid hours for directly hired and contract employees in 
occupations that provide the following services: nursing, physical 
therapy, occupational therapy, respiratory therapy, medical and 
clinical laboratory, dietary, and pharmacy. These services each include 
several standard occupational classifications (SOCs), as defined by the 
BLS' Occupational Employment Statistics (OES) survey. For the proposed 
FY 2006 wage index, we used revised survey data for 20 hospitals that 
took advantage of the opportunity we afforded hospitals to submit 
changes to their occupational mix data during the FY 2006 wage index 
data collection process (see discussion of wage data corrections 
process under section III.J. of this preamble). We also excluded survey 
data for hospitals that became designated as CAHs since the original 
survey data were collected and hospitals for which there are no 
corresponding cost report data for the proposed FY 2006 wage index. The 
proposed FY 2006 wage index includes occupational mix data from 3,563 
out of 3,765 hospitals (94.6 percent response rate). The results of the 
occupational mix survey are included in the chart below:

[[Page 23369]]

[GRAPHIC] [TIFF OMITTED] TP04MY05.026


[[Page 23370]]


2. Calculation of the Proposed FY 2006 Occupational Mix Adjustment 
Factor and the Proposed FY 2006 Occupational Mix Adjusted Wage Index
    For the proposed FY 2006 wage index, we are proposing to use the 
same methodology that we used to calculate the occupational mix 
adjustment to the FY 2005 wage index (69 FR 49042). We are proposing to 
use the following steps for calculating the proposed FY 2006 
occupational mix adjustment factor and the occupational mix adjusted 
wage index:
    Step 1--For each hospital, the percentage of the general service 
category attributable to an SOC is determined by dividing the SOC hours 
by the general service category's total hours. Repeat this calculation 
for each of the 19 SOCs.
    Step 2--For each hospital, the weighted average hourly rate for an 
SOC is determined by multiplying the percentage of the general service 
category (from Step 1) by the national average hourly rate for that SOC 
from the 2001 BLS OES survey, which was used in calculating the 
occupational mix adjustment for the FY 2005 wage index. The 2001 OES 
survey is BLS' latest available hospital-specific survey. (See Chart 4 
in the FY 2005 IPPS final rule, 69 FR 49038.) Repeat this calculation 
for each of the 19 SOCs.
    Step 3--For each hospital, the hospital's adjusted average hourly 
rate for a general service category is computed by summing the weighted 
hourly rate for each SOC within the general category. Repeat this 
calculation for each of the 7 general service categories.
    Step 4--For each hospital, the occupational mix adjustment factor 
for a general service category is calculated by dividing the national 
adjusted average hourly rate for the category by the hospital's 
adjusted average hourly rate for the category. (The national adjusted 
average hourly rate is computed in the same manner as Steps 1 through 
3, using instead, the total SOC and general service category hours for 
all hospitals in the occupational mix survey database.) Repeat this 
calculation for each of the 7 general service categories. If the 
hospital's adjusted rate is less than the national adjusted rate 
(indicating the hospital employs a less costly mix of employees within 
the category), the occupational mix adjustment factor will be greater 
than 1.0000. If the hospital's adjusted rate is greater than the 
national adjusted rate, the occupational mix adjustment factor will be 
less than 1.0000.
    Step 5--For each hospital, the occupational mix adjusted salaries 
and wage-related costs for a general service category is calculated by 
multiplying the hospital's total salaries and wage-related costs (from 
Step 5 of the unadjusted wage index calculation in section F) by the 
percentage of the hospital's total workers attributable to the general 
service category and by the general service category's occupational mix 
adjustment factor (from Step 4 above). Repeat this calculation for each 
of the 7 general service categories. The remaining portion of the 
hospital's total salaries and wage-related costs that is attributable 
to all other employees of the hospital is not adjusted for occupational 
mix.
    Step 6--For each hospital, the total occupational mix adjusted 
salaries and wage-related costs for a hospital are calculated by 
summing the occupational mix adjusted salaries and wage-related costs 
for the 7 general service categories (from Step 5) and the unadjusted 
portion of the hospital's salaries and wage-related costs for all other 
employees. To compute a hospital's occupational mix adjusted average 
hourly wage, divide the hospital's total occupational mix adjusted 
salaries and wage-related costs by the hospital's total hours (from 
Step 4 of the unadjusted wage index calculation in Section F).
    Step 7--To compute the occupational mix adjusted average hourly 
wage for an urban or rural area, sum the total occupational mix 
adjusted salaries and wage-related costs for all hospitals in the area, 
then sum the total hours for all hospitals in the area. Next, divide 
the area's occupational mix adjusted salaries and wage-related costs by 
the area's hours.
    Step 8--To compute the national occupational mix adjusted average 
hourly wage, sum the total occupational mix adjusted salaries and wage-
related costs for all hospitals in the nation, then sum the total hours 
for all hospitals in the nation. Next, divide the national occupational 
mix adjusted salaries and wage-related costs by the national hours. The 
proposed national occupational mix adjusted average hourly wage for FY 
2006 is $27.9988.
    Step 9--To compute the occupational mix adjusted wage index, divide 
each area's occupational mix adjusted average hourly wage (Step 7) by 
the national occupational mix adjusted average hourly wage (Step 8).
    Step 10--To compute the Puerto Rico specific occupational mix 
adjusted wage index, follow the Steps 1 through 9 above. The proposed 
Puerto Rico occupational mix adjusted average hourly wage for FY 2006 
is $12.9875.
    An example of the occupational mix adjustment was included in the 
FY 2005 IPPS final rule (69 FR 49043).
    For the FY 2005 final wage index, we used the unadjusted wage data 
for hospitals that did not submit occupational mix survey data. For 
calculation purposes, this equates to applying the national SOC mix to 
the wage data for these hospitals, because hospitals having the same 
mix as the Nation would have an occupational mix adjustment factor 
equaling 1.0000. In the FY 2005 IPPS final rule (69 FF 49035), we noted 
that we would revisit this matter with subsequent collections of the 
occupational mix data. Because we are using essentially the same survey 
data for the proposed FY 2006 occupational mix adjustment that we used 
for FY 2005, with the only exceptions as stated in section III.C.1. of 
this preamble, we are proposing to treat the wage data for hospitals 
that did not respond to the survey in this same manner for the proposed 
FY 2006 wage index.
    In implementing an occupational mix adjusted wage index based on 
the above calculation, the proposed wage index values for 14 rural 
areas (29.8 percent) and 206 urban areas (53.5 percent) would decrease 
as a result of the adjustment. Six (6) rural areas (12.8 percent) and 
111 urban areas (28.8 percent) would experience a decrease of 1 percent 
or greater in their wage index values. The largest negative impact for 
a rural area would be 1.9 percent and for an urban area, 4.3 percent. 
Meanwhile, 33 rural areas (70.2 percent) and 179 urban areas (46.5 
percent) would experience an increase in their wage index values. 
Although these results show that rural hospitals would gain the most 
from an occupational mix adjustment to the wage index, their gains may 
not be as great as might have been expected. Further, it might not have 
been anticipated that almost one-third of rural hospitals would 
actually fare worse under the adjustment. Overall, a fully implemented 
occupational mix adjusted wage index would have a redistributive effect 
on Medicare payments to hospitals.
    In the FY 2005 IPPS, we indicated that, for future data 
collections, we would revise the occupational mix survey to allow 
hospitals to provide both salaries and hours data for each of the 
employment categories that are included on the survey. We also 
indicated that we would assess whether future occupational mix surveys 
should be based on the calendar year or if the data should be collected 
on a fiscal year basis as part of the Medicare cost report. (One 
logistical problem is that cost

[[Page 23371]]

report data are collected yearly, but occupational mix survey data are 
collected only every 3 years.) We are currently reviewing options for 
revising the occupational mix survey and improving the data collection 
process. We will publish any changes we make to the occupational mix 
survey in a Federal Register notice.
    In our continuing efforts to meet the information needs of the 
public, we are providing three additional public use files for the 
proposed occupational mix adjusted wage index: (1) A file including 
each hospital's unadjusted and adjusted average hourly wage (FY 2006 
Proposed Rule Occupational Mix Adjusted and Unadjusted Average Hourly 
Wage by Provider); (2) a file including each CBSA's adjusted and 
unadjusted average hourly wage (FY 2006 Proposed Rule Occupational Mix 
Adjusted and Unadjusted Average Hourly Wage and Pre-Reclassified Wage 
Index by CBSA); and (3) a file including each hospital's occupational 
mix adjustment factors by occupational category (Provider Occupational 
Mix Adjustment Factors for Each Occupational Category). These 
additional files are being released concurrently with the publication 
of this proposed rule and are posted on the Internet, at http://www.cms.hhs.gov/providers/hipps/ippswage.asp. We will also post these 
files with future applications of the occupational mix adjustment.

D. Worksheet S-3 Wage Data for the Proposed FY 2006 Wage Index Update

    (If you choose to comment on issues in this section, please include 
the caption ``Wage Data'' at the beginning of your comment.)
    The proposed FY 2006 wage index values (effective for hospital 
discharges occurring on or after October 1, 2005 and before October 1, 
2006) in section VI. of the Addendum to this proposed rule are based on 
the data collected from the Medicare cost reports submitted by 
hospitals for cost reporting periods beginning in FY 2002 (the FY 2005 
wage index was based on FY 2001 wage data).
    The proposed FY 2006 wage index includes the following categories 
of data associated with costs paid under the IPPS (as well as 
outpatient costs):
     Salaries and hours from short-term, acute care hospitals 
(including paid lunch hours and hours associated with military leave 
and jury duty).
     Home office costs and hours.
     Certain contract labor costs and hours (which includes 
direct patient care, certain top management, pharmacy, laboratory, and 
nonteaching physician Part A services).
     Wage-related costs, including pensions and other deferred 
compensation costs.
    The September 1, 1994 Federal Register (59 FR 45356) included a 
list of core wage-related costs that are included in the wage index, 
and discussed criteria for including other wage-related costs. In that 
discussion, we instructed hospitals to use generally accepted 
accounting principles (GAAPs) in developing wage-related costs for the 
wage index for cost reporting periods beginning on or after October 1, 
1994. We discussed our rationale that ``the application of GAAPs for 
purposes of compiling data on wage-related costs used to construct the 
wage index will more accurately reflect relative labor costs, because 
certain wage-related costs (such as pension costs), as recorded under 
GAAPs, tend to be more static from year to year.''
    Since publication of the September 1, 1994 rule, we have 
periodically received inquiries for more specific guidance on 
developing wage-related costs for the wage index. In response, we have 
provided clarifications in the IPPS rules (for example, health 
insurance costs (66 FR 39859)) and in the cost report instructions 
(Provider Reimbursement Manual (PRM), Part II, Section 3605.2). Due to 
recent questions and concerns we received regarding inconsistent 
reporting and overreporting of pension and other deferred compensation 
plan costs, as a result of an ongoing Office of Inspector General 
review, we are clarifying in this proposed rule that hospitals must 
comply with the PRM, Part I, sections 2140. 2141, and 2142 and related 
Medicare program instructions for developing pension and other deferred 
compensation plan costs as wage-related costs for the wage index. The 
Medicare instructions for pension costs and other deferred compensation 
costs combine GAAPs, Medicare payment principles, and other Federal 
labor requirements. We believe that the Medicare instructions allow for 
consistent reporting among hospitals and for the development of 
reasonable deferred compensation plan costs for purposes of the wage 
index.
    Beginning with the FY 2007 wage index, hospitals and fiscal 
intermediaries must ensure that pension, post-retirement health 
benefits, and other deferred compensation plan costs for the wage index 
are developed according to the above terms.
    Consistent with the wage index methodology for FY 2005, the 
proposed wage index for FY 2006 also excludes the direct and overhead 
salaries and hours for services not subject to IPPS payment, such as 
SNF services, home health services, costs related to GME (teaching 
physicians and residents) and certified registered nurse anesthetists 
(CRNAs), and other subprovider components that are not paid under the 
IPPS. The proposed FY 2006 wage index also excludes 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 (68 FR 45395). In addition, 
salaries, hours and wage-related costs of CAHs are excluded from the 
wage index, for the reasons explained in the FY 2004 IPPS final rule 
(68 FR 45397).
    Data collected for the IPPS wage index are also currently used to 
calculate wage indices applicable to other providers, such as SNFs, 
home health agencies, and hospices. In addition, they are used for 
prospective payments to rehabilitation, psychiatric, and long-term care 
hospitals, and for hospital outpatient services.
    In the August 11, 2004 final rule, we stated that a commenter had 
asked CMS to designate provider-based clinics as IPPS-excluded areas in 
order to remove the costs from the wage index (69 FR 49049). The 
commenter noted that provider-based clinics are like physician private 
offices, which are excluded from the wage index calculation, and that 
services provided in the provider-based clinics are paid for not 
through the IPPS, but rather under the hospital outpatient PPS. In 
response to the comment, we stated that we were not prepared to grant 
the commenter's request without first studying the issue, and that we 
would explore the matter of salaries related to provider-based clinics 
in a future rule.
    Regulations at 42 CFR 413.65 describe the criteria and procedures 
for determining whether a facility or organization is provider-based. 
Historically, under the Medicare program, some providers, referred to 
as ``main providers,'' have functioned as single entities while owning 
and operating multiple provider-based departments, locations, and 
facilities that are treated as part of the main provider for Medicare 
purposes. Section 413.65(a)(2) defines various types of provider-based 
facilities, including ``department of a provider.'' A ``department of a 
provider'' means a facility or organization that is either created by, 
or acquired by, a main provider for the purposes of furnishing health 
care services of the same type as those furnished by the main provider 
under the name, ownership, and financial and administrative control of 
the main provider * * * a department

[[Page 23372]]

of a provider may not itself be qualified to participate in Medicare as 
a provider under Sec.  489.2 * * * the term `department of a provider' 
does not include an RHC or * * * an FQHC.'' Thus, if a facility offers 
services that are similar to those provided in a freestanding 
physician's office, and the facility meets the criteria to become 
provider-based under Sec.  413.65, the facility would be considered a 
``department of a provider.'' More specifically, the facility would be 
part of the main provider's outpatient department, since the facility 
offers health care services of the same type as those furnished by the 
main provider, and because a physician's office would not be subject to 
a provider agreement or receive a Medicare provider number under Sec.  
489.2. (We note that a provider-based RHC or FQHC may, by itself, be 
qualified to participate in Medicare as a provider under Sec.  489.2 
and, thus, would be classified not as a ``department of a provider'' 
but as a ``provider-based entity,'' as defined at Sec.  413.65(a)(2)). 
This provider-based facility, or provider-based clinic, as the 
commenter referred to it, would be reported on the main provider's 
Medicare cost report as an outpatient service cost center, on Worksheet 
A, line 60. With the exception of RHC and FQHC salaries that have been 
excluded from the wage index beginning with FY 2004 (68 FR 45395, 
August 1, 2003), the salaries attributable to employees working in 
these outpatient service cost centers, including emergency departments, 
are included in the main provider's total salaries on Worksheet S-3, 
Part II, line 1, and accordingly, are included in the wage index 
calculation. We have historically included the salaries and wages of 
hospital employees working in the outpatient departments in the 
calculation of the hospital wage index since these employees often work 
in both the IPPS and in the outpatient areas of the hospital. 
Consistent with this longstanding treatment of outpatient salary costs 
in the wage index calculation, we believe it is appropriate to continue 
to include the salaries and wages of employees working in outpatient 
departments, including provider-based clinics, in the wage index 
calculation.

E. Verification of Worksheet S-3 Wage Data

    (If you choose to comment on issues in this section, please include 
the caption ``Wage Data'' at the beginning of your comment.)
    The wage data for the proposed FY 2006 wage index were obtained 
from Worksheet S-3, Parts II and III of the FY 2002 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 data file used to construct the proposed wage index 
includes FY 2002 data submitted to us as of February 23, 2005. As in 
past years, we performed an intensive review of the wage data, mostly 
through the use of edits designed to identify aberrant data.
    We asked our fiscal intermediaries to revise or verify data 
elements that resulted in specific edit failures. Some unresolved data 
elements are included in the calculation of the proposed FY 2006 wage 
index, pending their resolution before calculation of the final FY 2006 
index. We instructed the fiscal intermediaries to complete their data 
verification of questionable data elements and to transmit any changes 
to the wage data no later than April 15, 2005. We believe all 
unresolved data elements will be resolved by the date the final rule is 
issued. The revised data will be reflected in the final rule.
    Also, as part of our editing process, we removed the data for 438 
hospitals from our database: 402 hospitals became CAHs by the time we 
published the February public use file, and 28 hospitals were low 
Medicare utilization hospitals or failed edits that could not be 
corrected because the hospitals terminated the program or changed 
ownership. In addition, we removed the wage data for 8 hospitals with 
incomplete or inaccurate data resulting in zero or negative, or 
otherwise aberrant, average hourly wages. We have notified the fiscal 
intermediaries of these hospitals and will continue to work with the 
fiscal intermediaries to correct these data until we finalize our 
database to compute the final wage index. The data for these hospitals 
will be included in the final wage index if we receive corrected data 
that passes our edits. As a result, the proposed FY 2006 wage index is 
calculated based on FY 2002 wage data from 3,765 hospitals.
    In constructing the proposed FY 2006 wage index, we include the 
wage data for facilities that were IPPS hospitals in FY 2002, even for 
those facilities that have since terminated their participation in the 
program as hospitals, as long as those data do not fail any of our 
edits for reasonableness. We believe that including the wage data for 
these hospitals is, in general, appropriate to reflect the economic 
conditions in the various labor market areas during the relevant past 
period. However, we exclude the wage data for CAHs (as discussed in 68 
FR 45397). The proposed wage index in this proposed rule excludes 
hospitals that are designated as CAHs by February 1, 2005, the date of 
the latest available Medicare CAH listing at the time we released the 
proposed wage index public use file on February 25, 2005.

F. Computation of the Proposed FY 2006 Unadjusted Wage Index

    (If you choose to comment on issues in this section, please include 
the caption ``Wage Index'' at the beginning of your comment.)
    The method used to compute the proposed FY 2006 wage index without 
an occupational mix adjustment follows:
    Step 1--As noted above, we based the proposed FY 2006 wage index on 
wage data reported on the FY 2002 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, 2001 and before October 1, 2002. In addition, we 
included data from some hospitals that had cost reporting periods 
beginning before October 2001 and reported a cost reporting period 
covering all of FY 2002. These data were included because no other data 
from these hospitals would be available for the cost reporting period 
described above, and because particular labor market areas might be 
affected due to the omission of these hospitals. However, we generally 
describe these wage data as FY 2002 data. We note that, if a hospital 
had more than one cost reporting period beginning during FY 2002 (for 
example, a hospital had two short cost reporting periods beginning on 
or after October 1, 2001 and before October 1, 2002), 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, 6, and 6.01, 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

[[Page 23373]]

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 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, 6.01, 
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, 6.01, 7, 8, and 8.01); (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, 2001 through 
April 15, 2003 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 23374]]

[GRAPHIC] [TIFF OMITTED] TP04MY05.027

    For example, the midpoint of a cost reporting period beginning 
January 1, 2002 and ending December 31, 2002 is June 30, 2002. An 
adjustment factor of 1.03083 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 2002 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. Dividing the data by the number 
of days in the cost report and then multiplying the results by 365 
accomplishes annualization.
    Step 6--Each hospital was assigned to its appropriate urban or 
rural labor market area before any reclassifications under section 
1886(d)(8)(B), section 1886(d)(8)(E), 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 proposed national average hourly wage is $27.9730.
    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 proposed average hourly 
wage of $12.9957 for Puerto Rico. For each labor market area in Puerto 
Rico, we calculated the Puerto Rico-specific wage index value by 
dividing the area average hourly wage (as calculated in Step 7) by the 
overall Puerto Rico average hourly wage.

[[Page 23375]]

    Step 11--Section 4410 of Pub. L. 105-33 provides that, for 
discharges on or after October 1, 1997, the area wage index applicable 
to any hospital that is located in an urban area of a State may not be 
less than the area wage index applicable to hospitals located in rural 
areas in that State. Furthermore, this wage index floor is to be 
implemented in such a manner as to ensure that aggregate 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 2006, this change affects 
147 hospitals in 52 urban areas. The areas affected by this provision 
are identified by a footnote in Table 4A in the Addendum of this 
proposed rule.

G. Computation of the Proposed FY 2006 Blended Wage Index

    (If you choose to comment on issues in this section, please include 
the caption ``Blended Wage Index'' at the beginning of your comments.)
    For the final FY 2005 wage index, we used a blend of the 
occupational mix adjusted wage index and the unadjusted wage index. 
Specifically, we adjusted 10 percent of the FY 2005 wage index 
adjustment factor by a factor reflecting occupational mix. Given that 
2003-2004 was the first time for the administration of the occupational 
mix survey, hospitals had a short timeframe for collecting their 
occupational mix survey data and documentation, the wage data were not 
in all cases from a 1-year period, and there was no baseline data for 
purposes of developing a desk review program, we found it prudent not 
to adjust the entire wage index factor by the occupational mix. 
However, we did find the data sufficiently reliable for applying an 
adjustment to 10 percent of the wage index. We found the data reliable 
because hospitals were given an opportunity to review their survey data 
and submit changes in the Spring of 2004, hospitals were already 
familiar with the BLS OES survey categories, hospitals were required to 
be able to provide documentation that could be used by fiscal 
intermediaries to verify survey data, and the results of our survey 
were consistent with the findings of the 2001 BLS OES survey, 
especially for nursing and physical therapy categories. In addition, we 
noted that we were moving cautiously with implementing the occupational 
mix adjustment in recognition of changing trends in hiring nurses, the 
largest group in the survey. We noted that some States had recently 
established floors on the minimum level of registered nurse staffing in 
hospitals in order to maintain licensure. In addition, in some rural 
areas, we believed that hospitals might be accounting for shortages of 
physicians by hiring more registered nurses. (A complete discussion of 
the FY 2005 wage index adjustment factor can be found in section III.G. 
of the FY 2005 IPPS final rule (69 FR 49052)).
    In the FY 2005 final rule, we noted that while the statute required 
us to collect occupational mix data every 3 years, the statute does not 
specify how the occupational mix adjustment is to be constructed or 
applied. We are clarifying in this proposed rule that the October 1, 
2004 deadline for implementing an occupational mix adjustment is not 
codified in section 1886(d)(3)(E) of the Act, which requires only a 
collection and measurement of occupational mix data, but rather stems 
from the effective date provisions in section 304(c) of the Medicare, 
Medicaid and SCHIP Benefits Improvement and Protection Act of 2000, 
Pub. L. 106-554 (BIPA). Although we believe that applying the 
occupational mix to 10 percent of the wage index factor fully 
implements the occupational mix adjustment, we also interpret BIPA as 
requiring only that we begin applying an adjustment by October 1, 2004. 
BIPA required the Secretary to complete, ``by not later than September 
30, 2003, for application beginning October 1, 2004,'' both the 
collection of occupational mix data and the measurement of such data. 
(BIPA, section 304(c)(3).) Thus, even if adjusting 10 percent of the 
wage index for occupational mix were not (as we believe it to be) 
considered to be full implementation of the BIPA effective date, we 
certainly began our application of the adjustment as of October 1, 
2004.
    In addition, section 1886(d)(3)(E) of the Act provides broad 
authority for us to establish the factor we use to adjust hospital 
costs to take into account area differences in wage levels. The statute 
is clear that the wage index factor is to be ``established by the 
Secretary.'' The occupational mix is only one part of this wage index 
factor, which, for the most part, is calculated on the basis of average 
hourly wage data submitted by all hospitals in the United States. In 
exercising the Secretary's broad discretion to establish the factor 
that adjusts for geographic wage differences, in FY 2005 we adjusted 10 
percent of such factor to account for occupational mix.
    Indeed, we have often used percentage figures or blended amounts in 
exercising the Secretary's authority to establish the factor that 
adjusts for wage differences. For example, in the FY 2005 final rule, 
we implemented new mapping boundaries for assigning hospitals to the 
geographic labor market areas used for calculating the wage index. For 
hospitals that were harmed by the new geographic boundaries, we used a 
blended rate based on 50 percent of the wage index that would apply 
using the new geographic boundaries effective for FY 2005 and 50 
percent of the wage index that would apply using the old geographic 
boundaries that were effective during FY 2004 (69 FR 49033). Similarly, 
beginning with FY 2000, we began phasing out costs related to GME and 
CRNAs from the wage index (64 FR 41505). Thus, for example, the FY 2001 
wage index was based on a blend of 60 percent of an average hourly wage 
including these costs, and 40 percent of an average hourly wage 
excluding these costs (65 FR 47071).
    For FY 2006, we are again proposing to adjust 10 percent of the 
wage index factor for occupational mix. In computing the occupational 
mix adjustment for the proposed FY 2006 wage index, we used the 
occupational mix survey data that we collected for the FY 2005 wage 
index, replacing the survey data for 20 hospitals that submitted 
revised data, and excluding the survey data for hospitals with no 
corresponding Worksheet S-3 wage data for FY 2006 wage index. While we 
considered adjusting 100 percent of the wage index by the occupational 
mix, we did not believe it was appropriate to use first-year survey 
data to make such a large adjustment. As hospitals gain additional 
experience with the occupational mix survey, and as we develop more 
information upon which to audit the data we receive, we expect to 
increase the portion of the wage index that is adjusted.
    We also acknowledge the District Court opinion in Bellevue Hospital 
Center v. Leavitt, No. 04-8639 (S.D.N.Y, March 2005) finding that the 
statute requires full implementation of the occupational mix adjustment 
beginning October 1, 2004, and granting summary judgment to plaintiffs 
on the matter. At the time this proposed rule was written, an appeal 
had not yet been heard in the Circuit Court. Thus, because it was not 
yet clear whether the decision would be appealed, we determined that, 
for FY 2006, we would continue to propose the policy we believe to be 
most prudent in light of the survey data being used to adjust the wage 
index.
    With 10 percent of the proposed FY 2006 wage index adjusted for 
occupational mix, the wage index values for 13 rural areas (27.7 
percent) and 204 urban areas (53.0 percent) would decrease as a result 
of the adjustment. These decreases would be minimal; the largest 
negative impact for

[[Page 23376]]

a rural area would be 0.19 percent and for an urban area, 0.42 percent. 
Conversely, 34 rural areas (72.3 percent) and 181 urban areas (47.0 
percent) would benefit from this adjustment, with 1 urban area 
increasing 2.1 percent and 1 rural area increasing 0.39 percent. As 
there are no significant differences between the FY 2005 and the FY 
2006 occupational mix survey data and results, we believe it is 
appropriate to again apply the occupational mix to 10 percent of the 
proposed FY 2006 wage index. (See Appendix A to this proposed rule for 
further analysis of the impact of the occupational mix adjustment on 
the proposed FY 2006 wage index.)
    The wage index values in Tables 4A, 4B, 4C, and 4F and the average 
hourly wages in Tables 2, 3A, and 3B in the Addendum to this proposed 
rule include the occupational mix adjustment.

H. Proposed Revisions to the Wage Index Based on Hospital Redesignation

    (If you choose to comment on issues in this section, please include 
the caption ``Hospital Redesignations and Reclassifications'' at the 
beginning of your comment.)
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 must apply to the MGCRB to reclassify by September 1 of the 
year preceding the year during which reclassification is sought. 
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. The MGCRB 
issues its decisions by the end of February for reclassifications that 
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 requires the Secretary to treat a 
hospital located in a rural county adjacent to one or more urban areas 
as being located in the MSA to which the greatest number of workers in 
the county commute if: the rural county would otherwise be considered 
part of an urban area under the standards for designating MSAs if the 
commuting rates used in determining outlying counties 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. In light of the new CBSA definitions 
and the Census 2000 data that we implemented for FY 2005 (69 FR 49027), 
we undertook to identify those counties meeting these criteria. The 
eligible counties are identified below under section III.H.5. of this 
preamble.
2. Effects of Reclassification
    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. These requirements for determining the wage index values 
for redesignated hospitals is applicable both to the hospitals located 
in rural counties deemed urban under section 1886(d)(8)(B) of the Act 
and hospitals that were reclassified as a result of the MGCRB decisions 
under section 1886(d)(10) of the Act. Therefore, as provided in section 
1886(d)(8)(C) of the Act,\3\ the wage index values were determined by 
considering the following:
---------------------------------------------------------------------------

    \3\ Although section 1886(d)(8)(C)(iv)(I) of the Act also 
provides that the wage index for an urban area may not decrease as a 
result of redesignated hospitals if the urban area wage index is 
already below the wage index for rural areas in the State in which 
the urban area is located, the provision was effectively made moot 
by section 4410 of Pub. L. 105-33, which provides that the area wage 
index applicable to any hospital that is located in an urban area of 
a State may not be less than the area wage index applicable to 
hospitals located in rural areas in that State. Also, section 
1886(d)(8)(C)(iv)(II) of the Act provides that an urban area's wage 
index may not decrease as a result of redesignated hospitals if the 
urban area is located in a State that is composed of a single urban 
area.
---------------------------------------------------------------------------

     If including the wage data for the redesignated hospitals 
would reduce the wage index value for the area to which the hospitals 
are redesignated by 1 percentage point or less, the area wage index 
value determined exclusive of the wage data for the redesignated 
hospitals applies to the redesignated hospitals.
     If including the wage data for the redesignated hospitals 
reduces the wage index value for the area to which the hospitals are 
redesignated by more than 1 percentage point, the area wage index 
determined inclusive of the wage data for the redesignated hospitals 
(the combined wage index value) applies to the redesignated hospitals.
     If including the wage data for the redesignated hospitals 
increases the wage index value for the urban area to which the 
hospitals are redesignated, both the area and the redesignated 
hospitals receive the combined wage index value. Otherwise, the 
hospitals located in the urban area receive a wage index excluding the 
wage data of hospitals redesignated into the area.
     The wage data for a reclassified urban hospital is 
included in both the wage index calculation of the area to which 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.
     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).
     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.
3. Proposed Application of Hold Harmless Protection for Certain Urban 
Hospitals Redesignated as Rural
    Section 401(a) of Pub. L. 106-113 (the Balanced Budget Refinement 
Act of 1999) amended section 1886(d)(8) of the Act by adding paragraph 
(E). Section 401(a) created a mechanism that permits an urban hospital 
to apply to the Secretary to be treated, for purposes of subsection 
(d), as being located in the rural area of the State in which the 
hospital is located. A hospital that is granted redesignation under 
section 1886(d)(8)(E) of the Act, as added by section 401 of Pub. L. 
106-113 is, therefore, treated as a rural hospital for

[[Page 23377]]

all purposes of payment under the Medicare IPPS, including the 
standardized amount, wage index, and disproportionate share 
calculations as of the effective date of the redesignation. Under 
current policy, as a result of an approved redesignation of an urban 
hospital as a rural hospital, the wage index data are excluded from the 
wage index calculation for the area where the urban hospital is 
geographically located and included in the rural hospital wage index 
calculation.
    Last year, we became aware of an instance where the approved 
redesignation of an urban hospital as rural under section 1886(d)(8)(E) 
of the Act resulted in the hospital's data having an adverse impact on 
the rural wage index. We received a public comment noting that specific 
``hold harmless'' provisions apply to reclassifications that occur 
under section 1886(d)(8)(B) and section 1886(d)(10) of the Act. That 
is, if a hospital is granted geographic reclassification under section 
1886(d)(8)(B) or section 1886(d)(10) of the Act, there are certain 
rules that apply when the inclusion of the hospital's data results in a 
reduction of the reclassification area's wage index, and these rules 
are slightly different for urban areas versus rural areas. These rules 
are more fully described in the FY 2005 IPPS final rule (69 FR 49053). 
Generally stated, these rules prevent a rural area from being adversely 
affected as a result of reclassification. That is, if excluding the 
reclassifying hospitals' wage data would decrease the wage index of the 
rural area, the reclassifying hospitals are included in the rural 
area's wage index. Otherwise, the reclassifying hospitals are excluded. 
For hospitals reclassifying out of urban areas, the rules provide that 
the wage data for the reclassified urban hospital is included in the 
wage index calculation of the urban area where the hospital is 
physically located.
    The commenter recommended that we revise our regulations and apply 
similar hold harmless provisions and treat hospitals redesignated under 
1886(d)(8)(E) of the Act in the same manner as reclassifications under 
section 1886(d)(8)(B) and section 1886(d)(10) of the Act. In our 
continued effort to promote consistency, equity and to simplify our 
rules with respect to how we construct the wage indexes of rural and 
urban areas, we are persuaded that there is a need to modify our policy 
when hospital redesignations occur under section 1886(d)(8)(E) of the 
Act. Therefore, for the FY 2006 wage index, we are proposing to apply 
the hold harmless rule that currently applies when rural hospitals are 
reclassifying out of the rural area (from rural to urban) to situations 
where hospitals are reclassifying into the rural area (from urban to 
rural under section 1886(d)(8)(E) of the Act). Thus, the rule would be 
that the wage data of the urban hospital reclassifying into the rural 
area is included in the rural area's wage index, if including the urban 
hospital's data increases the wage index of the rural area. Otherwise, 
the wage data is excluded. Similarly, we are proposing to apply to 
these cases the rule that currently applies when urban hospitals 
reclassify under the MGCRB process. Thus, the wage data for an urban 
hospital reclassifying under section 1886(d)(8)(E) of the Act is always 
included in the wage index of the urban area where the hospital is 
located, and can also be included in the wage index of the rural area 
to which it is reclassifying (if doing so increases the rural area's 
wage index). We believe this proposal provides uniformity in the way 
geographic areas are treated under all types of reclassifications. In 
addition, our proposal promotes predictability by alleviating 
fluctuations in the wage indexes due to a section 401 redesignation.
    We are including in the Addendum to this proposed rule Table 9C, 
which shows hospitals redesignated under section 1886(d)(8)(E) of the 
Act.
4. FY 2006 MGCRB Reclassifications
    At the time this proposed rule was constructed, the MGCRB had 
completed its review of FY 2006 reclassification requests. There were 
295 hospitals approved for wage index reclassifications by the MGCRB 
for FY 2006. Because MGCRB wage index reclassifications are effective 
for 3 years, hospitals reclassified during FY 2004 or FY 2005 are 
eligible to continue to be reclassified based on prior 
reclassifications to current MSAs during FY 2006. There were 395 
hospitals reclassified for wage index for FY 2005, and 94 hospitals 
reclassified for wage index in FY 2004. Some of the hospitals that 
reclassified in FY 2004 and FY 2005 have elected not to continue their 
reclassifications in FY 2006 because, under the new labor market area 
definitions, they are now physically located in the areas to which they 
previously reclassified. Of all of the hospitals approved for 
reclassification for FY 2004, FY 2005, and FY 2006, 672 hospitals will 
be in a reclassification status for FY 2006.
    Prior to FY 2004, hospitals had been able to apply to be 
reclassified for purposes of either the wage index or the standardized 
amount. Section 401 of Pub. L. 108-173 established that all hospitals 
will be paid on the basis of the large urban standardized amount, 
beginning with FY 2004. Consequently, all hospitals are paid on the 
basis of the same standardized amount, which made such 
reclassifications moot. Although there could still be some benefit in 
terms of payments for some hospitals under the DSH payment adjustment 
for operating IPPS, section 402 of Pub. L. 108-173 equalized DSH 
payment adjustments for rural and urban hospitals, with the exception 
that the rural DSH adjustment is capped at 12 percent (except that RRCs 
have no cap). (A detailed discussion of this application appears in 
section IV.I. of the preamble of the FY 2005 IPPS final rule (69 FR 
49085.)
5. Proposed FY 2006 Redesignations Under Section 1886(d)(8)(B) of the 
Act
    Beginning October 1, 1988, section 1886(d)(8)(B) of the Act 
required us to treat a hospital located in a rural county adjacent to 
one or more urban areas as being located in the MSA if certain criteria 
were met. Prior to FY 2005, the rule was that a rural county adjacent 
to one or more urban areas would be treated as being located in the MSA 
to which the greatest number of workers in the county commute, if the 
rural county would otherwise be considered part of an urban area under 
the standards published in the Federal Register on January 3, 1980 (45 
FR 956) for designating MSAs (and NECMAs), and if the commuting rates 
used in determining outlying counties (or, for New England, similar 
recognized areas) were determined on the basis of the aggregate number 
of resident workers who commute to (and, if applicable under the 
standards, from) the central county or counties of all contiguous MSAs 
(or NECMAs). Hospitals that met the criteria using the January 3, 1980 
version of these OMB standards were deemed urban for purposes of the 
standardized amounts and for purposes of assigning the wage data index.
    On June 6, 2003, OMB announced the new CBSAs based on Census 2000 
data. For FY 2005, we used OMB's 2000 CBSA standards and the Census 
2000 data to identify counties qualifying for redesignation under 
section 1886(d)(8)(B) for the purpose of assigning the wage index to 
the urban area. We presented this listing, effective for discharges 
occurring on or after October 1, 2004 (FY 2005), in Chart 6 of the FY 
2005 final rule (69 FR 49057). However, Chart 6 in the FY 2005 final 
rule contained a printing error in which we misidentified rural 
counties that qualified for redesignation under

[[Page 23378]]

section 1886(d)(8)(B) of the Act. The list of rural counties qualifying 
to be urban in that Chart 6 incorrectly included Monroe, PA and 
Walworth, WI. This error was made only in the chart and not in the 
application of the rules; that is, we correctly applied the rules to 
the correct rural counties qualifying to be urban for FY 2005.
    In addition, we discovered that, in the FY 2005 IPPS final rule, we 
had erroneously printed the names of the entire Metropolitan 
Statistical Areas rather than the Metropolitan Division names. Because 
we recognized Metropolitan Divisions as MSAs in the FY 2005 IPPS final 
rule (69 FR 49029), we should have printed the division names for the 
following counties: Henry, FL; Starke, IN; Henderson, TX; Fannin, TX; 
and Island, WA.
    The chart below contains the corrected listing of the rural 
counties designated as urban under section 1886(d)(8)(B) of the Act 
that we are proposing to use for FY 2006. We are proposing that, for 
discharges occurring on or after October 1, 2005, hospitals located in 
the first column of this chart will be redesignated for purposes of 
using the wage index of the urban area listed in the second column.
BILLING CODE 4120-01-P

[[Page 23379]]

[GRAPHIC] [TIFF OMITTED] TP04MY05.028


[[Page 23380]]


[GRAPHIC] [TIFF OMITTED] TP04MY05.029

BILLING CODE 4120-01-C

[[Page 23381]]

[GRAPHIC] [TIFF OMITTED] TP04MY05.030

    As in the past, hospitals redesignated under section 1886(d)(8)(B) 
of the Act are also eligible to be reclassified to a different area by 
the MGCRB. Affected hospitals are permitted to compare the reclassified 
wage index for the labor market area in Table 4C in the Addendum of 
this proposed rule into which they have been reclassified by the MGCRB 
to the wage index for the area to which they are redesignated under 
section 1886(d)(8)(B) of the Act. Hospitals may withdraw from an MGCRB 
reclassification within 45 days of the publication of this proposed 
rule.
6. Reclassifications Under Section 508 of Pub. L. 108-173
    Under section 508 of Pub. L. 108-173, a qualifying hospital could 
appeal the wage index classification otherwise applicable to the 
hospital and apply for reclassification to another area of the State in 
which the hospital is located (or, at the discretion of the Secretary, 
to an area within a contiguous State). We implemented this process 
through notices published in the Federal Register on January 6, 2004 
(69 FR 661) and February 13, 2004 (69 FR 7340). Such reclassifications 
are applicable to discharges occurring during the 3-year period 
beginning April 1, 2004 and ending March 31, 2007. Under section 
508(b), reclassifications under this process do not affect the wage 
index computation for any area or for any other hospital and cannot be 
effected in a budget neutral manner.
    We show the reclassifications effective under the one-time appeal 
process in Table 9B in the Addendum to this proposed rule.

I. Proposed FY 2006 Wage Index Adjustment Based on Commuting Patterns 
of Hospital Employees

    (If you choose to comment on issues in this section, please include 
the caption ``Out-Migration Adjustment'' at the beginning of your 
comment.)
    In accordance with the broad discretion under section 1886(d)(13) 
of the Act, as added by section 505 of Pub. L. 108-173, beginning with 
FY 2005, we established a process to make adjustments to the hospital 
wage index based on commuting patterns of hospital employees. The 
process, outlined in the FY 2005 IPPS final rule (69 FR 49061), 
provides for an increase in the wage index for hospitals located in 
certain counties that have a relatively high percentage of hospital 
employees who reside in the county but work in a different county (or 
counties) with a higher wage index. Such adjustments to the wage index 
are effective for 3 years, unless a hospital requests to waive the 
application of the adjustment. A county will not lose its status as a 
qualifying county due to wage index changes during the 3-year period, 
and counties will receive the same wage index increase for those 3 
years. However, a county that qualifies in any given year may no longer 
qualify after the 3-year period, or it may qualify but receive a 
different adjustment to the wage index level. Hospitals that receive 
this adjustment to their wage index are not eligible for 
reclassification under section 1886(d)(8) or section 1886(d)(10) of the 
Act. Adjustments under this provision are not subject to the IPPS 
budget neutrality requirements at section 1886(d)(3)(E) or section 
1886(d)(8)(D) of the Act.
    Hospitals located in counties that qualify for the wage index 
adjustment are to receive an increase in the wage index that is equal 
to the average of the differences between the wage indexes of the labor 
market area(s) with higher wage indexes and the wage index of the 
resident county, weighted by the overall percentage of hospital workers 
residing in the qualifying county who are employed in any labor market 
area with a higher wage index. We have employed the prereclassified 
wage indexes in making these calculations.
    We are proposing that hospitals located in the qualifying counties 
identified in Table 4J in the Addendum to this proposed rule that have 
not already reclassified through section 1886(d)(10) of the Act, 
redesignated through section 1886(d)(8) of the Act, received a section 
508 reclassification, or requested to waive the application of the out-
migration adjustment would receive the wage index adjustment listed in 
the table for FY 2006. We used the same formula described in the FY 
2005 final rule (69 FR 49064) to calculate the out-migration 
adjustment. This proposed adjustment was calculated as follows:
    Step 1. Subtract the wage index for the qualifying county from the 
wage index for the higher wage area(s).
    Step 2. Divide the number of hospital employees residing in the 
qualifying county who are employed in such higher wage index area by 
the total number of hospital employees residing in the qualifying 
county who are employed in any higher wage index area. Multiply this 
result by the result obtaining in Step 1.
    Step 3. Sum the products resulting from Step 2 (if the qualifying 
county has workers commuting to more than one higher wage area).
    Step 4. Multiply the result from Step 3 by the percentage of 
hospital employees who are residing in the qualifying county and who 
are

[[Page 23382]]

employed in any higher wage index area.
    The proposed adjustments calculated for qualifying hospitals are 
listed in Table 4J in the Addendum to this proposed rule. These 
proposed adjustments would be effective for each county for a period of 
3 fiscal years. Hospitals that received the adjustment in FY 2005 will 
be eligible to retain that same adjustment for FY 2006 and FY 2007. For 
hospitals in newly qualified counties, adjustments to the wage index 
would be effective for 3 years, beginning with discharges occurring on 
or after October 1, 2005.
    As previously noted, hospitals receiving the wage index adjustment 
under section 1886(d)(13)(F) of the Act are not eligible for 
reclassification under section 1886(d)(10) of the Act or 
reclassifications under section 508 of Pub. L. 108-173. Hospitals that 
wish to waive the application of this wage index adjustment must notify 
CMS within 45 days of the publication of this proposed rule. Waiver 
notification should be sent to the following address: Centers for 
Medicare and Medicaid Services, Center for Medicare Management, 
Attention: Wage Index Adjustment Waivers, Division of Acute Care, Room 
C4-08-06, 7500 Security Boulevard, Baltimore, MD 21244-1850. We will 
assume that hospitals that have been redesignated under section 
1886(d)(8) of the Act or reclassified under section 886(d)(10) of the 
Act or under section 508 of Pub. L. 108-173 would prefer to keep their 
redesignation/reclassification unless they explicitly notify CMS that 
they would like to receive the out-migration adjustment instead. In 
addition, hospitals that wish to retain their redesignation/
reclassification (instead of receiving the out-migration adjustment) 
for FY 2006 do not need to submit a formal request to CMS, and will 
automatically retain their redesignation/reclassification status for FY 
2006. However, consistent with Sec.  412.273, hospitals that have been 
reclassified by the MGCRB are permitted to withdraw their applications 
within 45 days of the publication of this proposed rule. Hospitals that 
have been reclassified by the MGCRB (including reclassifications under 
section 508 of Pub. L. 108-173) may terminate an existing 3-year 
reclassification within 45 days of the publication of this proposed 
rule in order to receive the wage index adjustment under this 
provision. Hospitals that are eligible to receive the wage index 
adjustment and that withdraw their application for reclassification 
will then automatically receive the wage index adjustment listed in 
Table 4J in the Addendum to this proposed rule. The request for 
withdrawal of an application for reclassification or termination of an 
existing 3-year reclassification that would be effective in FY 2006 
must be received by the MGCRB within 45 days of the publication of this 
proposed rule. Hospitals should carefully review the wage index 
adjustment that they would receive under this provision (as listed in 
Table 2 in the Addendum to this proposed rule) in comparison to the 
wage index adjustment that they would receive under the MGCRB 
reclassification (Table 9 in the Addendum to this proposed rule).

J. Process for Requests for Wage Index Data Corrections

    (If you choose to comment on issues in this section, please include 
the caption ``Wage Index Data Corrections'' at the beginning of your 
comment.)
    In the FY 2005 IPPS final rule (68 FR 27194), we revised the 
process and timetable for application for development of the wage 
index, beginning with the FY 2005 wage index. The preliminary and 
unaudited Worksheet S-3 wage data and occupational mix survey files 
were made available on October 8, 2004 through the Internet on the CMS 
Web site at: http://cms.hhs.gov/providers/hipps/ippswage.asp. In a 
memorandum dated October 6, 2004, we instructed all Medicare fiscal 
intermediaries to inform the IPPS hospitals they service of the 
availability of the wage index data files 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 also made available directly through 
their representative hospital organizations.
    If a hospital wished to request a change to its data as shown in 
the October 8, 2004 wage and occupational mix data files, the hospital 
was to submit corrections along with complete, detailed supporting 
documentation to its fiscal intermediary by November 29, 2004. 
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 index data file on 
the Internet, through the October 6, 2004 memorandum referenced above.
    In the October 6, 2004 memorandum, we also specified that a 
hospital could only request revisions to the occupational mix data for 
the reporting period that the hospital used in its original FY 2005 
wage index occupational mix survey. That is, a hospital that submitted 
occupational mix data for the 12-month reporting period could not 
switch to submitting data for the 4-week reporting period and vice 
versa. Further, a hospital could not submit an occupational mix survey 
for the periods beginning before January 1, 2003, or after January 11, 
2004. In addition, a hospital that did not submit an occupational mix 
survey for the FY 2005 wage index was not permitted to submit a survey 
for the FY 2006 wage index.
    The fiscal intermediaries notified the hospitals by mid-February 
2005 of any changes to the wage index data as a result of the desk 
reviews and the resolution of the hospitals' late November 2004 change 
requests. The fiscal intermediaries also submitted the revised data to 
CMS by mid-February 2005. CMS published the proposed wage index public 
use files that included hospitals' revised wage data on February 25, 
2005. In a memorandum also dated February 25, 2005, we instructed 
fiscal intermediaries to notify all hospitals regarding the 
availability of the proposed wage index public use files and the 
criteria and process for requesting corrections and revisions to the 
wage index data. Hospitals had until March 14, 2005 to submit requests 
to the fiscal intermediaries for reconsideration of adjustments made by 
the fiscal intermediaries as a result of the desk review, and to 
correct errors due to CMS's or the fiscal intermediary's mishandling of 
the wage index data. Hospitals were also required to submit sufficient 
documentation to support their requests.
    After reviewing requested changes submitted by hospitals, fiscal 
intermediaries are to submit any additional revisions resulting from 
the hospitals' reconsideration requests by April 15, 2005. The deadline 
for a hospital to request CMS intervention in cases where the hospital 
disagrees with the fiscal intermediary's policy interpretations is 
April 22, 2005.
    Hospitals should also examine Table 2 in the Addendum to this 
proposed rule. Table 2 contains each hospital's adjusted average hourly 
wage used to construct the wage index values for the past 3 years, 
including the FY 2002 data used to construct the FY 2006 wage index. We 
note that the hospital average hourly wages shown in Table 2 only 
reflect changes made to a hospital's data and transmitted to CMS by 
February 23, 2005.
    We will release a final wage index data public use file in early 
May 2005 to hospital associations and the public on the Internet at 
http://www.cms.hhs.gov/providers/hipps/

[[Page 23383]]

ippswage.asp. The May 2005 public use file will be made available 
solely for the limited purpose of identifying any potential errors made 
by CMS or the fiscal intermediary in the entry of the final wage data 
that result from the correction process described above (revisions 
submitted to CMS by the fiscal intermediaries by April 15, 2005). If, 
after reviewing the May 2005 final file, a hospital believes that its 
wage data were incorrect due to a fiscal intermediary or CMS error in 
the entry or tabulation of the final wage data, it should send a letter 
to both its fiscal intermediary and CMS that outlines why the hospital 
believes an error exists and provide all supporting information, 
including relevant dates (for example, when it first became aware of 
the error). CMS and the fiscal intermediaries must receive these 
requests no later than June 10, 2005. Requests mailed to CMS should be 
sent to:

Centers for Medicare & Medicaid Services, Center for Medicare 
Management, Attention: Wage Index Team, Division of Acute Care, C4-08-
06, 7500 Security Boulevard, Baltimore, MD 21244-1850.

    Each request also must be sent to the fiscal intermediary. The 
fiscal intermediary will review requests upon receipt and contact CMS 
immediately to discuss its findings.
    At this point in the process, that is, after the release of the May 
2005 wage index data file, changes to the hospital wage data will only 
be made in those very limited situations involving an error by the 
fiscal intermediary or CMS that the hospital could not have known about 
before its review of the final wage index data file. Specifically, 
neither the intermediary nor CMS will approve the following types of 
requests:
     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 15, 2005.
     Requests for correction of errors that were not, but could 
have been, identified during the hospital's review of the February 25, 
2005 wage index data file.
     Requests to revisit factual determinations or policy 
interpretations made by the fiscal intermediary or CMS during the wage 
index data correction process.
    Verified corrections to the wage index received timely by CMS and 
the fiscal intermediaries (that is, by June 10, 2005) will be 
incorporated into the final wage index to be published by August 1, 
2005, and to be effective October 1, 2005.
    We created the processes described above to resolve all substantive 
wage index data correction disputes before we finalize the wage and 
occupational mix data for the FY 2006 payment rates. Accordingly, 
hospitals that do not meet the procedural deadlines set forth above 
will not be afforded a later opportunity to submit wage index data 
corrections or to dispute the fiscal 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 index data correction process described 
above provides hospitals with sufficient opportunity to bring errors in 
their wage index data to the fiscal intermediaries' attention. 
Moreover, because hospitals will have access to the final wage index 
data by early May 2005, they have the opportunity to detect any data 
entry or tabulation errors made by the fiscal intermediary or CMS 
before the development and publication of the final FY 2006 wage index 
by August 1, 2005, and the implementation of the FY 2006 wage index on 
October 1, 2005. If hospitals avail themselves of the opportunities 
afforded to provide and make corrections to the wage data, the wage 
index implemented on October 1 should be accurate. Nevertheless, in the 
event that errors are identified by hospitals and brought to our 
attention after June 10, 2005, we retain the right to make midyear 
changes to the wage index under very limited circumstances.
    Specifically, in accordance with Sec.  412.64(k)(1) of our existing 
regulations, we make midyear corrections to the wage index for an area 
only if a hospital can show that: (1) The fiscal intermediary or CMS 
made an error in tabulating its data; and (2) the requesting hospital 
could not have known about the error or did not have an opportunity to 
correct the error, before the beginning of the fiscal year. For 
purposes of this provision, ``before the beginning of the fiscal year'' 
means by the June deadline for making corrections to the wage data for 
the following fiscal year's wage index. 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 for the labor market 
area. As indicated earlier, since CMS makes the wage data available to 
a hospital on the CMS website prior to publishing both the proposed and 
final IPPS rules, and the fiscal intermediaries notify hospitals 
directly of any wage data changes after completing their desk reviews, 
we do not expect that midyear corrections would be necessary. However, 
under our current policy, 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 made.
    We are proposing to revise Sec.  412.64(k)(2) to specify that a 
change to the wage index can be made retroactive to the beginning of 
the Federal fiscal year only when: (1) The fiscal intermediary or CMS 
made an error in tabulating data used for the wage index calculation; 
(2) the hospital knew about the error and requested that the fiscal 
intermediary and CMS correct the error using the established process 
and within the established schedule for requesting corrections to the 
wage data, before the beginning of the fiscal year for the applicable 
IPPS update (that is, by the June 10, 2005 deadline for the FY 2006 
wage index); and (3) CMS agreed that the fiscal intermediary or CMS 
made an error in tabulating the hospital's wage data and the wage index 
should be corrected. We are proposing this change because there may be 
instances in which a hospital identifies an error in its wage data and 
submits a correction request using all appropriate procedures and by 
the June deadline, CMS agrees that the fiscal intermediary or CMS 
caused the error in the hospital's wage data and that the wage index 
must be corrected, but CMS fails to publish or implement the corrected 
wage index value by the beginning of the Federal fiscal year. We 
believe that the above proposed revision to Sec.  412.64(k)(2) is 
appropriate and fair. We also believe that unlike a generalized 
retroactive policy, the situations where this will occur will be 
minimal, thus minimizing the administrative burden associated with such 
retroactive corrections. In those circumstances where a hospital 
requests a correction to its wage data before CMS calculates the final 
wage index (that is, by the June deadline), and CMS acknowledges that 
the error in the hospital's wage data caused by CMS's or the fiscal 
intermediary's mishandling of the data, we believe that the hospital 
should not be penalized by our delay in publishing or implementing the 
correction. As with our current policy, this provision would not be 
available to a hospital seeking to revise another

[[Page 23384]]

hospital's data. In addition, the provision could not be used to 
correct prior years' wage data; it could only be used for the current 
Federal fiscal year. In other situations, we continue to believe that 
it is appropriate to make prospective corrections to the wage index in 
those circumstances where a hospital could not have known about or did 
not have the opportunity to correct the fiscal intermediary's or CMS's 
error before the beginning of the fiscal year (that is, by the June 
deadline).
    We are proposing to make this change to Sec.  412.64(k)(2) 
effective on October 1, 2005, that is, beginning with the FY 2006 wage 
index. We note that, as with prospective changes to the wage index, the 
proposed retroactive correction would be made irrespective of whether 
the change increases or decreases a hospital's payment rate. In 
addition, we note that the policy of retroactive adjustment would still 
apply in those instances where a judicial decision reverses a CMS 
denial of a hospital's wage data revision request.
    In addition, we are proposing to correct the FY 2005 wage index 
retroactively (that is, from October 1, 2004) on a one-time only basis 
for a limited circumstance using the authority provided under section 
903(a)(1) of Pub. L. 108-173. This provision authorizes the Secretary 
to make retroactive changes to items and services if failure to apply 
such changes would be contrary to the public interest. However, as 
indicated, our current regulations at Sec.  412.64(k)(1) allow only for 
a prospective correction to the hospitals' area wage index values. We 
are proposing to correct the FY 2005 wage index retroactively in the 
limited circumstance where a hospital meets all of the following 
criteria: (1) The fiscal intermediary or CMS made an error in 
tabulating a hospital's FY 2005 wage index data; (2) the hospital 
informed the fiscal intermediary or CMS, or both, about the error, 
following the established schedule and process for requesting 
corrections to its FY 2005 wage index data; and (3) CMS agreed before 
October 1 that the fiscal intermediary or CMS made an error in 
tabulating the hospital's wage data and the wage index should be 
corrected by the beginning of the Federal fiscal year (that is, by 
October 1, 2004), but CMS was unable to publish the correction by the 
beginning of the fiscal year.
    On December 30, 2004, we published in the Federal Register a 
correction notice to the FY 2005 IPPS final rule that included the 
corrected wage data for four hospitals that meet all of the three above 
stated criteria (69 FR 78526). These corrections were effective January 
1, 2005. As noted, our current regulations allow only for a prospective 
correction to the hospitals' area wage index values. However, we 
believe that, in the limited circumstance mentioned above, a 
retroactive correction to the FY 2005 wage index is appropriate and 
meets the condition of section 903(a)(1) of Pub. L. 108-173 that 
``failure to apply the change retroactively would be contrary to the 
public interest.''

IV. Proposed Rebasing and Revision of the Hospital Market Baskets

    (If you choose to comment on issues in this section, please include 
the caption ``Hospital Market Basket'' at the beginning of your 
comment.)

A. Background

    Effective for cost reporting periods beginning on or after July 1, 
1979, we developed and adopted a hospital input price index (that is, 
the hospital market basket for operating costs). Although ``market 
basket'' technically describes the mix of goods and services used to 
produce hospital care, this term is also commonly used to denote the 
input price index (that is, cost category weights and price proxies 
combined) derived from that market basket. Accordingly, the term 
``market basket'' as used in this document refers to the hospital input 
price index.
    The terms ``rebasing'' and ``revising,'' while often used 
interchangeably, actually denote different activities. ``Rebasing'' 
means moving the base year for the structure of costs of an input price 
index (for example, in this proposed rule, we are proposing to shift 
the base year cost structure for the IPPS hospital index from FY 1997 
to FY 2002). ``Revising'' means changing data sources, or price 
proxies, used in the input price index.
    The percentage change in the market basket reflects the average 
change in the price of goods and services hospitals purchase in order 
to furnish inpatient care. We first used the market basket to adjust 
hospital cost limits by an amount that reflected the average increase 
in the prices of the goods and services used to provide hospital 
inpatient care. This approach linked the increase in the cost limits to 
the efficient utilization of resources.
    Since the inception of the IPPS, the projected change in the 
hospital market basket has been the integral component of the update 
factor by which the prospective payment rates are updated every year. 
An explanation of the hospital market basket used to develop the 
prospective payment rates was published in the Federal Register on 
September 1, 1983 (48 FR 39764). We also refer the reader to the August 
1, 2002 Federal Register (67 FR 50032) in which we discussed the 
previous rebasing of the hospital input price index.
    The hospital market basket is a fixed weight, Laspeyres-type price 
index that is constructed in three steps. First, a base period is 
selected (in this proposed rule, FY 2002) and total base period 
expenditures are estimated for a set of mutually exclusive and 
exhaustive spending categories based upon type of expenditure. Then the 
proportion of total operating costs that each category represents is 
determined. These proportions are called cost or expenditure weights. 
Second, each expenditure category is matched to an appropriate price or 
wage variable, referred to as a price proxy. In nearly every instance, 
these price proxies are price levels derived from publicly available 
statistical series that are published on a consistent schedule, 
preferably at least on a quarterly basis.
    Finally, the expenditure weight for each cost category is 
multiplied by the level of its respective price proxy. The sum of these 
products (that is, the expenditure weights multiplied by their price 
levels) for all cost categories yields the composite index level of the 
market basket in a given period. Repeating this step for other periods 
produces a series of market basket levels over time. Dividing an index 
level for a given period by an index level for an earlier period 
produces a rate of growth in the input price index over that time 
period.
    The market basket is described as a fixed-weight index because it 
describes the change in price over time of the same mix of goods and 
services purchased to provide hospital services in a base period. The 
effects on total expenditures resulting from changes in the quantity or 
mix of goods and services (intensity) purchased subsequent to the base 
period are not measured. For example, shifting a traditionally 
inpatient type of care to an outpatient setting might affect the volume 
of inpatient goods and services purchased by the hospital, but would 
not be factored into the price change measured by a fixed weight 
hospital market basket. In this manner, the market basket measures only 
the pure price change. Only when the index is rebased using a more 
recent base period would the quantity and intensity effects be captured 
in the cost weights. Therefore, we rebase the market basket 
periodically so the cost weights reflect changes in the mix of goods 
and services that hospitals purchase (hospital inputs) to furnish 
inpatient care between base periods. We last

[[Page 23385]]

rebased the hospital market basket cost weights effective for FY 2003 
(67 FR 50032, August 1, 2002), with FY 1997 data used as the base 
period for the construction of the market basket cost weights.

B. Rebasing and Revising the Hospital Market Basket

1. Development of Cost Categories and Weights
a. Medicare Cost Reports
    The major source of expenditure data for developing the proposed 
rebased and revised hospital market basket cost weights is the FY 2002 
Medicare cost reports. These cost reports are from IPPS hospitals only. 
They do not reflect data from hospitals excluded from the IPPS or CAHs. 
The IPPS cost reports yield seven major expenditure or cost categories: 
wages and salaries, employee benefits, contract labor, pharmaceuticals, 
professional liability insurance (malpractice), blood and blood 
products, and a residual ``all other.''
[GRAPHIC] [TIFF OMITTED] TP04MY05.031

b. Other Data Sources
    In addition to the Medicare cost reports, other sources of data 
used in developing the market basket weights are the Benchmark Input-
Output Tables (I-Os) created by the Bureau of Economic Analysis, U.S. 
Department of Commerce, and the Business Expenses Survey developed by 
the Bureau of the Census, U.S. Department of Commerce, from its 
Economic Census.
    New data for these Census sources are scheduled for publication 
every 5 years, but often take up to 7 years after the reference year. 
Only an Annual I-O is produced each year, but the Annual I-O contains 
less industry detail than does the Benchmark I-O. When we rebased the 
market basket using FY 1997 data in the FY 2003 IPPS final rule, the 
1997 Benchmark I-O was not yet available. Therefore, we did not 
incorporate data from that source into the FY 1997-based market basket 
(67 FR 50033). However, we did use a secondary source, the 1997 Annual 
Input-Output tables. The third source of data, the 1997 Business 
Expenditure Survey (now known as the Business Expenses Survey) was used 
to develop weights for the utilities and telephone services categories.
    The 1997 Benchmark I-O data are a much more comprehensive and 
complete set of data than the 1997 Annual I-O estimates. The 1997 
Annual I-O is an update of the 1992 I-O tables, while the 1997 
Benchmark I-O is an entirely new set of numbers derived from the 1997 
Economic Census. The 2002 Benchmark Input-Output tables are not yet 
available. Therefore, we are proposing to use the 1997 Benchmark I-O 
data in the proposed FY 2002-based market basket, to be effective for 
FY 2006. Instead of using the less detailed, less accurate Annual I-O 
data, we aged the 1997 Benchmark I-O data forward to FY 2002. The 
methodology we used to age the data involves applying the annual price 
changes from the price proxies to the appropriate cost categories. We 
repeat this practice for each year.
    The ``all other'' cost category is further divided into other 
hospital expenditure category shares using the 1997 Benchmark Input-
Output tables. Therefore, the ``all other'' cost category expenditure 
shares are proportional to their relationship to ``all other'' totals 
in the I-O tables. For instance, if the cost for telephone services 
were to represent 10 percent of the sum of the ``all other'' I-O (see 
below) hospital expenditures, then telephone services would represent 
10 percent of the market basket's ``all other'' cost category.
2. PPS--Selection of Price Proxies
    After computing the FY 2002 cost weights for the proposed rebased 
hospital market basket, it is necessary to select appropriate wage and 
price proxies to reflect the rate-of-price change for each expenditure 
category. With the exception of the Professional Liability proxy, all 
the indicators are based on Bureau of Labor Statistics (BLS) data and 
are grouped into one of the following BLS categories:
     Producer Price Indexes--Producer Price Indexes (PPIs) 
measure price changes for goods sold in other than retail markets. PPIs 
are preferable price proxies for goods that hospitals purchase as 
inputs in producing their outputs because the PPIs would better reflect 
the prices faced by hospitals. For example, we use a special PPI for 
prescription drugs, rather than the Consumer Price Index (CPI) for 
prescription drugs because hospitals generally purchase drugs directly 
from the wholesaler. The PPIs that we use measure price change at the 
final stage of production.
     Consumer Price Indexes--Consumer Price Indexes (CPIs) 
measure change in the prices of final goods and services bought by the 
typical consumer. Because they may not represent the price faced by a 
producer, we used CPIs only if an appropriate PPI

[[Page 23386]]

was not available, or if the expenditures were more similar to those of 
retail consumers in general rather than purchases at the wholesale 
level. For example, the CPI for food purchased away from home is used 
as a proxy for contracted food services.
     Employment Cost Indexes--Employment Cost Indexes (ECIs) 
measure the rate of change in employee wage rates and employer costs 
for employee benefits per hour worked. These indexes are fixed-weight 
indexes and strictly measure the change in wage rates and employee 
benefits per hour. Appropriately, they are not affected by shifts in 
employment mix.
    We evaluated the price proxies using the criteria of reliability, 
timeliness, availability, and relevance. Reliability indicates that the 
index is based on valid statistical methods and has low sampling 
variability. Timeliness implies that the proxy is published regularly, 
at least once a quarter. Availability means that the proxy is publicly 
available. Finally, relevance means that the proxy is applicable and 
representative of the cost category weight to which it is applied. The 
CPIs, PPIs, and ECIs selected meet these criteria.
    Chart 2 sets forth the complete proposed market basket including 
cost categories, weights, and price proxies. For comparison purposes, 
the corresponding FY 1997-based market basket is listed as well. A 
summary outlining the choice of the various proxies follows the chart.
BILLING CODE 4120-01-P

[[Page 23387]]

[GRAPHIC] [TIFF OMITTED] TP04MY05.032


[[Page 23388]]


[GRAPHIC] [TIFF OMITTED] TP04MY05.033

BILLING CODE 4120-01-C

[[Page 23389]]

[GRAPHIC] [TIFF OMITTED] TP04MY05.034

BILLING CODE 4120-01-C
a. Wages and Salaries
    For measuring the price growth of wages in the proposed FY 2002-
based market basket, we are proposing to use the ECI for wages and 
salaries for civilian hospital workers as the proxy for wages in the 
hospital market basket. This same proxy was used for the 1997-based 
market basket.
b. Employee Benefits
    The proposed FY 2002-based hospital market basket uses the ECI for 
employee benefits for civilian hospital workers. This is the same proxy 
that was used in the FY 1997-based market basket.
c. Nonmedical Professional Fees
    The ECI for compensation for professional and technical workers in 
private industry is applied to this category because it includes 
occupations such as management and consulting, legal, accounting and 
engineering services. The same proxy was used in the FY 1997-based 
market basket.
d. Fuel, Oil, and Gasoline
    The percentage change in the price of gas fuels as measured by the 
PPI (Commodity Code 0552) is applied to this component. The 
same proxy was used in the FY 1997-based market basket.
e. Electricity
    The percentage change in the price of commercial electric power as 
measured by the PPI (Commodity Code 0542) is applied to this 
component. The same proxy was used in the FY 1997-based market basket.
f. Water and Sewerage
    The percentage change in the price of water and sewerage 
maintenance as measured by the CPI for all urban consumers (CPI Code 
CUUR0000SEHG01) is applied to this component. The same proxy 
was used in the FY 1997-based market basket.
g. Professional Liability Insurance
    The proposed FY 2002-based index uses the percentage change in the 
hospital professional liability insurance (PLI) premiums as estimated 
by the CMS Hospital Professional Liability Index, which we use as a 
proxy in the Medicare Economic Index (68 FR 63244), for the proxy of 
this category. Similar to the Physicians Professional Liability Index, 
we attempt to collect commercial insurance premiums for a fixed level 
of coverage, holding nonprice factors constant (such as a change in the 
level of coverage). In the FY 1997-based market basket, the same price 
proxy was used.
    We continue to research options for improving our proxy for 
professional liability insurance. This research includes exploring 
various options for expanding our current survey, including the 
identification of another entity that would be willing to work with us 
to collect more complete and comprehensive data. We are also exploring 
other options such as third party or industry data that might assist us 
in creating a more precise measure of PLI premiums. At this time, we 
have not yet identified a preferred option. Therefore, we are not 
proposing to make any changes to the proxy in this proposed rule.
h. Pharmaceuticals
    The percentage change in the price of prescription drugs as 
measured by the PPI (PPI Code PPI283DRX) is used as a 
proxy for this category. This is a special index produced by BLS and is 
the same proxy used in the 1997-based index.
i. Food: Direct Purchases
    The percentage change in the price of processed foods and feeds as 
measured by the PPI (Commodity Code 02) is applied to this 
component. The same proxy was used in the FY 1997-based market basket.
j. Food: Contract Services
    The percentage change in the price of food purchased away from home 
as measured by the CPI for all urban consumers (CPI Code 
CUUR0000SEFV) is applied to this component. The same proxy was 
used in the FY 1997-based market basket.
k. Chemicals
    The percentage change in the price of industrial chemical products 
as measured by the PPI (Commodity Code 061) is applied to this 
component. While the chemicals hospitals purchase include industrial as 
well as other types of chemicals, the industrial chemicals component 
constitutes the largest proportion by far. Thus, we believe that 
Commodity Code 061 is the appropriate proxy. The same proxy 
was used in the FY 1997-based market basket.
l. Medical Instruments
    The percentage change in the price of medical and surgical 
instruments as

[[Page 23390]]

measured by the PPI (Commodity Code 1562) is applied to this 
component. The same proxy was used in the FY 1997-based market basket.
m. Photographic Supplies
    The percentage change in the price of photographic supplies as 
measured by the PPI (Commodity Code 1542) is applied to this 
component. The same proxy was used in the FY 1997-based market basket.
n. Rubber and Plastics
    The percentage change in the price of rubber and plastic products 
as measured by the PPI (Commodity Code 07) is applied to this 
component. The same proxy was used in the FY 1997-based market basket.
o. Paper Products
    The percentage change in the price of converted paper and 
paperboard products as measured by the PPI (Commodity Code 
0915) is used. The same proxy was used in the FY 1997-based 
market basket.
p. Apparel
    The percentage change in the price of apparel as measured by the 
PPI (Commodity Code 381) is applied to this component. The 
same proxy was used in the FY 1997-based market basket.
q. Machinery and Equipment
    The percentage change in the price of machinery and equipment as 
measured by the PPI (Commodity Code 11) is applied to this 
component. The same proxy was used in the FY 1997-based market basket.
r. Miscellaneous Products
    The percentage change in the price of all finished goods less food 
and energy as measured by the PPI (Commodity Code SOP3500) is 
applied to this component. Using this index removes the double-counting 
of food and energy prices, which are already captured elsewhere in the 
market basket. The same proxy was used in the FY 1997-based index. The 
weight for this cost category is higher than in the FY 1997-based index 
because the weight for blood and blood products (1.082) is added to it. 
In the FY 1997-based market basket, we included a separate cost 
category for blood and blood products, using the BLS PPI (Commodity 
Code 063711) for blood and derivatives as a price proxy. A 
review of recent trends in the PPI for blood and derivatives suggests 
that its movements may not be consistent with the trends in blood costs 
faced by hospitals. While this proxy did not match exactly with the 
product hospitals are buying, its trend over time appears to be 
reflective of the historical price changes of blood purchased by 
hospitals. However, an apparent divergence over recent periods led us 
to reevaluate whether the PPI for blood and derivatives was an 
appropriate measure of the changing price of blood. We ran test market 
baskets classifying blood in three separate cost categories: blood and 
blood products, contained within chemicals as was done for the FY 1992-
based index, and within miscellaneous products. These categories use as 
proxies the following PPIs: The PPI for blood and blood products, the 
PPI for chemicals, and the PPI for finished goods less food and energy, 
respectively. Of these three proxies, the PPI for finished goods less 
food and energy moved most like the recent blood cost and price trends. 
In addition, the impact on the overall market basket by using different 
proxies for blood was negligible, mostly due to the relatively small 
weight for blood in the market basket. Therefore, we chose the PPI for 
finished goods less food and energy for the blood proxy because we 
believe it will best be able to proxy price changes (not quantities or 
required tests) associated with blood purchased by hospitals. We will 
continue to evaluate this proxy for its appropriateness and will 
explore the development of alternative price indexes to proxy the price 
changes associated with this cost.
s. Telephone
    The percentage change in the price of telephone services as 
measured by the CPI for all urban consumers (CPI Code  
CUUR0000SEED) is applied to this component. The same proxy was used in 
the FY 1997-based market basket.
t. Postage
    The percentage change in the price of postage as measured by the 
CPI for all urban consumers (CPI Code  CUUR0000SEEC01) is 
applied to this component. The same proxy was used in the FY 1997-based 
market basket.
u. All Other Services: Labor Intensive
    The percentage change in the ECI for compensation paid to service 
workers employed in private industry is applied to this component. The 
same proxy was used in the FY 1997-based market basket.
v. All Other Services: Nonlabor Intensive
    The percentage change in the all-items component of the CPI for all 
urban consumers (CPI Code  CUUR0000SA0) is applied to this 
component. The same proxy was used in the FY 1997-based market basket.
    For further discussion of the rationales for choosing many of the 
specific price proxies, we refer the reader to the August 1, 2002 final 
rule (67 FR 50037).

[[Page 23391]]

[GRAPHIC] [TIFF OMITTED] TP04MY05.035

    3. Labor-Related Share
    (If you choose to comment on issues in this section, please include 
the caption ``Labor-Related Share'' at the beginning of your comment.)
    Under section 1886(d)(3)(E) of the Act, the Secretary estimates 
from time to time the proportion of payments that are labor-related. 
``The Secretary shall adjust the proportion (as estimated by the 
Secretary from time to time) of hospitals' costs which are attributable 
to wages and wage-related costs of the DRG prospective payment rates. * 
* *'' We refer to the proportion of hospitals' costs that are 
attributable to wages and wage-related costs as the ``labor-related 
share.''
    The labor-related share is used to determine the proportion of the 
national PPS base payment rate to which the area wage index is applied. 
We are proposing to continue to use our current methodology of defining 
the labor-related share as the national average proportion of operating 
costs that are related to, influenced by, or vary with the local labor 
markets. We believe that the operating cost categories that are related 
to, influenced by, or vary with the local labor markets are wages and 
salaries, fringe benefits, professional fees, contract labor, and labor 
intensive services. Therefore, we are proposing to calculate the labor-
related share by adding the relative weights for these operating cost 
categories. After we reviewed all cost categories in the proposed IPPS 
market basket using this definition of labor-related, we removed 
postage costs from the proposed FY 2002-based labor-related share 
because we no longer believe these costs are likely to vary with the 
local labor market. Using the cost category weights that we determined 
in section IV.B. of this preamble, we calculated a labor-related share 
of 69.731 percent, using the FY 2002-based PPS market basket. 
Accordingly, we are proposing to implement a labor-related share of 
69.7 percent for discharges occurring on or after October 1, 2005. We 
note that section 403 of Pub. L. 108-173 amended sections 1886(d)(3)(E) 
and 1886(d)(9)(C)(iv) of the Act to provide that the Secretary must 
employ 62 percent as the labor-related share unless this employment 
``would result in lower payments than would otherwise be made.''
    We also are proposing an update to the labor-related share for 
Puerto Rico. Consistent with our methodology for determining the 
national labor-related share, we are proposing to add the Puerto Rico-
specific relative weights for wages and salaries, fringe benefits, and 
contract labor. Because there are no Puerto Rico-specific relative 
weights for professional fees and labor intensive services, we are 
proposing to use the national weights. Alternatively, we could apply 
the national labor-related share to the Puerto Rico-specific rate. We 
note that we are still reviewing our data and have not yet calculated 
the updated Puerto Rico-specific labor-related share percentage. 
Therefore, the labor-related and nonlabor-related portions of the 
Puerto Rico-specific standardized amount listed in Table 1C of the 
Addendum to this proposed rule reflect the current (FY 2005) labor-
related share for Puerto Rico of 71.3 percent. Once we have calculated 
the updated labor-related share for Puerto Rico, we will post it on the 
CMS website at http://www.cms.hhs.gov/providers/hipps. In addition, if 
we adopt this proposal, we would publish the updated Puerto Rico labor-
related share in the IPPS final rule. We welcome comments on our 
proposal to update the labor-related share for Puerto Rico.
    Unlike the 1997 Annual I-O which was based on Standard Industrial 
Codes (SIC), the 1997 Benchmark I-O is categorized using the North 
American Industrial Classification System (NAICS). This change required 
us to classify all cost categories under NAICS, including a 
reevaluation of labor-related costs on the NAICS definitions. Chart 4 
compares the FY 1992-based labor-related share, the current measure, 
with the FY 2002-based labor-related share. When we rebased the market 
basket to

[[Page 23392]]

reflect FY 1997 data, we did not change the labor-related share (67 FR 
50041). Therefore, the FY 1992-based labor-related share is the current 
measure.
[GRAPHIC] [TIFF OMITTED] TP04MY05.036

    Although we are proposing to continue to calculate the labor-
related share by adding the relative weights of the labor-related 
operating cost categories, we continue to evaluate alternative 
methodologies. In the May 9, 2002 Federal Register (67 FR 31447), we 
discussed our research on the methodology for the labor-related share. 
This research involved analyzing the compensation share (the sum of 
wages and salaries and benefits) separately for urban and rural 
hospitals, using regression analysis to determine the proportion of 
costs influenced by the area wage index, and exploring alternative 
methodologies to determine whether all or only a portion of 
professional fees and nonlabor intensive services should be considered 
labor-related.
    Our original analysis, which appeared in the May 9, 2002 Federal 
Register (67 FR 31447) and which focused mainly on edited FY 1997 
hospital data, found that the compensation share of costs for hospitals 
in rural areas was higher on average than the compensation share for 
hospitals in urban areas. We also researched whether only a proportion 
of the costs in professional fees and labor-intensive services should 
be considered labor-related, not the entire cost categories. However, 
there was not enough information available to make this determination.
    Our finding that the average compensation share of costs for rural 
hospitals was higher than the average compensation for urban hospitals 
was validated consistently through our regression analysis. Regression 
analysis is a statistical technique that determines the relationship 
between a dependent variable and one or more independent variables. We 
tried several regression specifications in an effort to determine the 
proportion of costs that are influenced by the area wage index. 
Furthermore, MedPAC raised the possibility that regression may be an 
alternative to the current market basket methodology. Our initial 
regression specification (in log form) was Medicare operating cost per 
Medicare discharge as the dependent variable and the independent 
variables being the area wage index, the case-mix index, the ratio of 
residents per bed (as proxy for IME status), and a dummy variable that 
equals one if the hospital is located in a metropolitan area with a 
population of 1 million or more. (A dummy variable represents the 
presence or absence of a particular characteristic.) This regression 
produced a coefficient for all hospitals for the area wage index of 
0.638 (which is equivalent to the labor share and can be interpreted as 
an elasticity because of the log specification) with an adjusted R-
squared of 64.3. (Adjusted R-squared is a measure of how well the 
regression model fits the data.) While, on the surface, this appeared 
to be a reasonable result, this same specification for urban hospitals 
had a coefficient of 0.532 (adjusted R-squared = 53.2) and a 
coefficient of 0.709 (adjusted R-squared = 36.4) for rural hospitals. 
This highlighted some apparent problems with the specification because 
the overall regression results appear to be masking underlying 
problems. It did not seem reasonable that urban hospitals would have a 
labor share below their actual compensation share or that the 
discrepancy between urban and rural hospitals would be this large. When 
we standardized the Medicare operating cost per Medicare discharge for 
case mix, the fit, as measured by adjusted R-squared, fell dramatically 
and the urban/rural discrepancy became even larger.
    Based on this initial result, we tried two modifications to the FY 
1997 regressions to correct for the underlying problems. First, we 
edited the data differently to determine if a few reports were causing 
the inconsistent results. We found when we tightened the edits, the 
wage index coefficient was lower and the fit was worse. When we 
loosened the edits, we found higher wage index coefficients and still a 
worse fit. Second, we added additional variables to the regression 
equation to attempt to explain some of the variation that was not being 
captured. We found the best fit occurred when the following variables 
were added: The occupancy rate, the number of hospital beds, a dummy 
variable that equals one if the hospital is privately owned and zero 
otherwise, a dummy variable that equals one if the hospital is 
government-controlled and zero otherwise, the Medicare length-of-stay, 
the number of FTEs per bed, and the age of fixed

[[Page 23393]]

assets. The result of this specification was a wage index coefficient 
of 0.620 (adjusted R-squared = 68.7), with the regression on rural 
hospitals having a coefficient of 0.772 (adjusted R-squared = 45.0) and 
the regression on urban hospitals having a coefficient of 0.474 
(adjusted R-squared = 60.9). Neither of these alternatives seemed to 
help the underlying difficulties with the regression analysis.
    Subsequent to the work described above, we have undertaken the 
research necessary to reevaluate the current assumptions used in 
determining the labor-related share. We ran regressions applying the 
previous specifications to more recent data (FY 2001 and FY 2002), and, 
as described below, we ran regressions using alternative 
specifications. Once again we encourage comments on this research and 
any information that is available to help determine the most 
appropriate measure.
    The first step in our regression analysis to determine the 
proportion of hospitals' costs that varied with labor-related costs was 
to edit the data, which had significant outliers in some of the 
variables we used in the regressions. We originally began with an edit 
that excluded the top and bottom 5 percent of reports based on average 
Medicare cost per discharge and number of discharges. We also used 
edits to exclude reports that did not meet basic criteria for use, such 
as having costs greater than zero for total, operating, and capital for 
the overall facility and just the Medicare proportion. We also required 
that the hospital occupancy rate, length-of-stay, number of beds, FTEs, 
and overall and Medicare discharges be greater than zero. Finally, we 
excluded reports with occupancy rates greater than one.
    Our regression specification (in log form) was Medicare operating 
cost per Medicare discharge as the dependent variable (the same 
dependent variable we used in the regression analysis described in the 
May 9, 2002 Federal Register) with the independent variables being the 
compensation per FTE, the ratio of interns and residents per bed (as 
proxy for IME status), the occupancy rate, the number of hospital beds, 
a dummy variable that equals one if the hospital is privately owned and 
is zero otherwise, a dummy variable that equals one if the hospital is 
government-controlled and is zero otherwise, the Medicare length-of-
stay, the number of FTEs per bed, the age of fixed assets, and a dummy 
variable that equals one if the hospital is located in a metropolitan 
area with a population of 1 million or more. This is a similar model to 
the one described in the May 9, 2002 Federal Register (67 FR 31447) as 
having the best fit, with two notable exceptions. First, the area wage 
index is replaced by compensation per FTE, where compensation is the 
sum of hospital wages and salaries, contract labor costs, and benefits. 
The area wage index is a payment variable computed by averaging wages 
across all hospitals within each MSA, whereas compensation per FTE 
differs from one hospital to the next. Second, the case-mix index is no 
longer included as a regressor because it is correlated with other 
independent variables in the regression. In other words, the other 
independent variables are capturing part of the effect of the case-mix 
index. We made these two specification changes in an attempt to only 
use cost variables to explain the variation in Medicare operating costs 
per discharge. We believe this is appropriate in order to compare to 
the results we are getting from the market basket methodology, which is 
based solely on cost data. As we will show below, the use of payment 
variables on the right-hand side of the equation appears to be 
producing less reasonable results when cost data are used.
    The revised specification for FY 2002 produced a coefficient for 
all hospitals for compensation per FTE of 0.673 (which is roughly 
equivalent to the labor share and can be interpreted as an elasticity 
because of the log specification) with an adjusted R-squared of 63.7. 
The coefficient result for FY 2001 is 64.5, with an adjusted R-squared 
of 65.2. (For comparison, a separate regression for FY 2002 with the 
log area wage index and log case-mix index included in the set of 
regressors displays a log area wage index coefficient of 75.6 (adjusted 
R-squared = 67.7).) For FY 2001, the coefficient for the log area wage 
index is 72.3 (adjusted R-squared = 67.9). On the surface, these seem 
to be reasonable results. However, a closer look reveals some problems. 
In FY 2001, the coefficient for urban hospitals was 59.6 (adjusted R-
squared = 57.3), and the coefficient for rural hospitals was 61.3 
(adjusted R-squared = 50.6). On the other hand, in FY 2002, the 
coefficient for urban hospitals increased to 69.2 (adjusted R-squared = 
55.9), and the coefficient for rural hospitals decreased to 58.2 
(adjusted R squared = 46.0). The results for FY 2001 seem reasonable, 
but not when compared with the results for FY 2002. Furthermore, for FY 
2002 the compensation share of costs for hospitals in rural areas was 
higher on average than the compensation share for hospitals in urban 
areas. Rural areas had an average compensation share of 63.3 percent, 
while urban areas had a share of 60.5 percent. This compares to a share 
of 61.2 percent for all hospitals.
    Due to these problems, we do not believe the regression analysis is 
producing sound enough evidence at this point for us to make the 
decision to change from the current method for calculating the labor-
related share. We continue to analyze these data and work on 
alternative specifications, including working with MedPAC, who in the 
past have done similar analysis in their studies of payment adequacy. 
Comments on this approach would be welcomed, given the difficulties we 
have encountered.
    We also continue to look into ways to refine our market basket 
approach to more accurately account for the proportion of costs 
influenced by the local labor market. Specifically, we are looking at 
the professional fees and labor-intensive cost categories to determine 
if only a proportion of the costs in these categories should be 
considered labor-related, not the entire cost category. Professional 
fees include management and consulting fees, legal services, accounting 
services, and engineering services. Labor-intensive services are mostly 
building services, but also include other maintenance and repair 
services.
    We conducted preliminary research into whether the various types of 
professional fees are more or less likely to be purchased in local 
labor markets. Through contact with a handful of hospitals in only two 
States, we asked for the percentages of their advertising, legal, and 
management and consulting services that they purchased in either local, 
regional, or national labor markets. The results were quite consistent 
across all of the hospitals, indicating most advertising and legal 
services are purchased in local or regional markets and nearly all 
management and consulting services are purchased in national labor 
markets. This suggested we may be appropriately reflecting advertising 
and legal services in the labor-related share, but we plan to 
investigate further whether management and consulting services are 
appropriately reflected. We do not believe that this limited effort 
produced enough evidence for us to change our methodology. However, we 
do plan to expand our efforts in this area to ensure we appropriately 
determine the labor-related share. We are soliciting data or studies 
that would be helpful in this analysis. We are unsure if we will be 
able to finish this analysis in time for inclusion in the FY 2006 IPPS 
final rule.

[[Page 23394]]

    As mentioned previously, we are proposing to continue to calculate 
the labor-related share by adding the relative weights of the operating 
cost categories that are related to, influenced by, or vary with the 
local labor markets. These categories include wages and salaries, 
fringe benefits, professional fees, contract labor and labor-intensive 
services. Since we no longer believe that postage costs meet our 
definition of labor-related, we are excluding them from the labor-
related share. Using this methodology, we calculated a labor-related 
share of 69.731. Therefore, we are proposing a labor-related share of 
69.731.

C. Separate Market Basket for Hospitals and Hospital Units Excluded 
from the IPPS

    (If you choose to comment on issues in this section, please include 
the caption ``Excluded Hospital Market Basket'' at the beginning of 
your comment.)
1. Hospitals Paid Based on Their Reasonable Costs
    On August 7, 2001, we published a final rule in the Federal 
Register (66 FR 41316) establishing the PPS for IRFs, effective for 
cost reporting periods beginning on or after January 1, 2002. On August 
30, 2002, we published a final rule in the Federal Register (67 FR 
55954) establishing the PPS for LTCHs, effective for cost reporting 
periods beginning on or after October 1, 2002. On November 15, 2004, we 
published a final rule in the Federal Register (69 FR 66922) 
establishing the PPS for the IPFs, effective for cost reporting periods 
beginning on or after January 1, 2005.
    Prior to being paid under a PPS, IRFs, LTCHs, and IPFs were 
reimbursed solely under the reasonable cost-based system under Sec.  
413.40 of the regulations, which impose rate-of-increase limits. 
Children's and cancer hospitals and religious nonmedical health care 
institutions (RNHCIs) are still reimbursed solely under the reasonable 
cost-based system, subject to the rate-of-increase limits. Under these 
limits, an annual target amount (expressed in terms of the inpatient 
operating cost per discharge) is set for each hospital based on the 
hospital's own historical cost experience trended forward by the 
applicable rate-of-increase percentages. To the extent a LTCH or IPF 
receives a blend of reasonable cost-based payment and the Federal 
prospective payment rate amount, the reasonable cost portion of the 
payment is also subject to the applicable rate-of-increase percentage. 
Section 1886(b)(3)(B)(ii) of the Act sets the percentage increase of 
the limits, which in certain years was based upon the market basket 
percentage increase. Beginning in FY 2003 and subsequent years, the 
applicable rate-of-increase is the market basket percentage increase. 
The market basket currently (and historically) used is the excluded 
hospital operating market basket, representing the cost structure of 
rehabilitation, long-term care, psychiatric, children's, and cancer 
hospitals (FY 2003 final rule, 67 FR 50042).
    Because IRFs, LTCHs, and some IPFs are now paid under a PPS, we are 
considering developing a separate market basket for these hospitals 
that contains both operating and capital costs. We would publish any 
proposal to use a revised separate market basket for each of these 
types of hospitals when we propose the nest update of their respective 
PPS rates. Children's and cancer hospitals are two of the remaining 
three types of hospitals excluded from the IPPS that are still being 
paid based solely on their reasonable costs, subject to target amounts. 
(RNHCIs, the third type of IPPS-excluded entity still subject to target 
amounts, are reimbursed under Sec.  403.752(a) of the regulations.) 
Because there are a small number of children's and cancer hospitals and 
RNHCIs, which receive in total less than 1 percent of all Medicare 
payments to hospitals and because these hospitals provide limited 
Medicare cost report data, we are not proposing to create a separate 
market basket specifically for these hospitals. Under the broad 
authority in sections 1886(b)(3)(A) and (B), 1886(b)(3)(E), and 1871 of 
the Act, we are proposing to use the proposed FY 2002 IPPS operating 
market basket percentage increase to update the target amounts for 
children's and cancer hospitals reimbursed under sections 1886(b)(3)(A) 
and (b)(3)(E) of the Act and the market basket for RNHCIs under Sec.  
403.752(a) of the regulations. This proposal reflects our belief that 
it is best to use an index that most closely represents the cost 
structure of children's and cancer hospitals and RNHCIs. The FY 2002 
cost weights for wages and salaries, professional liability, and ``all 
other'' for children's and cancer hospitals are noticeably closer to 
those in the IPPS operating market basket than those in the excluded 
hospital market basket, which is based on the cost structure of IRFs, 
LTCHs, IPFs, and children's and cancer hospitals and RNHCIs. Therefore, 
we believe it is more appropriate to use the IPPS operating market 
basket for children's and cancer hospitals and RNHCIs. However, when we 
compare the weights for LTCHs and IPFs to the weights for IPPS 
hospitals, we did not find them comparable. Therefore, we do not 
believe it is appropriate to use the IPPS market basket for LTCHs and 
IPFs.
    For similar reasons, we are considering at some other date 
proposing a separate market basket to update the adjusted Federal 
payment amount for IRFs, LTCHs, and IPFs. We expect that these changes 
would be proposed in separate proposed rules for each of these three 
hospital types. We envision that these changes should apply to the 
adjusted Federal payment rate, and not the portion of the payment that 
is based on a facility-specific (or reasonable cost) payment to the 
extent such a hospital or unit is paid under a blend methodology. In 
other words, to the extent any of these hospitals are paid under a 
blend methodology whereby a percentage of the payment is based on 
reasonable cost principles, we would not propose to make changes to the 
existing methodology for developing the market basket for the 
reasonable cost portion of the payment because this portion of the 
payment is being phased out, if it is not already a nonexistent feature 
of the PPSs for IRFs, LTCHs, and IPFs. We do not believe that it makes 
sense to propose to create an entirely new methodology for creating the 
market basket index which updates the ``reasonable cost'' portion of a 
blend methodology since the ``reasonable cost portion'' will last at 
most for just 1 or 3 additional years (1 year for LTCHs paid under a 
blend methodology since LTCHs only have 1 year remaining in their 
transition, and 3 years for IPFs since IPFs paid under a blend 
methodology only have 3 years remaining under a blend methodology). 
However, the same cannot be said for the adjusted Federal payment 
amount. In the case of the IRF PPS, all IRFs are paid at 100 percent of 
the adjusted Federal payment amount and will continue to be paid based 
on 100 percent of this amount for perpetuity. In the LTCH PPS, most 
LTCHs (98 percent) are already paid at 100 percent of the adjusted 
Federal payment amount. In the case of the few LTCHs that are paid 
under a blend methodology for cost reporting periods beginning on or 
after October 1, 2006, payment will be based entirely on the adjusted 
Federal prospective payment rate. In the case of IPFs, new IPFs (as 
defined in Sec.  412.426(c)) will be paid at 100 percent of the 
adjusted Federal prospective payment rate (the Federal per diem payment 
amount), while all others will

[[Page 23395]]

continue to transition to 100 percent of the Federal per diem payment 
amount. In any event, even those transitioning will be at 100 percent 
of the adjusted Federal prospective payment rate in 3 years.
    Chart 5 compares the updates for the FY 2002-based IPPS operating 
market basket, our proposed index used to update the target amounts for 
children's and cancer hospitals, and RNHCIs, with a FY 2002-based 
excluded hospital market basket that is based on the current 
methodology (that is, based on the cost structure of IRFs, LTCHs, IPFs, 
and children's and cancer hospitals). Although the percent change in 
the IPPS operating market basket is typically lower than the percent 
change in the FY 2002-based excluded hospital market basket (see 
charts), we believe it is important to propose using the market basket 
that most closely reflects the cost structure of children's and cancer 
hospitals. We invite comments on our proposal to use the proposed FY 
2002 IPPS operating market basket to update the target amounts for 
children's and cancer hospitals reimbursed under sections 1886(b)(3)(A) 
and (b)(3)(E) of the Act and the market basket for RNHCIs under Sec.  
403.752(a) of the regulations.
    Chart 5 shows the historical and forecasted updates under both the 
proposed FY 2002-based IPPS operating market basket and the proposed FY 
2002-based excluded hospital market basket. The forecasts are based on 
Global Insight, Inc. 4th quarter, 2004 forecast with historical data 
through the 3rd quarter of 2004. Global Insight, Inc. is a nationally 
recognized economic and financial forecasting firm that contracts with 
CMS to forecast the components of the market baskets.
[GRAPHIC] [TIFF OMITTED] TP04MY05.037

2. Excluded Hospitals Paid Under a Blend Methodology
    As we discuss in greater detail in Appendix B to this proposed 
rule, in the past, hospitals and hospital units excluded from the IPPS 
have been paid based on their reasonable costs, subject to TEFRA 
limits. However, some of these categories of excluded hospitals and 
hospital units are now paid under their own PPSs. Specifically, some 
LTCHs and most IPFs are or will be transitioning from reasonable cost-
based payments (subject to the TEFRA limits) to prospective payments 
under their respective PPSs. Under the respective transition period 
methodologies for the LTCH PPS and the IPF PPS, which are described 
below, payment is based, in part, on a decreasing percentage of the 
reasonable cost-based payment amount, which is subject to the TEFRA 
limits and an increasing percentage of the Federal prospective payment 
rate. For those LTCHs and IPFs whose PPS payment is comprised in part 
of a reasonable cost-based payment will have those reasonable cost-
based payment amounts limited by the hospital's TEFRA ceiling.
    Effective for cost reporting periods beginning on or after October 
1, 2002, LTCHs are paid under the LTCH PPS,

[[Page 23396]]

which was implemented with a 5-year transition period, transitioning 
existing LTCHs to a payment based on the fully Federal prospective 
payment rate (August 30, 2002; 67 FR 55954). However, a LTCH may elect 
to be paid at 100 percent of the Federal prospective rate at the start 
of any of its cost reporting periods during the 5-year transition 
period. A ``new'' LTCH, as defined in Sec.  412.23(e)(4), are paid 
based on 100 percent of the standard Federal rate. Effective for cost 
reporting periods beginning on or after January 1, 2005, IPFs are paid 
under the IPF PPS under which they receive payment based on a 
prospectively determined Federal per diem rate that is based on the sum 
of the average routine operating, ancillary, and capital costs for each 
patient day of psychiatric care in an IPF, adjusted for budget 
neutrality. During a 3-year transition period, existing IPFs are paid 
based on a blend of the reasonable cost-based payments and the Federal 
prospective per diem base rate. For cost reporting periods beginning on 
or after January 1, 2008, existing IPFs are to be paid based on 100 
percent of the Federal per diem rate. A ``new'' IPF, as defined in 
Sec.  412.426(c), are paid based on 100 percent of the Federal per diem 
payment amount. Any LTCHs or IPFs that receive a PPS payment that 
includes a reasonable cost-based payment during its respective 
transition period will have that portion of its payment subject to the 
TEFRA limits.
    Under the broad authority of section 1886(b)(3)(A) and (b)(3)(B) of 
the Act, for LTCHs and IPFs that are transitioning to the fully Federal 
prospective payment rate, we are proposing to use the rebased FY 2002 
based-excluded hospital market basket to update the reasonable cost-
based portion of their payments. The proposed market basket update is 
described in detail below. We do not believe the IPPS operating market 
basket should be used for the proposed update to the reasonable cost-
based portion of the payments to LTCHs or IPFs because this market 
basket does not reflect the cost structure of LTCHs and IPFs.
3. Development of Cost Categories and Weights for the Proposed FY 2002-
Based Excluded Hospital Market Basket
a. Medicare Cost Reports
    The major source of expenditure data for developing the proposed 
rebased and revised excluded hospital market basket cost weights is the 
FY 2002 Medicare cost reports. We choose FY 2002 as the base year 
because we believe this is the most recent, relatively complete year 
(with a 90-percent reporting rate) of Medicare cost report data. These 
cost reports are from rehabilitation, psychiatric, long-term care, 
children's, cancer, and religious nonmedical excluded hospitals. They 
do not reflect data from IPPS hospitals or CAHs. These are the same 
hospitals included in the FY 1997-based excluded hospital market 
basket, except for religious nonmedical hospitals. Due to insufficient 
Medicare cost report data for these excluded hospitals, their cost 
reports yield only four major expenditure or cost categories: Wages and 
salaries, pharmaceuticals, professional liability insurance 
(malpractice), and a residual ``all other.''
    Since the cost weights for the FY 2002-based excluded hospital 
market basket are based on facility costs, we are proposing to use 
those cost reports for IRFs, LTCHs, and children's, cancer, and RNHCIs 
whose Medicare average length of stay is within 15 percent (that is, 15 
percent higher or lower) of the total facility average length of stay 
for the hospital. We are proposing to use a less stringent edit for 
Medicare length of stay for IPFs, requiring the average length of stay 
to be within 30 or 50 percent (depending on the total facility average 
length of stay) of the total facility length of stay. This allows us to 
increase our sample size by over 150 reports and produce a cost weight 
more consistent with the overall facility. The edit we applied to IPFs 
when developing the FY 1997-based excluded hospital market basket was 
based on the best available data at the time.
    We believe that limiting our sample to hospitals with a Medicare 
average length of stay within a comparable range of the total facility 
average length of stay provides a more accurate reflection of the 
structure of costs for Medicare treatments. Our method results in 
including in our data set hospitals with a share of Medicare patient 
days relative to total patient days that was approximately three times 
greater than for those hospitals excluded from our sample. Our goal is 
to measure cost shares that are reflective of case-mix and practice 
patterns associated with providing services to Medicare beneficiaries.
    Cost weights for benefits, contract labor and blood and blood 
products were derived using the proposed FY 2002-based IPPS market 
basket. This is necessary because these data are poorly reported in the 
cost reports for non-IPPS hospitals. For example, the ratio of the 
benefit cost weight to the wages and salaries cost weight was applied 
to the proposed excluded hospital wages and salaries cost weight to 
derive a benefit cost weight for the proposed excluded hospital market 
basket.
[GRAPHIC] [TIFF OMITTED] TP04MY05.038


[[Page 23397]]


b. Other Data Sources
    In addition to the Medicare cost reports, the other source of data 
used in developing the excluded hospital market basket weights is the 
Benchmark Input-Output Tables (I-Os) created by the Bureau of Economic 
Analysis, U.S. Department of Commerce.
    New data for this source are scheduled for publication every 5 
years, but often take up to 7 years after the reference year. Only an 
Annual I-O is produced each year, but the Annual I-O contains less 
industry detail than does the Benchmark I-O. When we rebased the 
excluded hospital market basket using FY 1997 data in the FY 2003 IPPS 
final rule, the 1997 Benchmark I-O was not yet available. Therefore, we 
did not incorporate data from that source into the FY 1997-based 
excluded hospital market basket (67 FR 50033). However, we did use a 
secondary source the 1997 Annual Input-Output tables. The third source 
of data, the 1997 Business Expenditure Survey (now known as the 
Business Expenses Survey), was used to develop weights for the 
utilities and telephone services categories.
    The 1997 Benchmark I-O data are a much more comprehensive and 
complete set of data than the 1997 Annual I-O estimates. The 1997 
Annual I-O is an update of the 1992 I-O tables, while the 1997 
Benchmark I-O is an entirely new set of numbers derived from the 1997 
Economic Census. The 2002 Benchmark Input-Output tables are not yet 
available. Therefore, we are proposing to use the 1997 Benchmark I-O 
data in the proposed FY 2002-based excluded hospital market basket, to 
be effective for FY 2006. Instead of using the less detailed, less 
accurate Annual I-O data, we aged the 1997 Benchmark I-O data forward 
to FY 2002. The methodology we used to age the data involves applying 
the annual price changes from the price proxies to the appropriate cost 
categories. We repeat this practice for each year.
    The ``all other'' cost category is further divided into other 
hospital expenditure category shares using the 1997 Benchmark Input-
Output tables. Therefore, the ``all other'' cost category expenditure 
shares are proportional to their relationship to ``all other'' totals 
in the I-O tables. For instance, if the cost for telephone services 
were to represent 10 percent of the sum of the ``all other'' I-O (see 
below) hospital expenditures, then telephone services would represent 
10 percent of the market basket's ``all other'' cost category. The 
remaining detailed cost categories under the residual ``all other'' 
cost category were derived using the 1997 Benchmark Input-Output Tables 
aged to FY 2002 using relative price changes.
4. Proposed 2002-Based Excluded Hospital Market Basket--Selection of 
Price Proxies
    After computing the FY 2002 cost weights for the proposed rebased 
excluded hospital market basket, it is necessary to select appropriate 
wage and price proxies to reflect the rate-of-price change for each 
expenditure category. With the exception of the Professional Liability 
proxy, all the indicators are based on Bureau of Labor Statistics (BLS) 
data and are grouped into one of the following BLS categories:
     Producer Price Indexes--Producer Price Indexes (PPIs) 
measure price changes for goods sold in other than retail markets. PPIs 
are preferable price proxies for goods that hospitals purchase as 
inputs in producing their outputs because the PPIs would better reflect 
the prices faced by hospitals. For example, we use a special PPI for 
prescription drugs, rather than the Consumer Price Index (CPI) for 
prescription drugs because hospitals generally purchase drugs directly 
from the wholesaler. The PPIs that we use measure price change at the 
final stage of production.
     Consumer Price Indexes--Consumer Price Indexes (CPIs) 
measure change in the prices of final goods and services bought by the 
typical consumer. Because they may not represent the price faced by a 
producer, we used CPIs only if an appropriate PPI was not available, or 
if the expenditures were more similar to those of retail consumers in 
general rather than purchases at the wholesale level. For example, the 
CPI for food purchased away from home is used as a proxy for contracted 
food services.
     Employment Cost Indexes--Employment Cost Indexes (ECIs) 
measure the rate of change in employee wage rates and employer costs 
for employee benefits per hour worked. These indexes are fixed-weight 
indexes and strictly measure the change in wage rates and employee 
benefits per hour. Appropriately, they are not affected by shifts in 
employment mix.
    We evaluated the price proxies using the criteria of reliability, 
timeliness, availability, and relevance. Reliability indicates that the 
index is based on valid statistical methods and has low sampling 
variability. Timeliness implies that the proxy is published regularly, 
at least once a quarter. Availability means that the proxy is publicly 
available. Finally, relevance means that the proxy is applicable and 
representative of the cost category weight to which it is applied. The 
CPIs, PPIs, and ECIs selected meet these criteria and, therefore, we 
believe they continue to be the best measure of price changes for the 
cost categories to which they are applied.
    Chart 7 sets forth the complete proposed FY 2002-based excluded 
hospital market basket including cost categories, weights, and price 
proxies. For comparison purposes, the corresponding FY 1997-based 
excluded hospital market basket is listed as well. A summary outlining 
the choice of the various proxies follows the charts.
BILLING CODE 4120-01-P

[[Page 23398]]

[GRAPHIC] [TIFF OMITTED] TP04MY05.039


[[Page 23399]]


[GRAPHIC] [TIFF OMITTED] TP04MY05.040

BILLING CODE 4120-01-C
a. Wages and Salaries
    For measuring the price growth of wages in the proposed FY 2002-
based excluded hospital market basket, we are proposing to use the ECI 
for wages and salaries for civilian hospital workers as the proxy for 
wages. This same proxy was used for the FY 1997-based excluded hospital 
market basket.
b. Employee Benefits
    The proposed FY 2002-based excluded hospital market basket uses the 
ECI for employee benefits for civilian hospital workers. This is the 
same proxy that was used in the FY 1997-based excluded hospital market 
basket.
c. Nonmedical Professional Fees
    The ECI for compensation for professional and technical workers in 
private industry is applied to this category because it includes 
occupations such as management and consulting, legal, accounting and 
engineering services. The same proxy was used in the FY 1997-based 
excluded hospital market basket.

[[Page 23400]]

d. Fuel, Oil, and Gasoline
    The percentage change in the price of gas fuels as measured by the 
PPI (Commodity Code 0552) is applied to this component. The 
same proxy was used in the FY 1997-based excluded hospital market 
basket.
e. Electricity
    The percentage change in the price of commercial electric power as 
measured by the PPI (Commodity Code 0542) is applied to this 
component. The same proxy was used in the FY 1997-based excluded 
hospital market basket.
f. Water and Sewerage
    The percentage change in the price of water and sewerage 
maintenance as measured by the CPI for all urban consumers (CPI Code 
 CUUR0000SEHG01) is applied to this component. The same proxy 
was used in the FY 1997-based excluded hospital market basket.
g. Professional Liability Insurance
    The proposed FY 2002-based excluded hospital market basket uses the 
percentage change in the hospital professional liability insurance 
(PLI) premiums as estimated by the CMS Hospital Professional Liability 
Index for the proxy of this category. Similar to the Physicians 
Professional Liability Index, we attempt to collect commercial 
insurance premiums for a fixed level of coverage, holding nonprice 
factors constant (such as a change in the level of coverage). In the FY 
1997-based excluded hospital market basket, the same price proxy was 
used.
    We continue to research options for improving our proxy for 
professional liability insurance. This research includes exploring 
various options for expanding our current survey, including the 
identification of another entity that would be willing to work with us 
to collect more complete and comprehensive data. We are also exploring 
other options such as third party or industry data that might assist us 
in creating a more precise measure of PLI premiums. At this time, we 
have not yet identified a preferred option. Therefore, we are not 
proposing to make any changes to the proxy in this proposed rule.
h. Pharmaceuticals
    The percentage change in the price of prescription drugs as 
measured by the PPI (PPI Code PPI283DRX) is used as a 
proxy for this category. This is a special index produced by BLS and is 
the same proxy used in the FY 1997-based excluded hospital market 
basket.
i. Food: Direct Purchases
    The percentage change in the price of processed foods and feeds as 
measured by the PPI (Commodity Code 02) is applied to this 
component. The same proxy was used in the FY 1997-based excluded 
hospital market basket.
j. Food: Contract Services
    The percentage change in the price of food purchased away from home 
as measured by the CPI for all urban consumers (CPI Code  
CUUR0000SEFV) is applied to this component. The same proxy was used in 
the FY 1997-based excluded hospital market basket.
k. Chemicals
    The percentage change in the price of industrial chemical products 
as measured by the PPI (Commodity Code 061) is applied to this 
component. While the chemicals hospitals purchase include industrial as 
well as other types of chemicals, the industrial chemicals component 
constitutes the largest proportion by far. Thus, we believe that 
Commodity Code 061 is the appropriate proxy. The same proxy 
was used in the FY 1997-based excluded hospital market basket.
l. Medical Instruments
    The percentage change in the price of medical and surgical 
instruments as measured by the PPI (Commodity Code 1562) is 
applied to this component. The same proxy was used in the FY 1997-based 
excluded hospital market basket.
m. Photographic Supplies
    The percentage change in the price of photographic supplies as 
measured by the PPI (Commodity Code 1542) is applied to this 
component. The same proxy was used in the FY 1997-based excluded 
hospital market basket.
n. Rubber and Plastics
    The percentage change in the price of rubber and plastic products 
as measured by the PPI (Commodity Code 07) is applied to this 
component. The same proxy was used in the FY 1997-based excluded 
hospital market basket.
o. Paper Products
    The percentage change in the price of converted paper and 
paperboard products as measured by the PPI (Commodity Code 
0915) is used. The same proxy was used in the FY 1997-based 
excluded hospital market basket.
p. Apparel
    The percentage change in the price of apparel as measured by the 
PPI (Commodity Code 381) is applied to this component. The 
same proxy was used in the FY 1997-based excluded hospital market 
basket.
q. Machinery and Equipment
    The percentage change in the price of machinery and equipment as 
measured by the PPI (Commodity Code 11) is applied to this 
component. The same proxy was used in the FY 1997-based excluded 
hospital market basket.
r. Miscellaneous Products
    The percentage change in the price of all finished goods less food 
and energy as measured by the PPI (Commodity Code SOP3500) is 
applied to this component. Using this index removes the double-counting 
of food and energy prices, which are already captured elsewhere in the 
market basket. The same proxy was used in the FY 1997-based excluded 
hospital market basket. The weight for this cost category is higher 
than in the FY 1997-based index because it also includes blood and 
blood products. In the FY 1997-based excluded hospital market basket, 
we included a separate cost category for blood and blood products, 
using the BLS PPI (Commodity Code 063711) for blood and 
derivatives as a price proxy. A review of recent trends in the PPI for 
blood and derivatives suggests that its movements may not be consistent 
with the trends in blood costs faced by hospitals. While this proxy did 
not match exactly with the product hospitals are buying, its trend over 
time appears to be reflective of the historical price changes of blood 
purchased by hospitals. However, an apparent divergence over recent 
periods led us to reevaluate whether the PPI for blood and derivatives 
was an appropriate measure of the changing price of blood. We ran test 
market baskets classifying blood in three separate cost categories: 
blood and blood products, contained within chemicals as was done for 
the FY 1992-based index, and within miscellaneous products. These 
categories use as proxies the following PPIs: the PPI for blood and 
blood products, the PPI for chemicals, and the PPI for finished goods 
less food and energy, respectively. Of these three proxies, the PPI for 
finished goods less food and energy moved most like the recent blood 
cost and price trends. In addition, the impact on the overall market 
basket by using different proxies for blood was negligible, mostly due 
to the relatively small weight for blood in the market basket. 
Therefore, we chose the PPI for finished goods less food and energy for 
the blood proxy because we believe it will best be able to proxy price

[[Page 23401]]

changes (not quantities or required tests) associated with blood 
purchased by hospitals. We will continue to evaluate this proxy for its 
appropriateness and will explore the development of alternative price 
indexes to proxy the price changes associated with this cost.
s. Telephone
    The percentage change in the price of telephone services as 
measured by the CPI for all urban consumers (CPI Code 
CUUR0000SEED) is applied to this component. The same proxy was 
used in the FY 1997-based excluded hospital market basket.
t. Postage
    The percentage change in the price of postage as measured by the 
CPI for all urban consumers (CPI Code CUUR0000SEEC01) is 
applied to this component. The same proxy was used in the FY 1997-based 
excluded hospital market basket.
u. All Other Services: Labor Intensive
    The percentage change in the ECI for compensation paid to service 
workers employed in private industry is applied to this component. The 
same proxy was used in the FY 1997-based excluded hospital market 
basket.
v. All Other Services: Nonlabor Intensive
    The percentage change in the all-items component of the CPI for all 
urban consumers (CPI Code CUUR0000SA0) is applied to this 
component. The same proxy was used in the FY 1997-based excluded 
hospital market basket.
    For further discussion of the rationale for choosing many of the 
specific price proxies, we refer the reader to the August 1, 2002 final 
rule (67 FR 50037).
[GRAPHIC] [TIFF OMITTED] TP04MY05.041

D. Frequency of Updates of Weights in IPPS Hospital Market Basket

    Section 404 of Pub. L. 108-173 (MMA) requires CMS to report in this 
proposed rule the research that has been done to determine a new 
frequency for rebasing the hospital market basket. Specifically, 
section 404 states:
    ``(a) More frequent updates in weights. After revising the weights 
used in the hospital market basket under section 1886(b)(3)(B)(iii) of 
the Social Security Act (42 U.S.C. 1395ww(b)(3)(B)(iii)) to reflect the 
most current data available, the Secretary shall establish a frequency 
for revising such weights, including the labor share, in such market 
basket to reflect the most current data available more frequently than 
once every 5 years; and
    ``(b) Incorporation of explanation in rulemaking. The Secretary 
shall include in the publication of the final rule for payment for 
inpatient hospitals services under section 1886(d) of the Social 
Security Act (42 U.S.C. 1395ww(d)) for fiscal year 2006, an explanation 
of the reasons for, and options considered, in determining the 
frequency established under subsection (a).''
    This section of the proposed rule discusses the research we have 
done to fulfill this requirement, and proposes a rebasing frequency 
that makes optimal use of available data.
    Our past practice has been to monitor the appropriateness of the 
market basket on a consistent basis in order to rebase and revise the 
index when necessary. The decision to rebase and revise the index has 
been driven in large part by the availability of the data necessary to 
produce a complete index. In the past, we have supplemented the 
Medicare cost report data that are available on an annual basis with 
Bureau of the Census hospital expense data that are typically available 
only every 5 years (usually in years ending in 2 and 7). Because of 
this, we have generally rebased the index every 5 years. However, prior 
to the requirement associated with section 404 of Pub. L. 108-173, 
there was no legislative requirement regarding the timing of rebasing 
the hospital market basket nor was there a hard rule that we

[[Page 23402]]

used in determining this frequency. ProPAC, one of MedPAC's predecessor 
organizations, did a report to the Secretary on April 1, 1985, that 
supported periodic rebasing at least every 5 years.
    The most recent rebasing of the hospital market basket was just 3 
years ago, for the FY 2003 update. Since its inception with the 
hospital PPS in FY 1984, the hospital market basket has been rebased 
several times (FY 1987 update, FY 1991 update, FY 1997 update, FY 1998 
update, and FY 2003 update). One of the reasons we believe it 
appropriate to rebase the index on a periodic basis is that rebasing 
(as opposed to revising, as explained in section IV.A. of this 
preamble) tends to have only a minor impact on the actual percentage 
increase applied to the PPS update. There are two major reasons for 
this: (1) The cost category weights tend to be relatively stable over 
shorter term periods (3 to 5 years); and (2) the update is based on a 
forecast, which means the individual price series tend not to grow as 
differently as they have in some historical periods.
    We focused our research in two major areas. First, we reviewed the 
frequency and availability of the data needed to produce the market 
basket. Second, we analyzed the impact on the market basket of 
determining the market basket weights under various frequencies. We did 
this by developing market baskets that had base years for every year 
between 1997 and 2002, and then analyzed how different the market 
basket percent changes were over various periods. We used the results 
from these areas of research to assist in our determination of a new 
rebasing frequency. Based on this analysis, we are proposing to rebase 
the hospital market basket every 4 years. This would mean the next 
rebasing would occur for the FY 2010 update.
    As we have described in numerous Federal Register documents over 
the past few decades, the hospital market basket weights are the 
compilation of data from more than one data source. When we are 
discussing rebasing the weights in the hospital market basket, there 
are two major data sources: (1) The Medicare cost reports; and (2) 
expense surveys from the Bureau of the Census (the Economic Census is 
used to develop data for the Bureau of Economic Analysis' input-output 
series). We will explore the future availability of each of these data 
sources.
    Each Medicare-participating hospital submits a Medicare cost report 
to CMS on an annual basis. It takes roughly 2 years before ``nearly 
complete'' Medicare cost report data are available. For example, 
approximately 90 percent of FY 2002 Medicare cost report data were 
available in October 2004 (only 50 percent of FY 2003 data was 
available), although only 20 percent of these reports were settled. We 
choose FY 2002 as the base year because we believe this is the most 
recent, relatively complete year (with a 90 percent reporting rate) of 
Medicare cost report data. In developing the hospital market basket 
weights, we have used the Medicare cost reports to determine the 
weights for six major cost categories (wages, benefits, contract labor, 
pharmaceuticals, professional liability, and blood). In FY 2002, these 
six categories accounted for 68.5 percent of the hospital market 
basket. Therefore, it is possible to develop a new set of market basket 
weights for these categories on an annual basis, but with a substantial 
lag (for the FY 2006 update, we consider the latest year of historical 
data to be FY 2002).
    The second source of data is the U.S. Department of Commerce, 
Bureau of Economic Analysis' Benchmark Input-Output (I-O) table. These 
data are published every 5 years with a more significant lag than the 
Medicare cost reports. For example, the 1997 Benchmark I-O tables were 
not published until the beginning of 2003. We have sometimes used data 
from a third data source, the Bureau of the Census' Business Expenses 
Survey (BES), which is also published every 5 years. The BES data are 
used as an input into the I-O data, and thus are published a few months 
prior to the release of the I-O. However, the BES contains only a 
fraction of the detail contained in the I-O.
    Chart 9 below takes into consideration the expected availability of 
these major data sources and summarizes how they could be incorporated 
into the development of future market basket weights.

[[Page 23403]]

[GRAPHIC] [TIFF OMITTED] TP04MY05.042

    It would be necessary to age the I-O or BES data to the year for 
which cost report data are available using the price changes between 
those periods. While not a preferred method in developing the market 
basket weights, we have done this in the past when rebasing the index. 
We are proposing to age the 1997 Benchmark I-O data for this proposed 
rule.
    As the table clearly indicates, the most optimal rebasing frequency 
from a data availability standpoint is every 5 years. That is, if we 
were to next rebase for the FY 2011 update, we could use the 2002 
Benchmark I-O data that would recently be available. In order to match 
the Medicare cost report data that would be available at that time (FY 
2007 data), we would have to age the I-O data to FY 2007. However, this 
would be aging the data only 5 years, whereas if the rebasing frequency 
was determined to be every 4 years, we would have to age 1997 I-O data 
to FY 2006. While aging data over 5 years is problematic (there can be 
significant utilization and intensity changes over that length period, 
as opposed to only a year or two), it would be significantly worse to 
age data over an 8-year or 9-year period. If we were on a 5-year 
rebasing frequency, for the FY 2016 update, we would use cost report 
data for FY 2012 and the newly available 2007 I-O data. Again, the I-O 
data would have to be aged only 5 years to match the cost report data.
    We can look at the implications of determining a rebasing frequency 
of every 3 or 4 years. Considering a frequency of 3 years first, we 
would next rebase for the FY 2009 update using FY 2005 Medicare cost 
report data and 1997 I-O data (the same data currently being used in 
the proposed FY 2002-based market basket). This is problematic because 
the 1997 I-O data would need to be aged 8 years to match the cost 
report data. The next two rebasings would be for the FY 2012 update 
(using FY 2008 cost report data and 2002 I-O data) and FY 2015 (using 
FY 2011 cost report data and 2002 I-O data). This means that while we 
are making optimal use of the Medicare cost report data, we would be 
forced to use the same I-O data in consecutive rebasings and would have 
to age that data as much as 9 years to use the same year as the cost 
report data.
    For a rebasing frequency of every 4 years, our next rebasing would 
be for the FY 2010 update using FY 2006 Medicare cost report data and 
1997 I-O data. This is also problematic because the 1997 I-O data would 
need to be aged 9 years to match the cost report data. The next two 
rebasings would be for the FY 2014 update (using FY 2010 cost report 
data and 2002 I-O data) and FY 2018 (using FY 2014 cost report data and 
2007 I-O data). Again, this frequency would make optimal use of the 
Medicare cost report data but would require aging of the I-O data 
between 7 and 9 years in order to match the cost report data.

[[Page 23404]]

    It is clear from this analysis that neither the 3-year nor 4-year 
rebasing frequencies makes as good use of all the data as rebasing 
every 5 years. In addition, when comparing the 3-year and 4-year 
rebasing frequencies, no one method stands out as being significantly 
improved over another. Thus, this analysis does not lead us to draw any 
definitive conclusions as to a rebasing frequency more appropriate than 
every 5 years.
    Our second area of research in determining a new rebasing frequency 
was to analyze the impact on the market basket of determining the 
market basket weights under various frequencies. We did this by using 
the current historical data that are available (both Medicare cost 
report and I-O) to develop market baskets with base year weights for 
each year between FY 1997 and FY 2002. We then analyzed how differently 
the market baskets moved over various historical periods.
    Approaching the analysis this way allowed us to develop six 
hypothetical market baskets with different base years (FY 1997, FY 
1998, FY 1999, FY 2000, FY 2001, and FY 2002). As we have done when 
developing the official market baskets, we used Medicare cost report 
data where available. Thus, cost report data were used to determine the 
weights for wages and salaries, benefits, contract labor, 
pharmaceuticals, blood and blood products, and all other costs. We used 
the 1997 Benchmark I-O data to fill out the remainder of the market 
basket weights (note that this produces a different index for FY 1997 
than the official FY 1997-based hospital market basket that used the 
Annual 1997 I-O data), aging the data to the appropriate year to match 
the cost report data. This means the FY 2002-based index used in this 
analysis matches the FY 2002-based market basket we are proposing in 
this rule. Chart 10 shows the weights from these hypothetical market 
baskets:

[[Page 23405]]

[GRAPHIC] [TIFF OMITTED] TP04MY05.043

    Note that the weights remain relatively stable between periods. It 
is for this reason that we believe defining the market basket as a 
Laspeyres-type, fixed-weight index is appropriate. Because the weights 
in the market basket are generally for aggregated costs (for example, 
wages and salaries for all employees), there is not much volatility in 
the weights between periods, especially over shorter time spans. As the 
results of this analysis will show, it is for this reason that rebasing 
the market basket more frequently than every 5 years is expected to 
have little impact on the overall percent change in the hospital market 
basket.
    Using these hypothetical market baskets, we can produce market 
basket percent changes over historical periods to determine what is the 
impact of using various base periods. In our analysis, we consider the 
hypothetical FY 1997-based index to be the benchmark measure and the 
other indexes to indicate the impact of rebasing over various 
frequencies. The hypothetical FY 2000-based index would reflect the 
impact of rebasing every 3 years, the hypothetical FY 2001-based index 
would reflect the impact of rebasing every 4 years, and the 
hypothetical FY 2002-based index would reflect the

[[Page 23406]]

impact of rebasing every 5 years. Chart 11 shows the results of these 
comparisons.
[GRAPHIC] [TIFF OMITTED] TP04MY05.044

    It is clear from this comparison that there is little difference 
between the indexes, and, for some FYs, there would be no difference in 
the market basket update factor if we had rebased the market basket 
more frequently. In particular, there is no difference in the 
hypothetical indexes based between FY 2000 and FY 2002. This suggests 
that setting the rebasing frequency to 3, 4, or 5 years will have 
little or no impact on the resulting market basket. As we found when 
analyzing data availability, this portion of our research does not 
suggest that rebasing the market basket more frequently than every 5 
years results in an improved market basket or that there is any 
noticeable difference between rebasing every 3 or 4 years.
    Market basket rebasing is a 1-year to 2-year long process that 
includes data processing, analytical work, methodology reevaluation, 
and regulatory process. After developing a rebased and revised market 
basket, there are extensive internal review processes that a rule must 
undergo, both in proposed and final form. Once the proposed rule has 
been published, there is a 60-day comment period set aside for the 
public to respond to the proposed rule. After comments are received, we 
then need adequate time to research and reply to all comments 
submitted. The last part of the regulatory process is the 60-day 
requirement--the final rule must be published 60 days before the 
provisions of the rule can become effective.
    We would like to rebase all of our indexes (PPS operating, PPS 
capital, excluded hospital with capital, SNFs, HHAs, and Medicare 
Economic Index) on a regular schedule. Therefore, if we were to choose 
a 3-year rebasing schedule, we would have to rebase more than one index 
at a time. This may potentially limit the amount of time we could 
devote to the market basket rebasing process. In addition, we recognize 
that, in the future, we may be required to develop additional market 
baskets that would require frequent rebasing.
    Given the number of market baskets we are responsible for rebasing 
and revising, the regulatory process for each, and the availability of 
source data, we believe that while it is not necessary, rebasing and 
revising the hospital market baskets every 4 years is the most 
appropriate frequency to meet the legislative requirement.

E. Capital Input Price Index Section

    The Capital Input Price Index (CIPI) was originally described in 
the September 1, 1992 Federal Register (57 FR 40016). There have been 
subsequent discussions of the CIPI presented in the May 26, 1993 (58 FR 
30448), September 1, 1993 (58 FR 46490), May 27, 1994 (59 FR 27876), 
September 1, 1994 (59 FR 45517), June 2, 1995 (60 FR 29229), September 
1, 1995 (60 FR 45815), May 31, 1996 (61 FR 27466), and August 30, 1996 
(61 FR 46196) issues of the Federal Register. The August 1, 2002 (67 FR 
50032) rule discussed the most recent revision and rebasing of the CIPI 
to a FY 1997 base year, which reflects the capital cost structure 
facing hospitals in that year.
    We are proposing to revise and rebase the CIPI to a FY 2002 base 
year to reflect the more recent structure of capital costs in 
hospitals. Unlike the PPS operating market basket, we do not have FY 
2002 Medicare cost report data available for the development of the 
capital cost weights, due to a change in the FY 2002 cost reporting 
requirements. Rather, we used hospital capital expenditure data for the 
capital cost categories of depreciation, interest, and other capital 
expenses for FY 2001 and aged these data to a FY 2002 base year using 
the relevant vintage-weighted price proxies. As with the FY 1997-based 
index, we have developed two sets of weights in order to calculate the 
proposed FY 2002-based CIPI. The first set of proposed weights 
identifies the proportion of hospital capital expenditures attributable 
to each expenditure category, while the second set of proposed weights 
is a set of relative vintage weights for depreciation

[[Page 23407]]

and interest. The set of vintage weights is used to identify the 
proportion of capital expenditures within a cost category that is 
attributable to each year over the useful life of the capital assets in 
that category. A more thorough discussion of vintage weights is 
provided later in this section.
    Both sets of proposed weights are developed using the best data 
sources available. In reviewing source data, we determined that the 
Medicare cost reports provided accurate data for all capital 
expenditure cost categories. We are proposing to use the FY 2001 
Medicare cost reports for PPS hospitals, aged to FY 2002, excluding 
expenses from hospital-based subproviders, to determine weights for all 
three cost categories: depreciation, interest, and other capital 
expenses. We compared the weights determined from the Medicare cost 
reports to the 2002 Bureau of the Census' Business Expenses Survey and 
found the weights to be similar to those developed from the Medicare 
cost reports.
    Lease expenses are not broken out as a separate cost category in 
the CIPI, but are distributed among the cost categories of 
depreciation, interest, and other, reflecting the assumption that the 
underlying cost structure of leases is similar to capital costs in 
general. As was done in previous rebasings of the CIPI, we assumed 10 
percent of lease expenses are overhead and assigned them to the other 
capital expenses cost category as overhead. The remaining lease 
expenses were distributed to the three cost categories based on the 
proportion of depreciation, interest, and other capital expenses to 
total capital costs excluding lease expenses.
    Depreciation contains two subcategories: building and fixed 
equipment and movable equipment. The split between building and fixed 
equipment and movable equipment was determined using the Medicare cost 
reports. This methodology was also used to compute the FY 1997-based 
index.
    Total interest expense cost category is split between government/
nonprofit and profit interest. The FY 1997-based CIPI allocated 85 
percent of the total interest cost weight to government/nonprofit 
interest, proxied by average yield on domestic municipal bonds, and 15 
percent to for-profit interest, proxied by average yield on Moody's Aaa 
bonds (67 FR 50044). The methodology used to derive this split is 
explained in the June 2, 1995 issue of the Federal Register (60 FR 
29233). We are proposing to derive the split using the relative FY 2001 
Medicare cost report data on interest expenses for government/nonprofit 
and profit hospitals. Based on these data, we are proposing a 75/25 
split between government/nonprofit and profit interest. We believe it 
is important that this split reflects the latest relative cost 
structure of interest expenses. The proposed split of 75/25 had little 
(less than 0.1 percent in any given year) or no effect on the annual 
capital market basket percent change in both the historical and 
forecasted periods.
    Chart 12 presents a comparison of the proposed FY 2002-based CIPI 
capital cost weights and the FY 1997-based CIPI capital cost weights.
[GRAPHIC] [TIFF OMITTED] TP04MY05.045


[[Page 23408]]


    Because capital is acquired and paid for over time, capital 
expenses in any given year are determined by both past and present 
purchases of physical and financial capital. The vintage-weighted CIPI 
is intended to capture the long-term consumption of capital, using 
vintage weights for depreciation (physical capital) and interest 
(financial capital). These vintage weights reflect the proportion of 
capital purchases attributable to each year of the expected life of 
building and fixed equipment, movable equipment, and interest. We used 
the vintage weights to compute vintage-weighted price changes 
associated with depreciation and interest expense.
    Vintage weights are an integral part of the CIPI. Capital costs are 
inherently complicated and are determined by complex capital purchasing 
decisions, over time, based on such factors as interest rates and debt 
financing. In addition, capital is depreciated over time instead of 
being consumed in the same period it is purchased. The CIPI accurately 
reflects the annual price changes associated with capital costs, and is 
a useful simplification of the actual capital investment process. By 
accounting for the vintage nature of capital, we are able to provide an 
accurate, stable annual measure of price changes. Annual nonvintage 
price changes for capital are unstable due to the volatility of 
interest rate changes and, therefore, do not reflect the actual annual 
price changes for Medicare capital-related costs. CMS' CIPI reflects 
the underlying stability of the capital acquisition process and 
provides hospitals with the ability to plan for changes in capital 
payments.
    To calculate the vintage weights for depreciation and interest 
expenses, we needed a time series of capital purchases for building and 
fixed equipment and movable equipment. We found no single source that 
provides the best time series of capital purchases by hospitals for all 
of the above components of capital purchases. The early Medicare cost 
reports did not have sufficient capital data to meet this need. While 
the AHA Panel Survey provided a consistent database back to 1963, it 
did not provide annual capital purchases. The AHA Panel Survey provided 
a time series of depreciation expenses through 1997 which could be used 
to infer capital purchases over time. From 1998 to 2001, hospital 
depreciation expenses were calculated by multiplying the AHA Annual 
Survey total hospital expenses by the ratio of depreciation to total 
hospital expenses from the Medicare cost reports. Beginning in 2001, 
the AHA Annual Survey began collecting depreciation expenses. We hope 
to be able to use these data in future rebasings.
    In order to estimate capital purchases from AHA data on 
depreciation expenses, the expected life for each cost category 
(building and fixed equipment, movable equipment, and interest) is 
needed to calculate vintage weights. We used FY 2001 Medicare cost 
reports to determine the expected life of building and fixed equipment 
and movable equipment. The expected life of any piece of equipment can 
be determined by dividing the value of the asset (excluding fully 
depreciated assets) by its current year depreciation amount. This 
calculation yields the estimated useful life of an asset if 
depreciation were to continue at current year levels, assuming 
straight-line depreciation. From the FY 2001 cost reports, the expected 
life of building and fixed equipment was determined to be 23 years, and 
the expected life of movable equipment was determined to be 11 years. 
The FY 1997-based CIPI showed the same expected life for the two 
categories of depreciation.
    Although we are proposing to use this methodology for deriving the 
useful life of an asset, we intend to conduct a further review of the 
methodology between the publication of this proposed rule and the final 
rule. We plan to review alternate data sources, if available, and 
analyze in more detail the hospital's capital cost structure reported 
in the Medicare cost reports.
    We are proposing to use the building and fixed equipment and 
movable equipment weights derived from FY 2001 Medicare cost reports to 
separate the depreciation expenses into annual amounts of building and 
fixed equipment depreciation and movable equipment depreciation. Year-
end asset costs for building and fixed equipment and movable equipment 
were determined by multiplying the annual depreciation amounts by the 
expected life calculations from the FY 2001 Medicare cost reports. We 
then calculated a time series back to 1963 of annual capital purchases 
by subtracting the previous year asset costs from the current year 
asset costs. From this capital purchase time series, we were able to 
calculate the vintage weights for building and fixed equipment and 
movable equipment. Each of these sets of vintage weights is explained 
in detail below.
    For building and fixed equipment vintage weights, the real annual 
capital purchase amounts for building and fixed equipment derived from 
the AHA Panel Survey were used. The real annual purchase amount was 
used to capture the actual amount of the physical acquisition, net of 
the effect of price inflation. This real annual purchase amount for 
building and fixed equipment was produced by deflating the nominal 
annual purchase amount by the building and fixed equipment price proxy, 
the Boeckh Institutional Construction Index. Because building and fixed 
equipment have an expected life of 23 years, the vintage weights for 
building and fixed equipment are deemed to represent the average 
purchase pattern of building and fixed equipment over 23-year periods. 
With real building and fixed equipment purchase estimates available 
back to 1963, we averaged sixteen 23-year periods to determine the 
average vintage weights for building and fixed equipment that are 
representative of average building and fixed equipment purchase 
patterns over time. Vintage weights for each 23-year period are 
calculated by dividing the real building and fixed capital purchase 
amount in any given year by the total amount of purchases in the 23-
year period. This calculation is done for each year in the 23-year 
period, and for each of the sixteen 23-year periods. We are proposing 
to use the average of each year across the sixteen 23-year periods to 
determine the 2002 average building and fixed equipment vintage weights 
for the FY 2002-based CIPI.
    For movable equipment vintage weights, the real annual capital 
purchase amounts for movable equipment derived from the AHA Panel 
Survey were used to capture the actual amount of the physical 
acquisition, net of price inflation. This real annual purchase amount 
for movable equipment was calculated by deflating the nominal annual 
purchase amount by the movable equipment price proxy, the PPI for 
Machinery and Equipment. Based on our determination that movable 
equipment has an expected life of 11 years, the vintage weights for 
movable equipment represent the average expenditure for movable 
equipment over an 11-year period. With real movable equipment purchase 
estimates available back to 1963, twenty-eight 11-year periods were 
averaged to determine the average vintage weights for movable equipment 
that are representative of average movable equipment purchase patterns 
over time. Vintage weights for each 11-year period are calculated by 
dividing the real movable capital purchase amount for any given year by 
the total amount of purchases in the 11-year period. This calculation 
was done for each year in the 11-year period, and for

[[Page 23409]]

each of the twenty-eight 11-year periods. We are proposing to use the 
average of each year across the twenty-eight 11-year periods to 
determine the average movable equipment vintage weights for the FY 
2002-based CIPI.
    For interest vintage weights, the nominal annual capital purchase 
amounts for total equipment (building and fixed, and movable) derived 
from the AHA Panel and Annual Surveys were used. Nominal annual 
purchase amounts were used to capture the value of the debt instrument. 
Because we have determined that hospital debt instruments have an 
expected life of 23 years, the vintage weights for interest are deemed 
to represent the average purchase pattern of total equipment over 23-
year periods. With nominal total equipment purchase estimates available 
back to 1963, sixteen 23-year periods were averaged to determine the 
average vintage weights for interest that are representative of average 
capital purchase patterns over time. Vintage weights for each 23-year 
period are calculated by dividing the nominal total capital purchase 
amount for any given year by the total amount of purchases in the 23-
year period. This calculation is done for each year in the 23-year 
period and for each of the sixteen 23-year periods. We are proposing to 
use the average of each year across the sixteen 23-year periods to 
determine the average interest vintage weights for the FY 2002-based 
CIPI. The vintage weights for the FY 1997 CIPI and the proposed FY 2002 
CIPI are presented in Chart 13.
[GRAPHIC] [TIFF OMITTED] TP04MY05.046

    After the capital cost category weights were computed, it was 
necessary to select appropriate price proxies to reflect the rate of 
increase for each expenditure category. Our proposed price proxies for 
the FY 2002-based CIPI are the same as those used in the FY 1997-based 
CIPI. We still believe these are the most appropriate proxies for

[[Page 23410]]

hospital capital costs that meet our selection criteria of relevance, 
timeliness, availability, and reliability. We ran the proposed FY 2002-
based index using the Moody's Aaa bonds average yield and then using 
the Moody's Baa bonds average yield as proxy for the for-profit 
interest cost category. There was no difference in the two sets of 
index percent changes either historically or forecasted. The rationale 
for selecting these price proxies is explained more fully in the August 
30, 1996 final rule (61 FR 46196). The proposed proxies are presented 
in Chart 14.
[GRAPHIC] [TIFF OMITTED] TP04MY05.047

    Global Insight, Inc. forecasts a 0.7 percent increase in the FY 
2002-based CIPI for 2006, as shown in Chart 15. This is the result of a 
1.3 percent increase in projected depreciation prices (building and 
fixed equipment, and movable equipment) and a 2.7 percent increase in 
other capital expense prices, partially offset by a 2.3 percent 
decrease in vintage-weighted interest rates in FY 2006, as indicated in 
Chart 15. Accordingly, we are proposing a 0.7 percent increase in the 
CIPI.

[[Page 23411]]

[GRAPHIC] [TIFF OMITTED] TP04MY05.048

    Rebasing the CIPI from FY 1997 to FY 2002 decreased the percent 
change in the FY 2006 forecast by 0.1 percentage point, from 0.8 to 
0.7, as shown in Chart 12. The difference is caused mostly by changes 
in the relationships between the cost category weights within 
depreciation and interest. The fixed depreciation cost weight relative 
to the movable depreciation cost weight and the nonprofit/government 
interest cost weight relative to the for-profit interest cost weight 
are both less in the FY 2002-based CIPI. The changes in these 
relationships have a small effect on the FY 2002-based CIPI percent 
changes. However, when added together, they are responsible for a 
negative one-tenth percentage point difference between the FY 2002-
based CIPI and the FY 1997-based CIPI.

V. Other Decisions and Proposed Changes to the IPPS for Operating Costs 
and GME Costs

A. Postacute Care Transfer Payment Policy (Sec.  412.4)

    (If you choose to comment on issues in this section, please include 
the caption ``Postacute Care Transfers'' at the beginning of your 
comment.)
1. Background
    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. The purpose of the IPPS transfer 
payment policy is to avoid providing an incentive for a hospital to 
transfer patients to another hospital early in the patients' 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.
    2. Changes to DRGs Subject to the Postacute Care Transfer Policy 
(Sec. Sec.  412.4(c) and (d))
    Section 1886(d)(5)(J) of the Act provides that, effective for 
discharges on or after October 1, 1998, a ``qualified discharge'' from 
one of 10 DRGs selected by the Secretary to a postacute care provider 
would be treated as a transfer case. This section required the 
Secretary to define and pay as transfers all cases assigned to one of 
10 DRGs selected by the Secretary, if the

[[Page 23412]]

individuals are discharged to one of the following postacute care 
settings:
     A hospital or hospital unit that is not a subsection 
1886(d) hospital. (Section 1886(d)(1)(B) of the Act identifies the 
hospitals and hospital units that are excluded from the term 
``subsection (d) hospital'' as psychiatric hospitals and units, 
rehabilitation hospitals and units, children's hospitals, long-term 
care hospitals, and cancer hospitals.)
     A SNF (as defined at section 1819(a) of the Act).
     Home health services provided by a home health agency, if 
the services relate to the condition or diagnosis for which the 
individual received inpatient hospital services, and if the home health 
services are provided within an appropriate period (as determined by 
the Secretary).
    In the July 31, 1998 IPPS final rule (63 FR 40975 through 40976), 
we specified that a patient discharged to home would be considered 
transferred to postacute care if the patient received home health 
services within 3 days after the date of discharge. In addition, in the 
July 31, 1998 final rule, we did not include patients transferred to a 
swing-bed for skilled nursing care in the definition of postacute care 
transfer cases (63 FR 40977).
    Section 1886(d)(5)(J) of the Act directed the Secretary to select 
10 DRGs based upon a high volume of discharges to postacute care and a 
disproportionate use of postacute care services. As discussed in the 
July 31, 1998 final rule, these 10 DRGs were selected in 1998 based on 
the MedPAR data from FY 1996. Using that information, we identified and 
selected the first 20 DRGs that had the largest proportion of 
discharges to postacute care (and at least 14,000 such transfer cases). 
In order to select 10 DRGs from the 20 DRGs on our list, we considered 
the volume and percentage of discharges to postacute care that occurred 
before the mean length of stay and whether the discharges occurring 
early in the stay were more likely to receive postacute care. We 
identified 10 DRGs to be subject to the postacute care transfer rule 
starting in FY 1999.
    Section 1886(d)(5)(J)(iv) of the Act authorizes the Secretary to 
expand the postacute care transfer policy for FY 2001 or subsequent 
fiscal years to additional DRGs based on a high volume of discharges to 
postacute care facilities and a disproportionate use of postacute care 
services. In the FY 2004 IPPS final rule (68 FR 45412), we expanded the 
postacute care transfer policy to include additional DRGs. We 
established the following criteria that a DRG must meet, for both of 
the 2 most recent years for which data are available, in order to be 
included under the postacute care transfer policy:
     At least 14,000 postacute care transfer cases;
     At least 10 percent of its postacute care transfers 
occurring before the geometric mean length of stay;
     A geometric mean length of stay of at least 3 days; and
     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.
    In the FY 2004 IPPS final rule, we identified 21 new DRGs that met 
these criteria. We also determined that one DRG from the original group 
of 10 DRGs (DRG 263) no longer met the volume criterion of 14,000 
transfer cases. Therefore, we removed DRGs 263 and 264 (DRG 264 is 
paired with DRG 263) from the policy and expanded the postacute care 
transfer policy to include payments for transfer cases in the new 21 
DRGs, effective October 1, 2003. As a result, a total of 29 DRGs were 
subject to the postacute care transfer policy in FY 2004. In the FY 
2004 IPPS final rule, we indicated that we would review and update this 
list periodically to assess whether additional DRGs should be added or 
existing DRGs should be removed (68 FR 45413).
    For FY 2005, we analyzed the available data from the FY 2003 MedPAR 
file. For the 2 most recent years of available data (FY 2002 and FY 
2003), we found that no additional DRGs qualified under the four 
criteria set forth in the IPPS final rule for FY 2004. We also analyzed 
the DRGs included under the policy for FY 2004 to determine if they 
still met the criteria to remain under the policy. In addition, we 
analyzed the special circumstances arising from a change to one of the 
DRGs included under the policy in FY 2004.
    In the FY 2005 IPPS final rule (69 FR 48942), we deleted DRG 483 
(Tracheostomy With Mechanical Ventilation 96+ Hours or Principal 
Diagnosis Except Face, Mouth, and Neck Diagnosis) and established the 
following new DRGs as replacements: DRG 541 (Tracheostomy With 
Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, 
Mouth and Neck Diagnoses With Major O.R. Procedure) and DRG 542 
(Tracheostomy with Mechanical Ventilation 96+ Hours or Principal 
Diagnosis Except Face, Mouth and Neck Diagnoses Without Major O.R. 
Procedure). Cases in the existing DRG 483 were assigned to the new DRGs 
541 and 542 based on the presence or absence of a major O.R. procedure, 
in addition to the tracheostomy code that was previously required for 
assignment to DRG 483. Specifically, if the patient's case involves a 
major O.R. procedure (a procedure whose code is included on the list 
that is assigned to DRG 468 (Extensive O.R. Procedure Unrelated to 
Principal Diagnosis), except for tracheostomy codes 31.21 and 31.29), 
the case is assigned to the DRG 541. If the patient does not have an 
additional major O.R. procedure (that is, if there is only a 
tracheostomy code assigned to the case), the case is assigned to DRG 
542.
    Based on data analysis, we determined that neither DRG 541 nor DRG 
542 would have enough cases to meet the existing threshold of 14,000 
transfer cases for inclusion in the postacute care transfer policy. 
Nevertheless, we believed the cases that would be incorporated into 
these two DRGs remained appropriate candidates for application of the 
postacute care transfer policy and that the subdivision of DRG 483 
should not change the original application of the postacute care 
transfer policy to the cases once included in that DRG. Therefore, for 
FY 2005, we proposed alternate criteria to be applied in cases where 
DRGs do not satisfy the existing criteria, for discharges occurring on 
or after October 1, 2004 (69 FR 28273 and 28374). The proposed new 
criteria were designed to address situations such as those posed by the 
split of DRG 483, where there remain substantial grounds for inclusion 
of cases within the postacute care transfer policy, although one or 
more of the original criteria may no longer apply. Under the proposed 
alternate criteria, DRGs 430, 541, and 542 would have qualified for 
inclusion in the postacute care transfer policy.
    In the response to comments on our FY 2005 proposal, we decided not 
to adopt the proposed alternate criteria for including DRGs under the 
postacute care transfer policy in the FY 2005 IPPS final rule. Instead 
we adopted the policy of simply grandfathering, for a period of 2 
years, any cases that were previously included within a DRG that has 
split, when the split DRG qualified for inclusion in the postacute care 
transfer policy for both of the previous 2 years. Under this policy, 
the cases that were previously assigned to DRG 483 and that now fall 
into DRGs 541 and 542 continue to be subject to the policy. Therefore, 
effective for discharges on or after October 1, 2004, 30 DRGs, 
including new DRGs 541 and 542, are subject to the postacute care 
transfer policy. We indicated that we would monitor the frequency with 
which these

[[Page 23413]]

cases are transferred to postacute care settings and the percentage of 
these cases that are short-stay transfer cases. Because we did not 
adopt the proposed alternate criteria for DRG inclusion in the 
postacute care transfer policy, DRG 430 (Psychoses) did not meet the 
criteria for inclusion and has not been subject to the postacute care 
transfer policy for FY 2005. We also invited comments on how to treat 
the cases formerly included in a split DRG after the grandfathering 
period.
    We note that some commenters also suggested that, in place of the 
proposed alternate criteria, we should adopt a policy of permanently 
applying the postacute care transfer policy to a DRG once it has 
initially qualified for inclusion in the policy. These commenters noted 
that removing DRGs from the postacute care transfer policy makes the 
payment system less stable and results in inconsistent incentives over 
time. They also argued that ``a drop in the number of transfers to 
postacute care settings is to be expected after the transfer policy is 
applied to a DRG, but the frequency of transfers may well rise again if 
the DRG is removed from the policy.'' We indicated that we would 
consider adopting this general policy once we had evaluated the 
experience with the specific cases that are subject to the 
grandfathering policy for FY 2005 and FY 2006.
    In the May 18, 2004 proposed rule, we also called attention to the 
data concerning DRG 263, which was subject to the postacute care 
transfer policy until FY 2004. We removed DRG 263 from the postacute 
care transfer policy for FY 2004 because it did not have the minimum 
number of cases (14,000) transferred to postacute care (13,588 transfer 
cases in FY 2002, with more than 50 percent of transfer cases being 
short-stay transfers). The FY 2003 MedPAR data show that there were 
15,602 transfer cases in the DRG in FY 2003, of which 46 percent were 
short-stay transfers. Because we removed the DRG from the postacute 
care transfer policy in FY 2004, it must meet all criteria to be 
included under the policy in subsequent fiscal years. Because the 
geometric mean length of stay for DRG 263 showed only a 6-percent 
decrease since 1999, DRG 263 did not qualify to be added to the policy 
for FY 2005 under the existing criteria that were included in last 
year's rule. DRG 263 would have qualified under the volume threshold 
and percent of short-stay transfer cases under the proposed new 
alternate criteria contained in the FY 2005 proposed rule. However, it 
still would not have met the proposed required decline in length of 
stay to qualify to be added to the policy for FY 2005. We indicated 
that we would continue to monitor the experience with DRG 263, 
especially in light of the comment that recommended a general policy of 
grandfathering cases that qualify under the criteria for inclusion in 
the postacute care transfer policy.
    The table below displays the 30 DRGs that are included in the 
postacute care transfer policy, effective for discharges occurring on 
or after October 1, 2004.

[[Page 23414]]

[GRAPHIC] [TIFF OMITTED] TP04MY05.049

    For this year's proposed rule, we have conducted an extensive 
analysis of the FY 2003 and FY 2004 MedPAR data to monitor the effects 
of the postacute care transfer policy. We have also conducted an 
overall assessment of the postacute care transfer policy since its 
inception in FY 1999. Specifically, we have examined the relationship 
between rates of postacute care utilization and the geometric mean 
length of stay and the relationship between a high volume and a high 
proportion of postacute care transfers within a DRG in light of 
experience under the current policy. Specifically, we examined whether 
a decline in the geometric mean length of stay is associated with an 
increase in the volume and proportion of total cases in a DRG that are 
discharges to postacute care. We analyzed these data as part of 
determining whether to retain the criteria that a DRG must have a 
decline in the geometric mean length of stay of

[[Page 23415]]

at least 7 percent in the previous 5-year period to be included under 
the postacute care transfer policy.
    Our current criteria for inclusion in the postacute care transfer 
policy include a requirement that, if a DRG is not already included in 
the policy, there must be a decline of at least 7 percent in the DRG's 
geometric mean length of stay during the most recent 5-year period. It 
has come to our attention that not all DRGs that experience an increase 
in postacute care utilization also experience a decrease in geometric 
mean length of stay. In fact, some DRGs with increases in postacute 
care utilization during the past several years have also experienced an 
increase in the geometric mean length of stay. The table below lists a 
number of DRGs that experienced increases in postacute care utilization 
and increases in the geometric mean length of stay from FY 2002 through 
FY 2004:
[GRAPHIC] [TIFF OMITTED] TP04MY05.050

    Our current criteria also include a requirement that a DRG have at 
least 14,000 total postacute care transfer cases in order to be 
included in the policy. We have examined the data on the numbers of 
transfers and the percentage of postacute care transfer cases across 
DRGs. Among the 30 DRGs currently included within the postacute care 
transfer policy, the percentage of postacute care transfer cases ranges 
from a low of 15 percent to a high of 76 percent. Among DRGs that are 
not currently included within the policy, many have a relatively high 
percentage of postacute care transfer cases in proportion to the total 
volume of cases for the DRG or a relatively high volume of discharges 
to postacute care facilities, or both. For this reason, we reviewed the 
data for all DRGs before proposing a change to the postacute care 
transfer payment policy. As part of this review, we found that:
     Of 550 DRGs, 26 have been deactivated and 17 have no cases 
in the FY 2004 MedPAR files. We are not proposing any changes for these 
DRGs because application of the postacute care transfer policy to them 
would have no effect.
     Of the remaining 507 DRGs, 220 have geometric mean lengths 
of stay that are less than 3.0 days. Because the transfer payment 
policy provides 2 times the per diem rate for the first day of care 
(due to the large proportion of charges incurred on the first day of a 
patient's treatment), including these DRGs in the transfer policy would 
be relatively meaningless as they would all receive a full DRG payment. 
For this reason, we are not proposing any

[[Page 23416]]

changes to the postacute care transfer policy for these DRGs.
     Of the remaining 287 DRGs, 64 have fewer than 100 short-
stay transfer cases. In addition, 39 of these 64 DRGs have fewer than 
50 short-stay transfer cases. Consistent with the statutory guidance, 
we are not proposing any change to how we apply the postacute care 
transfer payment policy to these DRGs because we believe that these 
DRGs do not have a high volume of discharges to postacute care 
facilities or involve a disproportionate use of postacute care 
services.
    Once we eliminated the DRGs cited above from consideration for the 
postacute care transfer policy, we examined the characteristics of the 
remaining 223 DRGs. We found that these DRGs had three common 
characteristics:
     The DRG had at least 2,000 total postacute care transfer 
cases.
     At least 20 percent of all cases in the DRG were 
discharged to postacute care settings.
     10 percent of all discharges to postacute care were prior 
to the geometric mean length of stay for the DRG.
    Consistent with the statutory guidance giving the Secretary the 
authority to make a DRG subject to the postacute care transfer policy 
based on a high volume of discharges to postacute care facilities and a 
disproportionate use of postacute care services, we believe these DRGs 
have characteristics that make them appropriate for inclusion in the 
postacute care transfer policy.
    As a result of our analysis, we believe that it is appropriate to 
consider major revisions to the criteria for including a DRG within the 
postacute care transfer policy. First, our analysis calls into question 
the requirement that a DRG experience a decline in the geometric mean 
length of stay over the most recent 5-year period. Our findings that 
some DRGs with increases in postacute care utilization during the past 
several years have also experienced increases in geometric mean length 
of stay indicate that this criterion is no longer effective to identify 
those DRGs that should be subject to the postacute care transfer 
policy. In addition, our findings about the number of DRGs with 
relatively high volumes (at least 2,000 cases) and relatively high 
proportions (at least 20 percent) of postacute care utilization suggest 
that we should revise the requirement that a DRG have at least 14,000 
total postacute care transfer cases to be included within the postacute 
care transfer policy.
    Our analysis does confirm that it is appropriate to maintain the 
requirement that a DRG must have a geometric mean length of stay of at 
least 3.0 days in order to be included within the postacute care 
transfer policy. We believe that this policy should be retained 
because, under the transfer payment methodology, hospitals receive the 
entire payment for cases in these DRGs in the first 2 days of the stay. 
Lowering the limit below 3.0 days would, therefore, have no effect on 
payment for DRGs with geometric mean lengths-of-stay in this range. For 
the reasons discussed in the May 19, 2003 proposed rule (68 FR 27199) 
and because it is a common characteristic of DRGs with a large number 
of cases discharged to postacute care, we also continue to believe that 
it is appropriate to retain the criterion that at least 10 percent of 
all cases that are transferred to postacure care should be short-stay 
cases where the patient is transferred before the geometric mean length 
of stay for the DRG. We also continue to believe that both DRGs in a 
CC/non-CC pair should be subject to the postacute care transfer policy 
if one of the DRGs meets the criteria for inclusion. By including both 
DRGs in a CC/non-CC pair, our policy will preclude an incentive for 
hospitals to code cases in ways designed to avoid triggering the 
application of the policy, for example, by excluding codes that would 
identify a complicating or comorbid condition in order to assign a case 
to a non-CC DRG that is not subject to the policy.
    Therefore, we are considering substantial revisions to the four 
criteria that are currently used to determine whether a DRG qualifies 
for inclusion in the postacute care transfer policy. The current 
criteria provide that, in order to be included within the policy, a DRG 
must have, for both of the 2 most recent years for which data are 
available:
     At least 14,000 total postacute care transfer cases;
     At least 10 percent of its postacute care transfers 
occurring before the geometric mean length of stay;
     A geometric mean length of stay of at least 3 days;
     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; and
     If the DRG is one of a paired set of DRGs based on the 
presence or absence of a comorbidity or complication, both paired DRGs 
are included if either one meets the first three criteria above.
    As a result of our analysis, we considered two options for revising 
the current criteria. Option 1 is to include all DRGs within the 
postacute care transfer policy. This option has the advantage of 
providing consistent treatment of all DRGs. However, as we discussed 
above, our analysis tends to indicate that, at a minimum, it may be 
appropriate to maintain the requirement that a DRG must have a 
geometric mean length of stay of at least 3.0 days because, under the 
transfer payment methodology, hospitals receive the entire payment for 
these DRGs in the first 2 days of the stay. Lowering the limit below 
3.0 days, would therefore have little or no effect on payment for DRGs 
with geometric mean lengths of stay in this range.
    Option 2 that we considered is to expand the application of the 
postacute care transfer policy by applying the policy to any DRG that 
meets the following criteria:
     The DRG has at least 2,000 postacute care transfer cases;
     At least 20 percent of the cases in the DRG are discharged 
to postacute care;
     Out of the cases discharged to postacute care, at least 10 
percent occur before the geometric mean length of stay for the DRG;.
     The DRG has a geometric mean length of stay of at least 
3.0 days;
     If the DRG is one of a paired set of DRGs based on the 
presence or absence of a comorbidity or complication, both paired DRGs 
are included if either one meets the first three criteria above.
    Option 2 would expand the application of the postacute care 
transfer policy to 223 DRGs that have both a relatively high volume and 
a relatively high proportion of postacute care utilization. The 
proposed change would also avoid applying the postacute care transfer 
policy to DRGs with only a small number or proportion of cases 
transferred to postacute care. The table below shows the DRGs that 
would be included in the postacute care transfer policy under this 
option:

[[Page 23417]]

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[[Page 23418]]


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[[Page 23422]]


[GRAPHIC] [TIFF OMITTED] TP04MY05.056


[[Page 23423]]


[GRAPHIC] [TIFF OMITTED] TP04MY05.057

    We believe that the analysis that we have conducted suggest that 
substantial revisions to the criteria for including a DRG within the 
postacute care transfer policy are warranted. In this proposed rule, we 
are formally proposing Option 2 as presented above. However, we invite 
comments on both of these options and on the analysis that we have 
presented.
    The impact section in Appendix A of this proposed rule discusses 
our findings on the effects of adopting Option 2. The proposed DRG 
relative weights included in Tables 5 and 7 of the Addendum to this 
proposed rule also include the effect of changing the postacute care 
transfer policy as described in Option 2 above. We note that if we 
adopt either option discussed above, or a variation based on comments 
submitted, we would follow procedures similar to those that are 
currently followed for treating cases identified as transfers in the 
DRG recalibration process. That is, as described in the discussion of 
DRG recalibration in section II.C. of the preamble to this proposed 
rule, additional transfer cases would be counted as a fraction of a 
case based on the ratio of a hospital's transfer payment under the per 
diem payment methodology to the full DRG payment for nontransfer cases.
    Section 1886(d)(5)(J)(i) of the Act recognizes that, in some cases, 
a substantial portion of the cost of care is incurred in the early days 
of the inpatient stay. Similar to the policy for

[[Page 23424]]

transfers between two acute care hospitals, transferring hospitals 
receive twice the per diem rate for the first day of treatment and the 
per diem rate for each following day of the stay before the transfer, 
up to the full DRG payment, for cases discharged to postacute care. 
However, three of the DRGs subject to the postacute care transfer 
policy exhibit an even higher share of costs very early in the hospital 
stay in postacute care transfer situations. For these 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.
    In previous years, we determined that DRGs 209 and 211 met this 
cost threshold and qualified to receive this special payment 
methodology. Because DRG 210 is paired with DRG 211, we include payment 
for cases in that DRG for the same reason we include paired DRGs in the 
postacute care transfer policy (to eliminate any incentive to code 
incorrectly in order to receive higher payment for those cases). The FY 
2004 MedPAR data show that DRGs 209 and 211 continue to have charges on 
the first day of the stay that are higher than 50 percent of the 
average charges in the DRGs. In addition, several of the DRGs that may 
be added to the postacute care transfer policy under the options that 
we are considering may also meet the 50 percent threshold in their 
average charges. We have identified those additional DRGs that are 
subject to the special payment methodology in Tables 5 and 7 of the 
Addendum to this proposed rule.

B. Reporting of Hospital Quality Data for Annual Hospital Payment 
Update (Sec.  412.64(d)(2))

    (If you choose to comment on issues in this section, please include 
the caption ``Hospital Quality Data'' at the beginning of your 
document.)
1. Background
    Section 1886(b)(3)(B)(vii) of the Act, as added by section 501(b) 
of Pub. L. 108-173 revised the mechanism used to update the 
standardized amount of payment for inpatient hospital operating costs. 
Specifically, the statute provides for a reduction of 0.4 percentage 
points to the update percentage increase (also known as the market 
basket update) for each of FYs 2005 through 2007 for any ``subsection 
(d) hospital'' that does not submit data on a set of 10 quality 
indicators established by the Secretary as of November 1, 2003. The 
statute also provides that any reduction will apply only to the fiscal 
year involved, and will not be taken into account in computing the 
applicable percentage increase for a subsequent fiscal year. This 
measure establishes an incentive for IPPS hospitals to submit data on 
the quality measures established by the Secretary.
    We initially implemented section 1886(b)(3)(B)(vii) of the Act in 
the FY 2005 IPPS final rule (August 11, 2004, 69 FR 49078) in 
continuity with the Department's Hospital Quality Initiative as 
described at the CMS Web site: http://www.cms.hhs.gov/quality/hospitals. At a press conference on December 12, 2002, the Secretary of 
the Department of Health and Human Services (HHS) announced a series of 
steps that HHS and its collaborators were taking to promote public 
reporting of hospital quality information. These collaborators include 
the American Hospital Association, the Federation of American 
Hospitals, the Association of American Medical Colleges, the Joint 
Commission on Accreditation of Healthcare Organizations (JCAHO), the 
National Quality Forum, the American Medical Association, the Consumer-
Purchaser Disclosure Project, the American Association of Retired 
Persons, the American Federation of Labor-Congress of Industrial 
Organizations, the Agency for Healthcare Research and Quality, as well 
as CMS, Quality Improvement Organizations (QIOs), and others.
    In July 2003, CMS began the National Voluntary Hospital Reporting 
Initiative (NVHRI), now known as the Hospital Quality Alliance (HQA): 
Improving Care through Information. Data from this initiative have been 
used to populate a professional Web site providing data to healthcare 
professionals. This website will be followed by the development of a 
consumer Web site in an easy-to-use format. The consumer Web site is 
intended to be an important tool for individuals to use in making 
decisions about health care options. This information will assist 
beneficiaries by providing comparison information for consumers who 
need to select a hospital. It will also serve as a way to encourage 
accountability of hospitals for the care they provide to patients.
    The 10 measures that were employed in this voluntary initiative as 
of November 1, 2003, are:

 Heart Attack (Acute Myocardial Infarction)
    Was aspirin given to the patient upon arrival to the hospital?
    Was aspirin prescribed when the patient was discharged?
    Was a beta-blocker given to the patient upon arrival to the 
hospital?
    Was a beta-blocker prescribed when the patient was discharged?
    Was an ACE inhibitor given for the patient with heart failure?
 Heart failure
    Did the patient get an assessment of his or her heart function?
    Was an ACE inhibitor given to the patient?
 Pneumonia
    Was an antibiotic given to the patient in a timely way?
    Had a patient received a pneumococcal vaccination?
    Was the patient's oxygen level assessed?

    These measures have been endorsed by the National Quality Forum 
(NQF) and are a subset of the same measures currently collected for the 
JCAHO by its accredited hospitals. The Secretary adopted collection of 
data on these 10 quality measures in order to: (1) provide useful and 
valid information about hospital quality to the public; (2) provide 
hospitals with a sense of predictability about public reporting 
expectations; (3) begin to standardize data and data collection 
mechanisms; and (4) foster hospital quality improvement. Many hospitals 
are currently participating in the National Voluntary Hospital 
Reporting Initiative (NVHRI), and are submitting data to the QIO 
Clinical Warehouse for that purpose.
    Over the next several years, hospitals are encouraged to take steps 
toward the adoption of electronic medical records (EMRs) that will 
allow for reporting of clinical quality data from the electronic record 
directly to a CMS data repository. CMS intends to begin working toward 
creating measures specifications and a system or mechanism, or both, 
that will accept the data directly without requiring the transfer of 
the raw data into an XML file as currently exists. The Department is 
presently working cooperatively with other Federal agencies in the 
development of Federal health architecture data standards. CMS 
encourages hospitals that are developing systems to conform them to 
both industry standards and the Federal health architecture data 
standards, and to ensure that they would capture the data necessary for 
quality measures. Ideally, such systems will also provide point-of-care 
decision support that enables high levels of performance on the 
measures. Hospitals using EMRs to produce data on quality measures will 
be held to the same performance expectations as hospitals not using 
EMRs. We are exploring requirements for the submission of 
electronically produced data and other options to encourage the 
submission of such data, and invite comments on this issue.

[[Page 23425]]

2. Requirements for Hospital Reporting of Quality Data
    The procedures for participating in the Reporting Hospital Quality 
Data for the Annual Payment Update (RHQDAPU) program created in 
accordance with section 501(b) of Pub. L. 108-173 can be found on the 
QualityNet Exchange at the Web site: http://www.qnetexchange.org in the 
``Reporting Hospital Quality Data for Annual Payment Update Reference 
Checklist''. This checklist also contains all of the forms to be 
completed by hospitals participating in the program. In order to 
participate in the hospital reporting initiative, hospitals must follow 
these steps:
     The hospital must identify a QualityNet Exchange 
Administrator who follows the registration process and submits the 
information through the QIO. This must be done regardless of whether 
the hospital uses a vendor for transmission of data.
     All participants must first register with the QualityNet 
Exchange, regardless of the method used for data submission. If a 
hospital is currently participating in the voluntary reporting 
initiative, re-registration on QualityNet Exchange is unnecessary. 
However, the hospital must complete the Reporting Hospital Quality Data 
for Annual Payment Update Notice of Participation form. All hospitals 
must send this form to their QIOs.
     The hospital must collect data for all 10 measures and 
submit the data to the QIO Clinical Warehouse either using the CMS 
Abstraction & Reporting Tool (CART), the JCAHO Oryx Core Measures 
Performance Measurement System (PMS), or another third-party vendor 
that has met the measurement specification requirements for data 
transmission to QualityNet Exchange. The QIO Clinical Warehouse will 
submit the data to CMS on behalf of the hospitals. The submission will 
be done through QualityNet Exchange, which is a secure site that 
voluntarily meets or exceeds all current Health Insurance Portability 
and Accountability Act (HIPAA) requirements, while maintaining QIO 
confidentiality as required under the relevant regulations and 
statutes. The information in the Clinical Warehouse is considered QIO 
data and, therefore, is subject to the stringent QIO confidentiality 
regulations in 42 CFR Part 480.
    For the first year of the program, FY 2005, hospitals were required 
to begin the submission of data by July 1, 2004, under the provisions 
of section 1886(b)(3)(B)(vii)(II) of the Act, as added by section 
501(b) of Pub. L. 108-173. Because section 501(b) of Pub. L. 108-173 
granted a 30-day grace period for submission of data for purposes of 
the FY 2005 update, hospitals were given until August 1, 2004, for 
completed submissions to be successfully accepted into the QIO Clinical 
Warehouse. Hospitals were required to submit data for the first 
calendar quarter of 2004. We received data from over 98 percent of the 
eligible hospitals.
    For FY 2006, we are proposing that hospitals must continuously 
submit the required 10 measures each quarter according to the schedule 
found on the Web site at http://www.qnetexchange.org. New facilities 
must submit the data using the same schedule, as dictated by the 
quarter they begin discharging patients. We will expect that all 
hospitals will have submitted data to the QIO Clinical Warehouse for 
discharges through the fourth quarter of calendar year 2004 (October to 
December 2004). Hospitals have 4\1/2\ months from the end of the fourth 
quarter until the closing of the warehouse (from December 31, 2004, 
until May 15, 2005) to make sure there are no errors in the submitted 
data. The warehouse is closed at that time in order to draw the 
validation sample and to begin preparing the public file for Hospital 
Compare public reporting. Data from fourth quarter 2004 discharges 
(October through December 2004) will be the last quarter of data with a 
submission deadline (May 15, 2005) that precedes our deadline for 
certifying the hospitals eligible to receive the full update for FY 
2006. As we required for FY 2005, the data for each quarter must be 
submitted on time and pass all of the edits and consistency checks 
required in the clinical warehouse. Hospitals that do not treat a 
condition or have very few discharges will not be penalized and will 
receive the full annual payment update if they submit all the data they 
do possess.
    New hospitals should begin collecting and reporting data 
immediately and complete the registration requirements for the RHQDAPU. 
New hospitals will be held to the same standard as established 
facilities when determining the expected number of discharges for the 
calendar quarters covered for each fiscal year. The annual payment 
updates would be based on the successful submission of data to CMS via 
the QIO Clinical Warehouse by the established deadlines.
    For FY 2005, hospitals could withdraw from RHQDAPU at any time up 
to August 1, 2004. Hospitals withdrawing from the program did not 
receive the full market basket update and, instead, received a 
reduction of 0.4 percentage points in their update. By law, a 
hospital's actions each year will not affect its update in a subsequent 
year. Therefore, a hospital must meet the requirements for RHQDAPU each 
year the program is in effect. Failure of a hospital to receive the 
full update in one year does not affect its update in a succeeding 
year.
    For the first year, FY 2005, there were no chart-audit validation 
criteria in place. Based upon our experience from the FY 2005 
submissions, and upon our requirement for reliable and valid data, we 
are proposing to place the following additional requirements on 
hospitals for the data for the FY 2006 payment update. These 
requirements, as well as additional information on validation 
requirements, will be placed on QualityNet Exchange.
     The hospital must have passed our validation requirement 
of a minimum of 80 percent reliability, based upon our chart-audit 
validation process, for the third quarter data of calendar year 2004 in 
order to receive the full market basket update in FY 2006. These data 
were due to the clinical warehouse by February 15, 2005. We will use 
appropriate confidence intervals to determine if a hospital has 
achieved an 80-percent reliability. The use of confidence intervals 
will allow us to establish an appropriate range below the 80-percent 
reliability threshold that will demonstrate a sufficient level of 
validity to allow the data to still be considered valid. We will 
estimate the percent reliability based upon a review of five charts and 
then calculate the upper 95 percent confidence limit for that estimate. 
If this upper limit is above the required 80 percent, the hospital data 
will be considered validated. We are proposing to use the design 
specific estimate of the variance for the confidence interval 
calculation, which, in this case, is a single stage cluster sample, 
with unequal cluster sizes. (For reference, see Cochran, William G. 
(1977) Sampling Techniques, John Wiley & Sons, New York, chapter 3, 
section 3.12.)
    We will use a two-step process to determine if a hospital is 
submitting valid data. At the first step, we will calculate the percent 
agreement for all of the variables submitted in all of the charts, 
whether or not they are related to the 10 measures. If a hospital falls 
below the 80 percent cutoff, we will then restrict the comparison to 
those variables associated with the 10 measures required under section 
501(b) of Pub. L. 108-173. We will recalculate the percent agreement 
and the estimated 95 percent confidence interval and again compare to 
the 80 percent cutoff

[[Page 23426]]

point. If a hospital passes under this restricted set of variables, the 
hospital will be considered to be submitting valid data for purposes of 
this proposed rule.
    Under the standard appeal process, all hospitals are given the 
detailed results of the Clinical Data Abstraction Center (CDAC) 
reabstraction along with their estimated percent reliability and the 
upper bound of the 95 percent confidence interval. If a hospital 
disagrees with any of the abstraction results from the CDAC, the 
hospital has 10 days to appeal these results to their QIO. The QIO will 
review the appeal with the hospital and, if the QIO review agrees with 
the hospitals original abstraction, the QIO will forward the appeal to 
the CDAC for a final determination. If the QIO does not agree with the 
hospital's appeal, then the original results stand. When the CDAC has 
made its final determination, the new results will be provided to the 
hospital through the usual processes and the validation described 
previously will be repeated. This process is described in detail at the 
following Web site: http://www.qnetexchange.org. Hospitals that fail to 
receive the required 80-percent reliability after the standard appeals 
process may ask that CMS accept the fourth quarter of calendar year 
2004 validation results as a final attempt to present evidence of 
reliability. However, in order to process the fourth quarter data in 
time to meet our internal deadlines, these hospitals will need to 
submit the charts requested for reabstraction as soon as possible, but 
no later than August 1, 2005, in order for us to guarantee 
consideration of this information. Hospitals that make the early 
submission of these data and pass the 80-percent reliability minimum 
level will satisfy this requirement. In reviewing the data for these 
hospitals, we plan to combine the 5 cases from the third quarter and 
the 5 cases from the fourth quarter into a single sample to determine 
whether the 80 percent reliability level is met. This gives us the 
greatest accuracy when estimating the reliability level. The confidence 
interval approach accounts for the variation in coding among the 5 
charts pulled each quarter and for the entire year around the overall 
hospital mean score (on all individual data elements compared). The 
closer each case's reliability score is to the hospital mean score, the 
tighter the confidence interval established for that hospital. A 
hospital may code each chart equally inaccurately, achieve a tight 
confidence interval, and fail to pass even though its overall score is 
just below the passing threshold (75 percent, for example). A hospital 
with more variation among charts will achieve a broader confidence 
interval, which may allow it to pass even though some charts score very 
low and others very high. As we gain experience with this system, we 
will adjust it as appropriate over time as we build our sample of 
validated cases and learn more about hospital performance against the 
thresholds we establish.
    We believe we have adopted the most suitable statistical tests for 
the hospital data we are trying to validate, but we invite public 
comments on this and any other approaches hospitals choose to comment 
on. We are particularly interested in comments from hospitals on the 
initial starting points for the passing threshold, the confidence 
interval established, and the sampling approach. Because we will be 
receiving data each quarter from hospitals, our information on the 
sampling methodology will improve with each quarter's submissions. We 
will analyze this information to determine if any changes in our 
methodology are required. We will make any necessary revisions to the 
sampling methodology and the statistical approach through manual 
issuances and other guidance to hospitals.
     The hospital must have two consecutive quarters of 
publishable data. The information collected by CMS through this rule 
will be displayed for public viewing on the Internet. Prior to this 
display, hospitals are permitted to preview their information as we 
have it recorded. In our previous experience, a number of hospitals 
requested that this information not be displayed due to errors in the 
submitted data that were not of the sort that could be detected by the 
normal edit and consistency checks. We acquiesced to these requests in 
the public interest and because of our own desire to present correct 
data. However, we still believe that the hospital bears the 
responsibility of submitting correct data that can serve as valid and 
reliable information. Therefore, in order to receive the full market 
basket update for IPPS, we are proposing to establish a requirement for 
two consecutive quarters of publishable data. We published the first 
quarter of calendar year 2004 data in November 2004. The first two 
quarters of calendar year 2004 data were published in March 2005. Our 
plans are to publish the first three quarters of calendar year 2004 in 
August 2005. For the FY 2006 update, we will expect that all hospitals 
receiving the full market basket update for FY 2006 to have published 
data for all of the required 10 measures for both the March and August 
2005 publications. Allowances would be made for hospitals that do not 
treat a particular condition and for new hospitals that have not had 
the opportunity to provide the required data.

C. Sole Community Hospitals (SCHs) and Medicare Dependent Hospitals 
(MDHs) (Sec. Sec.  412.73, 412.75, 412.77, 412.92 and 412.108)

    (If you choose to comment on issues in this section, please include 
the caption ``Sole Community Hospitals and Medicare Dependent 
Hospitals'' at the beginning of your comments.)
1. Background
    Under the IPPS, special payment protections are provided to a sole 
community hospital (SCH). Section 1886(d)(5)(D)(iii) of the Act defines 
an SCH as a hospital that, by reason of factors such as isolated 
location, weather conditions, travel conditions, absence of other like 
hospitals (as determined by the Secretary), or historical designation 
by the Secretary as an essential access community hospital, is the sole 
source of inpatient hospital services reasonably available to Medicare 
beneficiaries. The regulations that set forth the criteria that a 
hospital must meet to be classified as an SCH are located in Sec.  
412.92 of the regulations. Although SCHs and MDHs are paid under a 
special payment methodology, they are hospitals that are paid under 
section 1886(d) of the Act. Like all IPPS hospitals paid under section 
1886(d) of the Act, SCHs and MDHs are paid for their discharges based 
on the DRG weights calculated under section 1886(d)(4) of the Act.
    Effective with hospital cost reporting periods beginning on or 
after October 1, 2000, section 1886(d)(5)(D)(i) of the Act (as amended 
by section 6003(e) of Pub. L. 101-239) and section 1886(b)(3)(I) of the 
Act (as added by section 405 of Pub. L. 106-113 and further amended by 
section 213 of Pub. L. 106-554), provide that SCHs are paid based on 
whichever of the following rates yields the greatest aggregate payment 
to the hospital for the cost reporting period:
     The Federal rate applicable to the hospital;
     The updated hospital-specific rate based on FY 1982 costs 
per discharge;
     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.
    For purposes of payment to SCHs for which the FY 1996 hospital-
specific rate yields the greatest aggregate payment, payments for 
discharges during FYs 2001, 2002, and 2003 were based on a

[[Page 23427]]

blend of the FY 1996 hospital-specific rate and the greater of the 
Federal rate or the updated FY 1982 or FY 1987 hospital-specific rate. 
For discharges during FY 2004 and subsequent fiscal years, payments 
based on the FY 1996 hospital-specific rate are 100 percent of the 
updated FY 1996 hospital-specific rate.
    For each cost reporting period, the fiscal intermediary determines 
which of the payment options will yield the highest rate of payment. 
Payments are automatically made at the highest rate using the best data 
available at the time the fiscal intermediary makes the determination. 
However, it may not be possible for the fiscal intermediary to 
determine in advance precisely which of the rates will yield the 
highest payment by year's end. In many instances, it is not possible to 
forecast the outlier payments, the amount of the DSH adjustment, or the 
IME adjustment, all of which are applicable only to payments based on 
the Federal rate. The fiscal intermediary makes a final adjustment at 
the close of the cost reporting period to determine precisely which of 
the payment rates would yield the highest payment to the hospital.
    If a hospital disagrees with the fiscal intermediary's 
determination regarding the final amount of program payment to which it 
is entitled, it has the right to appeal the fiscal intermediary's 
decision in accordance with the procedures set forth in subpart R of 
part 400, which concern provider payment determinations and appeals.
    Under section 1886(d)(5)(G) of the Act, Medicare dependent 
hospitals (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. The regulations that set forth the criteria that a 
hospital must meet to be classified as an MDH are located in Sec.  
412.108.
2. Budget Neutrality Adjustment to Hospital Payments Based on Hospital-
Specific Rate
    Under section 1886(d)(4)(C)(i) of the Act, beginning in FY 1988 and 
for each fiscal year thereafter, the Secretary is required to adjust 
the DRG classifications and weighting factors established under 
sections 1886(d)(4)(A) and (d)(4)(B) of the Act to reflect changes in 
treatment patterns, technology, and other factors that may change the 
use of hospital resources. For discharges beginning in FY 1991, section 
1886(d)(4)(C)(iii) of the Act requires the Secretary to ensure that 
adjustments to DRG classifications and weighting factors result in 
aggregate DRG payments that are budget neutral (not greater or less 
than the aggregate payments without the adjustments). In addition, 
section 1886(d)(3)(E) of the Act requires the Secretary to update the 
hospital wage index annually in a manner that does not affect aggregate 
payments to hospitals under section 1886(d) of the Act.
    As discussed in the May 9, 1990 IPPS proposed rule (55 FR 19466), 
we normalize the proposed 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. While this adjustment 
is intended to ensure that recalibration does not affect total payments 
to hospitals under section 1886(d) of the Act, our analysis has 
indicated that the normalization adjustment does not achieve budget 
neutrality with respect to aggregate payments to hospitals under 
section 1886(d) of the Act. In order to comply with the requirement of 
section 1886(d)(4)(C)(iii) of the Act that the DRG reclassification 
changes and recalibration of the relative weights be budget neutral and 
the requirement of section 1886(d)(3)(E) of the Act that the updated 
wage index be implemented in a budget neutral manner, we compare the 
estimated aggregate payments using the current year's relative weights 
and wage index factors to aggregate payments using the prior year's 
weights and factors. Based on this comparison, we compute a budget 
neutrality adjustment factor. This budget neutrality adjustment factor 
is then applied to the standardized per discharge payment amount. 
Beginning in FY 1994, in applying the current year's budget neutrality 
adjustment factor to both the standard Federal rate and hospital-
specific rates, we do not remove the prior years' budget neutrality 
adjustment factors because estimated aggregate payments after the 
changes in the DRG relative weights and wage index factors must equal 
estimated aggregate payments prior to the changes. If we removed the 
prior year adjustment, we would not satisfy this condition. (58 FR 
30269)
    We are bound by the Act to ensure that aggregate payments to 
hospitals under section 1886(d) of the Act are projected to neither 
increase nor decrease as a result of the annual updates to the DRG 
classifications and weighting factors and for the updated wage indices. 
However, we have broad authority under the statute to determine the 
method for implementing budget neutrality. We have maintained since 
1991 that the budget neutrality adjustment is applied, as described 
above, to all hospitals paid under section 1886(d) of the Act, 
including those that are paid based on a hospital-specific rate. Thus, 
the budget neutrality factor applies to payments to SCHs and MDHs.
    Hospitals that are paid under section 1886(d) of the Act based on a 
hospital-specific rate are subject to the DRG reclassification and 
recalibration factor component of the budget neutrality adjustment 
because, as IPPS hospitals, they are paid based on DRGs. As described 
above, changes in DRG relative weights from one year to the next affect 
aggregate SCH and MDH payments, which in turn affect total Medicare 
payments to hospitals under section 1886(d) of the Act. Because SCHs 
and MDHs are paid under section 1886(d) of the Act, we believe their 
DRG payments should be factored into the DRG reclassification and 
recalibration factor component of the budget neutrality adjustment to 
ensure that recalibration does not affect total payments to hospitals 
under section 1886(d) of the Act. Therefore, we continue to believe it 
is appropriate to apply the DRG reclassification and recalibration 
factor component of the budget neutrality adjustment to SCHs and MDHs. 
Furthermore, consistent with the requirement of section 
1886(d)(4)(C)(iii) of the Act that DRG reclassification changes and 
recalibration of relative weights be budget neutral, we continue to 
believe it is appropriate to apply this adjustment without removing the 
previous year's adjustment factor.
    In the May 9, 1990 proposed rule (55 FR 19466), we discussed the 
rationale behind our decision to apply the wage index portion of the 
budget neutrality adjustment factors to hospitals that are paid under 
section 1886(d) of the Act based on a hospital-specific rate. We 
described how, even though the wage index is only applicable to those 
hospitals that are paid based on the Federal rate, the changes in wage 
index can cause changes in the payment basis for some SCHs, and MDHs. 
That is, depending on the size of the increase in their wage index 
values, some hospitals that had been paid based on the hospital-
specific rate could now be paid based on the Federal rate when the wage 
index-adjusted Federal rate exceeds the hospital-specific rate. In some 
instances, hospitals that had previously been paid based on the Federal 
rate may be paid based on the hospital-specific rate if the Federal 
rate is adjusted by a lower wage

[[Page 23428]]

index and the hospital-specific rate now exceeds the Federal rate. 
These shifts in the payment basis affect aggregate program payments 
and, therefore, are taken into account in the budget neutrality 
adjustment. In addition, we maintained that because we apply the 
adjustment to all hospitals paid based on the Federal rate under 
section 1886(d) of the Act, it would be fair to apply it to hospitals 
that are paid under section 1886(d) of the Act based on hospital-
specific rates. We believed that if we did not apply the budget 
neutrality factor to hospitals paid based on their hospital-specific 
rate, hospitals that are paid on the Federal rate would be subject to 
larger reductions to make up for not adjusting payments to hospitals 
that are paid based on hospital-specific rates.
    Concerns have been raised that hospitals under section 1886(d) of 
the Act whose reimbursement is based on a hospital-specific rate should 
not be subject to the wage index component of the budget neutrality 
adjustment. Hospital-specific rates reflect the effects of hospitals' 
area wage levels and, therefore, are not adjusted by an area wage 
index. Accordingly, the concern is that a budget neutrality factor for 
changes in the wage index should not be applied to hospitals that are 
paid based on a hospital-specific rate. In addition, it has been 
suggested that the budget neutrality adjustment that CMS applies to 
hospitals paid on a hospital-specific rate should be similar to the 
budget neutrality adjustment made to hospitals in Puerto Rico. 
Hospitals in Puerto Rico that are paid under the IPPS are paid based on 
a blend of the national prospective payment rate and the Puerto Rico-
specific prospective payment rate (42 CFR 412.212). Beginning in FY 
1991, the Puerto Rico-specific standardized amount became subject to a 
budget neutrality adjustment. This budget neutrality adjustment 
included both the DRG reclassification and recalibration factor 
component and the wage index component. However, beginning in FY 1998, 
the Puerto Rico-specific rate has been subject only to the DRG 
reclassification and recalibration factor component of the budget 
neutrality adjustment (62 FR 46038) and not to the wage index component 
of the budget neutrality adjustment. In other words, beginning in FY 
1998, the budget neutrality adjustment for the Puerto Rico-specific 
rate reflects only the DRG reclassification and recalibration factor 
component. This adjustment is computed, as described above, for all 
hospitals paid under section 1886(d) of the Act, without removing the 
previous year's budget neutrality adjustment.
    We have considered the concern that it is inappropriate to apply a 
budget neutrality factor that includes a component for changes in the 
wage index to a hospital with a payment rate that is not adjusted by a 
wage index adjustment. In cases in which a hospital's payments are 
ultimately based on a hospital-specific rate, that portion of the 
payment is not adjusted by a wage index. We believe that our current 
policy is valid, for the reasons indicated above and in previous 
rulemaking documents, but we recognize that there are also valid 
grounds to review the regulations and consider other approaches. 
Accordingly, we are revisiting this policy. After further consideration 
of these issues, we are proposing to remove the wage index component 
from the budget neutrality adjustment applied to the hospital-specific 
rate for hospitals paid under section 1886(d) of the Act. The DRG 
reclassification and recalibration factor component of the budget 
neutrality adjustment would still apply to these hospitals, as payments 
to SCHs and MDHs are based on DRGs and affect total Medicare payments 
to hospitals under section 1886(d) of the Act. In applying this budget 
neutrality adjustment factor, which would include only the DRG 
reclassification and recalibration factor component, to the hospital-
specific rate, we would not remove the prior years' budget neutrality 
adjustment factors. This would satisfy the statutory requirement that 
estimated aggregate payments after the changes in the DRG relative 
weights equal estimated aggregate payments prior to the changes. We are 
proposing that the wage index portion of the budget neutrality 
adjustment would not be applied to hospital-specific amounts, as these 
amounts are not adjusted by an area wage index. While this may result 
in a slightly higher budget neutrality adjustment applied to all other 
IPPS hospitals, because these hospitals actually are paid based on the 
revised wage indices and are affected by wage index changes, we believe 
this is appropriate. In addition, we note that in FY 1990 when this 
policy was first discussed, we did not calculate a budget neutrality 
factor that reflected only the DRG changes. Because we now calculate 
such a budget neutrality factor for Puerto Rico hospitals, it would not 
be administratively burdensome to apply the same budget neutrality 
factor to SCHs and MDHs.
    We are proposing to add a new paragraph (f) to Sec.  412.73, a new 
paragraph (i) to Sec.  412.75, and a new paragraph (j) to Sec.  412.77 
relating to the computation of the hospital-specific rate to clarify 
our longstanding policy that CMS makes an adjustment to the hospital-
specific rate to ensure that changes to the DRG reclassifications and 
recalibrations of the DRG relative weights are made in a manner so that 
aggregate payments to hospitals under section 1886(d) of the Act are 
not affected, and that this adjustment is made without removing the 
budget neutrality adjustment for the prior year. These provisions are 
cross-referenced in Sec.  412.92 for SCHs and Sec.  412.108 for MDHs 
for purposes of computing the hospital-specific rates for these 
hospitals. This proposed regulatory text will reflect the proposed 
changes to the way CMS applies the budget neutrality adjustment to 
hospitals paid under section 1886(d) of the Act based on the hospital-
specific rate. Specifically, it would indicate that the budget 
neutrality adjustment made to hospitals paid under section 1886(d) of 
the Act based on the hospital-specific rate will only account for the 
DRG reclassification and recallibration factor component. The budget 
neutrality adjustment would no longer include the wage index factor 
component.
3. Technical Change
    In the September 4, 1990 IPPS final rule (55 FR 36056), we made 
changes to the regulations at Sec.  412.92 to incorporate the 
provisions of section 6003(e) of Pub. L. 101-239. Section 6003(e) of 
Pub. L. 101-239 provided for a permanent payment methodology for SCHs 
that recognized distortions in operating costs in years subsequent to 
the implementation of the IPPS and provided for opportunity for payment 
based on a new base year. As a result of this legislation, we deleted 
from the regulations a special provision that we had included under 
Sec.  412.92(g) that provided for a payment adjustment to compensate 
SCHs reasonably for the increased operating costs resulting from the 
addition of new services or facilities.
    We have discovered that, in making the changes to Sec.  412.92 in 
the September 4, 1990 final rule to remove paragraph (g), we 
inadvertently failed to make a conforming change to paragraph (d)(3) 
that references the provisions of paragraph (g) relating to a payment 
adjustment for significant increases in a SCH's operating costs. In 
this proposed rule, we are proposing to make this technical correction 
by revising paragraph (d)(3).

D. Rural Referral Centers (Sec.  412.96)

    (If you choose to comment on issues in this section, please include 
the

[[Page 23429]]

caption ``Rural Referral Centers'' at the beginning of your document.)
    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 standardized 
amount rather than the rural standardized amount. Although the other 
urban and rural standardized amounts are the same for discharges 
occurring on or after October 1, 1994, rural referral centers continue 
to receive special treatment under both the DSH payment adjustment and 
the criteria for geographic reclassification.
    Section 402 of Pub. L. 108-173 raised the DSH adjustment for other 
rural hospitals with less than 500 beds and rural referral centers. 
Other rural hospitals with less than 500 beds are subject to a 12-
percent cap on DSH payments. Rural referral centers are not subject to 
the 12.0 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.
    Section 4202(b) of Pub. L. 105-33 states, in part, ``[a]ny hospital 
classified as a rural referral center by the Secretary * * * for fiscal 
year 1991 shall be classified as such a rural referral center for 
fiscal year 1998 and each subsequent year.'' In the August 29, 1997 
final rule with comment period (62 FR 45999), we also reinstated rural 
referral center status for all hospitals that lost the status due to 
triennial review or MGCRB reclassification, but not to hospitals that 
lost rural referral center status because they were now urban for all 
purposes because of the OMB designation of their geographic area as 
urban. However, subsequently, in the August 1, 2000 final rule (65 FR 
47089), we indicated that we were revisiting that decision. 
Specifically, we stated that we would permit hospitals that previously 
qualified as a rural referral center and lost their status due to OMB 
redesignation of the county in which they are located from rural to 
urban to be reinstated as a rural referral center. Otherwise, a 
hospital seeking rural referral center status must satisfy the 
applicable criteria. For FYs 1984 through 2004, we used the definitions 
of ``urban'' and ``rural'' in Sec.  412.63. For FY 2005 and subsequent 
years, the revised definitions of ``urban'' and ``rural'' in Sec.  
412.64 apply.
    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--
     The hospital's case-mix index is at least equal to the 
lower of the median case-mix index for urban hospitals in its census 
region, excluding hospitals with approved teaching programs, or the 
median case-mix index for all urban hospitals nationally; and
     The hospital's number of discharges is at least 5,000 per 
year, or, if fewer, the median number of discharges for urban hospitals 
in the census region in which the hospital is located. (The number of 
discharges criterion for an osteopathic hospital is at least 3,000 
discharges per year, 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 median 
case-mix index value for FY 2006 includes all urban hospitals 
nationwide, and the proposed regional values for FY 2006 are 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 are based on discharges occurring 
during FY 2004 (October 1, 2003 through September 30, 2004) and include 
bills posted to CMS' records through December 2004.
    We are proposing that, in addition to meeting other criteria, if 
they are to qualify for initial rural referral center status for cost 
reporting periods beginning on or after October 1, 2005, rural 
hospitals with fewer than 275 beds must have a case-mix index value for 
FY 2004 that is at least--
     1.3659; or
     The median case-mix index value (not transfer-adjusted) 
for urban hospitals (excluding hospitals with approved teaching 
programs as identified in Sec.  412.105) calculated by CMS for the 
census region in which the hospital is located.
    The proposed median case-mix index values by region are set forth 
in the following table:

[[Page 23430]]

[GRAPHIC] [TIFF OMITTED] TP04MY05.058

    The preceding numbers will be revised in the final rule to the 
extent required to reflect the updated FY 2004 MedPAR file, which will 
contain data from additional bills through March 31, 2005.
    Hospitals seeking to qualify as rural referral centers or those 
wishing to know how their case-mix index value compares to the criteria 
should obtain hospital-specific case-mix index values (not transfer-
adjusted) from their fiscal intermediaries. Data are available on the 
Provider Statistical and Reimbursement (PS&R) System. In keeping with 
our policy on discharges, these case-mix index values are computed 
based on all Medicare patient discharges subject to DRG-based payment.
2. Discharges
    Section 412.96(c)(2)(i) provides that CMS will set forth the 
national and regional numbers of discharges in each year's annual 
notice of prospective payment rates for purposes of determining rural 
referral center status. As specified in section 1886(d)(5)(C)(ii) of 
the Act, the national standard is set at 5,000 discharges. We are 
proposing to update the regional standards based on discharges for 
urban hospitals' cost reporting periods that began during FY 2002 (that 
is, October 1, 2001 through September 30, 2002), which is the latest 
available cost report data we have at this time.
    Therefore, we are proposing that, in addition to meeting other 
criteria, a hospital, if it is to qualify for initial rural referral 
center status for cost reporting periods beginning on or after October 
1, 2005, must have as the number of discharges for its cost reporting 
period that began during FY 2002 a figure that is at least--
     5,000 (3,000 for an osteopathic hospital); or
     The median number of discharges for urban hospitals in the 
census region in which the hospital is located, as indicated in the 
following table:
[GRAPHIC] [TIFF OMITTED] TP04MY05.059


[[Page 23431]]


    These numbers will be revised in the final rule based on the latest 
available cost report data.
    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, 2005, the hospital would be required to have at least 
3,000 discharges for its cost reporting period that began during FY 
2002.
3. Technical Change
    In the FY 1998 IPPS final rule (62 FR 46028), we removed paragraph 
(f) from Sec.  412.96. Paragraph (f) was removed when the requirement 
for triennial reviews of rural referral centers was terminated (62 FR 
45998 through 45600, 46028 through 46029). However, we inadvertently 
failed to address all of the related cross-references to paragraph (f) 
in the entire Sec.  412.96. Therefore, we are proposing to revise Sec.  
412.96 to remove paragraphs (h)(4) and (i)(4), consistent with the 
removal of paragraph (f).

E. Payment Adjustment for Low-Volume Hospitals (Sec.  412.101)

    (If you choose to comment on issues in this section, please include 
the caption ``Low-Volume Hospital Payment Adjustment'' at the beginning 
of your comment.)
    Section 1886(d)(12) of the Act, as added by section 406 of Pub. L. 
108-173, provides for a payment adjustment to account for the higher 
costs per discharge of low-volume hospitals under the IPPS. Section 
1886(d)(12)(C)(i) of the Act defines a low-volume hospital as a 
``subsection (d) hospital * * * that the Secretary determines is 
located more than 25 road miles from another subsection (d) hospital 
and that has less than 800 discharges during the fiscal year.'' Section 
1886(d)(12)(C)(ii) of the Act further stipulates that the term 
``discharge'' refers to total discharges, and not merely to Medicare 
discharges. Specifically, the term refers to the ``inpatient acute care 
discharge of an individual regardless of whether the individual is 
entitled to benefits under part A.'' Finally, the provision requires 
the Secretary to determine an applicable percentage increase for these 
low-volume hospitals based on the ``empirical relationship'' between 
``the standardized cost-per-case for such hospitals and the total 
number of discharges of these hospitals and the amount of the 
additional incremental costs (if any) that are associated with such 
number of discharges.'' The statute thus mandates the Secretary to 
develop an empirically justifiable adjustment based on the relationship 
between costs and discharges for these low-volume hospitals. The 
statute also limits the adjustment to no more than 25 percent.
    According to the analysis conducted for the FY 2005 IPPS final rule 
(69 FR 49099 through 49102), a 25 percent low-volume adjustment to all 
qualifying hospitals with less than 200 discharges was found to be most 
consistent with the statutory requirement to provide relief to low-
volume hospitals where there is empirical evidence that higher 
incremental costs are associated with low numbers of total discharges. 
However, we acknowledged that the empirical evidence did not provide 
robust support for that conclusion and indicated that we would 
reexamine the empirical evidence for the FY 2006 IPPS final rule with 
the intention of modifying or even eliminating the adjustment if the 
empirical evidence indicates that it is appropriate to do so.
    In the FY 2005 IPPS final rule (69 FR 49102), we indicated that our 
analysis showed that there are fewer than 100 hospitals with less than 
200 total discharges. At that time, we were unable to determine how 
many of these hospitals also meet the requirement that a low-volume 
hospital be more than 25 road miles from the nearest IPPS hospital in 
order to qualify for the adjustment. Our data systems currently 
indicate that 10 hospitals are receiving the low-volume adjustment.
    As indicated in the FY 2005 IPPS final rule, we have now conducted 
a more detailed multivariate analysis on the empirical basis for a low-
volume adjustment for FY 2006. In order to further evaluate the need 
for a proposed change in the development of the low-volume adjustment, 
we replicated much of the analysis conducted for the FY 2005 IPPS final 
rule, using updated data. We again empirically modeled the relationship 
between hospital costs-per-case and total discharges in several ways. 
We used both regression analysis and straight-line statistics to 
examine this relationship.
    We conducted three different regression analyses. For all of the 
analyses, we simulated the FY 2005 cost environment by inflating FY 
2002 and FY 2003 hospital cost report data to FY 2005 using the full 
hospital market basket updates. We note that, at the time of this 
analysis, we only had cost report data from FY 2003 for approximately 
57 percent of the IPPS hospitals. Therefore, we have placed a greater 
weight on the results from the simulated FY 2002 cost data, which are 
significantly more complete. We again simulated the FY 2005 payment 
environment because payments have undergone several changes between FY 
2002 and FY 2003 and FY 2005, making the results of the earlier data 
less relevant. Furthermore, many of these policy changes may already 
have helped increase payments to low-volume hospitals. We were unable 
to simulate the FY 2006 environment because payment factors for FY 2006 
were not available at the time of our analysis.
    In the first regression analysis, we used a dummy variable approach 
to model the relationship between standardized costs and total 
discharges. Using FY 2002 cost data, we found some evidence for a low-
volume payment adjustment for hospitals with up to 199 discharges, 
consistent with our current policy. Using FY 2003 cost data, the 
empirical evidence only supported an adjustment for hospitals with up 
to 99 total discharges.
    We also used a descriptive analysis approach to understand 
empirically the relationship between costs and total discharges. We 
grouped all hospitals by their total discharges and compared the mean 
Medicare per discharge payment to Medicare per discharge cost ratios. 
Hospitals with less than 800 total discharges were split into 24 
cohorts based on increments of 25 discharges. When using the FY 2002 
cost report data, the mean payment-to-cost ratios were below one 
(implying that Medicare per discharge costs exceeded Medicare per 
discharge payments) for all cohorts of hospitals with less than 200 
discharges, after which the ratio was consistently above one. When 
using the FY 2003 cost report data, the mean payment-to-cost ratios 
were below one for all but two cohorts up to those with less than 175 
total discharges, after which the ratio was consistently above one. No 
obvious increasing trend in the ratios, from which it would be possible 
to infer a formula to generate adjustments for hospitals based upon the 
number of discharges, was evident. Because more than 70 percent of 
hospitals with less than 200 discharges had ratios below 0.80, this 
analysis supports applying the highest payment adjustment to all 
providers with less than 200 discharges that are eligible for the low-
volume adjustment.
    The second regression analysis modeled the Medicare per discharge 
cost to Medicare per discharge payment ratio as a function of total 
discharges. The cost-to-payment ratio model more explicitly accounts 
for the relative values of per discharge costs and per discharge 
payments. These models provided some evidence for a statistically 
significant negative relationship between the cost-to-payment ratio and 
total discharges. However, that result was limited to FY

[[Page 23432]]

2002 data. FY 2003 data displayed no significant relationship between 
the cost-to-payment ratio and total discharges.
    The third regression analysis employed per discharge costs minus 
per discharge payments as the dependent variable and total discharges 
as an explanatory variable. The results of this analysis were similar 
to the other regression analyses: some evidence was provided for an 
adjustment with the FY 2002 data, but not with the FY 2003 data, 
simulated for FY 2005. In fact, the FY 2003 data results suggest (with 
a positive intercept and positive coefficient on total discharges) that 
payments are greater than costs for all hospitals, including the low-
volume hospitals.
    Based upon these multivariate analyses using the FY 2002 cost 
report data, a case can be made that hospitals with fewer than 200 
total discharges have per discharge costs that are statistically 
significantly higher relative to their Medicare per discharge payments 
in comparison to hospitals with 200 or more total discharges. 
Therefore, we are proposing to extend the existing low-volume 
adjustment for FY 2006. That is, a low-volume adjustment would again be 
provided for qualifying hospitals with less than 200 discharges. As 
noted above, the descriptive data do not reveal any pattern that could 
provide a formula for calculating an adjustment in relation to the 
number of discharges. However, the descriptive analysis of the data 
does indicate that, for a large majority of the hospitals with less 
than 200 discharges, the maximum adjustment of 25 percent would be 
appropriate because, for example, the payment-to-cost ratios for more 
than 70 percent of these hospitals are 0.80 or less. The maximum 
adjustment of 25 percent would still leave most of these hospitals with 
payment-to-cost ratios below 1.00. Because a large majority of 
hospitals with less than 200 discharges have payment-to-cost ratios 
below 1.00, we are proposing to again provide hospitals with less than 
200 total discharges in the most recent submitted cost report an 
adjustment of 25 percent on each Medicare discharge. This policy is 
consistent with the existing language in Sec.  412.101(a) and (b).
    However, the initial analysis of the FY 2003 data does not seem to 
provide strong empirical evidence for a relationship between Medicare 
per discharge costs and total discharges. Therefore, we will reevaluate 
the appropriateness of the low-volume adjustment in the FY 2007 
proposed rule.

F. Indirect Medical Education (IME) Adjustment (Sec.  412.105)

    (If you choose to comment on issues in this section, please include 
the caption ``IME Adjustment'' at the beginning of your comment.)
1. Background
    Section 1886(d)(5)(B) of the Act provides that prospective payment 
hospitals that have residents in an approved graduate medical education 
(GME) program receive an additional payment to reflect the higher 
indirect costs of teaching hospitals relative to nonteaching hospitals. 
The regulations regarding the calculation of this additional payment, 
known as the indirect medical education (IME) adjustment, are located 
at Sec.  412.105. The IME adjustment to the DRG payment is based in 
part on the applicable IME adjustment factor. The IME adjustment factor 
is calculated using a hospital's ratio of residents to beds, which is 
represented as r, and a formula multiplier, which is represented as c, 
in the following equation: c x [{1 + r{time}  \.405\ - 1]. The formula 
is traditionally described in terms of a certain percentage increase in 
payment for every 10-percent increase in the resident-to-bed ratio.
2. IME Adjustment for TEFRA Hospitals Converting to IPPS Hospitals
    The Balanced Budget Act of 1997 (Pub. L. 105-33) established a 
limit on the number of allopathic and osteopathic residents that a 
hospital may include in its full-time equivalent (FTE) count for direct 
GME and IME payment purposes. Under section 1886(h)(4)(F) of the Act, a 
hospital's unweighted FTE count of residents may not exceed the 
hospital's unweighted FTE count for its most recent cost reporting 
period ending on or before December 31, 1996. Under section 
1886(d)(5)(B)(v) of the Act, the limit on the FTE resident count for 
IME purposes is effective for discharges occurring on or after October 
1, 1997. A similar limit is effective for direct GME purposes for cost 
reporting periods beginning on or after October 1, 1997.
    When these provisions were enacted, hospitals reported their 
weighted FTE resident count for direct GME and their unweighted FTE 
resident count for IME on the Medicare cost report. The cost report was 
subsequently modified to require reporting of unweighted FTE resident 
counts for both direct GME and IME. However, for cost reporting periods 
ending on or before December 31, 1996 (the cost report on which the FTE 
limit is based), hospitals were not required to report unweighted FTE 
resident counts for direct GME purposes. Therefore, a separate data 
collection effort was required to obtain the unweighted FTE resident 
counts. The fiscal intermediaries worked with hospitals to determine 
the unweighted FTE resident counts for direct GME for cost reporting 
periods ending on or before December 31, 1996, for purposes of 
implementing the FTE cap.
    During this process, the fiscal intermediaries did not determine 
IME FTE resident counts for hospitals that were excluded from the IPPS 
(that is, psychiatric hospitals, LTCHs, rehabilitation hospitals, 
children's hospitals, and cancer hospitals) because these hospitals 
were not paid under the IPPS and, therefore, did not receive any IME 
payment adjustments. Only the FTE resident data related to direct GME 
payments were relevant for these excluded hospitals and, therefore, 
only those data were collected. However, it has come to our attention 
that some hospitals that were excluded from the IPPS during the cost 
reporting period ending on or before December 31, 1996 (that is, the 
cost reporting period during which the hospital's FTE resident limit 
was established under section 1886(h)(4)(F) of the Act for purposes of 
direct GME payments) have either failed to continue to qualify for 
exclusion from the IPPS or deliberately changed their operations in a 
way to become subject to the IPPS and, as a result, have subsequently 
become subject to the IME payment adjustment provisions of the IPPS. 
For example, a provider that was a rehabilitation hospital during its 
cost reporting period ending on December 31, 1996, but no longer meets 
the regulatory criteria to qualify as a rehabilitation hospital would 
become subject to the IPPS and be able to receive IME payments. 
However, because no IME FTE resident count for the cost reporting 
period ending on or before December 31, 1996, was determined, such a 
hospital does not have an unweighted FTE resident limit for IME.
    To address this situation, we are proposing to incorporate in the 
regulations (proposed Sec.  412.105(f)(1)(xiii)) CMS' existing policy 
in such situations which provides for the establishment of an IME FTE 
cap for a hospital that was excluded from the IPPS during its base year 
and that subsequently became subject to the IPPS. We are clarifying and 
proposing to adopt into regulations our existing policy that, in such a 
situation, the fiscal intermediary would determine an IME FTE cap for 
the hospital, applicable beginning with the

[[Page 23433]]

hospital's payments under the IPPS, based on the FTE count of residents 
during the cost reporting period(s) used to determine the hospital's 
direct GME FTE cap in accordance with existing Sec.  412.105(f) of the 
regulations. The new IPPS hospital's IME FTE cap would be subject to 
the same rules and adjustments as any IPPS hospital's IME FTE cap in 
accordance with Sec.  412.105(f) of the regulations.
    While calculation of the IME FTE cap for a TEFRA hospital that 
converts to an IPPS hospital may require that fiscal intermediaries 
obtain information from cost reporting periods that are closed, 
allowing a fiscal intermediary to obtain this information should not be 
understood as allowing a fiscal intermediary to reopen closed cost 
reports that are beyond the normal reopening period in order to carry 
out the provisions of this proposed regulation.
    Finally, there may be situations where the data necessary to carry 
out this policy are not available. For example, under this proposal, if 
a children's hospital converts to an IPPS hospital on July 1, 2007, the 
fiscal intermediary may need to determine the count of FTE residents 
for IME purposes training at the hospital during the most recent cost 
reporting period ending on or before December 31, 1996, in order to 
establish an IME FTE cap for the hospital, effective for discharges 
occurring on or after October 1, 2007. However, the count of FTE 
residents for IME purposes from the cost reporting period ending on or 
before December 31, 1996, may no longer be available, as the minimum 
time that hospitals are required to retain records is 5 years from the 
date the hospital submits the cost report. We believe this problem may 
not occur with sufficient frequency to warrant specific regulatory 
action. We are specifically soliciting comments as to whether and how 
hospitals believe this is a problem that needs to be addressed.
    In some cases, a hospital that was previously excluded from the 
IPPS may become subject to the IPPS as a result of a merger between two 
or more hospitals where the surviving hospital is subject to the IPPS 
(and not creating an IPPS hospital with an excluded unit). In such 
cases, CMS policy is that the FTE resident cap for the surviving 
hospital should reflect the combined FTE resident caps for the 
hospitals that merged. If two or more hospitals merge after the 
conclusion of each hospital's base year for purposes of calculating 
resident FTE caps, the surviving hospital's FTE resident cap is an 
aggregation of the FTE resident cap for each hospital participating in 
the merger. When a merger involves an IPPS-excluded hospital, the base 
year IME FTE count for the IPPS-excluded hospital has not been 
determined. We are clarifying and proposing to codify in regulations 
our existing policy that, in such cases, the fiscal intermediary would 
determine an IME FTE cap for the IPPS-excluded hospital for purposes of 
determining the merged hospital's IME FTE cap in accordance with Sec.  
412.105(f) of the regulations. Once this cap is determined, the 
aggregate IME FTE cap of the surviving entity may be calculated in 
accordance with existing CMS policy for mergers.
    We note that we would compute an IME cap for an IPPS-excluded 
hospital only in cases of a merger between an IPPS-excluded hospital 
and an acute care IPPS hospital, where the entire surviving entity is 
subject to the IPPS. No such IME FTE cap would be computed for an IPPS-
excluded hospital in instances where an IPPS-excluded hospital and an 
acute care IPPS hospital agree to form a Medicare GME affiliated group 
for purposes of aggregating FTE resident caps. In cases where an IPPS-
excluded hospital enters into a Medicare GME affiliation agreement with 
other IPPS hospitals, the IPPS-excluded hospital can contribute only 
its direct GME FTE cap to the aggregate FTE cap for the group. This is 
because, as long as a hospital remains excluded from the IPPS, that 
hospital will not have an FTE resident cap established for purposes of 
IME. Under no circumstances may an IPPS-excluded hospital be considered 
to contribute any FTE residents to a Medicare GME affiliation group for 
purposes of the aggregate IME FTE resident cap. IPPS-excluded hospitals 
do not currently, and would not under this proposed policy, have an IME 
FTE resident cap.
3. Section 1886(d)(8)(E) Teaching Hospitals That Withdraw Rural 
Reclassification
    In section V.I. of this preamble, we discuss situations in which an 
urban hospital may become rural under a reclassification request under 
section 1886(d)(8)(E) of the Act. Under section 1886(d)(8)(E) of the 
Act, an urban hospital may file an application to be treated as being 
located in a rural area. Becoming rural under this provision affects 
only payments under section 1886(d) of the Act. If the hospital is a 
teaching hospital, the hospital could not receive adjustments to its 
direct GME FTE cap because payments for direct GME are made under 
section 1886(h) of the Act and the section 1886(d)(8)(E) 
reclassifications affect only the payments that are made under section 
1886(d) of the Act. Therefore, an urban hospital that reclassifies as 
rural under this provision may receive the 130-percent adjustment to 
its IME FTE resident cap. In addition, its IME FTE cap may be adjusted 
for any new programs (similar to a hospital that is actually located in 
an area designated as rural) under section 1886(d)(5)(B)(v) of the Act, 
as amended by section 407 of Pub. L. 106-113 (BBRA).
    An urban hospital treated as rural under section 1886(d)(8)(E) of 
the Act may subsequently withdraw its election and return to its urban 
status under the regulations at Sec.  412.103. We are proposing that, 
effective with discharges occurring on or after October 1, 2005, 
hospitals that rescind their section 1886(d)(8)(E) reclassifications 
and return to being urban would not be eligible for permanent increases 
in their IME caps. Rather, any adjustments the hospitals received to 
their IME caps due to their rural status would be forfeited upon 
returning to urban status. Although we read the relevant IME FTE cap 
provisions in section 1886(d)(5)(B) of the Act as effecting a permanent 
increase to the FTE cap, we believe we have the statutory authority 
under section 1886(d)(5)(I) of the Act to make necessary adjustments to 
these caps that we believe are appropriate. Section 1886(d)(5)(I)(i) of 
the Act grants the Secretary authority to provide by regulation for 
``such other exceptions and adjustments to such payment amounts under 
this subsection as the Secretary deems appropriate.'' We believe it is 
appropriate that a section 1886(d)(8)(E) hospital forfeit the 
adjustments it received solely due to its reclassification to rural 
status when it returns to being urban. Otherwise, urban hospitals might 
reclassify to rural areas under section 1886(d)(8)(E) of the Act for a 
short period of time solely as a means of receiving an increase to 
their IME FTE caps. These hospitals could reclassify for as little as 
one year, simply in order to receive a permanent increase to their IME 
FTE caps. Because section 1886(d)(8)(E) hospitals have control over 
when they switch in and out of rural status, we believe any other 
policy would be subject to gaming and inappropriate usage of the 
section 1886(d)(8)(E) authority. In contrast, hospitals that become 
urban due to the OMB-revised labor area designations have no control in 
the matter, and therefore would not be subject to the same type of 
manipulation of payment rates we believe would exist with the section 
1886(d)(8)(E) hospitals.
    (We note that the above proposed policy would have no effect on 
rural track resident training programs.

[[Page 23434]]

Section 1886(h)(4)(H)(iv) of the Act, which governs direct GME, 
provides that an urban hospital may receive adjustments to its FTE caps 
for establishing ``separately accredited approved medical residency 
training programs (or rural tracks) in an [sic] rural area.'' The 
provisions governing IME state that ``Rules similar to the rules of 
subsection (h)(4)(H) shall apply for purposes of'' determining FTE 
resident caps (section 1886(d)(5)(B)(viii) of the Act). Since the 
requirement that the hospital be located in a rural area is found in 
the provisions governing direct GME (section 1886(h) of the Act), not 
the provision governing IME, and since hospitals cannot reclassify as 
rural for purposes of section 1886(h) of the Act, we believe that, as 
provided in section 1886(h) of the Act, the hospital with which the 
urban hospital establishes the rural track must be physically located 
in an area designated as rural. We do not believe we would be properly 
incorporating the rules of section 1886(h) of the Act or creating a 
rule similar to that used in section 1886(h) of the Act if we were to 
allow counting of such reclassified hospitals.)
    For the reasons stated above, we are proposing to amend the 
regulations at Sec.  412.105 by adding a new paragraph (f)(1)(xiv) to 
provide that a hospital that rescinds its section 1886(d)(8)(E) 
reclassification will forfeit any adjustments to its IME FTE cap it 
received due to its rural status. Thus, for example, a hospital that 
reclassified as rural under section 1886(d)(8)(e) of the Act with an 
IME FTE cap of 10 would have received a 130 percent adjustment to its 
IME cap (that is, 10 FTEs x 1.3). Furthermore, if this hospital, while 
reclassified as rural, started a new 3-year residency program with 2 
residents in each program year, its FTE cap would have been increased 
by an additional 6 FTEs to 19 FTEs (that is, 13 FTEs + 6 FTEs). 
However, once this hospital rescinds its reclassification under section 
1886(d)(8)(E) of the Act to become urban again, its IME FTE cap would 
return to 10 FTEs (its original pre-reclassification IME FTE cap).

G. Payment to Disproportionate Share Hospitals (DSHs) (Sec.  412.106)

    (If you choose to comment on issues in this section, please include 
the caption ``DSH Adjustment Data'' at the beginning of your comment.)
1. Background
    Section 1886(d)(5)(F) of the Act provides for additional payments 
to subsection (d) hospitals that serve a disproportionate share of low-
income patients. The Act specifies two methods for a hospital to 
qualify for the Medicare disproportionate share hospital (DSH) 
adjustment. Under the first method, hospitals that are located in an 
urban area and have 100 or more beds may receive a DSH payment 
adjustment if the hospital can demonstrate that, during its cost 
reporting period, more than 30 percent of its net inpatient care 
revenues are derived from State and local government payments for care 
furnished to indigent patients. These hospitals are commonly known as 
``Pickle hospitals.'' The second method, which is also the most 
commonly used method for a hospital to qualify, is based on a complex 
statutory formula under which payment adjustments are based on the 
level of the hospital's DSH patient percentage, which is the sum of two 
fractions: the ``Medicare fraction'' and the ``Medicaid fraction.'' The 
Medicare fraction is computed by dividing the number of patient days 
that are furnished to patients who were entitled to both Medicare Part 
A and Supplemental Security Income (SSI) benefits by the total number 
of patient days furnished to patients entitled to benefits under 
Medicare Part A. The Medicaid fraction is computed by dividing the 
number of patient days furnished to patients who, for those days, were 
eligible for Medicaid but were not entitled to benefits under Medicare 
Part A by the number of total hospital patient days in the same period.
[GRAPHIC] [TIFF OMITTED] TP04MY05.088

2. Implementation of Section 951 of Pub. L. 108-173 (MMA)
    Section 951 of Pub. L. 108-173 requires the Secretary to arrange to 
furnish the data necessary for hospitals to compute the number of 
patient days used in calculating the disproportionate patient 
percentages. The provision is not specific as to whether it applies to 
the patient day data used to determine the Medicare fraction or the 
Medicaid fraction. We are interpreting section 951 to require the 
Secretary to arrange to furnish to hospitals the data necessary to 
calculate both the Medicare and Medicaid fractions. With respect to 
both the Medicare and Medicaid fractions, we also are interpreting 
section 951 to require CMS to arrange to furnish the personally 
identifiable information that would enable a hospital to compare and 
verify its records, in the case of the Medicare fraction, against the 
CMS' records, and in the case of the Medicaid fraction, against the 
State Medicaid agency's records. Currently, as explained in more detail 
below, CMS provides the Medicare SSI days to certain hospitals that 
request these data. Hospitals are currently required under the 
regulation at Sec.  412.106(b)(4)(iii) to provide the data adequate to 
prove eligibility for the Medicaid, non-Medicare days.
    As indicated above, the numerator of the Medicare fraction includes 
the number of patient days furnished by the hospital to patients who 
were entitled to both Medicare Part A and SSI benefits. This number is 
divided by the hospital's total number of patient days furnished to 
patients entitled to benefits under Medicare Part A. In order to 
determine the numerator of this fraction for each hospital, CMS obtains 
a data file from the Social Security Administration (SSA). CMS matches 
personally identifiable information from the SSI file against its 
Medicare Part A entitlement information for the fiscal year to 
determine the number of Medicare SSI days for each hospital during each 
fiscal year. These data are maintained in the MedPAR Limited Data Set 
(LDS) as described in more detail below and discussed in a notice 
published on August 18, 2000 in the Federal Register (65 FR 50548). The 
number of patient days furnished by the hospital to Medicare 
beneficiaries entitled to SSI is divided by the hospital's total number 
of Medicare days (the denominator of the Medicare fraction). CMS 
determines this number from Medicare claims data; hospitals also have 
this information in their records. The Medicare fraction for each 
hospital is posted on the CMS Web site (http://www.cms.hhs.gov) under 
the SSI/Medicare Part A Disproportionate Share Percentage File. Under 
current regulations at Sec.  412.106(b)(3), a hospital may request to 
have its Medicare fraction recomputed based on the hospital's cost 
reporting period if that year differs from the Federal fiscal year. 
This request may be made only once per

[[Page 23435]]

cost reporting period, and the hospital must accept the resulting DSH 
percentage for that year, whether or not it is a more favorable number 
than the DSH percentage based on the Federal fiscal year.
    In accordance with section 951 of Pub. L. 108-173, we are proposing 
to change the process that we use to make Medicare data used in the DSH 
calculation available to hospitals. Currently, as stated above, CMS 
calculates the Medicare fraction for each section 1886(d) hospital 
using data from the MedPAR LDS (as established in a notice published in 
the August 18, 2000 Federal Register (65 FR 50548)). The MedPAR LDS 
contains a summary of all services furnished to a Medicare beneficiary, 
from the time of admission through discharge, for a stay in an 
inpatient hospital or skilled nursing facility, or both; SSI 
eligibility information; and enrollment data on Medicare beneficiaries. 
The MedPAR LDS is protected by the Privacy Act of 1974 (5 U.S.C. 552a) 
and the Privacy Rule of the Health Insurance Portability and 
Accountability Act of 1996 (Pub. L. 104-191). The Privacy Act allows us 
to disclose information without an individual's consent if the 
information is to be used for a purpose that is compatible with the 
purpose(s) for which the information was collected. Any such compatible 
use of data is known as a ``routine use.'' In order to obtain this 
privacy-protected data, the hospital must qualify under the routine use 
that was described in the August 18, 2000 Federal Register. Currently, 
a hospital qualifies under the routine use if it has an appeal properly 
pending before the Provider Reimbursement Review Board (PRRB) or before 
an intermediary on the issue of whether it is entitled to DSH payments, 
or the amount of such payments. Once determined eligible to receive the 
data under the routine use, the hospital is then required to sign a 
data use agreement with CMS to ensure that the data are appropriately 
used and protected, and pay the requisite fee.
    Beginning with cost reporting periods that include December 8, 2004 
(within one year of the date of enactment of Pub. L. 108-173), we are 
proposing to furnish MedPAR LDS data for a hospital's patients eligible 
for both SSI and Medicare at the hospital's request, regardless of 
whether there is a properly pending appeal relating to DSH payments. We 
are proposing to make the information available for either the Federal 
fiscal year or, if the hospital's fiscal year differs from the Federal 
fiscal year, for the months included in the two Federal fiscal years 
that encompass the hospital's cost reporting period. Under our 
proposal, the hospital could use these data to calculate and verify its 
Medicare fraction, and to decide whether it prefers to have the 
fraction determined on the basis of its fiscal year rather than a 
Federal fiscal year. The data set made available to hospitals would be 
the same data set CMS uses to calculate the Medicare fractions for the 
Federal fiscal year.
    Because we interpret section 951 to require the Secretary to 
arrange to furnish these data, we do not believe that it will continue 
to be appropriate to charge hospitals to access the data. These 
proposed changes would require CMS to modify the current routine use 
for the MedPAR LDS to reflect changes in the data provided and the 
circumstances under which they are made available to hospitals. In a 
future Federal Register document, we will publish the details of any 
necessary modifications to the current routine use to implement section 
951 of Pub. L. 108-173. We welcome comments on all aspects of these 
proposed changes.
    The numerator of the Medicaid fraction includes hospital inpatient 
days that are furnished to patients who, for those days, were eligible 
for Medicaid but were not entitled to benefits under Medicare Part A. 
Under the regulation at Sec.  412.106(b)(4)(iii), hospitals are 
responsible for proving Medicaid eligibility for each Medicaid patient 
day and verifying with the State that patients were eligible for 
Medicaid on the claimed days. The number of Medicaid, non-Medicare days 
is divided by the hospital's total number of inpatient days in the same 
period. Total inpatient days are reported on the Medicare cost report. 
(This number is also available in the hospital's own records.)
    Much of the data used to calculate the Medicaid fraction of the DSH 
patient percentage are available to hospitals from their own records or 
from the States. We recognize that Medicaid State plans are only 
permitted to use and disclose information concerning applicants and 
recipients for ``purposes directly connected with the administration of 
the [State] plan'' under section 1902(a)(7) of the Act. Regulations at 
42 CFR 431.302 define these purposes to include establishing 
eligibility (Sec.  431.302(a)) and determining the amount of medical 
assistance (Sec.  431.302(b)). Thus, State plans are permitted under 
the currently applicable statutory and regulatory provisions governing 
the disclosure of individually identifiable data on Medicaid applicants 
and recipients to provide hospitals the data needed to meet their 
obligation under Sec.  412.106(b)(4)(iii) in the context of either an 
``eligibility inquiry'' with the State plan or in order to assist the 
hospital, and thus the State plan, in determining the amount of medical 
assistance.
    In the process of developing a plan for implementing section 951 
with respect to the data necessary to calculate the Medicaid fraction, 
we asked our regional offices to report on the availability of this 
information to hospitals and on any problems that hospitals face in 
obtaining the information that they need. The information we received 
suggested that, in the vast majority of cases, there are established 
procedures for hospitals or their authorized representatives to obtain 
the information needed for hospitals to meet their obligation under 
Sec.  412.106(b)(4)(iii) and to calculate their Medicaid fraction. 
There is no uniform national method for hospitals to verify Medicaid 
eligibility for a specific patient on a specific day. For instance, 
some States, such as Arizona, have secure online systems that providers 
may use to check eligibility information. However, in most States, 
providers send a list of patients to the State Medicaid office for 
verification. Other States, such as Hawaii, employ a third party 
private company to maintain the Medicaid database and run eligibility 
matches for providers. The information that providers submit to State 
plans (or third party contractors) differs among States as well. Most 
States require the patient's name, date of birth, gender, social 
security number, Medicaid identification, and admission and discharge 
dates. States or the third parties may respond with either ``Yes/No'' 
or with more detailed Medicaid enrollment and eligibility information 
such as whether or not the patient is a dual-eligible, whether the 
patient is enrolled in a fee-for-service or HMO plan, and under which 
State assistance category the individual qualified for Medicaid.\4\
---------------------------------------------------------------------------

    \4\ Bear in mind that States and hospitals should, in keeping 
with the HIPAA Privacy Rule, limit the data exchanged in the context 
of these inquiries and responses to the minimum necessary to 
accomplish the task
---------------------------------------------------------------------------

    We note that we have been made aware of at least one instance in 
which a State is concerned about providing hospitals with the requisite 
eligibility data. We understand that the basis for the State's 
objections is section 1902(a)(7) of the Act. The State is concerned 
that section 1902(a)(7) of the Act prohibits the State from providing 
eligibility data for any purpose other than a purpose related to State 
plan

[[Page 23436]]

administration. However, as described above, we believe that States are 
permitted to verify Medicaid eligibility for hospitals as a purpose 
directly related to State plan administration under Sec.  431.302.
    In addition, we believe it is reasonable to continue to place the 
burden of furnishing the data adequate to prove eligibility for each 
Medicaid patient day claimed for DSH percentage calculation purposes on 
hospitals because, since they have provided inpatient care to these 
patients for which they billed the relevant payors, including the State 
Medicaid plan, they will necessarily already be in possession of much 
of this information. We continue to believe hospitals are best situated 
to provide and verify Medicaid eligibility information. Although we 
believe the mechanisms are currently in place to enable hospitals to 
obtain the data necessary to calculate their Medicaid fraction of the 
DSH patient percentage, there is currently no mandatory requirement 
imposed upon State Medicaid agencies to verify eligibility for 
hospitals. At this point, we believe there is no need to modify the 
Medicaid State plan regulations to require that State plans verify 
Medicaid eligibility for hospitals. However, should we find that States 
are not voluntarily providing or verifying Medicaid eligibility 
information for hospitals, we will consider amending the State plan 
regulations to add a requirement that State plans provide certain 
eligibility information to hospitals.

H. Geographic Reclassifications (Sec. Sec.  412.103 and 412.230)

    (If you choose to comment on issues in this section, please include 
the caption ``Geographic Reclassifications'' at the beginning of your 
comment.)
1. Background
    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)). As a result 
of legislative changes under section 402(b) of Pub. L. 108-7, Pub. L. 
108-89, and section 401 of Pub. L. 108-173, the standardized amount 
reclassification criterion for large urban and other areas is no longer 
necessary or appropriate and has been removed from our reclassification 
policy (69 FR 49103). We implemented this provision in the FY 2005 IPPS 
final rule (69 FR 49103). As a result, hospitals can request 
reclassification for the purposes of the wage index only and not the 
standardized amount. Implementing regulations in Subpart L of Part 412 
(Sec. Sec.  412.230 et seq.) set forth criteria and conditions for 
reclassifications for purposes of the wage index 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.
    Under section 1886(d)(8)(E) of the Act, an urban hospital may file 
an application to be treated as being located in a rural area if 
certain conditions are met. The regulations implementing this provision 
are located under Sec.  412.103.
    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(d)(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 2006, the MGCRB used the 3-year average hourly 
wages published in Table 2 of the August 11, 2004 IPPS final rule (69 
FR 49295). These average hourly wages are taken from data used to 
calculate the wage indexes for FY 2003, FY 2004, and FY 2005, based on 
cost reporting periods beginning during FY 1999, FY 2000, and FY 2001, 
respectively.
2. Multicampus Hospitals (Sec.  412.230)
    As discussed in section III.B. of this preamble, on June 6, 2003, 
the OMB announced the new CBSAs, comprised of Metropolitan Statistical 
Areas (MSAs) and Micropolitan Statistical Areas, based on Census 2000 
data. Effective October 1, 2004, for the IPPS, we implemented new labor 
market areas based on the CBSA definitions of MSAs. In some cases, the 
new CBSAs resulted in previously existing MSAs being divided into two 
or more separate labor market areas. In the FY 2005 IPPS final rule (69 
FR 48916), we acknowledged that the implementation of the new MSAs 
would have a considerable impact on hospitals. Therefore, we made every 
effort to implement transitional provisions that would mitigate the 
negative effects of the new labor market areas on hospitals that 
request reclassification to another area for purposes of the wage index 
and on all hospitals.
    Subsequent to the publication of the FY 2005 IPPS final rule, we 
became aware of a situation in which, as a result of the new labor 
market areas, a multicampus hospital previously located in a single MSA 
is now located in more than one CBSA. Under our current policy, a 
multicampus hospital with campuses located in the same labor market 
area receives a single wage index. However, if the campuses are located 
in more than one labor market area, payment for each discharge is 
determined using the wage index value for the MSA (or metropolitan 
division, where applicable) in which the campus of the hospital is 
located. In addition, the current provision set forth in section 2779F 
of the Medicare State Operations Manual provides that, in the case of a 
merger of hospitals, if the merged facilities operate as a single 
institution, the institution must submit a single cost report, which 
necessitates a single provider identification number. This provision 
does not differentiate between merged facilities in a single wage index 
area or in multiple wage index areas. As a result, the wage index data 
for the merged facility is reported for the entire entity on a single 
cost report.
    The current criteria for a hospital being reclassified to another 
wage area by the MGCRB do not address the circumstances under which a 
single campus of a multicampus hospital may seek reclassification. That 
is, a hospital must provide data from the CMS hospital wage survey for 
the average hourly wage comparison that is used to support a request 
for reclassification. However, because a multicampus hospital is 
required to report data for the entire entity on a single cost report, 
there is no wage survey data for the individual hospital campus that 
can be used in a reclassification application. In an effort to remedy 
this situation, for FY 2007 and subsequent year reclassifications, we 
are proposing to allow a campus of a multicampus hospital system that 
wishes to seek geographic reclassification to another labor market area 
to report campus-specific wage data using a supplemental Form S-3 (CMS' 
manual version of Worksheet S-3) for purposes of the wage data 
comparison. These data would then constitute the appropriate wage data 
under Sec.  412.232(d)(2) for purposes of comparing the hospital's 
wages to the wages of hospitals in the area to which it seeks 
reclassification as well as the area in which it is located. Before the 
data could be used in a reclassification application, the

[[Page 23437]]

hospital's fiscal intermediary would have to review the allocation of 
the entire hospital's wage data among the individual campuses.
    For FY 2006 reclassification applications, we are proposing to 
allow a campus of a multicampus hospital system to use the average 
hourly wage data submitted for the entire multicampus hospital system 
as its appropriate wage data under Sec.  412.232(d)(2). We are 
establishing this special rule for FY 2006 reclassifications because 
the deadline for submitting an application to the MGCRB was September 
1, 2004, and there no longer is an opportunity to provide a 
Supplemental Form S-3 that allocates the wage data by individual 
hospital campus. This special rule will be applied only to an 
individual campus of a multicampus hospital system that made an 
application for reclassification for FY 2006 and that otherwise meets 
all of the reclassification criteria. We do not believe that the 
special rule is necessary for reclassifications for FY 2007 because the 
deadline for making those applications has not yet passed and a 
hospital seeking reclassification will be able to provide the 
Supplemental Form S-3 that allocates the wage data by individual 
hospital campus. We are proposing to apply these new criteria to 
geographic reclassification applications that were received by 
September 1, 2004, and that will take effect for FY 2006.
    We are proposing to revise the regulations at Sec.  412.230(d)(2) 
by redesignating paragraph (d)(2)(iii) as paragraph (d)(2)(v) and 
adding new paragraph (d)(2))(iii) and (d)(2)(iv) to incorporate the 
proposed new criteria for multicampus hospitals.
3. Urban Group Hospital Reclassifications
    In FY 2005 IPPS final rule (69 FR 49104), we set forth, under Sec.  
412.234(a)(3)(ii), revised criteria for urban hospitals to be 
reclassified as a group. After the publication of the final rule, we 
became aware that portions of our policy discussion with respect to the 
implementing decision were inadvertently omitted. This policy was 
corrected in the October 7, 2004, correction to the final rule (69 FR 
60248). The correction specified that ``hospitals located in counties 
that are in the same Combined Statistical Area (under the MSA 
definitions announced by the OMB on June 6, 2003); or in the same 
Consolidated Metropolitan Statistical Area (CMSA) (under the standards 
published by the OMB on March 30, 1990) as the urban area to which they 
seek redesignation qualify as meeting the proximity requirement for 
reclassification to the urban area to which they seek redesignation.''
    In making the determination to revise our urban group 
reclassification policy, we took into consideration the magnitude of 
the changes that would have resulted from our adoption of the new labor 
market areas. The resulting policy was intended to preserve the 
reclassification opportunities for urban county groups; in other words, 
an eligible urban county group would have to meet either the CSA or 
CMSA criteria, but not both to be eligible for consideration.
    As a result of adopting the new labor market area definitions, we 
reexamined the appropriateness of the FY 2005 changes with emphasis on 
determining whether including ``* * * or in the same Consolidated 
Metropolitan Statistical Area (CMSA) (under the standards published by 
the OMB on March 30, 1990)'' as a qualifying criterion, is necessary or 
consistent with our plans to fully implement the new labor area market 
definitions.
    Based on our experiences now that the new labor market areas are in 
effect and since we revised the urban county group regulations, we no 
longer think it is necessary to retain use of a 1990-based standard as 
a criterion for determining whether an urban county group is eligible 
for reclassification. We believe it is reasonable to use the area 
definitions that are based on the most recent statistics; in other 
words, the CSA standard. Therefore, we are proposing to delete Sec.  
412.234(a)(3)(ii) to remove reference to the CMSA eligibility 
criterion. Beginning with FY 2006, we are proposing to require that 
hospitals must be located in counties that are in the same Combined 
Statistical Area (under the MSA definitions announced by the OMB on 
June 6, 2003) as the urban area to which they seek redesignation to 
qualify as meeting the proximity requirement for reclassification to 
the urban area to which they seek redesignation. We believe that this 
proposed change would improve the overall consistency of our policies 
by using a single labor market area definition for all aspects of the 
wage index and reclassification.
4. Clarification of Goldsmith Modification Criterion for Urban 
Hospitals Seeking Reclassification as Rural
    Under section 1886(d)(8)(E) of the Act, certain urban hospitals may 
file an application for reclassification as rural if the hospital meets 
certain criteria. One of these criteria is that the hospital is located 
in a rural census tract of a CBSA, as determined under the most recent 
version of the Goldsmith Modification as determined by the Office of 
Rural Health Policy. This provision is implemented in our regulations 
at Sec.  412.103(a)(1).
    The original Goldsmith Modification was developed using data from 
the 1980 census. In order to more accurately reflect current 
demographic and geographic characteristics of the Nation, the Office of 
Rural Health Policy, in partnership with the Department of 
Agriculture's Economic Research Service and the University of 
Washington, has developed the Rural-Urban Commuting Area codes (RUCAs) 
(69 FR 47518 through 47529, August 5, 2004). Rather than being limited 
to large area metropolitan counties (LAMCs), RUCAs use urbanization, 
population density, and daily commuting data to categorize every census 
tract in the country. RUCAs are the updated version of the Goldsmith 
Modification and are used to identify rural census tracts in all 
metropolitan counties.
    We are proposing to update the Medicare regulations at Sec.  
412.103(a)(1) to incorporate this change in the identification of rural 
census tracts. We are also proposing to update the website and the 
agency location at which the RUCA codes are accessible.
5. Cross-Reference Changes
    In the FY 2005 IPPS final rule, in conjunction with changes made by 
various sections of Pub. L. 108-173 and changes in the OMB standards 
for defining labor market areas, we established a new Sec.  412.64 
governing rules for establishing Federal rates for inpatient operating 
costs for FY 2005 and subsequent years. In this new section, we 
included definitions of ``urban'' and ``rural'' for the purpose of 
determining the geographic location or classification of hospitals 
under the IPPS. These definitions were previous located in Sec.  
412.63(b), applicable to FYs 1985 through 2004, and in Sec.  412.62(f), 
applicable to FY 1984. References to the definitions under Sec.  
412.62(f) and Sec.  412.63(b), appear throughout 42 CFR Chapter IV. 
However, when we finalized the provisions of Sec.  412.64, we 
inadvertently omitted updating some of these cross-references to 
reflect the change in the location of the two definitions for FYs 2005 
and subsequent years. We are proposing to change the cross-references 
to the definitions of ``urban'' and ``rural'' to reflect their current 
locations in Subpart D of Part 412, as applicable.

[[Page 23438]]

I. Payment for Direct Graduate Medical Education (Sec.  413.79)

    (If you choose to comment on issues in this section, please include 
the caption ``Graduate Medical Education'' at the beginning of your 
comment.)
1. Background
    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 existing Sec. Sec.  413.75 
through 413.83, establishes a methodology for determining payments to 
hospitals for the costs of approved graduate medical education (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 beginning between October 1, 1983, through September 30, 
1984). Medicare direct GME payments are calculated by multiplying the 
PRA times the weighted number of full-time equivalent (FTE) residents 
working in all areas of the hospital (and nonhospital sites, when 
applicable), and the hospital's Medicare share of total inpatient days. 
In addition, as specified in section 1886(h)(2)(D)(ii) of the Act, for 
cost reporting periods beginning on or after October 1, 1993, through 
September 30, 1995, each hospital-specific PRA for the previous cost 
reporting period is not updated for inflation for any FTE residents who 
are not either a primary care or an obstetrics and gynecology resident. 
As a result, hospitals that train primary care and obstetrics and 
gynecology residents, as well as nonprimary care residents in FY 1994 
or FY 1995, have two separate PRAs: One for primary care and obstetrics 
and gynecology residents and one for nonprimary care residents.
    Pub. L. 106-113 amended section 1886(h)(2) of the Act to establish 
a methodology for the use of a national average PRA in computing direct 
GME payments for cost reporting periods beginning on or after October 
1, 2000, and on or before September 30, 2005. Pub. L. 106-113 
established a ``floor'' for hospital-specific PRAs equal to 70 percent 
of the locality-adjusted national average PRA. In addition, the BBRA 
established a ``ceiling'' that limited the annual adjustment to a 
hospital-specific PRA if the PRA exceeded 140 percent of the locality-
adjusted national average PRA. Section 511 of the BIPA (Pub. L. 106-
554) increased the floor established by the BBRA to equal 85 percent of 
the locality-adjusted national average PRA. Existing regulations at 
Sec.  413.77(d)(2)(iii) specify that, for purposes of calculating 
direct GME payments, each hospital-specific PRA is compared to the 
floor and the ceiling to determine whether a hospital-specific PRA 
should be revised.
    Section 1886(h)(4)(F) of the Act established limits on the number 
of allopathic and osteopathic residents that hospitals may count for 
purposes of calculating direct GME payments. For most hospitals, the 
limits were the number of allopathic and osteopathic FTE residents 
training in the hospital's most recent cost reporting period ending on 
or before December 31, 1996.
2. Direct GME Initial Residency Period (IRP) Sec.  413.79(a)(10)
a. Background
    As we have generally described above, the amount of direct GME 
payment to a hospital is based in part on the number of FTE residents 
the hospital is allowed to count for direct GME purposes during a year. 
The number of FTE residents, and thus the amount of direct GME payment 
to a hospital, is directly affected by CMS policy on how ``initial 
residency periods'' are determined for residents. Section 
1886(h)(4)(C)(ii) of the Act, implemented at Sec.  413.79(b)(1), 
provides that while a resident is in the ``initial residency period'' 
(IRP), the resident is weighted at 1.00. Section 1886(h)(4)(C)(iii) of 
the Act, implemented at Sec.  413.79(b)(2), requires that if a resident 
is not in the resident's IRP, the resident is weighted at .50 FTE 
resident.
    Section 1886(h)(5)(F) of the Act defines ``initial residency 
period'' as the ``period of board eligibility,'' and, subject to 
specific exceptions, limits the initial residency period to an 
``aggregate period of formal training'' of no more than 5 years for any 
individual. Section 1886(h)(5)(G) of the Act generally defines ``period 
of board eligibility'' for a resident as ``the minimum number of years 
of formal training necessary to satisfy the requirements for initial 
board eligibility in the particular specialty for which the resident is 
training.'' Existing Sec.  413.79(a) of the regulations generally 
defines ``initial residency period'' as the ``minimum number of years 
required for board eligibility.'' Existing Sec.  413.79(a)(5) provides 
that ``time spent in residency programs that do not lead to 
certification in a specialty or subspecialty, but that otherwise meet 
the definition of approved programs * * * is counted toward the initial 
residency period limitation.'' Section 1886(h)(5)(F) of the Act further 
provides that ``the initial residency period shall be determined, with 
respect to a resident, as of the time the resident enters the residency 
training program.''
    The IRP is determined as of the time the resident enters the 
``initial'' or first residency training program and is based on the 
period of board eligibility associated with that medical specialty. 
Thus, these provisions limit the amount of FTE resident time that may 
be counted for a resident who, after entering a training program in one 
specialty, switches to a program in a specialty with a longer period of 
board eligibility or completes training in one specialty training 
program and then continues training in a subspecialty (for example, 
cardiology and gastroenterology are subspecialties of internal 
medicine).
b. Direct GME Initial Residency Period Limitation: Simultaneous Match
    We understand that there are numerous programs, including 
anesthesiology, dermatology, psychiatry, and radiology, that require a 
year of generalized clinical training to be used as a prerequisite for 
the subsequent training in the particular specialty. For example, in 
order to become board eligible in anesthesiology, a resident must first 
complete a generalized training year and then complete 3 years of 
training in anesthesiology. This first year of generalized residency 
training is commonly known as the ``clinical base year.'' Often, the 
clinical base year requirement is fulfilled by completing either a 
preliminary year in internal medicine (although the preliminary year 
can also be in other specialties such as general surgery or family 
practice), or a transitional year program (which is not associated with 
any particular medical specialty).
    In many cases, during the final year of medical school, medical 
students apply for training in specialty residency training programs. 
Typically, a medical student who wants to train to become a specialist 
is ``matched'' to both the clinical base year program and the specialty 
residency training program at the same time. For example, the medical 
student who wants to become an anesthesiologist will apply and 
``match'' simultaneously for a clinical base year in an internal 
medicine program for year 1 and for an anesthesiology training program 
beginning in year 2.
    Prior to October 1, 2004, CMS' policy was that the IRP is 
determined for a

[[Page 23439]]

resident based on the program in which he or she participates in the 
resident's first year of training, without regard to the specialty in 
which the resident ultimately seeks board certification. Therefore, for 
example, a resident who chooses to fulfill the clinical base year 
requirement for an anesthesiology program with a preliminary year in an 
internal medicine program will be ``labeled'' with the IRP associated 
with internal medicine, that is, 3 years (3 years of training are 
required to become board eligible in internal medicine), even though 
the resident may seek board certification in anesthesiology, which 
requires a minimum of 4 years of training to become board eligible. As 
a result, this resident would have an IRP of 3 years and, therefore, be 
weighted at 0.5 FTE in his or her fourth year of anesthesiology 
training for purposes of direct GME payment.
    Effective with cost reporting periods beginning on or after October 
1, 2004, to address programs that require a clinical base year, we 
revised our policy in the FY 2005 IPPS final rule (69 FR 49170 through 
49174) concerning the IRP. Specifically, under the revised policy, if a 
hospital can document that a particular resident matches simultaneously 
for a first year of training in a clinical base year in one medical 
specialty, and for additional year(s) of training in a different 
specialty program, the resident's IRP will be based on the period of 
board eligibility associated with the specialty program in which the 
resident matches for the subsequent year(s) of training and not on the 
period of board eligibility associated with the clinical base year 
program. This change in policy is codified at Sec.  413.79(a)(10) of 
the regulations.
    This policy applies regardless of whether the resident completes 
the first year of training in a separately accredited transitional year 
program or in a preliminary (or first) year in another residency 
training program such as internal medicine.
    In addition, because programs that require a clinical base year are 
nonprimary care specialties, we specified in Sec.  413.79(a)(10) that 
the nonprimary care PRA would apply for the entire duration of the 
initial residency period. By treating the first year as part of a 
nonprimary care specialty program, the hospital will be paid at the 
lower nonprimary care PRA rather than the higher primary care PRA, even 
if the residents are training in a primary care program during the 
clinical base year.
    In the FY 2005 IPPS final rule (69 FR 49170 and 49171), we also 
defined ``residency match'' to mean, for purposes of direct GME, a 
national process by which applicants to approved medical residency 
programs are paired with programs on the basis of preferences expressed 
by both the applicants and the program directors.
    These policy changes, which were effective October 1, 2004, are 
only applicable to residents that simultaneously match in both a 
clinical base year program and a longer specialty residency program. We 
have become aware of situations where residents, upon completion of 
medical school, only match for a program beginning in the second 
residency year in an advanced specialty training program but fail to 
match for a clinical base year of training. Residents that match into 
an advanced program but fail to match into a clinical base year program 
may independently pursue unfilled residency positions in preliminary 
year programs after the match process is complete. However, because 
these residents do not ``simultaneously match'' into both a preliminary 
year and an advanced program, currently their IRP cannot be determined 
based on the period of board eligibility associated with the advanced 
program, as specified in Sec.  413.79(a)(10). Rather, the IRP for such 
residents would continue to be determined based on the specialty 
associated with the preliminary year program. For example, a student in 
the final year of medical school may match into a radiology program 
that begins in the second residency year, but not match with any 
clinical base year program. Under our current policy, if subsequent to 
conclusion of the match process, this resident secured a preliminary 
year position in an internal medicine program, the resident would not 
have met the requirements at Sec.  413.79(a)(10) for a simultaneous 
match and the IRP for this resident would be based on the length of 
time required to complete an internal medicine program (3 years) rather 
than the length of the radiology program (4 years).
    The intent of the ``simultaneous match'' provision of Sec.  
413.79(a)(10) is to identify in a verifiable manner the specialty 
associated with the program in which the resident will initially train 
and seek board certification. It is also the intent of Sec.  
413.79(a)(10) that a resident's IRP would not change if the resident, 
after initially entering a training program in one specialty, changes 
programs to train in another medical specialty. The ``simultaneous 
match'' provisions of Sec.  413.79(a)(10) allow CMS to both identify 
the specialty associated with the program in which the resident is 
ultimately expected to train and seek board certification and prevent 
inappropriate revision of the IRP in cases where a resident changes 
specialties subsequent to beginning residency training. However, we 
note that when a medical student in his or her final year of medical 
school matches into an advanced program (for example, anesthesiology) 
for the second program year, but fails to match in a clinical base 
year, and obtains a preliminary year position outside the match 
process, we can still identify the specialty associated with the 
program in which the resident is ultimately expected to train and seek 
board certification and prevent inappropriate changes to the IRP if the 
resident changes specialties subsequent to beginning residency 
training.
    Therefore, we are proposing to revise Sec.  413.79(a)(10) to state 
that, when a hospital can document that a resident matched in an 
advanced residency training program beginning in the second residency 
year prior to commencement of any residency training, the resident's 
IRP will be determined based on the period of board eligibility for the 
specialty associated with the advanced program, without regard to the 
fact that the resident had not matched for a clinical base year 
training program.
    We note that this proposed policy change would not result in a 
policy to determine the IRP for all residents who must complete a 
clinical base year during the second residency training year based on 
the specialty associated with that second residency training year. That 
is, we are not proposing that, for any resident whose first year of 
training is completed in a program that provides a general clinical 
base year as required by the ACGME for certain specialties, an IRP 
should be assigned in the second year based on the specialty the 
resident enters in the second year of training. As we stated in the FY 
2005 IPPS final rule (69 FR 49172), a ``second year'' policy would not 
allow CMS to distinguish between those residents who, in their second 
year of training, match in a specialty program prior to their first 
year of training, those residents who participated in a clinical base 
year in a specialty and then continued training in that specialty, and 
those residents who simply switched specialties in their second year. 
Rather, we are proposing that, if a hospital can document that a 
particular resident had matched in an advanced specialty program that 
requires completion of a clinical base year prior to the resident's 
first year of training, the IRP would not be determined based on the 
period of board eligibility for the specialty associated with the 
clinical base year

[[Page 23440]]

program, for purposes of direct GME payment. Rather, under those 
circumstances, the IRP would be determined based upon the period of 
board eligibility associated with the specialty program in which the 
resident has matched and is expected to begin training in the second 
program year.
3. New Teaching Hospitals' Participation in Medicare GME Affiliated 
Groups (Sec.  413.79(e)(1))
    In the August 29, 1997 final rule (62 FR 46005 through 46006) and 
the May 12, 1998 final rule (63 FR 26331 through 23336), we established 
rules for applying the FTE resident limit (or ``FTE cap'') for 
calculating Medicare direct GME and IME payments to hospitals. We added 
regulations, currently at Sec.  413.79(e), to provide for an adjustment 
to the FTE cap for certain hospitals that begin training residents in 
new medical residency training programs. For purposes of this 
provision, a new program is one that receives initial accreditation or 
begins training residents on or after January 1, 1995. Although we 
refer only to the direct GME provision throughout the remainder of this 
discussion, a similar cap adjustment is made under Sec.  412.105(f) for 
IME purposes. Therefore, this proposal applies to both IME and direct 
GME.
    A new teaching hospital is one that had no allopathic or 
osteopathic residents in its most recent cost reporting period ending 
on or before December 31, 1996. Under Sec.  413.79(e)(1), if a new 
teaching hospital establishes one or more new medical residency 
training programs, the hospital's unweighted FTE caps for both direct 
GME and IME will be based on the product of the highest number of FTE 
residents in any program year in the third year of the hospital's first 
new program and the number of years in which residents are expected to 
complete the program(s), based on the minimum number of years of 
training that are accredited for the type of program(s).
    The regulations at Sec.  413.79(e)(1)(iv) specify that hospitals in 
urban areas that qualify for an FTE cap adjustment for residents in 
newly approved programs under Sec.  413.79(e)(1) are not permitted to 
be part of a Medicare GME affiliated group for purposes of establishing 
an aggregate FTE cap. (A Medicare GME affiliated group is defined in 
the regulations at Sec.  413.75(b).) We established this policy because 
of our concern that hospitals with existing medical residency training 
programs could otherwise, with the cooperation of new teaching 
hospitals, circumvent the statutory FTE resident caps by establishing 
new medical residency programs in the new teaching hospitals solely for 
the purpose of affiliating with the new teaching hospitals to receive 
an upward adjustment to their FTE cap under an affiliation agreement. 
This would effectively allow existing teaching hospitals to achieve an 
increase in their FTE resident caps beyond the number allowed by their 
statutory caps.
    In contrast, hospitals in rural areas that qualify for an 
adjustment under Sec.  413.79(e)(1)(v) are allowed to enter into a 
Medicare GME affiliation. Although we recognize that rural hospitals 
would not be immune from the kind of ``gaming'' arrangement described 
above, we allow new rural teaching hospitals that begin training 
residents in new programs, and thereby increase their FTE cap, to 
affiliate because we understand that rural hospitals may not have a 
sufficient volume of patient care utilization at the rural hospital 
site to be able to support a training program that meets accreditation 
standards. Securing sufficient patient volumes to meet accreditation 
requirements may necessitate rotations of the residents to another 
hospital. Accordingly, the regulations allow new teaching hospitals in 
rural areas to enter into Medicare GME affiliation agreements. However, 
an affiliation is only permitted if the rural hospital provides 
training for at least one-third of the FTE residents participating in 
all of the joint programs of the affiliated hospitals because, as we 
stated in the May 12, 1998 Federal Register (63 FR 26333), we believe 
that requiring at least one-third of the training to take place in the 
rural area allows operation of programs that focus on, but are not 
exclusively limited to, training in rural areas.
    Through comment and feedback from industry trade groups and 
hospitals, we understand that, while these rules were meant to prevent 
gaming on the part of existing teaching hospitals, they could also 
preclude affiliations that clearly are designed to facilitate 
additional training at the new teaching hospital.
    For example, Hospital A had no allopathic or osteopathic residents 
in its most recent cost reporting period ending on or before December 
31, 1996. As such, Hospital A's caps for direct GME and IME are both 
zero. Hospital A and Hospital B enter into a Medicare GME affiliation 
for the academic year beginning on July 1, 2003, and ending on June 30, 
2004. On July 1, 2003, Hospital A begins training residents from an 
existing family medicine program located at Hospital B. This rotation 
will result in 5 FTE residents training at Hospital A. Through the 
affiliation agreement, Hospital A receives a positive adjustment of 5 
FTE's for both its direct GME and IME caps. Hospital B receives a 
corresponding negative adjustment of 5 FTEs under the affiliation 
agreement. Hospital A's Board of Directors is interested in starting a 
new residency program in Internal Medicine that would begin training 
residents at Hospital A on July 1, 2005. If Hospital A establishes the 
new program, under existing Medicare regulations, Hospital A will have 
its direct GME and IME caps (which were both previously established at 
zero) permanently adjusted to reflect the additional residents training 
in the newly approved program in accordance with Sec.  413.79(e)(1). 
However, under existing regulations, Hospital A may no longer enter 
into an affiliation with Hospital B after it receives the adjustment to 
its FTE caps under Sec.  413.79(e)(1).
    We are proposing to revise Sec.  413.79(e)(1)(iv) so that new urban 
teaching hospitals that qualify for an adjustment under Sec.  
413.79(e)(1) may enter into a Medicare GME affiliation agreement under 
certain circumstances. Specifically, a new urban teaching hospital that 
qualifies for an adjustment to its FTE caps for a newly approved 
program may enter into a Medicare GME affiliation agreement, but only 
if the resulting adjustments to its direct GME and IME caps are 
``positive adjustments.'' ``Positive adjustment'' means, for the 
purpose of this policy, that there is an increase in the new teaching 
hospital's caps as a result of the affiliation agreement. At no time 
would the caps of a hospital located in an urban area that qualifies 
for adjustment to its FTE caps for a new program under Sec.  
413.79(e)(1), be allowed to decrease as a result of a Medicare GME 
affiliation agreement. We believe this proposed policy change would 
allow new urban teaching hospitals flexibility to start new teaching 
programs without jeopardizing their ability to count additional FTE 
residents training at the hospital under an affiliation agreement.
    We remain concerned that hospitals with existing medical residency 
training programs could cooperate with a new teaching hospital to 
circumvent the statutory FTE caps by establishing new programs at the 
new teaching hospital, and, through a Medicare GME affiliation 
agreement, moving most or all of the new residency program to its own 
hospital, thereby receiving an upward adjustment to its FTE caps. For 
this reason, we are proposing to revise

[[Page 23441]]

Sec.  413.79(e)(1)(iv) of the regulations to provide that a hospital 
that qualifies for an adjustment to its caps under Sec.  413.79(e)(1) 
would not be permitted to enter into an affiliation agreement that 
would produce a negative adjustment to its FTE resident cap.
    Continuing the example shown above, under the proposed change in 
policy, Hospital A and Hospital B would be able to continue the 
Medicare GME affiliation agreement under which Hospital A trained 
residents from Hospital B's family practice program because Hospital A 
would receive an increase in its direct GME or IME caps under an 
affiliation after qualifying for a new program adjustment under Sec.  
413.79(e)(1). However, Hospital B would not be able to receive an 
increase in its caps as a result of a Medicare GME affiliation 
agreement with Hospital A.
    Thus, we are proposing the above policy change to provide some 
flexibility to hospitals that are currently prohibited from entering 
into a Medicare GME affiliation agreement, while continuing to protect 
the statutory FTE resident caps from being undermined by gaming. We 
solicit comments on the proposed change.
4. GME FTE Cap Adjustment for Rural Hospitals (Sec.  413.79(c) and (k))
    As stated earlier under section V.I.1. of this preamble, Medicare 
makes both direct and indirect GME payments to hospitals for the 
training of residents. Direct GME payments are made in accordance with 
section 1886(h) of the Act, based generally on the hospital-specific 
PRA, the number of FTE residents a hospital trains, and the hospital's 
percentage of Medicare inpatient utilization. Indirect GME payments 
(referred to as IME) are made in accordance with section 1886(d)(5)(B) 
of the Act as an adjustment to DRG payment and are 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 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.
    Effective October 1, 1997, Congress instituted caps on the number 
of allopathic and osteopathic residents a hospital is allowed to count 
for direct GME and IME purposes at sections 1886(h)(4)(F) (direct GME) 
and 1886(d)(5)(B)(v) (IME) of the Act. These caps were instituted in an 
attempt to end the implicit incentive for hospitals to increase the 
number of FTE residents. Dental and podiatric residents were not 
included in these statutorily mandated caps.
    Congress provided certain exceptions for rural hospitals when 
establishing the 1996 caps ``with the intent of encouraging physician 
training and practice in rural areas'' (65 FR 47032). For example, the 
statute states at section 1886(h)(4)(H)(i) that, in promulgating rules 
regarding application of the FTE caps to training programs established 
after January 1, 1995, ``the Secretary shall give special consideration 
to facilities that meet the needs of underserved rural areas.'' 
Accordingly, in implementing this provision, we provided in the 
regulations under Sec.  413.86(g)(6)(i)(C) (now Sec.  
413.79(e)(1)(iii)) that ``except for rural hospitals, the cap will not 
be adjusted for new programs established more than 3 years after the 
first program begins training residents. In other words, only hospitals 
located in rural areas (that is, areas that are not designated as an 
MSA), receive adjustments to their unweighted FTE caps to reflect 
residents in new medical residency training programs past the third 
year after the first residency program began training in that hospital 
(62 FR 46006).
    Section 413.79(e)(1) specifies the new program adjustment as the 
``product of the highest number of residents in any program year during 
the third year of the * * * program's existence * * * and the number of 
years in which residents are expected to complete the program based on 
the minimum accredited length for the type of program.'' The regulation 
applies only to new programs (as defined under Sec.  413.79(1)) 
established by rural hospitals, not for expansion of previously 
existing programs. For example, if a rural hospital has an unweighted 
FTE cap for direct GME of 100 and begins training residents in a new 3-
year residency program that has 10 residents in each of its first 3 
program years (for a total of 30 residents in the entire program in the 
program's third year), the hospital's direct GME FTE cap of 100 would 
be permanently adjusted at the conclusion of the third program year by 
30, and the hospital's new FTE cap would be 130. A similar adjustment 
would be made to the hospital's FTE cap for IME in accordance with the 
regulations at Sec.  412.105(f)(1)(iv)(A). However, the rural hospital 
would not be able to receive adjustments to its FTE cap for any 
expansion of a preexisting program.
    In 1999, Congress passed an additional provision under section 407 
of Pub. L. 106-113 (BBRA) to promote physician training in rural areas. 
Section 407 of the Pub. L. 106-113 amended the FTE caps provision at 
sections 1886(h)(4)(F) and 1886(d)(5)(B)(v) of the Act to provide that 
``effective for cost reporting periods beginning on or after April 1, 
2000, [a rural hospital's FTE cap] is 130 percent of the unweighted FTE 
count * * * for those residents for the most recent cost reporting 
period ending on or before December 31, 1996.'' In other words, the 
otherwise applicable FTE caps for rural hospitals were multiplied by 
1.3 to encourage rural hospitals to expand preexisting residency 
programs. (As described above, even prior to the BBRA change, rural 
hospitals were able to receive FTE cap adjustments for new programs.) 
For example, a hospital that was rural as of April 1, 2000, and had a 
direct GME cap of 100 FTEs would receive a permanent cap adjustment of 
30 FTEs (100 FTEs x 1.3 = 130 FTEs) and effective for cost reporting 
periods beginning on or after April 1, 2000, its FTE for direct GME 
would be 130. (A similar adjustment would be made to the FTE cap for 
IME for discharges occurring on or after April 1, 2000.)
    We recently received questions regarding the application of the 
130-percent FTE cap adjustment and the new program adjustment for rural 
hospitals in instances in which a rural teaching hospital is later 
redesignated as an urban hospital or reclassifies back to being an 
urban hospital after having been classified as rural. We are aware of 
two circumstances when a rural hospital may subsequently be 
reclassified as urban. The first circumstance involves labor market 
area changes, and the second involves urban hospitals, after having 
been reclassified as rural through section 1886(d)(8)(E) of the Act, 
that elect to be considered urban again. In both situations, if the 
hospital in question was a teaching hospital, its FTE caps would have 
been subject to the 130 percent and new program FTE cap adjustments 
while it was designated or classified as rural. The issue is whether 
the adjusted caps would continue to apply after the hospital becomes 
urban or returns to being treated as urban. Below we first address 
hospitals that lost their status as urban hospitals due to new labor 
market areas. We then address hospitals that rescinded their section 
1886(d)(8)(E) reclassifications. (We note that reclassification by the 
MGCRB under section 1886(d)(10) of the Act, as well as 
reclassifications under section 1886(d)(8)(B) of the Act, are effective 
only for purposes of the wage index and would not affect the hospital's 
IME or direct GME payments).

[[Page 23442]]

a. Formerly Rural Hospitals That Became Urban Due to the New CBSA Labor 
Market Areas
    In the FY 2005 IPPS final rule, we adopted the new CBSA-based labor 
market areas announced by OMB on June 6, 2003, and these areas became 
effective October 1, 2004. As a result of these new labor market areas, 
a number of hospitals that previously were located outside of an MSA 
and therefore considered rural are now located in a CBSA that is 
designated as urban and considered urban.
    We believe that previously rural hospitals that received 
adjustments due to establishing new medical training programs should 
not now be required to forego such adjustments simply because they have 
now been redesignated as urban. Such hospitals added and received 
accreditation for new medical training programs under the assumption 
that such programs would effect a permanent increase in their FTE caps. 
Indeed, we believe it would be nonsensical to view the fact that these 
hospitals are now urban as causing them to lose the adjustments that 
stemmed directly from the permissible and encouraged establishment of 
new medical training programs. Such hospitals cannot reach back into 
the past and alter whether they added the new programs or not. Nor 
would it be reasonable to prohibit them from counting FTE residents 
training in new programs that they worked to accredit. (We note that 
the hospitals would not be required to close the programs. Rather, if 
they were not permitted to retain the adjustments to their FTE caps 
they received as a result of having established new programs, they 
would no longer be permitted to count FTE residents that exceeded their 
original, preadjustment FTE caps for purposes of direct GME and IME 
payments. The effect might be that the hospital would have to close the 
program(s) as a result of decreased Medicare funding, but the hospital 
would be free to continue to operate the programs(s).)
    For these reasons, we believe the best reading of our regulation at 
Sec.  413.79(e)(3), which states that if a hospital ``is located in a 
rural area,'' it may adjust its FTE cap to reflect residents training 
in new programs, is that hospitals were permitted to receive a 
permanent adjustment to their FTE caps if, at the time of adding a new 
program, the hospitals were rural. A hospital's subsequent designation 
as urban or rural due to labor market area changes becomes irrelevant, 
because the central question is whether the hospital is rural at the 
time it adds the new programs. Therefore, we are clarifying in this 
proposed rule our policy that hospitals that became urban in FY 2005 
due to the new labor market areas would nevertheless be permitted to 
retain the adjustments they received for new programs as long as they 
were rural at the time they received them. (Once such hospitals receive 
a designation as ``urban,'' they may no longer seek FTE cap adjustments 
relating to new training programs; they may only retain the adjustments 
they received for the new programs they added when they were rural.)
    Similarly, we believe that rural hospitals that received the 
statutorily mandated 130 percent adjustment to their FTE caps would be 
disadvantaged if we were to rescind this adjustment due to new urban 
designation. Such hospitals expanded their already existing training 
programs under the assumption that these expansions would cause a 
permanent increase in their FTE caps. Many of these hospitals expanded 
their programs only once the BBRA became effective (in 2000). Thus, 
they have had only a few years to expand their programs and receive the 
cap adjustment mandated by statute. For these reasons, we believe it is 
permissible to read sections 1886(h)(4)(F)(i) and 1886(d)(5)(B)(v) of 
the Act as permitting a permanent adjustment to the FTE caps at the 
time a rural hospital adds residents to its already existing 
program(s). The language states that the total number of FTE residents 
with respect to a ``hospital's approved medical residency training 
program in the fields of allopathic medicine and osteopathic medicine 
may not exceed the number (or, 130 percent of such number in the case 
of a hospital located in a rural area) of such full-time equivalent 
residents for the hospital's most recent cost reporting period ending 
on or before December 31, 1996.'' As with the addition of new programs, 
we interpret the language ``130 percent of such number in the case of a 
hospital located in a rural area,'' as meaning only that the hospital 
was required to be rural at the time it received the 30-percent 
increase. Once the hospital received such increase, the increase became 
a permanent increase in the FTE cap and should not be rescinded based 
on subsequent designation as an urban hospital.
    We believe our interpretations are consistent with legislative 
intent. Congress provided for these FTE cap adjustments for rural 
hospitals with the intent of encouraging physician training and 
practice in rural areas. If rural hospitals had believed that new CBSAs 
would cause them to lose the adjustments, they would not have had the 
incentives Congress wished to increase the number of FTE residents 
training in their programs. These hospitals might have feared losing 
the adjustments as a result of new labor market areas, and therefore 
not carried out Congress' intent to expand their already existing 
residency training programs or add new residency training programs.
    To provide an example of the how the above statutory 
interpretations would be applied, a hospital located in a rural area 
prior to October 1, 2004, with an unweighted direct GME FTE cap of 100 
would have received a 30-percent increase in its FTE cap so that its 
adjusted cap was 130 FTEs. The rural hospital also could have received 
an adjustment for any new medical residency program. If this hospital, 
while rural, started a new 3-year residency program with 10 residents 
in each program year, its FTE cap would have been increased by an 
additional 30 FTEs to 160 FTEs (that is, (100 FTEs x 1.3) + 30 FTEs = 
160 FTEs). Under our reading of the statute, if this hospital is now 
located in an urban area due to the new CBSAs, it would retain this cap 
of 160 FTEs.
    We also believe that the statute should be interpreted as 
permitting urban hospitals with rural track training programs to retain 
the adjustment they received for such programs at Sec.  413.79(k), even 
if the ``rural'' tracks as of October 1, 2004, are now located in urban 
areas due to the new OMB labor market areas. As explained in the FY 
2001 IPPS final rule (66 FR 47033), we provided that an urban hospital 
that establishes a separately accredited medical residency training 
program in a rural area (that is, a rural track) may receive an 
adjustment to reflect the number of residents in that program (existing 
Sec.  413.79(k)). Section 1886(h)(4)(H)(iv) of the Act states: ``In the 
case of a hospital that is not located in a rural area but establishes 
separately accredited approved medical residency training programs (or 
rural tracks) in an (sic) rural area or has an accredited training 
program with an integrated 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.''
    Again, we believe that the reading that best carries out 
Congressional intent is one that allows the adjustment for rural tracks 
to remain permanent as long as the rural track training programs 
continue, even if the once-rural tracks

[[Page 23443]]

are now urban due to new labor market area boundaries. Congress clearly 
intended to encourage the training of physicians in the rural tracks 
identified by the statute. However, if the FTE cap adjustments were 
merely temporary, and hospitals could not rely on retaining the 
adjustments relating to the rural training programs in which they 
invested, then Congress' wishes to encourage rural training programs 
might not have been realized. Hospitals would always need to speculate 
as to whether the FTE cap adjustments relating to the rural track 
programs they established would be lost each time new labor market 
areas were adopted (which normally occurs once every 10 years). Thus, 
we believe the statutory language should be interpreted as allowing an 
urban hospital to retain its FTE cap adjustment for rural track 
programs as long as the tracks were actually located in rural areas at 
the time the urban hospital received its adjustment. However, if the 
urban hospital wants to receive a cap adjustment for a new rural track 
residency program, the rural track must involve rural hospitals that 
are located in rural areas based on the most recent OMB labor market 
designations as specified in the FY 2005 IPPS final rule. We are 
proposing to add a new paragraph (k)(7) to Sec.  413.79 to incorporate 
this proposal.
b. Section 1886(d)(8)(E) Hospitals
    As stated above, a second situation exists where a hospital that is 
treated as rural returns to being urban under section 1886(d)(8)(E) of 
the Act (Sec.  412.103 of the regulations). Under this provision, an 
urban hospital may file an application to be treated as being located 
in a rural area. A hospital's reclassification as located in a rural 
area under this provision affects only payments under section 1886(d) 
of the Act. Accordingly, a hospital that is treated as rural under this 
provision can receive the FTE cap adjustments that any other rural 
hospital receives, but only to the FTE cap that applies for purposes of 
IME payments, which are made under section 1886(d) of the Act. The 
hospital could not receive adjustments to its direct GME FTE cap 
because payments for direct GME are made under section 1886(h) of the 
Act and the section 1886(d)(8)(E) reclassifications affect only the 
payments that are made under that section 1886(d) of the Act. 
Therefore, a hospital that reclassifies as rural under section 
1886(d)(8)(E) of the Act may receive the 130-percent adjustment to its 
IME FTE cap and its IME FTE cap may be adjusted for any new programs, 
similar to hospitals that are actually located in a rural location. A 
hospital treated as rural under section 1886(d)(8)(E) of the Act may 
subsequently withdraw its election and return to its urban status under 
the regulations at Sec.  412.103. We are proposing that, effective with 
discharges occurring on or after October 1, 2005, a different policy 
should apply for hospitals that reclassify under section 1886(d)(8)(E) 
of the Act than the policy that applies to rural hospitals redesignated 
as urban due to changes in labor market areas, as discussed in section 
IV.F.3 of this preamble.
5. Technical Changes: Cross References
     In the FY 2005 IPPS final rule (69 FR 49234), we 
redesignated the contents of Sec.  413.86 as Sec. Sec.  413.75 through 
413.83. We also updated cross-references to Sec.  413.86 that were 
located in various sections under 42 CFR Parts 400 through 499. We 
inadvertently did not capture all of the needed cross-reference 
changes. In this proposed rule, we are proposing to correct the 
additional cross-references in 42 CFR Parts 405, 412, 413, 415, 419, 
and 422 that were not made in the August 11, 2004 final rule.
     When we redesignated Sec.  413.86 as Sec. Sec.  413.75 
through 413.83 in the FY 2005 IPPS final rule, we also made a 
corresponding redesignation of Sec.  413.80 as Sec.  413.89. We are 
proposing to correct cross-references to Sec.  413.80 in 42 CFR Parts 
412, 413, 417, and 419 to reflect the redesignation of this section as 
Sec.  413.89.

J. Provider-Based Status of Facilities and Organizations Under Medicare

    (If you choose to comment on issues in this section, please include 
the caption ``Provider-Based Entities'' at the beginning of your 
comment.)
1. Background
    Since the beginning of the Medicare program, some providers, which 
we refer to as ``main providers,'' have functioned as a single entity 
while owning and operating multiple provider-based departments, 
locations, and facilities that were treated as part of the main 
provider for Medicare purposes. Having clear criteria for provider-
based status is important because this designation can result in 
additional Medicare payments for services furnished at the provider-
based facility, and may also increase the coinsurance liability of 
Medicare beneficiaries for those services.
    To set forth Medicare policies with regard to the provider-based 
status of facilities and organizations, we have published a number of 
Federal Register documents as follows:
     In a proposed rule published in the Federal Register on 
September 8, 1998 (63 FR 47552), we proposed specific and comprehensive 
criteria for determining whether a facility or organization is 
provider-based. In the preamble to the proposed rule, we explained why 
we believed meeting each criterion would be necessary to a finding that 
a facility or organization qualifies for provider-based status. After 
considering public comments on the September 8, 1998 proposed rule and 
making appropriate revisions, on April 7, 2000 (65 FR 18504), we 
published a final rule setting forth the provider-based regulations at 
42 CFR 413.65.
     Before the regulations that were issued on April 7, 2000 
could be implemented, Congress enacted the Medicare, Medicaid, and 
SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), Pub. L. 
106-544. Section 404 of BIPA delayed implementation of the April 7, 
2000 provider-based rules with respect to many providers, and mandated 
changes in the criteria at Sec.  413.65 for determining provider-based 
status.
     In order to conform our regulations to the requirements of 
section 404 of BIPA and to codify certain clarifications of provider-
based policy that had previously been posted on the CMS Web site, we 
published another proposed rule on August 24, 2001 (66 FR 44672). After 
considering public comments on the August 24, 2001 proposed rule and 
making appropriate revisions, we published a final rule on November 30, 
2001 setting forth the provider-based regulations (66 FR 59909).
     On May 9, 2002, we proposed further significant revisions 
to the provider-based regulations at Sec.  413.65 (67 FR 31480). After 
considering public comments on the May 9, 2002 proposed rule and making 
appropriate revisions, on August 1, 2002, we published a final rule 
specifying the criteria that must be met to qualify for provider-based 
status (67 FR 50078). These regulations remain in effect and continue 
to be codified at Sec.  413.65.
    Following is a discussion of the major provisions of the provider-
based regulations: Section 413.65(a) of the regulations describes the 
scope of that section and provides definitions of key terms used in the 
regulations. Paragraph (b) describes the procedure for making provider-
based determinations, and paragraph (c) imposes requirements for 
reporting material changes in relationships between main providers and 
provider-based facilities or organizations. In paragraph (d), we

[[Page 23444]]

specify the requirements that are applicable to all facilities or 
organizations seeking provider-based status, and in paragraph (e), we 
describe the additional requirements applicable to off-campus 
facilities or organizations (generally, those located more than 250 
yards from the provider's main buildings). Paragraphs (f) through (o) 
set forth policies regarding joint ventures, obligations of provider-
based facilities, facilities operated under management contracts or 
providing all services under arrangements, procedures in connection 
with certain provider-based determinations, and specific types of 
facilities such as Indian Health Service (IHS) and Tribal facilities 
and Federally qualified health centers (FQHCs).
2. Limits on the Scope of the Provider-Based Regulations--Facilities 
for Which Provider-Based Determinations Will Not Be Made
    In Sec.  413.65(a) (1)(ii), we list specific types of facilities 
and organizations for which determinations of provider-based status 
will not be made. We previously concluded that provider-based 
determinations should not be made for these facilities because the 
outcome of the determination (that is, whether a facility, unit, or 
department is found to be freestanding or provider-based) would not 
affect the methodology used to make Medicare or Medicaid payment, the 
scope of benefits available to a Medicare beneficiary in or at the 
facility, or the deductible or coinsurance liability of a Medicare 
beneficiary in or at the facility.
    We have now concluded that, under the principle stated above, rural 
health clinics affiliated with hospitals having 50 or more beds should 
be added to the list of facilities for which provider-based status 
determinations are not made. Therefore, we are proposing to revise 
Sec.  413.65(a)(1)(ii) to add rural health clinics with hospitals 
having 50 or more beds to the listing of the types of facilities for 
which a provider-based status determination will not be made. We 
believe this proposed revision to Sec.  413.65(a)(1)(ii) is appropriate 
because all rural health clinics affiliated with hospitals having 50 or 
more beds are paid on the same basis as rural health clinics not 
affiliated with any hospital, and the scope of Medicare Part B benefits 
and beneficiary liability for Medicare Part B deductible and 
coinsurance amounts would be the same, regardless of whether the rural 
health clinic was found to be provider-based or freestanding.
    In setting forth this proposal, we recognize that rural health 
clinics affiliated with hospitals report their costs using the 
hospital's cost report rather than by filing a separate rural health 
clinic cost report, and that whether or not a rural health clinic is 
hospital-affiliated will affect the selection of a fiscal intermediary 
for the clinic. However, we do not believe these administrative 
differences provide a sufficient reason to make provider-based 
determinations for such rural health clinics.
3. Location Requirement for Off-Campus Facilities: Application to 
Certain Neonatal Intensive Care Units
    As we stated in the preamble to May 9, 2002 proposed rule for 
changes in the provider-based rules (67 FR 31485), we recognize that 
provider-based status is not limited to on-campus facilities or 
organizations and that facilities or organizations located off the main 
provider campus may also be sufficiently integrated with the main 
provider to justify a provider-based designation. However, the off-
campus location of the facilities or organizations may make such 
integration harder to achieve, and such integration should not simply 
be presumed to exist. Therefore, to ensure that off-campus facilities 
or organizations seeking provider-based status are appropriately 
integrated, we have adopted certain requirements regarding the location 
of off-campus facilities or organizations. These requirements are set 
forth in Sec.  413.65(e)(3). Section 413.65(e)(3) specifies that a 
facility or organization not located on the main campus of the 
potential main provider can qualify for provider-based status only if 
it is located within a 35-mile radius of the campus of the hospital or 
CAH that is the potential main provider, or meets any one of the 
following requirements.
     The facility or organization is owned and operated by a 
hospital or CAH that has a disproportionate share adjustment (as 
determined under Sec.  412.106) greater than 11.75 percent or is 
described in Sec.  412.106(c)(2) of the regulations which implement 
section 1886(e)(5)(F)(i)(II) of the Act and is--

--Owned or operated by a unit of State or local government;
--A public or nonprofit corporation that is formally granted 
governmental powers by a unit of State or local government; or
--A private hospital that has a contract with a State or local 
government that includes the operation of clinics located off the main 
campus of the hospital to assure access in a well-defined service area 
to health care services for low-income individuals who are not entitled 
to benefits under Medicare (or medical assistance under a Medicaid 
State plan). (Sec.  413.65(e)(3)(i))

     The facility or organization demonstrates a high level of 
integration with the main provider by showing that it meets all of the 
other provider-based criteria and demonstrates that it serves the same 
patient population as the main provider, by submitting records showing 
that, during the 12-month period immediately preceding the first day of 
the month in which the application for provider-based status is filed 
with CMS, and for each subsequent 12-month period--

--At least 75 percent of the patients served by the facility or 
organization reside in the same zip code areas as at least 75 percent 
of the patients served by the main provider (Sec.  
413.65(e)(3)(ii)(A)); or
--At least 75 percent of the patients served by the facility or 
organization who required the type of care furnished by the main 
provider received that care from that provider (for example, at least 
75 percent of the patients of a rural health clinic seeking provider-
based status received inpatient hospital services from the hospital 
that is the main provider (Sec.  413.65(e)(3)(ii)(B)).

    Section 413.65(e)(3)(ii)(C) of the regulations allows new 
facilities or organizations to qualify as provider-based entities. 
Under this section, if a facility or organization is unable to meet the 
criteria in Sec.  413.65(e)(3)(ii)(A) or (e)(3)(ii)(B) because it was 
not in operation during all of the 12-month period before the start of 
the period for which provider-based status is sought, the facility or 
organization may nevertheless meet the location requirement of 
paragraph (e)(3) of Sec.  413.65 if it is located in a zip code area 
included among those that, during all of the 12-month period before the 
start of the period for which provider-based status is sought, 
accounted for at least 75 percent of the patients served by the main 
provider.
    CMS has been advised that, in some cases, the location requirements 
in current regulations may inadvertently impede the delivery of 
intensive care services to newborn infants in areas where there is no 
nearby children's hospital with a neonatal intensive care unit (NICU). 
According to those who expressed this concern, hospitals participating 
in the Medicare program as children's hospitals establish off-site 
neonatal intensive care units (NICUs) which they operate and staff but 
which are located in space leased from other hospitals. The hospitals 
in which the offsite NICUs are housed typically are

[[Page 23445]]

short-term, acute care hospitals located in rural areas. According to 
comments that CMS has received, the nearest children's hospital in a 
rural area is usually located a considerable distance from individual 
rural communities, which prevents infants in these rural communities 
from having ready access to the specialized care offered by NICUs.
    We have received a suggestion that this configuration (that of a 
hospital participating in the Medicare program as a hospital whose 
inpatients are predominantly individuals under 18 years of age under 
section 1886(d)(1)(B)(iii) of the Act, establishing an offsite NICU 
which it operates and staffs but which is located in space leased from 
another hospital) can be very helpful in making neonatal intensive care 
more quickly available in areas where community hospitals are located. 
In addition, this configuration can offer relief to families who 
otherwise would be required to travel long distances to obtain this 
care for their infants. However, offsite NICUs would not be able to 
qualify for provider-based status under the location criteria in our 
current regulations if they are located more than 35 miles from the 
children's hospital that would be the main provider, are not owned and 
operated by a hospital meeting the requirements of Sec.  
413.65(e)(3)(i), and cannot meet either of the ``75 percent tests'' for 
service to the same patient population as the potential main provider 
that are specified in existing Sec.  413.65(e)(3)(ii)(A) and Sec.  
413.65(e)(3)(ii)(B).
    We understand the concern that requiring a patient to be 
transported to an NICU located on the campus of a distant children's 
hospital could create an unacceptable medical risk to the life of a 
newborn at a most critical time. To help us better understand this 
issue and determine what action, if any, CMS should take on it, we are 
soliciting specific public comment on the following question:
     Is the problem as described above actually occurring and, 
if so, in what locations? We are particularly interested in learning 
which areas of which States are experiencing such a problem, and in 
receiving specific information, such as the rates of transfer of 
newborns from community hospitals to children's hospital on-campus 
NICUs relative to adult or non-neonatal pediatric transfers for 
intensive care services, which describe the problem objectively. Such 
objective information will be much more useful than expressions of 
opinion or anecdotes.
    We also wish to ask those who believe such a problem is currently 
occurring to comment on which of the following approaches would be most 
effective in resolving it. The proposed approaches on which we are 
soliciting specific comments are:
    [s] A change in the Medicare provider-
based regulations to create an exception to the location requirements 
for NICUs located in community hospitals that are more than 35 miles 
from the children's hospital that is the potential main provider. The 
exception might take the form of a more generous mileage allowance 
(such as being within 50 miles of the potential main provider) or could 
require other criteria to be met. However, the exception would be 
available only if there is no other NICU within 35 miles of the 
community hospital.
    [s] A change in the national Medicaid 
regulations to allow off-campus NICUs that meet other provider-based 
requirements under Sec.  413.65 to qualify as provider-based for 
purposes of payment under Medicaid, even though those facilities would 
not qualify as provider-based under Medicare. (We note that under 42 
CFR 440.10(a)(3)(iii), services are considered to be ``inpatient 
hospital services'' under the Medicaid program only if they are 
furnished in an institution that meets the requirements for 
participation in Medicare as a hospital. Because of the age of the 
patients they serve, NICUs typically have no Medicare utilization but a 
substantial proportion of their patients may be Medicaid patients.)
    [s] A change in individual State's 
Medicaid plans that would provide enhanced financial incentives for 
community hospitals to establish NICUs, possibly in collaboration with 
children's hospitals.
    [s] The establishment of children's 
hospitals that meet the requirements for being hospitals-within-
hospitals under 42 CFR 412.22(e). (We note that this option, unlike the 
three above, would not require any revision of Medicare or Medicaid 
regulations or individual State Medicaid plans).
    We also welcome suggestions for specific options other than those 
listed above.
4. Technical and Clarifying Changes to Sec.  413.65
    a. Definitions. In paragraph (a)(2) of Sec.  413.65, we state that 
the term ``Provider-based entity'' means a provider of health care 
services, or an RHC as defined in Sec.  405.2401(b), that is either 
created by, or acquired by, a main provider for the purpose of 
furnishing health care services of a different type from those of the 
main provider under the name, ownership and administrative and 
financial control of the main provider, in accordance with the 
provisions of Sec.  413.65. In recognition of the fact that provider-
based entities, unlike departments of a provider, offer a type of 
services different from those of the main provider and participate 
separately in Medicare, we are proposing to revise this requirement by 
deleting the word ``name'' from this definition. This change would 
simplify compliance with the provider-based criteria since entities 
that do not now operate under the potential main provider's name will 
not be obligated to change their names in order to be treated as 
provider-based.
    b. Provider-based determinations. In paragraph (b)(3)(ii) of Sec.  
413.65, we state that, in the case of a facility not located on the 
campus of the potential main provider, the provider seeking a 
determination would be required to submit an attestation stating that 
the facility meets the criteria in paragraphs (d) and (e) of Sec.  
413.65, and if the facility is operated as a joint venture or under a 
management contract, the requirements of paragraph (f) or paragraph (h) 
of Sec.  413.65, as applicable. However, paragraph (f), which sets 
forth rules regarding provider-based status for joint ventures, states 
clearly that a facility or organization operated as a joint venture may 
qualify for provider-based status only if it is located on the main 
campus of the potential main provider. To avoid any misunderstanding 
regarding the content of attestations for off-campus facilities, we are 
proposing to revise paragraph (b)(3)(ii) by removing the reference to 
compliance with requirements in paragraph (f) for joint ventures. We 
also are proposing to add a sentence to paragraph (b)(3)(i), regarding 
attestations for on-campus facilities, to state that if the facility is 
operated as a joint venture, the attestation by the potential main 
provider regarding that facility would also have to include a statement 
that the provider will comply with the requirements of paragraph (f) of 
Sec.  413.65.
    c. Additional requirements applicable to off-campus facilities or 
organizations--Operation under the ownership and control of the main 
provider. In paragraph (e)(1)(i), regarding 100 percent ownership by 
the main provider of the business enterprise that constitutes the 
facility or organization seeking provider-bases status, we are 
proposing to add the word ``main'' before the word ``provider'', to 
clarify that the main provider must own and control the facility or 
organization seeking provider-based status. We are also proposing, for 
purposes of

[[Page 23446]]

clarifying the requirements in paragraph (e)(1), to add the word 
``main'' before the word ``provider'' in paragraphs (e)(1)(ii) and 
(e)(1)(iii).
    d. Additional requirements applicable to off-campus facilities or 
organizations--Location. We are proposing several clarifying changes to 
this paragraph, as follows:
    Currently, the opening sentence of Sec.  413.65(e)(3) states that a 
facility or organization for which provider-based status is sought must 
be located within a 35-mile radius of the campus of the hospital or CAH 
that is the potential main provider, except when the requirements in 
paragraph (e)(3)(i), (e)(3)(ii), or (e)(3)(iii) of that section are 
met. However, the regulation text that follows does not contain a 
paragraph designation as paragraph (e)(3)(iii). We are proposing to 
correct this error by redesignating existing paragraph (e)(3)(ii)(C) as 
paragraph (e)(3)(iv). We are also proposing to revise this sentence to 
state that the facility or organization must meet the requirements in 
paragraph (e)(3)(i), (e)(3)(ii), (e)(3)(iii), (e)(3)(iv) or, in the 
case of an RHC, paragraph (e)(3)(v) of Sec.  413.65 and the 
requirements in paragraph (e)(3)(vi) of Sec.  413.65.
    We are proposing to revise the opening sentence of Sec.  
413.65(e)(3) to reflect the changes in the coding of this paragraph as 
described above.
    We are also proposing to redesignate paragraph (v) of Sec.  
413.65(e)(3) as paragraph (e)(3)(vi) and correct a drafting error by 
adding the word ``that'' before ``has fewer than 50 beds''. This 
proposed addition is a grammatical change that is intended only to 
clarify the size of the hospital with which a rural health clinic must 
have a provider-based relationship in order to qualify under the 
special location requirement in that paragraph.
    e. Paragraph (g)--Obligations of hospital outpatient departments 
and hospital-based entities. We are proposing to revise the first 
sentence of paragraph (g)(7), regarding beneficiary notices of 
coinsurance liability, to clarify that notice must be given only if the 
service is one for which the beneficiary will incur a coinsurance 
liability for both an outpatient visit to the hospital and the 
physician service. This should help to make it clear that notice is not 
required for visits that do not result in additional coinsurance 
liability. In addition, we are proposing to reorganize the subsequent 
paragraphs of that section for clarity.

K. Rural Community Hospital Demonstration Program

    (If you choose to comment on issues in this section, please include 
the caption ``Rural Community Hospital Demonstration Program'' at the 
beginning of your comments.)
    In accordance with the requirements of section 410A(a) of Pub. L. 
108-173, the Secretary has established a 5-year demonstration 
(beginning with selected hospitals' first cost reporting period 
beginning on or after October 1, 2004) to test the feasibility and 
advisability of establishing ``rural community hospitals'' for Medicare 
payment purposes for covered inpatient hospital services furnished to 
Medicare beneficiaries. A rural community hospital, as defined in 
section 410A(f)(1), is a hospital that--
     Is located in a rural area (as defined in section 
1886(d)(2)(D) of the Act) or treated as being so located under section 
1886(d)(8)(E) of the Act;
     Has fewer than 51 beds (excluding beds in a distinct part 
psychiatric or rehabilitation unit) as reported in its most recent cost 
report;
     Provides 24-hour emergency care services; and
     Is not designated or eligible for designation as a CAH.
    As we indicated in the FY 2005 IPPS final rule (69 FR 49078), in 
accordance with sections 410A(a)(2) and (4) of Pub. L. 108-173 and 
using 2002 data from the U.S. Census Bureau, we identified 10 States 
with the lowest population density from which to select hospitals: 
Alaska, Idaho, Montana, Nebraska, Nevada, New Mexico, North Dakota, 
South Dakota, Utah, and Wyoming. (Source: U.S. Census Bureau 
Statistical Abstract of the United States: 2003) Thirteen rural 
community hospitals located within these States are participating in 
the demonstration.
    Under the demonstration, participating hospitals are paid the 
reasonable costs of providing covered inpatient hospital services 
(other than services furnished by a psychiatric or rehabilitation unit 
of a hospital that is a distinct part), applicable for discharges 
occurring in the first cost reporting period beginning on or after the 
October 1, 2004 implementation date of the demonstration program. 
Payment will be the lesser amount of reasonable cost or a target amount 
in subsequent cost reporting periods. The target amount in the second 
cost reporting period is defined as the reasonable costs of providing 
covered inpatient hospital services in the first cost reporting period, 
increased by the inpatient prospective payment update factor (as 
defined in section 1886(b)(3)(B) of the Act) for that particular cost 
reporting period. The target amount in subsequent cost reporting 
periods is defined as the preceding cost reporting period's target 
amount, increased by the inpatient prospective payment update factor 
(as defined in section 1886(b)(3)(B) of the Act) for that particular 
cost reporting period.
    Covered inpatient hospital services means inpatient hospital 
services (defined in section 1861(b) of the Act) and includes extended 
care services furnished under an agreement under section 1883 of the 
Act.
    Section 410A of Pub. L. 108-173 requires that ``in conducting the 
demonstration program under this section, the Secretary shall ensure 
that the aggregate payments made by the Secretary do not exceed the 
amount which the Secretary would have paid if the demonstration program 
under this section was not implemented.'' Generally, when CMS 
implements a demonstration on a budget neutral basis, the demonstration 
is budget neutral in its own terms; in other words, aggregate payments 
to the participating providers do not exceed the amount that would be 
paid to those same providers in the absence of the demonstration. This 
form of budget neutrality is viable when, by changing payments or 
aligning incentives to improve overall efficiency, or both, a 
demonstration may reduce the use of some services or eliminate the need 
for others, resulting in reduced expenditures for the demonstration 
participants. These reduced expenditures offset increased payments 
elsewhere under the demonstration, thus ensuring that the demonstration 
as a whole is budget neutral or yields savings. However, the small 
scale of this demonstration, in conjunction with the payment 
methodology, makes it extremely unlikely that this demonstration could 
be viable under the usual form of budget neutrality. Specifically, 
cost-based payments to 13 small rural hospitals are likely to increase 
Medicare outlays without producing any offsetting reduction in Medicare 
expenditures elsewhere. Therefore, a rural community hospital's 
participation in this demonstration is unlikely to yield benefits to 
the participant if budget neutrality were to be implemented by reducing 
other payments for these providers.
    In order to achieve budget neutrality for this demonstration, we 
are proposing to adjust national inpatient PPS rates by an amount 
sufficient to account for the added costs of this demonstration. In 
other words, we apply budget neutrality

[[Page 23447]]

across the payment system as a whole rather than merely across the 
participants of this demonstration. As we discussed in the FY 2005 IPPS 
final rule (69 FR 49183), we believe that the language of the statutory 
budget neutrality requirements permits the agency to implement the 
budget neutrality provision in this manner. For FY 2006, using the most 
recent cost report data (that is, data for FY 2003), adjusted for 
increased estimated cost for the 13 participating hospitals, we are 
proposing that the estimated adjusted amount would be $12,706,334. This 
adjusted amount reflects the estimated difference between cost and IPPS 
payment based on data from hospitals' cost reports. We discuss the 
proposed payment rate adjustment that would be required to ensure the 
budget neutrality of the demonstration in section II.A.4. of the 
Addendum to this proposed rule.
    The data collection instrument for the demonstration has been 
approved by OMB under the title ``Medicare Waiver Demonstration 
Application,'' under OMB approval number 0938-0880, with a current 
expiration date of July 30, 2006.

L. Definition of a Hospital in Connection With Specialty Hospitals

    (If you choose to comment on issues in this section, please include 
the caption ``Specialty Hospitals'' at the beginning of your comment.)
    Section 1861(e) of the Act provides a definition for a ``hospital'' 
for purposes of participating in the Medicare program. In order to be a 
Medicare-participating hospital, an institution must, among other 
things, be primarily engaged in furnishing services to inpatients. This 
requirement is incorporated in our regulations on conditions of 
participation for hospitals at 42 CFR 482.1. An institution that 
applies for a Medicare provider agreement as a hospital but is unable 
to meet this requirement will have its application denied in accordance 
with our authority at 42 CFR 489.12. In addition, institutions that 
have a Medicare hospital provider agreement but are no longer primarily 
engaging in furnishing services to inpatients are subject to having 
their provider agreements terminated pursuant to 42 CFR 489.53. 
Although compliance with this requirement is not problematic for most 
hospitals, the issue of whether an institution is primarily engaged in 
providing care to inpatients has recently come to our attention in two 
arisen two contexts. First, an institution has applied to be certified 
as an ``emergency hospital,'' yet the institution has 29 outpatient 
beds for emergency patients, including observation and post-anesthesia 
care, and only 2 inpatient beds. Emergency treatment by nature does not 
usually involve overnight stays. Second, the issue has also arisen in 
the area of ``specialty hospitals.'' (For purposes of this discussion, 
``specialty hospitals'' are those hospitals specifically defined as 
such in section 507 of Pub. L. 108-173 (MMA), that is, those hospitals 
that are primarily or exclusively engaged in the care and treatment of:
    (i) Patients with a cardiac condition; (ii) patients with an 
orthopedic condition; or (iii) patients receiving a surgical 
procedure.)
    ``Specialty hospitals'' are of interest partly because of section 
507 of Pub. L. 108-173, which amended the hospital ownership exception 
to the physician self-referral prohibition statute, section 1877 of the 
Act. Prior to the enactment of Pub. L. 108-173, the ``whole hospital'' 
exception contained in section 1877(d)(3) of the Act allowed a 
physician to refer Medicare patients to a hospital in which the 
physician (or an immediate family member of the physician) had an 
ownership or investment interest, if the physician was authorized to 
perform services at the hospital and the ownership or investment 
interest was in the entire hospital and not a subdivision of the 
hospital. Section 507 of Pub. L. 108-173 added an additional criterion 
to the whole hospital exception, specifying that for the 18-month 
period beginning on December 8, 2003 and ending on June 8, 2005, 
physician ownership and investment interests in ``specialty hospitals'' 
would not qualify for the whole hospital exception. The term 
``specialty hospital'' does not include any hospital determined by the 
Secretary to be in operation or ``under development'' as of November 
18, 2003.
    In our advisory opinions that we issue as to whether a requesting 
entity is subject to the 18-month moratorium described above, we inform 
the requesting entity that, among other things, it must meet the 
definition of a hospital that is contained in section 1861(e) of the 
Act. It has come to our attention that some institutions entities that 
describe themselves as surgical or orthopedic specialty hospitals may 
be primarily primarily engaged in furnishing services to outpatients, 
and thus would might not meet the definition of a hospital as contained 
in section 1861(e) of the Act. Therefore, although an institution 
entity may satisfy the ``under development'' criteria for purposes of 
being excepted from the moratorium on physician-owner referrals to 
specialty hospitals, if we were to determine such entity is not 
primarily engaged in inpatient care at the time it seeks certification 
to participate in the Medicare program, its application for a provider 
agreement as a hospital would will be denied and it would not be 
eligible for the whole hospital exception to the prohibition on 
physician self-referrals. Further, if we were to determine that a 
specialty hospital that is operating under an existing Medicare 
provider agreement but is not, or is no longer, primarily engaged in 
treating inpatients, the hospital is subject to having its provider 
agreement terminated; in this event, it could no longer take advantage 
of and lose the protection of the whole hospital exception.

VI. PPS for Capital-Related Costs

    (If you choose to comment on issues in this section, please include 
the caption ``Capital-Related Costs'' at the beginning of your 
comment.)
    In this proposed rule, we are not proposing any changes in the 
policies governing the determination of the payment rates for capital-
related costs for short-term acute care hospitals under the IPPS. 
However, for the readers' benefit, we are providing a summary of the 
statutory basis for the PPS for hospital capital-related costs and the 
methodology used to determine capital-related payments to hospitals. A 
discussion of the proposed rates and factors for FY 2006 (determined 
under our established methodology) can be found in section III. of the 
Addendum of this proposed rule.
    Section 1886(g) of the Act requires the Secretary to pay for the 
capital-related costs of inpatient acute 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 hospital inpatient capital-related costs. We 
initially implemented the PPS for capital-related costs 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. For cost reporting periods beginning 
in FY 2002, capital PPS payments are based solely on the Federal rate 
for most acute care hospitals (other than certain new hospitals and 
hospitals receiving certain exception payments). The basic

[[Page 23448]]

methodology for determining capital prospective payments using 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 + Capital DSH 
Adjustment Factor + Capital IME Adjustment Factor, if applicable)
    Hospitals also may receive outlier payments for those cases that 
qualify under the thresholds established for each fiscal year as 
specified in Sec.  412.312(c) of the regulations.
    The 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 originally 
established for hospitals during the 10-year transition period, but as 
we discussed in the August 1, 2002 IPPS final rule (67 FR 50102), we 
revised the regulations at Sec.  412.312 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). Additional information on the exceptions 
payment for extraordinary circumstances in Sec.  412.348(f) can be 
found in the FY 2005 IPPS final rule (69 FR 49185 through 49186).
    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 percentage 
of its Medicare allowable capital-related costs depending on the class 
of hospital (Sec.  412.348(c)), but were available only during the 10-
year transition period. After the end of the transition period, 
eligible hospitals can no longer receive this exception payment. 
However, even after the transition period, eligible hospitals receive 
additional payments under the special exceptions provisions at Sec.  
412.348(g), which guarantees all eligible hospitals a minimum payment 
of 70 percent of its Medicare allowable capital-related costs provided 
that special exceptions payments do not exceed 10 percent of total 
capital IPPS payments. Special exceptions payments may be made only for 
the 10 years from the cost reporting year in which the hospital 
completes its qualifying project, and the hospital must have completed 
the project 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).)
    Under the PPS for capital-related costs, Sec.  412.300(b) of the 
regulations defines a new hospital as a hospital that has operated 
(under current or previous ownership) for less than 2 years. (For more 
detailed information see the August 30, 1991 final rule (56 FR 43418).) 
During the 10-year transition period, a new hospital 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. 
Because we believe that special protection to new hospitals is also 
appropriate even after the transition period, as discussed in the 
August 1, 2002 IPPS final rule (67 FR 50101), we revised the 
regulations at Sec.  412.304(c)(2) to provide that, for cost reporting 
periods beginning on or after October 1, 2002, 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. (Refer to the August 
1, 2001 IPPS final rule (66 FR 39910) for a 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 exception payments.)
    Section 412.374 provides for the use of a blended payment amount 
for prospective payments for capital-related costs to hospitals located 
in Puerto Rico. Accordingly, under the capital PPS, we compute a 
separate payment rate specific to Puerto Rico hospitals using the same 
methodology used to compute the national Federal rate for capital-
related costs. In general, hospitals located in Puerto Rico are paid a 
blend of the applicable capital PPS Puerto Rico rate and the applicable 
capital PPS Federal rate.
    Prior to FY 1998, hospitals in Puerto Rico were paid a blended 
capital PPS rate that consisted of 75 percent of the applicable capital 
PPS Puerto Rico specific rate and 25 percent of the applicable capital 
PPS Federal rate. However, effective October 1, 1997 (FY 1998), in 
conjunction with the change to the operating PPS blend percentage for 
Puerto Rico hospitals required by section 4406 of Pub. L. 105-33, we 
revised the methodology for computing capital PPS payments to hospitals 
in Puerto Rico to be based on a blend of 50 percent of the Puerto Rico 
rate and 50 percent of the Federal rate. Similarly, effective beginning 
in FY 2005, in conjunction with the change in operating PPS payments to 
hospitals in Puerto Rico for FY 2005 required by section 504 of Pub. L. 
108-173, we again revised the methodology for computing capital PPS 
payments to hospitals in Puerto Rico to be based on a blend of 25 
percent of the Puerto Rico rate and 75 percent of the Federal rate for 
discharges occurring on or after October 1, 2004.

VII. Proposed Changes for Hospitals and Hospital Units Excluded From 
the IPPS

    (If you choose to comment on issues in this section, please include 
the caption ``Excluded Hospitals and Units'' at the beginning of your 
comment.)

A. Payments to Existing 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 cost 
reporting periods beginning on or after October 1, 1997 through 
September 30, 2002, for certain existing hospitals and hospital units 
excluded from the IPPS. Section 413.40(c)(4)(iii) of the implementing 
regulations states that ``In the case of a psychiatric hospital or 
unit, rehabilitation hospital or unit, or long-term care hospital, the 
target amount is the lower of amounts specified in paragraph 
(c)(4)(iii)(A) or (c)(4)(iii)(B) of this section.'' Accordingly, in 
general, for hospitals and units within these three classes of 
providers for the applicable 5-year period, the target amount is the 
lower of either: the hospital-specific target amount (Sec.  
413.40(c)(4)(iii)(A)) or the 75th percentile cap (Sec.  
413.40(c)(4)(iii)(B)). (We note that, in the case of LTCHs, for cost 
reporting periods beginning during

[[Page 23449]]

FY 2001, the hospital-specific target amount is the net allowable cost 
in a base period increased by the applicable update factors multiplied 
by 1.25.)
    Questions have been raised as to whether Sec.  413.40(c)(4)(iii) 
(specifically paragraph (c)(4)(iii)(A)) continues to apply beyond FY 
2002. In order to clarify the policy for periods after FY 2002, we note 
that Sec.  413.40(c)(4)(iii) applies only to cost reporting periods 
beginning on or after October 1, 1997 through September 30, 2002, for 
psychiatric hospitals and units, rehabilitation hospitals and units, 
and LTCHs. We discussed this applicable time period in the May 12, 1998 
Federal Register (63 FR 26344) when we discussed implementing the caps. 
Specifically, we clarified our regulations to indicate that the target 
amount for FYs 1998 through 2002 is equal to the lower of the hospital-
specific target amount or the 75th percentile of target amounts for 
hospitals in the same class for cost reporting periods ending during FY 
1996, increased by the applicable market basket percentage for the 
subject period. We did not intend for the provisions of Sec.  
413.40(c)(4)(iii) to apply beyond FY 2002, as we specifically included 
an ending date; that is, we stated that the target amount calculation 
provisions were for FYs 1998 through 2002. More recently, in the FY 
2003 IPPS final rule (67 FR 50103), we clarified again how the target 
amount for FY 2003 was to be determined by stating that: ``* * * for 
cost reporting periods beginning in FY 2003, the hospital or unit 
should use its previous year's target amount, updated by the 
appropriate rate-of-increase percentage.'' Thus, the time-limited 
provision of Sec.  413.40(c)(4)(iii) is neither a new policy nor a 
change in policy.
    For cost reporting periods beginning on or after October 1, 2002, 
to the extent one of the above-mentioned excluded hospitals or units 
has all or a portion of its payment determined under reasonable cost 
principles, the target amounts for the reasonable cost-based portion of 
the payment are determined in accordance with section 1886(b)(3)(A)(ii) 
of the Act and the regulations at Sec.  413.40(c)(4)(ii). Section 
413.40(c)(4)(ii) states, ``Subject to the provisions of [Sec.  413.40] 
paragraph (c)(4)(iii) of this section, for subsequent cost reporting 
periods, the target amount equals the hospital's target amount for the 
previous cost reporting period increased by the update factor for the 
subject cost reporting period unless the provisions of [Sec.  413.40] 
paragraph (c)(5)(ii) of this section apply.'' Thus, since Sec.  
413.40(c)(4)(ii) indicates that the provisions of that paragraph are 
subject to the provisions of Sec.  413.40(c)(4)(iii), which are 
applicable only for cost reporting periods beginning on or after 
October 1, 1997 through September 30, 2002, the target amount for FY 
2003 is determined by updating the target amount for FY 2002 (the 
target amount from the previous period) by the applicable update 
factor. Accordingly, we are proposing to make a change to the language 
in Sec.  413.40(c)(4)(iii) to clarify that the provisions of this 
paragraph relating to the caps on target amounts are for a specific 
period of time only, that is, cost reporting periods beginning on or 
after October 1, 1997, and before October 1, 2002.
    The inpatient operating costs of children's hospitals and cancer 
hospitals that are excluded from the IPPS are subject to the rate-of-
increase limits established under the authority of section 1886(b) of 
the Act and implemented in the regulations at Sec.  413.40. Under these 
limits, an annual target amount (expressed in terms of the inpatient 
operating cost per discharge) is set for each hospital, based on the 
hospital's own historical cost experience, trended forward by the 
applicable percentage increase. This target amount is applied as a 
ceiling on the allowable costs per discharge for the hospital's cost 
reporting period. (We note that, in accordance with Sec.  403.752(a) of 
the regulations, RNHCIs are also subject to the rate-of-increase limits 
established under Sec.  413.40 of the regulations.)
2. Updated Caps for New Excluded Hospitals and Units
    Section 1886(b)(7) of the Act established the method for 
determining the payment amount for new rehabilitation hospitals and 
units, psychiatric hospitals and units, and LTCHs that first received 
payment as a hospital or unit excluded from the IPPS on or after 
October 1, 1997. However, effective for cost reporting periods 
beginning on or after October 1, 2002, this payment amount (or ``new 
provider cap'') no longer applies to any new rehabilitation hospital or 
unit because they now are paid 100 percent of the Federal prospective 
rate under the IRF PPS.
    In addition, LTCHs that meet the definition of a new LTCH under 
Sec.  412.23(e)(4) are also paid 100 percent of the fully Federal 
prospective payment rate under the LTCH PPS. In contrast, those ``new'' 
LTCHs that meet the criteria under Sec.  413.40(f)(2)(ii) (that is, 
that were not paid as an excluded hospital prior to October 1, 1997), 
but were paid as a LTCH before October 1, 2002, may be paid under the 
LTCH PPS transition methodology with the reasonable cost portion of the 
payment subject to Sec.  413.40(f)(2)(ii). Finally, LTCHs that existed 
prior to October 1, 1997, may also be paid under the LTCH PPS 
transition methodology with the reasonable cost portion of the payment 
subject to Sec.  413.40(c)(4)(ii). (The last LTCHs that were subject to 
the payment amount limitation for ``new'' LTCHs were new LTCHs that had 
their first cost reporting period beginning on September 30, 2002. In 
that case, the payment amount limitation remained applicable for the 
next 2 years--September 30, 2002 through September 29, 2003, and 
September 30, 2003 through September 29, 2004. This is because, under 
existing regulations at Sec.  413.40(f)(2)(ii), a ``new hospital'' 
would be subject to the same payment (target amount) in its second cost 
reporting period that was applicable to the LTCH in its first cost 
reporting period. Accordingly, for these hospitals, the updated payment 
amount limitation that we published in the FY 2003 IPPS final rule (67 
FR 50103) applied through September 29, 2004. Consequently, there is no 
longer a need to publish updated payment amounts for new (Sec.  
413.40(f)(2)(ii)) LTCHs. A discussion of how the payment limitations 
were 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).
    A freestanding inpatient rehabilitation hospital, an inpatient 
rehabilitation unit of an acute care hospital, and an inpatient 
rehabilitation unit of a CAH are referred to as IRFs. Effective for 
cost reporting periods beginning on or after October 1, 2002, this 
payment limitation is also 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.
    For psychiatric hospitals and units, under the IPF PPS, there is a 
3-year transition period during which existing IPFs will receive a 
blended payment of the Federal per diem payment amount and the payment 
amount that IPFs would receive under the reasonable cost-based payment 
(TEFRA) methodology. However, new IPFs (those facilities that under 
present or previous ownership (or both) have their first cost reporting 
period as an IPF begin on or after January 1, 2005, are paid the fully 
Federal per diem payment amount rather than a blended payment amount.

[[Page 23450]]

(See section VII.A.5. of the preamble of this proposed rule for further 
discussion of the IPF PPS.) Thus, the payment limitations under the 
TEFRA payment system are not applicable for new IPFs that meet the 
definition in Sec.  412.426(c).
    However, ``new'' IPFs that meet the criteria under Sec.  
413.40(f)(2)(ii) (that is, that were not paid as an excluded hospital 
prior to October 1, 1997), but were paid as an IPF before January 1, 
2005, are paid under the IPF PPS transition methodology with the 
reasonable cost portion of the payment determined according to Sec.  
413.40(f)(2)(ii), that is, subject to the payment amount limitation. 
The last ``new'' IPFs that were subject to the payment amount 
limitation were IPFs that had their first cost reporting period 
beginning on December 31, 2004. For these hospitals, the payment amount 
limitation that was published in the FY 2005 IPPS final rule (69 FR 
49189) for cost reporting periods beginning on or after October 1, 
2004, and before January 1, 2005, remains applicable for the IPF's 
first two cost reporting periods. IPFs with a first cost reporting 
period beginning on or after January 1, 2005, are paid 100 percent of 
the Federal rate and are not subject to the payment amount limitation. 
Therefore, since the last IPFs eligible for a blended payment have a 
cost reporting period beginning on December 31, 2004, the payment 
limitation published for FY 2005 remains applicable for these IPFs, and 
publication of the updated payment amount limitation is no longer 
needed. We note that IPFs that existed prior to October 1, 1997, may 
also be paid under the IPF transition methodology with the reasonable 
cost portion of the payment subject to Sec.  413.40(c)(4)(ii).
    The payment limitations for new hospitals under TEFRA do not apply 
to new LTCHs, IRFs, or IPFs, that is, these hospitals with their first 
cost reporting period beginning on or after the date that the 
particular class of hospitals implemented their respective PPS. 
Therefore, for the reasons noted above, we are proposing to discontinue 
publishing Tables 4G and 4H (Pre-Reclassified Wage Index for Urban and 
Rural Areas, respectively) in the annual proposed and final IPPS rules.
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 for 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 payments based 
entirely on the adjusted Federal prospective payment 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. There was a transition period for cost reporting 
periods beginning on or after January 1, 2002 and ending before October 
1, 2002. For cost reporting periods beginning on or after October 1, 
2002, payments are based entirely on the Federal prospective payment 
rate determined under the IRF PPS.
4. Implementation of a PPS for LTCHs
    In accordance with the requirements of section 123 of 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.
    We published in the Federal Register on May 7, 2004, a final rule 
(69 FR 25673) that updated the payment rates for the upcoming rate year 
LTCH PPS and made policy changes effective as of July 1, 2004. The 5-
year transition period to the fully Federal prospective rate will end 
with cost reporting periods beginning on or after October 1, 2005 and 
before October 1, 2006. For cost reporting periods beginning on or 
after October 1, 2006, payment is based entirely on the adjusted 
Federal prospective payment rate. However, existing hospitals can elect 
payment under 100 percent of the adjusted Federal prospective payment 
rate. Moreover, LTCHs as defined in Sec.  412.23(e)(4) are paid under 
100 percent of the adjusted Federal prospective payment rate.
5. Implementation of a PPS for IPFs
    In accordance with section 124 of the BBRA and section 405(g)(2) of 
Pub. L. 108-173, we established a PPS for inpatient hospital services 
furnished in psychiatric hospitals and psychiatric units of acute care 
hospitals and CAHs (inpatient psychiatric facilities (IPFs)). On 
November 15, 2004, we issued in the Federal Register a final rule (69 
FR 66922) that established the IPF PPS, effective for IPF cost 
reporting periods beginning on or after January 1, 2005. Under the 
final rule, we compute a Federal per diem base rate to be paid to all 
IPFs for inpatient psychiatric services based on the sum of the average 
routine operating, ancillary, and capital costs for each patient day of 
psychiatric care in an IPF, adjusted for budget neutrality. The Federal 
per diem base rate is adjusted to reflect certain patient 
characteristics, including age, specified DRGs, selected high-cost 
comorbidities, and day of the stay, and certain facility 
characteristics, including a wage index adjustment, rural location, 
indirect teaching costs, the presence of a full-service emergency 
department, and cost-of-living adjustments for IPFs located in Alaska 
and Hawaii. We have established a 3-year transition period during which 
IPFs will be paid based on a blend of reasonable cost-based payment and 
IPF PPS payments. For cost reporting periods beginning on or after 
January 1, 2008, IPFs will be paid 100 percent of the Federal per diem 
payment amount.

B. Critical Access Hospitals (CAHs)

    (If you choose to comment on issues in this section, please include 
the caption ``Critical Access Hospitals'' at the beginning of your 
comment.)
1. Background
    Section 1820 of the Act provides for the establishment of Medicare 
Rural Hospital Flexibility Programs (MRHFPs), 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 (CoPs) under 42 CFR Part 485, Subpart F, will be 
certified as CAHs by CMS. Regulations governing payments to CAHs for 
services to Medicare beneficiaries are located in 42 CFR Part 413.

[[Page 23451]]

2. Proposed Policy Change Relating to Continued Participation by CAHs 
in Lugar Counties
    Criteria for the designation of a CAH under the MRHFP at section 
1820(c)(2)(b)(i) of the Act require that a hospital be located in a 
rural area as defined in section 1886(d)(2)(D) of the Act or be treated 
as being located in a rural area in accordance with section 
1886(d)(8)(E) of the Act. The regulations at Sec.  485.610 further 
define ``rural area'' for purposes of being a CAH. Under Sec.  
485.610(b), a CAH must meet any one of the following three location 
requirements. First, a CAH must not be located in an MSA as defined by 
the Office of Management and Budget, not be deemed to be located in an 
urban area under 42 CFR 412.63(b), and not be reclassified by CMS or 
the MGCRB as urban for purposes of the standardized payment amount, nor 
be a member of a group of hospitals reclassified to an urban area under 
42 CFR 412.232. Second, if a CAH does not meet the first criterion, if 
located in an MSA, a CAH will be treated as rural if it has 
reclassified under 42 CFR 412.103. Third, as we stated in the FY 2005 
IPPS final rule, if the CAH cannot meet either of the first two 
requirements and is located in a revised labor market area (CBSA) under 
the standards announced by OMB on June 6, 2003 and adopted by CMS 
effective October 1, 2004, it has until September 30, 2006, to meet one 
of the other classification requirements without losing its CAH status.
    Under section 1886(d)(8)(B) of the Act, hospitals that are located 
in a rural county that is adjacent to one or more urban counties are 
considered to be located in the urban MSA to which the greatest number 
of workers in the county commute, if certain conditions, specified in 
section 1886(d)(8)(B) of the Act, are met. Regulations implementing 
this provision are set forth in 42 CFR 412.62(f)(1) (for FY 1984), 42 
CFR 412.63(b)(3) (for FYs 1985 through 2004), and at 42 CFR 
412.64(b)(3) (for FY 2005 and subsequent fiscal years). The provision 
(section 1886(d)(8)(B) of the Act) is referred to as the ``Lugar 
provision'' and the counties described by it are referred to as the 
``Lugar counties.''
    As explained more fully in the FY 2005 IPPS final rule (69 FR 
48916), certain counties that previously were not considered Lugar 
counties were, effective October 1, 2004, redesignated as Lugar 
counties as a result of the most recent census data and the new labor 
market area definitions announced by OMB on June 6, 2003. Some CAHs 
located in these newly designated Lugar counties are now unable to meet 
the rural location requirements described above, even though they were 
in full compliance with the location requirements in effect at the time 
they converted from short-term acute care hospital to CAH status.
    We have received comments that suggest that it would be 
inappropriate for a facility to be required to terminate participation 
as a CAH and resume participating as a short-term acute care hospital 
because of a change in county classification that did not result from 
any change in functioning by the CAH. After consideration of these 
comments, we are clarifying our policy with respect to facilities 
located in Lugar counties. As we noted in the FY 2005 IPPS final rule, 
we believe it is appropriate to allow facilities located in counties 
that began to be considered part of MSAs effective October 1, 2004, as 
a result of data from the 2000 census and implementation of the new 
labor market area definitions announced by OMB on June 6, 2003, an 
opportunity to obtain rural designations under applicable State law or 
regulations from their State legislatures or regulatory agencies. 
Similarly, we believe that when a CAH's status as being located in a 
Lugar county occurs as a result of changes that the CAH did not 
originate and that were beyond its control, such as a change in the OMB 
standards for labor market area definitions, it is appropriate for the 
CAH to be allowed a reasonable opportunity to reclassify to rural 
status. Thus, we are clarifying our policy to note that CAHs in 
counties that were designated as Lugar counties effective October 1, 
2004, because of implementation of the new labor market area 
definitions announced by OMB on June 6, 2003, are to be given the same 
reclassification opportunity. Of course, the opportunity to reclassify 
would not be available to a CAH if the CAH itself were to initiate some 
change, such as a redesignation as urban rather than rural under State 
law or regulations, which would invalidate a prior Sec.  412.103 
reclassification. As a result, we are proposing to make changes to 
Sec.  485.610(b) of the regulations that would permit CAHs located in a 
county that, in FY 2004, was not part of a Lugar county, but as of FY 
2005 was included in such a county as a result of the new labor market 
area definitions, to maintain their CAH status until September 30, 
2006. These changes, if adopted in final form, would permit CAHs in 
newly designated Lugar counties to continue participating in Medicare 
as CAHs until September 30, 2006. We expect that this will provide 
these CAHs with sufficient time to seek reclassification as rural 
facilities under the current regulations at Sec.  412.103. In other 
words, after October 1, 2006, these facilities must meet at least one 
of the criteria in Sec.  412.103(a)(1) through (a)(3) to be eligible to 
reclassify from urban to rural status. Once the Sec.  412.103 
reclassification is approved, the facilities would meet the CAH rural 
location requirements in Sec.  485.610(b)(2). In addition, consistent 
with the clarification of the policy, we are proposing to amend the 
regulations at Sec.  412.103(a)(4) to reflect the proposed change in 
the text of the CAH location regulations at Sec.  485.610(b)(3).
    In addition, we are making a technical amendment to Sec.  
485.610(b)(1)(ii) by replacing the reference to 42 CFR 412.63(b) with 
42 CFR 412.64(b). This proposed technical amendment would conform the 
regulations to reflect the rules governing geographic reclassification 
(found at Sec.  412.64) that are already in place for fiscal years 
beginning on or after October 1, 2004 (69 FR 49242).
3. Proposed Policy Change Relating to Designation of CAHs as Necessary 
Providers
    Section 405(h) of Pub. L. 108-173 amended section 
1820(c)(2)(B)(i)(II) of the Act by adding language that terminated a 
State's authority to waive the location requirement for a CAH by 
designating the CAH as a necessary provider, effective January 1, 2006. 
Currently, a CAH is required to be located more than a 35-mile drive 
(or in the case of mountainous terrain or secondary roads, a 15-mile 
drive) from a hospital or another CAH, unless the CAH is certified by 
the State as a necessary provider of health care services to residents 
in the area. Under this provision, after January 1, 2006, States will 
no longer be able to designate a CAH based upon a determination that it 
is a necessary provider of health care. In addition, section 405(h) of 
Pub. L. 108-173 amended section 1820(h) of the Act to include a 
grandfathering provision for CAHs that are certified as necessary 
providers prior to January 1, 2006. In the FY 2005 IPPS final rule (69 
FR 49220), we incorporated these amendments in our regulations at Sec.  
485.610 (c). Under that regulation, any CAH that is designated as a 
necessary provider in its State rural health plan prior to January 1, 
2006, will be permitted to maintain its necessary provider designation. 
However, the regulations are limited to CAHs that were necessary 
providers as of January 1, 2006, and does not address the

[[Page 23452]]

situation where the CAH is no longer the same facility due to 
relocation, cessation of business, or a substitute facility. Currently, 
CMS Regional Offices make the decision for continued certification 
following relocation of a certified facility on a case-by-case basis.
    The criteria used to qualify a CAH as a necessary provider were 
established by each State in its MRHFP. The State's MRHFP defined those 
CAHs that provide necessary services to a particular patient community 
in the event that the facility did not meet the required 35-mile (or 
15-mile with stated exceptions) distance requirement from the nearest 
hospital or CAH. Each State's criteria are different, but the criteria 
share certain similarities and all define a necessary provider related 
to the facility location. Therefore, it becomes crucial to define 
whether the necessary provider designation remains pertinent in the 
event the certified CAH builds in a different location. Accordingly, 
the first step of this process is to determine whether building a new 
CAH facility in a different location is a replacement of an existing 
facility in essentially the same location, a relocation of the facility 
in a new location, or a cessation of business at one location and 
establishment of new business at another location.
a. Determination of the Relocation Status of a CAH
    (1) Replacement in the same location. Under this approach, we are 
proposing that, if the CAH is constructing renovation of the same 
building in the same location, the renovation is considered to be a 
replacement of the same provider and not relocation. We would consider 
a construction of the CAH to be a replacement if construction was 
undertaken within 250 yards of the current building, as set by prior 
precedence in defining a hospital campus. In addition, if the 
replacement is constructed on land that is contiguous to the current 
CAH, and that land was owned by the CAH prior to enactment of Pub. L. 
108-173, and the CAH is operating under a State-issued necessary 
provider waiver that is grandfathered by Pub. L. 108-173, we would 
consider that construction to be a replacement of the existing provider 
and the provisions of the grandfathered necessary provider designation 
would continue to apply regardless of when the construction or 
renovation work commenced and was completed.
    (2) Relocation of a CAH. Under our proposed approach, if the CAH is 
constructing a new facility in a location that does not qualify the 
construction as replacement of an existing facility in the same 
location under the criteria in the preceding paragraph, we would need 
to determine if this building would be a relocation of the current 
provider or a cessation of business at one location and establishment 
of a new business at another location. In the event of relocation, the 
CAH must ensure that the provider is functioning as essentially the 
same provider in order to operate under the same provider agreement. A 
provider that is changing location is considered to have closed the old 
facility if the original community or service area can no longer be 
expected to be served at the new location. The distance of the moved 
CAH from its old location will be considered, but it will not be the 
sole determining factor in granting the relocation of a CAH under the 
same provider agreement. For example, a specialty hospital may move a 
considerable distance and still care for generally the same inpatient 
population, while the relocation of a CAH at a relatively short 
distance within a rural area may greatly affect the community served.
    In the event that CMS determines the rebuilding of the CAH in a 
different location to be a relocation, the provider agreement would 
continue to apply to the CAH at the new location. In addition to the 
relocation being within the same service area, serving the same 
population, the CAH would need to be providing essentially the same 
services with the same staff; that is, at least 75 percent of the same 
staff and 75 percent of the range of services are maintained in the new 
location as the same provider of services. We are proposing the use of 
a 75-percent threshold because we believe it indicates that the CAH 
that is relocating demonstrates that it will maintain a high level of 
involvement, as opposed to just a majority involvement, in the current 
community. We note that CMS has also used a 75-percent threshold in 
other provider designation policies such as the provider-based policies 
at Sec.  413.65(e)(3)(ii).
    In all cases of relocation, the CAH must continue to meet all of 
the CoPs found at 42 CFR Part 485, Subpart F, including location in a 
rural area as provided for at Sec.  485.610.
    (3)  Cessation of business at one location. Under existing CMS 
policy, if the CAH relocation results in the cessation of furnishing 
services to the same community, we would not consider this to be a 
relocation, but instead would consider such a scenario a cessation of 
business at one location and establishment of a new business at another 
location. Cessation of business is a basis for voluntary termination of 
the provider agreement under 42 CFR Part 489. If the proposed move 
constitutes a cessation of business, the CMS Regional Office may assist 
the provider in obtaining an agreement to participate under a new 
provider number. Furthermore, in such a situation, the regulations 
require the provider to give advanced notice to CMS and the public 
regarding its intent to stop providing medical services to the 
community. There is no appeals process for a voluntary termination. 
Under our current policies, the cessation of business by a CAH 
automatically terminates the CAH designation, regardless of whether the 
designation was obtained through a necessary provider determination.
b. Relocation of a CAH Using a Necessary Provider Designation To Meet 
the CoP for Distance
    Once it has been determined that constructing a new facility will 
cause the CAH to relocate, the second step is to determine if the CAH 
that has a necessary provider designation can maintain this designation 
after relocating.
    We recognize that Sec.  485.610(c) relating to location relative to 
other facilities or necessary provider certification states that, after 
January 1, 2006, the ``necessary provider'' designation will no longer 
be used to waive the mileage requirements. In addition, CMS policy 
regarding a change of size or location of a provider states that there 
may be situations where the facility relocation is so far removed from 
the originally approved site that we would conclude that this is a 
different provider or supplier, for example, it has different 
employees, services, and patients. Furthermore, the language of section 
1820(c)(2)(i) of the Act allows a State to waive the mileage 
requirement and designate a facility as a necessary provider of health 
care services to residents in the area. We have interpreted ``services 
to residents in the area'' to mean that the necessary provider 
designation does not automatically follow the provider if the facility 
relocates to a different location because it is no longer furnishing 
``services to patients'' in the area determined to need a necessary 
provider.
    We do not intend to change this policy. Our proposal, noted below, 
is intended to establish a methodology to be used by all CMS Regional 
Offices in making such a decision consistent with the statutory 
provisions concerning necessary provider designation.
    In this proposed rule, we are proposing to amend the regulations at 
Sec.  485.610 to set forth the criteria by

[[Page 23453]]

which those relocated CAHs designated as necessary providers that 
embarked on a replacement facility project before the sunset provision 
was enacted on December 8, 2003, but find that they cannot be 
operational in the replacement facility by January 1, 2006, can retain 
their necessary provider status. As required by statute, no additional 
CAHs will be certified as a necessary provider on or after January 1, 
2006. We recognize that the statute refers to a facility designated as 
a CAH while relocation of a facility may result in a different 
building. However, to provide flexibility for a facility designated as 
a CAH whose location may change, but is essentially the same facility 
in a different location, we are proposing to amend the regulations to 
account for this scenario. Essentially, we recognize that the necessary 
provider designation may need to be applied to certain relocated CAHs. 
To this end, we are proposing to use the specified relocation criteria 
as the initial step to determine continuing necessary provider status. 
Specifically, in this proposed rule, we are proposing that, when a CAH 
is determined to have relocated, it may nonetheless continue to operate 
under its necessary provider designation that exempts the distance from 
other providers only if the following conditions are met:
    (1) The relocated CAH has submitted an application to the State 
agency for relocation prior to the January 1, 2006, sunset date. If the 
CAH is applying under a grandfathered status under section 1820(h)(3) 
of the Act, the following items would need to be included in the 
application:
     A demonstration that the CAH will meet the same State 
criteria for the necessary provider designation that were established 
when the waiver was originally issued. For example, if the location 
waiver was granted because the CAH was located in a health professional 
shortage area (HPSA), the CAH must remain in that HPSA.
     Assurance that, after the relocation, the CAH will be 
servicing the same community and will be operating essentially the same 
services with essentially the same staff (that is, a demonstration that 
it is serving at least 75 percent of the same service area, with 75 
percent of the same services offered, and staffed by 75 percent of the 
same staff, including medical staff, contracted staff, and employees). 
This is essentially the same criteria used in determining whether the 
CAH has relocated.
     Assurance that the CAH will remain in compliance with all 
of the CoPs at 42 CFR Part 485 in the new location. Compliance will be 
established with a full survey in the new location to include the Life 
Safety Code and would include any off-site locations and rehabilitation 
or psychiatric distinct part units.
     A demonstration that construction plans were ``under 
development'' prior to the effective date of Pub. L. 108-173 (December 
8, 2003) in the application the CAH submits to continue using a 
necessary provider designation. Supporting documentation could include 
the drafting of architectural specifications, the letting of bids for 
construction, the purchase of land and building supplies, documented 
efforts to secure financing for construction, expenditure of funds for 
construction, and compliance with state requirements for construction 
such as zoning requirements, application for a certificate of need, and 
architectural review. However, we recognize that it may not have been 
feasible for a CAH to have completed all of these activities noted 
above as examples prior to December 8, 2003. Thus, we expect the CMS 
Regional Offices to consider all of the criteria and make case-by-case 
determinations of whether a relocated CAH continues to warrant 
necessary provider status. We note that we have also used the above 
documentation guidelines in Publication 100-20 for grandfathered 
specialty hospitals to determine if construction plans were ``under 
development.''
    In proposing these criteria, our intent in clarifying the sunset of 
the necessary provider designation provision is to allow CAHs to 
complete construction projects that were initiated prior to the 
enactment of Pub. L. 108-173, which we believe is consistent with the 
statutory language of section 405(h) of Pub. L. 108-173.
    (2) In the application, the CAH demonstrates that the replacement 
will facilitate the access to care and improve the delivery of services 
to Medicare beneficiaries. We are soliciting comments on how a 
necessary provider CAH should demonstrate that the replacement will 
improve access to care.
    These guidelines are meant to be applied to the relocated CAH that 
meets the CoP in the new location and wishes to maintain a necessary 
provider designation in order to meet the distance requirement at Sec.  
485.610(c). They are not meant to preclude a CAH from relocating at any 
time if the CAH does not seek to maintain the necessary provider 
designation. Any CAH may relocate at any time if the CAH meets the 
definition of relocation and can meet all the CoPs at 42 CFR part 485, 
subpart F, as determined by the CMS Regional Offices on a case-by-case 
basis.
    Accordingly, we are proposing to revise Sec.  485.610 of the 
regulations by adding a new paragraph (d) to incorporate this proposal. 
Specifically, the proposed new paragraph (d) would specify that a CAH 
may maintain its necessary provider certification provided for under 
Sec.  485.610(c) if the new facility meets the requirements for either 
a replacement facility that is constructed within 250 yards of the 
current building or contiguous to the current CAH on land owned by the 
CAH prior to December 8, 2003; or as a relocated CAH if, at the 
relocated site, the CAH provides essentially (75 percent) the same 
services to the same service area with essentially the same staff. The 
CAH that plans to relocate must provide documentation demonstrating 
that its plans to rebuild in the relocated area were undertaken prior 
to December 8, 2003. We are also proposing that if a CAH that has a 
necessary provider certification from the State places a new facility 
in service on or after January 1, 2006, and does not meet either the 
requirements for a replacement facility or a relocated facility, as 
specified in the regulations, the action will be considered a cessation 
of business.

VIII. Payment for Blood Clotting Factor Administered to Hemophilia 
Inpatients

    (If you choose to comment on issues in this section, please include 
the caption ``Blood Clotting Factor'' at the beginning of your 
comment.)
    Section 1886(a)(4) of the Act excludes the costs of administering 
blood clotting factors to individuals with hemophilia from the 
definition of ``operating costs of inpatient hospital services.'' 
Section 6011(b) of Pub. L. 101-239 (the Omnibus Budget Reconciliation 
Act of 1989) states that the Secretary of Health and Human Services 
shall determine the payment amount made to hospitals under Part A of 
Title XVIII of the Act for the costs of administering blood clotting 
factors to individuals with hemophilia by multiplying a predetermined 
price per unit of blood clotting factor by the number of units provided 
to the individual. The regulations governing payment for blood clotting 
factor furnished to hospital inpatients are located in Sec. Sec.  
412.2(f)(8) and 412.115(b).
    Consistent with the rates paid under section 1842(o) of the Act for 
Medicare Part B drugs (including blood clotting factor furnished to 
individuals who are not inpatients), in FY 2005, we made payments for 
blood clotting factors furnished to inpatients at 95 percent of average 
wholesale price (AWP). Section 303 of Pub. L. 108-173 established

[[Page 23454]]

section 1847A of the Act which requires that almost all Medicare Part B 
drugs not paid on a cost or prospective basis be paid at 106 percent of 
average sales price (ASP) and provided for payment of a furnishing fee 
for blood clotting factor, effective January 1, 2005. On November 15, 
2004, we issued regulations in the Federal Register (69 FR 66299) that 
implemented the provisions of section 1847A for payment for Medicare 
Part B drugs using the 106 percent of ASP payment methodology and for 
payment of the furnishing fee. These regulations are codified at 42 CFR 
410.63 and subpart K of Part 414.
    To ensure consistency in payment for Medicare Part A and Medicare 
Part B drugs, we are proposing to revise Sec. Sec.  412.2(f)(8) and 
412.115(b) of the regulations governing the IPPS to specify that, for 
discharges occurring on or after October 1, 2005, the additional 
payment for the blood clotting factor administered to hemophilia 
inpatients is made based on the average sales price methodology 
specified in subpart K of 42 CFR part 414 and the furnishing fee 
specified in Sec.  410.63.
    The proposed payment amount per unit and the unit payment for the 
furnishing fee for blood clotting factor administered to hospital 
inpatients who have hemophilia that we are proposing to apply under the 
IPPS for FY 2006 are specified in section V. of the Addendum to this 
proposed rule.

IX. MedPAC Recommendations

    (If you choose to comment on issues in this section, please include 
the caption ``MedPAC Recommendations'' at the beginning of your 
comment.)
    We are required by section 1886(e)(4)(B) of the Act to respond to 
MedPAC's IPPS recommendations in our annual proposed IPPS rule. In 
March 2005, MedPAC released the following two reports to Congress, 
which included IPPS recommendations: ``Report to Congress: Medicare 
Payment Policy'' and ``Report to Congress: Physician-Owned Specialty 
Hospitals.'' We have reviewed each of these reports and have given them 
careful consideration in conjunction with the policies set forth in 
this document. These recommendations and our responses are set forth 
below. For further information relating specifically to the MedPAC 
reports or to obtain a copy of the reports, contact MedPAC at (202) 
653-7220, or visit MedPAC's Web site at: http://www.medpac.gov.

A. Medicare Payment Policy

    MedPAC's Recommendation 2A-1 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 proposed rule.
    Recommendation 4A: The Congress should establish a quality 
incentive payment policy for hospitals in Medicare.
    Response: We are exploring provider payment policies that link 
quality to Medicare reimbursement in a cost neutral manner under our 
demonstration authority. We currently have demonstrations underway that 
will identify and examine the components of such a policy.

B. Physician-Owned Specialty Hospitals

    Recommendation 1: The Secretary should improve payment accuracy in 
the hospital inpatient PPS by:
     Refining the current DRGs to more fully capture 
differences in severity of illness among patients.
     Basing the DRG relative weights on the estimated cost of 
providing care rather than on charges.
     Basing the weights on the national average of hospitals' 
relative values in each DRG.
    In making this recommendation, MedPAC recognized several 
implementation issues regarding potential low volume DRGs and potential 
changes in hospital coding and reporting behavior. In particular, 
MedPAC recommended that the Secretary project the likely effect of 
reporting improvements on total payments and make an offsetting 
adjustment to the standardized amounts.
    Response: We expect to make changes to the DRGs to better reflect 
severity of illness. The following discussion briefly describes some of 
the options we are considering. As we discussed in section II.B. of 
this preamble, there is a standard list of diagnoses that are 
considered complications or comorbidities (CC). These conditions, when 
present as a secondary diagnosis, may result in payment using a higher 
weighted DRG. Currently, 3,285 diagnosis codes on this list, and 121-
paired DRGs are differentiated based on the presence or absence of a 
CC. Our analysis indicates that the majority of cases assigned to these 
DRGs fall into the ``with CC'' DRGs. We believe that it is possible 
that the CC distinction has lost much of its ability to differentiate 
the resource needs of patients, given the long period of time since the 
original CC list was developed and the incremental nature of subsequent 
changes in an environment of major changes in the way inpatient care is 
delivered.
    We are planning a comprehensive and systematic review of the CC 
list for the IPPS rule for FY 2007. As part of this process, we will 
consider revising the standard for determining when a condition is a 
CC. For instance, we expect to use an alternative to the current method 
of classifying a condition as a CC based on how it affects the length 
of stay of a case. Similar to other aspects of the DRG system, we 
expect to consider the effect of a specific secondary diagnosis on the 
charges or costs of a case to evaluate whether to include the condition 
on the CC list.
    Another option we are considering is a selective review of the 
specific DRGs, such as cardiac, orthopedic, and surgical DRGs, that are 
alleged to be overpaid and that create incentives for physicians to 
form specialty hospitals. We expect to selectively review particular 
DRGs based on statistical criteria such as the range or standard 
deviation among charges for cases included within the DRG. It is 
possible specific DRGs have high variation in resource costs and that a 
better recognition of severity would reduce incentives for hospitals to 
select the least costly and most profitable patients within these DRGs. 
Any analysis we perform would balance the goal of making payment based 
on an accurate coding system that recognizes severity of illness with 
the premise that the IPPS is a system of payment based on averages. We 
agree with MedPAC that, in refining the DRGs, we must continue to be 
mindful of issues such as the instability of small volume DRGs and the 
potential impact of changes in hospital coding and reporting behavior. 
As MedPAC noted, previous refinements to DRG definitions have led to 
unanticipated increases in payment because of more complete reporting 
of patients' diagnoses and procedures. As part of our analysis of 
possible refinements to the DRGs, we have concerns with our ability to 
account for the effect of changes in coding behavior on payment.
    We are also considering the use of alternative DRG systems such as 
the all patient refined diagnosis related groups (APR-DRGs) in place of 
Medicare's current DRG system. The APR-DRGs have a greater number of 
DRGs that could relate payment rates more closely to patient resource 
needs, and thus reduce the advantages of selection of desirable 
patients within DRGs by specialty hospitals. However, any large change 
to the DRGs could have substantial effects across all hospitals. 
Therefore, we believe we must thoroughly analyze such options and

[[Page 23455]]

their impacts on the various types of hospitals before making any 
proposal. In addition, as noted above, we are concerned about our 
ability to account for the effect of changes in coding behavior on 
payment if we were to significantly expand the number of DRGs. 
Therefore, in light of the above, we must consider how to mitigate the 
risk of paying significantly more for the alternatives discussed above 
while measuring the benefit for Medicare beneficiaries.
    In response to MedPAC's recommendation that we improve payment 
accuracy by basing the DRG relative weights on the estimated cost of 
providing care rather than on charges, we note that we do not have 
access to any information that would provide a direct measure of the 
costs of individual discharges. Claims filed by hospitals do provide 
information on the charges for individual cases. At present, we use 
this information to set the relative weights for the DRGs. We obtain 
information on costs from the hospital cost reports, but this 
information is at best at the department level; it does not include 
information about the costs of individual cases. Consequently, the most 
straightforward way to estimate costs of an individual case is to 
calculate a cost-to-charge ratio for some body of claims (for example, 
for a hospital's radiology department), and then apply this ratio to 
the charges for that department.
    However, this procedure is not without disadvantages because 
assignment of costs to departments is not uniform from hospital to 
hospital, given the variability of hospital accounting systems, and 
because cost information is not available until a year or more after 
claims information. In addition, the application of a cost-to-charge 
ratio that is uniform across any body of claims may result in biased 
estimates of individual costs if hospital charging behavior is not 
uniform. Thus, it is alleged that hospitals mark up lower cost services 
less than higher cost services, and to the extent they do so, 
application of a uniform cost-to-charge ratio will result in 
underestimates of the costs of higher cost services and vice versa. We 
use estimated costs, based on hospital-specific, department-level cost-
to-charge ratios, in the hospital outpatient prospective payment 
system. The accuracy of this procedure has generated some concern, and 
without further analysis, the extent to which accuracy of inpatient 
payments would be improved by adopting this method is not obvious.
    We will closely analyze the impact of such a change from the 
current charge-based DRG weights to cost-based DRG weights. We note 
that such a change is complex and would require further analysis. With 
this in mind, CMS will consider the following issues in performing this 
analysis:
     The effect of using cost-to-charge ratio data, which is 
frequently older than the claims data we use to set the charge-based 
weights, and the impact on these data of any changes in hospitals' 
charging behavior that resulted from the recent modifications to the 
outlier payment methodology (68 FR 34494; June 9, 2003);
     Whether using this method has different effects on DRGs 
that have experienced substantial technological change compared to DRGs 
with more stable procedures for care;
     The effect of using a routine cost-to-charge ratio and 
department-level ancillary cost-to-charge data as compared to either an 
overall hospital cost-to-charge ratio or a routine cost-to-charge ratio 
and an overall ancillary cost-to-charge ratio, particularly in 
considering earlier studies performed for the Prospective Payment 
Assessment Commission, the predecessor to MedPAC, indicating that an 
overall ancillary cost-to-charge ratio led to more accurate estimates 
of case level costs; \5\
---------------------------------------------------------------------------

    \5\ Cost Accounting for Health Care Organizations, Technical 
Report Series, 1-93-01, ProPAC, March 1993, page 6. Using a cost 
report package, the contractor simulated single and multiple 
ancillary cost-to-charge ratios and found that inpatient ancillary 
costs were 2.5 percent understated relative to what hospitals 
thought their costs were with the single cost-to-charge ratio, and 
4.9 percent understated with the multiple cost-to-charge ratios.
---------------------------------------------------------------------------

     Whether developing relative weights by estimating costs 
from charges multiplied by cost-to-charge ratios versus whether the 
sole use of charges improves payment accuracy; and
     How payments to hospitals would be affected by MedPAC's 
suggestion intended to simplify recalibration, to recalibrate weights 
based on costs every few years, and to calculate an adjustment to 
charge-based weights for the intervening periods.
    In response to the recommendation that the Secretary should improve 
payment accuracy in the IPPS by basing the weights on the national 
average of hospitals' relative values in each DRG, we note that 
presently we set the relative weights using standardized charges 
(adjusted to remove the effects of differences in area wage costs and 
in IME and DSH payments). In contrast, MedPAC proposes that Medicare 
set the DRG relative weights using unstandardized, hospital-specific 
charges. Each hospital's unstandardized charges would become the basis 
for determining the relative weights for the DRGs for that hospital. 
These relative weights would be adjusted by the hospital's case-mix 
index when combining each hospital's relative weights to determine a 
national relative weight for all hospitals. This adjustment is designed 
to reduce the influence that a single hospital's charge structure could 
have on determining the relative weight when it provides a high 
proportion of the total, nationwide number of discharges in a 
particular DRG.
    We will analyze the possibility of moving to hospital specific 
relative values while conducting the analysis outlined above in 
response to the recommendations regarding improved severity adjustment 
and using charges adjusted to estimated cost using cost-to-charge 
ratios to set the relative weights. We note that we use this method at 
present to set weights for the LTCH PPS. We use this method for LTCHs 
because of the small volume of providers and the possibility that only 
a few providers provide care for certain DRGs. The charges of one or a 
few hospitals could thus materially affect the relative weights for 
these DRGs. In this event, looking at relative values within hospitals 
first can smooth out the hospital-specific effects on DRG weights. A 
1993 Rand Report on hospital specific relative values noted the 
possibility of DRG compression (or the undervaluing of high-cost cases 
and the overvaluing of low-cost cases) if we were to shift to a 
hospital-specific relative value method from the current method for 
determining DRG weights. We will need to consider whether the resultant 
level of compression is appropriate.
    Recommendation 2: The Congress should amend the law to give the 
Secretary authority to adjust the DRG relative weights to account for 
differences in the prevalence of high-cost outlier cases.
    Response: While MedPAC's language suggests that the law would need 
to be amended for us to adopt this suggestion, we believe the statute 
may give the Secretary broad discretion to consider all factors that 
change the relative use of hospital resources in calculating the DRG 
relative weights. We believe that MedPAC's recommendation springs from 
a concern that including high-charge outlier cases in the relative-
weight calculation results in overvaluing DRGs that have a high 
prevalence of outlier cases. However, we believe that excluding outlier 
cases completely in calculating the relative weights would be 
inappropriate. Doing

[[Page 23456]]

so would undervalue the relative weight for a DRG with a high 
percentage of outliers by not including that portion of hospital 
charges that is above the median but below the outlier threshold. We 
believe it would be preferable to adjust the charges used for 
calculating the relative weights to exclude the portion of charges 
above the outlier threshold but to include the charges up to the 
outlier threshold. At this time, we expect to further analyze these 
ideas as we consider the other changes recommended by MedPAC and 
welcome public comments on this issue.
    Finally, we believe that the recommendations made by MedPAC, or 
some variants of them, have significant promise in improving the 
accuracy of rates in the inpatient payment prospective payment system. 
We agree with MedPAC that they should be pursued even in the absence of 
concerns about the proliferation of specialty hospitals. However, until 
we have completed further analysis of these options and their effects, 
we cannot predict the extent to which they will provide payment equity 
between specialty and general hospitals. In fact, we must caution that 
any system that groups cases and provides a standard payment for cases 
in the group (that is, the IPPS among other Medicare payment systems) 
will always present some opportunities for providers to specialize in 
cases where they believe margins may be better. Improving payment 
accuracy should reduce these opportunities, and it may do so to the 
extent that Medicare payments no longer provide a significant impetus 
to further development of specialty hospitals.
    Recommendation 3: The Congress and the Secretary should implement 
the case-mix measurement and outlier policies over a transitional 
period.
    Response: Before proposing any changes to the DRGs, we would need 
to model the impact of any specific proposal and our authority under 
the statute to determine whether any changes should be implemented 
immediately or over a period of time. We do note that with regard to 
revising the existing DRG system with a new DRG system that fully 
captures differences in severity, there would likely be unique 
complexities in creating a transition from one DRG system to another. 
Our payment would be a blend of two different relative weights that 
would have to be determined using two different systems of DRGs. The 
systems and legal implications of such a transition or any other major 
change to the DRGs could be significant.

C. Other MedPAC Recommendations

    MedPAC also made the following recommendations that we will address 
in our Report to Congress on Specialty Hospitals:
    Recommendation 4: The Congress should extend the current [Pub. L. 
108-173] moratorium on physician-owned single specialty hospitals until 
January 1, 2007.
    Recommendation 5: The Congress should grant the Secretary the 
authority to allow gainsharing arrangements between physicians and 
hospitals and to regulate those arrangements to protect the quality of 
care and minimize financial incentives that could affect physician 
referrals.

X. 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.cms.hhs.gov/providers/hipps. Data files and the 
cost for each file, if applicable, are listed below. Anyone wishing to 
purchase data tapes, cartridges, or diskettes should submit a written 
request along with a company check or money order (payable to CMS-PUF) 
to cover the cost to the following address: Centers for Medicare & 
Medicaid Services, Public Use Files, Accounting Division, P.O. Box 
7520, Baltimore, MD 21207-0520, (410) 786-3691. Files on the Internet 
may be downloaded without charge.
1. CMS Wage Data
    This file contains the hospital hours and salaries for FY 2002 used 
to create the FY 2006 prospective payment system wage index. The file 
will be available by the beginning of February for the NPRM and the 
beginning of May for the final rule.
[GRAPHIC] [TIFF OMITTED] TP04MY05.060


[[Page 23457]]


    These files support the following:
     NPRM published in the Federal Register.
     Final Rule published in the Federal Register.
    Media: Diskette/most recent year on the Internet.
    File Cost: $165.00 per year.
    Periods Available: FY 2006 PPS Update.
2. CMS Hospital Wages Indices (Formerly: Urban and Rural Wage Index 
Values Only)
    This file contains a history of all wage indices since October 1, 
1983.
    Media: Diskette/most recent year on the Internet.
    File Cost: $165.00 per year.
    Periods Available: FY 2006 PPS Update.
3. FY 2006 Proposed Rule Occupational Mix Adjusted and Unadjusted AHW 
by Provider
    This file includes each hospital's adjusted and unadjusted average 
hourly wage.
    Media: Internet.
    Periods Available: FY 2006 PPS Update.
4. FY 2006 Proposed Rule Occupational Mix Adjusted and Unadjusted AHW 
and Pre-Reclassified Wage Index by CBSA
    This file includes each CBSA's adjusted and unadjusted average 
hourly wage.
    Media: Internet.
    Periods Available: FY 2006 PPS Update.
5. Provider Occupational Mix Adjustment Factors for Each Occupational 
Category
    This file contains each hospital's occupational mix adjustment 
factors by occupational category.
    Media: Internet.
    Periods Available: FY 2006 PPS Update.
6. PPS SSA/FIPS MSA State and County Crosswalk.
    This file contains a crosswalk of State and county codes used by 
the Social Security Administration (SSA) and the Federal Information 
Processing Standards (FIPS), county name, and a historical list of 
Metropolitan Statistical Areas (MSAs).
    Media: Diskette/Internet.
    File Cost: $165.00 per year.
    Periods Available: FY 2006 PPS Update.
7. Reclassified Hospitals New Wage Index (Formerly: Reclassified 
Hospitals by Provider Only)
    This file contains a list of hospitals that were reclassified for 
the purpose of assigning a new wage index. Two versions of these files 
are created each year. They support the following:
     NPRM published in the Federal Register.
     Final Rule published in the Federal Register.
    Media: Diskette/Internet.
    File Cost: $165.00 per year.
    Periods Available: FY 2006 PPS Update.
8. PPS-IV to PPS-XII Minimum Data Set
    The Minimum Data Set contains cost, statistical, financial, and 
other information from Medicare hospital cost reports. The data set 
includes only the most current cost report (as submitted, final 
settled, or reopened) submitted for a Medicare participating hospital 
by the Medicare fiscal intermediary to CMS. This data set is updated at 
the end of each calendar quarter and is available on the last day of 
the following month.
    Media: Tape/Cartridge.
    File Cost: $770.00 per year.
    [GRAPHIC] [TIFF OMITTED] TP04MY05.061
    
    (Note: The PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS-
XVIII, and PPS-XIX Minimum Data Sets are part of the PPS-XIII, PPS-
XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS-XVIII, PPS-XIX, and PPS-XX 
Hospital Data Set Files (refer to item 7 below).)
9. PPS-IX to PPS-XII Capital Data Set
    The Capital Data Set contains selected data for capital-related 
costs, interest expense and related information and complete balance 
sheet data from the Medicare hospital cost report. The data set 
includes only the most current cost report (as submitted, final settled 
or reopened) submitted for Medicare certified hospital by the Medicare 
fiscal intermediary to CMS. This data set is updated at the end of each 
calendar quarter and is available on the last day of the following 
month.
    Media: Tape/Cartridge.
    Fine Cost: $770.00 per year.

[[Page 23458]]

[GRAPHIC] [TIFF OMITTED] TP04MY05.062

    (Note: The PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS-
XVIII, and PPS-XIX Capital Data Sets are part of the PPS-XIII, PPS-
XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS-XVIII, PPS-XIX, and PPS-XX 
Hospital Data Set Files (refer to item 7 below).)
10. PPS-XIII to PPS-XX Capital Data Set
    The file contains costs, statistical, financial, and other data 
from the Medicare Hospital Cost Report. The data set includes only the 
most current cost report (as submitted, final settled or reopened) 
submitted for Medicare-certified hospital by the Medicare fiscal 
intermediary to CMS. This data set is updated at the end of each 
calendar quarter and is available on the last day of the following 
month.
    Media: Diskette/Internet.
    Fine Cost: $2,500.00.
    [GRAPHIC] [TIFF OMITTED] TP04MY05.063
    
11. Provider-Specific File
    This file is a component of the PRICER program used in the fiscal 
intermediary's system to compute DRG payments for individual bills. The 
file contains records for all prospective payment system eligible 
hospitals, including hospitals in waiver States, and data elements used 
in the prospective payment system recalibration processes and related 
activities. Beginning with December 1988, the individual records were 
enlarged to include pass-through per diems and other elements.
    Media: Diskette/Internet.
    File Cost: $265.00.
    Periods Available: FY 2006 PPS Update.
12. CMS Medicare Case-Mix Index File
    This file contains the Medicare case-mix index by provider number 
as published in each year's update of the Medicare hospital inpatient 
prospective payment system. The case-mix index is a measure of the 
costliness of cases treated by a hospital relative to the cost of the 
national average of all Medicare hospital cases, using DRG weights as a 
measure of relative costliness of cases. Two versions of this file are 
created each year. They support the following:
     NPRM published in the Federal Register.
     Final rule published in the Federal Register.
    Media: Diskette/most recent year on Internet.
    Price: $165.00 per year/per file.
    Periods Available: FY 1985 through FY 2006.
13. DRG Relative Weights (Formerly Table 5 DRG)
    This file contains a listing of DRGs, DRG narrative description, 
relative weights, and geometric and arithmetic mean lengths of stay as 
published in the Federal Register. The hard copy image has been copied 
to diskette. There are two versions of this file as published in the 
Federal Register:
     NPRM.
     Final rule.
    Media: Diskette/Internet.
    File Cost: $165.00.
    Periods Available: FY 2006 PPS Update.
14. PPS Payment Impact File
    This file contains data used to estimate payments under Medicare's 
hospital inpatient prospective payment systems for operating and 
capital-related costs. The data are taken from various sources, 
including the Provider-Specific File, Minimum Data Sets, and prior 
impact files. The data set is abstracted from an internal file used for 
the impact analysis of the changes to the prospective payment systems 
published in the Federal Register. This file is available for release 1 
month after the proposed and final rules are published in the Federal 
Register.
    Media: Diskette/Internet.
    File Cost: $165.00.
    Periods Available: FY 2006 PPS Update.
15. AOR/BOR Tables
    This file contains data used to develop the DRG relative weights. 
It contains mean, maximum, minimum, standard deviation, and coefficient 
of variation statistics by DRG for length of stay and standardized 
charges. The BOR tables are ``Before Outliers Removed'' and the AOR is 
``After Outliers Removed.'' (Outliers refers to statistical outliers, 
not payment outliers.)
    Two versions of this file are created each year. They support the 
following:
     NPRM published in the Federal Register.
     Final rule published in the Federal Register.
    Media: Diskette/Internet.
    File Cost: $165.00.
    Periods Available: FY 2006 PPS Update.

[[Page 23459]]

16. Prospective Payment System (PPS) Standardizing File
    This file contains information that standardizes the charges used 
to calculate relative weights to determine payments under the 
prospective payment system. Variables include wage index, cost-of-
living adjustment (COLA), case-mix index, disproportionate share, and 
the Metropolitan Statistical Area (MSA). The file supports the 
following:
     NPRM published in the Federal Register.
     Final rule published in the Federal Register.
    Media: Internet.
    File Cost: No charge.
    Periods Available: FY 2006 PPS Update.
    For further information concerning these data tapes, contact the 
CMS Public Use Files Hotline at (410) 786-3691.
    Commenters interested in obtaining or discussing any other data 
used in constructing this rule should contact Mark Hartstein at (410) 
786-4548.

B. Collection of Information Requirements

    Under the Paperwork Reduction Act of 1995 (PRA), we are required to 
provide 60-day notice in the Federal Register and solicit public 
comment before a collection of information requirement is submitted to 
the Office of Management and Budget (OMB) for review and approval. In 
order to evaluate fairly whether an information collection should be 
approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act 
of 1995 requires that we solicit comment on the following issues:
     The need for the information collection and its usefulness 
in carrying out the proper functions of our agency.
     The accuracy of our estimate of the information collection 
burden.
     The quality, utility, and clarity of the information to be 
collected.
     Recommendations to minimize the information collection 
burden on the affected public, including automated collection 
techniques.
    Therefore, we are soliciting public comments on each of these 
issues for the information collection requirements discussed below.
    The following information collection requirements included in this 
proposed rule and their associated burdens are subject to the PRA.
Section 412.64 Federal Rates for Inpatient Operating Costs for Federal 
Fiscal Year 2005 and Subsequent Fiscal Years
    Section 412.64(d)(2) requires hospitals to submit quality data on a 
quarterly basis to CMS, as specified by CMS. In this document, we are 
setting out the specific requirements related to the data that must be 
submitted. The burden associated with this section is the time and 
effort associated with collecting, copying and submitting this data. We 
estimate that there will be approximately 4,000 respondents per year. 
Of this number, approximately 3,600 hospitals are JCAHO accredited and 
are currently collecting measures and submitting data to the JCAHO on a 
quarterly basis. Of the JCAHO accredited hospitals, approximately 3,300 
are collecting the same measures CMS will be collecting for public 
reporting. Therefore, there will be no additional burden for these 
hospitals. Only approximately 300 of the JCAHO accredited hospitals 
will need to collect an additional topic in addition to the data 
already collected for maintaining JCAHO accreditation. In addition, 
there are approximately 400 hospitals that do not participate in the 
JCAHO accreditation process. These hospitals will have the additional 
burden of collecting data on all three topics.
    For JCAHO accredited hospitals that are not already collecting all 
of the required measures, we estimate it will take 25 hours per month 
per topic for collection. We expect the burden for all of these 
hospitals to total 102,000 hours per year, including time allotted for 
overhead. For non-JCAHO accredited hospitals, we estimate the burden to 
be 136,000 hours per year. This estimate also includes overhead. The 
total number of burden hours for all hospitals combined is 238,000. The 
number of responders will vary according to the level of voluntary 
participation. One hundred percent of the data may be collected 
electronically.
    In the preamble to this proposed rule, we are proposing additional 
validation criteria to ensure that the quality data being sent to CMS 
are accurate. Our validation process requires participating hospitals 
to submit five charts per quarter. The burden associated with this 
requirement is the time and effort associated with collecting, copying, 
and submitting these charts. It will take approximately 2 hours per 
hospital to submit the 5 charts per quarter. There will be a total of 
approximately 19,000 charts (3,800 hospitals x charts per hospital) 
submitted by the hospitals to CMS per quarter for a total burden of 
7,600 hours per quarter and a total annual burden of 30,400 hours.
Section 413.65 Requirements for a Determination That a Facility or an 
Organization Has Provider-Based Status
    Proposed Sec.  413.65(b)(3)(i) requires potential main providers 
seeking a determination of provider-based status for a facility that is 
located on the campus of the potential main provider to submit an 
attestation stating that the facility meets the criteria in paragraph 
(d) of Sec.  413.65 and, if it is a hospital, to also attest that it 
will fulfill the obligations of hospital outpatient departments and 
hospital-based entities described in paragraph (g) of Sec.  413.65. We 
are also proposing to amend this paragraph to require that in the case 
of a facility that is operated as a joint venture, the potential main 
provider attest that it will comply with the requirements of paragraph 
(f) of Sec.  413.65.
    Proposed Sec.  413.65(b)(3)(ii) provides that, if a facility is not 
located on the campus of the potential main provider, the potential 
main provider must submit an attestation stating that the facility 
meets the criteria in paragraph (d) and (e) of Sec.  413.65 and, if it 
is a hospital, to also attest that it will fulfill the obligations of 
hospital outpatient departments and hospital-based entities described 
in paragraph (g) of Sec.  413.65. If the facility is operated under a 
management contract, the potential main provider also attest that the 
facility meets the requirements of paragraph (h) of Sec.  413.65.
    Proposed Sec.  413.65(e)(3) requires that a facility or 
organization for which provider-based status is sought that is not 
located on the campus of a potential main provider must (i) be located 
within a 35-mile radius of the campus of the hospital or CAH that is 
the potential main provider, or (ii) be owned and operated by a 
hospital or CAH that has a disproportionate share adjustment (as 
determined under Sec.  412.106 of this chapter) greater than 11.75 
percent and is described in Sec.  412.106(c)(2) of this chapter 
implementing section 1886(e)(5)(F)(i)(II) of the Act and is (A) owned 
or operated by a unit of State or local government, (B) a public or 
nonprofit corporation formally granted governmental powers by a unit of 
State or local government; or (C) a private hospital having a contract 
with a State or local government that includes the operation of clinics 
located off the main campus of the hospital to assure access in a well-
defined service area to health care services for low-income individuals 
who are not entitled to benefits under Medicare (or medical assistance 
under a Medicaid State plan), or (iii) demonstrate a high level of 
integration

[[Page 23460]]

with the main provider by showing that it meets all of the other 
provider-based criteria and demonstrate that it serves the same patient 
population as the main provider, by submitting certain records showing 
the information contained in paragraphs (e)(3)(iii)(A) and 
(e)(3)(iii)(B) of this section or (iv) if the facility or organization 
is unable to meet the criteria in paragraph (e)(3)(iii)(A) or paragraph 
(e)(3)(iii)(B) because it was not in operation during all of the 12-
month period described in paragraph (e)(3)(iii), be located in a zip 
code area included among those that, during all of the 12-month period 
described in paragraph (e)(3)(iii), accounted for at least 75 percent 
of the patients served by the main provider, or (v) in the case of an 
RHC, (A) be an RHC that is otherwise qualified as a provider-based 
entity of a hospital that has fewer than 50 beds, and (B) the hospital 
with which the facility or organization has a provider-based 
relationship be located in a rural area, and (vi) be located in the 
same State as the main provider or, when consistent with the laws of 
both States, in adjacent States.
    Section 413.65(g)(7) provides that when a Medicare beneficiary is 
treated in a hospital outpatient department that is not located on the 
main provider's campus, the treatment is not required to be provided by 
the antidumping rules of section 489.24, and the beneficiary will incur 
a coinsurance liability for an outpatient visit to the hospital, as 
well as for the physician service the hospital must provide written 
notice to the beneficiary, before delivery of services of the amount of 
the beneficiary's potential financial liability. If the exact type and 
extent of care is not known, the hospital must provide written notice 
to the beneficiary that explains that the beneficiary will incur a 
coinsurance liability to the hospital that he or she would not incur if 
the facility were not provider-based, an estimate based on typical or 
average charges for visits to the facility, and a statement that the 
patient's actual liability will depend upon the actual services 
furnished by the hospital.
    While the information collection requirements contained in this 
section are subject to the PRA, the burden associated with this 
requirement is currently approved under OMB approval no. 0938-0798.
Section 485.610 Condition of Participation: Status and Location
    In order to be considered a relocation, we are proposing under 
Sec.  485.610(d)(2)(ii) to require a CAH to provide documentation 
demonstrating that its plans to rebuild in a relocated area were 
undertaken prior to December 8, 2003. This requirement does impose an 
information collection requirement. However, because this burden would 
be imposed on less than 10 CAHs, under 5 CFR 1320.2(c), these 
requirements are exempt from the PRA.
    We have submitted a copy of this proposed rule to OMB for its 
review of the information collection requirements described above.
    If you have any comments on the information collection and 
recordkeeping requirements, please mail the copies directly to the 
following:

Centers for Medicare & Medicaid Services, Office of Strategic 
Operations and Regulatory Affairs, Security and Standards Group, 
Regulations Development and Issuances Group, Room C4-24-02, 7500 
Security Boulevard, Baltimore, MD 21244-1850, Attn.: James Wickliffe, 
CMS-1500-P.
Office of Information and Regulatory Affairs, Office of Management and 
Budget, Room 3001, New Executive Office Building, Washington, DC 20503, 
Attn: Christopher Martin, CMS Desk Officer.

    Comments submitted to OMB may also be e-mailed to the following 
address: [email protected]; or faxed to OMB at (202) 395-
6974 or (202) 395-5167. Attn.: CMS-1500-P.

C. Public Comments

    Because of the large number of items of correspondence we normally 
receive on a proposed rule, we are not able to acknowledge or respond 
to them individually. However, in preparing the final rule, we will 
consider all comments concerning the provisions of this proposed rule 
that we receive by the date and time specified in the DATES section of 
this preamble and respond to those comments in the preamble to that 
rule. We emphasize that section 1886(e)(5) of the Act requires the 
final rule for FY 2006 to be published by August 1, 2005, and we will 
consider only those comments that deal specifically with the matters 
discussed in this proposed rule.

List of Subjects

42 CFR Part 405

    Administrative practice and procedure, Health facilities, Health 
professions, Kidney diseases, Medicare, Reporting and recordkeeping 
requirements, Rural area, X-rays.

42 CFR Part 412

    Administrative practice and procedure, Health facilities, Medicare, 
Puerto Rico, Reporting and recordkeeping requirements.

42 CFR Part 413

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

42 CFR Part 415

    Health facilities, Health professions, Medicare, and reporting and 
recordkeeping requirements.

42 CFR Part 419

    Hospitals, Medicare, Reporting and recordkeeping requirements.

42 CFR Part 422

    Health maintenance organizations (HMO), Medicare+Choice, Provider 
sponsored organizations (PSO).

42 CFR Part 485

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

    For the reasons stated in the preamble of this proposed rule, the 
Centers for Medicare & Medicaid Services is proposing to amend 42 CFR 
chapter IV as follows:

PART 405--FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED

    A. Part 405 is amended as follows:
    1. The authority citation for Part 405 continues to read as 
follows:

    Authority: Secs. 1102, 1861, 1862(a), 1871, 1874, 1881, and 
1886(k) of the Social Security Act (42 U.S.C. 1302, 1395x, 1395y(a), 
1395hh, 1395kk, 1395rr, and 1395ww(k)), and sec. 353 of the Public 
Health Service Act (42 U.S.C. 263a).


Sec.  405.2468  [Amended]

    2. In Sec.  405.2468(f)(1), the reference ``Sec.  413.86(b)'' is 
removed and the reference ``Sec.  413.75(b)'' is added in its place.

PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL 
SERVICES

    B. Part 412 is amended as follows:
    1. The authority citation for Part 412 continues to read as 
follows:

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).


Sec.  412.1  [Amended]

    2. In Sec.  412.1(a)(1), the reference ``Sec.  413.86'' is removed 
and the reference ``Sec. Sec.  413.75 through 413.83'' is added in its 
place.


Sec.  412.2  [Amended]

    3. In Sec.  412.2--

[[Page 23461]]

    a. In paragraph (f)(7), remove the reference ``Sec.  413.86'' and 
add in its place the reference ``Sec. Sec.  413.75 through 413.83''.
    b. At the end of paragraph (f)(8), add the following sentence: 
``For discharges occurring on or after October 1, 2005, the additional 
payment is made based on the average sales price methodology specified 
in Subpart K, Part 414 of this subchapter and the furnishing fee 
specified in Sec.  410.63 of this subchapter.''
    4. Section 412.64 is amended by revising paragraph (k)(2) to read 
as follows:


Sec.  412.64  Federal rates for inpatient operating costs for Federal 
fiscal year 2005 and subsequent fiscal years.

* * * * *
    (k) Midyear corrections to the wage index.
* * * * *
    (2)(i) Except as provided in paragraph (k)(2)(ii) of this section, 
a midyear correction to the wage index is effective prospectively from 
the date the change is made to the wage index.
    (ii) Effective October 1, 2005, a change to the wage index may be 
made retroactively to the beginning of the Federal fiscal year, if, for 
the fiscal year in question, CMS determines all of the following--
    (A) The fiscal intermediary or CMS made an error in tabulating data 
used for the wage index calculation;
    (B) The hospital knew about the error in its wage data and 
requested the fiscal intermediary and CMS to correct the error both 
within the established schedule for requesting corrections to the wage 
data (which is at least before the beginning of the fiscal year for the 
applicable update to the hospital inpatient prospective payment system) 
and using the established process; and
    (C) CMS agreed before October 1 that the fiscal intermediary or CMS 
made an error in tabulating the hospital's wage data and the wage index 
should be corrected.
* * * * *
    5. Section 412.73 is amended by adding a new paragraph (f) to read 
as follows:


Sec.  412.73  Determination of the hospital-specific rate based on a 
Federal fiscal year 1982 base period.

* * * * *
    (f) Maintaining budget neutrality. CMS makes an adjustment to the 
hospital-specific rate to ensure that changes to the DRG 
classifications and recalibrations of the DRG relative weights are made 
in a manner so that aggregate payments to section 1886(d) hospitals are 
not affected.
    6. Section 412.75 is amended by adding a new paragraph (i) to read 
as follows:


Sec.  412.75  Determination of the hospital-specific rate for inpatient 
operating costs based on a Federal fiscal year 1987 base period.

* * * * *
    (i) Maintaining budget neutrality. CMS makes an adjustment to the 
hospital-specific rate to ensure that changes to the DRG 
classifications and recalibrations of the DRG relative weights are made 
in a manner so that aggregate payments to section 1886(d) hospitals are 
not affected.
    7. Section 412.77 is amended by--
    a. Revising paragraph (a)(1).
    b. Adding a new paragraph (j).
    The revision and addition read as follows:


Sec.  412.77  Determination of the hospital-specific rate for inpatient 
operating costs for sole community hospitals based on a Federal fiscal 
year 1996 base period.

    (a) Applicability. (1) This section applies to a hospital that has 
been designated as a sole community hospital, as described in Sec.  
412.92. If the 1996 hospital-specific rate exceeds the rate that would 
otherwise apply, that is, either the Federal rate under Sec.  412.64 
(or under Sec.  412.63 for periods prior to FY 2005) or the hospital-
specific rates for either FY 1982 under Sec.  412.73 or FY 1987 under 
Sec.  412.75, this 1996 rate will be used in the payment formula set 
forth in Sec.  412.92(d)(1).
* * * * *
    (j) Maintaining budget neutrality. CMS makes an adjustment to the 
hospital-specific rate to ensure that changes to the DRG 
classifications and recalibrations of the DRG relative weights are made 
in a manner so that aggregate payments to section 1886(d) hospitals are 
not affected.
    8. Section 412.90 is amended by revising paragraph (e)(1) to read 
as follows:


Sec.  412.90  General rules.

* * * * *
    (e) Hospitals located in areas that are reclassified from urban to 
rural. (1) CMS adjusts the rural Federal payment amounts for inpatient 
operating costs for hospitals located in geographic areas that are 
reclassified from urban to rural as defined in subpart D of this part. 
This adjustment is set forth in Sec.  412.102.
* * * * *
    9. Section 412.92 is amended by--
    a. In paragraph (a) introductory text, removing the reference 
``Sec.  412.83(b)'' and adding in its place the reference ``Sec.  
412.64''.
    b. Revising paragraph (d)(1)(i).
    c. Revising paragraph (d)(3).
    The revisions and addition read as follows:


Sec.  412.92  Special treatment: Sole community hospitals.

* * * * *
    (d) Determining prospective payment rates for inpatient operating 
costs for sole community hospitals. (1) * * *
    (i) The Federal payment rate applicable to the hospitals as 
determined under subpart D of this part.
* * * * *
    (3) Adjustment to payments. A sole community hospital may receive 
an adjustment to its payments to take into account a significant 
decrease in the number of discharges, as described in paragraph (e) of 
this section.
* * * * *
    10. Section 412.96 is amended by--
    a. Revising paragraph (b)(1) introductory text.
    b. Revising paragraph (c) introductory text.
    c. In paragraph (c)(1) introductory text, removing the reference 
``paragraph (g)'' and adding in its place the reference ``paragraph 
(h)''.
    d. In paragraph (c)(2)(i), removing the reference ``paragraph (h)'' 
and adding in its place the reference ``paragraph (i)''.
    e. Revising paragraph (g)(1).
    f. In the introductory text of paragraph (h), removing the phrase 
``paragraphs (g)(1) through (g)(4)'' and adding in its place the phrase 
``paragraphs (h)(1) through (h)(4)''.
    g. In paragraph (h)(2), removing the reference ``(g)(1)'' and 
adding in its place the reference ``(h)(1)''.
    h. Removing paragraph (h)(4).
    i. In paragraph (i)(2), removing the reference ``(h)(1)'' and 
adding in its place the reference ``(i)(1)''.
    j. Removing paragraph (i)(4).
    The revisions read as follows:


Sec.  412.96  Special treatment: Referral centers.

* * * * *
    (b) Criteria for cost reporting periods beginning on or after 
October 1, 1983.* * *
    (1) The hospital is located in a rural area (as defined in subpart 
D of this part) and has the following number of beds, as determined 
under the provisions of Sec.  412.105(b) available for use:
* * * * *
    (c) Alternative criteria. For cost reporting periods beginning on 
or after October 1, 1985, a hospital that does not meet the criteria of 
paragraph (b) of this section is classified as a referral center if it 
is located in a rural area (as defined

[[Page 23462]]

in subpart D of this part) and meets the criteria specified in 
paragraphs (c)(1) and (c)(2) of this section and at least one of the 
three criteria specified in paragraphs (c)(3), (c)(4), and (c)(5) of 
this section.
* * * * *
    (g) Hospital cancellation of referral center status. (1) A hospital 
may at any time request cancellation of its status as a referral center 
and be paid prospective payments per discharge based on the applicable 
rural rate, as determined in accordance with subpart D of this part.
* * * * *
    11. Section 412.103 is amended by revising paragraphs (a)(1) and 
(a)(4) to read as follows:


Sec.  412.103  Special treatment: Hospitals located in urban areas and 
that apply for reclassification as rural.

    (a) * * *
    (1) The hospital is located in a rural census tract of a 
Metropolitan Statistical Area (MSA) as determined under the most recent 
version of the Goldsmith Modification, the Rural-Urban Commuting Area 
codes, as determined by the Office of Rural Health Policy (ORHP) of the 
Health Resources and Services Administration, which is available via 
the ORHP Web site at: http://www.ruralhealth.hrsa.gov or from the U.S. 
Department of Health and Human Services, Health Resources and Services 
Administration, Office of Rural Health Policy, 5600 Fishers Lane, Room 
9A-55, Rockville, MD 20857.
* * * * *
    (4) For any period after September 30, 2004 and before October 1, 
2006, a CAH in a county that, in FY 2004, was not part of an MSA as 
defined by the Office of Management and Budget and was not considered 
to be urban under Sec.  412.64(b)(3) of this chapter, but as of FY 2005 
was included as part of an MSA or was considered to be urban under 
Sec.  412.64(b)(3) of this chapter as a result of the most recent 
census data and implementation of the new MSA definitions announced by 
OMB on June 6, 2003, may be reclassified as being located in a rural 
area for purposes of meeting the rural location requirement under Sec.  
485.610(b) of this chapter if it meets any of the requirements in 
paragraphs (a)(1), (a)(2), or (a)(3) of this section.
* * * * *
    12. Section 412.105 is amended by--
    a. Adding a new paragraph (f)(1)(iv)(D).
    b. Adding a new paragraph (f)(1)(xiii).
    c. Adding a new paragraph (f)(1)(xiv).
    The additions read as follows:


Sec.  412.105  Special treatment: Hospitals that incur indirect costs 
for graduate medical education programs.

* * * * *
    (f) Determining the total number of full-time equivalent residents 
for cost reporting periods beginning on or after July 1, 1991. (1) * * 
*
    (iv) * * *
    (D) A rural hospital redesignated as urban after September 30, 
2004, as a result of the most recent census data and implementation of 
the new labor market area definitions announced by OMB on June 6, 2003, 
may retain the increases to its full-time equivalent resident cap that 
it received under paragraphs (f)(1)(iv)(A) and (f)(1)(vii) of this 
section while it was located in a rural area.
* * * * *
    (xiii) For a hospital that was excluded from the hospital inpatient 
prospective payment system under Part 413 of this chapter and that 
subsequently changed to a hospital subject to the hospital inpatient 
prospective payment system for cost reporting periods ending on or 
before December 31, 1996, the total number of full-time equivalent 
residents for payment purposes is determined in accordance with the 
provisions of this paragraph (f). In the case of a merger of two or 
more hospitals, for purposes of this paragraph, the surviving 
hospital's number of full-time equivalent residents for payment 
purposes is equal to the aggregate number of the full-time equivalent 
resident count of each of the merged hospitals as determined in 
accordance with the provisions of this paragraph (f).
    (xiv) Effective for discharges occurring on or after October 1, 
2005, an urban hospital that reclassifies to a rural area under Sec.  
412.103 and then subsequently elects to revert back to urban 
classification will not be allowed to retain the adjustment to its IME 
FTE resident cap that it received as a result of being reclassified as 
rural.
* * * * *
    13. Section 412.108 is amended by revising paragraph (c)(1) to read 
as follows:


Sec.  412.108  Special treatment: Medicare-dependent, small rural 
hospitals.

* * * * *
    (c) Payment methodology. * * *
    (1) The Federal payment rate applicable to the hospital, as 
determined under subpart D of this part, subject to the regional floor 
defined in Sec.  412.70(c)(6).
* * * * *
    14. Section 412.109 is amended by revising paragraph (b)(2) to read 
as follows:


Sec.  412.109  Special treatment: Essential access community hospitals 
(EACHs).

* * * * *
    (b) Location in a rural area. * * *
    (2) Is not deemed to be located in an urban area under subpart D of 
this part.
* * * * *


Sec.  412.113  [Amended]

    15. In Sec.  412.113--
    a. In paragraph (b)(2), the reference ``Sec.  413.86 of this 
chapter.'' is removed and the reference ``Sec. Sec.  413.75 through 
413.83 of this subchapter.'' is added in its place.
    b. In paragraph (b)(3), the reference ``Sec.  413.86(c) of this 
chapter,'' is removed and the reference ``Sec.  413.75(c) of this 
subchapter,'' is added in its place.


Sec.  412.115  [Amended]

    16. In Sec.  412.115--
    a. In paragraph (a), the reference ``Sec.  413.80'' is removed and 
the reference ``Sec.  413.89'' is added in its place.
    b. At the end of paragraph (b), add the following sentence: ``For 
discharges occurring on or after October 1, 2005, the additional 
payment is made based on the average sales price methodology specified 
in subpart K, part 414 of this chapter and the furnishing fee specified 
in Sec.  410.63 of this subchapter.''
    17. Section 412.230 is amended by--
    a. Redesignating paragraph (d)(2)(iii) as paragraph (d)(2)(v).
    b. Adding new paragraphs (d)(2)(iii) and (d)(2)(iv).
    The additions read as follows:


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

* * * * *
    (d) Use of urban or other rural area's wage index.--* * *
    (2) Appropriate wage data. * * *
    (iii) For applications submitted for reclassifications effective in 
FY 2006, a campus of a multicampus hospital system may seek 
reclassification to another CBSA. As part of its reclassification 
request, the requesting entity may submit the composite wage data for 
the entire multicampus hospital system as its hospital-specific data.
    (iv) For applications submitted for reclassifications effective in 
FY 2007 and subsequent years, a campus of a multicampus hospital system 
may seek reclassification to another CBSA. As part of its 
reclassification request, the requesting entity must submit campus-
specific wage data for purposes of the wage index comparison.
* * * * *
    18. Section 412.234 is amended by--
    a. In paragraph (a)(3)(ii), removing the phrase ``fiscal years 2006 
and thereafter''

[[Page 23463]]

and adding in its place the phrase ``fiscal year 2006''.
    b. Adding a new paragraph (a)(3)(iii).
    c. In paragraph (b)(1), removing the phrase ``or NECMA''.
    The addition reads as follows:


Sec.  412.234  Criteria for all hospitals in an urban county seeking 
redesignation to another urban area.

    (a) * * *
    (3) * * *
    (iii) For Federal fiscal year 2007 and thereafter, hospitals 
located in counties that are in the same Consolidated Statistical Area 
(CSA) (under the MSA definitions announced by the OMB on June 6, 2003) 
as the urban area to which they seek redesignation qualify as meeting 
the proximity requirement for reclassification to the urban area to 
which they seek redesignation.
* * * * *


Sec.  412.278  [Amended]

    19. In Sec.  412.278(b)(1), the phrase ``Office of Payment Policy'' 
is removed and the phrase ``Hospital and Ambulatory Policy Group'' is 
added in its place.
    20. Section 412.304 is amended by revising paragraph (a) to read as 
follows:


Sec.  412.304  Implementation of the capital prospective payment 
system.

    (a) General rule. As described in Sec. Sec.  412.312 through 
412.370, effective with cost reporting periods beginning on or after 
October 1, 1991, CMS pays an amount determined under the capital 
prospective payment system for each inpatient hospital discharge as 
defined in Sec.  412.4. This amount is in addition to the amount 
payable under the prospective payment system for inpatient hospital 
operating costs as determined under subpart D of this part.
* * * * *


Sec.  412.521  [Amended]

    21. In Sec.  412.521--
    a. Under paragraph (b)(2)(i), the reference ``Sec. Sec.  413.85, 
413.86, and 413.87 of this subchapter.'' is removed and the reference 
``Sec. Sec.  413.75 through 413.83, 413.85, and 413.87 of this 
subchapter.'' is added in its place.
    b. Under paragraph (b)(2)(ii), the reference ``Sec.  413.80'' is 
removed and the reference ``Sec.  413.89'' is added in its place.

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

    C. Part 413 is amended as follows:

    1. The authority citation for Part 413 continued 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).


Sec.  413.13  [Amended]

    2. In Sec.  413.13 (d)(1), the reference ``Sec.  413.80'' is 
removed and the reference ``Sec.  413.89'' is added in its place.
    3. Section 413.40 is amended by--
    a. In paragraph(a)(3), under the definition of ``Net inpatient 
operating costs'', removing the reference ``Sec. Sec.  413.85 and 
413.86'' and adding in its place the reference ``Sec. Sec.  413.75 
through 413.83 and 413.85''.
    b. Revising paragraph (c)(4)(iii).


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

* * * * *
    (c) Costs subject to the ceiling--* * *
    (4) Target amounts. * * *
    (iii) For cost reporting periods beginning on or after October 1, 
1997 through September 30, 2002, in the case of a psychiatric hospital 
or unit, rehabilitation hospital or unit, or long-term care hospital, 
the target amount is the lower of the amounts specified in paragraph 
(c)(4)(iii)(A) or paragraph (c)(4)(iii)(B) of this section.
* * * * *
    4. Section 413.65 is amended by--
    a. Reprinting the introductory text of paragraph (a)(1)(ii) and 
adding a new paragraph (a)(1)(ii)(L).
    b. Revising the definition of ``Provider-based entity'' under 
paragraph (a)(2).
    c. Revising paragraphs (b)(3)(i) and (b)(3)(ii).
    d. Revising paragraphs (e)(1) introductory text and (e)(1)(i).
    e. Revising paragraph (e)(3).
    f. Revising paragraph (g)(7).
    The addition and revision read as follows:


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

    (a) Scope and definitions. * * *
    (1) * * *
    (ii) The determinations of provider-based status for payment 
purposes described in this section are not made as to whether the 
following facilities are provider-based:
* * * * *
    (L) Rural health clinics (RHCs) affiliated with hospitals having 50 
or more beds.
* * * * *
    (2) Definitions. * * *
    Provider-based entity means a provider of health care services, or 
an RHC as defined in Sec.  405.2401(b) of this chapter, that is either 
created by, or acquired by, a main provider for the purpose of 
furnishing health care services of a different type from those of the 
main provider under the ownership and administrative and financial 
control of the main provider, in accordance with the provisions of this 
section. A provider-based entity comprises both the specific physical 
facility that serves as the site of services of a type for which 
payment could be claimed under the Medicare or Medicaid program, and 
the personnel and equipment needed to deliver the services at that 
facility. A provider-based entity may, by itself, be qualified to 
participate in Medicare as a provider under Sec.  489.2 of this 
chapter, and the Medicare conditions of participation do apply to a 
provider-based entity as an independent entity.
* * * * *
    (b) Provider-based determinations.-- * * *
    (3)(i) Except as specified in paragraphs (b)(2) and (b)(5) of this 
section, if a potential main provider seeks a determination of 
provider-based status for a facility that is located on the campus of 
the potential main provider, the provider would be required to submit 
an attestation stating that the facility meets the criteria in 
paragraph (d) of this section and, if it is a hospital, also attest 
that it will fulfill the obligations of hospital outpatient departments 
and hospital-based entities described in paragraph (g) of this section. 
The provider seeking such a determination would also be required to 
maintain documentation of the basis for its attestations and to make 
that documentation available to CMS and to CMS contractors upon 
request. If the facility is operated as a joint venture, the provider 
would also have to attest that it will comply with the requirements of 
paragraph (f) of this section.
    (ii) If the facility is not located on the campus of the potential 
main provider, the provider seeking a determination would be required 
to submit an attestation stating that the facility meets the criteria 
in paragraphs (d) and (e) of this section, and if the facility is 
operated under a management contract, the requirements of paragraph (h) 
of this section. If the potential main provider is a hospital, the 
hospital also would be required to attest that it will fulfill the 
obligations of hospital outpatient departments and hospital-based 
entities described in paragraph (g) of this section. The provider would 
be required

[[Page 23464]]

to supply documentation of the basis for its attestations to CMS at the 
time it submits its attestations.
* * * * *
    (e) * * *
    (1) Operation under the ownership and control of the main provider. 
The facility or organization seeking provider-based status is operated 
under the ownership and control of the main provider, as evidenced by 
the following:
    (i) The business enterprise that constitutes the facility or 
organization is 100 percent owned by the main provider.
* * * * *
    (3) Location. The facility or organization meets the requirements 
in paragraph (e)(3)(i), (e)(3)(ii), (e)(3)(iii), (e)(3)(iv), or, in the 
case of an RHC, paragraph (e)(3)(v) of this section, and the 
requirements in paragraph (e)(3)(vi) of this section.
    (i) The facility or organization is located within a 35-mile radius 
of the campus of the hospital or CAH that is the potential main 
provider.
    (ii) The facility or organization is owned and operated by a 
hospital or CAH that has a disproportionate share adjustment (as 
determined under Sec.  412.106 of this chapter) greater than 11.75 
percent and is described in Sec.  412.106(c)(2) of this chapter 
implementing section 1886(e)(5)(F)(i)(II) of the Act and is--
    (A) Owned or operated by a unit of State or local government;
    (B) A public or nonprofit corporation that is formally granted 
governmental powers by a unit of State or local government; or
    (C) A private hospital that has a contract with a State or local 
government that includes the operation of clinics located off the main 
campus of the hospital to assure access in a well-defined service area 
to health care services for low-income individuals who are not entitled 
to benefits under Medicare (or medical assistance under a Medicaid 
State plan).
    (iii) The facility or organization demonstrates a high level of 
integration with the main provider by showing that it meets all of the 
other provider-based criteria and demonstrates that it serves the same 
patient population as the main provider, by submitting records showing 
that, during the 12-month period immediately preceding the first day of 
the month in which the application for provider-based status is filed 
with CMS, and for each subsequent 12-month period--
    (A) At least 75 percent of the patients served by the facility or 
organization reside in the same zip code areas as at least 75 percent 
of the patients served by the main provider; or
    (B) At least 75 percent of the patients served by the facility or 
organization who required the type of care furnished by the main 
provider received that care from that provider (for example, at least 
75 percent of the patients of an RHC seeking provider-based status 
received inpatient hospital services from the hospital that is the main 
provider).
    (iv) If the facility or organization is unable to meet the criteria 
in paragraph (e)(3)(iii)(A) or paragraph (e)(3)(iii)(B) of this section 
because it was not in operation during all of the 12-month period 
described in paragraph (e)(3)(iii) of this section, the facility or 
organization is located in a zip code area included among those that, 
during all of the 12-month period described in paragraph (e)(3)(iii) of 
this section, accounted for at least 75 percent of the patients served 
by the main provider.
    (v) Both of the following criteria are met:
    (A) The facility or organization is an RHC that is otherwise 
qualified as a provider-based entity of a hospital that has fewer than 
50 beds, as determined under Sec.  412.105(b) of this chapter; and
    (B) The hospital with which the facility or organization has a 
provider-based relationship is located in a rural area, as defined in 
Subpart D of Part 412 of this subchapter.
    (vi) A facility or organization may qualify for provider-based 
status under this section only if the facility or organization and the 
main provider are located in the same State or, when consistent with 
the laws of both States, in adjacent States.
* * * * *
    (g) Obligations. * * *
    (7) When a Medicare beneficiary is treated in a hospital outpatient 
department that is not located on the main provider's campus, the 
treatment is not required to be provided by the antidumping rules in 
Sec.  489.24 of this chapter, and the beneficiary will incur a 
coinsurance liability for an outpatient visit to the hospital as well 
as for the physician service, the following requirements must be met:
    (i) The hospital must provide written notice to the beneficiary, 
before the delivery of services, of--
    (A) The amount of the beneficiary's potential financial liability; 
or
    (B) If the exact type and extent of care needed are not known, an 
explanation that the beneficiary will incur a coinsurance liability to 
the hospital that he or she would not incur if the facility were not 
provider-based, an estimate based on typical or average charges for 
visits to the facility, and a statement that the patient's actual 
liability will depend upon the actual services furnished by the 
hospital.
    (ii) The notice must be one that the beneficiary can read and 
understand.
    (iii) If the beneficiary is unconscious, under great duress, or for 
any other reason unable to read a written notice and understand and act 
on his or her own rights, the notice must be provided, before the 
delivery of services, to the beneficiary's authorized representative.
    (iv) In cases where a hospital outpatient department provides 
examination or treatment that is required to be provided by the 
antidumping rules of Sec.  489.24 of this chapter, notice, as described 
in this paragraph (g)(7), must be given as soon as possible after the 
existence of an emergency has been ruled out or the emergency condition 
has been stabilized.
* * * * *
    5. Section 413.75 is amended in paragraph (b) by revising paragraph 
(1) under the definition of ``Medicare GME affiliated group'' to read 
as follows:


Sec.  413.75  Direct GME payments: General requirements.

* * * * *
    (b) * * *
    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 subpart D of part 412 of this 
subchapter.
* * * * *


Sec.  413.77  [Amended]

    6. In Sec.  413.77, under paragraph (e)(1)(iii), the reference 
``Sec.  412.62(f)(1)(i) of this chapter.'' is removed and the reference 
``subpart D of part 412 of this subchapter''. is added in its place.
    7. Section 413.79 is amended by--
    a. Revising paragraph (a)(10).
    b. Revising the introductory text of paragraph (c)(2).
    c. In paragraph (c)(3)(i), removing the reference ``Sec.  
412.62(f)(iii)'' and adding in its place the reference ``subpart D of 
part 412 of this subchapter''.
    d. Adding a new paragraph (c)(6).
    e. Revising paragraph (e)(1)(iv).
    f. In the introductory text of paragraph (k), removing the 
reference ``(k)(6)'' and adding in its place the reference ``(k)(7)''.
    g. Adding a new paragraph (k)(7).
    The revisions and additions read as follows:


Sec.  413.79  Direct GME payments: Determination of the weighted number 
of FTE residents.

* * * * *

[[Page 23465]]

    (a) * * *
    (10) Effective for portions of cost reporting periods beginning on 
or after October 1, 2004, if a hospital can document that a resident 
simultaneously matched for one year of training in a particular 
specialty program, and for a subsequent year(s) of training in a 
different specialty program, the resident's initial residency period 
will be determined based on the period of board eligibility for the 
specialty associated with the program for which the resident matched 
for the subsequent year(s) of training. Effective for cost reporting 
periods beginning on or after October 1, 2005, if a hospital can 
document that a particular resident, prior to beginning the first year 
of residency training, matched in a specialty program for which 
training would begin at the conclusion of the first year of training, 
that resident's initial residency period will be determined in the 
resident's first year of training based on the period of board 
eligibility associated with the specialty program for which the 
resident matched for subsequent training year(s).
* * * * *
    (c) Unweighted FTE counts. * * *
    (2) Determination of the FTE resident cap. Subject to the 
provisions of paragraphs (c)(3) through (c)(6) of this section and 
Sec.  413.81, for purposes of determining direct GME payment--
* * * * *
    (6) FTE resident caps for rural hospitals that are reclassified as 
urban. A rural hospital redesignated as urban after September 30, 2004, 
as a result of the most recent census data and implementation of the 
new MSA definitions announced by OMB on June 6, 2003, may retain the 
increases to its FTE resident cap that it received under paragraphs 
(c)(2)(i), (e)(1)(iii), and (e)(3) of this section while it was located 
in a rural area.
* * * * *
    (e) New medical residency training programs. * * *
    (1) * * *
    (iv) An urban hospital that qualifies for an adjustment to its FTE 
cap under paragraph (e)(1) of this section is permitted to be part of a 
Medicare GME affiliated group for purposes of establishing an aggregate 
FTE cap only if the adjustment that results from the affiliation is an 
increase to the urban hospital's FTE cap.
* * * * *
    (k) Residents training in rural track programs. * * *
    (7) If an urban hospital had established a rural track training 
program under the provisions of this paragraph (k) with a hospital 
located in a rural area and that rural area subsequently becomes an 
urban area due to the most recent census data and implementation of the 
new labor market area definitions announced by OMB on June 6, 2003, the 
urban hospital may continue to adjust its FTE resident limit in 
accordance with this paragraph (k) for the rural track programs 
established prior to the adoption of such new labor market area 
definitions. In order to receive an adjustment to its FTE resident cap 
for a new rural track residency program, the urban hospital must 
establish a rural track program with hospitals that are designated 
rural based on the most recent geographical location designations 
adopted by CMS.
* * * * *


Sec.  413.87  [Amended]

    8. In Sec.  413.87(d) introductory text, the reference ``Sec.  
413.86(d)(4)'' is removed and the reference ``Sec.  413.76(d)(4)'' is 
added in its place.


Sec.  413.178  [Amended]

    9. In Sec.  413.178--
    a. In paragraph (a), the reference ``Sec.  413.80(b)'' is removed 
and the reference ``Sec.  413.89(b)'' is added in its place.
    b. In paragraph (b), the reference ``Sec.  413.80'' is removed and 
the reference ``Sec.  413.89'' is added in its place.

PART 415--SERVICES FURNISHED BY PHYSICIANS IN PROVIDERS, 
SUPERVISING PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN 
CERTAIN SETTINGS

    D. Part 415 is amended as follows:
    1. The authority citation for part 415 continued to read as 
follows:

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).


Sec.  415.55  [Amended]

    2. In Sec.  415.55(a)(5), the reference ``Sec.  413.86'' is removed 
and the reference ``Sec. Sec.  413.75 through 413.83'' is added in its 
place.


Sec.  415.70  [Amended]

    3. In Sec.  415.70(a)(2), the reference ``Sec.  413.86'' is removed 
and the reference ``Sec. Sec.  413.75 through 413.83'' is added in its 
place.


Sec.  415.102  [Amended]

    4. In Sec.  415.102(c)(1), the reference ``Sec.  413.86'' is 
removed and the reference ``Sec. Sec.  413.75 through 413.83'' is added 
in its place.


Sec.  415.150  [Amended]

    5. In Sec.  415.150(b), the reference ``Sec.  413.86'' is removed 
and the phrase ``Sec. Sec.  413.75 through 413.83'' is added in its 
place.


Sec.  415.152  [Amended]

    6. In Sec.  415.152--
    a. In paragraph (2) of the definition of ``Approved graduate 
medical education (GME) program'', the reference ``Sec.  413.86(b)'' is 
removed and the reference ``Sec.  413.75(b)'' is added in its place.
    b. In the definition of ``Teaching setting'', the reference ``Sec.  
413.86,'' is removed and the reference ``Sec. Sec.  413.75 through 
413.83,'' is added in its place.


Sec.  415.160  [Amended]

    7. In Sec.  415.160--
    a. In paragraph (c)(2), the reference ``Sec.  413.86'' is removed 
and the reference ``Sec.  413.78'' is added in its place.
    b. In paragraph (d)(2), the reference ``Sec.  413.86'' is removed 
and the reference ``Sec. Sec.  413.75 through 413.83'' is added in its 
place.


Sec.  415.174  [Amended]

    8. In Sec.  415.174(a)(1), the reference ``Sec.  413.86.'' is 
removed and the phrase ``Sec. Sec.  413.75 through 413.83.'' is added 
in its place.


Sec.  415.200  [Amended]

    9. In Sec.  415.200(a), the reference ``Sec.  413.86'' is removed 
and the reference ``Sec. Sec.  413.75 through 413.83'' is added in its 
place.


Sec.  415.204  [Amended]

    10. In Sec.  415.204(a)(2), the reference ``Sec.  413.86'' is 
removed and the reference ``Sec. Sec.  413.75 through 413.83'' is added 
in its place.


Sec.  415.206  [Amended]

    11. In Sec.  415.206(a), the reference ``Sec.  413.86(f)(1)(iii)'' 
is removed and the reference ``Sec.  413.78'' is added in its place.


Sec.  415.208  [Amended]

    12. In Sec.  415.208--
    a. In paragraph (b)(1), the reference ``Sec.  413.86'' is removed 
and the reference ``Sec. Sec.  413.75 through 413.83'' is added in its 
place.
    b. In paragraph (b)(4), the reference ``Sec.  413.86'' is removed 
and the reference ``Sec. Sec.  413.75 through 413. 83'' is added in its 
place.

PART 419--PROSPECTIVE PAYMENT SYSTEM FOR OUTPATIENT DEPARTMENT 
SERVICES

    F. Part 419 is amended as follows:
    1. The authority citation for part 419 continues to read as 
follows:

    Authority: Secs. 1102, 1833(t), and 1871 of the Social Security 
Act (42 U.S.C. 1302, 1395l(t), and 1395hh).

[[Page 23466]]

Sec.  419.2  [Amended]

    2. In Sec.  419.2--
    a. In paragraph (c)(1), the reference ``Sec.  413.86'' is removed 
and the reference ``Sec. Sec.  413.75 through 413.83'' is added in its 
place.
    b. In paragraph (c)(6), the reference ``Sec.  413.80(b)'' is 
removed and the reference ``Sec.  413.89(b)'' is added in its place.

PART 422--SPECIAL RULES FOR SERVICES FURNISHED BY NONCONTRACT 
PROVIDERS

    G. Part 422 is amended as follows:
    1. The authority citation of part 422 continues to read as follows:

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).


Sec.  422.214  [Amended]

    2. In Sec.  422.214--
    a. In paragraph (b), the phrase ``Sec. Sec.  412.105(g) and 
413.86(d))'' is removed and the phrase ``Sec. Sec.  412.105(g) and 
413.76))'' is added in its place.
    b. In paragraph (b), the phrase ``Section 413.86 (d)'' is removed 
and the phrase ``Section 413.76'' is added in its place.


Sec.  422.216  [Amended]

    3. In Sec.  422.216(a)(4), the reference ``Sec. Sec.  412.105(g) 
and 413.86(d)'' is removed and the reference ``Sec. Sec.  412.105(g) 
and 413.76'' is added in its place.

PART 485--CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS

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

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395(hh)).

    2. Section 485.610 is amended by--
    a. In paragraph (b)(1)(i), removing the reference ``Sec.  
412.62(f)'' and adding in its place the reference ``Sec.  412.64(b)''.
    b. In paragraph (b)(1)(ii), removing the reference ``Sec.  
412.63(b)'' and adding in its place the reference ``Sec.  412.64(b)''.
    c. Revising paragraph (b)(3).
    d. Adding a new paragraph (d).
    The revisions and additions read as follows:


Sec.  485.610  Condition of participation: Status and location.

* * * * *
    (b) * * *
    (3) Effective only for October 1, 2004 through September 30, 2006, 
the CAH does not meet the location requirements in either paragraph 
(b)(1) or paragraph (b)(2) of this section and is located in a county 
that, in FY 2004, was not part of a Metropolitan Statistical Area as 
defined by the Office of Budget Management and was not considered to be 
urban under Sec.  412.63(b)(3) of this chapter, but as of FY 2005 was 
included as part of such an MSA or was considered to be urban under 
Sec.  412.64(b)(3) of this chapter, as a result of the most recent 
census data and implementation of the new MSA definitions announced by 
OMB on June 6, 2003.
* * * * *
    (d) Standard: Relocation of CAHs with a necessary provider 
designation. A CAH that has a necessary provider certification from the 
State and places a new facility in service after January 1, 2006, can 
continue to meet the location requirement of paragraph (c) of this 
section based on the necessary provider certification only if the new 
facility meets either the requirement for replacement in the same 
location in paragraph (d)(1) of this section or the requirement for a 
relocation of a CAH in paragraph (d)(2) of this section.
    (1) A new construction of a CAH will be considered as a replacement 
facility if the construction is undertaken within 250 yards of the 
current building or contiguous to the current CAH on land owned by the 
CAH prior to December 8, 2003.
    (2) A new facility CAH will be considered as a relocation of a CAH 
if, at the relocated site--
    (i) The CAH serves at least 75 percent of the same service area 
that it served prior to its relocation, provides at least 75 percent of 
the same services that it provided prior to the relocation, and is 
staffed by 75 percent of the same staff (including medical staff, 
contracted staff, and employees); and
    (ii) The CAH provides documentation demonstrating that its plans to 
rebuild in the relocated area were undertaken prior to December 8, 
2003.
    (3) If a CAH that has a necessary provider certification from the 
State places a new facility in service on or after January 1, 2006, and 
does not meet either the requirements in paragraph (d)(1) or paragraph 
(d)(2) of this section, the action will be considered a cessation of 
business as described in Sec.  489.52(b)(3).

(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)


    Dated: April 19, 2005.
Mark B. McClellan,
Administrator, Centers for Medicare & Medicaid Services.
    Dated: April 22, 2005.
Michael O. Leavitt,
Secretary.

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

Addendum--Proposed Schedule of Standardized Amount Effective With 
Discharges Occurring On or After October 1, 2005 and Update Factors and 
Rate-of-Increase Percentages Effective With Cost Reporting Periods 
Beginning On or After October 1, 2005

    (If you choose to comment on issues in this section, please 
include the caption ``Operating Payment Rates'' at the beginning of 
your comment.)

I. Summary and Background

    In this Addendum, we are setting forth the proposed amounts and 
factors for determining prospective payment rates for Medicare 
hospital inpatient operating costs and Medicare hospital inpatient 
capital-related costs. We are also setting forth the proposed rate-
of-increase percentages for updating the target amounts for 
hospitals and hospital units excluded from the IPPS.
    For discharges occurring on or after October 1, 2005, 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 25 percent of a Puerto Rico rate that reflects base 
year average costs per case of Puerto Rico hospitals and 75 percent 
of the Federal national rate. (See section II.D.3. of this Addendum 
for a complete description.)
    As discussed below in section II. of this Addendum, we are 
proposing to make changes in the determination of the prospective 
payment rates for Medicare inpatient operating costs for FY 2006. 
The proposed changes, to be applied

[[Page 23467]]

prospectively effective with discharges occurring on or after 
October 1, 2005, affect the calculation of the Federal rates. In 
section III. of this Addendum, we discuss our proposed changes for 
determining the prospective payment rates for Medicare inpatient 
capital-related costs for FY 2006. Section IV. of this Addendum sets 
forth our proposed changes for determining the rate-of-increase 
limits for hospitals excluded from the IPPS for FY 2006. Section V. 
of this Addendum sets forth policies on payment for blood clotting 
factors administered to hemophilia patients. The tables to which we 
refer in the preamble of this proposed rule are presented in section 
VI. of this Addendum.

II. Proposed Changes to Prospective Payment Rates for Hospital 
Inpatient Operating Costs for FY 2006

    The basic methodology for determining prospective payment rates 
for hospital inpatient operating costs for FY 2005 and subsequent 
fiscal years is set forth at Sec.  412.64. The basic methodology for 
determining the prospective payment rates for hospital inpatient 
operating costs for hospitals located in Puerto Rico for FY 2005 and 
subsequent fiscal years is set forth at Sec. Sec.  412.211 and 
412.212. Below we discuss the factors used for determining the 
prospective payment rates.
    In summary, the proposed standardized amounts set forth in 
Tables 1A, 1B, 1C, and 1D of section VI. of this Addendum reflect--
     Equalization of the standardized amounts for urban and 
other areas at the level computed for large urban hospitals during 
FY 2004 and onward, as provided for under section 1886(d)(3)(A)(iv) 
of the Act, updated by the applicable percentage increase required 
under sections 1886(b)(3)(B)(i)(XIX) and 1886(b)(3)(B)(vii) of the 
Act.
     The two labor-related shares that are applicable to the 
standardized amounts, depending on whether the hospital's payments 
would be higher with a lower (in the case of a wage index below 
1.0000) or higher (in the case of a wage index above 1.0000) labor 
share, as provided for under sections 1886(d)(3)(E) and 
1886(d)(9)(C)(iv) of the Act;
     Updates of 3.2 percent for all areas (that is, the full 
market basket percentage increase of 3.2 percent, as required by 
section 1886(b)(3)(B)(i)(XIX) of the Act, and reflecting the 
requirements of section 1886(b)(3)(B)(vii) of the Act to reduce the 
applicable percentage increase by 0.4 percentage points for 
hospitals that fail to submit data, in a form and manner specified 
by the Secretary, relating to the quality of inpatient care 
furnished by the hospital;
     An adjustment to ensure the proposed DRG recalibration 
and wage index update and changes are budget neutral, as provided 
for under sections 1886(d)(4)(C)(iii) and 1886(d)(3)(E) of the Act, 
by applying new budget neutrality adjustment factors to the 
standardized amount;
     An adjustment to ensure the effects of the special 
transition measures adopted in relation to the implementation of new 
labor market areas are budget neutral;
     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 2005 budget neutrality 
factor and applying a revised factor;
     An adjustment to apply the new outlier offset by 
removing the FY 2005 outlier offset and applying a new offset;
     An adjustment to ensure the effects of the rural 
community hospital demonstration required under section 410A of Pub. 
L. 108-173 are budget neutral, as required under section 410A(c)(2) 
of Pub. L. 108-173.

A. Calculation of the Adjusted Standardized Amount

1. Standardization of Base-Year Costs or Target Amounts

    The national standardized amount is 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 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 and 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 section 1886(d)(3)(E) of the Act, the Secretary estimates, 
from time-to-time, the proportion of hospitals' costs that are 
attributable to wages and wage-related costs. The standardized 
amount is divided into labor-related and nonlabor-related amounts; 
only the proportion considered the labor-related amount is adjusted 
by the wage index. Section 403 of Pub. L. 108-173 revises the 
proportion of the standardized amount that is considered labor-
related. Specifically, section 1886(d)(3)(E) of the Act (as amended 
by section 403 of Pub. L. 108-173) requires that 62 percent of the 
standardized amount be adjusted by the wage index, unless doing so 
would result in lower payments to a hospital than would otherwise be 
made. (Section 403(b) of Pub. L. 108-173 extended this provision to 
the Puerto Rico standardized amounts.) We are proposing to update 
the labor-related share to 69.7 percent for FY 2006, as discussed in 
section IV.B.3. of the preamble to this proposed rule. We note that 
the revised labor-related share that we are proposing for FY 2006 
was determined to be 69.731, as discussed in section IV of the 
preamble to this proposed rule. We are proposing to continue with 
our previous methodology and round the labor-related share to 69.7 
percent for purposes of establishing the labor-related and nonlabor-
related portions of the standardized amount. As discussed in section 
IV. of the preamble to this proposed rule, we are also proposing to 
rebase the current labor-related share for the Puerto Rico-specific 
amounts for FY 2006. Since the proposed rebased Puerto Rico labor-
related share has not yet been calculated, the proposed standardized 
amounts that appear in Table 1C of this Addendum for providers with 
a wage index greater than 1.0000 reflect the current (FY 2005) 
labor-related share for the Puerto Rico-specific amounts of 71.3 
percent for FY 2006. However, in the final rule, if we adopt our 
proposal to rebase the labor-related share for Puerto Rico, these 
amounts would reflect this revised labor-related share. We are 
proposing to adjust 62 percent of the national standardized amount 
and 62 percent of the Puerto Rico-specific amount by the wage index 
for all hospitals whose wage indexes are less than or equal to 
1.0000. For all hospitals whose wage values are greater than 1.0000, 
we are proposing to adjust the national standardized amount by a 
labor-related share of 69.7 percent.

2. Computing the Average Standardized Amount

    Sections 1886(d)(3)(A)(iv) of the Act previously required the 
Secretary to compute the following 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 accordance with section 1886(b)(3)(B)(i) of the Act, the large 
urban average standardized amount was 1.6 percent higher than the 
other area average standardized amount. In addition, under sections 
1886(d)(9)(B)(iii) and 1886(d)(9)(C)(i) of the Act, the average 
standardized amounts per discharge were determined for hospitals 
located in urban and rural areas in Puerto Rico.
    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. Subsequently, Pub. L. 108-89 
extended section 402(b) of Pub. L. 108-7 beginning with discharges 
on or after October 1, 2003 and before March 31, 2004. Finally, 
section 401(a) of Pub. L. 108-173 amended section 1886(d)(3)(A)(iv) 
of the Act to require that, beginning with FY 2004 and thereafter, 
an equal standardized amount is to be computed for all hospitals at 
the level computed for large urban hospitals during FY 2003, updated 
by the applicable percentage update. This provision in effect makes 
permanent the equalization of the standardized amounts at the level 
of the previous standardized amount for large urban hospitals. 
Section 401(c) of Pub. L. 108-173 also amended section 1886(d)(9)(A) 
of the Act to equalize the Puerto Rico-specific urban and rural area 
rates. Accordingly, we are providing in this proposed rule for a 
single national standardized amount and a

[[Page 23468]]

single Puerto Rico standardized amount for FY 2006.

3. Updating the Average Standardized Amount

    In accordance with section 1886(d)(3)(A)(iv)(II) of the Act, we 
are proposing to update the equalized standardized amount for FY 
2006 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, as amended by section 501 of Pub. 
L. 108-173. 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 2006 is 3.2 percent. Thus, 
for FY 2006, the proposed update to the average standardized amount 
is 3.2 percent for hospitals in all areas.
    Section 1886(b)(3)(B) of the Act specifies the mechanism used to 
update the standardized amount for payment for inpatient hospital 
operating costs. Section 1886(b)(3)(B)(vii) of the Act, as amended 
by section 501(b) of Pub. L. 108-173, provides for a reduction of 
0.4 percentage points to the update percentage increase (also known 
as the market basket update) for each of FYs 2005 through 2007 for 
any ``subsection (d) hospital'' that does not submit data on a set 
of 10 quality indicators established by the Secretary as of November 
1, 2003. The statute also provides that any reduction will apply 
only to the fiscal year involved, and will not be taken into account 
in computing the applicable percentage increase for a subsequent 
fiscal year. This measure establishes an incentive for hospitals to 
submit data on quality measures established by the Secretary. The 
proposed standardized amounts in Tables 1A through 1D of section VI. 
of this Addendum reflect these differential amounts.
    Although the update factors for FY 2006 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 2006 for both 
IPPS hospitals and hospitals and hospital units 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 proposed rule.

4. Other Adjustments to the Average Standardized Amount

    As in the past, we are proposing to adjust the FY 2006 
standardized amount to remove the effects of the FY 2005 geographic 
reclassifications and outlier payments before applying the FY 2006 
updates. We then apply the new offsets for outliers and geographic 
reclassifications to the standardized amount for FY 2006.
    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.
    We are also proposing to adjust the standardized amount this 
year by an amount estimated to ensure that aggregate IPPS payments 
do not exceed the amount of payments that would have been made in 
the absence of the rural community hospital demonstration required 
under section 410A of Pub. L. 108-173. This demonstration is 
required to be budget neutral under section 410A(c)(2) of Pub. L. 
108-173.

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

    Section 1886(d)(4)(C)(iii) of the Act specifies that, beginning 
in FY 1991, the annual DRG reclassification and recalibration of the 
relative weights must be made in a manner that ensures that 
aggregate payments to hospitals are not affected. As discussed in 
section II. of the preamble, we normalized the recalibrated DRG 
weights by an adjustment factor, so that the average case weight 
after recalibration is equal to the average case weight prior to 
recalibration. However, equating the average case weight after 
recalibration to the average case weight before recalibration does 
not necessarily achieve budget neutrality with respect to aggregate 
payments to hospitals because payments to hospitals are affected by 
factors other than average case weight. Therefore, as we have done 
in past years, we are proposing to make a budget neutrality 
adjustment to ensure that the requirement of section 
1886(d)(4)(C)(iii) of the Act is met.
    Section 1886(d)(3)(E) of the Act requires us to update the 
hospital wage index on an annual basis beginning October 1, 1993. 
This provision also requires us to make any updates or adjustments 
to the wage index in a manner that ensures that aggregate payments 
to hospitals are not affected by the change in the wage index. For 
FY 2006, we are proposing to continue to adjust 10 percent of the 
wage index factor for occupational mix. We describe the proposed 
occupational mix adjustment in section III.C. of the preamble to 
this proposed rule. Because section 1886(d)(3)(E) of the Act 
requires us to update the wage index on a budget neutral basis, we 
are including the effects of this proposed occupational mix 
adjustment on the wage index in our budget neutrality calculations.
    In FY 2005, those urban hospitals that became rural under the 
new labor market area definitions were assigned the wage index of 
the urban area in which they were located under the previous labor 
market definitions for a 3-year period of FY 2005, FY 2006, and FY 
2007. Because we are in the second year of this 3-year transition, 
we are proposing to adjust the standardized amounts for FY 2006 to 
ensure budget neutrality for this policy. We discuss this adjustment 
in section III.B. of the preamble to this proposed rule.
    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. As discussed in the FY 2005 IPPS final rule (69 
FR 49110), we are in the second year of the 3-year provision that 
uses an imputed wage index floor for States that have no rural areas 
and States that have geographic rural areas, but that have no 
hospitals actually classified as rural. We are also adjusting for 
the effects of this provision in our calculation of the wage update 
budget neutrality factor.
    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 2004 discharge data to simulate payments and compared aggregate 
payments using the FY 2005 relative weights and wage index to 
aggregate payments using the proposed FY 2006 relative weights and 
wage index. The same methodology was used for the FY 2005 budget 
neutrality adjustment.
    Based on this comparison, we computed a proposed budget 
neutrality adjustment factor equal to 1.002494. We also are 
proposing to adjust the Puerto Rico-specific standardized amount for 
the effect of DRG reclassification and recalibration. We computed a 
proposed budget neutrality adjustment factor for the Puerto Rico-
specific standardized amount equal to 0.999003. These proposed 
budget neutrality adjustment factors are applied to the standardized 
amounts without removing the effects of the FY 2005 budget 
neutrality adjustments. In addition, as discussed in section V.C.2. 
of the preamble to this proposed rule, we are proposing to apply the 
same DRG reclassification and recalibration budget neutrality factor 
of 0.999003 to the hospital-specific rates that are effective for 
cost reporting periods beginning on or after October 1, 2005.
    Using the same data, we calculated a transition budget 
neutrality adjustment to account for the ``hold harmless'' policy 
under which urban hospitals that became rural under the new labor 
market area definitions were assigned the wage index of the urban 
area in which they were located under the previous labor market area 
definitions for a 3-year period of FY 2005, FY 2006, and FY 2007 
(see Table 2 in section VI. of this Addendum). Using the 
prereclassified wage index, we simulated payments under the new 
labor market area definitions and compared them to simulated 
payments under the ``hold harmless'' policy. Based on this 
comparison, we computed a proposed transition budget neutrality 
adjustment of 0.999529.

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

[[Page 23469]]

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 wage index.
    Under section 1886(d)(8)(D) of the Act, the Secretary is 
required to adjust the standardized amount 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. (We note that neither the wage index 
reclassifications provided under section 508 of Pub. L. 108-173 nor 
the wage index adjustments provided under section 505 of Pub. L. 
108-173 are budget neutral. Section 508(b) of Pub. L. 108-173 
provides that the wage index reclassifications approved under 
section 508(a) of Pub. L. 108-173 ``shall not be effected in a 
budget neutral manner.'' Section 505(a) of Pub. L. 108-173 similarly 
provides that any increase in a wage index under that section shall 
not be taken into account ``in applying any budget neutrality 
adjustment with respect to such index'' under section 1886(d)(8)(D) 
of the Act.) To calculate this proposed budget neutrality factor, we 
used FY 2004 discharge data to simulate payments, and compared total 
IPPS payments prior to any reclassifications under sections 
1886(d)(8)(B) and (C) and 1886(d)(10) of the Act to total IPPS 
payments after such reclassifications. Based on these simulations, 
we are proposing to apply an adjustment factor of 0.992905 to ensure 
that the effects of this reclassification are budget neutral.
    The proposed adjustment factor is applied to the standardized 
amount after removing the effects of the FY 2005 budget neutrality 
adjustment factor. We note that the proposed FY 2006 adjustment 
reflects FY 2006 wage index reclassifications approved by the MGCRB 
or the Administrator, and the effects of MGCRB reclassifications 
approved in FY 2004 and FY 2005 (section 1886(d)(10)(D)(v) of the 
Act makes wage index reclassifications effective 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.
    In accordance with section 1886(d)(5)(A)(iv) of the Act, outlier 
payments for any year are 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 amount 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. More information on 
outlier payments may be found on the CMS Web site at http://www.cms.hhs.gov/providers/hipps/ippsotlr.asp.
    i. Proposed FY 2006 outlier fixed-loss threshold. For FY 2006, 
we are proposing a new methodology to calculate the outlier fixed-
loss threshold. For FY 2004, we simulated outlier payments by 
applying FY 2004 rates and policies using cases from the FY 2002 
MedPAR file. In order to determine the FY 2004 outlier fixed-loss 
threshold, it was necessary to inflate the charges on the MedPAR 
claims by 2 years, from FY 2002 to FY 2004. In order to determine 
the FY 2004 threshold, we used the 2-year average annual rate-of-
change in charges per case to inflate FY 2002 charges to approximate 
FY 2004 charges. (We refer the reader to the FY 2004 IPPS final rule 
(67 FR 45476) for a complete discussion of the FY 2004 methodology.) 
In the IPPS proposed rule for FY 2005 (69 FR 28376), we proposed to 
use the same methodology we used for determining the FY 2004 outlier 
fix-loss threshold to determine the FY 2005 outlier threshold. We 
further noted that the rate-of-increase in the 2-year average annual 
rate-of-change in charges derived from the period before the changes 
we made to the policy affecting the applicable cost-to-charge ratios 
(68 FR 34494) and, therefore, they may have represented rates-of-
increase that could be higher than the rates-of-increase under our 
new policy. As a result, we welcomed comments on the data we were 
using to update charges for purposes of the threshold and 
specifically encouraged commenters to provide recommendations for 
data that might better reflect current trends in charge increases.
    In response to the many comments we received on this proposed FY 
2005 methodology, in the IPPS final rule for FY 2005 (69 FR 49275), 
we revised that proposed methodology and used the following 
methodology to calculate the final FY 2005 outlier fixed-loss 
threshold. Instead of using the 2-year average annual rate-of-change 
in charges per case from FY 2001 to FY 2002 and FY 2002 to FY 2003, 
we used more recent data to determine the annual rate-of-change in 
charges for the FY 2005 outlier threshold. Specifically, we compared 
the rate-of-increase in charges from the first half-year of FY 2003 
to the first half-year of FY 2004. We stated that we believed this 
methodology would result in a more accurate determination of the 
rate-of-change in charges per case between FY 2003 and FY 2005. 
Although a full year of data was available for FY 2003, we did not 
have a full year of FY 2004 data at the time we set the FY 2005 
outlier threshold. Therefore, we stated that we believed it was 
optimal to employ comparable periods in determining the rate-of-
change from one year to the next. We also stated that we believed 
this methodology was the best methodology for determining the rate-
of-change in charges per case because it used the most recent charge 
data available. Using this methodology, we established a fixed-loss 
cost outlier threshold for FY 2005 equal to the prospective payment 
rate for the DRG, plus any IME and DSH payment, and any add-on 
payment for new technology, plus $25,800.
    For FY 2006, we are proposing to use a new methodology to 
calculate the outlier threshold that will take into account the 
lower inflation in hospital charges that is occurring as a result of 
the June 9, 2003 outlier final rule (68 FR 34505), which changed our 
methodology for determining outlier payments by implementing the use 
of more current and accurate cost-to-charge ratios when paying for 
outliers. As we have done in the past, to calculate the proposed FY 
2006 outlier thresholds, we simulated payments by applying proposed 
FY 2006 rates and policies using cases from the FY 2004 MedPAR 
files. Therefore, in order to determine the appropriate proposed FY 
2006 outlier threshold, it was necessary to inflate the charges on 
the MedPAR claims by 2 years, from FY 2004 to FY 2006.
    However, we are not proposing to inflate charges using a 2-year 
average annual rate-of-change in charges per case from FY 2002 to FY 
2003 and FY 2003 to FY 2004 because of the distortion in FY 2002 and 
FY 2003 charge data caused by the exceptionally high rate of 
hospital charge inflation during those years. Instead, we are 
proposing to use more recent data that reflect changes under the new 
outlier policy. However, we will continue to consider other 
methodologies in the future when calculating the outlier threshold 
once we have 2 complete years of charge data under the new outlier 
policy.
    Specifically, we are proposing to establish the proposed FY 2006 
outlier threshold as follows: Using the latest data available, the 
1-year average annualized rate-of-change in charges per case from 
the last quarter of FY 2003 in combination with the first quarter of 
FY 2004 (July 1, 2003 through December 31, 2003) to the last quarter 
of FY 2004 in combination with the first quarter of FY 2005 (July 1, 
2004 through December 31, 2004) was 8.65 percent (1.0865), or 18.04 
percent (1.1804) over 2 years. As we have done in the past, we are 
proposing to use hospital cost-to-charge ratios from the most recent 
Provider Specific File, in this case the December 2004 update, in 
establishing the proposed FY 2006 outlier threshold. This file 
includes cost-to-charge ratios that reflect implementation of the 
changes to the policy for determining the applicable cost-to-charge 
ratios that became effective August 8, 2003 (68 FR 34494).
    Using this methodology, we are proposing to establish a fixed-
loss cost outlier threshold for FY 2006 equal to the prospective 
payment rate for the DRG, plus any IME and DSH payments, and any 
add-on payments for new technology, plus $26,675. In addition, as 
stated in the June 9, 2003 outlier final rule (68 FR 34505), we 
believe the use of charge inflation is more appropriate than our 
previous methodology of cost inflation because charges tend to 
increase at a much faster rate than costs. Although charges have 
increased at a slower rate since the implementation of changes to 
our outlier payment methodology in 2003, we believe the use of 
charges is still appropriate because this trend is still evident.

[[Page 23470]]

    As we did in establishing the FY 2005 outlier threshold (69 FR 
49278), we are not including in the calculation of the outlier 
threshold the possibility that hospitals' cost-to-charge ratios and 
outlier payments may be reconciled upon cost report settlement. We 
believe that, due to the policy implemented in the June 9, 2003 
outlier final rule, cost-to-charge ratios will no longer fluctuate 
significantly and, therefore, few hospitals, if any, will actually 
have these ratios reconciled upon cost report settlement. In 
addition, it is difficult to predict which specific hospitals will 
have cost-to-charge ratios and outlier payments reconciled in their 
cost reports in any given year. We also note that reconciliation 
occurs because hospitals' actual cost-to-charge ratios for the cost 
reporting period are different than the interim cost-to-charge 
ratios used to calculate outlier payments when a bill is processed. 
Our simulations assume cost-to-charge ratios accurately measure 
hospital costs and, therefore, are more reflective of post-
reconciliation than pre-reconciliation outlier payments. As a 
result, we omitted any assumptions about the effects of 
reconciliation from the outlier threshold calculation.
    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 lower percentage of 
outlier payments for capital-related costs than for operating costs. 
We project that the proposed thresholds for FY 2006 will result in 
outlier payments equal to 5.1 percent of operating DRG payments and 
5.03 percent of capital payments based on the Federal rate.
    In accordance with section 1886(d)(3)(B) of the Act, we reduced 
the proposed FY 2005 standardized amount by the same percentage to 
account for the projected proportion of payments paid to outliers.
    The proposed outlier adjustment factors that would be applied to 
the standardized amount for FY 2006 are as follows:
[GRAPHIC] [TIFF OMITTED] TP04MY05.064

    We are proposing to apply the outlier adjustment factors to the 
FY 2006 rates after removing the effects of the FY 2005 outlier 
adjustment factors on the standardized amount.
    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 outlier final rule (68 FR 34494) 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 1.220 or capital cost-to-charge ratios greater than 
0.169, or hospitals for whom the fiscal intermediary is unable to 
calculate a cost-to-charge ratio (as described at Sec.  412.84(i)(3) 
of our regulations), we are still using statewide average ratios to 
calculate costs to determine whether a hospital qualifies for 
outlier payments.\6\ Table 8A in section VI. of this Addendum 
contains the proposed statewide average operating cost-to-charge 
ratios for urban hospitals and for rural hospitals for which the 
fiscal intermediary is unable to compute a hospital-specific cost-
to-charge ratio within the above range. Effective for discharges 
occurring on or after October 1, 2005, these proposed statewide 
average ratios would replace the ratios published in the IPPS final 
rule for FY 2005 (69 FR 49687). Table 8B in section VI. of this 
Addendum contains the proposed comparable statewide average capital 
cost-to-charge ratios. Again, the proposed cost-to-charge ratios in 
Tables 8A and 8B would be used during FY 2006 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.
---------------------------------------------------------------------------

    \6\ These figures represent 3.0 standard deviations from the 
mean of the log distribution of cost-to-charge ratios for all 
hospitals.
---------------------------------------------------------------------------

    iii. FY 2004 and FY 2005 outlier payments. In the FY 2005 IPPS 
final rule, we stated that, based on available data, we estimated 
that actual FY 2004 outlier payments would be approximately 3.6 
percent of actual total DRG payments (69 FR 49278, as corrected at 
69 FR 60252). This estimate was computed based on simulations using 
the FY 2003 MedPAR file (discharge data for FY 2003 bills). That is, 
the estimate of actual outlier payments did not reflect actual FY 
2004 bills, but instead reflected the application of FY 2004 rates 
and policies to available FY 2003 bills.
    Our current estimate, using available FY 2004 bills, is that 
actual outlier payments for FY 2004 were approximately 3.5 percent 
of actual total DRG payments. Thus, the data indicate that, for FY 
2004, the percentage of actual outlier payments relative to actual 
total payments is lower than we projected before FY 2004 (and, thus, 
is less than the percentage by which we reduced the standardized 
amounts for FY 2004). We note that, for FY 2005, the outlier 
threshold was lowered to $25,800 compared to $31,000 for FY 2004. 
The outlier threshold was lower in FY 2005 than FY 2004 as a result 
of slower growth in hospital charge inflation. We believe that this 
slower growth was due to changes in hospital charge practices 
following implementation of the outlier final rule published on June 
9, 2003. 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 2004 are equal to 5.1 
percent of total DRG payments.
    We currently estimate that actual outlier payments for FY 2005 
will be approximately 4.4 percent of actual total DRG payments, 0.7 
percentage points lower than the 5.1 percent we projected in setting 
outlier policies for FY 2005. This estimate is based on simulations 
using the FY 2004 MedPAR file (discharge data for FY 2004 bills). We 
used these data to calculate an estimate of the actual outlier 
percentage for FY 2005 by applying FY 2005 rates and policies, 
including an outlier threshold of $25,800 to available FY 2004 
bills.

d. Rural Community Hospital Demonstration Program Adjustment (Section 
410A of Pub. L. 108-173)

    Section 410A of Pub. L. 108-173 requires the Secretary to 
establish a demonstration that will modify reimbursement for 
inpatient services for up to 15 small rural hospitals. Section 
410A(c)(2) of Pub. L. 108-173 requires that ``in conducting the 
demonstration program under this section, the Secretary shall ensure 
that the aggregate payments made by the Secretary do not exceed the 
amount which the Secretary would have paid if the demonstration 
program under this section was not implemented.'' As discussed in 
section V.K. of the preamble to this proposed rule, we are proposing 
to satisfy this requirement by adjusting national IPPS rates by a 
factor that is sufficient to account for the added costs of this 
demonstration. We estimate that the average additional annual 
payment that will be made to each participating hospital under the 
demonstration will be approximately $977,410. We based this estimate 
on the recent historical experience of the difference between 
inpatient cost and payment for hospitals that are participating in 
the demonstration. For 13 participating hospitals, the total annual 
impact of the demonstration program is estimated to be $12,706,334. 
The required adjustment to the Federal rate used in calculating 
Medicare inpatient prospective payments as a result of the 
demonstration is 0.999863.

[[Page 23471]]

    In order to achieve budget neutrality, we are proposing to 
adjust national IPPS rates by an amount sufficient to account for 
the added costs of this demonstration. In other words, we are 
proposing to apply budget neutrality across the payment system as a 
whole rather than merely across the participants of this 
demonstration. We believe that the language of the statutory budget 
neutrality requirement permits the agency to implement the budget 
neutrality provision in this manner. This is because the statutory 
language requires that ``aggregate payments made by the Secretary do 
not exceed the amount which the Secretary would have paid if the 
demonstration * * * was not implemented,'' but does not identify the 
range across which aggregate payments must be held equal.

5. Proposed FY 2006 Standardized Amount

    The adjusted standardized amount is divided into labor-related 
and nonlabor-related portions. Tables 1A and 1B in section VI. of 
this Addendum contain the national standardized amount that we are 
proposing to apply to all hospitals, except hospitals in Puerto 
Rico. The amounts shown in the two tables differ only in that the 
labor-related share applied to the standardized amounts in Table 1A 
is 69.7 percent, and the labor-related share applied to the 
standardized amounts in Table 1B is 62 percent. In accordance with 
sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act, we are 
applying the labor-related share of 62 percent, unless the 
application of that percentage would result in lower payments to a 
hospital than would otherwise be made. The effect of this proposed 
application is that the labor-related share of the standardized 
amount is 62 percent for all hospitals whose wage indexes are less 
than or equal to 1.0000.
    As discussed in section IV.B.3. of the preamble to this proposed 
rule (reflecting the Secretary's current estimate of the proportion 
of costs that are attributable to wages and wage-related costs), we 
are proposing to set the labor-related share of the standardized 
amount at 69.7 percent for hospitals whose wage indexes are greater 
than 1.0000. In addition, Tables 1A and 1B include proposed 
standardized amounts reflecting the full 3.2 percent update for FY 
2006, and proposed standardized amounts reflecting the 0.4 
percentage point reduction to the update applicable for hospitals 
that fail to submit quality data consistent with section 501(b) of 
Pub. L. 108-173. (Tables 1C and 1D show the proposed standardized 
amounts for Puerto Rico for FY 2006, reflecting the different labor-
related shares that apply, that is, 71.3 percent or 62 percent.)
    The following table illustrates the proposed changes from the FY 
2005 national average standardized amount. The first column shows 
the proposed changes from the FY 2005 standardized amounts for 
hospitals that satisfy the quality data submission requirement for 
receiving the full update (3.2 percent). The second column shows the 
proposed changes for hospitals receiving the reduced update (2.8 
percent). The first row of the table shows the proposed updated 
(through FY 2005) average standardized amount after restoring the FY 
2005 offsets for outlier payments, demonstration budget neutrality, 
the wage index transition budget neutrality and geographic 
reclassification budget neutrality. The DRG reclassification and 
recalibration and wage index budget neutrality factor is cumulative. 
Therefore, the FY 2005 factor is not removed from the amount in the 
table. We have added separate rows to this table to reflect the 
different labor-related shares that apply to hospitals.

[[Page 23472]]

[GRAPHIC] [TIFF OMITTED] TP04MY05.065

    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 (as set 
forth in Table 1A). The labor-related and nonlabor-related 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-related share applied to the Puerto Rico standardized amount 
is 71.3 percent, or 62 percent, depending on which is more 
advantageous to the hospital. (Section 1886(d)(9)(C)(iv) of the Act, 
as amended by section 403(b) of Pub. L. 108-173, provides that the 
labor-related share for hospitals in Puerto Rico will be 62 percent, 
unless the application of that percentage would result in lower 
payments to the hospital.)

[[Page 23473]]

B. Adjustments for Area Wage Levels and Cost-of-Living

    Tables 1A through 1D, as set forth in section VI. of this 
Addendum, contain the labor-related and nonlabor-related shares that 
we are proposing to use to calculate the prospective payment rates 
for hospitals located in the 50 States, the District of Columbia, 
and Puerto Rico. This section addresses two types of adjustments to 
the standardized amounts that are made in determining the proposed 
prospective payment rates as described in this Addendum.

1. Adjustment for Area Wage Levels

    Sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act require 
that we make an adjustment to the labor-related portion of the 
national and Puerto Rico prospective payment rates, respectively, to 
account for area differences in hospital wage levels. This 
adjustment is made by multiplying the labor-related portion of the 
adjusted standardized amounts by the appropriate wage index for the 
area in which the hospital is located. In section III. of the 
preamble to this proposed rule, we discuss the data and methodology 
for the proposed FY 2006 wage index. The proposed FY 2006 wage 
indexes are 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 2006, we are proposing to adjust the payments for hospitals 
in Alaska and Hawaii by multiplying the nonlabor-related portion of 
the standardized amount by the appropriate adjustment factor 
contained in the table below. If the Office of Personnel Management 
releases revised cost-of-living adjustment factors before July 1, 
2005, we will publish them in the final rule and use them in 
determining FY 2006 payments.
[GRAPHIC] [TIFF OMITTED] TP04MY05.066

C. DRG Relative Weights

    As discussed in section II. of the preamble, we have developed a 
classification system for all hospital discharges, assigning them 
into DRGs, and have developed relative weights for each DRG that 
reflect the resource utilization of cases in each DRG relative to 
Medicare cases in other DRGs. Table 5 of section VI. of this 
Addendum contains the relative weights that we are proposing to use 
for discharges occurring in FY 2006. These factors have been 
recalibrated as explained in section II. of the preamble of this 
proposed rule.

D. Calculation of Proposed Prospective Payment Rates for FY 2006

General Formula for Calculation of Prospective Payment Rates for FY 
2006

    The proposed operating prospective payment rate for all 
hospitals paid under the IPPS located outside of Puerto Rico, except 
SCHs and MDHs, equals the Federal rate based on the corresponding 
amounts in Table 1A or Table 1B in section VI. of this Addendum.
    The proposed prospective payment rate for SCHs equals the higher 
of the applicable Federal rate (from Table 1A or Table 1B) or the 
hospital-specific rate as described below. The proposed prospective 
payment rate for MDHs equals the higher of the Federal rate, or the 
Federal rate plus 50 percent of the difference between the Federal 
rate and the hospital-specific rate as described below. The proposed 
prospective payment rate for Puerto Rico equals 25 percent of the 
Puerto Rico rate plus 75 percent of the applicable national rate 
from Table 1C or Table 1D in section VI. of this Addendum.

1. Federal Rate

    For discharges occurring on or after October 1, 2005 and before 
October 1, 2006, 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 applicable wage index (Table 1A for wage indexes 
greater than 1.0000 and Table 1B for wage indexes less than or equal 
to 1.0000) and whether the hospital has submitted qualifying quality 
data (full update for qualifying hospitals, update minus 0.4 
percentage points for nonqualifying hospitals).
    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.

[[Page 23474]]

    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 the FY 1982 costs per discharge, the FY 1987 
costs per discharge, or, for SCHs, the FY 1996 costs per discharge. 
For a more detailed discussion of the calculation of the hospital-
specific rates, we refer the reader to the September 1, 1983 interim 
final rule (48 FR 39772); the April 20, 1990 final rule with comment 
(55 FR 15150); the September 4, 1990 final rule (55 FR 35994); and 
the August 1, 2000 final rule (65 FR 47082). In addition, for both 
SCHs and MDHs, the hospital-specific rate is adjusted by the 
proposed budget neutrality adjustment factor (that is, by the 
recalibration budget neutrality factor of 0.999003) as discussed in 
section V.C.2. of the preamble to this proposed rule. The resulting 
rate would be used in determining the payment rate an SCH or MDH 
would receive for its discharges beginning on or after October 1, 
2005.

b. Updating the FY 1982, FY 1987, and FY 1996 Hospital-Specific Rates 
for FY 2005

    We are proposing to increase the hospital-specific rates by 3.2 
percent (the hospital market basket percentage increase) for SCHs 
and MDHs for FY 2006. 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 2006, is the 
market basket rate of increase. Section 1886(b)(3)(D) of the Act 
provides that the update factor applicable to the hospital-specific 
rates for MDHs also equals the update factor provided under section 
1886(b)(3)(B)(iv) of the Act, which, for FY 2006, is the market 
basket rate-of-increase.

3. General Formula for Calculation of Proposed Prospective Payment 
Rates for Hospitals Located in Puerto Rico Beginning On or After 
October 1, 2005 and Before October 1, 2006

    Under section 504 of Pub. L. 108-173, effective for discharges 
occurring on or after October 1, 2004, hospitals located in Puerto 
Rico are paid based on a blend of 75 percent of the national 
prospective payment rate and 25 percent of the Puerto Rico-specific 
rate.

a. Puerto Rico Rate

    The Puerto Rico prospective payment rate is determined as 
follows:
    Step 1--Select the appropriate average standardized amount 
considering the applicable wage index (see Table 1C).
    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 amount from Step 3 by the appropriate DRG 
relative weight.
    Step 5--Multiply the result in Step 4 by 25 percent (see Table 5 
of section VI. of the Addendum).

b. National Rate

    The national prospective payment rate is determined as follows:
    Step 1--Select the appropriate average standardized amount 
considering the applicable wage index (see Table 1C).
    Step 2--Add the amount from Step 1 and the nonlabor-related 
portion of the national average standardized amount.
    Step 3--Multiply the amount from Step 2 by the appropriate DRG 
relative weight (see Table 5 of section VI. of the Addendum).
    Step 4--Multiply the result in Step 3 by 75 percent.
    The sum of the Puerto Rico rate and the national rate computed 
above equals the prospective payment for a given discharge for a 
hospital located in Puerto Rico. This rate may then be further 
adjusted if the hospital qualifies for either the IME or DSH 
adjustment.

III. Proposed Changes to Payment Rates for Acute Care Hospital 
Inpatient Capital-Related Costs for FY 2006

    (If you choose to comment on issues in this section, please 
include the caption ``Capital Payment Rate'' at the beginning of 
your comment.)
    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, 
hospitals were paid during a 10-year transition period (which 
extended through FY 2001) to change the payment methodology for 
Medicare acute care hospital inpatient capital-related costs from a 
reasonable cost-based methodology to a prospective methodology 
(based fully on the Federal rate).
    The basic methodology for determining Federal capital 
prospective rates is set forth in regulations at Sec. Sec.  412.308 
through 412.352. Below we discuss the factors that we are proposing 
to use to determine the capital Federal rate for FY 2006, which 
would be effective for discharges occurring on or after October 1, 
2005. The 10-year transition period ended with hospital cost 
reporting periods beginning on or after October 1, 2001 (FY 2002). 
Therefore, for cost reporting periods beginning in FY 2002, all 
hospitals (except ``new'' hospitals under Sec.  412.304(c)(2)) are 
paid based on 100 percent of the capital Federal rate. For FY 1992, 
we computed the standard Federal payment rate for capital-related 
costs under the 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 at Sec.  
412.308(c)(1), to account for capital input price increases and 
other factors. The regulations at Sec.  412.308(c)(2) provide 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) 
exceptions under Sec.  412.348. Section 412.308(c)(4)(ii) requires 
that the capital standard Federal rate be adjusted so that the 
effects of 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 required 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 FY 2003 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 FY 2002 IPPS final rule (66 FR 39911), beginning in 
FY 2002, 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)). Because, effective with cost 
reporting periods beginning in FY 2002, payments are no longer being 
made under the regular exception policy, 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 FY 
2002 IPPS final rule (66 FR 40099).
    Section 412.374 provides for the use of a blended payment system 
for payments to Puerto Rico hospitals under the PPS for acute care 
hospital inpatient capital-related costs. Accordingly, under the 
capital PPS, we compute a separate payment rate specific to Puerto 
Rico hospitals using the same methodology used to compute the 
national Federal rate for capital-related costs. In

[[Page 23475]]

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 
operating 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. Similarly, 
prior to FY 1998, hospitals in Puerto Rico were paid a blended 
capital rate that consisted of 75 percent of the applicable capital 
Puerto Rico specific rate and 25 percent of the applicable capital 
Federal rate. However, effective October 1, 1997, in accordance with 
section 4406 of Pub. L. 105-33, operating payments to hospitals in 
Puerto Rico were revised to be 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 occurring on or after October 1, 1997, we 
also revised the methodology for computing capital payments to 
hospitals in Puerto Rico to be based on a blend of 50 percent of the 
Puerto Rico capital rate and 50 percent of the capital Federal rate.
    As we discussed in the FY 2005 IPPS final rule (69 FR 49185), 
section 504 of Pub. L. 108-173 increased the national portion of the 
operating IPPS payments for Puerto Rico hospitals from 50 percent to 
62.5 percent and decreased the Puerto Rico portion of the operating 
IPPS payments from 50 percent to 37.5 percent for discharges 
occurring on or after April 1, 2004 through September 30, 2004 (see 
the March 26, 2004 One-Time Notification (Change Request 3158)). In 
addition, section 504 of Pub. L. 108-173 provided that the national 
portion of operating IPPS payments for Puerto Rico hospitals is 
equal to 75 percent and the Puerto Rico portion of operating IPPS 
payments is equal to 25 percent for discharges occurring on or after 
October 1, 2004. Consistent with that change in operating IPPS 
payments to hospitals in Puerto Rico, for FY 2005 (as we discussed 
in the FY 2005 IPPS final rule), we revised the methodology for 
computing capital payments to hospitals located in Puerto Rico to be 
based on a blend of 25 percent of the Puerto Rico capital rate and 
75 percent of the capital Federal rate for discharges occurring on 
or after October 1, 2004.

A. Determination of Proposed Federal Hospital Inpatient Capital-
Related Prospective Payment Rate Update

    In the FY 2005 IPPS final rule (69 FR 49283) and corrected in a 
December 30, 2004 correction notice (69 FR 78532), we established a 
capital Federal rate of $416.53 for FY 2005.
    In the discussion that follows, we explain the factors that were 
used to determine the proposed FY 2006 capital Federal rate. In 
particular, we explain why the proposed FY 2006 capital Federal rate 
would increase 0.7 percent compared to the FY 2005 capital Federal 
rate. We also estimate aggregate capital payments would decrease by 
0.1 percent during this same period. This decrease is due to several 
factors, including a projected decrease in the number of Medicare 
fee-for-service hospital admissions, and a decrease in the proposed 
geographic adjustment factor (GAF) values (which are based on the 
proposed wage index values). Our Office of the Actuary projects a 
decrease in Medicare fee-for-service Part A enrollment, in part, 
because of a projected increase in Medicare managed care enrollment 
as a result of the implementation of several provisions of Pub. L. 
108-173. We are projecting a slight increase in the proposed GAF 
values (based on the proposed wage index) for some hospitals as a 
result of the completion of the transition to the CBSA-based labor 
market area definitions (as discussed in section III. of the 
preamble of this proposed rule). Thus, we are projecting that 
capital PPS payments would remain relatively unchanged from FY 2005 
to FY 2006.
    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 IPPS are estimated to decrease slightly in FY 2006 
compared to FY 2005, as discussed above.

1. Projected 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. The proposed update factor for FY 2006 under that 
framework is 0.7 percent based on the best data available at this 
time. The proposed update factor is based on a projected 0.7 percent 
increase in the CIPI, a 0.0 percent adjustment for intensity, a 0.0 
percent adjustment for case-mix, a 0.0 percent adjustment for the FY 
2004 DRG reclassification and recalibration, and a forecast error 
correction of 0.0 percent. As discussed below in section III.C. of 
this Addendum, we believe that the CIPI is the most appropriate 
input price index for capital costs to measure capital price changes 
in a given year. We also explain the basis for the FY 2006 CIPI 
projection in that same section of this Addendum. Below we describe 
the proposed 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:
     The average resource use of Medicare patients changes 
(``real'' case-mix change);
     Changes in hospital coding of patient records result in 
higher weight DRG assignments (``coding effects''); and
     The annual DRG reclassification and recalibration 
changes may not be budget neutral (``reclassification effect'').
    We define real case-mix change as actual changes in the mix (and 
resource requirements) of Medicare patients as opposed to changes in 
coding behavior that result in assignment of cases to higher 
weighted DRGs but do not reflect higher resource requirements. The 
capital update framework includes the same case-mix index adjustment 
used in the former operating IPPS update framework (as discussed in 
the May 18, 2005 IPPS proposed rule for FY 2005 (69 FR 28816)). (We 
are no longer using an update framework in making a recommendation 
for updating the operating IPPS standardized amounts as discussed in 
section III. of Appendix B of this proposed rule.)
    For FY 2006, we are projecting a 1.0 percent total increase in 
the case-mix index. We estimate that the real case-mix increase 
would also equal 1.0 percent in FY 2006. The net adjustment for 
change in case-mix is the difference between the projected increase 
in real case-mix and the projected total increase in real case-mix. 
Therefore, the net proposed adjustment for case-mix change in FY 
2006 is 0.0 percentage points.
    The capital update framework also contains an adjustment for the 
effects of DRG reclassification and recalibration. This adjustment 
is intended to 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 those due to patient severity. Due to the lag time in the 
availability of data, there is a 2-year lag in data used to 
determine the adjustment for the effects of DRG reclassification and 
recalibration. For example, we are adjusting for the effects of the 
FY 2004 DRG reclassification and recalibration as part of our 
proposed update for FY 2006. We estimate that FY 2004 DRG 
reclassification and recalibration would 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 proposing to 
make a 0.0 percent adjustment for DRG reclassification and 
recalibration in the update for FY 2006 to maintain budget 
neutrality.
    The capital update framework also 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

[[Page 23476]]

lag between the forecast and the measurement of the forecast error. 
A forecast error of -0.1 percentage points was calculated for the FY 
2004 update. That is, current historical data indicate that the 
forecasted FY 2004 CIPI used in calculating the FY 2004 update 
factor (0.7 percent) slightly overstated the actual realized price 
increases (0.6 percent) by 0.1 percentage points. This slight 
overprediction was mostly due to a prediction of the cuts in the 
interest rate by the Federal Reserve Board in 2004. However, the 
Federal Reserve Board did not cut interest rates during 2004, 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 proposing to make a 0.0 percent 
adjustment for forecast error in the update for FY 2006.
    Under the capital IPPS 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.
    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 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 2002 and 2003, 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. For FYs 2004 and 2005, we found that the charge data 
appeared to be skewed (as discussed in greater detail below) and we 
established a 0.0 percent adjustment in each of those years. 
Furthermore, we stated that we would continue to apply a 0.0 percent 
adjustment for intensity until any increase in charges can be tied 
to intensity rather than attempts to maximize outlier payments.
    Using the methodology described above, for FY 2006 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 1999 through 2004. We found that, over this 
period and in particular the last 4 years of this period (FYs 2000 
through 2003), the charge data appear to be skewed. More 
specifically, we found a dramatic increase in hospital charges for 
FYs 2000 through 2004 without a corresponding increase in the 
hospital case-mix index. These findings are similar to the 
considerable increase in hospitals' charges, which we found when we 
were determining the intensity factor in the FY 2004 and FY 2005 
update recommendations as discussed in the FY 2004 IPPS final rule 
(68 FR 45482) and the FY 2005 IPPS final rule (69 FR 49285), 
respectively. 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.
    As we discussed in the FY 2005 IPPS final rule (69 FR 49285), 
because our intensity calculation relies heavily upon charge data 
and we believe that these charge data may be inappropriately skewed, 
we established a 0.0 percent adjustment for intensity for FY 2005. 
We believed that it was appropriate to apply a zero intensity 
adjustment until we believe that any increase in charges can be tied 
to intensity rather than to attempts to maximize outlier payments. 
As discussed above, we believe that the most recently available 
charge data used to make this determination may still be 
inappropriately skewed. Therefore, we are proposing a 0.0 percent 
adjustment for intensity for FY 2006. In the past (FYs 1996 through 
2001) when we found intensity to be declining, we believed a zero 
(rather than negative) intensity adjustment was appropriate. 
Similarly, we believe that it is appropriate to propose to apply a 
zero intensity adjustment for FY 2006 until any increase in charges 
can be tied to intensity rather than to attempts to maximize outlier 
payments.
    Above we described the basis of the components used to develop 
the proposed 0.7 percent capital update factor for FY 2006 as shown 
in the table below.
[GRAPHIC] [TIFF OMITTED] TP04MY05.067


[[Page 23477]]



b. Comparison of CMS and MedPAC Update Recommendation

    In the past, MedPAC has included update recommendations for 
capital PPS in a Report to Congress. In its March 2005 Report to 
Congress, MedPAC did not make an update recommendation for capital 
PPS payments for FY 2006. However, in that same report, MedPAC made 
an update recommendation for hospital inpatient and outpatient 
services (page 40). MedPAC reviews inpatient and outpatient services 
together since they are so closely interrelated. MedPAC recommended 
an increase in the payment rate for the operating IPPS by the 
projected increase in the hospital market basket index, less 0.4 
percent for FY 2006, based on their assessment of beneficiaries' 
access to care, volume of services, access to capital, quality of 
care, and the relationship of Medicare payments and costs. In 
addition, the Commission considered the efficient provision of 
services in making its FY 2006 update recommendations. (MedPAC's 
Report to the Congress: Medicare Payment Policy, March 2005, page 
44.)

2. Proposed 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 FY 2005 IPPS final rule (69 FR 49286), we estimate that 
outlier payments for capital will equal 4.94 percent of inpatient 
capital-related payments based on the capital Federal rate in FY 
2005. Based on the thresholds as set forth in section II.A.4.c. of 
this Addendum, we estimate that outlier payments for capital would 
equal 5.03 percent for inpatient capital-related payments based on 
the proposed Federal rate in FY 2006. Therefore, we are proposing to 
apply an outlier adjustment factor of 0.9497 to the capital Federal 
rate. Thus, the percentage of capital outlier payments to total 
capital standard payments for FY 2006 would be higher than the 
percentages for FY 2005.
    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. The proposed FY 2006 outlier 
adjustment of 0.9497 is a -0.09 percent change from the FY 2005 
outlier adjustment of 0.9506. The net change in the proposed outlier 
adjustment to the capital Federal rate for FY 2006 is 0.9991 
(0.9497/0.9506). Thus, the proposed outlier adjustment decreases the 
FY 2006 capital Federal rate by 0.09 percent compared with the FY 
2005 outlier adjustment.

3. Proposed Budget Neutrality Adjustment Factor for Changes in DRG 
Classifications and Weights and the GAF

    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 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 GAF for Puerto Rico, we apply 
separate budget neutrality adjustments for the national GAF and the 
Puerto Rico GAF. 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 
because the GAF for Puerto Rico was implemented in FY 1998.
    In the past, we used the actuarial capital cost model (described 
in Appendix B of the FY 2002 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 2002, an adjustment for regular exception 
payments is no longer necessary. Therefore, we are no longer using 
the capital cost model. Instead, we are using historical data based 
on hospitals' actual cost experiences to determine the exceptions 
payment adjustment factor for special exceptions payments.
    To determine the proposed factors for FY 2006, we compared 
(separately for the national capital rate and the Puerto Rico 
capital rate) estimated aggregate capital Federal rate payments 
based on the FY 2005 DRG relative weights and the average FY 2005 
GAF (that is, the weighted average of the GAFs applied from October 
2004 through December 2004 and the GAFs applied from January 2005 
through September 2005) to estimated aggregate capital Federal rate 
payments based on the proposed FY 2006 relative weights and the 
proposed FY 2006 GAF. As we established in the FY 2005 IPPS final 
rule (69 FR 49287), the budget neutrality factors were 0.9914 for 
the national capital rate and 0.9895 for the Puerto Rico capital 
rate for discharges occurring on or after October 1, 2004 through 
December 31, 2004 (the first quarter of FY 2005). As a result of the 
corrections to the FY 2005 GAF values established in the December 
30, 2004 correction notice (69 FR 78531), effective for January 1, 
2005 through September 30, 2005 (the last three quarters of FY 
2005), the budget neutrality factor for the national capital rate is 
0.9912 and the budget neutrality factor for the Puerto Rico capital 
rate remained unchanged (0.9895). For FY 2005, the weighted average 
budget neutrality adjustment factors were 0.9912 (0.9914 x \1/4\ + 
0.9912 x \3/4\) for the national capital rate (calculations were 
done on unrounded numbers) and 0.9895 for the Puerto Rico capital 
rate. In making the comparison, we set the regular and special 
exceptions reduction factors to 1.00. To achieve budget neutrality 
for the changes in the national GAF, based on calculations using 
updated data, we are proposing to apply an incremental budget 
neutrality adjustment of 1.0022 for FY 2006 to the weighted average 
of the previous cumulative FY 2005 adjustments of 0.9912 (yielding a 
proposed adjustment of 0.9934) through FY 2006 (calculations done on 
unrounded numbers). For the Puerto Rico GAF, we are proposing to 
apply an incremental budget neutrality adjustment of 1.0240 for FY 
2006 to the previous cumulative FY 2005 adjustment of 0.9895, 
yielding a proposed cumulative adjustment of 1.0132 through FY 2006.
    We then compared estimated aggregate capital Federal rate 
payments based on the FY 2005 DRG relative weights and the average 
FY 2005 GAF to estimated aggregate capital Federal rate payments 
based on the proposed FY 2006 DRG relative weights and the proposed 
FY 2006 GAF. The proposed incremental adjustment for DRG 
classifications and changes in relative weights is 0.9998 both 
nationally and for Puerto Rico. The proposed cumulative adjustments 
for DRG classifications and changes in relative weights and for 
changes in the GAF through FY 2005 are 0.9931 nationally and 1.013 
for Puerto Rico. The following table summarizes the adjustment 
factors for each fiscal year:

[[Page 23478]]

[GRAPHIC] [TIFF OMITTED] TP04MY05.068

    The methodology used to determine the proposed recalibration and 
geographic (DRG/GAF) budget neutrality adjustment factor for FY 2006 
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 FY 2005 IPPS final rule (69 FR 49288), we calculated a 
GAF/DRG budget neutrality factor of 1.0006 for FY 2005. As we noted 
above, as a result of the revisions to the GAF effective for 
discharges occurring on or after January 1, 2005 established in the 
December 30, 2004 correction notice (69 FR 78351), we calculated a 
GAF/DRG budget neutrality factor of 1.0004 for discharges occurring 
in the remainder of FY 2005. For FY 2006, we are proposing a GAF/DRG 
budget neutrality factor of 1.0019. The GAF/

[[Page 23479]]

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 proposed incremental 
change in the adjustment from the average from FY 2005 to FY 2006 is 
1.0019. The proposed cumulative change in the capital Federal rate 
due to this adjustment is 0.9931 (the product of the incremental 
factors for FYs 1993 through 2005 and the proposed incremental 
factor of 1.0019 for FY 2006). (We note that averages of the 
incremental factors that were in effect during FYs 2004 and 2005, 
respectively, were used in the calculation of the proposed 
cumulative adjustment of 0.9931 for FY 2006.)
    This proposed factor accounts for DRG reclassifications and 
recalibration and for changes in the GAF. It also incorporates the 
effects on the GAF of FY 2006 geographic reclassification decisions 
made by the MGCRB compared to FY 2005 decisions. However, it does 
not account for changes in payments due to changes in the DSH and 
IME adjustment factors or in the large urban add-on.

4. Proposed 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 FY 
2002 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 proposed FY 2006 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 FY 2002 IPPS final rule (66 FR 39949), in FY 2002 
and subsequent fiscal years, no payments will be made under the 
regular exceptions provision. However, in accordance with Sec.  
412.308(c), we still need to compute a budget neutrality adjustment 
for special exception payments under Sec.  412.348(g). We describe 
our methodology for determining the special exceptions adjustment 
used in calculating the proposed FY 2006 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).
    Based on information compiled from our fiscal intermediaries, 
six hospitals have qualified for special exceptions payments under 
Sec.  412.348(g). Since we have cost reports ending in FY 2004 for 
all of these hospitals, we calculated the proposed adjustment based 
on actual cost experience. Using data from cost reports ending in FY 
2004 from the December 2004 update of the HCRIS data, we divided the 
capital special exceptions payment amounts for the six hospitals 
that qualified for special exceptions by the total capital PPS 
payment amounts (including special exception payments) for all 
hospitals. Based on the data from cost reports ending in FY 2004, 
this ratio is rounded to 0.0003. Because we have not received all 
cost reports ending in FY 2004, we also divided the FY 2004 special 
exceptions payments by the total capital PPS payment amounts for all 
hospitals with cost reports ending in FY 2003. This ratio also 
rounds to 0.0003. Because special exceptions are budget neutral, we 
are proposing to offset the capital Federal rate by 0.03 percent for 
special exceptions payments for FY 2006. Therefore, the proposed 
exceptions adjustment factor is equal to 0.9997 (1-0.0003) to 
account for special exceptions payments in FY 2006.
    In the FY 2005 IPPS final rule (69 FR 49288), we estimated that 
total (special) exceptions payments for FY 2005 would equal 0.04 
percent of aggregate payments based on the capital Federal rate. 
Therefore, we applied an exceptions adjustment factor of 0.9996 (1-
0.0004) in determining the FY 2005 capital Federal rate. As we 
stated above, we estimate that exceptions payments in FY 2006 would 
equal 0.03 percent of aggregate payments based on the proposed FY 
2006 capital Federal rate. Therefore, we are proposing to apply an 
exceptions payment adjustment factor of 0.9997 to the capital 
Federal rate for FY 2006. The proposed exceptions adjustment factor 
for FY 2006 is 0.01 percent higher than the factor for FY 2005 
published in the FY 2005 IPPS final rule (69 FR 49288). 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 proposed net 
change in the exceptions adjustment factor used in determining the 
proposed FY 2006 capital Federal rate is 1.0001 (0.9997/0.9996).

5. Proposed Capital Standard Federal Rate for FY 2006

    In the FY 2005 IPPS final rule (69 FR 49283) and corrected in a 
December 30, 2004 correction notice (69 FR 78532), we established a 
capital Federal rate of $416.53 for FY 2005. In this proposed rule, 
we are proposing to establish a capital Federal rate of $419.90 for 
FY 2006. The proposed capital Federal rate for FY 2006 was 
calculated as follows:
     The proposed FY 2006 update factor is 1.0070; that is, 
the update is 0.7 percent.
     The proposed FY 2006 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 1.0019.
     The proposed FY 2006 outlier adjustment factor is 
0.9497.
     The proposed FY 2006 (special) exceptions payment 
adjustment factor is 0.9997.
    Because the proposed 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 proposing to 
make 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 proposed 
factors and adjustments for FY 2006 affected the computation of the 
proposed FY 2006 capital Federal rate in comparison to the average 
FY 2005 capital Federal rate. The proposed FY 2006 update factor has 
the effect of increasing the capital Federal rate by 0.70 percent 
compared to the average FY 2005 Federal rate. The proposed GAF/DRG 
budget neutrality factor has the effect of increasing the capital 
Federal rate by 0.19 percent. The proposed FY 2006 outlier 
adjustment factor has the effect of decreasing the capital Federal 
rate by 0.09 percent compared to the average FY 2005 capital Federal 
rate, and the proposed FY 2006 exceptions payment adjustment factor 
has the effect of increasing the capital Federal rate by 0.01 
percent compared to the exceptions payment adjustment factor for the 
FY 2005 capital Federal rate. The combined effect of all the 
proposed changes is to increase the capital Federal rate by 0.81 
percent compared to the average FY 2005 capital Federal rate.

[[Page 23480]]

[GRAPHIC] [TIFF OMITTED] TP04MY05.069

6. Proposed Special Capital Rate for Puerto Rico Hospitals

    Section 412.374 provides for the use of a blended payment system 
for payments to Puerto Rico hospitals under the PPS for acute care 
hospital inpatient capital-related costs. Accordingly, under the 
capital PPS, we compute a separate payment rate specific to Puerto 
Rico hospitals using the same methodology used to compute the 
national Federal rate for capital-related costs. Under the broad 
authority of section 1886(g) of the Act, as discussed in section VI. 
of the preamble of this proposed rule, beginning with discharges 
occurring on or after October 1, 2004, capital payments to hospitals 
in Puerto Rico are based on a blend of 25 percent of the Puerto Rico 
capital rate and 75 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 IPPS (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 IPPS wage 
index and varies, depending on the labor market area 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 above in section 
III.A.4. of this Addendum, for Puerto Rico, the proposed GAF budget 
neutrality factor is 1.0240, while the proposed DRG adjustment is 
0.9998, for a combined cumulative adjustment of 1.0130.
    In computing the payment for a particular Puerto Rico hospital, 
the Puerto Rico portion of the capital rate (25 percent) is 
multiplied by the Puerto Rico-specific GAF for the labor market area 
in which the hospital is located, and the national portion of the 
capital rate (75 percent) is multiplied by the national GAF for the 
labor market area in which the hospital is located (which is 
computed from national data for all hospitals in the United States 
and Puerto Rico). In FY 1998, we implemented a 17.78 percent 
reduction to the Puerto Rico capital rate as a result of Pub. L. 
105-33. In FY 2003, a small part of that reduction was restored.
    For FY 2005, before application of the GAF, the special capital 
rate for Puerto Rico hospitals was $199.01 for discharges occurring 
on or after October 1, 2004 through September 30, 2005. With the 
changes we are proposing to the factors used to determine the 
capital rate, the proposed FY 2006 special capital rate for Puerto 
Rico is $205.64.

B. Calculation of Proposed Inpatient Capital-Related Prospective 
Payments for FY 2006

    Because the 10-year capital PPS transition period ended 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 2006. The applicable proposed capital 
Federal rate was determined by making adjustments as follows:
     For outliers, by dividing the proposed capital standard 
Federal rate by the proposed outlier reduction factor for that 
fiscal year; and
     For the payment adjustments applicable to the hospital, 
by multiplying the hospital's proposed GAF, disproportionate share 
adjustment factor, and IME adjustment factor, when appropriate.
    For purposes of calculating payments for each discharge during 
FY 2006, 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 proposed outlier thresholds for FY 
2006 are in section II.A.4.c. of this Addendum. For FY 2006, 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 $26,675.
    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 
SCHs, 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

[[Page 23481]]

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 hospitals under the appropriate transition 
methodology. If the hold-harmless methodology were 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. 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 its 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 FY 2003 IPPS final rule (67 FR 50044). (We note that we 
are proposing a rebasing to FY 2002 in section IV. of the preamble 
of this proposed rule.)

2. Forecast of the CIPI for FY 2006

    Based on the latest forecast by Global Insight, Inc. (first 
quarter of 2005), we are forecasting the CIPI to increase 0.7 
percent in FY 2006. This reflects a projected 1.3 percent increase 
in vintage-weighted depreciation prices (building and fixed 
equipment, and movable equipment) and a 2.7 percent increase in 
other capital expense prices in FY 2006, partially offset by a 2.3 
percent decline in vintage-weighted interest expenses in FY 2006. 
The weighted average of these three factors produces the 0.7 percent 
increase for the CIPI as a whole in FY 2006.

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

    (If you choose to comment on issues in this section, please 
include the caption ``Excluded Hospitals Rate-of-Increase'' at the 
beginning of your comment.)

A. Payments to Existing Excluded Hospitals and Units

    As discussed in section VII. of the preamble of this proposed 
rule, in accordance with section 1886(b)(3)(H)(i) of the Act and 
effective for cost reporting periods beginning on or after October 
1, 2002, payments to existing psychiatric hospitals and units, 
rehabilitation hospitals and units, and long-term care hospitals 
(LTCHs) excluded from the IPPS are no longer subject to a cap on a 
hospital-specific target amount (expressed in terms of the inpatient 
operating cost per discharge under TEFRA) that is set for each 
hospital, based on the hospital's own historical cost experience 
trended forward by the applicable percentage increase. However, the 
inpatient operating costs of children's hospitals and cancer 
hospitals that are excluded from the IPPS continue to be subject to 
the rate-of-increase limits established under the authority of 
section 1886(b) of the Act and Sec.  413.40 of the regulations. This 
target amount is applied as a ceiling on the allowable costs per 
discharge for the hospital's cost reporting period.
    Effective for cost reporting periods beginning on or after 
October 1, 2002, rehabilitation hospitals and units are paid 100 
percent of the adjusted Federal prospective payment rate under the 
IRP PPS. Effective for cost reporting periods beginning on or after 
October 1, 2002, LTCHs also are no longer paid on a reasonable cost 
basis, but are paid under a LTCH DRG-based PPS. In implementing the 
LTCH PPS for existing LTCHs, we established a 5-year transition 
period from reasonable cost-based payments (subject to the TEFRA 
limit) to fully Federal prospective payment amounts during which a 
LTCH may receive a blended payment consisting of two payment 
components--one based on reasonable cost under the TEFRA payment 
system, and the other based on the standard Federal prospective 
payment rate. However, an existing LTCH may elect to be paid based 
on 100 percent of the standard Federal prospective payment rate 
during the transition period.
    IPFs that have their first cost reporting period beginning on or 
after January 1, 2005, are not paid on a reasonable cost basis but 
paid under a prospective per diem payment system. As part of the PPS 
for existing IPFs, we have established a 3-year transition period 
during which IPFs will be paid based on a blend of reasonable cost-
based payment (subject to the TEFRA limit) and the prospective per 
diem payment rate. For cost reporting periods beginning on or after 
January l, 2008, IPFs will be paid 100 percent of the Federal 
prospective per diem payment amount.
    Excluded psychiatric hospitals and units as well as LTCHs that 
are paid under a blended methodology will have the reasonable cost-
based portion of their payment subject to a hospital target amount 
and, if applicable, the payment amount limitation.

B. Updated Caps for New Excluded Hospitals and Units

    Section 1886(b)(7) of the Act established the method for 
determining the payment amount for new rehabilitation hospitals and 
units, psychiatric hospitals and units, and LTCHs that first 
received payment as a hospital or unit excluded from the IPPS on or 
after October 1, 1997. However, due to the implementation of the IRF 
PPS, effective for cost reporting periods beginning on or after 
October 1, 2002, this payment amount (or ``new provider cap'') no 
longer applies to any new rehabilitation hospital or unit because 
they now are paid 100 percent of the Federal prospective rate under 
the IRF PPS. In addition, LTCHs that meet the definition of a new 
LTCH under Sec.  412.23(e)(4) are paid 100 percent of the fully 
Federal prospective payment rate. In contrast, those ``new'' LTCHs 
that meet the criteria under Sec.  413.40(f)(2)(ii) (that is, that 
were not paid as an excluded hospital prior to October 1, 1997, but 
were paid as a LTCH before October 1, 2002), may be paid under the 
LTCH PPS transition methodology, with the reasonable cost portion of 
the payment subject to Sec.  413.40(f)(2)(ii). Finally, LTCHs that 
existed prior to October 1, 1997, may also be paid under the LTCH 
PPS transition methodology, with the reasonable cost portion subject 
to Sec.  413.40(c)(4)(ii). (The last LTCHs that were subject to the 
payment amount limitation for ``new'' LTCHs were new LTCHs that had 
their first cost reporting period beginning on September 30, 2002. 
In that case, the payment amount limitation remained applicable for 
the next 2 years--September 30, 2002 through September 29, 2003, and 
September 30, 2003 through September 29, 2004. This is because, 
under existing regulations at Sec.  413.40(f)(2)(ii), the ``new 
hospital'' would be subject to the same payment (target amount) in 
its second cost reporting period that was applicable to the LTCH in 
its first cost reporting period. Accordingly, for this hospital, the 
updated payment amount limitation that we published in the FY 2003 
IPPS final rule (67 FR 50103) applied through September 29, 2004. 
Consequently, there is no longer a need to publish updated payment 
amounts for new (Sec.  413.40(f)(2)(ii)) LTCHs. A discussion of how 
the payment limitations were 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).
    With the implementation of the LTCH PPS, payment limitations do 
not apply to any new LTCHs that meet the definition at Sec.  
412.23(e)(4) because they are paid 100 percent of the Federal 
prospective payment rate.
    A freestanding inpatient rehabilitation hospital, an inpatient 
rehabilitation unit of an acute care hospital, and an inpatient 
rehabilitation unit of a CAH are referred to as IRFs. Effective for 
cost reporting periods beginning on or after October 1, 2002, this

[[Page 23482]]

payment limitation is also 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.
    Under the IPF PPS, there is a 3-year transition period during 
which existing IPFs will receive a blended payment of the Federal 
per diem payment amount and the payment amount that IPFs would 
receive under the reasonable cost-based payment (TEFRA) methodology. 
IPFs that were ``new'' under Sec.  413.40(f)(2)(ii) (that is, that 
were not paid as an excluded hospital prior to October 1, 1997, but 
were paid as an IPF prior to January 1, 2005), would have the 
reasonable cost portion of the transition period payment subject to 
the payment amount limitation as determined according to Sec.  
413.40(f)(2)(ii). The last ``new'' IPFs that were subject to the 
payment amount limitation were IPFs that had their first cost 
reporting period beginning on December 31, 2004. For these 
hospitals, the payment amount limitation that was published in the 
FY 2005 IPPS final rule (69 FR 49189) for cost reporting periods 
beginning on or after October 1, 2004, and before January 1, 2005, 
remains applicable for the IPF's first two cost reporting periods. 
IPFs with a first cost reporting period beginning on or after 
January 1, 2005, are paid 100 percent of the Federal rate and are 
not subject to the payment amount limitation. Therefore, since the 
last IPFs eligible for a blended payment have a cost reporting 
period beginning on December 31, 2004, the payment limitation 
published for FY 2005 remains applicable for these IPFs, and 
publication of the updated payment amount limitation is no longer 
needed. We note that IPFs that existed prior to October 1, 1997, may 
also be paid under the IPF transition methodology with the 
reasonable cost portion of the payment subject to Sec.  
413.40(c)(4)(ii).
    The payment limitations for new hospitals under TEFRA do not 
apply to new LTCHs, IRFs, or IPFs, that is, these hospitals with 
their first cost reporting period beginning on or after the date 
that the particular class of hospitals implemented the respective 
PPS. Therefore, for the reasons noted above, we are proposing to 
discontinue publishing Tables 4G and 4H (Pre-Reclassified Wage Index 
for Urban and Rural Areas, respectively) in the annual proposed and 
final IPPS rules.

V. Payment for Blood Clotting Factor Administered to Hemophilia 
Inpatients

    (If you choose to comment on issues in this section, please 
include the caption ``Payment for Blood Clotting Factor'' at the 
beginning of your comments.)
    As discussed in section VIII. of the preamble to this proposed 
rule, section 1886(a)(4) of the Act excludes the costs of 
administering blood clotting factors to individuals with hemophilia 
from the definition of ``operating costs of inpatient hospital 
services.'' Section 6011(b) of Pub. L. 101-239 (the Omnibus Budget 
Reconciliation Act of 1989) provides that the Secretary shall 
determine the payment amount made to hospitals under Part A of Title 
XVIII of the Act for the costs of administering blood clotting 
factors to individuals with hemophilia by multiplying a 
predetermined price per unit of blood clotting factor by the number 
of units provided to the individual. Currently, we use the average 
wholesale price (AWP) methodology used to determine rates paid for 
Medicare Part B drugs to price blood clotting factors administered 
to inpatients who have hemophilia under Medicare Part A. Section 303 
of Pub. L. 108-173 amended the Act by adding section 1847A, which 
changed the drug pricing system under Medicare Part B. Effective 
January 1, 2005, section 1847A of the Act established a payment 
methodology based on average sales price (ASP) under which almost 
all Medicare Part B drugs and biologicals not paid on a cost or 
prospective basis are paid at 106 percent of the ASP.
    In the FY 2005 IPPS final rule (69 FR 49292), we had instructed 
the fiscal intermediaries for FY 2005 to continue to use the Single 
Drug Pricer (SDP) to establish the pricing limits for the blood 
clotting factor administered to hemophilia inpatients at 95 percent 
of the AWP. We did not use the new ASP pricing methodology for Part 
A blood clotting factor in FY 2005 because the IPPS final rule was 
published in advance of final regulations implementing the ASP 
payment methodology for Part B drugs and biologicals. Final 
regulations establishing the ASP methodology and the furnishing fee 
for blood clotting factor under Medicare Part B were published on 
November 15, 2004 (69 FR 66299). Therefore, we believe that a 
consistent methodology should be used to pay for blood clotting 
factor administered under both Medicare Part A and Part B. For this 
reason, we are proposing for FY 2006 that the fiscal intermediaries 
make payment for blood clotting factor using 106 percent of ASP and 
make payment for the furnishing fee at $0.14 per individual unit 
(I.U.) that is currently used for Medicare Part B drugs. The ASP 
will be updated quarterly. The furnishing fee will be updated 
annually based on the consumer price index.

VI. Tables

    This section contains the tables referred to throughout the 
preamble to this proposed rule and in this Addendum. Tables 1A, 1B, 
1C, 1D, 2, 3A, 3B, 4A, 4B, 4C, 4F, 4J, 5, 6A, 6B, 6C, 6D, 6E, 6F, 
6G, 6H, 7A, 7B, 8A, 8B, 9A, 9B, 9C, 10, and 11 are presented below. 
The tables presented below are as follows:

Table 1A--National Adjusted Operating Standardized Amounts, Labor/
Nonlabor (69.7 Percent Labor Share/30.3 Percent Nonlabor Share If 
Wage Index Is Greater Than 1);
Table 1B--National Adjusted Operating Standardized Amounts, Labor/
Nonlabor (62 Percent Labor Share/38 Percent Nonlabor Share If Wage 
Index Is Less Than or Equal To 1);
Table 1C--Adjusted Operating Standardized Amounts for Puerto Rico, 
Labor/Nonlabor;
Table 1D--Capital Standard Federal Payment Rate;
Table 2--Hospital Case-Mix Indexes for Discharges Occurring in 
Federal Fiscal Year 2004; Hospital Average Hourly Wage for Federal 
Fiscal Years 2004 (2000 Wage Data), 2005 (2001 Wage Data), and 2006 
(2002 Wage Data) Wage Indexes and 3-Year Average of Hospital Average 
Hourly Wages;
Table 3A--FY 2006 3-Year Average Hourly Wage for Urban Areas by 
CBSA;
Table 3B--FY 2006 and 3-Year Average Hourly Wage for Rural Areas by 
CBSA;
Table 4A--Wage Index and Capital Geographic Adjustment Factor (GAF) 
for Urban Areas by CBSA;
Table 4B--Wage Index and Capital Geographic Adjustment Factor (GAF) 
for Rural Areas by CBSA;
Table 4C--Wage Index and Capital Geographic Adjustment Factor (GAF) 
for Hospitals That Are Reclassified by CBSA;
Table 4F--Puerto Rico Wage Index and Capital Geographic Adjustment 
Factor (GAF) by CBSA;
Table 4J--Out-Migration Adjustment--FY 2006;
Table 5--List of Diagnosis Related Groups (DRGs), Relative Weighting 
Factors, Geometric and Arithmetic Mean Length of Stay;
Table 6A--New Diagnosis Codes;
Table 6B--New Procedure Codes;
Table 6C--Invalid Diagnosis Codes;
Table 6D--Invalid Procedure Codes;
Table 6E--Revised Diagnosis Code Titles;
Table 6F--Revised Procedure Code Titles;
Table 6G--Additions to the CC Exclusions List;
Table 6H--Deletions from the CC Exclusions List;
Table 7A--Medicare Prospective Payment System Selected Percentile 
Lengths of Stay FY 2004 MedPAR Update December 2004 GROUPER V22.0;
Table 7B--Medicare Prospective Payment System Selected Percentile 
Lengths of Stay FY 2004 MedPAR Update December 2004 GROUPER V23.0;
Table 8A--Statewide Average Operating Cost-to-Charge Ratios--March 
2005;
Table 8B--Statewide Average Capital Cost-to-Charge Ratios--March 
2005;
Table 9A--Hospital Reclassifications and Redesignations by 
Individual Hospital and CBSA--FY 2006;
Table 9B--Hospital Reclassifications and Redesignations by 
Individual Hospital Under Section 508 of Pub. L. 108-173--FY 2006;
Table 9C--Hospitals Redesignated as Rural under Section 
1886(s)(8)(E) of the Act--FY 2006;
Table 10--Geometric Mean Plus the Lesser of .75 of the National 
Adjusted Operating Standardized Payment Amount (Increased to Reflect 
the Difference Between Costs and Charges) or .75 of One Standard 
Deviation of Mean Charges by Diagnosis-Related Groups (DRGs)--March 
2005;
Table 11--Proposed FY 2006 LTC-DRGs, Relative Weights, Geometric 
Average Length of Stay, and 5/6ths of the Geometric Average Length 
of Stay.

[[Page 23483]]



   Table 1A.--National Adjusted Operating Standardized Amounts, Labor/
                                NonLabor
   [69.7 Percent labor share/30.3 percent nonlabor share if wage index
                             greater than 1]
------------------------------------------------------------------------
      Full update (3.2 Percent)          Reduced update (2.8 Percent)
------------------------------------------------------------------------
  Labor-related     Nonlabor-related    Labor-related   Nonlabor-related
------------------------------------------------------------------------
       $3,286.14          $1,428.55         $3,273.40         $1,423.01
------------------------------------------------------------------------


   Table 1B.--National Adjusted Operating Standardized Amounts, Labor/
                                Nonlabor
  [62 Percent labor share/38 percent nonlabor share if wage index less
                           than or equal to 1]
------------------------------------------------------------------------
      Full update (3.2 Percent)          Reduced update (2.8 Percent)
------------------------------------------------------------------------
  Labor-related     Nonlabor-related    Labor-related   Nonlabor-related
------------------------------------------------------------------------
       $2,923.11          $1,791.58         $2,911.78         $1,784.63
------------------------------------------------------------------------


               Table 1C.--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor
----------------------------------------------------------------------------------------------------------------
                                                                                        Rates if wage index less
---------------------------------------------------------------------------------------    than or equal to 1
                                                                                       -------------------------
             Rates if wage index greater than 1                  Labor       Nonlabor      Labor       Nonlabor
----------------------------------------------------------------------------------------------------------------
National....................................................    $3,286.14    $1,428.55    $2,923.11    $1,791.58
uerto Rico..................................................    $1,608.99      $647.66    $1,431.24      $812.25
----------------------------------------------------------------------------------------------------------------


            Table 1D.--Capital Standard Federal Payment Rate
------------------------------------------------------------------------
                                                                 Rate
------------------------------------------------------------------------
National...................................................      $419.90
Puerto Rico................................................      $205.64
------------------------------------------------------------------------


   Table 2.--Hospital Case-Mix Indexes for Discharges Occurring in Federal Fiscal Year 2004; Hospital Average
  Hourly Wage for Federal Fiscal Years 2004 (2000 Wage Data), 2005 (2001 Wage Data), and 2006 (2002 Wage Data)
                        Wage Indexes and 3-Year Average of Hospital Average Hourly Wages
----------------------------------------------------------------------------------------------------------------
                                                                                                       Average
                                      Case-mix    Wage index    Average      Average      Average    hourly wage
          Provider number              index       FY 2006    hourly wage  hourly wage  hourly wage     **  (3
                                                                FY 2004      FY 2005      FY 2006       years)
----------------------------------------------------------------------------------------------------------------
010001............................       1.4678       0.7743      19.4061      20.6563      21.3753      20.5001
010004............................          ***            *      22.2674      22.7585            *      22.4801
010005 h..........................       1.1407       0.8872      19.6063      20.4937      22.4906      20.9007
010006............................       1.4394       0.8305      19.0976      21.0241      23.4823      21.1655
010007............................       1.0619       0.7495      17.5462      16.8811      18.2430      17.5458
010008............................       0.9712       0.8276      19.6573      23.8333      20.4591      21.3782
010009............................       0.9770       0.8517      20.4309      21.6422      23.2229      21.7690
010010 h..........................       1.0191       0.9124      19.2644      22.3021      22.3366      21.3489
010011............................       1.5689       0.8979      25.8231      24.8166      27.4850      26.0626
010012............................       1.2232       0.9099      20.0896      21.7622      22.7020      21.5233
010015............................       0.9785       0.7495      18.8890      20.4732      22.1736      20.6719
010016............................       1.3257       0.8979      21.7918      23.0414      25.1502      23.3217
010018............................       1.3369       0.8979      19.2071      20.5888      22.2990      20.6865
010019............................       1.2272       0.8305      18.9177      20.1336      22.0906      20.4039
010021 h..........................       1.1869       0.7743      17.7596      20.7108      18.6785      19.0123
010022............................       0.9401       0.9414      22.2267      25.8797      24.5670      24.2502
010023............................       1.8430       0.8600      20.4901      23.7791      27.3303      23.6794
010024............................       1.5884       0.8600      18.5942      20.0067      20.7265      19.7702
010025............................       1.3235       0.8402      19.3649      19.8561      21.2674      20.1430
010027............................       0.7634       0.7495      14.0975      14.9585      15.3704      14.7992
010029............................       1.5415       0.8402      20.9868      21.6724      22.6976      21.8061
010031............................          ***            *      21.0176      20.9463            *      20.9818
010032............................       0.8730       0.7495      16.4713      18.5073      19.1555      18.1219
010033............................       2.0553       0.8979      24.5088      25.5165      26.4666      25.5126
010034............................       0.9588       0.8600      14.9333      17.1625      16.9686      16.3417
010035............................       1.2540       0.8872      21.6182      23.1319      22.2870      22.3532
010036............................       1.1183       0.7495      19.2501      20.5125      22.9747      20.9446
010038............................       1.3277       0.7702      18.6578      20.3935      21.4509      20.2189

[[Page 23484]]

 
010039............................       1.6315       0.9124      23.0339      23.4151      25.8594      24.1509
010040............................       1.4605       0.7974      20.7779      21.6708      22.8851      21.7864
010043............................       1.0587       0.8979      19.9012      19.5422      22.5945      20.7320
010044............................       1.0475       0.8872      25.8560      23.0220      21.4036      23.2608
010045............................       1.0959       0.8872      22.7713      20.5658      20.0357      20.9382
010046............................       1.4626       0.7974      19.6754      20.8935      21.6965      20.8067
010047............................       0.8793       0.7495      16.1695      19.5937      21.0604      18.8438
010049............................       1.0828       0.7495      16.2973      17.7801      20.2413      18.1494
010050............................       1.0401       0.8979      20.7398      21.5625      22.1584      21.5077
010051............................       0.8969       0.8724      14.3006      14.7053      15.2208      14.7351
010052............................       0.8624       0.7495      11.9019      21.3673      16.4959      15.4174
010053............................       1.0098       0.7495      17.3238      17.4160      19.0108      17.9166
010054............................       1.0570       0.8517      20.6382      23.1894      22.5554      22.1149
010055............................       1.4983       0.7743      18.9664      19.1847      22.6828      20.2397
010056............................       1.5206       0.8979      21.1104      22.7183      23.7144      22.5773
010058............................       0.8800       0.8979      17.7800      20.3182      18.5537      18.9295
010059............................       1.0562       0.8517      20.5534      23.6963      21.3237      21.8874
010061............................       0.9666       0.7495      17.0447      20.5683      21.9374      19.8090
010062............................       1.0674       0.7743      17.1786      18.1323      18.3435      17.8796
010064............................       1.7183       0.8979      22.2280      25.4345      26.1110      24.2542
010065............................       1.4288       0.8276      17.2698      20.0108      21.2363      19.5522
010066............................       0.8327       0.7495      14.8696      17.0935      17.6152      16.5083
010068............................       1.2192       0.8979      18.3308      17.5690      19.0789      18.3440
010069............................       1.0478       0.7495      17.0957      19.6317      21.3608      19.4027
010072............................       1.1391       0.7702      18.8807      21.5419      21.8169      20.7331
010073............................       0.9330       0.7495      14.9826      16.4043      16.4168      15.9303
010078............................       1.3809       0.7702      20.1447      21.0633      21.5616      20.9141
010079............................       1.1647       0.9124      20.7401      20.4254      21.8199      21.0143
010083 h..........................       1.2094       0.8089      19.8524      20.2166      22.3041      20.7945
010084............................       1.5531       0.8979      21.6522      22.5219      24.7127      22.9810
010085............................       1.2261       0.8517      22.5282      23.7007      24.4710      23.5499
010086............................       1.0771       0.7495      18.0122      19.4332      18.6081      18.6721
010087............................       1.9176       0.7902      19.7620      21.6226      22.5225      21.2536
010089............................       1.2348       0.8979      19.5783      22.2508      22.7508      21.4924
010090............................       1.6643       0.7902      20.0287      21.4322      23.6948      21.7237
010091............................       0.9178       0.7495      17.4672      19.4222      18.6912      18.5367
010092............................       1.5079       0.8724      19.9351      22.0709      24.6542      22.1991
010095............................       0.8622       0.8724      12.5243      13.4426      13.9326      13.3037
010097............................       0.7734       0.8600      15.1593      17.1735      16.7548      16.2912
010098............................       1.1131       0.7495      15.1629      19.6717      14.3076      16.0844
010099............................       0.9798       0.7495      16.3307      18.1849      18.7909      17.7973
010100 h..........................       1.6637       0.8089      19.8146      20.0027      21.2915      20.4113
010101............................       1.1105       0.7702      19.0718      21.0085      21.6593      20.5878
010102............................       0.8953       0.7495      16.4637      19.9196      21.0903      19.1526
010103............................       1.8475       0.8979      22.5709      24.2201      26.1163      24.2529
010104............................       1.7281       0.8979      20.9391      24.1929      24.9226      23.2581
010108............................       1.0770       0.8600      20.7787      23.7803      28.4624      24.2639
010109............................       0.9471       0.7495      18.2235      21.7128      21.7997      20.5179
010110............................       0.7216       0.7495      16.0015      19.2706      18.6633      18.1283
010112............................       0.9699       0.7495      17.9243      17.2963      16.8902      17.3960
010113............................       1.6431       0.7902      19.4106      20.4181      21.4209      20.4385
010114............................       1.3235       0.8979      20.1763      21.5319      22.3431      21.3345
010115............................       0.8225       0.7495      15.7872      17.5985      29.1465      19.5466
010118............................       1.2436       0.8276      19.5302      18.8560      19.7673      19.4467
010119............................          ***            *      20.5245      21.8215            *      21.1743
010120............................       0.9483       0.7902      19.4368      20.5855      20.9450      20.3424
010121............................          ***            *      17.1640      17.0329      24.0867      18.5589
010125............................       1.0257       0.7495      16.8622      16.8419      18.4114      17.3762
010126............................       1.1015       0.8276      19.9647      23.1856      23.1381      22.1149
010128............................       0.8325       0.7495      14.7646      17.9354      21.4201      18.0579
010129 h..........................       0.9813       0.7902      16.4905      18.7821      21.3555      19.1436
010130............................       0.9433       0.8979      18.7190      18.4944      23.2488      20.0658
010131............................       1.3281       0.9124      22.9969      24.2197      25.7837      24.4029
010134............................          ***       0.7495      17.7717            *            *      17.7717
010138............................       0.6035       0.7495      14.2025      13.5082      13.8475      13.8713
010139............................       1.5206       0.8979      22.8390      24.9410      25.3014      24.4108
010143............................       1.1648       0.8872      20.5639      22.1312      22.0215      21.5734

[[Page 23485]]

 
010144............................       1.5626       0.7902      19.1497      20.6425      20.7433      20.2040
010145............................       1.2572       0.8724      22.1394      23.1976      25.1442      23.5267
010146............................       1.0392       0.7702      21.3083      19.9944      20.8917      20.7213
010148............................       0.8756       0.7495      17.6829      18.5309      20.5294      19.0227
010149............................       1.3179       0.8600      21.0086      23.1593      26.5854      23.4663
010150............................       1.0456       0.7495      21.2360      20.6738      21.6377      21.1783
010152............................       1.1957       0.7902      21.6038      22.1626      22.6202      22.1446
010157............................       1.1130       0.8305      19.6977      21.3574      24.3560      21.7462
010158............................       1.0822       0.8517      18.5464      22.4440      24.3531      21.6528
010161............................          ***            *            *      27.5119            *      27.5119
020001............................       1.6973       1.2110      30.1452      31.6091      33.6407      31.9031
020004............................       1.1807       1.1977      27.3516      29.9926      32.0966      29.8229
020005............................       0.9509       1.1977      32.7936            *            *      32.7936
020008............................       1.2368       1.1977      33.4543      34.5856      35.9236      34.6652
020010............................          ***       1.1977      20.7929            *            *      20.7929
020013............................          ***       1.1977      30.6423            *            *      30.6423
020017............................       1.9426       1.2110      30.3017      32.9281      33.5852      32.3606
020024............................       1.1382       1.1977      28.0930      27.9799      33.0644      29.9221
030001............................       1.3278       1.0139      25.7513      27.7572      29.9840      27.8499
030002............................       2.0596       1.0139      25.6038      27.9628      29.0519      27.5075
030003............................          ***            *      22.1436            *            *      22.1436
030007............................       1.3390       0.8991      26.1551      26.9442      29.6174      27.6578
030009............................       0.8821       0.9007      19.9131      21.4065      22.3992      21.1294
030010............................       1.3277       0.9007      20.7204      22.8647      24.8275      22.8055
030011............................       1.4456       0.9007      21.0028      22.8422      25.1361      23.0075
030012............................       1.2863       0.9884      24.2366      25.5205      26.3859      25.4550
030013............................       1.3235       0.9102      21.9766      23.5229      25.7050      23.8047
030014............................       1.4420       1.0139      23.3663      25.1189      25.6259      24.7232
030016............................       1.2336       1.0139      24.3380      27.1583      26.7003      26.0910
030017............................       1.9999       1.0139      21.8792      24.4055      26.2452      24.0378
030018............................       1.2176       1.0139      24.9216      24.4308      28.9476      25.9371
030019............................       1.3058       1.0139      23.2973      28.4917      27.3156      26.2053
030022............................       1.5630       1.0139      24.9941      25.1461      26.4404      25.5437
030023............................       1.6295       1.2094      28.6627      28.4112      33.8333      30.2808
030024............................       1.9347       1.0139      26.7641      28.3470      31.6658      28.9293
030027............................       0.9159       0.8991      19.4583      21.0527      20.4031      20.3074
030030............................       1.6344       1.0139      25.2425      24.6005      30.2712      26.5838
030033............................       1.1959       1.1713      26.3814      26.6009      26.6531      26.5511
030036............................       1.3185       1.0139      24.9432      26.5708      30.3521      27.3868
030037............................       2.1135       1.0139      23.0542      30.3907      28.6453      27.0409
030038............................       1.5694       1.0139      25.2632      26.5178      29.5509      27.6724
030040............................       0.9316       0.8991      21.2717      22.5130      24.8145      22.8703
030043............................       1.3135       0.8991      23.5172      26.0825      24.7932      24.8113
030044............................       0.8987       0.8991      21.9503      19.5714            *      20.6512
030055 h..........................       1.3518       1.1416      22.8612      23.1837      24.5202      23.5684
030059............................          ***            *            *      24.7676            *      24.7676
030060............................       1.1006       0.8991      21.7685      22.3551      24.3523      22.7950
030061............................       1.6076       1.0139      22.9706      23.4722      25.5529      24.0363
030062............................       1.1689       0.8991      21.1639      21.9849      23.8068      22.3433
030064............................       1.9175       0.9007      22.8009      24.6732      25.4922      24.2954
030065............................       1.5581       1.0139      24.6064      25.6738      27.1646      25.8836
030067............................       1.0095       0.8991      18.4003      19.1332      20.4376      19.2370
030068............................       1.0906       0.8991      19.7097      19.7030      20.8846      20.1346
030069 h..........................       1.3425       1.1416      24.5432      25.6243      26.3518      25.5167
030080............................       1.5124       0.9007      22.8953      24.3573      25.2077      24.1500
030083............................       1.2683       1.0139      24.3273      24.9269      27.5353      25.6343
030085............................       1.5138       0.9007      21.8196      23.2070      24.5792      23.3008
030087............................       1.5725       1.0139      25.6351      26.3878      26.6594      26.2197
030088............................       1.3763       1.0139      23.5761      23.2478      26.6796      24.5472
030089............................       1.5398       1.0139      24.5055      26.2166      27.1835      26.0965
030092............................       1.3775       1.0139      24.0515      25.4127      27.3203      25.7452
030093............................       1.2260       1.0139      23.2485      23.5623      25.8955      24.3686
030094............................       1.3354       1.0139      24.5992      26.9985      29.5948      27.0516
030099............................       0.8991       0.8991      20.3310      26.7996      26.3236      24.0344
030100............................       1.9686       0.9007      27.6299            *      29.0691      28.4177
030101 h..........................       1.3930       1.1416      23.7661      25.0077      26.1927      25.0150
030102............................       2.4590       1.0139      27.9419            *      29.0942      28.5553

[[Page 23486]]

 
030103............................       1.6379       1.0139      29.1105      28.2832      30.1994      29.2117
030104............................          ***            *      34.6028            *            *      34.6028
030106............................       1.5145       1.0139            *      30.4791      34.7222      32.1177
040001............................       1.0582       0.8615      18.7141      23.1475      23.7718      21.8056
040002............................       1.1265       0.7478      18.0776      19.3429      20.1384      19.2037
040003............................       1.0545       0.7478      16.3918      18.5000            *      17.3854
040004............................       1.5197       0.8615      21.2335      23.3504      25.0286      23.2843
040007............................       1.6581       0.8768      23.3992      23.4565      25.7142      24.1728
040010............................       1.3488       0.8615      20.7114      22.0984      23.0274      21.9856
040011............................       1.0063       0.7478      18.8346      19.0319      17.9740      18.5849
040014............................       1.3420       0.8552      22.4970      24.0846      25.3451      23.9535
040015............................       1.0378       0.7478      18.8513      18.0793      19.2831      18.7435
040016............................       1.6546       0.8768      21.2198      22.7219      22.1228      22.0244
040017............................       1.0968       0.8251      17.7545      19.4365      21.9875      19.7066
040018............................       0.9839       0.8231      22.0408      23.8515      23.6044      23.2404
040019............................       1.1290       0.9108      21.1711      21.5316      23.7328      22.1722
040020............................       1.5076       0.9108      18.6419      20.9136      21.6603      20.4199
040021............................       1.2489       0.8768      23.5620      24.7771      25.6917      24.7363
040022............................       1.6031       0.8615      21.4194      23.7462      25.3039      23.4686
040024............................       1.0523       0.7478      17.5750      20.1101            *      18.8371
040026............................       1.4887       0.9066      22.7699      24.3053      25.4072      24.2169
040027............................       1.3418       0.8251      19.3388      19.9348      21.1412      20.1077
040029............................       1.5379       0.8768      22.1882      22.8770      24.0704      23.0869
040032............................       0.9581       0.7478      16.2781      18.5171            *      17.4291
040035............................       0.9080       0.7478      11.8237      13.4265            *      12.6475
040036............................       1.5682       0.8768      21.6742      24.2851      26.3226      24.0976
040039............................       1.3369       0.7793      15.9673      17.7976      19.5998      17.8170
040041............................       1.1827       0.8552      20.4646      22.0188      22.1531      21.5535
040042............................       1.3549       0.9346      16.2285      18.9550      19.9627      18.3286
040045............................       0.9321       0.7478      19.5572      18.7952      17.6742      18.6280
040047............................       1.0748       0.7793      21.6323      21.5334      21.9163      21.6924
040050............................       1.0797       0.7478      15.1428      15.4782      16.3930      15.6589
040051............................       0.9177       0.7478      17.6964      18.8943      19.1401      18.6103
040053............................       0.9720       0.7478      19.2586      20.8153      20.7824      20.2863
040054............................       1.0287       0.7478      16.5573      16.7370      18.2684      17.1740
040055............................       1.5474       0.8231      19.7336      22.2237      23.3156      21.7960
040062............................       1.5855       0.8231      21.9336      21.6403      23.1543      22.2707
040066............................       1.0396       0.7478      21.7766      23.4616            *      22.6592
040067............................       1.0244       0.7478      16.0516      15.1441      16.8799      16.0038
040069............................       1.0357       0.9108      20.5968      21.7607      24.4662      22.2668
040071............................       1.5128       0.8552      19.4324      22.9350      24.3824      22.1870
040072............................       1.0728       0.8552      19.3079      20.8269      19.9009      19.9951
040074............................       1.1860       0.8768      22.0800      22.6147      25.2423      23.2187
040075............................       0.9521       0.7478      15.7875      16.2583      18.3254      17.1733
040076............................       1.0208       0.8552      23.5947      21.0442      20.6272      21.3785
040077............................       0.9549       0.7478      16.7832      18.3261      17.1210      17.3842
040078............................       1.5395       0.8552      21.4854      24.4589      24.5378      23.4806
040080............................       0.9908       0.7793      18.4470      21.3483      22.3392      20.6867
040081............................       0.8047       0.7478      13.2797      13.7148      15.1081      14.0348
040084............................       1.0773       0.8768      20.1163      22.6441      24.7225      22.5619
040085............................       0.9955       0.7478      15.5811      18.0756      29.8444      19.6100
040088............................       1.3084       0.8767      20.0032      21.2974      22.6183      21.3215
040091............................       1.1599       0.8293      20.6688      23.0252      23.0080      22.2365
040100............................       1.3376       0.8552      17.8889      19.3560      20.0460      19.1639
040105............................       1.0117       0.7478      15.4697      15.8171      18.2182      16.4079
040107............................       0.7276       0.7478      17.6695            *            *      17.6695
040114............................       1.7030       0.8768      21.6849      23.5628      24.8992      23.4046
040118............................       1.4016       0.7968      21.7913      24.2547      24.7363      23.6447
040119............................       1.4402       0.8552      19.9013      20.1631      21.0103      20.3637
040126............................       0.8718       0.7478      13.3832      12.5944      14.0701      13.3074
040132............................          ***            *      29.2343      36.5525      28.1390      31.3524
040134............................       2.4142       0.8768      24.4646            *      27.3412      25.9794
040137............................       1.1908       0.8768      24.7813      23.4672      25.2907      24.5263
040138............................       1.2572       0.8615      22.3523      23.3615      25.7513      23.9295
040140............................          ***            *            *      25.1224            *      25.1224
040141............................       0.7691       0.8615            *            *      24.0901      24.0901
040142............................       1.2882       0.9066            *            *      27.9695      27.9695

[[Page 23487]]

 
050002............................       1.3621       1.5474      30.9729      31.9709      34.1948      32.4064
050006............................       1.6269       1.1909      25.4604      27.6176      30.5373      27.9248
050007............................       1.4885       1.4970      34.1406      37.5804      38.7033      36.8959
050008............................       1.3528       1.4970      32.4067      36.9371      39.1539      36.3445
050009............................       1.7971       1.3955      30.2740      35.5384      39.6393      35.2947
050013............................       2.0269       1.3955      29.8401      31.7637      31.9837      31.2570
050014............................       1.1326       1.2953      27.7646      29.5726      33.0373      30.2311
050015............................       1.2904       1.0848      27.5652      30.1398      30.7940      29.4852
050016............................       1.2223       1.1357      25.5508      25.5735      26.2162      25.7788
050017............................       1.9454       1.2953      28.4911      30.5863      36.8978      31.9726
050018............................       1.1521       1.1762      17.9621      20.3179      22.3472      20.1629
050022............................       1.5867       1.1297      28.1312      28.2773      29.8632      28.8610
050024............................       1.0894       1.1417      25.1425      26.9378      27.5587      26.6747
050025............................       1.8083       1.1417      29.8262      31.7242      36.1622      32.6605
050026............................       1.5241       1.1417      24.2564      26.6406      28.3027      26.5474
050028............................       1.2262       1.0848      18.7866      21.5448      26.6160      21.9931
050029............................          ***            *      30.2538      34.3934            *      31.9320
050030............................       1.2312       1.0848      21.9251      22.9148      24.9707      23.2719
050032............................          ***            *      28.8046            *            *      28.8046
050038............................       1.5479       1.5114      36.1619      35.0441      38.7527      36.6692
050039............................       1.6010       1.0848      26.8993      29.8179      31.6734      29.4369
050040............................       1.2018       1.1762      30.7426      31.8983      32.7413      31.8084
050042............................       1.3668       1.1909      27.6765      29.8062      33.9415      30.4516
050043............................       1.6285       1.5474      37.3217      39.6054      43.1589      40.0134
050045............................       1.2751       1.0848      22.1691      22.7051      23.8408      22.8906
050046............................       1.2116       1.1660      25.5490      25.2786      25.6875      25.5104
050047............................       1.7028       1.4970      34.4427      39.3993      40.9874      38.4201
050054............................       1.1776       1.1297      21.3495      27.1437      24.1262      24.0051
050055............................       1.2386       1.4970      36.1182      36.9386      37.5879      36.9364
050056............................       1.3348       1.1762      27.1458      29.4829      27.9330      28.1647
050057............................       1.6190       1.0848      24.2759      26.2099      29.4351      26.6650
050058............................       1.5358       1.1762      25.9389      27.3584      33.8215      29.0264
050060............................       1.4954       1.0848      22.9491      26.5515      27.3282      25.6824
050061............................       0.8559       1.1525      25.3042            *      32.2172      28.5425
050063............................       1.3227       1.1762      28.6093      32.0515      33.3039      31.3845
050065............................       1.7399       1.1660      28.8369      33.8223      34.0280      32.3405
050067............................       1.2228       1.1885      27.8867      29.6982      31.9597      29.7844
050068............................          ***            *      21.9031            *            *      21.9031
050070............................       1.2848       1.4970      39.5178      40.5645      45.3382      41.9509
050071............................       1.3395       1.5474      40.1344      41.1036      45.3882      42.3609
050072............................       1.3403       1.5474      39.2529      40.8108      44.2651      41.6223
050073............................       1.3622       1.5474      38.6763      41.3430      45.9765      42.1975
050075............................       1.2439       1.5474      40.2265      43.7101      47.2356      44.0053
050076............................       2.0351       1.5474      40.8075      43.0845      46.4990      43.5903
050077............................       1.6700       1.1417      27.1234      29.6264      32.0245      29.6181
050078............................       1.2906       1.1762      24.1091      25.6814      27.9269      25.7615
050079............................       1.4307       1.5474      38.8981      42.7385      47.8597      43.4884
050082............................       1.6699       1.1660      27.5022      28.9139      37.7783      31.5037
050084............................       1.5479       1.1333      26.0607      28.2664      33.0179      29.0525
050088............................          ***       1.1357      27.1103      26.4093      25.7385      26.4472
050089............................       1.3648       1.1660      24.7857      29.4884      33.5323      29.3416
050090............................       1.2969       1.4739      27.4193      31.1774      32.9584      30.4520
050091............................       1.1034       1.1762      29.2522      30.1534      30.8560      30.1209
050093............................       1.5128       1.0848      29.2642      31.1083      33.4119      31.3614
050096............................       1.3036       1.1762      23.0525      24.2277      24.6680      23.9648
050097............................          ***            *      24.6726      26.6788            *      25.5991
050099............................       1.5210       1.1660      27.1282      28.7711      31.0437      29.0188
050100............................       1.7200       1.1417      25.6798      28.0303      29.6949      27.8627
050101............................       1.2944       1.4888      32.9866      35.4655      39.5330      36.1079
050102............................       1.3036       1.1297      25.5763      24.9381      29.1364      26.2832
050103............................       1.5463       1.1762      27.8079      28.7375      34.2529      30.2688
050104............................       1.4057       1.1762      26.1592      29.1240      29.7326      28.3301
050107............................       1.3890       1.1525      22.6900      27.6002      33.1358      27.7768
050108............................       1.9703       1.2953      28.5244      31.4271      35.5711      32.0693
050110............................       1.2602       1.1525      21.9297      20.0769      22.4428      21.4435
050111............................       1.2835       1.1762      23.7715      26.6345      28.1588      26.1803
050112............................       1.5361       1.1762      31.9797      34.0258      36.8026      34.4310

[[Page 23488]]

 
050113............................       1.2729       1.4970      32.6932      34.2851      33.8064      33.6092
050114............................       1.3830       1.1762      28.1938      29.2858      31.1294      29.5973
050115............................       1.4364       1.1417      24.1481      27.5207      30.9288      27.6106
050116............................       1.5151       1.1762      28.2924      28.8193      34.5110      30.5901
050117............................       1.2630       1.1123      24.7555      28.2227      32.4414      28.3268
050118............................       1.1710       1.1885      28.9358      33.0650      35.4044      32.6634
050121............................       1.3350       1.0848      25.0858      25.5962      27.9537      26.3210
050122............................       1.5372       1.1333      29.1534      29.7629      34.2416      31.1709
050124............................       1.2385       1.1762      23.0843      26.7065      28.0288      25.9680
050125............................       1.3685       1.5114      35.6573      40.9218      41.7020      39.5040
050126............................       1.3912       1.1762      27.7126      29.6203      26.4194      27.8473
050127............................       1.3401       1.2953      21.8719      23.6208      26.0500      23.7297
050128............................       1.5403       1.1417      28.7668      28.3278      31.0662      29.4553
050129............................       1.7571       1.1660      25.2780      27.8488      32.2680      28.7272
050131............................       1.2972       1.4970      37.7845      38.6834      40.5321      39.0707
050132............................       1.4262       1.1762      27.8805      29.4317      35.1544      30.7495
050133............................       1.4967       1.0951      25.1948      27.6030      31.3530      28.2112
050135............................       0.9765       1.1762            *      24.9415      24.3927      24.6796
050136............................       1.2106       1.4739      31.6146      35.2834      37.4560      34.8123
050137............................       1.2468       1.1762      35.0503      36.5409      38.4827      36.7225
050138............................       1.9167       1.1762      43.0858      43.8671      46.9557      44.6742
050139............................       1.2908       1.1762      33.8749      35.1013      37.6217      35.5604
050140............................       1.4660       1.1660      36.1708      37.5473      39.6269      37.8550
050144............................       1.4053       1.1762      30.3679      32.4042      33.5109      32.1636
050145............................       1.3142       1.4140      37.5722      39.5676      42.3134      39.8846
050148............................       1.1060       1.0848      17.3908      24.7063      27.3005      22.6027
050149............................       1.4351       1.1762      28.0500      30.1596      33.2270      30.4737
050150............................       1.1785       1.2953      26.7728      31.5333      31.7560      29.9321
050152............................       1.4009       1.4970      34.5694      40.3464      43.6487      39.6060
050153............................       1.5352       1.5114      34.5870      40.4446      43.3190      39.3912
050155............................       0.9838       1.1762      21.2068      21.8829      21.8550      21.6128
050158............................       1.2377       1.1762      30.6598      33.6400      35.1326      33.3121
050159............................       1.3232       1.1660      27.4051      30.8069      31.3199      29.8120
050167............................       1.3635       1.1333      23.2022      25.9850      28.5179      25.9911
050168............................       1.6244       1.1660      27.5313      30.8036      33.2506      30.5684
050169............................       1.4269       1.1762      25.6896      26.2864      27.4644      26.5104
050170............................          ***            *      29.4075            *            *      29.4075
050173............................       1.2514       1.1660      27.7070      27.6097      30.3582      28.5541
050174............................       1.6425       1.4739      33.5204      36.3117      40.1747      36.7717
050175............................       1.2918       1.1762      26.9627      31.5615      30.5733      29.6977
050177............................       1.2491       1.1660      23.1575      24.7531      25.1442      24.3743
050179............................       1.2005       1.1885      23.0583      25.8072      27.1155      25.4092
050180............................       1.5845       1.5474      36.9905      40.8101      39.8123      39.2517
050186............................          ***            *      27.6638            *            *      27.6638
050189............................       0.9939       1.4140      32.3513      20.0709      29.1280      26.2226
050191............................       1.4343       1.1762      28.1689            *      34.2091      31.2052
050192............................       0.9731       1.0848      19.5327      21.2448      27.0424      22.7189
050193............................       1.1968       1.1660      24.6307      30.7341      29.6421      28.4881
050194............................       1.3119       1.5159      28.1413      38.6750      40.9096      35.6972
050195............................       1.5170       1.5474      42.1735      43.9696      48.4358      44.9294
050196............................       1.0762       1.0848      20.7257      25.2168      32.1933      25.8088
050197............................       1.9645       1.4970            *      40.8832      48.9052      44.8389
050204............................       1.4068       1.1762      24.9458      25.2512      28.6423      26.2829
050205............................       1.2244       1.1762      25.2841      28.0504      27.8611      27.0700
050207............................       1.2714       1.0951      25.1863      27.0216      29.5215      27.2272
050211............................       1.2713       1.5474      34.3396      38.3319      41.2166      37.8840
050214............................          ***       1.1762      22.4773      24.4785      23.9972      23.6229
050215............................       1.6351       1.5114      36.6063      41.6886      43.7985      40.7257
050217............................       1.1451       1.0848      22.2055      23.6286      24.9606      23.6369
050219............................       1.0993       1.1762      21.8649      22.9226      22.4065      22.4391
050222............................       1.6663       1.1417      25.2922      26.3882      29.1094      27.0242
050224............................       1.7203       1.1660      26.2108      26.7916      29.3143      27.4653
050225............................       1.5203       1.0848      25.0219      29.5184      29.9656      28.1785
050226............................       1.5875       1.1660      26.0826      29.2259      30.6541      28.6959
050228............................       1.3521       1.5474      38.6751      40.1362      42.4226      40.4482
050230............................       1.3593       1.1660      30.0380      34.1417      32.9555      32.4641
050231............................       1.6236       1.1762      27.8896      30.1298      30.9607      29.7082

[[Page 23489]]

 
050232............................       1.4386       1.1357      25.3439      24.4383      27.4099      25.6865
050234............................       1.1726       1.1417      24.0754      29.2421      29.6560      27.4243
050235............................       1.5578       1.1762      27.2838      27.8965      29.2979      28.1654
050236............................       1.3813       1.1660      27.0687      28.1969      32.1647      29.0012
050238............................       1.4440       1.1762      26.0312      29.1481      31.1764      28.8569
050239............................       1.5765       1.1762      27.0866      28.2327      31.0963      28.8857
050240............................       1.6442       1.1762      32.8542      35.2284      35.5735      34.6528
050242............................       1.3378       1.5159      34.4412      39.7629      44.3130      39.6054
050243............................       1.6214       1.1297      28.5626      31.8153      31.4883      30.6830
050245............................       1.3020       1.1660      25.7585      27.0949      28.6527      27.2127
050248............................       1.0286       1.4140      29.1192      31.6240      35.3864      32.0261
050251............................       1.0004       1.0848      24.4552      26.5021      27.2675      26.0899
050253............................          ***       1.1564      23.9246      22.2450      24.0044      23.3808
050254............................       1.2166       1.2953      23.3358      24.1512      26.3150      24.6804
050256............................       1.5778       1.1762      26.8618      28.4728      29.8194      28.4077
050257............................       0.9814       1.0848      17.4909      20.8367      21.3216      19.7770
050261............................       1.3007       1.0848      21.4693      25.3005      27.3234      24.7145
050262............................       2.1232       1.1762      33.0425      36.1162      44.0256      37.8981
050264............................       1.3196       1.5474      37.4742      41.3478      41.1211      39.9496
050267............................          ***            *      26.6558      26.7060            *      26.6806
050270............................       1.3272       1.1417      27.9871      30.0540      32.4812      30.2697
050272............................       1.3628       1.1660      24.0921      25.9103      27.1989      25.7666
050276............................       1.1883       1.5474      34.7422      41.2251      39.3778      38.5361
050277............................       1.0330       1.1762      35.6323      35.8246      32.5213      34.3014
050278............................       1.5907       1.1762      26.0331      28.0351      29.9244      28.0988
050279............................       1.2108       1.1660      23.5145      25.5299      27.6573      25.5685
050280............................       1.6443       1.2207      28.5504      30.6723      35.2030      31.5494
050281............................       1.4863       1.1762      25.7832      26.2623      27.3824      26.5030
050283............................       1.5233       1.5474      35.1831      38.5600      42.8618      39.0003
050286............................          ***            *      19.7352      19.4973            *      19.6057
050289............................       1.5691       1.4970      34.9645      38.6875      41.1061      38.2220
050290............................       1.6177       1.1762      31.9510      32.6388      34.5482      33.0758
050291............................       1.8090       1.4739      28.3451      29.6162      35.3653      31.1027
050292............................       0.9624       1.1297      27.6114      27.0775      26.8879      27.1685
050295............................       1.5134       1.0848      25.4332      31.5960      36.1950      30.7774
050296............................       1.1551       1.5114      33.5948      34.9952      39.0061      36.0343
050298............................       1.1272       1.1660      26.1707      25.8232      27.7416      26.6026
050299............................       1.2244       1.1762      26.9870      27.7535      31.5435      28.9060
050300............................       1.5741       1.1660      26.3182      28.3862      30.7148      28.5022
050301............................       1.2254       1.0848      25.7167      28.5769      31.9995      28.7858
050305............................       1.4519       1.5474      38.7597      40.9978      44.8630      41.5654
050308............................       1.4919       1.5114      31.6790      38.0564      43.0691      37.5162
050309............................       1.3873       1.2953      25.5367      28.9181      34.4278      29.9079
050312............................       1.4865       1.2207      28.2557      32.6846      33.9022      31.7615
050313............................       1.2403       1.1333      25.3372      27.5321      31.4999      28.4222
050315............................       1.2710       1.0848      23.6638      26.1224      27.6037      25.8181
050320............................       1.2238       1.5474      31.4570      36.3252      40.2352      36.0082
050324............................       1.9289       1.1417      28.4931      30.9958      32.9792      30.9355
050325............................       1.1756       1.0848      26.6325      30.2280      30.6117      29.1581
050327............................       1.6847       1.1660      33.0549      29.8327      33.0087      31.8986
050329............................       1.2743       1.1297      26.6341      26.8021      26.2120      26.5339
050331............................       1.1721       1.4739      21.5193      20.9847      20.2692      20.9637
050333............................       1.0706       1.0848      15.6929      15.3119      23.4009      17.5306
050334............................       1.6937       1.4140      37.2336      38.7635      40.7467      38.9455
050335............................       1.4438       1.0848      24.9274      27.4046      26.2576      26.2253
050336............................       1.1664       1.1333      23.2687      25.3062      28.5659      25.7519
050342............................       1.2238       1.0848      23.0282      24.7654      26.8507      24.9581
050348............................       1.6959       1.1660      28.9864      33.2676      37.7898      33.4975
050349............................       0.9453       1.0848      15.6043      16.9251      17.4791      16.6299
050350............................       1.3661       1.1762      27.2573      29.4262      31.1833      29.2715
050351............................       1.5133       1.1762      27.4042      29.3082      30.8661      29.2314
050352............................       1.2358       1.2953      32.6572      24.2931      33.9362      30.0053
050353............................       1.5568       1.1762      25.4309      26.6332      29.1630      27.0686
050355............................          ***       1.0848            *      11.2498       5.0506       7.4928
050357............................       1.4494       1.1525      25.2126      26.7265      32.3095      27.5322
050359............................       1.1442       1.0848      22.9175      23.6030      24.7311      23.7960
050360............................       1.4616       1.4970      35.9032      38.8658      37.0769      37.3332

[[Page 23490]]

 
050366............................       1.2256       1.0848      23.4696      25.7692      31.1854      26.8679
050367............................       1.4438       1.4888      32.6760      34.4959      38.7604      35.6778
050369............................       1.3974       1.1762      28.0909      27.1327      29.5697      28.2751
050373............................       1.4860       1.1762      30.7301      32.2315      32.2596      31.7447
050376............................       1.4575       1.1762      30.3530      30.7562      32.5870      31.2266
050377............................          ***            *      14.3892      20.2484            *      16.9896
050378............................       0.9702       1.1762      30.4937      33.9087      34.2417      32.8674
050379............................          ***       1.0848      27.5151      31.7645      32.9575      30.5157
050380............................       1.5471       1.5114      35.8014      39.1098      42.0782      38.9514
050382............................       1.4204       1.1762      26.8950      26.0927      27.4131      26.8049
050385............................       1.3521       1.4739            *      25.5735      34.5184      29.9098
050390............................       1.1788       1.1297      25.7881      28.7761      26.0066      26.7871
050391............................       1.3048       1.1762      20.2887      21.3012      18.1004      19.7304
050392............................       1.0187       1.0848      21.8139      22.7209            *      22.2790
050393............................       1.3163       1.1762      26.4918      28.2369      30.0661      28.2139
050394............................       1.4938       1.1660      25.1869      26.0074      27.2543      26.2043
050396............................       1.5902       1.1525      28.4161      30.5470      33.5699      30.9065
050397............................       0.8283       1.0848      24.7279      27.4716      28.1640      26.7356
050407............................       1.1949       1.4970      33.2894      35.6035      37.9066      35.6609
050410............................       0.9616            *      19.8436      19.4995      21.3814      20.2094
050411............................       1.4055       1.1762      35.5207      37.3817      37.8064      36.9551
050414............................       1.3026       1.2953      28.2381      28.8561      34.6532      30.6007
050417............................       1.2841       1.0848      24.5360      25.2930      29.5031      26.5285
050419............................       1.3330       1.1909      26.4357      28.4471      33.3125      29.3954
050420............................       1.1285       1.1762      26.7537      26.1838      24.9401      25.8686
050423............................       0.9475       1.1297      26.5188      28.5944      30.6416      28.6936
050424............................       1.9635       1.1417      27.5273      29.9133      31.0730      29.4697
050425............................       1.3899       1.2953      37.7347      38.5317      42.4177      39.7789
050426............................       1.3183       1.1660      30.9610      30.0077      30.6899      30.5313
050430............................       0.9585       1.0848      31.5170      24.6684      25.0607      26.4412
050432............................       1.5149       1.1762      28.1105      30.3547      30.8030      29.8170
050433............................       0.9214       1.0848      14.3846      20.7565      23.0806      19.1896
050434............................       1.1299       1.0848            *      25.9506      26.1621      26.0550
050435............................       1.0952       1.1417      22.6618      32.2183      28.0306      27.3138
050438............................       1.5305       1.1762      26.5535      26.4668      27.2662      26.7804
050441............................       1.9649       1.5114      36.6680      38.2823      42.9765      39.2937
050444............................       1.3319       1.1123      23.5299      27.6971      30.5504      27.3177
050447............................       0.8880       1.1417      25.7274      21.8552      25.2573      24.1974
050448............................       1.1326       1.0848      26.6967      25.0983      27.9759      26.6380
050454............................       1.8679       1.4970      34.4813      36.8383      43.3278      38.3744
050455............................       1.6861       1.0848      24.1694      24.5314      21.8846      23.4157
050456............................       1.2166       1.1762      23.7594      22.1675      22.5630      22.8117
050457............................       1.6122       1.4970      37.4570      40.2725      45.5829      41.0011
050464............................       1.6731       1.1885      31.4768      37.1342      37.3692      35.4838
050468............................       1.4533       1.1762      17.8128      29.4280      29.5448      24.3346
050469............................       1.0831       1.0848      25.7995      27.3281      28.9079      27.4122
050470............................       1.0907       1.0848      21.6981      18.4689      23.6649      21.2384
050471............................       1.7659       1.1762      32.3570      34.5484      34.5211      33.8184
050476............................       1.3587       1.0848      26.0482      30.9974      34.6585      30.3567
050477............................       1.4963       1.1762      32.1676      34.6400      34.6995      33.8960
050478............................       0.9760       1.1525      28.3894      30.9865      33.3998      30.9361
050481............................       1.4169       1.1762      30.3890      31.9177      33.7446      32.0928
050485............................       1.5976       1.1762      27.1437      28.8459      31.4233      29.1407
050488............................       1.3096       1.5474      37.2438      40.5313      42.9904      40.3037
050491............................          ***       1.1564      29.2987      30.6461      32.1379      30.5664
050492............................       1.4025       1.0848      23.7384      27.4933      27.1540      26.2639
050494............................       1.3712       1.0848      30.8706      35.1457      34.8963      33.6068
050496............................       1.7798       1.5474      35.7115      38.2871      42.2672      38.6931
050497............................          ***            *      14.4481      15.9501            *      15.1581
050498............................       1.2871       1.2953      28.2196      28.2667      32.7708      29.8260
050502............................       1.7452       1.1762      28.0102      28.7200      29.5615      28.8118
050503............................       1.4596       1.1417      26.7924      29.2001      31.6418      29.3049
050506............................       1.7058       1.1357      30.4731      32.4509      36.0164      33.1455
050510............................       1.2059       1.5474      39.6005      44.3883      47.5510      44.1129
050512............................       1.4016       1.5474      39.0767      41.8921      46.9233      42.8915
050515............................       1.3200       1.1417      36.3131      37.4251      38.9978      37.6365
050516............................       1.4489       1.2953      30.0985      29.4936      36.2618      31.8675

[[Page 23491]]

 
050517............................       1.0642       1.1660      23.4131      23.6034      23.9007      23.6377
050522............................          ***            *      38.9157            *            *      38.9157
050526............................       1.2090       1.1660      29.0004      29.9495      31.3744      30.1287
050528............................       1.1389       1.0848      23.9177      28.6273      29.6838      27.7337
050531............................       1.0915       1.1762      22.7311      25.0157      26.9420      24.9597
050534............................       1.2648       1.1297      26.7941      29.7546      29.8603      28.8863
050535............................       1.3449       1.1660      29.7904      32.3646      32.3723      31.6438
050537............................       1.3781       1.2953      25.1291      27.4196      31.4527      28.1309
050539............................       1.2398       1.0848      25.3328      28.0586      29.6856      27.7611
050541............................       1.5362       1.5474      41.1980      43.7765      46.1121      43.8355
050542............................       1.0327       1.0848      21.2846            *            *      21.2846
050545............................       0.6959       1.1762      33.4322      42.9451      30.5554      35.4562
050546............................       0.7147       1.0848      42.8052      52.7180      30.2329      41.5266
050547............................       0.8260       1.4739      40.6483      45.1842      33.2205      39.9154
050548............................       0.7101       1.1660      32.3944      37.1314            *      34.6019
050549............................       1.5565       1.1604      31.8525      33.8288      34.9818      33.6342
050550............................       1.3762       1.1660      29.0938      31.1918      30.2302      30.2108
050551............................       1.2853       1.1660      28.6834      31.6782      31.6165      30.7425
050552............................       1.1118       1.1762      24.9755      26.8274      27.1744      26.5471
050557............................       1.5548       1.1885      25.8719      28.3111      31.1871      28.6462
050559............................          ***            *      25.3299      26.9662            *      26.0948
050561............................       1.2178       1.1762      35.9611      37.5863      38.8651      37.5449
050567............................       1.5865       1.1660      27.8475      30.1167      32.9829      30.4114
050568............................       1.2251       1.0848      20.8324      22.5008      24.4061      22.5795
050569............................       1.3462       1.3480      27.7955      30.4874      33.0259      30.5066
050570............................       1.5162       1.1660      29.9470      32.6896      34.0171      32.2949
050571............................       1.2578       1.1762      29.1716      32.1656      33.6156      31.7338
050573............................       1.7100       1.1297      27.2328      30.5249      33.3268      30.3962
050575............................       1.2597       1.1762      23.1358      23.2447      25.2513      23.9658
050577............................       1.2157       1.1762      26.4806      28.7060      30.8841      28.7176
050578............................       1.7450       1.1762      30.4934      31.5953      33.8825      31.9512
050579............................       1.4291       1.1762      34.9794      40.2740      39.4976      38.3190
050580............................       1.2595       1.1660      27.2431      29.4337      31.6256      29.3950
050581............................       1.4452       1.1762      28.9696      32.0823      32.1801      31.1581
050583............................       1.5670       1.1417      30.0427      33.5209      33.3697      32.3610
050584............................       1.2914       1.1660      24.5544      24.5757      24.8180      24.6565
050585............................       1.1457       1.1660      26.0595      27.2982      22.7121      24.9986
050586............................       1.1583       1.1660      25.7172      25.3551      27.4173      26.0841
050588............................       1.3347       1.1762      30.5453      32.3603      32.8212      31.9715
050589............................       1.2362       1.1660      27.9845      30.6273      30.9547      29.9199
050590............................       1.2814       1.2953      27.0620      31.5987      32.1654      30.1866
050591............................       1.1623       1.1762      28.6151      28.5915      28.8549      28.6959
050592............................       1.1716       1.1660      25.9545      32.5000      24.4542      27.4073
050594............................       1.9876       1.1660      30.8028      34.6747      34.7946      33.5328
050597............................       1.2330       1.1762      24.5542      25.4868      27.5691      25.8776
050598............................          ***            *      24.6875            *            *      24.6875
050601............................       1.5414       1.1762      32.3033      35.0325      34.7409      34.0841
050603............................       1.3839       1.1660      25.0996      28.6982      30.2464      28.0787
050604............................       1.2162       1.5114      42.0018      45.4433      49.9429      45.9484
050608............................       1.3821       1.0848      20.7955      22.1999      23.3630      22.1922
050609............................       1.3707       1.1660      37.4563      38.4561      41.1797      39.1280
050615............................       1.3061       1.1762      29.4323      32.8786      33.2909      31.8903
050616............................       1.3796       1.1660      23.1748      28.5636      36.9017      29.6253
050618............................       1.0245       1.0848      22.3481      25.4500      27.4539      25.0614
050623............................          ***       1.1762      29.9553      29.6550      32.0627      30.4768
050624............................       1.2620       1.1762      23.3492      28.1941      32.2907      27.6796
050625............................       1.7422       1.1762      30.8013      33.5137      36.3631      33.6260
050630............................          ***            *      27.7051      28.0726      30.9410      28.9666
050633............................       1.2315       1.1357      30.2883      33.4771      35.3734      33.1070
050636............................       1.3084       1.1417      23.2573      27.2360      30.5156      27.0926
050641............................       1.2243       1.1762      21.5030      20.4720      21.4612      21.1520
050644............................       0.8876       1.1762      28.4054      25.6614      27.6547      27.1915
050662............................       0.7678       1.5114      40.9242      47.5065      32.6362      40.4932
050663............................       1.0263       1.1762      22.9161      25.1493      25.7747      24.4728
050667............................       0.8884       1.3955      31.4906      25.9250      26.3937      27.9100
050668............................       0.9981       1.5474      55.9594            *      31.8065      41.1707
050674............................       1.2840       1.2953      36.8871      38.4454      42.6866      39.5960

[[Page 23492]]

 
050677............................       1.4811       1.1762      36.2702      37.3389      38.7984      37.5511
050678............................       1.2324       1.1660      27.1337      29.1159      30.7220      29.1295
050680............................       1.2133       1.4888      32.7065      35.6614      38.3946      35.9028
050682............................       0.8920       1.0848      23.0984      21.7264      21.7791      22.0865
050684............................       1.1341       1.1297      23.7443      25.2575      26.4234      25.2119
050686............................       1.2605       1.1297      37.3033      38.5595      40.9486      39.0574
050688............................       1.2096       1.5114      36.5555      41.3305      41.9325      39.9230
050689............................       1.5618       1.5474      37.5449      40.3815      42.2018      40.1932
050690............................       1.2343       1.4739      41.1385      43.9228      47.2769      44.3743
050693............................       1.2978       1.1660      32.6638      34.8040      35.0621      34.2547
050694............................       1.1914       1.1297      25.8298      26.7041      28.9544      27.1978
050695............................       1.1012       1.1333      27.8742      30.1226      35.6549      31.4872
050696............................       2.0751       1.1762      29.9410      36.9314      35.9220      34.4812
050697............................       1.0277       1.2207      18.6962      19.2603      25.1984      20.8006
050699............................          ***            *      26.0909      25.6818      26.8210      26.1958
050701............................       1.2779       1.1297      28.4650      29.6896      29.6253      29.3536
050704............................       1.0120       1.1762      24.6072      24.6609      25.3488      24.8998
050707............................       1.3813       1.4970      27.7366      32.4877      34.0550      31.4563
050708............................       1.6591       1.0848      22.1606      21.2163      22.5034      21.9751
050709............................       1.2193       1.1660      22.7897      21.9079      25.6119      23.3937
050710............................       1.4396       1.0848      33.7204      34.8311      39.9858      36.4647
050713............................       1.2543       1.1762      19.0071      20.7448      20.2803      19.9969
050714............................       1.3580       1.5159      30.3263      32.4491      33.6676      32.2064
050717............................       1.0612       1.1762      33.0719      34.5519      38.0796      35.2375
050718............................       1.0152       1.1297      21.7835      15.4037      21.4996      18.9377
050719............................          ***            *      22.0998            *            *      22.0998
050723............................       1.2353       1.1762      33.0797      34.9814      35.0119      34.4384
050724............................       2.1341       1.0848      23.7567            *      34.4267      28.5323
050725............................       0.9684       1.1762      20.6592      22.0946      21.7816      21.6358
050726............................       1.6664       1.1885      25.8742      27.0928      27.8433      27.0367
050727............................       1.2727       1.1762            *      23.7179      23.9437      23.8301
050728............................       1.3207       1.4739            *      31.4768      36.0820      33.6891
050729............................       1.4238       1.1762            *            *      34.2580      34.2580
050730............................       1.2649       1.1762            *            *      51.5425      51.5425
060001............................       1.5772       1.0517      23.1548      24.9410      26.8470      25.0779
060003............................       1.3962       1.0517      23.0807      24.7856      24.2224      24.0730
060004............................       1.1960       1.0710      25.0037      28.0656      29.9649      27.8289
060006............................       1.3423       0.9379      21.8609      22.7493      24.5704      23.0964
060007............................       1.0128       0.9379      21.4244      21.4792            *      21.4535
060008............................       1.1014       0.9379      19.8803      21.8037      23.3859      21.7601
060009............................       1.4646       1.0710      24.7920      27.0511      28.7645      26.9116
060010............................       1.7149       1.0146      25.8475      27.2290      28.9850      27.4402
060011............................       1.4232       1.0710      25.8919      26.1958      27.2833    0126.4630
060012............................       1.4557       0.9379      22.6374      24.1557      26.2469      24.3434
060013............................       1.3659       0.9379      23.3954      24.9708      24.5994      24.0758
060014............................       1.7846       1.0710      27.0326      29.6744      31.2588      29.2315
060015............................       1.7206       1.0710      27.6338      30.1158      30.4533      29.4109
060016............................       1.1655       0.9379      22.9300      23.9655      25.6527      24.2479
060018............................       1.2136       0.9379      21.0581      23.6620      25.7628      23.4747
060020............................       1.5388       0.9379      20.9025      22.2052      22.6748      21.9753
060022............................       1.5930       0.9457      24.7928      25.7832      26.5238      25.7483
060023............................       1.6438       0.9578      24.3749      26.7285      27.7644      26.3625
060024............................       1.7403       1.0710      25.2409      28.7231      29.0130      27.7028
060027............................       1.5666       1.0517      25.1480      26.6348      28.0909      26.7085
060028............................       1.3838       1.0710      27.1303      27.9686      30.0448      28.4352
060029............................          ***       0.9379      19.7379            *            *      19.7379
060031............................       1.5393       0.9457      23.8781      25.6207      26.3650      25.3306
060032............................       1.5419       1.0710      27.1783      28.2234      30.4247      28.6396
060033............................       0.9865       0.9379      16.7266            *            *      16.7266
060036............................       1.1170       0.9379      19.4144      20.4635      20.7131      20.1878
060041............................       0.9219       0.9379      20.8746      22.7123      23.4978      22.3670
060043............................       0.9477       0.9379      19.1085      20.0939      18.7896      19.3418
060044............................       1.1417       1.0517      25.6112      25.2471      25.0360      25.3737
060049............................       1.2784       1.0146      25.3425      26.8089      29.0598      27.1748
060050............................       1.1981       0.9379      20.4386      21.9108            *      21.1679
060054............................       1.4335       0.9590      21.1281      23.5803      22.3490      22.3633
060057............................       1.0788       0.9379      24.3982      26.9891            *      25.7472

[[Page 23493]]

 
060064............................       1.4680       1.0710      29.1806      30.0963      31.3105      30.2470
060065............................       1.2936       1.0710      29.2377      28.5282      31.1987      29.6323
060070............................          ***       0.9379      22.6894            *            *      22.6894
060075............................       1.2070       0.9379      27.7835      30.7835      32.7563      30.4907
060076............................       1.2848       0.9379      23.6266      25.5406      26.8236      25.4496
060096............................       1.5124       1.0517      26.4167      27.4085      30.0602      27.9908
060100............................       1.6735       1.0710      28.0561      29.7690      32.1537      30.0220
060103............................       1.1833       1.0517      26.6863      28.8063      30.3002      28.6961
060104............................       1.3558       1.0710      26.7683      30.8625      32.0889      29.9703
060107............................       1.4178       1.0710            *      26.8267      26.1883      26.4984
060108............................          ***            *      19.0011            *            *      19.0011
060111............................          ***            *            *      31.2571            *      31.2571
070001............................       1.6316       1.1790      29.9592      32.2718      34.0302      32.0467
070002............................       1.8165       1.1790      28.1101      29.0663      31.1530      29.4722
070003............................       1.0898       1.1790      29.8684      31.3716      32.7173      31.3528
070004............................       1.1896       1.1790      25.7207      27.3004      29.2292      27.3764
070005............................       1.3796       1.1790      29.8173      29.3265      32.1668      30.4848
070006 \2\........................       1.3118       1.2607      33.3814      33.9310      36.8469      34.7695
070007............................       1.2843       1.1790      29.0336      30.3648      31.7097      30.4054
070008............................       1.2463       1.1790      24.3907      24.9176      26.4806      25.2986
070009............................       1.1856       1.1790      25.6072      28.8649      30.2706      28.2076
070010............................       1.8269       1.2607      30.4192      33.1535      32.5798      32.0648
070011............................       1.3577       1.1790      24.9457      27.5391      29.9105      27.3901
070012............................       1.1771       1.1790      34.9099      40.3337      44.1424      39.6372
070015............................       1.4329       1.1790      30.0614      30.9728      33.4595      31.5141
070016............................       1.3424       1.1790      29.7505      29.6662      31.0903      30.2000
070017............................       1.3696       1.1790      29.2978      30.3951      31.7223      30.4949
070018 \2\........................       1.3351       1.2607      33.8654      35.7189      37.6081      35.8796
070019............................       1.2584       1.1790      27.9838      29.6290      31.8148      29.8448
070020............................       1.3392       1.1790      28.4084      29.9507      31.0935      29.8423
070021............................       1.2614       1.1790      30.3254      31.4397      33.2357      31.7179
070022............................       1.7784       1.1790      29.7376      32.3625      33.9804      32.0199
070024............................       1.3851       1.1790      28.3460      30.8308      32.0430      30.4352
070025............................       1.8564       1.1790      28.3017      29.2540      30.9938      29.5451
070027............................       1.2911       1.1790      36.9700      27.3487      31.8018      31.4568
070028............................       1.5983       1.2607      28.2078      29.5653      31.5036      29.7843
070029............................       1.2773       1.1790      25.8107      26.3871      27.7213      26.6692
070031............................       1.2393       1.1790      25.5880      27.2359      28.9190      27.3126
070033............................       1.2635       1.3191      34.3904      35.5355      37.1929      35.7524
070034 \2\........................       1.3877       1.2607      32.8074      35.6831      36.2719      34.9418
070035............................       1.2964       1.1790      26.1693      27.1816      27.5585      26.9760
070036............................       1.6654       1.1790      35.0701      34.0555      36.1610      35.1155
070038............................       1.1608            *            *      31.1133      25.7516      26.9407
070039............................       0.9382       1.1790      32.6059      35.0164      31.2269      32.9340
080001............................       1.6701       1.0652      28.0859      30.2463      30.0242      29.4815
080002............................          ***            *      23.7309      26.4192      27.9670      26.0445
080003............................       1.5462       1.0652      24.8199      27.1131      29.2266      26.9651
080004............................       1.3741       1.0652      24.2251      26.0092      27.4735      25.9428
080006............................       1.2769       0.9606      23.6838      24.4204      25.6160      24.5955
080007............................       1.3900       1.0289      23.4964      24.6485      27.0074      25.0565
090001............................       1.7108       1.0935      29.5432      31.3552      35.0413      32.0128
090002............................          ***            *      23.5158      29.6780            *      25.5760
090003............................       1.2607       1.0935      22.7014      27.0514      29.2660      26.1789
090004............................       1.9783       1.0935      28.7417      29.9785      32.0186      30.3834
090005............................       1.3818       1.0935      28.6142      30.2504      30.7728      29.9417
090006............................       1.3806       1.0935      23.7241      25.9086      29.5590      26.3083
090007............................          ***            *      25.8430      30.1419            *      27.7359
090008............................       1.4284       1.0935      19.3212      29.6744      29.1059      25.7761
090011............................       2.0113       1.0935      31.7710      32.4412      34.0693      32.7262
100001............................       1.5628       0.9303      22.6150      25.2381      24.4060      24.0790
100002............................       1.3511       1.0061      22.5982      22.1269      25.3389      23.3729
100004............................       0.9314       0.8613      15.6306      16.2637      16.5974      16.2012
100006............................       1.6100       0.9446      23.3745      26.2372      26.2258      25.3340
100007............................       1.6285       0.9446      24.3305      25.4333      26.5612      25.5135
100008............................       1.6365       0.9757      22.7706      25.7377      27.4314      25.4374
100009............................       1.4157       0.9757      24.7811      24.4666      25.9381      25.0983
100010............................          ***            *      25.5614      26.9486            *      26.2759

[[Page 23494]]

 
100012............................       1.6376       0.9333      24.2602      24.5762      26.3798      25.1067
100014............................       1.2930       0.9307      21.7566      22.3054      24.5862      22.8508
100015............................       1.3050       0.9292      22.1272      22.5781      24.6038      23.0946
100017............................       1.5188       0.9307      21.1905      22.9545      26.1580      23.5300
100018............................       1.6120       1.0115      24.1885      27.8582      28.1191      26.7581
100019............................       1.6412       0.9826      24.2888      25.5566      27.5435      25.8847
100020............................       1.3242       0.9757      23.5303      23.6106      23.8785      23.6811
100022............................       1.7131       1.0508      27.9072      29.0519      29.9345      29.0212
100023............................       1.4290       0.9446      21.8111      21.4015      23.0074      22.0889
100024............................       1.2486       0.9757      24.4070      27.6476      30.2395      27.3189
100025............................       1.6929       0.8613      21.2568      21.1174      22.1580      21.5429
100026............................       1.6114       0.8613      20.1602      21.3533      21.3651      20.9595
100027............................       1.2106       0.8613      23.8982      12.0314      16.1223      16.3797
100028............................       1.2795       0.9826      21.8879      23.7818      26.8661      24.1693
100029............................       1.1347       0.9757      24.6814      26.9307      27.5844      26.4439
100030............................       1.2887       0.9446      21.8567      22.4887      24.0943      22.9211
100032............................       1.6962       0.9292      21.6415      23.0174      25.2033      23.3437
100034............................       1.8227       0.9757      23.1111      24.4064      25.9415      24.5360
100035............................       1.5678       0.9554      22.6349      25.3590      26.9407      24.9239
100038............................       1.8717       1.0508      25.7948      27.4422      29.8583      27.7714
100039............................       1.3916       1.0508      23.8060      26.6016      28.4627      26.3398
100040............................       1.6805       0.9303      22.4679      23.5372      23.6443      23.2382
100043............................       1.2649       0.9292      21.7738      22.8963      25.2273      23.3549
100044............................       1.4156       1.0162      23.9952      26.3208      28.3596      26.2570
100045............................       1.3130       0.9446      25.2285      23.0520      26.9641      25.0756
100046............................       1.2283       0.9292      24.2746      26.6169      26.3673      25.8723
100047............................       1.6670       0.9274      24.3522      24.4212      25.0404      24.6186
100048............................       0.9388       0.8613      17.5533      18.3767      18.8771      18.2575
100049............................       1.1939       0.8934      21.8679      22.9532      22.9810      22.6230
100050............................       1.1699       0.9757      20.0405      20.6893      19.8713      20.2035
100051............................       1.3249       0.9446      20.0231      22.3311      23.2764      22.0397
100052............................       1.3546       0.8934      20.5916      20.9078      22.3920      21.3174
100053............................       1.2271       0.9757      23.7837      27.3383      27.3224      26.2170
100054............................       1.1950       0.8877      22.0352      25.7279      28.0512      25.3241
100055............................       1.3505       0.9292      19.6350      22.1051      23.5332      21.7040
100056............................          ***            *      25.9245      25.7945            *      25.8574
100057............................       1.4813       0.9446      24.6417      22.6038      25.3897      24.1823
100061............................       1.5361       0.9757      26.1273      26.7673      29.2565      27.4077
100062............................       1.7092       0.8955      24.9807      24.1413      25.2340      24.7789
100063............................       1.2093       0.9292      21.5620      21.5566      24.7026      22.5862
100067............................       1.4142       0.9292      23.8892      23.9333      25.4597      24.4499
100068............................       1.7170       0.9307      23.7840      24.9025      25.9202      25.2289
100069............................       1.3251       0.9292      19.6037      22.4386      24.3111      22.1685
100070............................       1.6333       0.9554      23.5524      23.7746      24.9751      24.0912
100071............................       1.2241       0.9292      21.7675      23.4176      24.9682      23.4234
100072............................       1.3679       0.9307      23.5362      24.2934      26.0379      24.6995
100073............................       1.6820       1.0508      23.5843      25.3685      30.3358      26.4443
100075............................       1.4565       0.9292      22.3890      23.3503      25.1691      23.6907
100076............................       1.2340       0.9757      19.6444      21.0777      21.9483      20.8673
100077............................       1.4278       0.9274      22.3755      24.3478      26.0347      24.2410
100080............................       1.7259       1.0061      22.8704      26.3596      27.0126      25.4415
100081............................       1.0413       0.8672      16.8087      16.9168      15.6662      16.4022
100084............................       1.7911       0.9446      24.1122      25.4140      26.3475      25.2653
100086............................       1.2082       1.0508      25.2375      26.4817      28.2641      26.6950
100087............................       1.8721       0.9554      26.5915      25.9909      26.4999      26.3569
100088............................       1.6620       0.9303      23.6270      24.8729      25.9182      24.8465
100090............................       1.4618       0.9303      22.5894      24.0501      24.2422      23.6608
100092............................       1.5036       0.9826      25.4630      26.0856      28.4789      26.7319
100093............................       1.6987       0.8613      20.2949      21.1547      21.3524      20.9431
100098............................       1.0859       0.8613      20.0639      21.2505            *      20.6613
100099............................       1.0146       0.8934      18.5287      20.4328      21.3036      20.1035
100102............................       1.0412       0.8613      21.6772      22.8850      23.8596      22.8413
100103............................       0.9567       0.8613      20.3633      21.7494      22.9256      21.7001
100105............................       1.3654       0.9458      24.5464      24.9503      26.8091      25.4381
100106............................       0.9426       0.8613      20.3417      20.2882      24.0389      21.6406
100107............................       1.1491       0.9333      23.3789      24.4484      26.1337      24.6951
100108............................       0.7656       0.8613      14.8039      16.3757      22.0750      17.7359

[[Page 23495]]

 
100109............................       1.2500       0.9446      23.0779      23.8836      24.9951      24.0208
100110............................       1.5138       0.9446      24.4533      28.3699      29.1494      27.5406
100113............................       1.9521       0.9461      24.3614      25.0067      26.6479      25.3817
100114............................       1.3471       0.9757      25.3699      27.7413      29.2195      27.4364
100117............................       1.1856       0.9303      23.9134      26.0451      26.4536      25.5634
100118............................       1.3280       0.9303      24.1104      23.6669      28.0569      25.5448
100121............................       1.0708       0.8934      23.1100      24.0937      24.8579      24.0497
100122............................       1.2187       0.8877      24.1820      21.2597      23.4751      22.8811
100124............................       1.1623       0.8613      24.3048      21.6483      22.7023      22.7933
100125............................       1.1807       0.9757      22.4185      25.3532      26.7452      24.9756
100126............................       1.4012       0.9292      21.7977      23.2996      24.0192      23.0655
100127............................       1.6390       0.9292      21.0153      21.3223      23.8920      22.0931
100128............................       2.1468       0.9292      24.4104      25.6763      29.4979      26.6451
100130............................       1.1903       1.0061      20.2478      22.8324      24.2046      22.4252
100131............................       1.2656       0.9757      25.4811      25.8316      29.2462      26.9103
100132............................       1.2174       0.9292      21.1538      23.0428      24.3293      22.8670
100134............................       0.9426       0.8613      18.3391      19.5337      20.9244      19.6271
100135............................       1.5934       0.8712      20.4915      22.3071      24.0024      22.2526
100137............................       1.1612       0.8934      20.4007      23.3692      25.1974      23.1447
100139............................       0.8526       0.9461      18.2204      14.5046      17.5489      16.8211
100140............................       1.1665       0.9303      22.5124      24.8165      26.4720      24.7189
100142............................       1.2175       0.8613      20.0689      20.7219      22.9577      21.2432
100147............................          ***       0.8613      17.1045            *            *      17.1045
100151............................       1.7655       0.9303      26.6470      26.1848      28.1322      27.0891
100154............................       1.5497       0.9757      23.0820      26.3703      27.6127      25.8181
100156............................       1.1022       0.8613      20.6928      22.2757      26.7092      23.2451
100157............................       1.5782       0.9292      23.1045      25.9133      27.3851      25.4671
100160............................       1.1887       0.8613      23.4877      27.2019      26.9851      25.9544
100161............................       1.5792       0.9446      24.6268      28.3607      28.8077      27.4143
100162............................          ***            *      23.8001            *            *      23.8001
100167............................       1.2864       1.0508      26.4517      26.8584      30.3694      27.8827
100168............................       1.3732       1.0061      24.6276      26.0864      27.1292      25.9577
100169............................          ***            *      23.4575            *            *      23.4575
100173............................       1.7343       0.9292      19.7190      22.4866      24.5390      22.2987
100175............................       0.9876       0.8613      21.0474      22.0666      23.5455      22.2224
100176............................       1.8792       1.0162      26.8740      29.8326      31.2694      29.3692
100177............................       1.3177       0.9826      24.5078      25.3973      26.6781      25.6089
100179............................       1.7603       0.9303      24.1801      26.6537      29.5619      26.9037
100180............................       1.3719       0.9292      24.9433      26.3299      27.1804      26.1924
100181............................       1.0880       0.9757      18.1320      19.5022      21.8540      19.8108
100183............................       1.1753       0.9757      24.4575      26.7893      27.4951      26.3276
100187............................       1.2686       0.9757      23.4760      26.1394      27.3653      25.7401
100189............................       1.3096       1.0508      26.6846      26.5763      28.4136      27.3048
100191............................       1.3075       0.9292      24.1911      24.3553      26.6340      25.0785
100200............................       1.3785       1.0508      24.8120      28.0926      29.8963      27.6635
100204............................       1.5254       0.9461      22.2613      24.4697      25.7537      24.2423
100206............................       1.2968       0.9292      22.8782      23.0340      25.2196      23.7228
100208............................          ***            *      24.1482      24.9854            *      24.5807
100209............................       1.3575       0.9757      23.8502      25.0778      26.6246      25.2683
100210............................       1.5359       1.0508      26.0933      28.6449      28.9486      27.9114
100211............................       1.1787       0.9292      24.3243            *      24.7095      24.5352
100212............................       1.4636       0.8955      22.6584      24.2669      24.7566      23.9351
100213............................       1.5843       0.9554      24.4467      25.1893      27.1983      25.6153
100217............................       1.1771       1.0162      24.0291      25.2635      25.2907      24.8791
100220............................       1.6524       0.9333      24.9733      25.0154      26.0905      25.3692
100223............................       1.5843       0.8877      21.2434      23.4556      24.7015      23.2004
100224............................       1.2340       1.0508      23.0804      23.3593      24.8077      23.7932
100225............................       1.2707       1.0508      23.9971      27.9473      28.4316      26.8326
100226............................       1.2697       0.9303      23.8701      27.8003      29.3317      27.1288
100228............................       1.3187       1.0508      26.2593      27.2873      29.8952      28.0013
100229............................          ***            *      21.0038            *            *      21.0038
100231............................       1.6878       0.8613      23.5418      24.6994      25.5175      24.6455
100232 h..........................       1.2214       0.9303      21.8105      23.9405      24.9322      23.5285
100234............................       1.3110       1.0061      24.9141      25.2574      26.3601      25.5144
100236............................       1.3623       0.9274      23.9781      25.9282      26.6585      25.5663
100237............................       1.9568       1.0508      26.7664      25.6112      31.3543      27.7849
100238............................       1.5077       0.9292      24.6513      27.1748      28.4302      26.8154

[[Page 23496]]

 
100239............................       1.2789       0.9554      25.0509      26.9668      27.7592      26.6605
100240............................       0.9534       0.9757      23.0650      23.4830      25.3265      24.0024
100242............................       1.3586       0.8613      20.4681      21.5130      24.0990      22.0856
100243............................       1.5324       0.9292      23.2812      25.2987      26.1131      24.9766
100244............................       1.3330       0.9333      23.4876      24.1515      25.2584      24.3502
100246............................       1.6049       1.0162      26.7630      27.6382      28.9894      27.8151
100248............................       1.4986       0.9292      23.8742      25.9170      27.7797      25.9263
100249............................       1.2539       0.8955      21.3942      23.4021      23.2084      22.6697
100252............................       1.1974       1.0162      22.6475      24.9860      25.8540      24.5257
100253............................       1.3797       1.0061      23.6939      24.4051      25.7121      24.6472
100254............................       1.5814       0.8712      23.2794      25.0192      25.7338      24.6995
100255............................       1.1947       0.9292      22.9793      22.2341      24.1169      23.1055
100256............................       1.9673       0.9292      24.1969      26.0629      28.8856      26.4333
100258............................       1.4847       1.0061      24.5699      31.8772      31.2482      29.0443
100259............................       1.2244       0.9292      24.1148      24.9404      26.0175      25.0705
100260............................       1.3413       1.0162      23.5164      25.2630      27.5188      25.5518
100262............................          ***            *      23.8006      26.3954            *      25.1412
100264............................       1.2531       0.9292      22.4800      25.0250      25.5489      24.4115
100265............................       1.2774       0.9292      21.0688      23.4758      23.6151      22.8276
100266............................       1.4031       0.8613      21.5258      22.6614      23.2340      22.5196
100267............................       1.2776       0.9554      23.3760      26.5059      27.3768      25.7444
100268............................       1.1529       1.0061      26.0297      29.8289      29.2898      28.4053
100269............................       1.3034       1.0061      24.9002      25.3228      26.7450      25.7303
100275............................       1.2616       1.0061      23.1419      24.3059      26.0361      24.5544
100276............................       1.2369       1.0508      25.4557      27.2589      30.0576      27.6322
100277............................       1.3339       0.9757      25.2985      47.3905      16.5427      24.0477
100279............................       1.2334       0.9333      24.8484      25.4909      26.8606      25.7747
100281............................       1.2641       1.0508      25.3382      27.0864      28.6660      27.1929
100284............................       1.0813       0.9757      22.3046      22.5927      23.8170      22.9628
100286............................       1.5579       1.0115            *      27.1051      29.4284      28.3288
100287............................       1.3676       1.0061            *      28.2229      28.3427      28.2858
100288............................       1.5140       1.0061            *      37.4785      33.8141      35.4781
100289............................       1.7415       1.0508            *      28.4504      29.2915      28.8970
100290............................       1.1280       0.8613            *            *      23.5080      23.5080
100292............................       1.2103       0.8672            *            *      25.9093      25.9093
110001............................       1.2172       0.9637      24.0561      25.1164      25.2695      24.8146
110002............................       1.2471       0.9637      20.4502      21.8616      25.3897      22.5380
110003............................       1.2762       0.9303      19.7061      20.0968      21.4002      20.4029
110004............................       1.2242       0.9099      21.8791      22.7929      23.9911      22.8563
110005............................       1.1543       0.9637      23.6146      22.3645      22.8082      22.9077
110006............................       1.4983       0.9813      23.8762      25.0719      28.6090      25.8225
110007............................       1.5952       0.8645      28.2025      30.7430      23.8785      27.0990
110008............................       1.3541       0.9637      22.6308      23.4662      27.0198      24.4256
110010............................       2.1112       0.9637      27.2029      28.7690      29.7142      28.5850
110011............................       1.1841       0.9637      23.2149      25.4620      26.0899      24.9213
110015............................       1.1253       0.9637      23.2280      25.5661      26.6610      25.2080
110016............................       1.1938       0.7684      18.8228      18.8376      21.7610      19.7802
110018............................       1.1764       0.9637      24.7007      25.6485      28.2431      26.2640
110020............................       1.2808       0.9637      23.3004      24.8735      26.8501      25.0177
110023............................       1.3725       0.9637      23.5673      25.3746      27.3029      25.5307
110024............................       1.3712       0.9483      22.1471      23.8091      25.7205      23.8901
110025............................       1.4319       0.9303      29.0965      31.5253      26.1311      28.6493
110026............................       1.1005       0.7684      19.3201      20.5740      21.2826      20.4005
110027............................       1.0627       0.7684      19.8351      19.2323      20.2175      19.7328
110028............................       1.7504       0.9567      25.9474      25.1836      27.9184      26.3393
110029............................       1.6515       0.9637      22.7981      25.2335      24.8893      24.3542
110030............................       1.1953       0.9637      22.2341      25.0842      26.4770      24.7162
110031............................       1.2600       0.9637      22.8695      24.1711      26.0384      24.4325
110032............................       1.1631       0.7684      18.0744      20.7211      21.9407      20.2437
110033............................       1.3973       0.9637      24.1447      25.2326      28.3210      25.8930
110034............................       1.6993       0.9567      24.0791      24.4141      27.0099      25.1876
110035............................       1.4949       0.9637      24.2581      25.7562      27.5532      25.9518
110036............................       1.7799       0.9483      24.4788      25.4854      26.8789      25.6507
110038............................       1.5400       0.8420      20.1710      20.5880      21.2138      20.6802
110039............................       1.4119       0.9567      17.0608      19.4032      19.7892      18.7582
110040............................       1.1097       0.9637      17.3095      18.8744      19.7509      18.6568
110041............................       1.2580       0.9684      20.8080      21.5402      23.4074      21.9417

[[Page 23497]]

 
110042............................       1.0979       0.9637      25.5588      26.8321      23.4645      25.2397
110043............................       1.7289       0.9483      22.7589      25.2788      26.7522      24.9357
110044............................       1.1609       0.7684      19.2562      19.6940      20.9654      19.9819
110045............................       1.1384       0.9637      19.7746      21.3922      24.9821      22.1119
110046............................       1.1501       0.9637      21.6201      24.0022      23.8292      23.2190
110049............................       0.9635       0.7684      18.9096      19.8706            *      19.4074
110050............................       1.0937       0.9033            *      25.6020            *      25.6020
110051............................       1.1347       0.7684      17.6816      19.0995      19.4276      18.7634
110054............................       1.4875       0.9637      20.5387      22.2250      25.7085      22.7254
110056............................       0.9430       0.7684      21.7608      23.0080            *      22.3710
110059............................       1.0697       0.7684      19.9802      18.7097      20.5565      19.6943
110061............................          ***       0.8873      18.6696            *            *      18.6696
110064............................       1.4700       0.8570      21.7636      23.8739      24.2739      23.3486
110069............................       1.2734       0.9087      21.0518      22.3006      24.1669      22.5324
110071............................       0.9739       0.7684      15.2336      13.3731      18.0224      15.4555
110073............................       1.0759       0.7684      15.2711      16.3610      18.6336      16.6863
110074............................       1.4999       0.9813      24.4094      27.5836      27.0337      26.3402
110075............................       1.2670       0.9316      20.4634      20.9973      22.0935      21.2149
110076............................       1.4563       0.9637      23.8211      25.2424      26.3506      25.1774
110078............................       2.0424       0.9637      28.2149      27.8627      24.8746      26.9445
110079............................       1.3966       0.9637      22.8017      24.5255      23.1024      23.4646
110080............................       1.2439       0.9637      24.1958      21.5482      22.3213      22.5788
110082............................       1.9154       0.9637      27.2931      28.9731      29.8366      28.7072
110083............................       1.9070       0.9637      24.6460      26.2604      27.8245      26.3029
110086............................       1.3847       0.7684      18.8751      20.8557      21.1509      20.2673
110087............................       1.4065       0.9637      25.7908      26.2872      28.0471      26.7332
110089............................       1.1502       0.7684      20.6757      21.2013      21.9509      21.2887
110091............................       1.2996       0.9637      24.3354      26.3857      26.5523      25.8218
110092............................       1.0125       0.7684      16.9116      18.7397      18.5527      18.0853
110095............................       1.3953       0.8710      20.1024      21.8709      23.4846      21.8636
110096............................       0.9779       0.7684      18.5513      19.4498            *      19.0000
110100............................       0.9643       0.7684      15.1316      16.5833      16.5600      16.0845
110101............................       1.0706       0.7684      13.3943      14.4630      16.4270      14.7428
110104............................       1.0494       0.7684      17.9805      19.5575      18.7951      18.8040
110105............................       1.3229       0.7684      19.2156      20.6270      21.1077      20.3365
110107............................       1.8630       0.9485      21.8167      26.0763      26.2526      24.6977
110109............................       1.0104       0.7684      18.7397      20.4726      21.4280      20.2690
110111............................       1.1313       0.9567      20.9535      20.5577      29.2190      22.9282
110112............................       0.9374       0.7684      20.4565      21.0612      24.2463      21.7104
110113............................       1.0686       0.9567      18.0770      16.7641      19.1753      18.0155
110115............................       1.6816       0.9637      26.3274      29.8699      32.0197      29.3454
110118............................          ***       0.7684      17.7344            *            *      17.7344
110121............................       1.0384       0.7684      19.5230      21.2534      21.6637      20.8173
110122............................       1.5295       0.8420      20.4184      22.0210      23.7589      22.1314
110124............................       1.0742       0.7684      19.7004      20.9334      22.7058      21.1178
110125............................       1.2373       0.9087      19.8695      22.1458      22.4238      21.5044
110128............................       1.2076       0.9316      28.4943      23.2576      24.4596      24.9779
110129............................       1.5230       0.8570      21.8204      22.4202      23.3631      22.5595
110130............................       0.9412       0.7684      17.5272      17.6529      18.7549      18.0115
110132............................       1.0349       0.7684      17.2924      18.9927      19.2307      18.5224
110135............................       1.2847       0.7684      18.5125      20.0057      20.4411      19.6750
110136............................       1.0675       0.7684      21.1235      22.7715      15.3030      19.7964
110142............................       0.9587       0.7684      16.3359      17.3328      18.1980      17.2921
110143............................       1.3701       0.9637      24.3898      25.4932      24.2240      24.6996
110146............................       1.0472       0.7684      17.2250      19.9221      23.9067      20.1122
110149............................       1.3335       0.9637      25.3619      24.7686      27.1477      25.8232
110150............................       1.2656       0.9087      22.7366      23.8157      22.6624      23.0726
110153............................       1.1467       0.9087      21.5300      22.8660      24.5368      22.9872
110155............................          ***            *      16.1785            *            *      16.1785
110163............................       1.4114       0.8645      21.9411      25.5461      26.0764      24.4314
110164............................       1.5149       0.9485      23.7801      26.4450      27.0600      25.7931
110165............................       1.3808       0.9637      23.4071      24.3897      26.8378      24.9170
110166............................          ***       0.9485      23.6665      25.2264      26.8070      25.1758
110168............................       1.8280       0.9637      23.3426      24.6321      27.0022      25.0628
110169............................          ***            *      24.7083            *            *      24.7083
110172............................       1.1832       0.9637      25.2396      27.0240      29.1703      27.1002
110177............................       1.6699       0.9567      24.0700      25.0129      26.7504      25.3590

[[Page 23498]]

 
110179............................          ***            *      26.0365      26.1173      26.0759      26.0760
110183............................       1.2345       0.9637      26.4248      27.6020      26.8591      26.9602
110184............................       1.2007       0.9637      24.3379      25.5420      23.3803      24.3763
110186............................       1.3771       0.8570      21.1176      23.2348      25.0299      23.1796
110187............................       1.2237       0.9637      23.2571      22.5730      24.2933      23.3967
110188............................          ***            *      24.4785            *            *      24.4785
110190............................       1.0046       0.7684      21.9008      19.1054      14.2517      17.7557
110191............................       1.2930       0.9637      24.0572      25.8409      26.8277      25.5872
110192............................       1.3222       0.9637      24.3823      25.7406      26.7852      25.7103
110193............................       1.4229       0.9637      25.1779      27.8223      27.3341      26.8213
110194............................       0.9346       0.7684      16.8075      16.3148      18.4776      17.2529
110198............................       1.3834       0.9637      28.0634      30.8014      31.7748      30.3084
110200............................       1.8830       0.8570      20.1816      21.2177      22.3249      21.2486
110201............................       1.3894       0.9485      24.1171      27.0388      28.2232      26.3653
110203............................       0.9912       0.9637      30.2609      25.8951      26.8768      27.4232
110205............................       1.0674       0.9637      23.1969      20.6150      19.7409      21.0203
110209............................       0.5352       0.7684      17.4145      19.1000      19.0450      18.5793
110212............................       1.0406       0.8873      18.7651      20.9365      40.5120      27.9394
110215............................       1.2618       0.9637      22.5679      23.9657      25.7886      24.2458
110218............................          ***            *            *      26.1073            *      26.1073
110219............................       1.3845       0.9637            *      27.1880      27.0362      27.1115
120001............................       1.7853       1.1206      30.0871      31.7108      34.6602      32.1463
120002............................       1.2134       1.0598      24.2715      26.9900      29.9913      27.2572
120004............................       1.2673       1.1206      26.8010      28.3569      28.6527      27.9367
120005............................       1.2757       1.0598      23.0113      26.9053      29.3405      26.3828
120006............................       1.2232       1.1206      28.1562      29.6751      31.1372      29.6846
120007............................       1.6776       1.1206      27.8497      28.7964      30.4247      29.0434
120010............................       1.6785       1.1206      25.4050      27.1265      30.1659      27.2823
120011............................       1.4508       1.1206      30.9308      31.7447      34.1643      32.3199
120014............................       1.2099       1.0598      25.3682      28.0786      28.6416      27.3772
120016............................       1.6705            *      39.1173      52.1034      19.6034      33.6763
120019............................       1.2043       1.0598      24.4036      28.9661      30.3809      27.8836
120022............................       1.8525       1.1206      22.4951      24.7875      26.6100      24.7024
120025............................          ***       1.0598      40.2473      48.7148      30.2358      39.7283
120026............................       1.2887       1.1206      26.3653      28.5048      30.3293      28.4200
120027............................       1.2295       1.1206      24.9464      26.4630      28.4378      26.4965
120028............................       1.2577       1.1206      29.5070      31.3195      30.3794      30.4272
130002............................       1.3569       0.9048      20.1143      21.6626      23.6078      21.8876
130003............................       1.3696       1.0061      23.9403      25.4904      27.6345      25.7287
130005............................          ***            *      24.4844      25.2550      25.7523      25.1326
130006............................       1.7884       0.9048      22.8567      24.3982      25.3221      24.2894
130007............................       1.7321       0.9048      22.8475      24.8764      24.9562      24.2827
130011............................       1.2145       0.8810      23.1120      22.9336            *      23.0196
130013............................       1.2894       0.9048      23.5316      26.3118      27.9209      25.9669
130014............................       1.1794       0.9048      21.6495      23.4789      24.3884      23.2115
130018............................       1.5937       0.8810      22.2249      23.9798      26.4125      24.2860
130021............................          ***       0.8810      18.0006      18.9400      16.1658      17.7607
130022............................       1.1803       0.8810      21.5602            *            *      21.5602
130025............................       1.1842       0.8810      18.7814      19.7066      20.1452      19.5513
130026............................       1.1103       0.8810      24.4976      25.4020            *      24.9502
130028............................       1.3641       0.9348      21.1492      25.2938      26.3443      24.2492
130036............................          ***            *      18.5921      16.7907            *      17.6689
130045............................          ***       0.9183      19.0270            *            *      19.0270
130060............................          ***            *      24.6773      26.7516            *      25.7861
130062............................          ***       0.9409      24.0494      16.7951      20.6642      20.3051
130063............................       1.4243       0.9048      18.8782      20.9502      22.5904      20.7967
140001............................       1.0825       0.8285      20.0247      21.4779      22.3170      21.3141
140002............................       1.2711       0.8953      23.0207      24.4908      24.6954      24.0687
140003............................       1.0209       0.8285      19.2097      22.6230            *      20.9305
140005............................          ***       0.8285      13.2365            *            *      13.2365
140008............................       1.4951       1.0846      26.3287      27.2211      28.5297      27.3790
140010............................       1.4434       1.0846      29.0224      31.5774      36.6365      32.6197
140011............................       1.1508       0.8285      19.0903      20.6338      22.4091      20.7429
140012............................       1.2283       1.0698      24.4070      24.3675      28.6564      25.7920
140013............................       1.4165       0.8844      19.9800      22.6022      23.3065      21.9604
140015............................       1.3843       0.8953      21.4328      22.2266      23.0600      22.2778
140016............................       1.0074       0.8285      16.3417      17.1372      18.1242      17.2195

[[Page 23499]]

 
140018............................       1.4161       1.0846      24.3285      27.3334      27.7548      26.4350
140019............................       0.9635       0.8285      17.4206      18.4554      18.9228      18.2432
140024............................       0.9981       0.8285      15.6616      16.9672      17.5249      16.7192
140026............................       1.1611       0.8285      20.4084      21.6847      23.0470      21.6994
140027............................       1.1589       0.8285      20.9855      22.6208            *      21.8225
140029............................       1.5505       1.0846      25.0485      27.7304      28.9717      27.3787
140030............................       1.6859       1.0846      26.5733      28.7623      29.3100      28.2629
140032............................       1.1817       0.8953      20.6273      22.8157      24.0574      22.5257
140033............................       1.2115       1.0444      23.4279      26.1553      25.6068      25.0497
140034............................       1.2308       0.8953      20.9635      22.1003      23.0034      21.9987
140037............................       0.8583       0.8285      15.5578            *            *      15.5578
140043............................       1.2327       0.9667      23.3751      26.0330      26.7996      25.3939
140045............................       1.0328       0.8285      18.9587      21.0042      20.6548      20.2345
140046............................       1.4582       0.8953      21.7969      22.5022      23.2127      22.5567
140048............................       1.2496       1.0846      25.9122      27.0874      28.2222      27.0819
140049............................       1.5568       1.0846      21.9546      26.6533      27.4009      25.3465
140051............................       1.5044       1.0846      24.2472      27.9935      27.7901      26.6740
140052............................       1.1992       0.8953      21.8161      22.2588      23.5662      22.5560
140053............................       1.8567       0.8879      22.6099      23.5477      24.8455      23.6468
140054............................       1.4302       1.0846      35.5659      31.7265      31.8564      32.8769
140058............................       1.2547       0.8953      20.5089      22.1269      22.8423      21.8133
140059............................       1.0783       0.8953      19.9777      22.7121      22.4651      21.7552
140061............................       0.9751       0.8953      22.7515      30.9925      20.8063      24.6734
140062............................       1.2085       1.0846      30.7005      31.2359      34.7113      32.2167
140063............................       1.3649       1.0846      30.5430      26.5584      27.8306      28.2367
140064............................       1.1568       0.8844      20.6505      21.7470      22.0407      21.4911
140065............................       1.3774       1.0846      26.3521      26.1904      34.6406      28.8914
140066............................       1.1153       0.8953      18.0915      20.4353      19.4775      19.2927
140067............................       1.8344       0.8844      21.9579      23.5906      25.3986      23.6801
140068............................       1.1769       1.0846      24.1316      25.8963      27.3956      25.8156
140070............................          ***            *      25.2960            *            *      25.2960
140077............................       0.9555       0.8953      18.0487      19.0922      19.1363      18.7657
140079............................          ***            *      25.7090      29.3040            *      27.5634
140080............................       1.4264       1.0846      24.4056      26.0109      23.2575      24.4826
140082............................       1.3940       1.0846      25.0474      26.8077      25.6645      25.8332
140083............................       1.0155       1.0846      23.2822      24.6491      26.5562      24.8886
140084............................       1.1998       1.0444      25.4818      27.6819      29.2515      27.5306
140088............................       1.8091       1.0846      28.4219      31.0364      32.4978      30.6729
140089............................       1.1918       0.8285      20.7632      22.1227      23.3401      22.0452
140090............................          ***            *      35.0300            *            *      35.0300
140093............................       1.1539       0.9048      21.5376      22.1540      25.3127      22.9099
140094............................       1.0354       1.0846      24.2166      25.3678      27.0578      25.5410
140095............................       1.2149       1.0846      24.7706      29.9746      27.6799      27.5947
140100............................       1.2204       1.0444      27.1868      32.8743      37.0819      32.5610
140101............................       1.1371       1.0846      24.6106      25.4784      28.5365      26.3107
140102............................       1.0407       0.8285      19.8678      21.2278            *      20.5493
140103............................       1.2439       1.0846      21.2404      21.7512      23.3258      22.1297
140105............................       1.2336       1.0846      27.3323      26.3054      27.4531      27.0018
140109............................       1.1423       0.8285      16.4261      17.8103      19.5675      17.9602
140110............................       1.0533       1.0698      21.9880      25.6561      27.9844      25.2166
140113............................       1.5519       0.9591      25.6621      23.5337      26.7969      25.2477
140114............................       1.4645       1.0846      24.1926      25.7968      28.3014      26.1695
140115............................       1.1252       1.0846      25.3410      26.3677      25.1498      25.6313
140116............................       1.2744       1.0846      26.8924      30.5166      31.9902      29.9696
140117............................       1.5049       1.0846      23.3531      25.6314      26.8973      25.3122
140118............................       1.6963       1.0846      26.7350      27.7392      29.7570      28.1023
140119............................       1.7432       1.0846      31.3486      33.6302      36.1419      33.6518
140120............................       1.2478       0.8844      20.3237      22.5795      22.7375      21.8812
140121............................       1.6002       0.8844      17.6019            *            *      17.6019
140124............................       1.2606       1.0846      30.9648      35.2798      36.1327      34.0784
140125............................       1.2180       0.8953      19.5359      20.7189      20.4014      20.2151
140127............................       1.5733       0.9083      21.3102      22.8172      24.1658      22.7988
140129............................          ***       0.8285      21.6495            *            *      21.6495
140132............................          ***            *      23.0595            *            *      23.0595
140135............................       1.3954       0.8285      19.7919      21.2104      22.3264      21.1811
140137............................       1.0383       0.8953      21.6017      20.5053      21.4700      21.1955
140140............................       1.0049       0.8285      19.1636      21.4710            *      20.3063

[[Page 23500]]

 
140141............................       1.0111       0.8953      20.3706      23.0515      21.7871      21.7302
140143............................       1.1472       0.8844      22.0009      23.8255      26.2954      24.0154
140144............................       0.9464       1.0846      26.9258      27.8046            *      27.3474
140145............................       1.1245       0.8953      19.6429      21.6168      23.4608      21.6090
140147............................       1.1208       0.8285      18.2692      19.5896      19.8541      19.2467
140148............................       1.7042       0.8879      21.5777      23.0022      25.2030      23.2104
140150............................       1.5763       1.0846      32.9291      33.9013      35.2711      34.0702
140151............................       0.8471       1.0846      21.5167      22.4842      23.4879      22.5018
140152............................       1.1463       1.0846      28.5468      29.6882      27.6086      28.6011
140155 \2\........................       1.2537       1.0991      25.2034      27.6610      28.9724      27.2937
140158............................       1.3922       1.0846      22.5638      23.8542      28.6818      24.8001
140160............................       1.2262       0.9667      20.9986      22.7002      24.5373      22.7502
140161............................       1.1181       1.0698      22.2191      24.1071      23.1647      23.1691
140162............................       1.5842       0.9083      22.6426      26.0312      27.4472      25.4182
140164............................       1.7335       0.8953      19.7774      22.0424      23.7457      21.8696
140165............................       1.0648       0.8285      17.0666      15.9312      16.6304      16.5175
140166............................       1.1685       0.8285      20.7849      21.7776      23.1005      21.8859
140167............................       1.0308       0.8285      19.5959      19.7610      22.8911      20.7477
140168............................       1.1558       0.8953      18.7504      20.0225            *      19.4021
140170............................       0.9276       0.8285      17.0665      17.1608            *      17.1147
140171............................          ***       0.8285      17.3214            *            *      17.3214
140174............................       1.4550       1.0846      23.6893      24.7011      27.8131      25.3970
140176............................       1.2096       1.0846      25.6824      28.9378      31.3490      28.8390
140177............................       0.8782       1.0846      20.8526      19.3328      22.5610      20.9656
140179............................       1.3651       1.0846      24.1539      26.3200      27.6376      26.0525
140180............................       1.2658       1.0846      25.4022      27.4366      28.3649      27.0717
140181............................       1.1677       1.0846      23.7308      23.6034      25.0100      24.1182
140182............................       1.4864       1.0846      32.1969      28.0337      28.2211      28.8901
140184............................       1.2150       0.8285      20.6499      20.1279      21.1802      20.6885
140185............................       1.4160       0.8953      20.0903      22.0222      23.8531      22.0093
140186 \2\........................       1.4842       1.0991      26.0970      28.1977      31.7593      28.8521
140187............................       1.4808       0.8953      20.5829      22.0674      23.2892      21.9710
140189............................       1.1406       0.9335      22.5875      25.6954      23.7198      24.0159
140190............................       1.0678       0.8285      17.9193      18.8530      19.8297      18.8585
140191............................       1.3038       1.0846      24.5446      25.2817      25.8813      25.2456
140193............................       0.9615       0.8285      20.5958      22.9443            *      21.7731
140197............................       1.2361       1.0846      19.2980      21.8060      23.0684      21.2577
140199............................       1.0379       0.8285      19.7888      21.3464      22.0315      21.0597
140200............................       1.4887       1.0846      24.1358      24.9217      26.6881      25.2459
140202............................       1.5458       1.0444      26.2460      27.4336      29.7870      27.9702
140203............................       1.0810       1.0846      26.5789      28.2212            *      27.4338
140205............................       0.5846       0.9975      25.1010            *            *      25.1010
140207............................       1.3693       1.0846      23.3197      25.7331      24.1048      24.4812
140208............................       1.6342       1.0846      27.4671      27.6586      29.4708      28.2131
140209............................       1.5435       0.8844      22.0813      23.3886      24.4266      23.3169
140210............................       1.0967       0.8285      15.5339      16.6729      19.2639      17.1406
140211............................       1.3023       1.0846      25.8556      29.5114      29.7054      28.4947
140213............................       1.1645       1.0846      27.4607      29.1649      30.2945      29.0178
140215............................          ***            *      18.6962      22.3097            *      20.4262
140217............................       1.4239       1.0846      24.7146      29.3711      31.5324      28.5274
140223............................       1.4296       1.0846      27.4355      29.2540      30.4923      29.0769
140224............................       1.3921       1.0846      27.1725      29.0350      28.2177      28.1560
140228............................       1.5304       0.9975      22.9899      25.0074      25.6419      24.5738
140231............................       1.4741       1.0846      25.5536      28.3545      30.6410      28.2754
140233............................       1.5549       1.0698      24.7103      27.3379      28.6305      26.9841
140234............................       1.0501       0.8844      20.8676      23.2604      23.6928      22.6766
140239............................       1.5495       0.9975      23.9205      24.2112      29.0092      25.6976
140240............................       1.3929       1.0846      25.0325      27.2654      31.8945      27.8715
140242............................       1.4842       1.0846      28.8686      30.4005      32.0522      30.5576
140245............................       0.9866       0.8285      15.2537      16.0772            *      15.6642
140246............................          ***       0.8285      16.1305            *            *      16.1305
140251............................       1.2806       1.0846      24.8256      26.7266      27.1870      26.2433
140252............................       1.3977       1.0846      28.3479      30.2656      33.3885      30.8286
140258............................       1.5252       1.0846      27.5741      27.9478      30.2639      28.6430
140271............................       0.8733       0.8285      17.5174      18.8535            *      18.2163
140275............................       1.2740       0.8716      23.1871      25.2824      26.1473      24.8583
140276............................       1.7772       1.0846      25.3222      27.5936      29.1983      27.3299

[[Page 23501]]

 
140280............................       1.4521       0.8716      21.7004      21.9302      23.4343      22.3632
140281............................       1.6920       1.0846      27.9115      29.2602      30.4849      29.2420
140285............................          ***       0.8879            *      17.7824      20.7576      19.1679
140286............................       1.1088       1.0846      25.5805      28.4378      29.1543      27.7906
140288............................       1.5237       1.0846      26.3572      26.9581      29.3988      27.5648
140289............................       1.3248       0.8953      20.7506      22.3274      22.6211      21.9308
140290............................       1.3237       1.0846      29.9098      28.6926      31.7341      30.1371
140291............................       1.2597       1.0698      27.6675      28.2338      29.8958      28.6610
140292............................       1.1534       1.0846      26.4077      26.1781      27.6230      26.7673
140294............................       1.1263       0.8285      21.7473      22.6123      23.4504      22.6034
140300............................       1.1599       1.0846      30.5172      33.3983      34.8568      32.8808
140301............................       1.1555       1.0846            *            *      31.7073      31.7073
150001............................       1.1532       0.9922      25.4897      27.1021      29.6844      27.4774
150002............................       1.3813       1.0698      22.3327      23.3804      25.0063      23.5866
150003............................       1.6528       0.8730      21.0944      23.3196      25.3458      23.2610
150004............................       1.5181       1.0698      23.6169      24.8884      26.8458      25.1066
150005............................       1.1975       0.9922      23.8818      25.4443      27.2369      25.6152
150006............................       1.2943       0.9785      23.1779      24.8976      26.4061      24.8616
150007............................       1.2960       0.9555      22.1098      23.5841      26.6073      24.2353
150008............................       1.4015       1.0698      23.8916      23.6953      26.6928      24.7814
150009............................       1.3653       0.9264      19.4763      20.4993      22.2147      20.7473
150010............................       1.3255       0.9555      22.5445      23.9740      26.8524      24.4792
150011............................       1.1602       0.9776      22.1559      23.2249      24.3490      23.2593
150012............................       1.5342       0.9785      23.1644      22.9314      27.3031      24.2924
150013............................       0.9799       0.8632      19.8564      19.7689      21.8465      20.4949
150014............................       1.2880       0.9922      24.3754      26.5785            *      25.4309
150015............................       1.3161       1.0698      23.1616      24.3015      26.2434      24.6064
150017............................       1.8224       0.9797      22.7979      23.7180      25.2342      23.9446
150018............................       1.6280       0.9616      24.6138      24.7048      26.3289      25.2344
150019............................       1.0534       0.8632      17.3170            *            *      17.3170
150021............................       1.7262       0.9797      24.3658      27.8168      29.6967      27.2581
150022............................       1.0471       0.8632      22.2973      22.8035      22.6773      22.6089
150023............................       1.5248       0.8632      20.6926      23.1253      23.7159      22.4697
150024............................       1.3936       0.9922      21.7593      24.7879      27.1589      24.7582
150026............................       1.2781       0.9616      23.2169      23.7185      28.1127      25.1166
150027............................       0.9951       0.9922      21.5766      21.2855      17.4862      19.9164
150029............................       1.4269       0.9785      25.2067      23.4103      26.9680      25.0754
150030............................       1.2034       0.9776      23.0196      24.4361      26.9533      24.8565
150031............................       1.0678       0.8632      18.9180            *            *      18.9180
150034............................       1.4639       0.9366      22.8812      23.9388      26.0465      24.3610
150035............................       1.4585       0.9366      23.5468      26.0952      26.6620      25.4702
150037............................       1.2877       0.9922      24.4997      27.7009      28.5451      26.8949
150038............................       1.0995       0.9922      21.6608      24.4188      28.8054      24.9650
150042............................       1.3907       0.8632      23.7838      21.9917      23.0102      22.8781
150044............................       1.3121       0.9264      20.5156      23.1200      23.7065      22.4683
150045 h..........................       1.0499       0.9797      23.0361      24.2899      25.2225      24.2205
150046............................       1.4135       0.8632      20.3453      21.0417      21.9369      21.1254
150047............................       1.7002       0.9797      24.8786      24.5455      25.8349      25.1035
150048............................       1.3259       0.9604      22.5181      24.5864      27.1817      24.7509
150049............................       1.1169       0.8632      18.4942      20.2178      22.3370      20.2342
150051............................       1.5540       0.8632      21.4009      22.6866      23.7061      22.5941
150052 h..........................       1.0320       0.9264      19.1070      19.6073      20.6339      19.7871
150056............................       1.8253       0.9922      24.7841      27.6754      28.2842      26.9368
150057............................       2.0135       0.9922      28.0884      22.7804      24.8605      24.9551
150058............................       1.5550       0.9785      24.9479      26.9753      27.5341      26.5322
150059............................       1.5671       0.9922      25.6738      27.0792      28.5715      27.1975
150060............................       1.0728       0.8632      19.8990      23.2409      24.8544      22.6276
150061............................       1.1040       0.8632      19.2826      21.3640      22.2822      20.9919
150062............................       1.1136       0.8632      22.9214      23.5550      24.6088      23.7293
150063............................          ***            *      24.4091      19.0377            *      21.8339
150064............................       1.1597       0.8632      21.2512      21.6370      23.7707      22.2400
150065............................       1.2439       0.9776      23.0636      24.4451      25.9461      24.5094
150067............................       1.0162       0.8632      21.4374            *            *      21.4374
150070............................       0.9415       0.8632      20.7413      22.6260            *      21.7117
150072............................       1.1999       0.8632      18.5447      20.3191      20.5111      19.8274
150073............................          ***            *      14.8287            *            *      14.8287
150075............................       1.0759       0.9797      20.1119      24.2085      24.0745      22.8038

[[Page 23502]]

 
150076............................       1.2278       0.9785      25.4519      24.1434      28.1874      25.9085
150078............................       0.9426       0.8632      20.1259      21.2476      21.9771      21.1303
150079............................       1.0871       0.9264      19.3860      20.6486      21.4067      20.5165
150082............................       1.7137       0.8735      21.0651      22.2054      25.5860      22.9776
150084............................       1.7636       0.9922      27.8354      28.7722      29.3905      28.6939
150086............................       1.2074       0.9604      21.5815      22.4471      23.9404      22.7151
150088............................       1.2662       0.9776      22.2627      23.0998      23.6253      23.0168
150089............................       1.4706       0.8952      21.6806      22.6545      25.0449      23.0977
150090............................       1.4690       1.0698      24.9021      24.6758      26.2899      25.3163
150091 h..........................       1.0853       0.9797      26.4248      27.8087      30.6209      28.2762
150096............................       0.9741       0.8632      19.7975      21.9091      23.8092      21.8206
150097............................       1.0577       0.9922      22.4564      24.4179      25.0367      24.0346
150100............................       1.6892       0.8735      21.2980      22.2687      24.3530      22.6387
150101............................       1.0267       0.9797      26.1271      27.9745      29.1657      27.6430
150102............................       1.0711       0.9366      21.3313      22.6870      24.5923      22.8112
150104............................       1.0414       0.9922      21.0799      21.8172      25.5871      22.8454
150106 h..........................       1.0517       0.9797      19.1976      20.9955      20.9387      20.4063
150109............................       1.3698       0.8730      23.4642      24.3786      23.5865      23.8124
150112............................       1.4147       0.9776      23.5151      24.7455      26.5643      24.9478
150113............................       1.1907       0.9776      21.2412      23.0450      24.8760      23.1460
150115............................       1.3246       0.8632      20.3863      20.5215      19.3411      20.0486
150122............................       1.1182       0.8632      22.2752      24.2471      26.0173      24.2508
150123............................          ***       0.8735      15.5997      15.3050            *      15.4580
150124............................       1.1187       0.8632      17.9063      18.8218      21.3933      19.4269
150125............................       1.4937       1.0698      23.1464      24.3872      26.7666      24.8140
150126............................       1.4161       1.0698      24.1917      25.5585      26.9887      25.6255
150128............................       1.3711       0.9922      20.9869      23.1660      26.4976      23.5710
150129............................       1.1881       0.9922      34.3166      35.4311      29.9099      32.9368
150130............................       1.0196       0.8735      18.5578      21.5678      21.7399      20.5294
150132............................       1.3880       1.0698      22.2707      24.2559      25.6257      24.1021
150133............................       1.2457       0.9797      21.8807      21.8839      22.7293      22.1682
150134............................       1.0951       0.9264      20.7680      22.1085      23.8526      22.2228
150136............................          ***       0.9922      25.8467      25.7004      26.2703      25.9403
150146............................       1.0119       0.9797      25.1827      26.1168      29.3383      26.7878
150147............................       1.1985       1.0698            *      32.3336      22.8456      26.0420
150148............................          ***            *      26.2188      27.2081            *      26.7661
150149............................       0.9756       0.8735            *      23.8554      23.6361      23.7419
150150............................       1.2639       0.9797            *      26.5138      25.5331      26.0172
150151............................          ***            *            *            *      38.1446      38.1446
150152............................          ***       0.9922            *            *      44.7143      44.7143
160001............................       1.1965       0.9231      22.8426      23.8657      25.1220      23.9155
160002............................          ***       0.8563      19.9607            *            *      19.9607
160005............................       1.1819       0.8563      20.3313      21.1745      21.8950      21.1337
160008............................       1.0624       0.8563      17.9463      19.8066      20.7200      19.4883
160013............................       1.2044       0.8563      21.0541      23.0163      23.7163      22.5118
160014............................       0.9866       0.8563      18.3097      19.2447      20.9256      19.5050
160016............................       1.5746       0.9413      21.8400      21.2785      23.3031      22.1576
160020............................       1.0649       0.8563      16.6092      19.0043      19.5752      18.4226
160024............................       1.5772       0.9650      22.4256      24.2385      26.2392      24.3248
160026............................       0.9843       0.9231      22.8967      24.2045      24.7424      23.9779
160028............................       1.3058       0.9555      25.1998      26.0052      26.2948      25.8671
160029............................       1.6068       0.9751      23.7268      24.9493      27.9277      25.5651
160030............................       1.2629       0.9546      23.3687      24.9920      26.7068      25.0247
160031............................       0.9566       0.8563      17.8994      18.5281      19.7585      18.7487
160032............................       1.0533       0.8563      20.5024      22.3837      23.4727      22.1329
160033............................       1.7259       0.8716      22.2660      23.4148      24.6768      23.4865
160034............................       0.9398       0.8563      19.0684      19.4837      19.3503      19.3060
160039............................       0.9260       0.8563      19.8851      20.9623      22.1629      21.0029
160040............................       1.2162       0.8564      20.0567      21.8187      23.9053      21.9454
160043............................          ***       0.8563      15.5765            *            *      15.5765
160045............................       1.6924       0.8605      22.1285      24.4957      25.4153      24.0445
160047............................       1.3599       0.9555      22.1550      24.5000      25.2072      23.9813
160048............................       1.0546       0.8563      18.1174      19.5701      19.6431      19.1317
160050............................       1.1022       0.8563      21.6247      23.8830      24.5403      23.3364
160057............................       1.2499       0.9574      20.8345      22.0472      23.2913      22.0638
160058............................       1.8388       0.9751      23.5663      25.5244      27.1646      25.4595
160064............................       1.5830       0.8563      23.8367      27.6301      28.6139      26.8350

[[Page 23503]]

 
160066............................       1.0921       0.8563      20.4609      21.4631      22.7453      21.6034
160067............................       1.3469       0.8564      19.9422      21.9418      23.4060      21.8952
160069............................       1.4317       0.9116      21.7197      22.7514      25.8067      23.4426
160072............................          ***       0.8563      15.8236            *            *      15.8236
160076............................       0.9917       0.8563      20.1603      20.9749            *      20.5825
160079............................       1.4983       0.8605      21.6562      22.5299      22.4291      22.2178
160080............................       1.3105       0.9667      21.1713      23.5721      23.0138      22.5698
160081............................       1.1704       0.8563      20.4415      21.3614      23.1930      21.6437
160082............................       1.7449       0.9650      21.6230      23.8181      26.2453      23.8567
160083............................       1.6465       0.9650      23.4670      25.0617      28.2193      25.6738
160089............................       1.2795       0.9413      19.9688      21.5693      22.6551      21.4092
160090............................       0.9949       0.8563      19.6767      21.2753            *      20.4851
160091............................       0.9514       0.8563      16.1660      18.0630      17.9255      17.3725
160092............................       0.9582       0.8563      20.4731      22.0841            *      21.2805
160093............................          ***       0.8605      22.8553            *            *      22.8553
160104............................       1.3676       0.8716      23.2832      24.0075      24.9134      24.0516
160106............................       1.1242       0.8563      19.8905      21.4912            *      20.6919
160107............................       1.0394       0.8563      19.5111      21.3754            *      20.4402
160110............................       1.6369       0.8564      21.9299      24.1762      24.9434      23.7256
160112............................       1.2659       0.8563      20.4038      21.8901      23.0673      21.8008
160113............................       0.9601       0.8563      16.7574      18.6599            *      17.7162
160114............................       0.9804       0.8563      19.1743            *            *      19.1743
160116............................       1.0412       0.8563      19.6923      22.2019            *      20.9445
160117............................       1.2747       0.9116      22.3228      23.4250      25.0278      23.6002
160118............................       1.0219       0.8563      16.9466      18.3322      19.7764      18.4025
160122............................       1.0854       0.8563      21.2843      22.9565      22.5810      22.2832
160124............................       1.1255       0.8563      21.2279      22.7223      23.1690      22.3848
160126............................       1.0455       0.8563      20.0149      20.3748      19.6296      20.0068
160131............................       0.9332       0.8563      18.0486            *            *      18.0486
160143............................       1.0569       0.8563      19.0623            *            *      19.0623
160147............................       1.2103       0.9231      22.7993      26.6577      25.1228      24.8830
160153............................       1.5766       0.9360      23.5212      26.3671      28.9881      26.3386
170001............................       1.1572       0.8032      19.8149      20.9837      21.9131      20.9143
170006............................       1.2459       0.8458      19.4488      20.6460      21.9019      20.7240
170008............................          ***       0.8032      18.2352            *            *      18.2352
170010............................       1.2414       0.8313      20.6294      21.2131      24.0008      21.9435
170012............................       1.6156       0.8946      21.8587      22.6869      24.7392      23.0750
170013............................       1.5825       0.8946      21.4954      23.1159      24.9709      23.1630
170014............................       0.9823       0.9454      21.3416      22.9772      23.5960      22.6522
170015............................       1.0532       0.8032      18.0485      19.1902      20.2367      19.1620
170016............................       1.6153       0.8921      22.9479      24.2336      25.9482      24.4090
170017............................       1.1022       0.9156      21.6323      23.3030      24.7771      23.3226
170018............................       0.8898       0.8032      16.9169      17.9497      17.2199      17.3753
170019............................       1.2134       0.8032      18.7916      20.3243      22.0251      20.4068
170020............................       1.5747       0.8946      20.6658      22.2571      23.1800      22.0586
170022............................       1.0924       0.9454      21.1947      22.9313      22.2878      22.1486
170023............................       1.4742       0.8946      21.6273      23.2690      22.5551      22.4908
170024............................          ***       0.8032      16.1196            *            *      16.1196
170026............................          ***       0.8032      17.0836            *            *      17.0836
170033............................       1.3844       0.8946      20.0627      20.0801      20.5954      20.2325
170034............................       0.8698       0.8032      18.1074            *            *      18.1074
170040............................       1.8787       0.9454      24.5234      27.1771      28.2856      26.8014
170041............................          ***       0.8032      13.9709            *            *      13.9709
170052............................       1.1985       0.8032      15.8809      17.3794      18.5291      17.3370
170054............................       0.9966       0.8032      18.5239      17.5500            *      18.0250
170056............................          ***       0.8032      17.1872            *            *      17.1872
170068............................       1.1985       0.9165      20.5512      20.8771      22.6087      21.3531
170070............................       1.0679       0.8032      15.0539      16.4767      16.0162      15.8428
170074............................       1.1969       0.8032      18.5446      20.4936      21.0565      20.0516
170075............................       0.8302       0.8032      15.6809      16.2047      16.5444      16.1586
170077............................          ***       0.8032      14.6377            *            *      14.6377
170082............................          ***       0.8032      15.9973            *            *      15.9973
170086............................       1.5458       0.8921      22.1067      22.7737      24.0812      23.0117
170090............................       0.9249       0.8032      16.3550      15.9807            *      16.1812
170093............................       0.8184       0.8032      15.0307      16.8710      16.5553      16.1514
170094............................       0.9938       0.8032      20.1253      20.3678      21.3887      20.6420
170097............................       0.8884       0.8032      18.9865      20.3391            *      19.6594

[[Page 23504]]

 
170098............................       1.0009       0.8032      18.6676      20.0078      19.8881      19.5154
170099............................       0.8971       0.8032      15.8117            *            *      15.8117
170103............................       1.2452       0.9156      20.1263      21.4985      22.8707      21.5590
170104............................       1.5039       0.9454      23.6589      26.1866      26.6100      25.5135
170105............................       1.0723       0.8032      18.3824      19.6687      21.4422      19.8723
170109............................       0.9921       0.9454      20.7580      22.7166      23.2626      22.2703
170110............................       0.9659       0.8032      16.5883      21.8904      22.2650      20.1717
170113............................       1.0330       0.8032      19.9957            *            *      19.9957
170116............................       0.9958       0.8032      20.8800      23.1127            *      21.9980
170120............................       1.2748       0.8458      18.5895      19.8723      21.0499      19.8632
170122............................       1.6149       0.9156      22.2681      24.5826      25.3981      24.1100
170123............................       1.6579       0.9156      25.0073      26.4676      27.2239      26.2255
170133............................       1.0482       0.9454      20.0593      21.7748      22.9309      21.5574
170137............................       1.2299       0.8032      21.4394      22.7676      23.8863      22.7099
170142............................       1.3359       0.8785      19.8269      22.4095      22.5778      21.6027
170143............................       1.1294       0.8032      18.0308      19.7643      20.4459      19.4072
170144............................          ***            *      23.9180      24.4259      24.6260      24.3634
170145............................       1.0646       0.8032      20.5143      21.4472      21.2071      21.0600
170146............................       1.5346       0.9454      27.0312      28.1965      28.8062      28.0903
170147............................       1.2185       0.9156      18.2480      23.1610      20.7436      20.6771
170148............................          ***            *      26.3491            *            *      26.3491
170151............................       1.0014       0.8032      15.7242            *            *      15.7242
170171............................          ***            *      14.7251            *            *      14.7251
170176............................       1.2996       0.9454      25.5404      24.2283      26.2366      25.2863
170180............................          ***            *      25.0935            *      25.1366      25.1166
170182............................       1.4072       0.9454      23.2115      24.3820      25.7443      24.4497
170183............................       1.9491       0.9156      19.6919      22.8633      24.5539      22.4468
170185............................       1.2969       0.9454      26.8307      24.8478      26.7797      26.1506
170186............................       2.9412       0.9156      28.5602      30.5157      31.7896      30.4381
170187............................       1.1355       0.8032      20.8289      21.0780      23.3702      21.8354
170188............................       2.0008       0.9454      25.2504      27.2225      29.9751      27.6756
170189............................          ***            *      28.1996            *            *      28.1996
170191............................       1.1514       0.8032            *      24.9599      21.3069      23.1771
170192............................       2.0555       0.9156            *            *      27.0380      27.0380
170193............................       1.2126       0.8032            *            *      24.7430      24.7430
170194............................       1.6735       0.9454            *            *      27.9904      27.9904
180001............................       1.2733       0.9604      22.2674      24.7647      25.4217      24.1342
180002............................       1.0456       0.7788      20.5135      21.6843      22.9727      21.7424
180004............................       1.0968       0.7788      19.8552      19.0834      19.5437      19.4871
180005............................       1.1514       0.9119      22.6704      22.8871      24.5561      23.3888
180006............................       0.8988       0.7788      14.4066      15.7136      14.8011      14.9439
180007............................       1.4096       0.9060      21.3545      21.8724      22.7606      21.9873
180009............................       1.6162       0.9482      22.4450      24.0971      25.3837      24.0052
180010............................       1.9470       0.9060      22.6846      16.6893      24.7256      20.7808
180011............................       1.3310       0.8830      18.8056      22.3183      22.7364      21.2726
180012............................       1.4989       0.9264      20.2758      22.9096      24.6642      22.6125
180013............................       1.4422       0.9492      21.0512      21.4728      22.9512      21.8902
180016............................       1.3138       0.9264      20.5203      22.2148      23.1832      22.0005
180017............................       1.2408       0.8286      18.0329      19.0694      20.8630      19.3296
180018............................       1.3264       0.8830      17.5670      18.3314      19.0992      18.3166
180019............................       1.1667       0.9604      20.8416      22.0379      24.1342      22.3292
180020............................       1.0301       0.7788      20.9964      22.3477      21.9494      21.7537
180021............................       1.0255       0.7788      17.6331      17.9346      18.5966      18.0522
180024............................       1.1362       0.9264      22.3922      23.6826      32.1824      25.9352
180025............................       1.0433       0.9264      18.3306      17.4781      19.1543      18.3232
180026............................       1.1055       0.7788      15.5354      15.8431      18.2120      16.5328
180027............................       1.2138       0.8092      20.5017      22.1072      23.8763      22.1722
180028............................       0.8828       0.9119      20.6324      21.4766      24.7968      22.1418
180029............................       1.2700       0.8095      20.4262      21.2110      23.0536      21.5776
180035............................       1.5412       0.9604      24.3874      26.7702      29.8438      27.1206
180036............................       1.1727       0.9482      22.2389      23.1636      25.1154      23.5250
180037............................       1.2780       0.9264      22.7893      24.4451      25.7361      24.4985
180038............................       1.3465       0.8806      20.6888      22.2750      24.6348      22.4970
180040............................       2.0835       0.9264      23.2341      24.5590      26.2125      24.7248
180041............................       1.0740       0.7788      19.1325      18.5483            *      18.8494
180043............................       1.1986       0.7788      20.6498      18.8436      19.0617      19.4791
180044............................       1.5046       0.9119      21.8163      21.6837      23.0971      22.1791

[[Page 23505]]

 
180045............................       1.3290       0.9604      22.1027      24.5856      25.8349      24.1325
180046............................       1.0500       0.9060      23.1139      24.7562      27.2244      25.0514
180047............................       0.8429       0.7788      17.8574      20.4768      21.8037      20.0588
180048............................       1.2624       0.9264      20.0114      22.3601      21.6571      21.3621
180049 h..........................       1.3812       0.9060      18.5188      19.4488      23.3407      20.4067
180050............................       1.1118       0.7788      19.9082      21.7150      22.6473      21.3727
180051............................       1.3901       0.8272      18.8186      19.2100      21.3312      19.7863
180053............................       1.0384       0.7788      17.6239      18.6610      19.1578      18.5083
180054............................       0.9619       0.7788      19.1340      19.0657            *      19.0979
180055 h..........................       1.0038       0.9060      17.8704      21.1989      20.7237      19.9661
180056............................       1.0631       0.8735      19.4072      21.4695      22.8910      21.2490
180063............................       1.1680       0.7788      15.5078      15.9185      17.9741      16.5674
180064............................       1.2463       0.7788      21.1067      15.3819      16.2638      17.3349
180066............................       1.0468       0.9492      21.1884      24.6359      24.9543      23.6588
180067............................       1.9180       0.9060      22.0056      24.0551      25.4080      23.7960
180069............................       1.0456       0.9119      20.3982      20.8797      22.3674      21.2166
180070............................       1.1131       0.7788      16.9892      17.4266      20.1308      18.1917
180072............................          ***            *      17.5411            *            *      17.5411
180079............................       1.1252       0.7788      18.0472      19.5783      19.7791      19.1405
180080............................       1.3087       0.8470      18.9582      20.1651      21.7380      20.2813
180087............................       1.1742       0.7788      16.4726      17.7758      18.4331      17.6017
180088............................       1.5651       0.9264      23.7217      24.6053      27.5767      25.3642
180092............................       1.1282       0.9060      19.6790      22.4864      22.5679      21.6047
180093............................       1.4227       0.8508      18.8469      19.2748      20.5422      19.5520
180094............................       0.9602       0.7788      15.7640            *            *      15.7640
180099............................          ***       0.7788      14.0115            *            *      14.0115
180102............................       1.5476       0.8092      20.1885      19.1136      18.4388      19.1595
180103............................       2.2069       0.9060      21.3867      25.1577      26.9407      24.4722
180104............................       1.6243       0.8092      21.3866      22.8911      24.9441      23.1113
180105............................       0.8484       0.7788      18.3521      19.5364      19.7615      19.2381
180106............................       0.9458       0.7788      15.4937      15.7851      17.8020      16.4485
180108............................          ***       0.7788      16.7327            *            *      16.7327
180116............................       1.2066       0.8285      20.5453      21.8698      22.7353      21.7465
180117............................       0.9835       0.7788      17.7885      20.5952      21.1854      19.7909
180120............................       0.7761       0.7788      20.4507            *            *      20.4507
180124............................       1.3086       0.9492      20.5369      21.4270      23.1917      21.6877
180126............................       1.0372       0.7788      14.5644      15.1776            *      14.8844
180127............................       1.2754       0.9264      20.0059      21.4633      23.4765      21.6735
180128............................       0.9399       0.7788      19.8502      20.5575      20.8406      20.4307
180129............................          ***       0.7788      14.1861            *            *      14.1861
180132............................       1.3264       0.8830      19.9358      22.2101      23.7652      21.9796
180134............................       1.0635       0.7788            *      17.3449      18.6779      18.0324
180138............................       1.2100       0.9264      23.0996      25.1789      27.3400      25.1767
180139............................       1.0372       0.8830      20.6287      21.3797      23.5363      21.8425
180141............................       1.7146       0.9264      22.6722      24.3140      25.3042      24.1450
180143............................       1.4820       0.9060      20.1309      14.2734      25.1613      19.0124
190001............................       1.0754       0.9003      20.4946      19.5680      19.7516      19.8963
190002............................       1.7155       0.8429      20.7172      21.7000      22.0056      21.4744
190003............................       1.4560       0.8429      20.7505      21.8156      23.4977      22.0368
190004............................       1.2890       0.7903      20.5272      22.1835      23.3290      21.9727
190005............................       1.4326       0.9003      20.0551      20.7987      22.3208      21.0635
190006............................       1.2504       0.8429      18.8115      19.4573      22.2467      20.1618
190007............................       1.1174       0.7445      17.9392      18.7854      19.7528      18.8587
190008............................       1.6429       0.7903      20.3278      21.4137      24.0111      21.9572
190009............................       1.2155       0.8048      17.5144      18.8295      19.8404      18.6932
190010............................       1.1212       0.7445      18.1797      19.9788      21.6889      19.9508
190011............................       1.0256       0.8044      15.4699      18.1525      19.7319      17.7235
190013............................       1.3334       0.7847      18.7538      19.6346      20.8626      19.7509
190014............................       1.1677       0.7445      17.0630      17.4740      22.4596      18.7727
190015............................       1.3076       0.9003      20.6167      22.1046      22.8875      21.9289
190017 h..........................       1.3418       0.8429      18.3528      18.6962      21.5033      19.4006
190018............................          ***       0.7445      19.2055            *            *      19.2055
190020............................       1.1401       0.8605      18.5659      19.8505      21.6136      19.9828
190025............................       1.2473       0.7445      19.9969      20.4651      20.8950      20.4776
190026............................       1.5166       0.8048      19.9229      21.3386      22.5087    0121.3125
190027............................       1.6352       0.7847      19.4057      21.2449      21.2526      20.6470
190034............................       1.1567       0.7445      16.8439      17.5002      19.6943      18.0127

[[Page 23506]]

 
190036............................       1.6456       0.9003      23.3903      23.7356      24.8359      24.0024
190037............................       0.9457       0.7847      15.6062      16.7629      18.6393      17.0499
190039............................       1.4625       0.9003      20.4900      23.3105      25.6665      23.2338
190040............................       1.3133       0.9003      22.9262      23.8076      26.7428      24.3506
190041............................       1.4459       0.8767      21.9983      23.9082      24.6734      23.4433
190043............................       1.0017       0.7445      15.7333      16.8944      17.3477      16.6784
190044 h..........................       1.2058       0.8429      17.7460      19.5304      19.5567      18.9595
190045............................       1.5902       0.9003      22.8709      24.0490      25.3854      24.1220
190046............................       1.4233       0.9003      21.1019      22.2884      24.2128      22.4847
190048............................       1.0523       0.7445      18.1698      18.6148      19.6288      18.7855
190049............................       1.0149       0.7445      19.3768      20.1229            *      19.7625
190050............................       1.0741       0.7445      18.6663      18.5287      19.1076      18.7685
190053............................       1.1232       0.7445      13.8037      15.7258      16.4968      15.3819
190054............................       1.3671       0.7445      19.9370      20.3525      20.1108      20.1339
190059............................       0.8367       0.8605      18.3334      19.2396            *      18.7888
190060............................       1.5006       0.7847      20.2207      22.1499      23.6278      21.9859
190064............................       1.5577       0.8605      21.1262      21.5514      23.3617      22.0132
190065............................       1.4890       0.8605      20.3583      23.0523      23.7450      22.3992
190077............................       0.8526       0.8044      17.0480      18.4043      18.8409      18.0986
190078 h..........................       1.0049       0.8429      19.8607      21.5782      21.3786      20.9721
190079............................       1.2488       0.9003      20.5000      21.8158      21.2546      21.1972
190081............................       0.8882       0.7445      11.4756      14.9141      15.6146      13.9838
190083............................       0.8728       0.7445      18.4954      19.2683            *      18.9013
190086............................       1.2357       0.8767      18.2005      18.8306      19.8823      18.9783
190088 h..........................       1.0702       0.8767      18.6738      22.5045      22.3480      20.9939
190089............................       0.9609       0.7445      15.5151      16.2961            *      15.9103
190090............................       1.0843       0.7445      19.0519      20.0745      20.2045      19.8076
190095............................          ***            *      16.9519      18.7302      18.0174      17.8930
190098............................       1.5840       0.8767      20.7537      23.0802      24.6353      22.7792
190099............................       1.0296       0.8470      23.1606      21.1657      20.4597      21.4552
190102............................       1.6258       0.8429      22.0190      23.4618      25.2267      23.6255
190106............................       1.2114       0.8048      20.3114      21.5643      21.7228      21.2163
190109............................       1.1376       0.7903      16.6515      17.4842      18.6524      17.5941
190110 h..........................       0.8513       0.8429      16.5007      19.0611            *      17.8105
190111............................       1.5580       0.8767      24.4380      25.2370      24.4998      24.7275
190114............................       1.0513       0.7445      13.6101      14.6258      15.8031      14.6821
190115............................       1.1772       0.8767      25.4984      26.0272      26.6295      26.0395
190116............................       1.2394       0.7445      17.8297      18.6074      20.3844      18.9443
190118............................       0.9389       0.8767      17.5060      19.0200      19.7025      18.7558
190122............................       1.1878       0.8605      17.7811      19.3131      23.7082      20.0706
190124............................       1.5270       0.9003      23.3859      23.4862      24.6675      23.8477
190125............................       1.6350       0.8044      21.5692      22.3976      23.9649      22.6514
190128............................       1.0700       0.8605      23.8786      24.7842      27.9136      25.5637
190130............................       0.9482       0.7445      15.2678      16.6910            *      15.9880
190131............................       1.1718       0.9003      21.3154      22.5032      25.1917      22.9740
190133............................       0.8895       0.7445      13.4062      14.3089      13.6266      13.7628
190135............................       1.4454       0.9003      24.4908      26.9920      26.8238      26.1247
190140............................       0.9845       0.7445      15.4030      17.0371      17.6936      16.7104
190144 h..........................       1.1367       0.8767      21.3838      21.1658      21.7547      21.4426
190145............................       0.9459       0.7445      17.4407      17.3361      18.9678      17.9319
190146............................       1.5445       0.9003      22.1502      23.7721      26.1792      24.0255
190147............................          ***       0.7445      16.3596            *            *      16.3596
190149............................       0.9266       0.7445      18.4197      17.1671      18.8819      18.1219
190151............................       1.0072       0.7445      17.3402      17.8741      18.6293      17.9597
190152............................       1.3530       0.9003      25.1136      27.4708      27.6099      26.7879
190156............................       0.8717       0.7445      18.0528      18.3702            *      18.2089
190158............................       1.3600       0.9003      23.2361      26.2352      26.3042      25.4140
190160............................       1.4780       0.8044      19.8428      20.0025      21.6740      20.5204
190161............................       1.1157       0.7847      16.5322      17.8794      19.1022      17.8227
190162............................          ***       0.9003      20.7350      22.1781      25.0328      22.6102
190164............................       1.1345       0.8048      20.2791      21.4247      22.8599      21.6241
190167............................       1.2264       0.7445      17.2643      17.8604      24.3185      19.7786
190175............................       1.3314       0.9003      22.7574      24.6790      27.1531      25.0038
190176............................       1.7308       0.9003      25.2536      25.8482      25.6997      25.6097
190177............................       1.5627       0.9003      22.3318      25.4769      27.4621      25.2171
190182............................       0.9036       0.9003      23.6016      25.0837      28.4799      25.6314
190183............................       1.1870       0.7903      17.1805      18.3151      19.8084      18.4205

[[Page 23507]]

 
190184............................       1.0174       0.7445      20.6096      21.3191      23.9609      21.8425
190185............................       1.3314       0.9003      29.7870      24.4176      24.7912      25.8807
190190............................       0.8693       0.7445      16.2819      14.0052      16.1195      15.4593
190191 h..........................       1.3627       0.8470      21.9141      22.3755      23.5734      22.6642
190196............................       0.8706       0.8429      20.7601      21.9355      24.7135      22.5497
190197............................       1.3476       0.8044      21.6908      22.9631      24.3735      23.0241
190199............................       1.1533       0.8605      19.7776      18.5317      14.1410      17.3575
190200............................       1.5526       0.9003      24.1667      26.4258      27.5681      25.9873
190201............................       1.2736       0.7847      21.4335      22.5588      24.5877      22.9165
190202............................       1.2371       0.8605      22.4062      21.8900      24.7944      23.0825
190203............................       1.5000       0.9003      24.9518      26.9099      26.8795      26.2979
190204............................       1.4751       0.9003      26.1231      28.8777      28.3684      27.8932
190205............................       1.7106       0.8429      20.2374      21.7696      24.4540      22.1979
190206............................       1.6684       0.9003      24.2892      26.9117      26.0139      25.7960
190207............................          ***            *      21.5325            *            *      21.5325
190218............................       1.1570       0.7445      21.6206      23.9182      25.0356      23.6192
190236............................       1.4154       0.8767      24.4661      23.8233      23.6824      23.9582
190240............................       0.9780       0.7445      15.4026      13.9888            *      14.7116
190241............................       1.2944       0.7903      24.2462      28.9620      23.9700      25.7012
190242............................       1.1208       0.8605      18.6672      20.5937      23.0072      20.7608
190243............................          ***            *            *      30.6060            *      30.6060
190245............................       2.1960       0.8044            *            *      27.1786      27.1786
200001............................       1.2980       0.9985      21.6050      23.2210      25.1145      23.3710
200002............................       1.1625       0.9884      22.0700      24.1446      25.7478      23.9468
200007............................       1.0638       1.0382      21.0603      22.3920            *      21.7470
200008............................       1.2535       1.0382      25.1115      25.1741      27.4412      25.9041
200009............................       1.9724       1.0382      24.9041      28.1409      31.1056      28.0391
200012............................       1.1372       0.8840      21.8529      24.1243      25.7623      23.9787
200013............................       1.1001       0.8840      22.8909      23.9048      24.4131      23.7685
200018............................       1.1627       0.8840      21.1330      24.3294      23.6337      23.0851
200019............................       1.2839       1.0382      23.1114      24.0926      25.1367      24.1296
200020............................       1.2562       1.0503      27.0798      28.7351      31.7083      29.2990
200021............................       1.1892       1.0382      24.9925      25.1027      24.5519      24.8792
200024............................       1.5272       0.9884      22.9698      24.6484      26.0080      24.6372
200025............................       1.0696       1.0382      22.9023      24.3646      26.0573      24.4151
200026............................       1.0384       0.8840      19.7172      21.9997            *      20.8927
200027............................       1.2155       0.8840      21.0156      23.2912      26.3118      23.4478
200028............................       1.0270       0.8840      21.2180      24.3061      24.3271      23.3297
200031............................       1.3580       0.8840      18.8262      20.6202      21.9489      20.4626
200032............................       1.2155       0.8840      23.0487      24.2221      25.5227      24.3050
200033............................       1.8521       0.9985      25.1723      26.8727      28.6479      26.9328
200034............................       1.3802       0.9884      23.5415      26.1150      26.2926      25.3574
200037............................       1.1932       0.8840      22.6534      23.3490      23.2333      23.0870
200039............................       1.2758       0.9884      22.1333      24.0474      25.1196      23.8217
200040............................       1.2240       1.0382      21.8528      23.6791      25.5405      23.6763
200041............................       1.1389       0.8840      21.3816      23.6797      24.5532      23.3316
200050............................       1.2560       0.9985      23.4391      25.5233      26.4992      25.2144
200052............................       1.0527       0.8840      19.0535      22.7763      21.8726      21.2769
200063............................       1.1744       0.9884      23.0135      24.7235      25.0167      24.2686
200066............................       1.2279       0.8840      19.5890      21.6354            *      20.6005
210001............................       1.4095       0.9528      22.6614      26.3144      27.7561      25.5750
210002............................       1.9808       0.9892      25.6975      25.2859      26.4992      25.8584
210003............................       1.6574       1.0935      23.0790      32.3042      29.8684      28.0698
210004............................       1.4432       1.1471      29.4841      29.4300      34.2392      31.0347
210005............................       1.2836       1.1471      24.7185      27.1276      28.7557      26.8963
210006............................       1.0893       0.9892      24.7327      25.6396      25.4081      25.2468
210007............................       1.8793       0.9892      27.5104      28.4496      30.2548      28.7829
210008............................       1.3153       0.9892      24.6569      26.3008      25.2833      25.4086
210009............................       1.8013       0.9892      23.4889      24.6332      26.2360      24.8136
210010............................          ***       0.9099      23.7761      24.5071      25.7850      24.6945
210011............................       1.4100       0.9892      22.3262      24.8373      27.5031      24.9589
210012............................       1.5973       0.9892      25.2892      25.7934      27.4103      26.2116
210013............................       1.2668       0.9892      23.0151      23.9875      25.1348      24.0450
210015............................       1.3230       0.9892      23.8419      25.8532      28.2029      25.9683
210016............................       1.8143       1.1471      27.2632      28.6992      32.2081      29.4293
210017............................       1.1663       0.9099      19.0248      21.3983      23.2168      21.2523
210018............................       1.2267       1.1471      25.3112      27.5431      29.2153      27.3955

[[Page 23508]]

 
210019............................       1.7403       0.9099      23.5259      24.9252      26.1824      24.9054
210022............................       1.4002       1.1471      27.6680      30.1470      33.8015      30.5481
210023............................       1.4502       0.9892      26.7837      29.0844      30.4656      28.8005
210024............................       1.6742       0.9892      24.8939      27.1756      29.5579      27.2560
210025............................       1.2278       0.9310      22.8882      23.8943      26.0771      24.3114
210027............................       1.4821       0.9310      19.3517      23.9255      26.0111      22.9283
210028............................       1.0800       0.9099      22.4054      24.1265      25.9221      24.1901
210029............................       1.2469       0.9892      26.2082      31.2888      27.9741      28.3176
210030............................       1.2604       0.9099      20.7802      27.5507      29.5702      25.7230
210032............................       1.1336       1.0652      20.3407      25.7138      26.1829      23.9925
210033............................       1.1618       0.9892      25.0301      26.6113      29.0420      26.9838
210034............................       1.2910       0.9892      22.8827      26.3896      28.4308      25.7800
210035............................       1.3279       1.0935      21.6973      24.5198      26.1082      24.1712
210037............................       1.1827       0.9099      23.5536      24.1913      24.8719      24.2175
210038............................       1.2100       0.9892      26.5696      28.3414      29.5979      28.1851
210039............................       1.1063       1.0935      24.0987      25.8415      27.6940      25.8514
210040............................       1.2556       0.9892      25.4729      28.3723      29.3514      27.8674
210043............................       1.3070       0.9892      22.2177      24.3070      27.5657      24.7038
210044............................       1.3455       0.9892      23.8101      24.8083      28.8700      25.7966
210045............................       1.0505       0.9099      11.8350      15.0867      15.6380      14.3653
210048............................       1.3334       0.9892      24.4328      25.0617      28.4638      26.0370
210049............................       1.2251       0.9892      24.7148      25.9342      26.9656      25.9278
210051............................       1.3202       1.0935      25.7103      27.3692      29.2998      27.5052
210054............................       1.3345       1.0935      27.3551      24.6658      26.2295      26.0806
210055............................       1.1840       1.0935      27.4218      28.0014      29.9708      28.5097
210056............................       1.3191       0.9892      23.5881      26.6884      28.6091      26.3638
210057............................       1.4185       1.1471      27.3520      29.2233      32.2883      29.7939
210058............................       1.0819       0.9892      22.0351      24.8576      29.7841      25.5191
210060............................       1.1664       1.0935      25.8377      28.7531      28.5087      27.8143
210061............................       1.2457       0.9099      22.5455      24.1369      23.6662      23.5086
220001............................       1.2068       1.1233      25.8030      27.3238      28.9854      27.3824
220002............................       1.3775       1.1233      26.3348      28.9722      30.3598      28.5921
220003............................       1.1465       1.1233      18.8150      20.5790      22.0549      20.5049
220006............................       1.5005       1.0525      27.1576      29.5946      30.7583      29.2881
220008............................       1.2473       1.0952      25.6647      27.1675      30.1043      27.7253
220010............................       1.2849       1.1233      24.5020      27.4161      29.7998      27.3015
220011............................       1.1320       1.1233      32.2266      32.6624      33.6258      32.9286
220012............................       1.4769       1.2518      32.0521      32.9791      36.2075      33.8319
220015............................       1.1789       1.0259      25.0272      25.5449      28.3397      26.3904
220016............................       1.1162       1.0259      25.7740      26.8798      28.0609      26.8986
220017............................       1.3302       1.1537      28.9024      28.8264      29.7108      29.1461
220019............................       1.1847       1.1233      21.6620      22.2294      23.2544      22.3943
220020............................       1.2561       1.0952      23.5737      24.2279      26.3475      24.7620
220024............................       1.2397       1.0259      24.1071      25.5837      27.3488      25.6784
220025............................       1.1085       1.1233      23.2374      24.5186      23.0637      23.5753
220028............................       1.4399       1.1233      31.4858      31.3592      32.0980      31.6438
220029............................       1.1188       1.1233      27.4792      28.1432      28.6970      28.1288
220030............................       1.1096       1.0259      20.0816      23.6257      24.4289      22.7602
220031............................       1.5358       1.1537      30.8324      32.2660      34.7388      32.5988
220033............................       1.1835       1.1233      25.4500      26.8049      28.1859      26.8967
220035............................       1.3734       1.1233      26.8486      27.5533      28.6238      27.6997
220036............................       1.4886       1.1537      28.2182      29.6296      31.5184      29.8330
220041............................          ***            *      28.8184      29.7464            *      29.2230
220046............................       1.3512       1.0183      26.1955      27.7726      28.1396      27.3951
220049............................       1.1526       1.1233      26.7688      27.0464      27.7517      27.2011
220050............................       1.1149       1.0259      23.7326      24.9945      26.3768      25.0718
220051............................       1.2065       1.0183      22.2965      26.5575      29.8380      26.3369
220052............................       1.1597       1.1537      26.3043      28.0925      29.8577      28.1429
220058............................       1.0018       1.1233      22.4885      25.0598      24.9642      24.1665
220060............................       1.1851       1.2254      29.6960      30.8242      32.3362      31.0565
220062............................       0.5670       1.1233      22.6598      21.9489      24.2779      22.9699
220063............................       1.1890       1.1233      23.3704      25.5840      27.3967      25.3936
220065............................       1.2103       1.0259      22.4143      24.8737      26.5513      24.6535
220066............................       1.2809       1.0259      27.5575      26.2561      27.1317      26.9786
220067............................       1.1716       1.1537      22.4968      28.5220      29.8911      26.7470
220070............................       1.1474       1.1233      26.2697      28.9100      31.9283      28.7436
220071............................       1.8635       1.1537      27.7773      31.8322      32.2591      30.6680

[[Page 23509]]

 
220073............................       1.2181       1.0952      27.9309      29.2399      31.2591      29.4595
220074............................       1.2979       1.1537      25.7840      27.5763      28.4930      27.3187
220075............................       1.3687       1.1537      26.0527      27.9503      29.1588      27.7387
220076............................          ***       1.1078      24.8040      27.2534      29.7507      27.1315
220077............................       1.7008       1.1085      27.0946      28.0935      30.2684      28.5352
220080............................       1.2093       1.1233      24.7399      27.1578      28.9101      27.0523
220082............................       1.2445       1.1233      23.9542      24.8060      26.9841      25.2609
220083............................       1.1182       1.1537      28.3533      29.9001      32.9143      30.3719
220084............................       1.2198       1.1233      26.8596      29.0505      32.5711      29.5958
220086............................       1.7240       1.1537      29.4911      31.7482      34.1236      31.7544
220088............................       1.8430       1.1537      26.5849      28.5711      28.5462      27.9606
220089............................       1.2383       1.1233      28.9252      32.4409      31.1708      30.8836
220090............................       1.2019       1.1233      26.5552      29.7945      30.8685      29.1558
220095............................       1.0909       1.1233      23.7629      24.9871      27.4273      25.3894
220098............................       1.1705       1.1233      26.2287      26.8538      28.8314      27.2888
220100............................       1.2709       1.1537      27.0265      28.4848      29.6912      28.4369
220101............................       1.3268       1.1233      26.9992      31.0834      33.1690      30.4912
220105............................       1.2174       1.1233      26.7570      30.0892      31.9421      29.7099
220108............................       1.2235       1.1537      26.0166      29.0804      30.6252      28.5516
220110............................       2.0895       1.1537      33.0445      35.4242      36.6043      35.0919
220111............................       1.1852       1.1537      27.7395      28.9092      31.1850      29.2950
220116............................       2.0126       1.1537      30.9871      32.2337      32.9988      32.0845
220119............................       1.1414       1.1537      25.9789      27.8372      28.2844      27.4417
220126............................       1.1438       1.1537      26.9853      26.7660      28.7805      27.5408
220133............................          ***            *      33.0819      31.2981      33.6003      32.6683
220135............................       1.3023       1.2518      31.9159      31.3246      32.1205      31.7903
220153............................       1.0112       1.0259            *      18.9267            *      18.9267
220154............................       1.0325       1.1537      25.6069      30.9009      28.6462      28.0721
220163............................       1.6217       1.1233      29.9312      30.5056      33.6484      31.2574
220171............................       1.7280       1.1233      27.2647      28.9733      29.5666      28.6148
220174............................       1.1830       1.1233            *      30.3356      31.7572      31.0464
230001............................       1.1145       0.8923      22.0875      24.3660            *      23.2049
230002............................       1.2858       1.0453      23.7972      27.0305      28.7861      26.5792
230003............................       1.1978       0.9133      22.4322      25.2596      26.1278      24.6604
230004............................       1.6865       0.9677      23.0827      25.5573      26.7206      25.1973
230005 h..........................       1.2420       1.0885      20.3750      22.1018      24.1902      22.4061
230006............................       1.1260       0.9786      22.0733      22.7656      23.8835      22.9495
230013............................       1.3537       0.9858      20.4633      22.7014      23.7822      22.3686
230015............................       1.0330       0.8923      21.7640      23.4512      24.6570      23.3267
230017............................       1.6186       1.0403      26.1609      27.3259      29.5178      27.7392
230019............................       1.5499       0.9858      24.7472      27.6563      28.4575      26.9496
230020............................       1.6718       1.0453      25.8267      26.8516      29.2869      27.3788
230021............................       1.5066       0.8923      22.0757      23.4663      24.9551      23.5352
230022............................       1.1968       1.0628      22.2179      22.2528      23.3000      22.6032
230024............................       1.5303       1.0453      24.7364      27.6555      30.0866      27.3402
230027............................       1.0785       0.9398      21.2223      22.5736      23.5511      22.4431
230029............................       1.6353       0.9858      26.7646      27.9012      29.0935      27.9121
230030............................       1.2551       0.9090      19.9853      20.9867      22.3174      21.1301
230031............................       1.3778       0.9858      22.1874      23.2910      25.4678      23.7275
230032............................          ***            *      23.8366            *            *      23.8366
230035............................       1.2892       0.9398      18.0735      20.9197      21.2317      19.9973
230036............................       1.3478       0.8923      25.9801      26.5854      28.3622      26.9984
230037............................       1.1932       1.0628      24.4115      24.7875      26.0167      25.1030
230038............................       1.6544       0.9398      23.4685      25.2499      26.3480      25.2371
230040............................       1.1923       0.9398      21.8062      21.9813      24.2349      22.7262
230041............................       1.4739       0.9535      24.2297      25.2518      26.1760      25.1852
230042............................       1.1899       0.9133      21.8241      24.3640      26.2037      24.1687
230046............................       1.8546       1.0885      28.2320      29.2683      30.3591      29.3515
230047............................       1.3775       1.0453      24.3622      26.2447      28.1351      26.3210
230053............................       1.5876       1.0453      26.1415      28.3030      29.9871      28.0856
230054............................       2.0368       0.9439      23.0818      24.0137      24.9905      24.0601
230055............................       1.2813       0.8923      20.9350      23.7671      25.4143      23.4450
230058............................       1.1454       0.8923      22.4516      21.9308      24.0657      22.7966
230059............................       1.4370       0.9398      21.2743      23.1451      25.5350      23.3695
230060............................       1.2849       0.8923      22.3512      24.5073      25.5015      24.1280
230065............................          ***       1.0453      26.3217      27.9179      28.4631      27.5421
230066............................       1.3075       0.9677      23.9696      25.8517      27.4928      25.8295

[[Page 23510]]

 
230069............................       1.1753       1.0654      26.0438      27.6815      29.5556      27.8051
230070............................       1.5701       0.9474      22.8588      25.1587      24.2342      24.0769
230071............................       0.8485       0.9858      23.6674      24.7707      26.3907      24.9681
230072............................       1.3590       0.9133      22.9626      24.1560      24.4933      23.9114
230075............................       1.3133       0.9492      22.6799      24.1482      27.6193      24.8869
230077............................       1.9292       1.0654      29.2041      27.3117      30.3431      28.9610
230078............................       1.0254       0.8923      20.5427      21.9200      23.9901      22.2077
230080............................       1.2619       0.9090      20.2405      21.2840      21.2314      20.9185
230081............................       1.1862       0.8923      20.4289      20.6777      23.0788      21.3975
230082............................       1.0168       0.8923      21.3100      23.1240      22.2165      22.1964
230085............................       1.2173       1.0403      24.2802      22.2569      22.7314      23.1872
230086............................       1.1453       0.8923      27.8923      20.8759      22.2965      23.4562
230087............................          ***            *      22.2688            *      16.9168      19.0752
230089............................       1.3414       1.0453      23.3847      23.9486      28.7015      25.3973
230092............................       1.2758       0.9300      22.3122      24.3768      26.3584      24.3257
230093............................       1.1471       0.9398      25.1213      24.5055      26.4967      25.3702
230095............................       1.2485       0.8923      19.1810      19.2244      21.3915      19.9401
230096............................       1.1644       1.0403      26.7156      26.7578      28.7681      27.4077
230097............................       1.7922       0.8923      22.9902      25.2104      26.5773      24.9608
230099............................       1.2029       1.0628      23.5490      25.0390      26.4882      25.0486
230100............................       1.0901       0.8923      19.8016      20.4565      21.8895      20.6965
230101............................       1.0867       0.8923      22.3310      23.1349      24.3772      23.3147
230103............................       0.9926       0.9786      19.4434      18.4304      21.6609      19.7646
230104............................       1.5316       1.0453      27.4119      27.8864      30.5570      28.5801
230105............................       1.9274       0.9535      23.9851      24.6853      27.2705      25.3146
230106............................       1.1151       0.9398      23.1962      24.1128      24.3980      23.9236
230108............................       1.1539       0.8923      19.9842      22.4966      18.4063      20.1757
230110............................       1.2559       0.8923      21.5523      22.7621      28.7704      24.4693
230117............................       1.8428       1.0403      28.1220      29.6361      29.4775      29.0873
230118............................       1.0609       0.8923      22.2208      21.4886      22.3636      22.0278
230119............................       1.2750       1.0453      25.3562      29.2509      30.4910      28.0624
230120 h..........................       1.1085       1.0885      22.7243      21.7894      24.1485      22.9095
230121............................       1.2547       0.9786      22.3708      23.4394      24.5220      23.4095
230124............................       1.3011       0.8923      22.0097      23.0508            *      22.5308
230130............................       1.7348       0.9858      23.7854      26.9907      26.6076      25.8001
230132............................       1.3708       1.0654      29.0292      29.9106      30.5074      29.8111
230133............................       1.4219       0.8923      20.4801      21.2273      22.7380      21.5235
230135............................       1.1067       1.0453      19.8290      23.9000      25.8406      23.1673
230141............................       1.6290       1.0654      23.9885      30.4643      28.6326      27.6090
230142............................       1.2390       1.0453      22.9036      25.6044      26.9433      25.2019
230143............................       1.2372       0.8923      19.5446      19.5387      21.4083      20.1494
230144............................          ***       1.0885      23.6959            *            *      23.6959
230146............................       1.2340       1.0453      21.3539      24.3891      26.3432      24.1395
230149............................       0.9394       0.8923      20.8933      21.4753            *      21.1778
230151............................       1.3038       0.9858      23.8527      26.4669      27.1965      25.8699
230153............................       1.0978       0.9786      22.8584      22.3404      22.8644      22.6896
230155............................       1.0445       0.8923      18.0743      24.0404            *      20.6336
230156............................       1.5897       1.0885      27.7164      29.4855      31.1909      29.5181
230165............................       1.6979       1.0453      25.9534      27.3164      28.9636      27.4184
230167............................       1.6158       0.9786      24.7935      26.6828      27.3362      26.2749
230169............................          ***       1.0453      24.9265      27.1172      31.8442      27.6798
230171............................       1.0700       0.8923      19.9097      22.0635            *      20.9931
230172............................       1.2263       1.0403      23.0023      24.0236      25.7402      24.2756
230174............................       1.3089       0.9133      24.4671      26.2770      27.6920      26.1839
230175............................          ***            *      22.5964            *            *      22.5964
230180............................       1.0957       0.8923      20.9832      22.5454      24.7358      22.8206
230184............................       1.2135       0.9300      21.4031      21.9346      23.6707      22.3438
230186............................          ***            *      21.6147      27.1126      26.2282      24.5338
230188............................       0.9259       0.8923      18.8076            *            *      18.8076
230190............................       1.0114       1.0403      27.3430      28.7365      29.9604      28.6717
230193............................       1.2672       0.9858      22.8916      24.3181      23.3565      23.5189
230195............................       1.4253       1.0453      25.3285      27.1266      28.2892      26.9865
230197............................       1.5717       1.0654      26.9840      28.3439      30.0367      28.4836
230204............................       1.2871       1.0453      24.4095      25.9871      29.1466      26.3875
230207............................       1.3574       0.9858      22.2848      22.2854      24.4641      22.9909
230208............................       1.1926       0.9398      20.3171      20.9420      21.9651      21.0908
230212............................       1.0168       1.0885      26.0656      27.3686      29.7980      27.6833

[[Page 23511]]

 
230216............................       1.5428       0.9858      23.4262      26.1468      27.5230      25.7787
230217............................       1.2812       0.9786      24.3650      26.7929      28.5002      26.7214
230222 h..........................       1.3221       0.9474      24.6101      24.8925      26.3990      25.3118
230223............................       1.2599       0.9858      28.5549      27.1503      29.2853      28.3304
230227............................       1.5008       1.0453      27.7510      28.1105      29.6068      28.4994
230230............................       1.4934       0.9786      23.9568      25.4471      27.9607      25.8281
230235............................       1.0134       0.9090      19.9118      19.6046      21.8777      20.4653
230236............................       1.4098       0.9398      25.7463      26.3988      28.4754      26.9289
230239............................       1.2173       0.8923      19.8370      21.1643      22.1040      21.0930
230241............................       1.1712       0.9858      24.2063      25.8671      27.4890      25.8668
230244............................       1.3245       1.0453      23.9004      25.3817      26.4326      25.2154
230254............................       1.3405       0.9858      24.2594      26.4431      28.1216      26.2901
230257............................       1.0228       1.0453      24.8069      25.4086      27.8197      25.8794
230259............................       1.2092       1.0885      24.8598      24.3067      26.8677      25.3750
230264............................       2.1560       1.0453      17.4847      19.9992      19.2398      19.0176
230269............................       1.3453       0.9858      25.3367      27.4732      28.8187      27.2692
230270............................       1.2537       1.0453      22.8842      26.1113      27.8488      25.6802
230273............................       1.4149       1.0453      25.8466      30.2209      29.9307      28.6762
230275............................       0.4478       0.9474      29.4180      30.2244      23.1095      27.7059
230276............................          ***            *      23.4928            *            *      23.4928
230279............................       0.5281       1.0654      21.2467      23.1636      24.7673      22.9663
230283............................       0.8624       1.0453      25.0038      24.9272      26.2622      25.3910
230288............................          ***            *      30.3422            *            *      30.3422
230290............................          ***            *            *      29.4792            *      29.4792
230291............................          ***            *            *            *      30.9655      30.9655
230292............................          ***       0.9474            *            *      31.8943      31.8943
240001............................       1.5054       1.1055      28.2239      29.9123      31.5753      29.9731
240002............................       1.8195       1.0224      24.7674      26.9608      28.9860      26.9851
240004............................       1.5291       1.1055      26.8197      27.8796      30.8072      28.5006
240006............................       1.0536       1.1128      29.5789      30.2330      30.1950      30.0237
240007............................       1.1446       0.9183      21.4367      23.7588      24.7344      23.3456
240010............................       2.0425       1.1128      29.0955      30.4139      31.3733      30.3196
240011............................       1.0425       0.9183      24.0364      22.9561            *      23.3835
240013............................       1.2687       1.0905      27.3855      28.7202      28.3860      28.1704
240014............................       1.0309       0.9183      26.5144      28.3788      29.8623      28.2985
240016............................       1.2584       0.9183      25.2629      24.9211      26.7814      25.7376
240017............................       1.2467       0.9183      21.6243      23.3314      24.4417      23.1535
240018............................       1.2293       1.0905      27.3634      27.9218      25.6484      26.6329
240019............................       1.1105       1.0224      25.1331      27.5441      28.6723      27.1439
240020............................       1.0806       1.1055      24.7516      28.1568      31.2443      28.0203
240021............................       0.8545       0.9183      23.9568      23.7096      27.1235      24.8433
240022............................       1.1064       0.9183      23.4702      23.7368      25.2066      24.1392
240025............................       1.0776       0.9183      21.2597      27.8656            *      24.3444
240027............................       0.9440       0.9183      18.3340      20.2531      18.2481      18.8765
240029............................       1.0819       0.9183      21.2342      24.3017      25.3568      23.3870
240030............................       1.3564       0.9785      22.0200      23.3753      24.7154      23.4178
240031............................       0.9494       1.0905      23.4389      26.7242      26.7778      25.6303
240036............................       1.6880       1.0905      23.4857      27.0821      28.0812      26.3323
240037............................       1.0359       0.9183      21.8392      24.3986            *      23.1115
240038............................       1.5291       1.1055      28.9676      29.8465      31.0779      30.0073
240040............................       1.0854       1.0224      21.3870      26.3177      27.4895      24.8843
240043............................       1.1301       0.9183      19.5532      20.7155      21.8685      20.7481
240044............................       1.1203       0.9183      22.7482      24.3009      22.5843      23.1864
240045............................       1.1212       1.0224      25.9223      26.1743      27.5013      26.5626
240047............................       1.5649       1.0224      29.6184      29.1211      28.8288      29.1562
240050............................       1.0196       1.1055      24.7589      26.6687      26.4854      26.0710
240052............................       1.1991       0.9183      23.5898      24.9870      26.4256      25.0236
240053............................       1.4186       1.1055      26.7122      28.4733      29.5315      28.3118
240056............................       1.2420       1.1055      28.5169      30.8619      31.6623      30.4153
240057............................       1.8473       1.1055      27.7600      29.4870      30.6258      29.3431
240059............................       1.0902       1.1055      27.0517      28.6340      29.7916      28.5358
240061............................       1.7485       1.1128      28.7372      30.0031      30.6383      29.8381
240063............................       1.5546       1.1055      26.7960      29.9603      32.3487      29.6692
240064............................       1.2568       1.0224      24.9928      26.6996      29.9662      27.5790
240066............................       1.3913       1.1055      27.4066      30.2716      33.4532      30.4657
240069............................       1.1378       1.1128      25.6943      27.4990      28.9496      27.4534
240071............................       1.1486       1.1128      24.8036      26.4780      28.0585      26.4808

[[Page 23512]]

 
240075............................       1.1988       0.9785      24.4084      26.6607      26.1956      25.7681
240076............................       1.1046       1.1055      26.7112      28.4519      29.8562      28.4067
240077............................          ***       0.9183      18.9735            *            *      18.9735
240079............................       0.9411       1.1521      20.6644      20.9220            *      20.8010
240080............................       1.6892       1.1055      27.8807      29.6274      31.6484      29.7472
240083............................       1.2481       0.9183      24.4352      25.0214      26.6582      25.4096
240084............................       1.1252       1.0224      23.9942      24.7856      26.8142      25.2047
240087............................       1.0235       0.9183      20.1002      24.8479      24.9419      23.3753
240088............................       1.2698       0.9785      25.5587      27.6323      28.0825      27.1245
240089............................          ***       0.9183      23.4028            *            *      23.4028
240094............................       1.0759       1.1055      24.4166      27.3974      28.3973      26.8076
240097............................          ***            *      34.2810            *            *      34.2810
240101............................       1.1412       0.9183      24.3455      26.6078      25.5355      25.5132
240103............................       1.0495       0.9183      20.2324      22.5416      22.7078      21.8542
240104............................       1.1424       1.1055      27.4946      30.1392      31.4306      29.9577
240106............................       1.4870       1.1055      25.5890      27.5171      29.3455      27.5527
240107............................       0.9093       0.9183      24.5583      25.5199      26.1078      25.4514
240109............................       0.9472       0.9183      14.5892      15.2076      16.5051      15.4279
240115............................       1.6156       1.1055      27.0312      29.0261      31.3869      29.1786
240117............................       1.1377       0.9183      20.1436      22.0463      23.8076      22.0056
240121............................       0.9139       1.0224      24.5455            *            *      24.5455
240123............................       1.0528       0.9183      20.0721      20.5755      21.7500      20.8397
240124............................       0.9638       0.9183      23.5139      23.9297            *      23.7277
240127............................          ***            *      19.3857      24.4824            *      21.5460
240128............................       1.0138       0.9183      20.1960      21.2638      21.5791      21.0226
240132............................       1.2654       1.1055      26.7063      29.5310      31.7139      29.3306
240133............................       1.1406       0.9183      23.6068      26.1836      27.7658      25.8348
240135............................          ***            *      17.8573      16.1837            *      16.9824
240137............................       1.1919       0.9183      23.1752      23.8666            *      23.5315
240139............................       1.0798       0.9183      22.4473      23.7898            *      23.1612
240141............................       1.0222       1.1055      25.1597      26.7173      26.4016      26.1666
240143............................       0.8521       0.9183      18.9442      21.1180      21.7416      20.6376
240145............................          ***       0.9183      22.6063            *            *      22.6063
240154............................       1.0199       0.9183      21.3809      23.9643            *      22.6453
240162............................       1.1601       0.9183      20.4807      22.3136      22.2721      21.7043
240166............................       1.1135       0.9183      21.5002      23.4265      25.7509      23.5628
240179............................       0.8255       0.9183      19.8249      20.8449            *      20.3419
240187............................       1.2137       1.0905      24.8879      26.5129      27.8811      26.4667
240196............................       0.8421       1.1055      27.2901      28.9380      30.7719      29.0287
240207............................       1.2007       1.1055      27.4330      29.2395      31.7414      29.5819
240210............................       1.2500       1.1055      26.6545      29.7227      32.1564      29.5372
240211............................       0.9023       1.0905      32.8801      44.4214      18.8503      27.6876
240213............................       1.3095       1.1055      27.5104      31.3974      32.7532      30.8794
250001............................       1.8170       0.8313      20.9338      21.9176      22.7827      21.9287
250002............................       0.8813       0.7685      21.6643      20.1310      23.3845      21.6434
250004............................       1.8313       0.9108      20.9295      20.6828      24.1065      21.8737
250006............................       1.0428       0.9108      20.3061      21.4038      24.0191      21.9290
250007............................       1.2343       0.8922      21.2226      23.6933      25.8710      23.5817
250009............................       1.2453       0.8799      19.7610      20.4329      22.2323      20.8522
250010............................       0.9833       0.7685      17.6204      19.4130      19.4403      18.8097
250012............................       0.9469       0.9346      15.6117      20.0493      20.2921      18.4571
250015............................       1.0268       0.7685      19.3794      20.6931      20.7555      20.2702
250017............................       1.0970       0.7685      19.0436      18.1013      21.3950      19.5260
250018............................       0.9215       0.7685      16.8783      17.0689      16.6294      16.8678
250019............................       1.5528       0.8922      22.9085      22.8358      23.9741      23.2493
250020............................       0.9918       0.7685      19.1877      19.3390      21.4019      19.9847
250021............................          ***            *      15.8485      15.1242      20.3559      16.0142
250023............................       0.8443       0.8612      14.7355      16.1820      16.2418      15.7024
250025............................       1.0405       0.7685      21.2651      20.6892      20.5258      20.8816
250027............................       0.9794       0.7685      17.5937      17.3313      17.3481      17.4314
250030............................          ***       0.7685      27.2140            *            *      27.2140
250034............................       1.5307       0.9108      20.3681      20.6752      24.3189      21.8100
250035............................       0.8545       0.7685      17.1071      14.6149      17.2045      16.2933
250036............................       1.0038       0.8164      17.0469      17.8313      19.1975      18.0476
250037............................       0.8638       0.7685      16.6347      17.4463      17.4012      17.1789
250038............................       0.9832       0.8313      16.8610      18.0209      18.9050      17.9032
250039............................       0.9125       0.8313      16.8729      15.2939      17.3155      16.4505

[[Page 23513]]

 
250040............................       1.4718       0.8612      20.8178      21.3451      23.2285      21.8161
250042............................       1.2038       0.9108      19.4367      21.4117      23.4135      21.3957
250043............................       1.0429       0.7685      17.7554      18.3322      19.8098      18.6971
250044............................       1.0199       0.7685      20.3711      21.1198      23.3862      21.6199
250045............................       1.0872       0.8922      25.3236      25.0863      26.3831      25.6144
250048............................       1.5843       0.8313      19.3635      21.6547      22.9765      21.3756
250049............................       0.8410       0.7685      13.4396      17.8154      17.7005      16.2411
250050............................       1.1957       0.7685      16.6723      18.3170      19.1467      18.0183
250051............................       0.8358       0.7685      10.5027      10.6908      10.6095      10.6008
250057............................       1.1292       0.7685      19.0571      19.6789      20.1900      19.6573
250058............................       1.2515       0.7685      16.5565      17.5160      18.1704      17.4280
250059............................       0.9814       0.7685      19.0733      17.7270      19.2977      18.6884
250060............................       0.7926       0.7685      14.0155      20.8115      16.8247      17.2475
250061............................       0.8412       0.7685      11.4573      15.2515      12.8174      12.9127
250065............................       0.8170       0.8313      16.2010      16.1984            *      16.1997
250066............................       0.7831       0.7685      16.1044            *            *      16.1044
250068............................       0.7547       0.7685      16.3759      16.9585            *      16.6506
250069............................       1.4860       0.8614      21.2224      21.6617      22.8162      21.9460
250071............................       0.8305       0.7685      13.7056      17.7149            *      15.4400
250072............................       1.4976       0.8313      20.7827      22.9316      24.6587      22.7773
250077............................       0.9403       0.7685      14.0318      14.2271      14.7632      14.3259
250078 \2\........................       1.5963       0.7685      17.5186      18.6563      20.9354      19.1036
250079............................       0.8383       0.8182      21.3506      27.2549      38.0031      29.5848
250081............................       1.2295       0.8182      20.4513      21.3830      24.7031      21.9463
250082............................       1.2744       0.8099      19.5962      20.5212      19.6966      19.9404
250083............................       0.9072       0.7685      19.5217      19.9484            *      19.7505
250084............................       1.1575       0.7685      22.4632      21.8001      18.5775      20.7280
250085............................       0.9532       0.7685      18.0473      18.7367      19.7007      18.8283
250089............................       1.0502       0.7685      16.0203            *            *      16.0203
250094............................       1.5886       0.8612      19.9619      22.3312      22.7312      21.7001
250095............................       0.9965       0.7685      18.6616      19.9553      21.3511      19.9748
250096............................       1.0784       0.8313      20.7246      22.7458      22.6298      22.0767
250097............................       1.3963       0.8470      18.8399      19.4534      20.1687      19.4858
250098............................          ***       0.7685      17.9561            *            *      17.9561
250100............................       1.4464       0.8614      18.8877      22.0328      24.2209      21.7570
250101............................          ***            *            *      21.2234            *       9.7147
250102............................       1.5446       0.8313      21.3213      22.5518      24.2868      22.7655
250104............................       1.4244       0.8182      20.5035      21.4431      22.6591      21.5782
250105............................       0.8995       0.7685      17.0136      17.9468      18.1196      17.6992
250107............................       0.9071       0.7685      16.7104      16.5369      17.8999      17.0742
250112............................       0.9521       0.7685      16.8696      19.6172      21.2824      19.4217
250117............................       1.0298       0.8612      18.8863      19.9774      23.3673      20.6608
250119............................          ***       0.7685      17.1373            *            *      17.1373
250122............................       1.0617       0.7685      19.7966      23.7230      24.5854      22.7156
250123............................       1.2675       0.8922      22.2184      22.0486      24.5115      22.9495
250124............................       0.8390       0.8313      15.6866      15.4343      17.2181      16.1302
250125............................       1.2819       0.8922      25.3415      26.8379      27.7077      26.6997
250126............................       0.9380       0.9346      20.1118      20.4085      21.7111      20.7174
250128............................       0.8826       0.7685      15.8352      15.9344      17.6269      16.4363
250131............................       0.8879       0.7685      11.5396            *            *      11.5396
250136............................       0.9767       0.8313      21.9977      22.5832      23.0637      22.5479
250138............................       1.2637       0.8313      21.2490      22.7902      23.8861      22.6997
250141............................       1.5358       0.9346      22.5187      24.5772      27.6158      25.2301
250146............................       0.8784       0.7685      16.9341      17.2328      18.6486      17.5743
250149............................       0.8979       0.7685      16.4228      15.0367      15.0641      15.5315
250151............................       0.7214       0.7685      20.4581      21.8697      17.2205      18.4362
250152............................       1.6630       0.8313            *            *      25.7837      25.7837
250153............................          ***       0.8313            *            *      29.0461      29.0461
260001............................       1.6129       0.8594      22.6646      25.3084      25.9250      24.6413
260002............................          ***       0.8953      24.6812      27.2329      26.4879      26.0819
260003............................       1.0250       0.7927      16.5931      17.6339            *      17.1135
260004............................       0.9578       0.7927      16.4423      16.7742      16.9421      16.7356
260005............................       1.4759       0.8953      25.5927      24.6142      26.5773      25.6220
260006............................       1.4271       0.7927      24.1078      26.4948      26.7587      25.8174
260008............................          ***            *      21.6256      17.6040      18.9522      19.2926
260009............................       1.1793       0.9454      20.1679      21.2729      22.1816      21.2122
260011............................       1.3859       0.8346      21.1625      21.4409      22.7061      21.7937

[[Page 23514]]

 
260012............................       1.0499       0.7927      17.7854      19.3389      20.3061      19.2632
260013............................       1.0044       0.8594      18.4857      19.2065      20.5007      19.3903
260015............................       1.0786       0.7927      21.7581      22.4450      22.5409      22.2644
260017............................       1.3014       0.8953      20.7837      21.1359      22.7022      21.5787
260018............................       1.0599       0.7927      14.3278      14.8425      17.0434      15.4340
260020............................       1.7361       0.8953      22.4709      25.7898      26.0407      24.8648
260021............................       1.3546       0.8953      27.2478      27.8332      27.6330      27.5756
260022............................       1.2242       0.8563      20.5417      21.7707      22.8085      21.6784
260023............................       1.2675       0.8953      19.6324      21.2519      21.2077      20.7002
260024............................       1.1370       0.7927      16.9968      17.5351      18.4829      17.6819
260025............................       1.2646       0.8953      19.3535      20.0901      22.4645      20.6596
260027............................       1.5961       0.9454      22.9973      24.7605      25.3348      24.3810
260029............................       1.0866       0.9454      22.0390      22.2892      23.1185      22.4857
260031............................          ***            *      24.3626      24.2877            *      24.3260
260032............................       1.7985       0.8953      21.8830      23.1125      23.8459      22.9657
260034............................       0.9517       0.9454      21.6108      23.3034      24.1143      23.0518
260035............................       0.9459       0.7927      15.0468      16.8502      17.8741      16.5641
260036............................       0.9500       0.9454      19.4559      20.1324      22.1912      20.4830
260040............................       1.6194       0.8251      20.0422      21.9452      23.3566      21.8297
260044............................       0.9352       0.7927      18.2413      20.0686      22.4498      20.3210
260047............................       1.5009       0.8346      22.4585      22.6169      24.4185      23.1892
260048............................       1.2518       0.9454      26.6363      25.8089      24.3906      25.5119
260050............................       1.1354       0.7927      20.8510      20.6364      23.6849      21.9007
260052............................       1.3148       0.8953      21.1297      22.5809      24.5165      22.8077
260053............................       1.0393       0.8594      18.9606      20.0051      21.6607      20.2038
260057............................       1.0346       0.9454      15.8404      16.4875      19.3335      17.1879
260059............................       1.1931       0.7927      17.2807      18.6379      19.7243      18.6135
260061............................       1.0883       0.7927      18.7280      19.6674      21.5264      19.9180
260062............................       1.1811       0.9454      25.2958      26.0439      26.4539      25.9705
260063............................       0.9686       0.9454      21.1284      22.0826            *      21.6180
260064............................       1.3672       0.8346      17.5188      19.1587      19.0543      18.5908
260065............................       1.7230       0.8251      22.0058      23.6969      23.0015      22.9155
260067............................       0.8937       0.7927      14.9792      16.5364      17.6256      16.4270
260068............................       1.7577       0.8346      22.0951      23.9340      24.9504      23.7077
260070............................       0.9581       0.7927      11.2251      14.3881      18.4779      14.0836
260073............................       1.0189       0.7927      17.8185      19.2744      21.6214      19.6354
260074............................       1.1674       0.8346      18.7639      23.9301      24.8654      22.4254
260077............................       1.6385       0.8953      21.9947      23.5466      25.5782      23.7347
260078............................       1.1970       0.7927      16.9217      18.4017      19.0802      18.1811
260080............................       0.8933       0.7927      13.6815      11.2817      14.7774      13.2210
260081............................       1.4823       0.8953      22.6627      23.7447      26.3969      24.2793
260085............................       1.5874       0.9454      22.7394      24.6046      25.6302      24.3659
260086............................       0.8704       0.7927      17.2048      17.1202      19.1702      17.8711
260091............................       1.5058       0.8953      23.9975      26.1149      27.2407      25.8446
260094............................       1.6399       0.8251      20.1043      20.6805      23.2544      21.4540
260095............................       1.3081       0.9454      22.8156      23.8671      25.5668      24.0702
260096............................       1.4315       0.9454      23.5009      25.9932      27.5592      25.8492
260097............................       1.1515       0.7927      19.6203      21.5077      21.3957      20.9049
260102............................       0.8325       0.9454      24.1041      22.9283      24.2368      23.7509
260103............................          ***            *      21.6192      23.3175            *      22.4894
260104............................       1.4636       0.8953      22.4769      24.0038      26.2867      24.3941
260105............................       1.7197       0.8953      24.6572      28.4652      28.8849      27.3498
260107............................       1.3072       0.9454      23.1564      24.2001      26.7782      24.6444
260108............................       1.8305       0.8953      22.7975      24.0936      25.0171      23.9907
260110............................       1.6192       0.8953      22.0026      22.2730       3.7978      22.7167
260113............................       1.0827       0.8285      16.3440      19.2467      20.9644      18.7740
260115............................       1.1542       0.8953      20.4880      21.7450      21.9859      21.4408
260116............................       1.1207       0.8285      16.9807      17.2698      18.5076      17.6168
260119............................       1.3355       0.7927      18.7959      22.1588      24.9937      22.8442
260120............................          ***            *      18.7651            *            *      18.7651
260123............................       0.9970       0.7927      17.7996      16.1169            *      17.0002
260127............................       0.9648       0.7927      19.7946      22.5328      21.8534      21.3553
260134............................       1.1483       0.8953      18.4511      18.1531            *      18.2845
260137............................       1.6384       0.8594      20.7638      21.3426      22.7431      21.6630
260138............................       1.9066       0.9454      25.6579      27.8229      28.5610      27.3740
260141............................       1.9089       0.8346      21.0771      21.1511      22.4886      21.5378
260142............................       1.0487       0.7927      18.6412      19.6582      20.3993      19.6104

[[Page 23515]]

 
260147............................       0.9384       0.7927      16.1171      17.2291      18.5153      17.2858
260159............................          ***       0.8953      23.1093      26.8924      23.7427      24.4817
260160............................       1.0773       0.7927      18.8723      19.4997      21.0544      19.7923
260162............................       1.3864       0.8953      22.5705      24.1246      25.1423      23.9984
260163............................       1.1422       0.7927      18.1310      19.2885      20.1949      19.2038
260164............................       1.0696       0.7927      16.9403      19.5539      19.7068      18.6878
260166............................       1.1854       0.9454      22.8409      25.5151      27.0237      25.1725
260172............................       0.9089       0.7927      17.1504      18.1438            *      17.6539
260175............................       1.1001       0.7927      19.7939      21.1257      22.6171      21.1462
260176............................       1.5811       0.8953      25.7802      29.2184      27.4244      27.5317
260177............................       1.2174       0.9454      24.0550      25.0724      26.1178      25.1274
260178............................       1.8186       0.8346      21.7704      21.4781      22.2251      21.8190
260179............................       1.5692       0.8953      23.2824      24.8541      26.1419      24.7933
260180............................       1.5399       0.8953      21.8585      21.9679      26.7461      23.4659
260183............................       1.6506       0.8953      24.2330      23.3924      26.0418      24.6030
260186............................       1.6276       0.8346      21.6620      23.4317      25.3148      23.5713
260190............................       1.1384       0.9454      24.5014      25.1653      26.4505      25.4095
260191............................       1.3158       0.8953      21.1331      22.4369      23.3856      22.3648
260193............................       1.2140       0.9454      22.9556      24.4705      26.2979      24.7042
260195............................       1.2803       0.8251      20.0889      20.1327      22.3958      20.9711
260198............................       1.1855       0.8953      25.3390      27.6116      27.5996      26.8633
260200............................       1.2198       0.8953      22.3913      25.1134      24.8624      24.2536
260207............................       1.0594       0.8251      18.5247      19.2467      19.7294      19.2332
260208............................          ***            *      28.3158            *            *      28.3158
260210............................       1.2045       0.8953            *            *      25.3782      25.3782
260211............................       1.5796       0.9454            *            *      33.9109      33.9109
270002 \2\........................       1.2881       0.8822      19.7588      20.7620      22.7322      21.1317
270003............................       1.2770       0.9074      23.0396      24.2823      26.4843      24.5714
270004............................       1.6910       0.8855      21.5577      22.9081      23.5454      22.7035
270009............................       1.2674       0.8822      21.5655            *            *      21.5655
270012 \2\........................       1.4482       0.9074      21.7634      23.1697      25.2873      23.4084
270014............................       1.8188       0.9535      20.3456      25.0650      26.2025      23.6425
270017............................       1.2612       0.9535      23.2320      24.6186      27.5483      25.1665
270021............................       1.0085       0.8822      21.1624      21.6758      21.7056      21.5330
270023............................       1.5160       0.9535      23.7486      25.5525      26.7576      25.3555
270032............................       1.0500       0.8822      20.1801      18.2377      19.6212      19.3552
270036............................       0.7848       0.8822      18.8785      21.8255      20.4242      20.3944
270040............................       1.1798       0.8822      20.7240            *            *      20.7240
270050............................       1.0303       0.8822      21.0901      22.4195            *      21.7451
270051............................       1.5685       0.9535      22.2580      26.4457      26.6619      25.1119
270057............................       1.2222       0.8822      21.9997      22.6251      24.2980      23.0119
270060............................       0.8776       0.8822            *      16.6592            *      16.6592
270079............................       0.8473       0.8822            *      21.6382            *      21.6382
270081............................       1.0052       0.8822      15.6833      17.3174      17.4862      16.8348
270082............................       1.0621       0.8822      21.0150      19.6173            *      20.3610
270084 \2\........................       0.9843       0.8822      19.6104      22.2340            *      21.0235
280003............................       1.8332       1.0197      26.0937      27.2844      29.3921      27.8614
280005............................          ***            *      23.9753            *            *      23.9753
280010............................          ***            *      23.8325      22.6516            *      23.2571
280013............................       1.8041       0.9555      23.4920      24.5214      26.1908      24.7334
280020............................       1.7943       1.0197      23.4577      25.7522      26.5068      25.3300
280021............................       1.1390       0.8666      21.5215      22.2864      22.0489      21.9595
280023............................       1.4073       0.9666      19.6265      22.7207      22.3230      21.6126
280030............................       1.9343       0.9555      29.2221      32.5601      30.7481      30.8807
280032............................       1.3356       0.9666      21.5150      22.6510      23.6462      22.6240
280040............................       1.6685       0.9555      23.6597      25.2965      26.9827      25.3499
280047............................       0.7767       0.9555      19.5815            *            *      19.5815
280057............................       0.8190       0.9666      22.5481      23.6793      20.4830      22.0597
280060............................       1.6115       0.9555      23.1128      25.2288      26.2139      24.9273
280061............................       1.3565       0.9207      21.2901      23.9110      24.9482      23.4090
280065............................       1.2692       0.9597      23.8128      27.9937      26.0135      25.9591
280077............................       1.3308       0.9555      22.7244      24.0516      25.5624      24.1150
280081............................       1.6019       0.9555      24.3199      25.1973      26.0541      25.2026
280085............................          ***            *      21.8473            *            *      21.8473
280108............................       1.0415       0.8666      20.9016      22.5584      23.2502      22.2006
280111............................       1.2083       0.8666      20.7398      22.1424      23.4770      22.1827
280117............................       1.0762       0.8666      20.5464      22.0611      24.1521      22.2744

[[Page 23516]]

 
280118............................       0.9146       0.8666      19.3466            *            *      19.3466
280125............................       1.5050       0.8666      20.0643      21.8385      21.7658      21.2295
280126............................          ***            *      33.8918            *            *      33.8918
290002............................       0.8621       0.9786      16.8363      16.8433      18.3469      17.3909
290003............................       1.7448       1.1416      27.4732      27.1099      28.1625      27.5886
290005............................       1.3375       1.1416      24.6877      27.1531      27.6697      26.5417
290006............................       1.2159       1.0805      24.2211      26.3617      27.9502      26.1547
290007............................       1.5966       1.1416      35.1020      35.4193      37.5559      36.0546
290008............................       1.1726       1.1249      27.0115      26.4086      27.9714      27.1141
290009............................       1.8521       1.0984      26.9020      27.6011      29.8019      28.1837
290010............................       1.0895       1.1416      25.4598      23.8733      23.9654      24.4204
290012............................       1.3288       1.1416      25.8036      27.2675      31.0843      28.0502
290016............................       1.1453       0.9079      22.5111      25.1726      26.1925      24.6281
290019............................       1.3967       1.0805      25.1684      27.2484      28.6158      27.0192
290020 h..........................       0.9611       1.1416      24.2373      21.3094      21.6993      22.1469
290021............................       1.7247       1.1416      26.2510      28.3837      33.2116      29.2014
290022............................       1.5056       1.1416      27.5364      29.8144      29.4422      28.9634
290027............................       0.9165       0.9079      13.5031      17.8850      15.1448      15.3083
290032............................       1.3609       1.0984      27.5425      29.4164      31.7105      29.6070
290039............................       1.5069       1.1416      28.7599      29.6801      31.2941      30.0435
290041............................       1.3172       1.1416      28.6294      30.1346      33.9878      31.0661
290045............................       1.5063       1.1416      26.5644      26.9319      30.9612      28.4883
300001............................       1.5520       1.0668      27.1312      29.4130      27.5032      28.0073
300003............................       2.0702       1.0668      26.7859      27.8059      33.3560      29.3633
300005............................       1.4218       1.0668      22.8163      25.1869      25.5583      24.5574
300006............................       1.1092       1.0668      22.0187      20.6787      23.3200      21.9532
300007............................       1.2560       1.0903      23.6919      25.3125      26.8347      25.3232
300010............................       1.2942       1.0668      24.6295      26.9346      27.5028      26.4641
300011............................       1.3026       1.0903      25.0979      27.3325      28.4044      26.9920
300012............................       1.3884       1.0903      26.3914      28.4234      30.5198      28.4955
300013............................       1.0657       1.0668      21.3397      23.1529            *      22.1888
300014............................       1.2155       1.0668      23.7144      25.5059      27.5151      25.6846
300015............................       1.0860       1.0668      24.4869      24.0620            *      24.2732
300016............................          ***       1.0668      18.9756      24.5498            *      21.6922
300017............................       1.2121       1.0668      26.1104      28.3959      29.6957      28.0967
300018............................       1.3882       1.0668      25.7851      28.0308      29.7209      27.9654
300019............................       1.2223       1.0903      23.8076      25.3845      25.9656      25.1005
300020............................       1.1875       1.0903      24.8189      26.8402      28.6723      26.8622
300022............................       1.1118       1.0668      22.3918      23.5948      24.4048      23.4922
300023............................       1.4230       1.0668      24.9992      25.4873      28.6309      26.4774
300024............................       1.2139       1.0668      22.4883      23.9205            *      23.2005
300029............................       1.7645       1.0668      24.5772      26.9484      29.0806      26.9920
300034............................       2.0805       1.0903      26.9093      28.5375      29.7484      28.4471
310001............................       1.7701       1.3191      30.1786      33.9360      35.3612      33.2483
310002............................       1.8371       1.3191      33.9058      35.4567      37.3461      35.5944
310003............................       1.2057       1.3191      30.4234      31.1040      32.8935      31.5180
310005............................       1.3245       1.2192      26.0227      27.5690      29.0084      27.5943
310006............................       1.2346       1.3191      25.9000      27.0436      27.4545      26.7958
310008............................       1.3149       1.3191      28.0970      29.5857      31.2579      29.6725
310009............................       1.2458       1.3191      24.6353      29.7760      32.7384      29.0885
310010............................       1.2847       1.0837      26.7889      25.3139      28.5852      26.9172
310011............................       1.2662       1.1031      26.1586      28.5241      30.8612      28.5543
310012............................       1.6801       1.3191      31.1705      33.1622      34.6882      33.0545
310013............................       1.3585       1.3191      25.0951      28.5016      30.6248      28.1586
310014............................       1.8139       1.0607      29.1931      32.7222      29.7204      30.4762
310015............................       1.8694       1.3191      30.1767      32.4980      36.4776      33.0707
310016............................       1.3353       1.3191      25.7368      28.9788      33.9862      29.9150
310017............................       1.3378       1.2192      25.2636      28.0930      30.9233      28.1646
310018............................       1.1407       1.3191      25.9108      26.9399      30.3381      27.8107
310019............................       1.6282       1.3191      26.8663      31.0524      29.6592      29.1388
310020............................       1.5855       1.3191      25.0147      29.3392      30.6722      28.2107
310021............................       1.6207       1.0837      29.4003      29.6308      31.3410      30.1313
310022............................       1.2275       1.0607      26.7487      26.1914      28.2024      27.0808
310024............................       1.3520       1.2192      26.9499      27.5278      30.9171      28.3714
310025............................       1.2683       1.3191      26.8719      27.7960      31.1274      28.7415
310026............................       1.2192       1.3191      24.6697      25.3970      27.5171      25.9064
310027............................       1.2914       1.2192      22.1935      27.0982      53.3590      32.8604

[[Page 23517]]

 
310028............................       1.2218       1.2192      25.7246      29.1101      31.3849      28.7946
310029............................       1.8622       1.0607      25.9606      29.1439      30.7707      28.6905
310031............................       2.9677       1.1301      29.5581      30.2345      33.9685      31.2972
310032............................       1.2894       1.0652      25.7088      27.8754      27.5232      27.0476
310034............................       1.3320       1.1301      26.5224      27.8517      29.9162      28.1036
310037............................       1.3242       1.3191      30.1264      32.1471      35.0329      32.5209
310038............................       1.9813       1.3191      32.3865      32.1977      33.4822      32.7188
310039............................       1.2457       1.1301      24.6045      27.1054      28.8292      26.9337
310040............................       1.3638       1.3191      27.4041      28.0068      34.1113      29.8744
310041............................       1.2679       1.1301      26.8145      29.7335      32.8085      29.8863
310042............................       1.1514       1.3191      26.9695      29.0207      30.7358      28.9101
310044............................       1.3163       1.0837      25.1618      27.7752      31.3206      28.1678
310045............................       1.5833       1.3191      31.7376      32.6359      34.0151      32.8526
310047............................       1.3107       1.1618      26.1353      28.3415      32.8380      29.2921
310048............................       1.3562       1.2192      27.4050      28.4715      30.2025      28.7345
310049............................          ***            *      26.5332      32.7666      27.8564      27.2897
310050............................       1.2751       1.2192      25.3772      27.2276      27.3033      26.7397
310051............................       1.3708       1.2192      29.2386      32.0113      33.7168      31.6981
310052............................       1.3032       1.1301      27.0324      28.1498      30.8036      28.6341
310054............................       1.2802       1.3191      28.1880      30.6905      34.1860      31.0476
310057............................       1.3058       1.0607      26.3903      26.4606      29.5221      27.5782
310058............................       1.0940       1.3191      28.1753      26.4816      28.0815      27.5746
310060............................       1.2669       1.0607      22.1914      23.2146      25.1575      23.5782
310061............................       1.2605       1.0607      24.9678      27.5400      28.2129      26.9521
310063............................       1.3317       1.2192      25.9868      28.3457      31.4884      28.5345
310064............................       1.5192       1.1618      27.8388      29.5979      33.4440      30.4173
310067............................          ***       1.2192      26.3624      26.8068            *      26.5479
310069............................       1.2630       1.0652      25.7690      27.9656      28.1681      27.3281
310070............................       1.3475       1.3191      30.1917      32.1806      33.2310      31.9325
310072............................          ***            *      25.3145      26.3520            *      25.8709
310073............................       1.7716       1.1301      28.8791      29.6611      32.0329      30.2191
310074............................       1.2859       1.3191      27.6789      28.4361      29.4834      28.5348
310075............................       1.2656       1.1301      25.7726      26.2479      31.6870      27.8786
310076............................       1.5940       1.3191      32.4533      34.9428      36.4280      34.6292
310077............................       1.6607       1.3191      28.7352      30.7465      32.6644      30.7450
310078............................       1.2963       1.3191      24.7753      26.9589      29.8014      27.2209
310081............................       1.2485       1.0607      24.6083      26.4259      26.6136      25.9041
310083............................       1.2961       1.3191      25.2465      24.6563      28.2392      25.9836
310084............................       1.2192       1.1301      27.3680      29.9437      32.9001      30.0920
310086............................       1.2110       1.0607      25.2751      27.3601      29.3058      27.3522
310088............................       1.1766       1.1618      23.7846      25.5274      26.4966      25.2810
310090............................       1.2599       1.2192      25.3640      27.1661      30.8941      27.8574
310091............................       1.1909       1.0652      25.6405      27.1115      27.7204      26.8559
310092............................       1.3547       1.0837      23.2226      25.7071      29.4999      26.1525
310093............................       1.1809       1.3191      24.6942      25.8727      28.0401      26.2654
310096............................       2.0766       1.3191      28.4705      30.3675      34.4275      31.1262
310105............................       1.2212       1.3191      28.7333      30.9968      31.9769      30.6308
310108............................       1.3809       1.1301      24.9090      29.1548      30.1002      28.0512
310110............................       1.2871       1.0837      26.4175      27.8707      31.2164      28.8347
310111............................       1.1936       1.1301      26.2496      28.8692      30.7475      28.7020
310112............................       1.2335       1.1301      27.8796      28.9928      30.4192      29.1502
310113............................       1.2365       1.1301      25.9143      27.5203      29.6079      27.7501
310115............................       1.2658       1.0607      24.5413      26.2803      29.6020      26.9083
310116............................       1.2404       1.3191      25.1189      26.6287      25.6976      25.7970
310118............................       1.2786       1.3191      28.0517      28.1238      28.8797      28.3510
310119............................       1.7690       1.3191      34.7468      35.6786      37.7876      36.1340
310120............................       1.1565       1.2192      24.7078      27.2010      31.4110      27.6263
320001............................       1.4765       0.9696      23.0290      26.1962      26.9434      25.3673
320002............................       1.3821       1.0908      26.7332      28.6963      30.5158      28.6521
320003............................       1.1105       0.8649      20.7939      22.3911      28.1402      23.4549
320004............................       1.2830       0.8649      19.4799      24.0362      24.9481      23.1709
320005............................       1.4230       0.9558      22.1677      21.2164      23.8264      22.4376
320006............................       1.3163       1.0163      21.1222      22.5615      24.2812      22.6734
320009............................       1.5090       0.9696      21.5870      24.4237      22.8293      22.9608
320011............................       1.1653       0.8649      20.7714      23.1539      24.2279      22.7686
320013............................       1.1462       1.0163      19.4487      27.8671      28.9276      24.8284
320014............................       1.1040       0.8649      19.7656      26.7112      24.5310      23.5594

[[Page 23518]]

 
320016............................       1.1520       0.8649      19.9326      21.7001      23.5040      21.7285
320017............................       1.2523       0.9696      22.5460      23.6861      25.0286      23.7296
320018............................       1.4565       0.8649      21.4650      23.0915      23.2360      22.6002
320019............................       1.5397       0.9696      26.6900      31.2250      31.5192      29.7045
320021............................       1.6254       0.9696      21.0913      28.5620      27.2357      25.1851
320022............................       1.0969       0.8649      20.7919      22.1492      23.7160      22.2284
320030............................       1.0284       0.8649      16.8696      18.0990      22.1971      18.9458
320033............................       1.1545       1.0163      24.2703      24.1185      27.6393      25.3263
320037............................       1.1552       0.9696      19.6466      21.6080      23.3999      21.6108
320038............................       1.1959       0.8649      19.2962      21.2181      20.1533      20.2270
320046............................       1.1718       0.8649      21.5915      22.9114      24.3534      22.9610
320063............................       1.2785       0.9593      20.7804      24.9141      24.4696      23.4155
320065............................       1.0973       0.9593      19.9012      21.6189      26.6603      22.8070
320067............................       0.8271       0.8649      13.9459      20.4431      23.7745      19.8406
320069............................       1.0924       0.8649      18.5375      19.7296      20.9167      19.7352
320074............................       1.1664       0.9696      28.3086      35.5980      22.2175      28.2084
320079............................       1.1142       0.9696      21.9090      23.8092      25.2105      23.6814
320083............................       2.5985       0.9696      20.6771            *      28.2114      23.7546
320084............................       1.0974       0.8649            *            *      17.2511      17.2511
320085............................       1.6090       0.8649            *            *      24.8752      24.8752
330001............................          ***       1.3191      30.8509      31.3735      33.4718      31.9148
330002............................       1.4447       1.3191      28.0882      29.3459      31.1924      29.5603
330003............................       1.2641       0.8565      20.2744      21.6506      22.9945      21.6443
330004............................       1.2725       1.0576      24.3703      23.9959      26.0445      24.8414
330005............................       1.5973       0.8888      24.3578      25.9287            *      25.1198
330006............................       1.2917       1.3191      28.3904      29.7509      31.5370      29.8730
330008............................       1.1113       0.8888      20.6816      21.3269      21.8198      21.2850
330009............................       1.2845       1.3191      33.3605      35.8367      35.4986      34.8796
330010............................          ***            *      19.8211      17.9178      19.6920      19.0804
330011............................       1.2998       0.8588      19.8035      20.3641      21.8008      20.6687
330013............................       2.1105       0.8565      21.2063      23.9070      24.3512      23.1632
330014............................       1.3351       1.3191      32.0824      35.4053      38.8123      35.4565
330016............................       0.9933       0.8220      18.1603      18.9388      28.4392      20.9735
330019............................       1.2932       1.3191      31.9042      32.3413      34.7814      33.0323
330023 \2\........................       1.5678       1.0767      29.4538      29.2669      29.8943      29.5534
330024............................       1.7206       1.3191      35.3598      36.5648      38.8643      36.8845
330025............................       1.0421       0.8888      18.7663      19.7561      20.2775      19.6152
330027............................       1.4553       1.3191      34.1281      35.1325      39.0717      36.0189
330028............................       1.3838       1.3191      31.8452      33.5312      34.2709      33.2330
330029............................       0.4208       0.8888      18.4354      18.6623      19.1589      18.7332
330030............................       1.2550       0.9117      22.0574      22.4368      22.9937      22.4866
330033............................       1.2667       0.8220      18.6316      21.3762      22.5681      20.8260
330036............................       1.1360       1.3191      27.0970      27.6813      28.9409      27.8674
330037............................       1.0926       0.9117      18.3557      19.6385      20.6904      19.5992
330041............................       1.1922       1.3191      34.5461      36.2481      36.0286      35.6239
330043............................       1.2957       1.2781      31.7873      34.1039      34.7480      33.5850
330044............................       1.2690       0.8313      22.0465      23.1450      23.8719      23.0325
330045............................       1.3308       1.2781      30.9046      34.4956      36.1749      33.9185
330046............................       1.4018       1.3191      41.6759      42.0900      44.8494      42.8629
330047 h..........................       1.1968       0.8565      20.1646      21.1244      24.0678      21.8925
330049............................       1.3533       1.0767      24.7766      25.7022      29.2904      26.5366
330053............................       1.0847       0.9117      18.1728      19.6807      18.5290      18.7942
330055............................       1.6314       1.3191      34.9709      35.1393      38.4839      36.2207
330056............................       1.4539       1.3191      32.0982      32.9295      37.8444      34.2883
330057............................       1.6969       0.8565      20.9282      22.6519      24.4680      22.6890
330058............................       1.3165       0.9117      19.2916      19.5520      20.8234      19.9138
330059............................       1.5179       1.3191      36.4176      38.1019      39.7386      38.0767
330061............................       1.2264       1.3191      28.6725      32.7427      33.2848      31.6301
330062............................       1.1819       0.9204      20.0222      21.4270      21.0464      20.8258
330064............................       1.1415       1.3191      36.0976      38.5719      36.6153      37.0956
330065............................       1.0281       0.8888      20.5958      21.9192      23.9128      22.1517
330066............................       1.3120       0.8565      20.9990      23.0916      24.7941      23.0025
330067 \2\........................       1.4150       1.0767      24.8927      34.8416      26.4243      28.0084
330072............................       1.3818       1.3191      32.9665      32.7905      36.4336      34.0607
330073............................       1.1228       0.9117      18.4162      19.0781      20.1490      19.1772
330074............................       1.3126       0.9117      21.7299      20.2874      21.4274      21.1093
330075............................       1.1656       0.9595      19.9781      22.0240      22.4188      21.4854

[[Page 23519]]

 
330078............................       1.4256       0.8888      20.8379      22.7762      23.3786      22.3586
330079............................       1.3180       0.8220      21.1153      22.1064      22.5237      21.9214
330080............................       1.1477       1.3191      33.5537      36.1171      39.1724      36.3260
330084............................       1.0829       0.8220      19.2135      22.6365      21.5455      21.1058
330085............................       1.1913       0.9315      21.8271      23.2927      23.9568      23.0352
330086............................       1.3193       1.3191      27.1585      28.8425      29.1784      28.3884
330088............................       1.0442       1.2781      29.5181      31.2631            *      39.0244
330090............................       1.4373       0.8276      20.9327      22.7721      23.6174      22.4292
330091............................       1.3675       0.8888      22.9396      22.5796      23.1637      22.8973
330094............................       1.2532       0.8904      21.3659      22.1495      23.0001      22.1769
330095............................          ***            *      28.9794      28.9914      31.9872      29.7944
330096............................       1.0690       0.8220      21.1648      22.4895      22.0337      21.9119
330097............................       1.1327       0.8220      18.6291      19.2233      20.2158      19.3250
330100............................       1.0066       1.3191      31.5775      32.8406      34.4621      32.9762
330101............................       1.8242       1.3191      38.4810      39.2601      38.7468      38.8311
330102............................       1.3460       0.8888      23.5254      23.6141      24.8184      23.9846
330103............................       1.0963       0.8220      17.9017      18.8763      21.1452      19.3116
330104............................       1.3563       1.3191      36.8451      33.7556      32.8818      34.4566
330106............................       1.7244       1.2781      38.7822      39.8558      41.2202      39.9816
330107............................       1.2325       1.2781      29.1958      31.8528      31.3888      30.7790
330108............................       1.1108       0.8276      20.2536      21.4680      22.2607      21.3131
330111............................       1.0397       0.8888      17.7020      17.6185      20.9387      18.7250
330114............................          ***            *      19.2566            *            *      19.2566
330119............................       1.7468       1.3191      34.6591      36.5873      39.1114      36.7610
330121............................       0.9116       0.8220      17.9757      19.7388      23.9397      20.5934
330122............................          ***            *      25.6500      26.3849            *      26.0090
330125............................       1.7658       0.9117      22.8078      24.6945      26.6379      24.8334
330126............................       1.2826       1.0767      27.7155      28.8299      31.6370      29.4715
330127............................       1.2655       1.3191      42.2836      43.7479      44.4667      43.5141
330128............................       1.1790       1.3191      32.7050      34.5289            *      33.6278
330132............................       1.0730       0.8220      16.0311      16.3088      17.4946      16.8474
330133............................       1.3118       1.3191      35.3136      44.0704      36.6962      38.2248
330135............................       1.2237       1.0767      25.6504      26.9969      29.0837      27.3649
330136............................       1.4654       0.9315      21.4225      22.5447      24.2010      22.7506
330140............................       1.7896       0.9595      21.1787      23.5774      25.7573      23.5011
330141............................       1.3034       1.2781      29.3283      30.6616      34.8902      31.6934
330144............................       1.0332       0.8220      17.3920      20.1805      20.9935      19.3948
330148............................       1.0266       0.8313      17.6560      18.5443            *      18.0744
330151............................       1.1030       0.8220      16.4028      17.6782      19.1841      17.7056
330152............................       1.3177       1.3191      32.3332      32.0616      36.5136      33.6447
330153............................       1.7022       0.8565      21.2843      21.9935      23.7172      22.3124
330157............................       1.3678       0.9315      23.5522      23.6939      24.9042      24.0644
330158............................       1.5489       1.3191      32.7159      33.0067      32.2990      32.6514
330159............................       1.3811       0.9595      22.5580      24.1916      28.8391      25.0788
330160............................       1.5392       1.3191      32.1266      34.0373      34.1960      33.4347
330162............................       1.2612       1.3191      29.6042      31.3812      32.1783      31.0913
330163............................       1.2015       0.8888      21.1517      22.4644      24.0200      22.5391
330164............................       1.4792       0.9117      23.5427      24.4306      28.8481      25.6753
330166 h..........................       1.0593       0.8220      18.4262      18.8777      19.4360      18.9008
330167............................       1.7665       1.2781      30.9667      33.7365      34.4405      33.1152
330169............................       1.4095       1.3191      36.2725      38.3498      39.3361      37.9349
330171............................       1.1728       1.3191      25.9946      27.7810      30.0122      27.7871
330175............................       1.1137       0.8220      20.4628      21.1944      22.2067      21.3007
330177............................       0.9453       0.8220      19.0005      20.1850      19.6100      19.6031
330180............................       1.2265       0.8565      19.8951      21.9641      22.1920      21.3178
330181............................       1.3091       1.3191      37.1218      35.8846      38.5351      37.1836
330182............................       2.3204       1.3191      35.2416      36.3831      39.6038      37.1311
330184............................       1.4141       1.3191      30.7479      33.2843      34.4044      32.7893
330185............................       1.2671       1.2781      28.9787      31.0179      32.3466      30.8714
330188............................       1.2490       0.8888      21.1196      22.6803      23.9210      22.6030
330189............................       0.9765       0.8565      19.0726      19.2538      21.6229      19.9266
330191............................       1.2880       0.8565      20.9392      22.3719      24.0232      22.4577
330193............................       1.2567       1.3191      36.2427      36.9866      37.1807      36.8214
330194............................       1.7888       1.3191      38.5372      39.9177      43.9910      40.8421
330195............................       1.7407       1.3191      36.4249      38.6867      40.0206      38.4696
330196............................       1.2724       1.3191      31.1915      32.5883      33.2171      32.3484
330197............................       1.1300       0.8220      20.8386      22.3117      23.4291      22.2164

[[Page 23520]]

 
330198............................       1.3527       1.2781      25.3622      29.5359      30.5485      28.5487
330199............................       1.1121       1.3191      34.1354      32.7870      35.0059      33.9687
330201............................       1.6454       1.3191      29.3745      33.3215      39.3682      33.7813
330202............................       1.2540       1.3191      30.7990      34.3545      35.0804      33.5414
330203............................       1.4787       0.9595      24.7422      26.2459      26.5882      25.8191
330204............................       1.3191       1.3191      30.3699      30.3273      37.6849      32.8372
330205............................       1.2677       1.0767      29.0622      30.0101      32.1617      30.4707
330208............................       1.1879       1.3191      30.6158      28.2667      29.6282      29.4819
330209............................       1.1738       1.0767      27.7071      28.7213      29.7988      28.7477
330211............................       1.1533       0.8220      20.8224      21.1094      22.9966      21.6469
330212............................          ***       1.3191      24.9434      27.0585      27.2232      26.1185
330213............................       1.1308       0.8220      20.7967      21.7208      22.5191      21.6931
330214............................       1.9065       1.3191      32.7647      33.7670      37.8500      34.8451
330215............................       1.3146       0.8313      19.9226      20.6343      22.5715      21.0552
330218............................       1.0371       0.9595      20.6012      21.4095      24.1106      22.0618
330219............................       1.6407       0.8888      28.7448      27.7400      29.3803      28.6143
330221............................       1.3773       1.3191      34.9345      34.7033      36.5539      35.4233
330222............................       1.2919       0.8565      23.5491      25.9825      23.9746      24.4778
330223............................       1.0310       0.8220      18.8253      18.4291      19.4229      18.9058
330224............................       1.2912       0.9260      22.7847      23.9379      25.7396      24.1533
330225............................       1.1790       1.2781      29.1744      28.9952      29.2719      29.1527
330226............................       1.3067       0.9117      23.5405      23.4783      21.8977      22.8832
330229 h..........................       1.1699       0.8424      18.5590      19.5670      20.6095      19.5838
330230............................       0.9941       1.3191      32.5997      32.1101      33.3175      32.6586
330231............................       0.9977       1.3191      30.2184      33.9324      37.0175      33.7403
330232............................       1.1923       0.8565      21.1277      21.4765      24.2810      22.2924
330233............................       1.4170       1.3191      39.5133      41.9968      45.5132      42.4372
330234............................       2.2593       1.3191      37.7135      36.8500      40.6314      38.3961
330235............................       1.1320       0.9315      21.4643      22.1217      23.3866      22.3225
330236............................       1.4277       1.3191      31.8491      32.9391      35.6347      33.4921
330238............................       1.2507       0.9117      18.3846      19.2407      20.8639      19.5443
330239 h..........................       1.2261       0.8424      19.7561      20.4936      21.5397      20.5927
330240............................       1.2179       1.3191      37.3866      40.7478      36.7910      38.3109
330241............................       1.8763       0.9595      26.7598      27.7213      29.0882      27.8974
330242............................       1.2925       1.3191      30.5172      32.2178      46.0013      35.2529
330245............................       1.9001       0.8313      20.2037      21.6857      22.7032      21.5626
330246............................       1.3295       1.2781      31.8857      31.6763      34.6329      32.7279
330247............................       1.0067       1.3191      25.6063      32.1733      32.2300      29.8298
330249............................       1.2019       0.9595      19.1469      21.4345      22.9834      21.2588
330250............................       1.2791       0.9306      22.1272      23.0641      25.1664      23.4900
330259............................       1.4142       1.2781      27.4131      30.0488      31.9495      29.9063
330261............................       1.2516       1.3191      30.4771      30.9356      30.7942      30.7386
330263............................       0.9776       0.8220      20.0831      20.8456      22.4675      21.1560
330264............................       1.2367       1.0767      26.3652      28.1501      30.0139      28.1122
330265............................       1.2729       0.9117      18.2547      19.9414      20.4635      19.5583
330267............................       1.4649       1.3191      29.0499      30.3709      31.5478      30.3522
330268............................       0.9506       0.8565      18.7991      18.9142      20.9720      19.5863
330270............................       2.0316       1.3191      36.5976      38.2605      52.4880      42.6074
330273............................       1.4020       1.3191      28.8548      29.5106      30.3976      29.6096
330276............................       1.1013       0.8220      20.7973      21.7826      22.2353      21.6210
330277............................       1.1667       0.9204      21.8866      25.1438      25.3582      24.1682
330279............................       1.4462       0.8888      23.8793      23.4816      24.9772      24.1439
330285............................       1.9363       0.9117      26.0446      27.1260      27.9018      27.0364
330286............................       1.3657       1.2781      31.1344      32.3244      33.3377      32.3174
330290............................       1.7357       1.3191      35.5617      36.3764      36.9981      36.3009
330293............................          ***            *      17.6506      19.0290            *      18.3452
330304............................       1.2821       1.3191      31.1146      33.4431      34.5111      33.0739
330306............................       1.4608       1.3191      30.4426      30.7551      35.6640      32.2831
330307............................       1.2103       0.9855      23.8583      25.4128      27.5699      25.6624
330314............................       1.2270       1.2781      26.2954      26.0150      25.5597      25.9594
330316............................       1.2997       1.3191      33.7857      33.1512      34.8623      33.9322
330327............................          ***            *      19.3465            *            *      19.3465
330332............................       1.2570       1.2781      30.5104      31.8389      33.0652      31.9293
330333............................          ***       1.2781      29.7725      33.7637      26.1917      29.6723
330336............................          ***            *      32.9548            *            *      32.9548
330339............................       0.8062       0.8565      20.8424      22.2812      22.6569      21.9390
330340............................       1.1756       1.2781      29.8140      31.4322      33.5504      31.6312

[[Page 23521]]

 
330350............................       1.4934       1.3191      35.5656      39.3541      36.6250      37.1672
330353............................       1.1504       1.3191      35.6821      38.6962      37.6549      37.3737
330357............................       1.2908       1.3191      36.5461      34.3965      35.5975      35.5017
330372............................       1.2505       1.2781      28.2490      30.1505      32.6721      30.3998
330385............................       1.1112       1.3191      44.3387      42.6671      34.7820      40.7280
330386............................       1.2069       1.0576      25.2064      25.9228      27.9943      26.4367
330389............................       1.9214       1.3191      32.2112      34.7552      34.7669      33.9210
330390............................       1.2676       1.3191      32.7450      33.2628      36.0573      33.8898
330393............................       1.7382       1.2781      33.0953      34.8213      34.8095      34.2742
330394............................       1.6408       0.8588      21.3678      23.3505      25.2229      23.3324
330395............................       1.3921       1.3191      32.1089      35.4619      39.6666      35.4994
330396............................       1.2486       1.3191      31.2429      32.5345      35.0297      32.9828
330397............................       1.3537       1.3191      40.0884      34.5110      38.4741      37.5361
330399............................       1.1709       1.3191      32.1248      33.6753      32.3688      32.7392
330401............................       1.3161       1.2781      33.8633      35.7435      40.5332      36.7926
330402............................       0.7916       0.9260            *      21.3302            *      21.3302
330403............................          ***       0.9117            *            *      23.1887      23.1887
340001............................       1.4809       0.9717      21.6113      23.2436      25.0041      23.2441
340002............................       1.7358       0.9312      24.0145      25.1099      27.3349      25.5169
340003............................       1.0930       0.8570      20.8205      21.5562      23.3066      21.9251
340004............................       1.4023       0.9020      23.3756      24.2055      25.4474      24.3851
340005............................       0.9977       0.8570      20.8150      22.9830      22.3814      22.0177
340007............................          ***       0.9133      19.5208      21.1519            *      20.3174
340008............................       1.0820       0.9585      22.7338      24.2089      26.6314      25.0622
340010............................       1.3214       0.9476      21.3024      23.1349      24.5666      23.0280
340011............................       1.0509       0.8570      18.1926      18.1843      19.9484      18.7756
340012............................       1.2823       0.8570      19.6350      22.0583      22.7189      21.4818
340013............................       1.2354       0.9585      21.0066      22.4787      23.0261      22.1688
340014............................       1.5332       0.9020      22.6757      24.4831      25.1872      24.1069
340015 h..........................       1.3596       0.9717      24.3410      24.3870      26.2276      25.0387
340016............................       1.2110       0.8570      20.2859      22.7574      23.0359      22.0228
340017............................       1.2648       0.9312      21.7083      22.8879      23.8229      22.8228
340018............................       1.1294       0.9183      17.3480      20.3840      23.7243      20.2881
340019............................       0.9618       0.9020      16.7901      17.8768            *      17.3292
340020............................       1.1895       0.8570      21.3385      24.1955      23.7995      23.1233
340021............................       1.2956       0.9585      22.9208      23.6884      26.0995      24.2587
340022............................          ***       0.8570      19.9078            *            *      19.9078
340024............................       1.1553       0.8570      20.4906      21.2671      22.2521      21.3515
340025............................       1.2401       0.9312      20.2864      20.9915      21.2276      20.8493
340027............................       1.1523       0.9414      21.0975      22.6107      23.6326      22.4564
340028............................       1.5451       0.9426      22.2028      24.6836      26.3298      24.3471
340030............................       2.0360       1.0260      26.7753      27.4664      29.3043      27.9060
340032............................       1.3877       0.9717      23.2204      24.8031      26.7475      25.0122
340035............................       1.0281       0.8570      16.4821      21.2407      23.5476      20.1377
340036............................       1.1712       0.9709      20.8313      22.2089      25.2077      22.9528
340037............................       1.0024       0.8570      21.9524      22.5089      21.6411      22.0344
340038............................       1.1871       0.8570      13.9936      14.0203      14.0713      14.0327
340039............................       1.2862       0.9585      24.8246      25.6605      27.1275      25.9204
340040............................       1.9063       0.9414      22.4777      24.1523      26.3325      24.3631
340041............................       1.2302       0.8931      17.6319      23.0497      23.4891      21.2362
340042............................       1.0903       0.8570      21.1107      22.1107      23.0236      22.0702
340044............................       0.9395       0.8570      18.2154      21.7089      22.8948      20.8194
340045............................       0.9726       0.8570      17.4066      14.5004      23.1918      18.0750
340047............................       1.8926       0.9020      22.5199      25.3727      25.0605      24.3496
340049............................       2.0329       1.0260      21.2734      22.3082      30.4827      24.7548
340050............................       1.0881       0.9193      20.3262      21.4511      24.2533      22.0481
340051............................       1.2288       0.8931      20.3057      21.9069      23.4091      21.9456
340053............................       1.5911       0.9717      24.9768      26.9361      27.7261      26.5947
340055............................       1.2318       0.8931      23.2990      24.3728      24.1057      23.9407
340060............................       1.0613       0.9133      20.8077      22.4303      22.8657      22.0570
340061............................       1.8009       1.0260      25.1081      26.6657      27.5594      26.4994
340064............................       1.0787       0.8570      19.4523      22.3631      22.9143      21.5916
340065............................       1.1887       0.8570      20.3296      20.8413            *      20.5941
340067............................          ***            *      22.2565            *            *      22.2565
340069............................       1.8692       0.9993      24.4650      27.5045      27.4473      26.5163
340070............................       1.2588       0.8902      22.2605      23.6045      24.9033      23.6142
340071............................       1.1237       0.9476      19.9561      22.1854      25.4537      22.5747

[[Page 23522]]

 
340072............................       1.1835       0.8570      19.2773
21.3320...........................      22.6474      21.0148
340073............................       1.3746       0.9993      26.6829      29.4189      30.2076      28.9147
340075............................       1.2112       0.8931      23.2904      24.1297      26.0225      24.4391
340084............................       1.1875       0.9717      20.8175      21.3227      21.2580      21.1447
340085 h..........................       1.1572       0.9133      21.7112      23.0890      23.9793      22.8869
340087............................       1.1889       0.8570      17.8215      18.4202      22.0070      19.3351
340088............................       1.3425       0.8570      22.8687      24.3299            *      23.5994
340090............................       1.2312       0.9709      20.3261      21.7173      23.4542      21.9222
340091............................       1.5335       0.9020      23.1430      24.9411      25.8266      24.6682
340096 h..........................       1.1818       0.9133      22.1174      23.6345      25.2169      23.6523
340097............................       1.1843       0.8570      20.8690      22.5775      24.2127      22.5886
340098............................       1.4546       0.9717      24.2262      25.4823      27.3308      25.7030
340099............................       1.1671       0.8570      17.5114      20.0178      20.3683      19.3181
340104............................       0.8280       0.8570      12.9949      14.3252      15.7521      14.3947
340106............................       1.0782       0.8570      20.1076      22.6979      22.4894      21.8047
340107............................       1.1794       0.8924      21.0960      22.5583      22.9698      22.2242
340109............................       1.3188       0.8841      20.4341      22.3826      23.4419      22.1467
340113............................       1.8523       0.9717      25.0729      26.0776      28.2546      26.5138
340114............................       1.6227       0.9993      19.9142      25.4533      26.6813      23.7911
340115............................       1.5773       0.9993      23.8284      25.1907      25.0212      24.7040
340116............................       1.7011       0.8931      23.9643      26.1641      25.3213      25.1777
340119............................       1.1252       0.9717      21.2239      22.4821      24.2287      22.6894
340120............................       1.0360       0.8570      19.9860      21.8548      23.0916      21.7078
340121............................       1.0374       0.9580      19.9409      20.3701      21.7576      20.7129
340123............................       1.1858       0.9133      22.3711      23.1879      26.1083      23.9306
340124............................       1.0791       0.9476      17.5691      18.3866      20.8018      18.8482
340126 h..........................       1.2269       0.9709      21.4271      23.5405      25.0189      23.3764
340127............................       1.1717       0.9993      22.9672      24.6096      25.4786      24.4245
340129............................       1.2519       0.9585      22.3260      24.1356      25.4902      24.1365
340130............................       1.3631       0.9717      22.7687      23.0937      25.2941      23.7854
340131............................       1.5298       0.9414      24.1370      25.2989      27.9358      25.8415
340132............................       1.1782       0.8570      17.8771      20.4222      21.3521      19.8892
340133............................       0.9920       0.8570      23.1444      22.1588      22.5558      22.6188
340137............................       0.9669       0.8931      33.1751      29.9903      21.0642      28.4915
340138............................       0.8241       0.9993      29.5286      27.4767            *      28.5643
340141............................       1.6446       0.9580      24.2033      24.8132      27.3355      25.5266
340142............................       1.1805       0.8570      20.4320      22.1298      22.9907      21.8836
340143............................       1.4579       0.8931      23.0416      24.8904      25.3633      24.4002
340144............................       1.2329       0.9585      25.4598      25.6538      27.2686      26.1330
340145............................       1.2957       0.9585      21.8120      23.7028      23.7131      23.0768
340146............................       1.0505       0.8570      20.7252      18.8354            *      19.6880
340147............................       1.2003       0.9476      22.6057      23.9998      25.4534      24.0568
340148............................       1.3349       0.9020      20.8156      22.4205      23.5880      22.2985
340151............................       1.1033       0.8570      19.2593      22.2613      22.0052      21.1161
340153............................       1.9092       0.9717      23.7426      25.7078      26.4896      25.3204
340155............................       1.4341       1.0260      26.3663      28.8758      30.5006      28.6119
340158............................       1.1034       0.9580      21.7489      23.4724      26.4849      23.8953
340159............................       1.1424       1.0260      21.2983      22.1872      23.2991      22.2743
340160............................       1.2720       0.8570      18.7569      19.1330      20.7525      19.5589
340166............................       1.3649       0.9717      22.8349      25.7398      26.0557      24.9254
340168............................          ***       0.9580      16.8278      16.8076      17.3249      17.0046
340171............................       1.1811       0.9717      25.9603      27.2074      28.2734      27.2246
340173............................       1.2448       0.9993      23.7037      26.6128      27.5072      26.0994
340176............................          ***            *      26.5277            *            *      26.5277
340178............................          ***       0.9426            *            *      28.7219      28.7219
350002............................       1.7334       0.7519      20.4398      20.6474      22.0283      21.0339
350003............................       1.1580       0.7278      21.0585      25.3076      21.8061      22.5764
350004............................          ***            *      28.3773      27.5891            *      28.0246
350006............................       1.6770       0.7278      19.7577      19.5870      19.4985      19.5737
350009............................       1.0756       0.8778      20.2558      20.7014      23.0873      21.3437
350010............................       1.0942       0.7278      17.2489      18.5682      19.1965      18.3109
350011............................       1.9473       0.8778      21.9111      22.3896      23.1947      22.5594
350014............................       0.9131       0.7278      16.1718      18.5360      17.7565      17.4777
350015............................       1.6703       0.7519      18.5437      18.6381      19.7027      18.9716
350017............................       1.4352       0.7278      19.1952      20.1943      21.0243      20.1512
350019 \2\........................       1.6643       1.1521      21.3589      24.2382      32.2306      26.4362

[[Page 23523]]

 
350027............................       1.0413       0.7278      17.6731      14.2262            *      15.5713
350030............................       0.9514       0.7278      18.8822      19.2282      18.9978      19.0373
350043............................          ***            *      18.8378      20.9732            *      19.9618
350058............................       0.9697       0.7278      15.0196            *            *      15.0196
350070............................       1.9138       0.8778            *      24.4464      25.2836      24.8833
360001............................       1.3315       0.9604      22.2387      23.7750      23.9101      23.2970
360002............................       1.1905       0.8788      20.7586      22.6923      24.5789      22.7274
360003............................       1.8081       0.9604      24.4144      26.3180      27.5029      26.0650
360006............................       1.9867       0.9848      24.0814      25.7041      27.9925      25.9633
360007............................          ***            *      19.1315            *            *      19.1315
360009............................       1.5653       0.9263      22.4076      23.2659      23.1012      22.9250
360010............................       1.1890       0.8979      20.6290      22.0262      23.1178      21.9858
360011............................       1.3220       0.9848      21.4293      22.4482      25.5340      23.0257
360012............................       1.3639       0.9848      24.3618      25.5913      27.5470      25.9629
360013............................       1.0996       0.9263      24.4232      25.1588      26.8129      25.4875
360014............................       1.1458       0.9848      22.9372      23.8305      25.3861      24.0832
360016............................       1.4261       0.9604      22.8430      24.6587      26.1283      24.5377
360017............................       1.7197       0.9848      23.6181      25.4969      27.2910      25.5905
360018............................          ***            *      29.9085            *            *      29.9085
360020............................       1.6198       0.9197      21.5085      22.3795      24.4343      22.8262
360024............................          ***            *      22.5356      24.0612      23.5499      23.3173
360025............................       1.3926       0.9197      21.6676      23.6574      25.5633      23.7829
360026............................       1.2762       0.9069      20.8825      22.3303      23.5898      22.2676
360027............................       1.6543       0.9197      23.5907      24.7093      25.4894      24.6187
360029............................       1.0888       0.9573      20.4924      20.8778      22.7785      21.4073
360031............................          ***            *      24.3482      24.4324            *      24.3900
360032 h..........................       1.1314       0.9263      21.1743      22.9759      23.2638      22.4807
360034............................       1.1035       0.8788      21.5621      25.1366            *      23.3553
360035............................       1.7092       0.9848      24.2433      25.6895      27.5220      25.8774
360036............................       1.2117       0.9197      22.3567      25.0910      27.6094      25.0649
360037............................       1.3504       0.9197      32.6245      25.1615      24.3982      26.6839
360038............................       1.4244       0.9604      23.4855      24.8294      22.8009      23.7144
360039............................       1.4713       0.9848      23.4642      22.5921      24.0218      23.3755
360040............................       1.1396       0.8788      21.3307      22.8729      24.0942      22.7498
360041............................       1.4432       0.9197      22.1352      23.2625      24.1080      23.2048
360044............................       1.0612       0.8788      19.7212      20.4724      21.8411      20.6845
360046............................       1.1923       0.9604      22.8425      23.8918      25.0775      23.9800
360047............................       0.9522       0.8788      17.5885      17.1973      21.7248      18.9388
360048............................       1.7400       0.9573      24.7150      27.2274      28.8107      26.8831
360049............................       1.1298       0.9197      22.4939      24.2605      25.8367      24.2864
360051............................       1.6658       0.9069      23.0658      25.1785      25.7556      24.7297
360052............................       1.5398       0.9069      22.5005      23.3285      24.5405      23.5101
360054............................       1.2774       0.8788      19.2884      20.3176      22.6157      20.7734
360055............................       1.3753       0.8788      23.5586      25.1475      26.3112      24.9991
360056............................       1.5352       0.9604      22.4475      23.4638      23.1024      22.9631
360058............................       1.1220       0.8788      21.0768      22.7943      23.4434      22.4515
360059............................       1.4684       0.9197      23.0775      25.5222      25.3516      24.6433
360062............................       1.5341       0.9848      24.5746      26.8091      28.6518      26.7475
360064............................       1.5318       0.8788      21.3424      22.8729      22.2393      22.1811
360065............................       1.2012       0.9197      22.9727      24.0868      26.3036      24.5445
360066............................       1.5310       0.9263      24.6806      25.2316      27.3362      25.7779
360068............................       1.8254       0.9573      22.1110      23.7895      25.8414      23.9678
360069............................       1.1231       0.9573      20.5349      25.7032      24.2444      23.4234
360070............................       1.6302       0.8957      21.8228      23.1687      24.8863      23.3191
360071 h..........................       1.2089       0.9263      21.4478      21.6176      22.0786      21.6950
360072............................       1.3941       0.9848      21.3736      23.0464      24.1825      22.9257
360074............................       1.2640       0.9573      22.2368      23.6172      24.9055      23.6214
360075............................       1.1808       0.9197      23.8492      24.7610      26.8453      25.2573
360076............................       1.3773       0.9604      22.5863      22.5943      25.9369      23.7285
360077............................       1.5368       0.9197      23.3686      24.7086      25.6505      24.5864
360078............................       1.2606       0.9197      23.3799      24.6821      26.1313      24.7447
360079............................       1.7689       0.9604      25.9623      25.8762      26.0935      25.9804
360080............................       1.0696       0.8788      18.7213      19.5436      20.8309      19.7267
360081............................       1.3058       0.9573      22.1973      25.1439      27.5695      24.8761
360082............................       1.3694       0.9197      25.2254      27.4264      27.1197      26.6255
360084............................       1.5327       0.8957      23.3257      25.2059      25.8415      24.8445
360085............................       2.0605       0.9848      24.6618      27.5792      29.0081      27.1579

[[Page 23524]]

 
360086............................       1.5132       0.9069      21.5983      22.3005      22.1859      22.0265
360087............................       1.4212       0.9197      23.9638      25.9131      25.4040      25.0901
360089............................       1.1144       0.8788      21.0229      21.0253      22.7951      21.6142
360090............................       1.4694       0.9573      22.6236      24.4291      26.7717      24.5859
360091............................       1.2086       0.9197      23.5759      26.0541      27.5067      25.7352
360092............................       1.2241       0.9848      21.9732      23.5100      25.6618      23.7647
360093............................       1.0308       0.8788      21.4623      24.1238      23.2648      22.9528
360094............................          ***            *      22.6440      27.1864      26.6348      24.9723
360095............................       1.2895       0.8788      23.6518      24.6984            *      24.1867
360096............................       1.0859       0.8788      22.0673      22.2333      24.6317      22.9802
360098............................       1.4042       0.9197      22.7644      23.6413      24.8447      23.7933
360099............................          ***       0.8788      20.8524            *            *      20.8524
360101............................       1.3585       0.9197      26.2875      27.7584      26.6208      26.9092
360106............................       1.0794       0.8788      19.8658      21.6450      24.1588      21.9428
360107............................       1.0416       0.9197      23.6880      24.5365      25.9697      24.7438
360109............................       1.0852       0.8788      23.0178      24.3236      25.4184      24.2613
360112............................       2.0143       1.0628      25.5910      26.7880      28.6784      26.9982
360113............................       1.2415       0.9604      22.3348      23.5138      25.6493      23.7408
360115............................       1.2494       0.9197      22.3926      24.0232      24.0052      23.4857
360116............................       1.2224       0.9604      21.3809      23.4049      18.0655      20.9510
360118............................       1.4861            *      23.0070      24.2526            *      23.6564
360121............................       1.2367       0.8788      23.2515      25.2037            *      24.2319
360123............................       1.4129       0.9197      23.1310      24.1761      22.6523      23.2730
360125............................       1.1792       0.9197      21.1408      22.6871      22.1096      21.9849
360126............................          ***            *      22.2409            *            *      22.2409
360129............................       0.9317       0.8788      17.9151      19.5336            *      18.7493
360130............................       1.4471       0.9197      20.1257      21.7015      22.9762      21.5955
360131............................       1.2314       0.8957      21.7838      23.1730      24.0495      23.0299
360132............................       1.2426       0.9604      23.4179      25.7991      25.9453      25.1258
360133............................       1.6206       0.9069      22.0958      23.9457      24.6208      23.6001
360134............................       1.6811       0.9604      23.6817      25.3013      29.2975      26.0944
360137............................       1.6781       0.9197      23.8947      25.7647      26.9522      25.5442
360141............................       1.6446       0.8788      25.1442      31.0127      27.7085      27.9618
360142............................       0.9699       0.8788      20.6728      21.2084      22.1610      21.3780
360143............................       1.3211       0.9197      22.2275      23.8938      24.6306      23.6169
360144............................       1.3179       0.9197      24.7973      26.7160      24.0350      25.1500
360145............................       1.7297       0.9197      22.4813      23.4743      25.8268      23.9319
360147............................       1.3504       0.8788      20.0409      22.7172      24.1953      22.4020
360148............................       1.0603       0.8788      21.3211      24.4873      26.1946      24.0470
360150............................       1.1923       0.9197      24.8485      25.8703      24.7667      25.1568
360151............................       1.4859       0.8957      21.7215      22.2179      24.8629      22.8949
360152............................       1.4689       0.9848      22.9352      24.9894      27.9147      25.0211
360153............................       0.9512       0.8788      17.3367      19.0844      19.0226      18.4206
360154............................       0.9805       0.8788      16.2416      17.1274            *      16.6874
360155............................       1.4857       0.9197      23.0020      23.9466      25.3787      24.1428
360156............................       1.1333       0.8788      21.2853      22.6709      24.0510      22.6856
360159............................       1.2322       0.9848      23.3359      25.7108      33.1613      27.1828
360161............................       1.3645       0.8788      21.5114      22.6005      24.3792      22.8785
360163............................       1.8834       0.9604      23.1500      25.7966      26.9728      25.2619
360170............................       1.1824       0.9848      22.2815      22.9359      24.3620      23.3031
360172............................       1.3907       0.9197      22.7104      23.4727      26.3388      24.1922
360174............................       1.2111       0.9069      21.7129      22.8167      24.9990      23.2230
360175............................       1.1979       0.9848      22.7887      24.6152      26.5949      24.7311
360177............................       1.1457       0.8788      20.8194      23.4256      24.4712      22.9543
360178............................          ***       0.8788      18.2393            *            *      18.2393
360180............................       2.2595       0.9197      25.1499      26.8720      26.1514      26.0861
360185............................       1.1807       0.8788      21.1245      21.8641      23.7173      22.2403
360187............................       1.5760       0.9069      21.9499      23.8362      24.8173      23.5639
360189............................       1.1222       0.9848      20.0275      24.2512      24.2136      22.8164
360192............................       1.3138       0.9197      24.9995      26.2976      26.7577      26.0512
360194 h..........................       1.1529            *      20.3677      22.3297            *      21.3611
360195............................       1.0716       0.9197      23.1897      25.8043      26.1280      25.1222
360197............................       1.0908       0.9848      23.1378      24.7539      26.7508      24.9131
360203............................       1.1451       0.8788      19.3642      21.5564      22.1414      21.0862
360210............................       1.1668       0.9848      25.0811      26.5665      27.8415      26.5578
360211............................       1.5541       0.8840      22.4529      23.0884      22.5449      22.6945
360212............................       1.3654       0.9197      22.8041      24.5310      25.2756      24.2166

[[Page 23525]]

 
360218............................       1.1698       0.9848      22.8060      24.4720      27.4288      25.0106
360230............................       1.6048       0.9197      24.7681      26.6444      27.0223      26.1931
360234............................       1.3014       0.9604      22.1787      23.3325      24.2539      23.2304
360236............................       1.1515       0.9604      22.8821      21.3795      35.8144      24.3729
360239............................       1.3119       0.9069      23.5802      24.4398      25.2474      24.5362
360241............................          ***       0.9197      23.4061      24.8089      24.7001      24.1133
360245............................       0.5232       0.9197      18.1015      18.7966      19.1885      18.7327
360247............................       0.3785       0.9848            *      25.1083      19.8892      22.3390
360253............................       2.2434       0.9069      31.3006      28.2555      30.4276      29.8452
360254............................          ***            *      30.0792            *            *      30.0792
360257............................       1.0766       0.8788            *      17.9652            *      17.9652
360259............................       1.1777       0.9573            *            *      25.1338      25.1338
360260............................          ***       0.8979            *            *      27.3903      27.3903
360261............................       1.7759       0.9482            *            *      22.5431      22.5431
360262............................       1.3387       0.9573            *            *      27.1680      27.1680
360263............................       1.6685       0.9263            *            *      20.8884      20.8884
370001............................       1.6782       0.8313      25.5838      26.2391      27.7549      26.5495
370002............................       1.1821       0.7615      18.9544      19.7718      20.1479      19.6308
370004............................       1.0932       0.8458      21.5041      24.7694      25.3919      23.7972
370006............................       1.2069       0.7615      15.6333      16.9469      20.1063      17.6384
370007............................       1.0399       0.7615      16.7598      17.2084      17.6547      17.2160
370008............................       1.3885       0.9043      22.1596      22.7419      24.2978      23.1423
370011............................       1.0810       0.9043      17.1458      19.2266      19.7821      18.6737
370013............................       1.5187       0.9043      21.1512      22.6451      24.9295      22.9792
370014............................       1.0403       0.8971      21.8473      24.8138      25.3576      24.0194
370015............................       0.9737       0.8313      20.3966      21.1833      23.6693      21.7009
370016 h..........................       1.4747       0.8682      20.4407      24.2737      25.4062      23.3330
370018............................       1.4098       0.8313      20.8357      23.4286      23.5336      22.5984
370019............................       1.2184       0.7615      18.1260      19.6761      21.4474      19.7475
370020............................       1.2243       0.7615      16.8631      17.4835      18.5046      17.6368
370022............................       1.1976       0.7673      20.2432      18.4217      19.6495      19.4375
370023............................       1.2396       0.7615      19.3386      20.6002      21.5762      20.5441
370025............................       1.2545       0.8313      20.2845      22.0287      23.5659      21.9757
370026 h..........................       1.5077       0.8682      21.9140      22.5734      23.0848      22.5236
370028............................       1.8453       0.9043      24.1009      24.8661      26.6153      25.1976
370029............................       1.0293       0.7615      19.5811      22.1163      23.9956      21.8559
370030............................       1.0428       0.7615      18.6541      20.3315      23.3037      20.7201
370032............................       1.4479       0.9043      20.0827      21.6029      23.4843      21.7536
370034............................       1.1924       0.7986      16.1540      17.6247      18.2341      17.3349
370036............................       1.0216       0.7615      16.5844      16.9222      17.7576      17.1504
370037............................       1.6563       0.9043      21.0719      23.1256      23.9685      22.7803
370039............................       1.0902       0.8313      20.3137      21.0793      21.8220      21.0783
370040............................       1.0053       0.8231      18.9981      21.1061      22.4048      20.8291
370041............................       0.8812       0.8313      19.0144      22.0082      22.3496      21.1267
370042............................       0.9473       0.7615      14.0899      15.3613            *      14.7180
370043............................       0.9286       0.7615      20.2929      21.5588            *      20.9707
370045............................       0.9116       0.7615      12.6613      14.6370            *      13.6711
370047............................       1.4244       0.8971      19.4856      19.7112      20.4657      19.9082
370048............................       1.0975       0.7615      15.4768      17.7273      19.2464      17.4431
370049............................       1.2985       0.9043      20.4826      21.6878      23.2171      21.8100
370051............................       1.0467       0.7615      12.0397      14.6254      17.2618      14.4702
370054............................       1.2568       0.7615      20.3788      21.5521      21.5043      21.1653
370056............................       1.6060       0.7916      20.4872      21.7647      22.0312      21.4507
370057............................       0.9425       0.8313      17.3020      18.0426      19.7284      18.3749
370060............................       0.9342       0.8313      23.1897      23.8007      18.7592      21.7395
370064............................       0.8954       0.7615      11.9044      14.1879      14.2053      13.4809
370065............................       1.0179       0.7615      18.3966      20.6537      20.0226      19.6691
370072............................       0.7985       0.7615      12.5765      14.6387       9.9616      11.8723
370076............................          ***            *      19.0230      21.5461            *      20.2863
370078............................       1.6061       0.8313      22.2318      23.9507      25.4161      23.9078
370080............................       0.9012       0.7615      16.1444      17.4857      18.0665      17.2314
370082............................          ***       0.7615      12.6060            *            *      12.6060
370084............................       0.9685       0.7615      16.1278      17.2735      16.6514      16.7384
370089............................       1.0714       0.7615      18.0505      19.9021      20.4699      19.4850
370091............................       1.6980       0.8313      24.2117      22.9893      20.8950      22.6316
370093............................       1.6152       0.9043      23.5685      25.7296      26.9774      25.3740
370094............................       1.3966       0.9043      20.6507      22.0591      23.1191      21.9907

[[Page 23526]]

 
370095............................       0.8800       0.7615      14.3563      16.5310            *      15.4277
370097............................       1.2850       0.7916      20.3218      21.7150      22.3267      21.5064
370099............................       1.0065       0.8313      20.2001      20.5217      20.5075      20.4227
370100............................       0.9736       0.7615      13.0681      14.1883      14.7712      14.0181
370103............................       0.9494       0.8038      15.6110      16.1408      17.8018      16.5505
370105............................       1.8469       0.9043      22.4493      22.1584      23.8978      22.8583
370106............................       1.3329       0.9043      24.1115      24.2393      26.5867      25.0105
370108............................          ***       0.7615      13.8170            *            *      13.8170
370113............................       1.1317       0.8615      21.4267      23.3011      25.3565      23.3322
370114............................       1.5494       0.8313      19.4933      21.0603      21.7880      20.8230
370123............................          ***       0.9043      20.5180      22.8174      25.4733      22.7986
370125............................       0.8500       0.7615      17.9240      17.2013      17.1361      17.4038
370138............................       1.0187       0.7615      19.0403      19.8308      18.3113      19.0435
370139............................       0.9394       0.7615      16.3224      17.8900      18.5225      17.5400
370141............................          ***            *      24.7859            *            *      24.7859
370149 h..........................       1.2033       0.9043      18.2260      21.0608      22.3537      20.7832
370153............................       1.0423       0.7615      17.9692      18.5417      19.8349      18.7951
370154............................          ***       0.7615      17.4760            *            *      17.4760
370158............................       1.0192       0.9043      17.3412      17.3161      18.5578      17.7592
370166............................       0.9772       0.8313      21.3628      21.9070      23.1681      22.1327
370169............................       0.8969       0.7615      16.5607      15.7686      15.8002      16.0704
370176............................       1.1057       0.8313      22.1456      23.0324      25.0509      23.4362
370177............................       1.0170       0.7615      14.0279      15.6723      14.7193      14.7923
370178............................       0.8922       0.7615      12.9635      14.9767      14.6070      14.1857
370179............................       0.9231       0.8313      21.9673      22.8322      23.5794      22.6918
370183............................       1.0143       0.8313      17.9270      20.5025      21.8147      20.0076
370186............................       0.9064       0.7615      16.3879            *            *      16.3879
370192............................       1.7741       0.9043      24.3832      26.1338      31.4930      27.6466
370196............................       1.0758       0.9043      23.6334      29.4383      22.6824      25.4359
370199............................       0.9440       0.9043      20.7075      23.7340      26.0451      23.4652
370200............................       1.1666       0.7615      16.7164      18.1008      17.6317      17.5059
370201............................       1.7335       0.9043      18.9906      23.1240      23.3550      21.7730
370202............................       1.5326       0.8313      24.0239      24.4920      25.1181      24.5965
370203............................       1.3678       0.9043      19.8772      21.2426      23.5190      21.5182
370206............................       1.6351       0.9043      22.3471      27.4495      26.0912      25.5795
370207............................          ***            *      26.3746            *            *      26.3746
370210............................       2.0839       0.8313            *      20.0360      21.2682      20.6946
370211............................       0.9454       0.9043            *            *      26.5344      26.5344
370212............................       1.5402       0.9043            *            *      21.0758      21.0758
370213............................          ***       0.9043            *            *      29.3777      29.3777
370215............................       2.4364       0.9043            *            *      32.3589      32.3589
380001............................       1.1877       1.1229      20.9585      27.8554      29.7467      26.1275
380002............................       1.1956       1.0284      25.2629      26.3348      27.1861      26.3148
380003............................          ***       1.0284      24.6377            *            *      24.6377
380005............................       1.3582       1.0284      26.3472      28.0682      30.2211      28.3075
380006............................       1.1408       1.0284      24.7492      26.0475            *      25.3948
380007............................       1.9556       1.1229      30.0497      31.5207      33.9969      31.9322
380008............................       1.1289       1.0328      24.6149      25.4494      25.8356      25.3227
380009............................       1.8990       1.1229      26.0012      30.4198      31.7042      29.4616
380010............................       0.9763       1.1229      25.5234      27.5291      30.2957      27.8451
380011............................          ***       1.0284      21.9382            *            *      21.9382
380014............................       1.8048       1.0711      28.4536      27.7255      29.9648      28.7806
380017............................       1.7793       1.1229      29.2543      31.7440      32.2447      31.1318
380018............................       1.7996       1.0284      27.5171      27.8952      28.0701      27.8359
380020............................       1.3856       1.0810      23.7066      25.8320      28.3563      26.0268
380021............................       1.4351       1.1229      28.0334      29.3001      29.3295      28.9428
380022............................       1.2181       1.0328      26.4794      27.8683      29.2642      27.9316
380023............................       1.1682       1.0284      23.0079      23.7073      26.5439      24.4358
380025............................       1.2837       1.1229      28.8525      30.2628      33.2105      30.8181
380026............................       1.1324       1.0284      23.8666      26.5217            *      25.2072
380027............................       1.2867       1.0492      21.5822      23.8758      25.5161      23.7359
380029............................       1.2971       1.0445      24.2939      26.2070      26.9966      25.9075
380033............................       1.6592       1.0810      30.4783      29.7995      30.8767      30.3883
380035............................       1.0421       1.0284      26.2434      26.4784            *      26.3599
380037............................       1.2266       1.1229      25.0200      27.1884      30.5818      27.7342
380038............................       1.2591       1.1229      29.1804      30.5903      34.2303      31.3814
380039............................       0.9755       1.1229      27.5115      30.1544      32.3959      30.0601

[[Page 23527]]

 
380040............................       1.1950       1.0284      21.5958      28.4373      32.0103      27.1504
380047............................       1.8037       1.0492      26.5017      27.8385      29.8627      28.1638
380050............................       1.3931       1.0284      23.1332      24.2416      25.6190      24.3627
380051............................       1.5718       1.0445      26.2384      28.1305      29.7219      28.0410
380052............................       1.1643       1.0284      21.2567      22.6799      24.9476      22.9567
380056............................       0.9458       1.0445      22.3571      25.0068      25.1475      24.2275
380060............................       1.4020       1.1229      27.8551      30.2507      29.5370      29.2476
380061............................       1.6536       1.1229      27.3827      29.5145      29.8217      28.9273
380066............................       1.2243       1.0284      23.3581      27.5412            *      25.5211
380070............................       1.1747       1.1229      34.1039            *            *      34.1039
380072............................       0.8417       1.0284      21.9516      22.5275            *      22.2419
380075............................       1.3046       1.0284      25.1930      27.4795      29.0368      27.3082
380081............................       1.1379       1.0284      22.1822      21.0708      21.8850      21.7195
380082............................       1.2215       1.1229      28.0668      30.2721      32.4909      30.3569
380089............................       1.2717       1.1229      29.6989      30.8396      33.4214      31.3234
380090............................       1.2689       1.0284      31.8702      33.6822      34.4536      33.3615
380091............................       1.2950       1.1229      31.2807      35.7002      33.8950      33.5968
390001............................       1.6397       0.8530      21.5154      22.4407      22.5309      22.1581
390002............................       1.2571       0.8840      22.0646      23.0113      22.4388      22.5092
390003 h..........................       1.1657       0.8530      19.1857      21.3182      21.6478      20.7084
390004............................       1.5540       0.9317      21.3475      23.4063      24.3249      23.1020
390005............................       0.9829       0.8746      19.0727      19.0318            *      19.0497
390006............................       1.8357       0.9145      23.0378      23.3960      25.1216      23.8687
390008 h..........................       1.1582       0.8840      19.9417      21.0021      22.2680      21.0752
390009............................       1.7277       0.8746      21.9459      24.2789      25.5482      23.9471
390010............................       1.2001       0.8840      19.4377      21.6273      23.5390      21.5537
390011............................       1.3112       0.8348      18.6548      19.8602      21.9279      20.1129
390012............................       1.2176       1.1030      28.5114            *      28.5076      28.5093
390013............................       1.2121       0.9145      22.1679      23.3180      24.0044      23.1713
390016 h..........................       1.1998       0.8446      18.1536      19.9899      21.9549      20.1569
390017 h..........................          ***       0.8840      19.1962      20.6575            *      19.8788
390018............................          ***            *      19.9117            *            *      19.9117
390022............................       1.3090       1.1030      27.5504      31.0971      29.0710      29.1659
390023............................       1.2577       1.1030      25.3767      27.1600      31.7149      28.1614
390024............................       1.0501       1.1030      25.9806      37.4330      35.3959      29.4333
390025............................       0.5266       1.1030      14.8690      15.0282      17.2977      15.7085
390026............................       1.2353       1.1030      24.0326      27.0802      29.5157      26.9256
390027............................       1.5482       1.1030      33.2139      28.9159      35.6568      32.4911
390028............................       1.5912       0.8840      24.6796      23.6616      25.7246      24.7268
390029............................          ***            *            *      24.4276            *      24.4276
390030............................       1.1837       0.9844      20.0598      20.9859      22.1581      21.0867
390031............................       1.2104       0.9500      20.3568      21.2949      22.6828      21.4388
390032............................       1.1735       0.8840      20.8450      20.9971      22.7205      21.5225
390035............................       1.2222       1.1030      23.2173      24.7281      26.2647      24.7742
390036............................       1.4446       0.8840      20.5751      23.3858      24.6032      22.8336
390037............................       1.3365       0.8840      20.1665      22.9008      24.7820      22.6385
390039 h..........................       1.1565       0.8348      18.4580      17.8461      20.3787      18.9083
390040............................          ***            *      20.5371      23.1807            *      21.7860
390041............................       1.3009       0.8840      21.0074      20.6789      21.5925      21.0799
390042............................       1.3204       0.8840      22.2351      23.9632      25.6328      23.9486
390043............................       1.1602       0.8300      19.8641      20.9835      22.2549      21.0509
390044............................       1.6591       0.9698      22.4235      24.2586      27.1505      24.6634
390045............................       1.5712       0.8368      20.2082      22.2582      23.0877      21.8830
390046............................       1.5379       0.9422      23.1271      25.0825      27.6367      25.3031
390048............................       1.0828       0.9145      20.3523      23.6622      24.7738      22.8564
390049............................       1.5860       0.9844      24.0933      25.4056      27.1366      25.5929
390050............................       2.0343       0.8840      22.6951      24.5424      26.6931      24.6339
390052............................       1.1848       0.8942      22.1380      21.6736      23.6105      22.4994
390054............................       1.1909       0.8530      19.8602      21.4983      22.8087      21.3801
390055............................          ***       0.8840      23.5292      25.5675      25.6945      24.9860
390056............................       1.0653       0.8300      21.4239            *      19.5537      20.4834
390057............................       1.3195       1.1030      24.8235      25.1901      27.9583      26.0368
390058............................       1.2715       0.9317      22.0113      25.3415      27.4799      24.8349
390061............................       1.5355       0.9716      24.4550      25.5012      28.4538      26.1704
390062............................       1.1167       0.8942      17.6303      19.0692      21.4052      19.4592
390063............................       1.7404       0.8746      21.7120      23.5469      24.7614      23.4097
390065............................       1.2046       1.0813      23.1384      23.4021      25.9184      24.2223

[[Page 23528]]

 
390066............................       1.2713       0.9145      21.7717      23.0891      24.2087      23.0471
390067............................       1.8233       0.9317      23.5136      25.4576      26.3287      25.0668
390068............................       1.3022       0.9716      21.1177      25.9890      25.8291      24.3019
390070............................       1.3629       1.1030      24.4403      26.9235      30.9499      27.4435
390071............................       0.9895       0.8300      17.8117      20.9443      20.6652      19.7095
390072 h..........................       1.0397       0.8530      20.0561      22.0155      24.9388      22.3043
390073............................       1.5559       0.8942      22.7073      24.8013      26.3698      24.6228
390074............................       1.1407       0.8840      21.8456      21.0941      22.8545      21.9412
390075............................          ***            *      19.9775      22.6530      24.6359      22.3701
390076............................       1.3409       1.1030      21.2039      18.1276      27.9004      21.9007
390079............................       1.8970       0.8471      19.9169      21.4323      23.3053      21.5091
390080............................       1.2828       1.1030      23.3742      25.0921      27.2616      25.2851
390081............................       1.2236       1.0652      28.1056      28.7974      30.3840      29.1503
390084............................       1.2243       0.8300      18.3551      20.7799      19.8605      19.6630
390086............................       1.5445       0.8300      19.6488      20.7383      22.5317      20.9944
390090............................       1.7972       0.8840      22.4688      20.7474      25.2014      22.8601
390091............................       1.1421       0.8446      19.7361      20.8243      21.5586      20.7010
390093............................       1.1685       0.8446      19.9209      21.0427      21.4401      20.8186
390095............................       1.1908       0.8530      18.3939      21.0754      23.6240      20.9725
390096............................       1.4974       0.9698      22.9502      24.4145      27.0763      24.8874
390097............................       1.1901       1.1030      24.5304      25.3012      25.6660      25.2008
390100............................       1.6968       0.9716      23.4155      26.7267      27.7208      26.0717
390101............................       1.2400       0.9422      20.1271      20.1694      21.2641      20.5324
390102............................       1.3469       0.8840      20.9807      21.6629      24.8898      22.6239
390103............................       1.0080       0.8840      21.0637      18.6703      20.6775      20.1561
390104............................       1.0501       0.8300      16.5081      19.1803      19.6428      18.4897
390107............................       1.3679       0.8840      21.5852      23.1023      24.1386      23.0080
390108............................       1.2171       1.1030      23.7842      24.7486      27.2661      25.2833
390109............................       1.1229       0.8530      17.2667      18.7558      19.9156      18.6551
390110............................       1.5720       0.8840      22.3968      23.3355      23.9808      23.2737
390111............................       2.0139       1.1030      30.5814      30.6809      32.6510      31.3439
390112 h..........................       1.1736       0.8348      15.6710      16.6113      19.2126      17.1537
390113............................       1.2850       0.8446      20.1160      21.7729      22.2591      21.3940
390114............................       1.3024       0.8840      23.6162      22.6630      24.0473      23.4341
390115............................       1.4409       1.1030      24.1951      26.4751      27.7333      26.1536
390116............................       1.2529       1.1030      24.9581      28.5563      29.7436      27.8303
390117............................       1.0952       0.8300      19.0983      20.0040      20.3946      19.8418
390118............................       1.1665       0.8300      17.8460      19.3332      21.5001      19.5328
390119............................       1.2920       0.8530      20.3034      21.2761      22.2746      21.3271
390121............................       1.6614       0.8942      20.8017      22.0556      23.1408      22.0024
390122............................       1.0973       0.8300      18.5130      21.6981      22.5785      20.8388
390123............................       1.1985       1.1030      23.2232      25.2209      28.6269      25.7365
390125............................       1.2705       0.8300      18.2411      19.4406      20.9456      19.5654
390127............................       1.3061       1.1030      25.0836      28.9238      30.9374      28.4999
390128............................       1.1865       0.8840      21.3668      21.8837      23.0255      22.1158
390130............................       1.2623       0.8348      19.4835      21.0694      24.0685      21.4556
390131............................       1.2940       0.8840      19.5296      21.2164      22.5177      21.1193
390132............................       1.3983       1.1030      24.6889      26.8153      27.7250      26.4427
390133............................       1.6988       1.1030      25.2110      26.1458      28.7162      26.7622
390135............................          ***       1.1030      24.0445            *      24.4738      24.2670
390136............................       1.0748       0.8840      21.9531      24.8042      22.1415      22.9715
390137............................       1.4810       0.8530      19.5457      21.8830      23.4877      21.5609
390138............................       1.1787       1.0813      21.4705      22.7210      24.2769      22.8713
390139............................       1.3178       1.1030      26.3622      28.2089      30.4246      28.3708
390142............................       1.4621       1.1030      29.8874      32.0827      32.3517      31.4330
390145............................       1.4545       0.8840      20.6580      22.4255      23.8041      22.3138
390146............................       1.2491       0.8300      21.4580      22.3260      25.2460      23.0540
390147............................       1.2294       0.8840      22.3135      23.6380      25.0971      23.6939
390150............................       1.1557       0.8840      20.0261      24.5256      24.1855      22.9524
390151............................       1.2703       1.0813      24.7843      25.1422      27.1539      25.7127
390152............................       0.9999       0.8942      21.5474      11.7774            *      15.1275
390153............................       1.3749       1.1030      25.3391      27.5167      30.0586      27.7812
390154............................       1.2331       0.8300      19.1300      20.4408      20.6982      20.0794
390156............................       1.3484       1.0652      25.0801      27.8096      31.2571      28.0054
390157............................       1.2887       0.8840      20.6933      22.0222      22.7493      21.8431
390160............................       1.1601       0.8840      19.3598      19.5942      21.4877      20.1709
390162............................       1.4642       0.9844      24.0291            *      30.0900      26.8901

[[Page 23529]]

 
390163............................       1.2667       0.8840      18.8585      19.8863      22.1741      20.2736
390164............................       2.0562       0.8840      24.2334      25.1277      26.4971      25.3882
390166............................       1.1534       0.8840      19.8531      20.9510      24.9810      21.8402
390168............................       1.4369       0.8840      20.6777      21.9344      24.5820      22.5085
390169............................       1.4033       0.8530      22.7695      24.1682      27.2242      24.7030
390173............................       1.1624       0.8300      20.6958      21.6562      22.8220      21.7639
390174............................       1.7303       1.1030      28.4490      30.3725      32.6265      30.5109
390176............................       1.1510       0.8840      18.0752      17.1387            *      17.5532
390178............................       1.2958       0.8609      17.2384      19.2731      20.7270      19.1018
390179............................       1.3648       1.1030      24.0501      24.8350      27.2222      25.3975
390180............................       1.4462       1.0652      28.4842      30.4264      32.4375      30.5043
390181............................       1.0361       0.8300            *      25.7357      24.4573      25.1039
390183............................       1.0850       0.8300      21.6811      22.0117      25.6554      23.0449
390184............................       1.0849       0.8840      21.1962      21.3407      22.5519      21.7060
390185............................       1.2694       0.8530      20.4476      21.8871      23.0202      21.7597
390189............................       1.1071       0.8300      20.1365      21.2711      22.3722      21.3477
390191............................       1.0835       0.8300      18.5972      19.2308      20.8761      19.5306
390192............................       1.0157       0.8530      19.1883      20.0395      21.2620      20.1833
390193............................          ***       0.8746      18.9764      18.5516      20.1024      19.2196
390194............................       1.1011       0.9844      21.5850      23.1814      25.4235      23.4479
390195............................       1.6321       1.1030      26.2024      28.3480      31.0019      28.5392
390197............................       1.3925       0.9844      22.8349      24.9234      25.7739      24.4854
390198............................       1.1641       0.8746      17.3937      16.8529      18.7222      17.6295
390199............................       1.2174       0.8300      18.9787      19.9653      21.3157      20.1079
390200............................          ***       0.9716      19.4471      23.1486      23.7471      21.9484
390201............................       1.2961       0.8300      22.7849      24.8222      26.3658      24.6735
390203............................       1.6357       1.1030      26.9436      28.2741      28.9054      28.0870
390204............................       1.2498       1.1030      23.9673      25.6342      28.6829      26.1129
390211............................       1.2717       0.8609      21.0450      22.4472      23.1450      22.2313
390215............................          ***            *      25.2617      26.4180      28.0402      26.4046
390217............................       1.1533       0.8840      21.4058      21.3281      24.3610      22.3261
390219............................       1.2908       0.8840      20.0594      22.8559      25.1705      22.7113
390220............................       1.0977       1.1030      23.4385      24.7553      41.6138      28.9098
390222............................       1.2483       1.0652      24.9345      27.0954      28.7488      26.9594
390223............................       1.9554       1.1030      22.8725      28.2538      27.6407      26.2383
390224............................       0.8462       0.8471      16.1289      18.1226      18.7624      17.7120
390225............................       1.1871       0.9716      20.9232      23.4945      24.9391      23.3545
390226............................       1.7312       1.1030      25.6917      27.0061      28.5890      27.1866
390228............................       1.3206       0.8840      21.0164      22.5999      23.3078      22.3536
390231............................       1.4382       1.1030      24.7757      27.0576      29.2653      27.1070
390233............................       1.3700       0.9422      21.8043      22.8667      24.8690      23.1907
390235............................          ***            *      23.7068            *            *      23.7068
390237............................       1.5540       0.8530      23.2054      24.6316      26.9533      24.9348
390238............................          ***            *      19.2171      26.4748            *      22.5836
390246............................       1.1671       0.8300      22.0687      23.3275      20.1581      21.8667
390249............................       0.8767       0.8471      14.7215            *            *      14.7215
390258............................       1.5307       1.1030      25.0634      27.2038      29.4626      27.3466
390262............................          ***            *      21.3264            *            *      21.3264
390265............................       1.4456       0.8840      20.5948      21.6751      23.4836      21.9520
390266............................       1.1763       0.8609      18.2424      19.2836      20.3918      19.3171
390267............................       1.1835       0.8840      21.4801      22.5464      23.1051      22.3821
390268............................       1.3066       0.8368      23.1124      24.2050      25.0021      24.1351
390270............................       1.4615       0.8530      22.5258      24.0837      24.1496      23.6565
390278............................       0.5214       1.1030      21.1387      21.6893      23.6843      22.1694
390279............................       1.1519       0.8368      16.0510      15.3569      17.0012      16.1304
390285............................       1.5472       1.1030      30.6300      33.5347      35.0427      33.0866
390286............................       1.1613       1.1030      25.4499      27.4090      28.1761      27.0003
390287............................       1.4298       1.1030      32.9709      35.7147      37.6569      35.5140
390288............................          ***       1.1030      28.0957      28.5267      29.7287      28.6956
390289............................       1.0920       1.1030      25.1658      28.4577      28.8826      27.4320
390290............................       1.9082       1.1030      31.0967      36.4991      37.9040      35.0787
390291............................          ***       0.8840      21.0057      21.3015            *      21.1542
390294............................          ***            *      33.3537            *            *      33.3537
390296............................          ***            *      25.6981            *            *      25.6981
390298............................          ***            *            *      26.8290            *      26.8290
390299............................          ***            *            *      31.9423            *      31.9423
390300............................          ***            *            *      40.4697            *      40.4697

[[Page 23530]]

 
390301............................          ***       0.8530            *            *      30.9838      30.9838
400001............................       1.2643       0.4686      11.7572      16.1114      13.1847      13.4859
400002............................       1.7313       0.5178      11.6804      14.8607      16.7583      14.1458
400003............................       1.3456       0.5178      10.5963      13.0776      13.6751      12.3819
400004............................       1.1394       0.4686      11.4041      10.4716      14.3108      11.8780
400005............................       1.1205       0.4686      10.5356      10.2878      10.7207      10.5186
400006............................       1.1887       0.4686       9.2852       8.9919       9.2265       9.1710
400007............................       1.1804       0.4686       8.6022       8.7152       9.2463       8.8511
400009............................       1.0804       0.3186       9.4413       9.2007       9.3116       9.3159
400010............................       0.8250       0.4736       9.2799      10.9354      10.0962      10.0495
400011............................       1.0865       0.4686       8.9111       8.5868       8.5534       8.6726
400012............................       1.3545       0.4686       9.0740       8.3580       8.3802       8.5938
400013............................       1.2691       0.4686       9.9905       9.5584      10.3347       9.9727
400014............................       1.3193       0.4016      11.4580      11.7023      12.5363      11.8896
400015............................       1.3649       0.4686            *      15.6066      17.4086      16.6535
400016............................       1.3515       0.4686      14.6491      15.3497      14.7607      14.9193
400017............................       1.1959       0.4686      10.7475      10.1238      10.2734      10.3916
400018............................       1.1949       0.4686      10.8254      10.7948      11.6165      11.0939
400019............................       1.3212       0.4686      13.7007      14.9892      13.7754      14.1263
400021............................       1.3102       0.4646      13.5224      13.8643      14.1533      13.8469
400022............................       1.3444       0.5178      15.2904      16.0539      16.8806      16.0784
400024............................       0.8372       0.4016       9.8650       9.1316      12.4649      10.2156
400026............................       1.0673       0.3186       5.9206       5.2085       5.8200       5.6501
400028............................       1.2057       0.5178       9.5266      10.3354      10.9808      10.2872
400032............................       1.1946       0.4686      10.7100      10.7195      10.2652      10.5650
400044............................       1.2777       0.5178       9.0275      10.7890      13.7509      11.4819
400048............................       1.0975       0.4686      10.8618      14.0887      10.4266      11.8488
400061............................       1.7250       0.4686      16.5895      15.1639      20.3206      17.3616
400079............................       1.1310       0.4736       8.7218       9.4218      12.7825      10.1505
400087............................       1.1988       0.4686      10.7118       9.5860      10.6849      10.3421
400094............................          ***            *       9.2871       8.8646            *       9.1244
400098............................       1.5719       0.4686      13.8036      13.7938      12.8230      13.4850
400102............................       1.1198       0.4686      10.9973      10.1795      10.2677      10.4779
400103............................       1.7425       0.4016      11.5797      12.8288       9.3859      10.9876
400104............................       1.1364       0.4686       7.1781       8.2758       8.3900       7.8760
400105............................       1.1274       0.4686      11.5608      12.7725      14.5339      12.8828
400106............................       1.1815       0.4686      10.1241       9.6902      11.4507      10.3951
400109............................       1.4714       0.4686      12.8921      14.2169      14.2111      13.7444
400110............................       1.0965       0.4413      12.0159      11.8458      12.3449      12.0750
400111............................       1.0774       0.4736      12.7701      13.4777      14.5029      13.5496
400112............................       1.1915       0.4686      12.2859       8.9469      19.3945      12.3541
400113............................       1.2040       0.5178      10.4416      10.0830      11.0072      10.4939
400114............................       1.0880       0.4686       9.7444      12.1920      11.5478      11.0784
400115............................       1.1179       0.4686       7.0411       9.1132      13.7392       9.2213
400117............................       1.1002       0.4686       9.7314      10.2911      12.7600      10.8102
400118............................       1.2310       0.4686      12.4590      11.9324      12.5743      12.3218
400120............................       1.2997       0.4686      11.8837      11.9714      12.7955      12.2196
400121............................       1.0671       0.4686       8.3575       8.6665       8.2197       8.4118
400122............................       1.9548       0.4686       9.6644       9.6463       8.3069       9.4955
400123............................       1.1994       0.4016      10.5643      11.8135      11.9825      11.4619
400124............................       2.8727       0.4686      14.3496      17.2258      16.1812      15.8787
400125............................       1.1319       0.4160      10.6642      10.7425      11.6386      11.0069
400126............................       1.2093       0.4646            *      13.3932       9.8008      11.0632
410001............................       1.3081       1.1233      24.0033      27.0309      28.0816      26.3767
410004............................       1.2319       1.1233      23.6409      25.4578      27.4209      25.5908
410005............................       1.2822       1.1233      24.6522      27.1171      30.1606      27.3044
410006............................       1.2503       1.1233      26.1372      27.1842      29.4395      27.6190
410007............................       1.7094       1.1233      27.7171      30.1360      31.8548      30.0135
410008............................       1.2098       1.1233      25.4183      28.4245      29.6092      27.8277
410009............................       1.2932       1.1233      26.9135      27.7337      29.4094      28.0697
410010............................       1.1636       1.0952      30.3860      30.7826      32.8599      31.3979
410011............................       1.2966       1.1233      29.7664      28.5875      29.9001      29.4052
410012............................       1.7532       1.1233      28.1791      32.1679      32.6009      31.1120
410013............................       1.2276       1.1233      28.9386      31.7482      35.4624      32.1157
420002............................       1.5184       0.9717      25.1067      27.9312      28.2848      27.1910
420004............................       1.9550       0.9433      23.4579      26.0279      28.4845      26.0443
420005............................       1.0179       0.8663      19.5521      19.8167      23.1943      20.8182

[[Page 23531]]

 
420006............................       1.0874       0.9433      22.7896      22.8920      24.0811      23.2220
420007............................       1.5636       0.9183      22.0228      25.0395      25.2650      24.2318
420009............................       1.3786       0.9807      18.6866      23.8668      25.5079      22.5621
420010............................       1.1844       0.8988      19.1746      21.6478      23.4562      21.5057
420011............................       1.1190       1.0138      17.7300      20.8895      21.4030      20.0081
420014............................       0.9635       0.9057      21.2045      21.5658            *      21.3876
420015............................       1.2398       1.0138      23.1274      24.7383      26.1298      24.6961
420016............................       0.9619       0.8663      17.0051      17.3837      17.1229      17.1752
420018............................       1.7534       0.9057      20.4649      23.6356      24.7324      22.8696
420019............................       1.1129       0.8663      19.6836      20.5472      22.5312      20.8812
420020............................       1.2595       0.9317      22.1616      24.6592      25.7225      24.3050
420023............................       1.6530       1.0138      23.2568      25.1035      26.7263      25.0152
420026............................       1.8566       0.9057      23.7406      29.2961      27.4814      26.8241
420027............................       1.5759       0.8887      21.0637      22.8322      24.8624      22.9488
420030............................       1.2331       0.9317      22.6766      24.2847      26.0079      24.3704
420033............................       1.1361       1.0138      26.2711      27.5740      31.8759      28.5975
420036............................       1.2525       0.9585      20.6649      21.9641      22.8294      21.8110
420037............................       1.2494       1.0138      25.5492      26.8750      29.4156      27.3838
420038............................       1.2524       1.0138      21.6133      22.6741      24.2259      22.8531
420039............................       1.0376       0.9183      21.9737      24.0637      25.1148      23.7048
420043 h..........................       1.0680       0.9183      21.8816      22.9764      23.0555      22.6545
420048............................       1.2700       0.9057      21.9517      23.1515      24.1910      23.1357
420049............................       1.2080       0.8869      21.2604      23.2156      23.4769      22.6938
420051............................       1.4889       0.8988      20.6629      23.9455      24.8026      23.1828
420053............................       1.1415       0.8663      19.9013      21.1177      22.2825      21.1778
420054............................       1.0212       0.8663      20.8471      24.0653      24.8931      23.2676
420055............................       1.0684       0.8663      19.6817      20.3599      21.9764      20.6871
420056............................       1.4085       0.8663      20.0527      21.1640      21.6963      20.9682
420057............................       1.0376       0.8988      17.6727      19.7653      23.4311      20.1207
420059............................       1.0455       0.8663      20.2917      21.4260            *      20.8684
420061............................       1.1273       0.8663      19.9789      20.8684            *      20.4341
420062............................       1.0823       0.8663      17.4764      25.6683      25.8389      22.4958
420064............................       1.1956       0.8869      20.9057      22.1290      23.3610      22.2043
420065............................       1.3471       0.9433      22.0784      22.8674      24.5715      23.1699
420066............................       0.9655       0.8988      20.7782      20.5893      23.9048      21.7523
420067............................       1.2942       0.9316      22.8104      24.6038      25.0345      24.2301
420068............................       1.3390       0.9317      21.7257      22.2638      23.4248      22.4620
420069............................       1.0589       0.8663      17.6291      19.6959      20.5546      19.3217
420070............................       1.2778       0.9057      20.3664      22.4370      23.4355      22.1331
420071............................       1.3635       0.9807      21.8579      23.1727      24.9418      23.3888
420072............................       1.0926       0.8663      16.2578      17.5899      18.6742      17.5511
420073............................       1.3459       0.9057      21.4718      24.0274      24.5813      23.3018
420074............................          ***            *      18.7010            *            *      18.7010
420078............................       1.8001       1.0138      24.3273      25.3032      29.4985      26.4127
420079............................       1.5104       0.9433      23.3992      25.2939      25.5354      24.7810
420080............................       1.3725       0.9316      26.7489      28.4569      28.4734      27.9158
420082............................       1.4774       0.9567      23.6936      26.1221      29.8528      26.5169
420083............................       1.3224       0.9183      24.8508      25.3043      27.1322      25.7973
420085............................       1.6210       0.9394      24.4040      25.3180      26.8692      25.5532
420086............................       1.3930       0.9057      24.5760      25.1372      25.7580      25.1689
420087............................       1.7766       0.9433      22.4526      23.2230      24.3609      23.3441
420088............................          ***            *      23.5174      23.1273            *      23.4240
420089............................       1.3873       0.9433      23.3240      25.2729      26.0074      24.9015
420091............................       1.3034       0.8988      23.7936      23.4710      27.0189      24.8440
420093............................       0.9851       0.9183      21.4678      25.1457      27.4766      24.8258
420097............................          ***            *            *      24.7809            *      24.7809
430005............................       1.2209       0.8475      18.2647      19.9454      21.8605      19.9621
430008 \2\........................       1.1152       0.8475      20.0124      20.9442      22.9340      21.2902
430011............................       1.2481       0.8475      19.9835      20.6597            *      20.3142
430012............................       1.2707       0.9616      21.2588      22.7530      24.0850      22.7129
430013 \2\........................       1.1784       0.8475      21.3389      22.9675      23.8572      22.7428
430014............................       1.2515       0.8778      22.0285      25.5387      26.4964      24.6896
430015............................       1.1338       0.8475      20.5849      23.2035      22.7947      22.1979
430016............................       1.5813       0.9616      24.2450      26.1495      27.8453      26.0153
430018............................          ***       0.8475      17.9850            *            *      17.9850
430024............................          ***       0.8475      18.8357            *            *      18.8357
430029............................       0.8995       0.8475      18.9464      20.2708            *      19.6526

[[Page 23532]]

 
430031 \2\........................       0.9339       0.8475      15.2321      15.6112      15.9156      15.5961
430033............................          ***       0.8475      21.6254            *            *      21.6254
430047............................       0.9833       0.8475      18.2774      21.9116      18.8982      19.7432
430048............................       1.2364       0.8475      20.0607      21.1718      23.0783      21.5127
430054............................       0.9420       0.9616      17.8871            *            *      17.8871
430064............................       1.0393       0.8475      14.3407      16.4314      17.5376      16.1075
430077............................       1.6950       0.9027      21.6786      23.4835      25.1763      23.4802
430089............................       1.6248       0.9360      19.8572      21.1109      22.5625      21.3078
430090............................       1.4120       0.9616      25.6873      26.0851      25.7499      25.8502
430091............................       2.1791       0.9027      22.2824      23.8897      25.0828      23.8977
430092............................       1.7787       0.8475      19.7354      20.2570      23.8858      21.3414
430093............................       0.9141       0.9027      23.8820      23.1526      29.5244      25.7876
430094............................       1.8543       0.9207      20.8743      18.5429      19.0014      19.4190
430095............................       2.3163       0.9616            *      24.7074      28.1749      26.5823
430096............................       1.9499       0.8475            *            *      21.7103      21.7103
440001............................       1.1144       0.7958      18.9833      17.4802      19.3100      18.5533
440002............................       1.6911       0.8964      22.0178      23.2177      24.6664      23.3294
440003............................       1.2046       0.9757      21.6336      24.5168      25.9209      24.0777
440006............................       1.4022       0.9757      24.3173      26.7983      28.5951      26.6300
440007............................       0.9406       0.7915      14.8015      13.7042      25.8236      17.2437
440008............................       0.9974       0.8508      20.9237      22.1405      23.4301      22.0908
440009............................       1.1859       0.7915      19.6564      21.1274      21.5970      20.8327
440010............................       0.9389       0.7915      16.7270      16.9060      17.1803      16.9489
440011............................       1.3028       0.8470      20.5036      21.6861      22.5068      21.6145
440012............................       1.4390       0.8095      21.1213      21.4769      22.3029      21.6368
440015............................       1.8237       0.8470      23.4485      22.5583      23.7422      23.2495
440016............................       0.9690       0.7915      20.1504      20.0982      22.1646      20.8341
440017............................       1.7649       0.8095      21.8033      22.5313      22.9364      22.4333
440018............................       1.1326       0.7958      21.2242      21.7239      23.3444      22.1229
440019............................       1.7880       0.8470      21.8854      23.8802      25.2553      23.6676
440020............................       1.0554       0.9124      21.1075      23.1718      23.9475      22.7656
440023............................       0.9515       0.7915      15.5410      17.0335      18.2884      16.9816
440024............................       1.2316       0.8160      19.9751      20.3658      23.2478      21.1469
440025............................       1.1856       0.7915      19.1478      19.5995      20.6798      19.8282
440026............................          ***            *      25.1655      26.9149      26.8986      26.2876
440029............................       1.3373       0.9757      24.1379      25.8538      28.0779      26.0679
440030............................       1.2498       0.8758      19.9056      20.0586      26.1060      22.0081
440031............................       1.0626       0.7915      17.0289      18.0944      19.6685      18.2797
440032............................       1.0136       0.8095      14.7683      16.0734      18.5277      16.4708
440033............................       1.0486       0.7915      17.2637      18.7749      20.7917      19.0076
440034............................       1.5293       0.8470      22.2478      23.1121      23.5403      22.9348
440035............................       1.3430       0.9492      21.4990      22.3230      24.3752      22.7486
440039............................       1.9897       0.9757      25.0874      26.4647      28.1729      26.6593
440040............................       0.9253       0.7915      16.9886      17.7647      17.8510      17.5455
440041............................       0.9316       0.8160      15.5784      17.4074      17.9409      17.0933
440046............................       1.1385       0.9757      22.3380      25.5329      26.1341      24.7333
440047............................       0.8547       0.7915      18.7962      20.4812      21.4280      20.2387
440048............................       1.8251       0.9346      23.1553      24.3283      27.7560      24.7999
440049............................       1.5582       0.9346      21.1930      22.9755      25.3043      23.1991
440050............................       1.2790       0.9312      21.1397      21.8972      23.1362      22.0679
440051............................       0.9362       0.7915      19.0165      20.7948      21.9108      20.5095
440052............................       0.9561       0.7915      18.1935      20.1875      21.1133      19.9032
440053............................       1.2082       0.9757      22.0345      23.9083      25.4345      23.8916
440054............................       1.1252       0.7915      15.4208      20.5992      21.4400      18.6411
440056............................       1.1345       0.8758      19.3108      20.4088      22.1068      20.7270
440057............................       1.0371       0.7915      14.1477      14.6242      16.4451      15.0915
440058............................       1.1730       0.9099      21.7512      22.6014      22.9263      22.4470
440059............................       1.5012       0.9492      22.4248      23.9301      26.3531      24.2538
440060............................       1.0098       0.8799      20.2189      22.7133      23.3014      22.1119
440061............................       1.0870       0.7915      19.5458      21.2085      21.8274      20.8215
440063............................       1.5962       0.7958      19.7468      21.8578      22.3256      21.2848
440064............................       0.9863       0.9099      19.4020      20.9742      22.0955      20.8374
440065............................       1.2170       0.9757      19.9099      21.4794      22.3247      21.2895
440067............................       1.1694       0.8470      19.5643      22.1410      23.1089      21.6500
440068............................       1.1443       0.9099      20.9188      23.1705      24.5971      22.9451
440070............................       0.9466       0.7915      18.3717      19.0240      19.4372      18.9540
440072............................       1.1880       0.9108      19.6579      20.9294      27.1443      22.1374

[[Page 23533]]

 
440073............................       1.3595       0.9492      20.7181      22.2959      23.9198      22.3108
440081 h..........................       1.1378       0.8470      18.3141      19.0328      19.7918      19.0786
440082............................       2.1607       0.9757      26.1497      28.7828      27.9724      27.6484
440083............................       0.9067       0.7915      15.7015      16.0956      17.3329      16.4160
440084............................       1.1637       0.7915      15.0510      15.2825      16.3738      15.6128
440091............................       1.6254       0.9099      23.0296      26.1122      25.6797      24.9494
440102............................       1.1346       0.7915      16.6548      17.5140      17.5261      17.2560
440104............................       1.7607       0.9099      21.9870      23.3731      25.3739      23.6244
440105............................       1.0199       0.7958      19.2902      20.7821      22.3438      20.8223
440109............................       0.9843       0.7915      17.3578      18.2508      18.6720      18.1156
440110............................       1.1772       0.8470      19.9715      20.9039      21.3287      20.7233
440111............................       1.2422       0.9757      24.9883      25.8821      28.5705      26.5016
440114............................       0.9851       0.7915      20.1152      21.4271      24.0147      21.9369
440115............................       0.9888       0.7915      18.5389      20.0642      21.7830      20.1587
440120............................       1.5755       0.8470      22.4031      23.9003      25.7636      24.0777
440125............................       1.5716       0.8470      21.1018      21.9337      22.3888      21.8259
440130............................       1.1649       0.7915      20.6363      21.6480      23.4517      21.9020
440131............................       1.1987       0.9346      21.0640      22.4119      24.9598      22.8950
440132............................       1.2681       0.7915      18.9580      20.5716      21.5085      20.3655
440133............................       1.5674       0.9757      23.3600      27.5019      26.2422      25.6963
440135............................       1.0782       0.9757      23.9749      25.3928      26.6615      25.3742
440137............................       1.0485       0.7915      16.5529      18.2073      20.6663      18.4329
440141............................       0.9487       0.7915      19.2607      19.4528      21.3313      20.0578
440142............................       0.8702       0.9757      17.7587            *            *      17.7587
440144............................       1.1976       0.7915      19.7938      22.3671      23.3828      21.8222
440145............................       0.9916       0.7915      18.2019      20.9863      20.7875      19.9424
440147............................          ***            *      25.0780      28.9038      31.2003      28.2394
440148............................       1.1199       0.9492      20.7693      23.0697      24.6412      22.8692
440149............................       1.0185       0.7915      18.1316      19.8020      20.4562      19.4498
440150............................       1.3517       0.9757      22.8733      25.4952      26.8308      25.0868
440151............................       1.0856       0.9492      21.1576      23.3037      23.9808      22.8559
440152............................       1.8738       0.9346      22.7498      25.9495      26.5513      25.0265
440153............................       1.0018       0.7915      19.9486      22.7744      22.2846      21.7049
440156............................       1.4931       0.9099      23.7799      25.6333      26.9689      25.5243
440159............................       1.4244       0.9346      20.5719      21.1073      22.8645      21.5659
440161............................       1.8202       0.9757      26.1354      28.6774      28.6854      27.8923
440162............................          ***            *      20.3909      16.5305      21.1418      19.2406
440166............................       1.5235       0.9346      23.1692      27.1355      22.6509      24.5576
440168............................       0.9905       0.9346      21.2113      22.1764      22.8768      22.0809
440173............................       1.6407       0.8470      20.8442      20.8723      22.8692      21.5604
440174............................       0.8745       0.7915      19.2201      20.7960      22.0974      20.6472
440175............................       1.0488       0.9492      22.3331      24.0005      22.7299      23.0174
440176............................       1.2854       0.8095      20.4861      22.0079      23.6659      22.0556
440180............................       1.2061       0.8470      21.2398      21.9781      23.3808      22.2150
440181............................       0.9106       0.7915      19.6133      21.1406      22.7150      21.1984
440182............................       0.9022       0.7915      19.3928      20.2630      22.3612      20.6845
440183............................       1.5283       0.9346      24.9282      27.7769      27.1515      26.6633
440184............................       0.9990       0.7958      21.4484      20.8219      22.3475      21.5303
440185............................       1.1611       0.9099      22.1845      23.4172      23.9052      23.2612
440186............................       1.0310       0.9757      23.0193      24.6773      25.7445      24.4615
440187............................       1.0821       0.7915      19.9478      21.7637      21.3252      21.0131
440189............................       1.3728       0.8964      23.2866      24.7851      27.5435      25.2579
440192............................       1.0167       0.9492      21.3228      25.1119      25.7495      24.1386
440193............................       1.2566       0.9757      22.0345      24.3911      24.4299      23.6341
440194............................       1.3630       0.9757      24.4508      26.2498      26.6527      25.8291
440197............................       1.2605       0.9757      24.2660      26.4999      27.1534      25.9812
440200............................       0.9405       0.9757      16.7752      17.0633      17.7491      17.1850
440203............................       0.9753       0.7915            *      17.7639      19.3864      18.5423
440217............................       1.3463       0.9346      23.3544      25.9667      28.5968      26.1820
440218............................       0.8931       0.9757      20.1377      26.3741      24.6465      23.5719
440220............................          ***            *      21.9117            *            *      21.9117
450002............................       1.4427       0.8954      24.0411      25.4975      25.7171      25.1126
450005............................       1.0651       0.8422      21.7110      23.4049      23.5576      22.9913
450007............................       1.2962       0.8987      18.3738      19.2875      20.7321      19.4904
450008............................       1.3133       0.8566      20.1816      22.0934      22.9669      21.7810
450010............................       1.5052       0.8327      20.3023      22.4133      23.7529      22.1525
450011............................       1.6756       0.8911      22.1472      24.0715      24.8831      23.7169

[[Page 23534]]

 
450014............................       1.0286       0.8148      20.6936      22.5001            *      21.5732
450015............................       1.5729       1.0226      23.9526      24.0730      27.4012      25.2046
450016............................          ***            *      20.1232      22.1368            *      21.1548
450018............................       1.3942       1.0008      22.9019      24.6443      26.7999      24.7633
450020............................       0.9466       0.9451      19.1087      17.7148      18.3047      18.3252
450021............................       1.8194       1.0226      25.0769      28.5578      29.1350      27.5806
450023............................       1.3878       0.8148      19.1645      20.9278      22.0558      20.7053
450024............................       1.3228       0.8954      20.7727      20.5868      23.6211      21.6539
450028............................       1.5658       0.9853      22.7775      25.6030      26.8250      25.1270
450029............................       1.5162       0.8101      19.9198      23.9709      23.2995      22.4069
450031............................       1.4488       1.0226      21.7621      27.0328      27.9626      25.5466
450032............................       1.1987       0.8767      20.5217      20.8306      27.0748      22.7202
450033............................       1.6186       0.9853      26.5990      29.0541      28.5266      28.0983
450034............................       1.5259       0.8422      21.6097      23.4615      24.1589      23.0888
450035............................       1.5166       1.0008      24.1860      25.4580      26.2838      25.3196
450037............................       1.5141       0.8741      23.1179      23.1176      24.2684      23.5229
450039............................       1.3588       0.9955      22.0058      23.3034      24.7347      23.3847
450040............................       1.7455       0.8790      21.2990      23.8047      24.9590      23.3165
450042............................       1.6976       0.8532      21.8886      22.6936      24.1181      22.9317
450044............................       1.6507       1.0226      24.1127      25.8403      28.8098      26.9711
450046............................       1.5525       0.8557      20.9239      22.0695      23.4907      22.1959
450047............................       0.8562       0.9853      21.8840      22.7242      19.8221      21.4269
450050............................       0.9271       0.8038      19.5171      21.6933      23.3044      21.3893
450051............................       1.7617       1.0226      24.5533      27.2523      28.0411      26.6907
450052............................       0.9686       0.8038      17.6543      19.7185      19.7774      19.2138
450053............................       0.9574       0.8038      18.6556      19.4978      21.9082      20.0823
450054............................       1.6531       0.8566      23.2915      25.1229      24.2782      24.2283
450055............................       1.1284       0.8038      18.2235      20.5235      22.1979      20.3131
450056............................       1.7820       0.9451      24.4197      25.6685      27.0530      25.7808
450058............................       1.5325       0.8987      22.0158      24.7442      25.9653      24.1658
450059............................       1.3149       0.9451      22.8792      26.8209      26.6535      25.4407
450064............................       1.4037       0.9955      19.1271      24.2920      23.8748      22.4752
450068............................       2.0137       1.0008      24.0925      26.2864      27.9633      26.1666
450072............................       1.1350       1.0008      20.3683      22.5010      24.0166      22.2336
450073............................       0.9362       0.8038      19.2398      20.0464      21.7337      20.3411
450078............................       0.9261       0.8038      14.8285      17.2196      15.8968      15.9697
450079............................       1.5320       1.0226      24.0085      27.0443      28.1096      26.3674
450080............................       1.1799       0.8621      21.0353      21.2482      22.9835      21.7735
450081............................       1.0360       0.8038      19.2632            *            *      19.2632
450083............................       1.7207       0.9322      22.5063      24.9182      25.8214      24.4447
450085............................       1.0173       0.8038      18.1922      19.4524      22.0840      19.8958
450087............................       1.3393       0.9955      24.5976      26.4203      29.1587      26.8455
450090............................       1.1561       0.8038      17.1073      17.6506      19.4244      18.0792
450092............................       1.1362       0.8038      16.0199      20.4921      23.2071      19.7031
450094............................       1.0935       1.0226      25.8313      25.3618      25.2434      25.4570
450096............................       1.3677       0.8422      19.8012      22.8722      24.1619      22.3082
450097............................       1.4253       1.0008      22.2467      24.9380      26.4965      24.6105
450098............................       0.9223       0.8621      20.4795      22.9005      22.6626      21.9800
450099............................       1.1731       0.9165      21.4482      24.0293      26.6796      24.1168
450101............................       1.5502       0.8532      20.1473      20.6575      23.6905      21.4670
450102............................       1.7209       0.9322      20.9900      23.1773      24.5503      22.9587
450104............................       1.1697       0.8987      19.7126      22.5165      23.8469      22.0194
450107............................       1.4575       0.8954      23.2209      23.8770      25.9326      24.3252
450108............................       1.1001       0.8987      18.8084      19.3561      19.4935      19.2181
450109............................          ***       0.8038      15.1459            *            *      15.1459
450113............................          ***       0.8038      37.8944            *      54.6681      43.1390
450119............................       1.2979       0.8945      20.8840      24.1392      25.7008      23.6793
450121............................       1.4458       0.9955      24.6090      25.8826      25.7051      25.4063
450123............................       1.1207       0.8422      17.8629      19.5872      21.2154      19.5002
450124............................       1.8251       0.9451      24.2788      26.0280      27.4198      26.0262
450126............................       1.3283       1.0008      24.1961      27.3021      28.3033      26.6832
450128............................       1.2202       0.8945            *      21.4190      23.3633      22.3457
450130............................       1.1654       0.8987      19.6199      20.2777      21.5226      20.5273
450131............................       1.2121       0.8557      20.0434      23.2317      23.7098      22.3750
450132............................       1.5283       0.9893      22.4680      26.8476      28.6954      25.9595
450133............................       1.5415       0.9522      25.3928      25.0972      26.8344      25.8308
450135............................       1.6894       0.9955      22.5673      24.3858      26.0755      24.4084

[[Page 23535]]

 
450137............................       1.6059       0.9955      24.9732      27.0081      30.4254      27.6976
450140............................       0.8835       0.8038      18.3835      22.4695            *      20.3190
450143............................       1.0330       0.9451      18.4204      19.7487      21.8705      20.0996
450144............................       1.1455       0.9593      21.3896      20.9599      21.3289      21.2289
450146............................          ***       0.8038      16.6808            *            *      16.6808
450148............................       1.1489       0.9955      22.1351      23.5037      25.3498      23.7382
450151............................       1.1987       0.8038      17.9127      20.1356      22.2915      20.0948
450152............................       1.1854       0.8566      20.0146      21.6351      22.7463      21.4376
450154............................       1.2665       0.8038      16.5204      18.6058      21.2021      18.7210
450155............................       1.0266       0.8038      18.4021      17.9306      18.0589      18.1275
450157............................       1.0057       0.8038      17.8764      17.8812            *      17.8788
450160............................       0.9248       0.8038      20.7736      21.9118            *      21.3607
450162............................       1.3639       0.8790      26.0570      31.0645      30.9903      29.3951
450163............................       0.9730       0.8038      19.8194      20.3280      23.1400      21.0903
450165............................       1.1177       0.8987      16.1632      20.2414      24.3242      20.2279
450176............................       1.3178       0.8945      19.1823      20.9392      20.9297      20.4107
450177............................       1.2130       0.8038      17.2637      19.7657      21.3322      19.4690
450178............................       0.9642       0.8038      19.1186      20.2992      24.7301      21.2492
450184............................       1.5254       1.0008      24.0596      25.3935      26.8458      25.4934
450185............................       0.9793       0.8038      14.3594      15.5838            *      14.9644
450187............................       1.1635       1.0008      22.6275      24.2400      25.6786      24.2306
450188............................       0.9262       0.8038      17.6158      18.9586      20.4070      19.0169
450191............................       1.1247       0.9451      23.2261      25.9078      26.0298      25.1584
450192............................       1.0805       0.9955      20.1718      22.5118      22.5880      21.7848
450193............................       2.0537       1.0008      26.6580      29.2751      32.2964      29.4595
450194............................       1.3506       0.9955      22.7310      22.3348      24.8972      23.2572
450196............................       1.4168       0.9955      20.1938      23.6170      24.7557      23.2376
450200............................       1.4482       0.8293      20.4656      22.0923      23.5344      22.0868
450201............................       0.9125       0.8038      19.5907      20.3350      20.9809      20.3028
450203............................       1.1655       0.9514      22.9226      23.3953      24.1675      23.5222
450209............................       1.8856       0.9165      23.4794      24.4977      26.0958      24.6956
450210............................       0.9537       0.8038      16.7851      19.6340      19.9832      18.8463
450211............................       1.3415       1.0008      20.0280      20.7982      23.8230      21.4806
450213............................       1.7482       0.8987      21.1280      21.7930      23.9676      22.3693
450214............................       1.1722       1.0008      22.4543      23.9112      25.9598      24.1177
450219............................       0.9721       0.8038      21.0691      20.8255      21.7934      21.2690
450221............................       1.1435       0.8038      19.6778      20.6887      20.3186      20.2506
450222............................       1.5561       1.0008      23.5033      26.2975      27.4426      25.8797
450224............................       1.4143       0.9164      20.4453      22.2250      24.1956      22.3315
450229............................       1.6333       0.8038      17.9811      19.8279      21.4459      19.7433
450231............................       1.6297       0.9165      21.3086      23.9532      25.2852      23.5313
450234............................       0.9831       0.8038      22.3954      23.6695      18.4451      21.2354
450235............................       0.9124       0.8038      18.7028      19.1453      21.5138      19.8415
450236............................       1.0405       0.8038      17.7373      19.2987      22.0788      19.5556
450237............................       1.6743       0.8987      22.4477      25.1504      24.8901      24.1935
450239............................       0.9310       0.8566      19.3655      21.8595      21.1945      20.7705
450241............................       0.9436       0.8038      17.4151      18.1155      18.7957      18.0879
450243............................       1.0022       0.8038      13.0790      14.0589      15.4636      14.1605
450249............................       0.9833       0.8038      13.1222      16.5616            *      14.7712
450250............................          ***       0.8038      13.3731            *            *      13.3731
450264............................       0.9236       0.8038      13.5345      15.4111            *      14.4829
450269............................       1.0146       0.8038      12.6907      14.8204            *      13.7206
450270............................       1.0976       0.8038      13.9053      15.0879      14.4325      14.4468
450271............................       1.1532       0.9514      18.3659      19.4299      21.7719      19.9620
450272............................       1.2039       0.9451      21.4520      23.7933      25.9864      23.7631
450276............................       0.8990       0.8038      12.8895      16.0264      16.6319      15.2952
450280............................       1.5066       1.0226      23.1664      27.4523      28.7233      26.4522
450283............................       1.0602       0.9955      17.1013      20.0069      20.9680      19.5520
450289............................       1.3288       1.0008      23.7108      27.3864      28.5665      26.5635
450292............................       1.2940       1.0226      23.4257      23.5330      25.0411      24.0121
450293............................       0.8704       0.8038      17.7673      20.0898      21.3136      19.7647
450296............................       1.0400       1.0008      20.4483      29.2006      27.9690      25.4406
450299............................       1.5781       0.8911      22.9849      25.8183      26.4933      25.0990
450303............................       0.8372       0.8790      16.1330            *            *      16.1330
450315............................          ***       1.0226      26.4677      27.9780            *      27.2229
450320............................          ***            *      26.8089            *            *      26.8089
450327............................          ***       0.8038      14.3848            *            *      14.3848

[[Page 23536]]

 
450340............................       1.3755       0.8287      20.0621      22.7826      24.0636      22.3350
450346............................       1.3855       0.8422      20.1921      21.9717      22.2469      21.4909
450347............................       1.1384       1.0008      21.7142      22.8133      27.2203      23.9176
450348............................       0.9886       0.8038      15.6324      17.0198      18.7675      17.1642
450351............................       1.2212       0.9514      22.2597      23.5895      25.6859      23.9245
450352............................       1.1057       1.0226      21.8138      23.4297      24.8012      23.3447
450353............................       1.2803       0.8038      19.5263      20.9271      24.4454      21.5974
450358............................       2.0076       1.0008      25.9105      29.3408      30.4280      28.6741
450362............................       0.9855       0.8038      20.6340      22.0223      25.4372      22.7898
450369............................       1.0166       0.8038      16.5636      17.5360      18.4848      17.6077
450370............................       1.1704       0.8038      19.0340      22.6815      20.0832      20.4877
450371............................          ***            *      17.3415            *            *      17.3415
450373............................       0.9087       0.8038      17.7955      20.5789      22.2213      20.1017
450374............................       0.9164       0.8038      15.0670      17.4509      23.2285      18.2702
450378............................       1.3340       1.0008      25.8048      29.5108      30.7684      28.7797
450379............................       1.3574       1.0226      29.0865      31.1573      30.6072      30.3060
450381............................       0.9257       0.9451      19.0584      20.9200      22.0482      20.7572
450388............................       1.6460       0.8987      22.4441      24.1598      25.8674      24.3854
450389............................       1.1827       0.9955      20.7160      22.3803      23.8764      22.4221
450393............................          ***       0.9518      23.8237      24.6872      18.4551      22.6427
450395............................       1.0142       0.8038      19.1938      23.9689      24.8656      22.6314
450399............................       0.9249       0.8038      19.1571      19.5928      18.2074      18.9826
450400............................       1.1916       0.8532      20.1376      22.0103      23.1739      21.7697
450403............................       1.2709       1.0226      24.6215      27.8138      29.3063      27.2736
450411............................       0.9558       0.8038      16.9558      17.6570      19.6086      18.1139
450417............................       0.8643       1.0008      16.1957      17.8078      20.0350      18.0319
450418............................       1.2488       1.0008      25.1306      27.0283      26.8434      26.3230
450419............................       1.1760       0.9955      26.7662      28.4122      31.0404      28.7694
450422............................       1.0462       1.0226      29.0032      29.5592      30.6659      29.7888
450424............................       1.2797       1.0008      22.0682      23.1253      28.3149      24.8057
450431............................       1.5343       0.9451      22.9545      24.7346      25.2477      24.3602
450438............................       1.1444       1.0008      19.2165      22.0476      21.9351      21.1413
450446............................       0.6161       1.0008      14.1684      14.9983      14.3132      14.4984
450447............................       1.1971       0.9955      21.0247      22.5602      23.5047      22.3940
450451............................       1.0873       0.9514      21.1046      22.3834      23.3042      22.3121
450460............................       0.9348       0.8038      17.9487      19.5709      20.5812      19.4136
450462............................       1.6600       1.0226      24.0081      25.6952      27.8923      25.9496
450464............................          ***       0.8038      16.1987            *            *      16.1987
450469............................       1.4541       0.9518      24.0794      26.6781      28.7890      26.6238
450473............................          ***            *      18.6002            *            *      18.6002
450484............................       1.3734       1.0008      23.2881      23.0604      25.3527      23.9206
450488............................       1.1123       0.8741      22.5650      22.3949      23.9144      22.9600
450489............................       1.0160       0.8038      18.5941      19.6884      21.4771      19.8409
450497............................       1.0329       0.8038      17.1327      17.6614      18.8344      17.8832
450498............................       0.8732       0.8038      19.2984      16.4358      17.7822      17.7509
450508............................       1.4085       0.9164      20.8183      23.5066      23.9572      22.7686
450514............................       1.1119       0.8422      21.0116      21.4034      22.6552      21.6987
450517............................       0.9088       0.8038      14.4246      15.2707      22.0440      17.2013
450518............................       1.6338       0.8422      21.1015      22.2587      24.1194      22.4755
450523............................          ***            *      22.3034      28.6387            *      25.2834
450530............................       1.1553       1.0008      23.3005      26.1998      28.7451      26.1850
450534............................       0.8962       0.8038      22.5156      20.4715            *      21.4079
450535............................          ***            *      23.7255      29.4427            *      26.5477
450537............................       1.3531       1.0226      22.5972      23.9256      27.5856      24.8361
450539............................       1.2112       0.8038      18.4299      20.0343      21.0442      19.8677
450545............................          ***            *      21.7762      22.8130            *      22.2858
450547............................       0.9601       0.9955      22.6557      21.8106      21.6542      22.0062
450558............................       1.7596       0.8038      21.4201      25.0837      26.1551      24.1840
450563............................       1.3725       0.9955      27.5671      27.9427      28.7289      28.1251
450565............................       1.2388       0.8038      17.2171      22.1971      23.8847      20.9966
450571............................       1.4990       0.8287      21.5688      20.9651      22.7703      21.7784
450573............................       1.1238       0.8038      18.6233      21.6974      20.1479      20.0755
450578............................       0.9390       0.8038      17.3010      20.0454      20.2695      19.1233
450580............................       1.1057       0.8038      18.5225      20.4293      21.1574      20.0321
450584............................       1.0396       0.8038      16.9021      19.0373      21.0808      18.9453
450586............................       0.9605       0.8038      14.9061      14.6574      16.1003      15.2149
450587............................       1.1650       0.8038      19.0648      19.9712      20.4512      19.8609

[[Page 23537]]

 
450591............................       1.2007       1.0008      19.6229      22.4991      23.9992      22.0639
450596 h..........................       1.0985       0.9514      24.3714      24.7477      25.3317      24.8345
450597............................       0.9702       0.8038      19.9596      22.9337      23.1711      22.1268
450603............................          ***       0.8038      20.6138            *            *      20.6138
450605............................       1.1521       0.8557      22.0210      23.8820      22.2205      22.7037
450609............................       0.9809       0.8038      16.6870      18.3856            *      17.5807
450610............................       1.5974       1.0008      24.7706      22.5451      26.8710      24.6655
450614............................          ***            *      18.5895            *            *      18.5895
450617............................       1.3959       1.0008      22.7514      25.2211      26.5026      24.9284
450620............................       0.9943       0.8038      17.1333      18.1819      17.7138      17.6710
450623............................       1.0833       0.9955      25.1400      28.3354      28.3552      27.2112
450626............................       0.9113       0.8038      17.7454      21.4445      26.8375      21.3925
450630............................       1.5237       1.0008      24.8096      27.8856      29.6796      27.5230
450631............................          ***            *      22.8637      24.5409            *      23.7681
450634............................       1.5840       1.0226      24.8258      27.0412      28.1705      26.8022
450638............................       1.5909       1.0008      26.3653      29.5385      29.6184      28.6129
450639............................       1.5269       0.9955      24.2919      27.3593      29.2669      27.0735
450641............................       0.9690       0.8038      17.4072      17.0805      17.5845      17.3565
450643............................       1.3272       0.8101      20.2000      20.9674      21.1205      20.7972
450644............................       1.4121       1.0008      24.4574      27.2047      29.0186      27.0517
450646............................       1.3665       0.8954      21.8500      22.6541      23.8908      22.8626
450647............................       1.8080       1.0226      26.8276      28.8881      30.7334      28.8704
450648............................       0.9048       0.8038      17.3678      18.2826            *      17.7872
450649............................       0.9413       0.8038      17.5761      18.1118            *      17.8381
450651............................       1.6207       1.0226      26.9215      28.9829      32.4822      29.5833
450653............................       1.1208       0.9317      22.7236      21.8654      23.2603      22.6099
450654............................       0.9014       0.8038      16.3057      19.6054      19.9992      18.6631
450656............................       1.3925       0.9164      20.7824      22.7284      23.8280      22.4984
450658............................       0.9005       0.8038      19.6855      19.9597      20.5398      20.0788
450659............................       1.4288       1.0008      26.0224      28.8671      30.1727      28.5108
450661............................       1.1620       0.9893      20.0716      21.5537      23.2989      21.6941
450662............................       1.5437       0.9853      26.3794      24.5815      28.0913      26.3697
450665............................       0.8590       0.8038      15.8571      17.2566      18.6054      17.2495
450668............................       1.5024       0.8954      24.0081      26.4508      26.2375      25.5681
450669............................       1.2076       1.0226      25.0200      25.6411      27.4677      26.1106
450670............................       1.3351       1.0008      19.9621      22.0495      25.1575      22.3620
450672............................       1.6955       0.9955      25.3106      26.7785      27.6359      26.6135
450673............................       1.0764       0.8327      16.3319      19.4030            *      17.7858
450674............................       0.9403       1.0008      24.8137      26.8081            *      25.8948
450675............................       1.4122       0.9955      24.8661      26.1555      28.7765      26.7882
450677............................       1.3184       0.9955      22.9529      24.0218      28.4544      25.1326
450678............................       1.3836       1.0226      28.1917      30.1134      30.1500      29.5324
450683............................       1.1313       1.0226      24.5013      24.0080      24.6609      24.3870
450684............................       1.2141       1.0008      23.8945      26.2906      27.6789      25.9648
450686............................       1.6245       0.8790      17.9181      21.0565      23.2367      20.7924
450688............................       1.1771       1.0226      21.7922      23.7796      27.9057      24.4771
450690............................       1.4853       0.9322      33.1576      28.7529      28.0400      29.1149
450694............................       1.0990       1.0008      21.4784      22.3081      23.5790      22.4747
450697............................       1.3237       0.8987      20.8951      21.2662      23.7155      22.0489
450698............................       0.8758       0.8038      18.1764      18.5436      18.6494      18.4560
450700............................       0.9198       0.8038      17.3458      18.6373      18.4602      18.1609
450702............................       1.5061       0.8741      22.2953      24.8628      25.6147      24.3137
450709............................       1.2645       1.0008      23.4246      25.0932      25.4855      24.7135
450711............................       1.6067       0.8945      22.1489      24.8277      28.0104      25.1428
450712............................          ***            *      18.4547            *            *      18.4547
450715............................       1.2343       1.0226            *      16.1897      28.0365      20.5948
450716............................       1.2179       1.0008      24.8614      28.8043      30.8440      28.2641
450718............................       1.1954       0.9451      24.9162      27.6672      27.3408      26.7229
450723............................       1.3817       1.0226      24.1618      27.0055      28.0812      26.5571
450724............................          ***            *      21.9630            *            *      21.9630
450730............................       1.2563       1.0226      27.8476      30.7567      29.9430      29.5510
450733............................          ***            *      23.8143      25.5624      26.4976      25.4115
450742............................       1.1492       1.0226      25.1295      26.3414      26.1190      25.8920
450743............................       1.4553       1.0226      23.7424      24.7397      27.3213      25.3404
450746............................       0.9449       0.8038      11.1672      16.9209      12.4748      13.1222
450747............................       1.1996       0.9955      21.5883      24.2674      22.2870      22.7471
450749............................       1.0081       0.8038      17.8696      18.4095      17.8227      18.0184

[[Page 23538]]

 
450751............................       1.2551       0.8293      23.3154      22.9070      19.3265      21.7472
450754............................       0.9215       0.8038      19.2827      21.3043      20.8968      20.5167
450755............................       0.9643       0.8790      19.2768      19.5168      18.0092      18.8178
450758............................       1.2430       1.0226      22.8713      24.0226      25.6548      24.1232
450760............................       1.1495       0.8954      23.2959      25.7453      24.6349      24.3909
450761............................       0.8380       0.8038      15.5151      16.2605      15.7483      15.8642
450763............................       1.1245       0.8038      19.8939      21.4171      22.4905      21.2790
450766............................       1.8603       1.0226      27.2499      28.8576      30.0441      28.7197
450770............................       1.1786       0.9451      19.9412      20.1763      20.3656      20.1550
450771............................       1.6492       1.0226      25.0490      26.0618      31.3924      27.9152
450774............................       1.7122       1.0008      21.7906      24.8562      24.9683      23.8170
450775............................       1.1967       1.0008      23.6621      25.3924      24.4006      24.5023
450776............................       0.9653       0.8038      14.6695            *            *      14.6695
450780............................       1.9234       0.8987      21.9046      22.8688      23.9516      22.9443
450788............................       1.5485       0.8557      21.4467      24.2643      25.4172      23.7014
450795............................       1.1361       1.0008      19.1371      28.1448      23.7510      23.4235
450796............................       2.1587       0.9165      22.4973      24.7564      27.9734      25.1133
450797............................          ***       1.0008      18.6839      23.8708      20.5379      20.9547
450801............................       1.4873       0.8293      19.7790      22.2426      23.0373      21.7315
450803............................       1.2163       1.0008      23.8343      26.3054      30.6093      27.0662
450804............................       1.8040       1.0008      22.8275      26.0003      26.0980      25.0247
450808............................       1.6335       0.9451      18.6555      22.8247      23.8067      21.6597
450809............................       1.5600       0.9451      23.8758      24.7763      26.3659      25.0664
450811............................       1.8007       0.8945      22.7583      23.1022      25.8491      24.4306
450813............................       1.1082       0.8038      21.7208      22.1326      25.5949      23.1456
450817............................          ***            *      28.4441            *            *      28.4441
450822............................       1.1421       1.0226      26.7821      29.7067      31.1431      29.3455
450824............................       2.3620       0.9451      24.5885            *      26.7803      25.7897
450825............................       1.4475       0.8945      18.8510      18.7069      20.2959      19.3490
450827............................       1.4188       0.8327      29.5838      21.1788      20.9704      23.0851
450828............................       1.1739       0.8038      20.9509      21.4128      22.3667      21.5956
450829............................          ***       0.8987      14.4463      18.2860      19.5014      17.2726
450830............................       0.9282       0.9593      24.7834      26.9917      28.1617      26.6450
450831............................       1.6369       1.0008            *      20.0581      22.7885      21.7038
450832............................       1.1025       1.0008      24.8572      26.4725      26.6628      26.1075
450833............................       1.1371       1.0226      18.3196      26.1256      26.0044      23.5951
450834............................       1.3563       0.8911      21.7217      22.7691      21.2204      21.8968
450835............................          ***            *      24.8374            *            *      24.8374
450838............................       1.1289       0.8038            *      15.0454      15.8026      15.4717
450839............................       0.9271       0.8767            *      21.1905      22.9711      22.0566
450840............................       0.9946       1.0226            *      29.5215      31.1914      30.4233
450841............................       1.6236       0.9853            *      17.6635      18.9468      18.3289
450842............................          ***            *            *      23.0945            *      23.0945
450844............................       1.2573       1.0008            *      34.4235      28.7296      30.4450
450845............................       1.8144       0.8954            *      26.5040      27.7461      27.1743
450846............................          ***            *            *      24.0791            *      24.0791
450847............................       1.1792       1.0008            *      26.8892      27.6854      27.3036
450848............................       1.1875       1.0008            *      26.5609      27.8100      27.1855
450850............................       1.4887       0.9522            *            *      22.1334      22.1334
450851............................       2.2455       1.0226            *            *      30.1213      30.1213
450852............................          ***       1.0226            *            *      30.0191      30.0191
460001............................       1.8903       0.9578      24.8844      25.6932      27.0757      25.8934
460003............................       1.4892       0.9436      26.5141      24.3527      26.1372      25.6304
460004............................       1.6546       0.9436      24.3409      25.2191      26.4498      25.3907
460005............................       1.4234       0.9436      25.0063      22.6809      23.5633      23.6783
460006............................       1.2864       0.9436      23.4200      24.4350      25.4787      24.4752
460007............................       1.3119       0.9416      23.3603      24.2875      25.6686      24.4644
460008............................       1.3319       0.9436      24.8233      24.4453      26.5672      25.2587
460009............................       1.9172       0.9436      24.5865      25.0984      26.2833      25.3688
460010............................       2.0750       0.9436      25.1240      26.2331      27.4648      26.2912
460011............................       1.2723       0.9578      21.2634      22.3601      23.4023      22.3027
460013............................       1.3340       0.9578      23.1467      23.4765      25.2448      23.9897
460014............................       1.0825       0.9436      22.6125      23.9400      24.5384      23.7842
460015............................       1.2767       0.9183      23.1068      24.0939      25.6576      24.3035
460016............................          ***       0.8134      18.7453            *            *      18.7453
460018 h..........................       0.8785       1.2094      16.7143      18.8942      20.3755      18.6334
460019............................       1.0897       0.8134      18.1995      20.3625      19.9900      19.5496

[[Page 23539]]

 
460020............................       1.0465       0.8134      15.2162      19.4960      19.5669      17.9384
460021............................       1.6825       1.1249      23.8565      24.9725      26.3420      25.1139
460023............................       1.1620       0.9578      25.0874      25.0376      25.3094      25.1556
460025............................       0.9769       0.8134      22.3098      18.7978            *      20.4201
460026............................       0.9752       0.8134      21.9316      22.7589      24.1547      22.9505
460029............................       1.0584       0.8134      24.4379            *            *      24.4379
460032............................       0.9659       0.9578      21.2715      22.8987            *      22.1308
460033............................       0.9161       0.8134      21.7216      22.7816      22.0248      22.1909
460035............................       0.9171       0.8134      16.9657      16.9019      17.5723      17.1694
460036............................       1.2351       0.9578      23.9910      25.2647      27.2865      25.5949
460037............................       0.8624       0.8134      20.0323      19.8478      21.1035      20.3240
460039............................       1.0000       0.9048      26.3795      27.5912      28.5656      27.5288
460041............................       1.3167       0.9436      23.5132      24.0431      25.2744      24.2809
460042............................       1.3210       0.9436      22.0844      23.5819      22.9949      22.8865
460043............................       0.9066       0.9578      26.0277      26.6870      28.2089      27.0296
460044............................       1.2356       0.9436      24.7138      25.7342      26.6795      25.7463
460047............................       1.6135       0.9436      24.9214      25.1721      25.7920      25.3219
460049............................       1.9769       0.9436      21.9357      23.0683      24.5164      23.1856
460051............................       1.1333       0.9436      22.7540      23.4970      25.5881      24.0241
460052............................       1.4446       0.9578      23.1717      24.0797      25.3163      24.2177
460053............................          ***            *      23.2274            *            *      23.2274
470001............................       1.2123       1.0668      23.5882      24.5499      27.7329      25.2768
470003............................       1.8981       1.0199      24.1739      24.6660      26.4919      25.1321
470005............................       1.3303       1.0199      24.9625      25.7288      29.8255      26.8311
470006............................       1.1851       1.0199      21.6036      26.0884      26.9651      24.9417
470008............................       1.1624       1.0199      20.7659      21.8951            *      21.3386
470010............................       1.1493       1.0199      23.2072      22.9777      26.1273      24.1019
470011............................       1.2027       1.0903      24.6034      25.9246      28.3911      26.3395
470012............................       1.2167       1.0199      20.5072      22.9159      24.3425      22.6924
470018............................       1.1669       1.0199      21.2904      25.9300      28.3419      25.0848
470023............................       1.2183       1.0199      24.1395      26.7486            *      25.4614
470024............................       1.1449       1.0199      22.4659      23.7745      25.8652      24.1048
490001............................       1.0907       0.8024      22.3622      21.7111      21.9953      22.0191
490002............................       1.0623       0.8024      17.5098      18.5220      19.5613      18.6066
490003............................          ***            *      20.9783      23.8112      27.3456      23.8351
490004............................       1.2757       0.9806      22.7154      24.4580      25.4597      24.2345
490005............................       1.6453       1.0813      25.2213      27.6425      28.5744      27.1963
490006............................       1.1847       1.0214      13.4277      16.7679            *      15.2211
490007............................       2.2466       0.8841      22.2526      24.9533      26.2481      24.5292
490009............................       1.9263       1.0230      25.2181      27.5905      29.1962      27.2686
490011............................       1.4460       0.8841      20.0136      22.4410      24.5687      22.4266
490012............................       0.9964       0.8024      15.8346      18.3697      19.2275      17.8014
490013............................       1.2634       0.8596      19.5094      21.4838      22.2736      21.0913
490015............................          ***            *      21.2557      22.5641            *      21.9516
490017............................       1.3989       0.8841      20.7691      22.9632      24.6845      22.9273
490018............................       1.2537       0.9806      22.0810      23.2215      24.5196      23.2792
490019 h..........................       1.1521       1.0935      23.3077      24.4524      25.9761      24.6213
490020............................       1.2668       0.9319      21.2094      23.6611      24.8001      23.2943
490021............................       1.4407       0.8706      22.2537      23.5930      24.6440      23.5199
490022............................       1.4865       1.0935      24.4682      25.0277      28.0749      25.8811
490023............................       1.2256       1.0935      24.9734      28.8354      29.7774      27.9947
490024............................       1.6758       0.8450      21.2619      21.7268      23.0982      22.0522
490027............................       1.1416       0.8024      20.3644      19.8345      18.9409      19.7128
490031............................       1.1051       0.8024      18.4826      22.4300      22.0579      20.9706
490032............................       1.8812       0.9319      23.6489      22.8942      25.1381      23.9005
490033............................       1.0518       1.0935      24.4370      27.6355      30.0909      27.5418
490037............................       1.1577       0.8024      17.5104      19.0583      21.3035      19.2834
490038............................       1.1503       0.8024      18.1405      19.6427      22.1374      19.9691
490040............................       1.5115       1.0935      27.0513      30.1820      32.8738      30.0780
490041............................       1.4077       0.8841      19.9314      22.2955      24.5738      22.3542
490042............................       1.2563       0.8024      19.5127      20.5845      21.8749      20.7701
490043............................       1.1666       1.0935      25.4354      28.2969      30.8871      28.4640
490044............................       1.3756       0.8841      20.8739      22.1324      20.8351      21.2628
490045............................       1.3043       1.0935      24.7131      27.2132      28.8279      27.0743
490046............................       1.5526       0.8841      22.0040      24.6391      25.6328      24.1719
490047............................       1.0113       0.8998      19.8220      21.9156      22.5424      21.3597
490048............................       1.4287       0.8450      22.3138      24.1639      25.0097      23.8716

[[Page 23540]]

 
490050............................       1.5254       1.0935      26.1521      29.4660      30.5037      28.7334
490052............................       1.6709       0.8841      19.2480      21.4035      22.8889      21.2086
490053............................       1.2926       0.8095      18.6541      20.9367      21.8432      20.4783
490057............................       1.5826       0.8841      22.1612      25.1898      26.1128      24.5153
490059............................       1.5692       0.9319      23.3895      26.1518      28.7276      26.1974
490060............................       1.0283       0.8024      20.6028      21.0828      22.4200      21.3908
490063............................       1.8332       1.0935      31.0162      29.4216      30.3648      30.2236
490066............................       1.3174       0.8841      22.1034      23.3835      24.7146      23.4575
490067............................       1.1859       0.9319      20.4058      21.8730      22.9188      21.7183
490069............................       1.5306       0.9319      20.6957      24.4542      26.8791      24.1400
490071............................       1.2929       0.9319      25.4678      27.0374      28.4381      27.0687
490073............................       1.6276       1.0935      27.6711      25.2859      31.7743      27.8898
490075............................       1.4205       0.8514      22.3230      22.8303      23.8191      23.0000
490077............................       1.3109       1.0230      22.2643      24.8309      26.0800      24.4773
490079............................       1.2705       0.9020      19.2196      19.8100      23.4728      20.7435
490084............................       1.1954       0.8024      19.8598      22.7945      24.6045      22.3588
490088............................       1.0683       0.8706      19.7549      21.4818      22.4186      21.1984
490089............................       1.0461       0.8450      21.1522      21.2123      22.6461      21.7546
490090............................       1.1132       0.8024      20.3015      21.3410      22.2907      21.2854
490092............................       1.1103       0.9319      23.8364      21.6466      23.8656      23.0587
490093............................       1.4305       0.8841      20.7388      23.6779      25.0751      23.2941
490094............................       0.9993       0.9319      21.9886      26.0755      26.5726      25.0296
490097............................       1.0181       0.8024      18.1022      23.5366      23.8005      21.5573
490098............................       1.2311       0.8024      19.7116      20.9805      21.7231      20.8214
490101............................       1.2761       1.0935      28.5200      30.1800      30.4285      29.7644
490104............................       0.7943       0.9319      28.0286      33.1215      17.3295      24.4559
490105............................       0.7131       0.8095      40.6821      38.2813      24.7923      34.3492
490106............................       0.9458       0.9806      31.6541      30.1492      23.0199      28.3157
490107............................       1.2758       1.0935      26.5312      28.7296      29.7000      28.3786
490108............................       0.9611       0.8706      28.7277      27.9090      22.4345      26.3471
490109............................       0.9766       0.9319      28.0978      28.0548      21.9878      25.9914
490110............................       1.3198       0.8024      23.6080      21.3126      22.5974      22.4319
490111............................       1.2838       0.8024      19.4041      20.6373      22.0199      20.6805
490112............................       1.6692       0.9319      23.6028      25.8312      26.6453      25.4222
490113............................       1.2540       1.0935      28.0893      29.1786      29.5698      28.9669
490114............................       0.9717       0.8024      19.9725      20.0555      20.7017      20.2462
490115............................       1.1772       0.8024      19.9151      20.3615      21.4666      20.5969
490116............................       1.1327       0.8024      19.7007      21.3083      22.9017      21.2429
490117............................       1.1880       0.8024      15.6078      17.4111      18.0277      17.0302
490118............................       1.7046       0.9319      25.2230      26.8810      27.4050      26.6600
490119............................       1.3161       0.8841      21.3883      23.7813      25.2549      23.5234
490120............................       1.3813       0.8841      22.2389      23.1535      24.4434      23.3020
490122............................       1.4487       1.0935      27.3509      28.7020      31.0449      29.0227
490123............................       1.0953       0.8024      20.9506      22.9511      23.9233      22.6075
490124............................          ***            *      21.3713      29.7939            *      25.7258
490126............................       1.2378       0.8024      20.4660      23.1423      22.2859      21.9403
490127............................       1.0786       0.8024      17.8070      19.4005      20.4289      19.2585
490130............................       1.3182       0.8841      18.6038      22.0769      22.8512      21.1640
490132............................          ***       0.8024      19.5849            *            *      19.5849
500001............................       1.5872       1.1573      26.6420      26.7502      29.3707      27.5939
500002............................       1.4024       1.0459      24.0374      25.0665      25.3347      24.8482
500003............................       1.2634       1.1573      27.3435      28.4174      29.6341      28.5098
500005............................       1.8137       1.1573      28.9512      31.4415      32.0972      30.7955
500007............................       1.2933       1.0459      23.5774      26.1318      28.0476      25.9648
500008............................       1.9138       1.1573      28.9380      31.0128      31.8837      30.6288
500011............................       1.3458       1.1573      27.6762      28.3391      30.6508      28.9502
500012............................       1.5792       1.0459      26.2263      29.2045      30.6856      28.7227
500014............................       1.6444       1.1573      27.4248      30.1061      33.7536      30.6058
500015............................       1.3785       1.1573      27.3397      30.1596      32.0592      29.8941
500016............................       1.6460       1.1573      27.7863      29.3634      31.4221      29.6282
500019............................       1.2688       1.0459      25.7691      26.9702      28.6669      27.1697
500021............................       1.3005       1.0794      26.4648      28.5926      30.1690      28.5893
500023............................       1.1295       1.0459      23.9513      27.3823            *      25.6872
500024............................       1.6961       1.0794      27.2967      29.3946      30.7917      29.1683
500025............................       1.7523       1.1573      29.0400      31.7335      34.7252      31.7861
500026............................       1.4441       1.1573      28.7532      31.4152      33.2937      31.1325
500027............................       1.5647       1.1573      30.6901      29.5939      34.2175      31.5063

[[Page 23541]]

 
500030............................       1.5791       1.1705      29.0487      30.5926      32.7446      30.8324
500031............................       1.1888       1.0970      26.0740      28.5398      31.2186      28.5887
500033............................       1.2976       1.0459      25.4345      26.6704      29.4627      27.2338
500036............................       1.3747       1.0459      25.4753      26.0223      27.0072      26.1929
500037............................       1.0310       1.0459      23.5414      24.6548      26.9969      25.0377
500039............................       1.4511       1.1573      26.1409      27.9651      29.8809      28.0919
500041............................       1.2975       1.1229      24.9004      26.9101      26.5976      26.1814
500044............................       1.9843       1.0898      27.0880      26.9323      30.3164      28.1645
500049............................       1.3010       1.0459      26.6407      25.6104      27.1819      26.4960
500050............................       1.4422       1.1229      25.0907      26.8971      29.9791      27.4347
500051............................       1.7552       1.1573      26.9538      29.0100      31.9406      29.4441
500053............................       1.2441       1.0619      26.0112      26.8074      28.4130      27.1467
500054............................       2.0525       1.0898      27.1965      28.8062      30.8067      28.9786
500055............................          ***       1.0459      25.3095            *            *      25.3095
500058............................       1.6605       1.0619      27.3411      28.4247      30.4699      28.8635
500060............................       1.2823       1.1573      31.7480      33.5169      34.1523      33.1768
500064............................       1.7416       1.1573      29.2539      31.1459      31.5371      30.6791
500065............................       1.2445       1.0459      26.5880      26.0960            *      26.3295
500071............................       1.1734       1.0459      23.2071            *            *      23.2071
500074............................          ***       1.0459      21.9019            *            *      21.9019
500079............................       1.3420       1.0794      27.1775      28.4934      29.6623      28.4444
500084............................       1.3103       1.1573      26.5864      27.6306      29.3484      27.9397
500086............................       1.2807       1.0459      25.9705            *            *      25.9705
500092............................       0.8995       1.0459      20.8601      23.2466            *      22.0417
500104............................       1.0691       1.1573      26.8007      27.0034            *      26.9067
500108............................       1.6596       1.0794      27.4156      28.7206      29.4244      28.5667
500110............................       1.1857       1.0459      24.8448      25.4785      26.4560      25.6025
500118............................       1.1171       1.0459      26.1971      28.1074            *      27.1693
500119............................       1.3607       1.0898      25.1576      27.2335      30.9999      27.7928
500122............................       1.1916       1.0459      26.9006      27.4405      30.1396      28.2069
500124............................       1.4090       1.1573      24.8357      28.6598      31.5438      28.2647
500129............................       1.5325       1.0794      27.8351      30.0223      30.7536      29.5772
500134............................       0.4749       1.1573      21.3921      24.2990      26.8608      24.3808
500139............................       1.5310       1.0794      27.7281      29.2357      31.6591      29.5383
500141............................       1.2664       1.1573      28.2968      30.7478      30.5456      29.9289
500143............................       0.4570       1.0794      19.0982      20.7093      22.1419      20.7552
500147............................       0.8043       1.0459            *      16.3669      24.5807      16.9814
500148............................       1.1051       1.0459            *      18.2168      22.2161      20.0814
510001............................       1.9174       0.8840      21.4247      22.9351      23.4477      22.6536
510002............................       1.1623       0.8450      20.9822      22.4751      25.9597      23.1031
510006............................       1.2491       0.8840      21.0214      22.2947      23.5727      22.3142
510007............................       1.5458       0.9482      23.4411      24.3499      25.2835      24.3672
510008............................       1.1920       0.9528      22.7595      24.5293      24.6959      24.0287
510012............................       0.9435       0.7742      16.7710      18.5816      18.2845      17.8391
510013............................       1.1671       0.7742      19.7937      19.9710      20.8782      20.2065
510015............................       0.9561       0.8429      17.9040            *            *      17.9040
510022............................       1.8301       0.8429      22.7534      24.1481      24.2125      23.7112
510023............................       1.2510       0.7821      17.9267      19.4321      20.4908      19.2664
510024............................       1.7224       0.8840      21.3662      23.3115      24.0444      22.9061
510026............................       1.0110       0.7742      16.5389      18.0855      16.6192      17.0257
510028............................       0.9965       0.8274      24.6544      23.0518      21.7134      23.1596
510029............................       1.2527       0.8429      19.8202      21.7527      22.0060      21.2311
510030............................       1.1843       0.8332      19.8220      22.3658      21.5583      21.2766
510031............................       1.3895       0.8429      20.5743      21.6294      21.7637      21.3498
510033............................       1.3921       0.8303      19.6921      21.0707      23.0305      21.2329
510038............................       1.0245       0.7742      16.1016      16.8744      17.2832      16.7659
510039............................       1.2658       0.7742      17.6173      19.1280      19.5468      18.7692
510043............................       0.8986       0.7742      15.5857      16.0586            *      15.8328
510046............................       1.2834       0.8274      19.2802      21.2792      21.2540      20.5978
510047............................       1.1340       0.8840      22.1953      23.2093      24.0954      23.1668
510048............................       1.1071       0.7742      16.3761      17.6785      17.5096      17.1529
510050............................       1.5329       0.7742      18.9990      20.1943      19.9766      19.7250
510053............................       1.1350       0.7742      18.1054      20.7538      20.8609      19.9625
510055............................       1.4505       0.9482      27.7422      29.3962      30.7868      29.3287
510058............................       1.2970       0.8303      20.1104      21.9352      22.6976      21.6021
510059............................       0.6811       0.8429      18.1543      18.8712      21.9550      19.5138
510061............................       0.9818       0.9310      14.8848      15.3355            *      15.1074

[[Page 23542]]

 
510062............................       1.1655       0.7742      21.3405      21.1568      23.3216      21.9387
510067............................       1.1669       0.7742      18.0113      22.1582      21.2099      20.4433
510068............................       1.1126       1.0935      19.9056      20.0007      23.1011      21.0310
510070............................       1.1882       0.8274      20.0974      21.1895      23.2382      21.5724
510071............................       1.2853       0.8274      19.4029      21.5439      23.1685      21.4107
510072............................       1.0629       0.7742      18.4566      19.7990      20.1997      19.5568
510077............................       1.1621       0.9119      20.9153      22.8104      23.6585      22.4770
510082............................       1.1043       0.7742      17.2891      16.4742      19.1878      17.5963
510085............................       1.2020       0.8429      20.6364      22.6563      23.7173      22.3503
510086............................       1.0874       0.7742      16.3051      17.8234      17.5933      17.2267
510088............................       0.9820       0.7742      16.4373      18.3401            *      17.3534
510089............................          ***            *            *            *      27.7062      27.7062
520002............................       1.2821       0.9964      22.0838      23.7316      24.9950      23.6544
520003............................       1.1724       0.9478      20.4234      21.8662            *      21.1608
520004............................       1.3395       0.9557      22.8530      24.4711      25.4639      24.2888
520008............................       1.5856       1.0111      26.0931      27.8127      29.8354      27.9737
520009............................       1.6869       0.9478      21.5169      23.4265      26.1503      23.6455
520010............................       1.1228       1.1055      26.3965      28.5569      29.2491      28.0349
520011............................       1.2647       0.9478      22.7880      23.7785      25.2747      23.9992
520013............................       1.3725       0.9478      23.1173      24.4766      26.6225      24.8211
520014............................       1.0762       1.0629      20.4281      22.1064            *      21.2683
520015............................       1.1411        .9478      22.8094      23.0403            *      22.9239
520017............................       1.1442       0.9478      21.7542      23.4044      24.6676      23.3009
520019............................       1.2709       0.9478      22.6895      24.9871      25.0377      24.2463
520021............................       1.3765       1.0698      24.1284      25.4872      26.6935      25.4468
520024............................       1.0697       0.9478      17.5368      18.5072            *      18.0423
520026............................       1.0913       1.1055      25.0504      26.1056            *      25.6168
520027............................       1.2710       1.0111      22.2089      26.2516      27.5490      25.5645
520028............................       1.2544       1.0416      24.3592      25.7778      25.4164      25.1844
520030............................       1.7713       0.9964      23.9474      25.3807      27.0185      25.5053
520032............................       1.1260       1.0629      22.7220      25.3059      25.3696      24.4819
520033............................       1.3031       0.9478      22.2650      23.9791      24.6125      23.6548
520034............................       1.1362       0.9478      22.6160      23.6563      23.9850      23.4634
520035............................       1.2757       0.9478      20.8563      23.2625      24.7767      23.0160
520037............................       1.7957       0.9964      25.0587      28.6984      29.7234      27.8508
520038............................       1.2023       1.0111      23.1036      24.6650      26.6470      24.8476
520040............................       1.3551       1.0111      21.5671      23.8501      25.1096      23.5636
520041............................       1.1069       1.0629      22.6216      22.8236      22.7596      22.7396
520042............................       1.0666       0.9478      21.9935      24.0788      23.6326      23.2471
520044............................       1.3206       0.9478      22.7627      24.9387      26.0191      24.5777
520045............................       1.4958       0.9478      24.1624      24.5844      26.0030      24.9427
520047............................       0.9463       0.9478      22.5686      25.5346            *      24.0011
520048............................       1.6494       0.9478      20.5069      23.1653      25.1724      22.8848
520049............................       2.1923       0.9478      22.7424      24.1083      25.9256      24.2130
520051............................       1.6606       1.0111      27.6695      28.8249      28.3040      28.2799
520057............................       1.1487       0.9478      21.2729      23.3205      25.3745      23.3399
520058............................          ***       1.0224      23.2907            *            *      23.2907
520060............................       1.3001       0.9478      21.1271      22.0132      23.8817      22.3382
520062............................       1.2975       1.0111      23.7166      24.9988      28.2215      25.7059
520063............................       1.1228       1.0111      23.3037      25.3674      27.4101      25.4095
520064............................       1.4701       1.0111      24.3043      27.1120      28.6101      26.6968
520066............................       1.5188       1.0416      23.9212      25.8812      27.1657      25.6782
520068............................       0.8883       0.9478      21.4413      23.4746      24.8184      23.2981
520069............................          ***            *      32.6484            *            *      32.6484
520071............................       1.2141       0.9957      23.4832      26.3154      27.6202      25.7950
520075............................       1.5364       0.9478      23.7322      26.0600      27.1699      25.6758
520076............................       1.1767       1.0416      22.2993      24.0879      26.1698      24.2625
520078............................       1.4830       1.0111      23.4414      25.7662      27.5989      25.6772
520083............................       1.7454       1.0629      25.7108      27.0012      28.8407      27.2481
520084............................       1.0616       1.0629      24.7909      25.5777            *      25.1765
520087............................       1.6953       0.9557      22.8974      24.5280      27.3374      24.8782
520088............................       1.3362       0.9957      23.8938      26.0882      26.9936      25.7252
520089............................       1.5475       1.0629      24.4435      26.6013      30.0448      27.0527
520091............................       1.2659       0.9478      22.8914      24.8269      24.6320      24.0764
520092............................       1.0263       0.9478      21.8662      23.4043            *      22.6433
520094............................          ***       0.9957      22.3925      25.3166      25.7567      24.5483
520095............................       1.2045       1.0416      25.1402      28.6376      26.7863      26.8360

[[Page 23543]]

 
520096............................       1.3205       0.9957      21.1759      22.9929      24.5758      22.9775
520097............................       1.3919       0.9478      23.6512      25.1135      26.3321      25.1104
520098............................       2.0001       1.0629      25.8184      28.0730      30.6150      28.2679
520100............................       1.2767       0.9561      21.7072      24.5914      26.2161      24.1896
520102............................       1.0905       0.9957      23.7739      25.6146      26.8234      25.4621
520103............................       1.6066       1.0111      23.5984      25.5361      27.9147      25.8275
520107............................       1.2224       0.9478      25.7379      27.7413      28.3431      27.2253
520109............................       1.0371       0.9478      20.6357      22.4048      24.9379      22.6443
520111............................          ***            *      26.9666      26.3095            *      26.6016
520112............................       1.1078       0.9478      19.1409      20.4034            *      19.7623
520113............................       1.2717       0.9478      24.0822      26.7926      27.4135      26.1479
520114............................       1.1620       0.9478      21.9847      22.0536            *      22.0194
520116............................       1.2099       0.9957      23.9066      26.3057      26.9902      25.8557
520117............................       1.0283       0.9478      21.9915      22.0023            *      21.9973
520123............................       1.0715       1.1055      21.2360      22.2430            *      21.7461
520130............................          ***       0.9478      20.0277            *            *      20.0277
520134............................          ***       0.9478      20.8502            *            *      20.8502
520136............................       1.6003       1.0111      23.2573      25.5145      27.7703      25.5032
520138............................       1.8350       1.0111      25.1434      26.9047      28.4394      26.8513
520139............................       1.2505       1.0111      23.7727      25.4424      26.5110      25.3279
520140............................       1.6615       1.0111      23.9176      26.1616      28.3001      26.0657
520145............................          ***            *      25.0770            *            *      25.0770
520151............................       1.0251       0.9478      20.1995      22.9592            *      21.5728
520152............................       1.0564       0.9478      22.5440      23.2493      24.9392      23.6620
520154............................       1.1733       0.9478      23.2635      23.7160            *      23.4910
520156............................       1.0529       1.1055      23.7157      24.9258            *      24.3330
520160............................       1.8094       0.9478      22.9475      24.3528      25.7588      24.4208
520161............................       0.9206       0.9478      22.1857      24.0673            *      23.1340
520170............................       1.2905       1.0111      25.5470      25.6124      27.2221      26.1781
520173............................       1.0948       1.0224      24.4723      26.2224      28.0995      26.3133
520177............................       1.6337       1.0111      27.5560      28.4663      30.7317      29.0456
520178............................       0.9691       0.9478      22.3193      23.0419      20.2666      21.8785
520189............................       1.1063       1.0698      23.1658      26.3172      28.4720      26.3169
520192............................          ***            *      22.5641            *            *      22.5641
520194............................       1.5971            *            *            *      24.9408      24.9408
520195............................       0.3562       1.0111            *            *      36.6973      36.6973
520196............................       1.5022       0.9478            *            *      35.1043      35.1043
530002............................       1.1527       0.9207      23.8852      25.2983      26.8356      25.4030
530004............................          ***            *      19.7857            *            *      19.7857
530007............................       1.2447       0.9207      22.3309      19.3476      20.4391      20.6774
530008 \2\........................       1.2307       0.9207      21.8714      23.8271      23.8589      23.1777
530009............................       0.9699       0.9207      22.0450      24.2426      26.8316      24.1997
530010 \2\........................       1.2457       0.9207      21.4890      23.9255      25.8482      23.7290
530011............................       1.0112       0.9207      22.5720      24.1396      24.8245      23.8464
530012............................       1.6902       0.9207      22.4716      24.3454      25.2526      24.0014
530014............................       1.6077       0.9207      21.7314      23.6907      24.5947      23.3995
530015............................       1.2773       0.9207      25.3915      26.3107      27.6876      26.4934
530016............................       1.3351       0.9207      21.0666      21.6575            *      21.3685
530017............................       0.9556       0.9207      19.5630      23.5415      25.3362      22.8987
530023............................       1.1558       0.9207      22.5535      24.1493      21.3813      22.6451
530025............................       1.2781       1.0146      25.4693      27.7988      28.6938      27.3568
530026............................          ***       0.9207      21.0732            *            *      21.0732
530031............................       0.9546       0.9207      16.8825      16.3472            *      16.6017
530032............................       1.0215       0.9207      19.4449      22.6584      22.9391     21.6640
----------------------------------------------------------------------------------------------------------------
\1\ Based on salaries adjusted for occupational mix, according to the calculation in section III.C.2. of the
  preamble to this proposed rule.
\2\ These hospitals are assigned a wage index value according to section III.H. of the preamble of this proposed
  rule.
h These hospitals are assigned a wage index value according to section III.G. of the preamble to this proposed
  rule.
*Denotes wage data not available for the provider for that year.
**Based on the sum of the salaries and hours computed for Federal FYs 2004, 2005, and 2006.
***Denotes MedPAR data not available for the provider for FY 2004.


[[Page 23544]]


  Table 3A.--FY 2006 and 3-Year* Average Hourly Wage for Urban Areas by
                                  CBSA
[*Based on the sum of the salaries and hours computed for Federal fiscal
                       years 2004, 2005, and 2006]
------------------------------------------------------------------------
                                                  FY 2006       3-Year
     CBSA code               Urban area           average      average
                                                hourly wage  hourly wage
------------------------------------------------------------------------
10180..............  Abilene, TX..............      22.1701      20.4985
10380..............  Aguadilla-Isabela-San          13.2502      11.5908
                      Sebastin, PR.
10420..............  Akron, OH................      25.1189      23.9584
10500..............  Albany, GA...............      24.1844      26.6216
10580..............  Albany-Schenectady-Troy,       23.9528      22.6259
                      NY.
10740..............  Albuquerque, NM..........      27.1248      25.7999
10780..............  Alexandria, LA...........      22.5148      21.3129
10900..............  Allentown-Bethlehem-           27.5389      25.5680
                      Easton, PA-NJ.
11020..............  Altoona, PA..............      25.0167      22.9759
11100..............  Amarillo, TX.............      25.6410      24.0270
11180..............  Ames, IA.................      26.7068      25.0247
11260..............  Anchorage, AK............      33.8779      32.1826
11300..............  Anderson, IN.............      24.1549      23.0714
11340..............  Anderson, SC.............      24.8624      22.9488
11460..............  Ann Arbor, MI............      30.4505      29.2076
11500..............  Anniston-Oxford, AL......      21.4718      20.7611
11540..............  Appleton, WI.............      25.9098      24.1044
11700..............  Asheville, NC............      26.0511      24.5466
12020..............  Athens-Clarke County, GA.      27.4532      26.1928
12060..............  Atlanta-Sandy Springs-         26.9604      26.0983
                      Marietta, GA.
12100..............  Atlantic City, NJ........      32.5013      29.4922
12220..............  Auburn-Opelika, AL.......      22.6976      21.8061
12260..............  Augusta-Richmond County,       26.7647      24.8652
                      GA-SC.
12420..............  Austin-Round Rock, TX....      26.4408      25.2181
12540..............  Bakersfield, CA..........      28.9777      26.6414
12580..............  Baltimore-Towson, MD.....      27.6740      26.1267
12620..............  Bangor, ME...............      27.9343      26.2399
12700..............  Barnstable Town, MA......      35.0207      33.2353
12940..............  Baton Rouge, LA..........      24.0727      22.2239
12980..............  Battle Creek, MI.........      26.5543      24.8160
13020..............  Bay City, MI.............      26.1760      25.1852
13140..............  Beaumont-Port Arthur, TX.      23.5603      22.3855
13380..............  Bellingham, WA...........      32.7446      30.8324
13460..............  Bend, OR.................      30.1666      28.0136
13644..............  Bethesda-Frederick-            32.0917      29.4434
                      Gaithersburg, MD.
13740..............  Billings, MT.............      24.7710      23.5742
13780..............  Binghamton, NY...........      24.0264      22.4051
13820..............  Birmingham-Hoover, AL....      25.1185      23.9577
13900..............  Bismarck, ND.............      21.0353      20.1696
13980..............  Blacksburg-Christiansburg-     22.3143      21.3890
                      Radford, VA.
14020..............  Bloomington, IN..........      23.7061      22.5941
14060..............  Bloomington-Normal, IL...      25.4101      23.7897
14260..............  Boise City-Nampa, ID.....      25.3133      24.3052
14484..............  Boston-Quincy, MA........      32.2755      30.7174
14500..............  Boulder, CO..............      27.2574      26.2715
14540..............  Bowling Green, KY........      23.0011      21.8437
14740..............  Bremerton-Silverdale, WA.      29.8809      28.0919
14860..............  Bridgeport-Stamford-           35.2686      33.7851
                      Norwalk, CT.
15180..............  Brownsville-Harlingen, TX      27.5656      26.6683
15260..............  Brunswick, GA............      26.1311      28.6493
15380..............  Buffalo-Niagara Falls, NY      24.8634      24.3177
15500..............  Burlington, NC...........      24.9033      23.6142
15540..............  Burlington-South               26.4165      25.0134
                      Burlington, VT.
15764..............  Cambridge-Newton-              30.9921      29.2429
                      Framingham, MA.
15804..............  Camden, NJ...............      29.4132      28.1192
15940..............  Canton-Massillon, OH.....      25.0564      23.6833
15980..............  Cape Coral-Fort Myers, FL      26.1095      25.0250
16180..............  Carson City, NV..........      28.6158      27.0192
16220..............  Casper, WY...............      25.2526      24.0014
16300..............  Cedar Rapids, IA.........      24.0727      23.2382
16580..............  Champaign-Urbana, IL.....      26.8325      25.4853
16620..............  Charleston, WV...........      23.5802      22.9895
16700..............  Charleston-North               26.3883      24.7642
                      Charleston, SC.
16740..............  Charlotte-Gastonia-            27.1825      25.6465
                      Concord, NC-SC.
16820..............  Charlottesville, VA......      28.6200      26.8014
16860..............  Chattanooga, TN-GA.......      25.4537      24.0895
16940..............  Cheyenne, WY.............      24.5947      23.3995
16974..............  Chicago-Naperville-            30.3410      28.6963
                      Joliet, IL.
17020..............  Chico, CA................      29.4447      27.4655

[[Page 23545]]

 
17140..............  Cincinnati-Middletown, OH-     26.8669      25.0229
                      KY-IN.
17300..............  Clarksville, TN-KY.......      23.1419      21.5444
17420..............  Cleveland, TN............      22.8278      21.2133
17460..............  Cleveland-Elyria-Mentor,       25.7303      25.0687
                      OH.
17660..............  Coeur d'Alene, ID........      26.9749      25.1364
17780..............  College Station-Bryan, TX      24.9298      23.8550
17820..............  Colorado Springs, CO.....      26.4562      25.5825
17860..............  Columbia, MO.............      23.3470      22.3003
17900..............  Columbia, SC.............      25.3362      24.0049
17980..............  Columbus, GA-AL..........      23.9764      22.7919
18020..............  Columbus, IN.............      26.8458      25.0573
18140..............  Columbus, OH.............      27.5495      25.7193
18580..............  Corpus Christi, TX.......      23.9399      22.6210
18700..............  Corvallis, OR............      29.9648      28.7806
19060..............  Cumberland, MD-WV........      26.0448      22.8828
19124..............  Dallas-Plano-Irving, TX..      28.6076      26.7125
19140..............  Dalton, GA...............      25.2695      24.8431
19180..............  Danville, IL.............      25.3127      22.9099
19260..............  Danville, VA.............      23.8191      23.0000
19340..............  Davenport-Moline-Rock          24.3842      23.2403
                      Island, IA-IL.
19380..............  Dayton, OH...............      25.3708      24.4405
19460..............  Decatur, AL..............      23.7138      22.9734
19500..............  Decatur, IL..............      22.5852      21.4281
19660..............  Deltona-Daytona Beach-         26.0379      24.0560
                      Ormond Beach, FL.
19740..............  Denver-Aurora, CO........      29.9610      28.5110
19780..............  Des Moines, IA...........      26.9975      24.6647
19804..............  Detroit-Livonia-Dearborn,      29.2431      27.2952
                      MI.
20020..............  Dothan, AL...............      21.6602      20.2540
20100..............  Dover, DE................      27.4735      25.9428
20220..............  Dubuque, IA..............      25.5030      23.5042
20260..............  Duluth, MN-WI............      28.5299      27.0543
20500..............  Durham, NC...............      28.7033      27.3555
20740..............  Eau Claire, WI...........      25.7563      24.1573
20764..............  Edison, NJ...............      31.5082      29.5433
20940..............  El Centro, CA............      25.1083      23.7136
21060..............  Elizabethtown, KY........      24.6642      22.6125
21140..............  Elkhart-Goshen, IN.......      26.9005      25.1975
21300..............  Elmira, NY...............      23.1540      22.0419
21340..............  El Paso, TX..............      25.0500      23.9275
21500..............  Erie, PA.................      24.4677      22.8915
21604..............  Essex County, MA.........      29.4434      27.9641
21660..............  Eugene-Springfield, OR...      30.2425      29.2693
21780..............  Evansville, IN-KY........      24.4379      22.4627
21820..............  Fairbanks, AK............      31.8995      29.8198
21940..............  Fajardo, PR..............      11.6386      10.6772
22020..............  Fargo, ND-MN.............      23.7360      23.9742
22140..............  Farmington, NM...........      23.8264      22.4376
22180..............  Fayetteville, NC.........      26.3708      24.3719
22220..............  Fayetteville-Springdale-       24.0127      22.5998
                      Rogers, AR-MO.
22380..............  Flagstaff, AZ............      33.8333      30.2808
22420..............  Flint, MI................      29.7989      28.6871
22500..............  Florence, SC.............      25.1444      23.2705
22520..............  Florence-Muscle Shoals,        23.2344      21.0532
                      AL.
22540..............  Fond du Lac, WI..........      26.9936      25.7252
22660..............  Fort Collins-Loveland, CO      28.2568      26.7964
22744..............  Fort Lauderdale-Pompano        29.1773      27.0873
                      Beach-Deerfield Beach,
                      FL.
22900..............  Fort Smith, AR-OK........      23.0272      21.9069
23020..............  Fort Walton Beach-             24.8333      23.4332
                      Crestview-Destin, FL.
23060..............  Fort Wayne, IN...........      27.4082      25.7154
23104..............  Fort Worth-Arlington, TX.      26.6167      24.9487
23420..............  Fresno, CA...............      29.6215      27.6921
23460..............  Gadsden, AL..............      22.3074      21.3197
23540..............  Gainesville, FL..........      26.4676      25.1553
23580..............  Gainesville, GA..........      24.8893      24.3542
23844..............  Gary, IN.................      26.2014      24.6755
24020..............  Glens Falls, NY..........      24.0232      22.4577
24140..............  Goldsboro, NC............      24.5666      23.0280
24220..............  Grand Forks, ND-MN.......      32.2306      26.3170
24300..............  Grand Junction, CO.......      26.8293      25.6655

[[Page 23546]]

 
24340..............  Grand Rapids-Wyoming, MI.      26.2918      24.9274
24500..............  Great Falls, MT..........      25.2873      23.4084
24540..............  Greeley, CO..............      26.8470      25.0779
24580..............  Green Bay, WI............      26.4060      25.1220
24660..............  Greensboro-High Point, NC      25.5495      24.2161
24780..............  Greenville, NC...........      26.3325      24.3631
24860..............  Greenville, SC...........      28.3616      25.8028
25020..............  Guayama, PR..............      08.9125      09.5939
25060..............  Gulfport-Biloxi, MS......      24.9592      23.9056
25180..............  Hagerstown-Martinsburg,        26.6548      25.0347
                      MD-WV.
25260..............  Hanford-Corcoran, CA.....      28.1814      25.1270
25420..............  Harrisburg-Carlisle, PA..      26.0656      24.4935
25500..............  Harrisonburg, VA.........      25.4597      24.2345
25540..............  Hartford-West Hartford-        31.0121      29.5959
                      East Hartford, CT.
25620..............  Hattiesburg, MS..........      21.3089      19.6542
25860..............  Hickory-Lenoir-Morganton,      24.9837      24.3032
                      NC.
25980..............  \1\Hinesville-Fort            .-------     .-------
                      Stewart, GA.
26100..............  Holland-Grand Haven, MI..      25.4579      24.5609
26180..............  Honolulu, HI.............      31.3501      29.2509
26300..............  Hot Springs, AR..........      25.3627      24.1181
26380..............  Houma-Bayou Cane-              22.1079      20.5356
                      Thibodaux, LA.
26420..............  Houston-Baytown-Sugar          27.9993      26.1356
                      Land, TX.
26580..............  Huntington-Ashland, WV-KY-     26.5266      25.2510
                      OH.
26620..............  Huntsville, AL...........      25.5254      23.9276
26820..............  Idaho Falls, ID..........      26.3236      24.2135
26900..............  Indianapolis, IN.........      27.7571      26.3923
26980..............  Iowa City, IA............      27.2791      25.4755
27060..............  Ithaca, NY...............      27.5699      25.6624
27100..............  Jackson, MI..............      26.0171      24.0809
27140..............  Jackson, MS..............      23.2553      21.9059
27180..............  Jackson, TN..............      25.0772      23.6035
27260..............  Jacksonville, FL.........      26.0254      24.9544
27340..............  Jacksonville, NC.........      23.0236      22.0702
27500..............  Janesville, WI...........      26.7462      25.0136
27620..............  Jefferson City, MO.......      23.4699      22.4350
27740..............  Johnson City, TN.........      22.2633      21.2152
27780..............  Johnstown, PA............      23.3540      22.1239
27860..............  Jonesboro, AR............      22.2913      21.0721
27900..............  Joplin, MO...............      24.0416      22.8597
28020..............  Kalamazoo-Portage, MI....      29.1036      28.0902
28100..............  Kankakee-Bradley, IL.....      30.7469      28.2579
28140..............  Kansas City, MO-KS.......      26.4479      25.2795
28420..............  Kennewick-Richland-Pasco,      29.7070      27.8472
                      WA.
28660..............  Killeen-Temple-Fort Hood,      23.9626      23.6807
                      TX.
28700..............  Kingsport-Bristol-             22.5380      21.6656
                      Bristol, TN-VA.
28740..............  Kingston, NY.............      25.9063      24.4214
28940..............  Knoxville, TN............      23.6960      22.7400
29020..............  Kokomo, IN...............      26.7312      24.3627
29100..............  La Crosse, WI-MN.........      26.7369      24.6616
29140..............  Lafayette, IN............      24.4215      23.5470
29180..............  Lafayette, LA............      23.5797      22.0745
29340..............  Lake Charles, LA.........      21.9512      20.7252
29404..............  Lake County-Kenosha            29.2180      27.3940
                      County, IL-WI.
29460..............  Lakeland, FL.............      24.9925      23.4702
29540..............  Lancaster, PA............      27.1801      25.5025
29620..............  Lansing-East Lansing, MI.      27.3767      25.6366
29700..............  Laredo, TX...............      22.6637      21.9619
29740..............  Las Cruces, NM...........      23.6548      22.8284
29820..............  Las Vegas-Paradise, NV...      31.9355      30.3760
29940..............  Lawrence, KS.............      23.8863      22.7099
30020..............  Lawton, OK...............      22.1442      21.4717
30140..............  Lebanon, PA..............      24.2087      23.0471
30300..............  Lewiston, ID-WA..........      27.6345      24.9793
30340..............  Lewiston-Auburn, ME......      26.1064      24.8965
30460..............  Lexington-Fayette, KY....      25.3464      22.7343
30620..............  Lima, OH.................      25.7797      24.7454
30700..............  Lincoln, NE..............      28.5262      27.0530
30780..............  Little Rock-North Little       24.5286      23.3089
                      Rock, AR.
30860..............  Logan, UT-ID.............      25.6905      24.3475

[[Page 23547]]

 
30980..............  Longview, TX.............      24.4521      23.4643
31020..............  Longview, WA.............      26.5976      26.1814
31084..............  Los Angeles-Long Beach-        32.9050      31.0454
                      Glendale, CA.
31140..............  Louisville, KY-IN........      25.9154      24.2971
31180..............  Lubbock, TX..............      24.5905      22.7060
31340..............  Lynchburg, VA............      24.3559      23.5846
31420..............  Macon, GA................      26.5343      25.0025
31460..............  Madera, CA...............      24.4061      22.5247
31540..............  Madison, WI..............      29.7363      27.4059
31700..............  Manchester-Nashua, NH....      28.8847      27.6772
31900..............  \1\Mansfield, OH.........      -------      -------
32420..............  Mayag[uuml]ez, PR........      11.2362      11.3917
32580..............  McAllen-Edinburg-Pharr,        25.0238      22.9932
                      TX.
32780..............  Medford, OR..............      28.6299      27.7062
32820..............  Memphis, TN-MS-AR........      26.1471      24.2118
32900..............  Merced, CA...............      31.1184      27.6673
33124..............  Miami-Miami Beach-             27.2942      25.9755
                      Kendall, FL.
33140..............  Michigan City-La Porte,        26.3221      24.7313
                      IN.
33260..............  Midland, TX..............      26.6395      25.3824
33340..............  Milwaukee-Waukesha-West        28.2858      26.5793
                      Allis, WI.
33460..............  Minneapolis-St. Paul-          30.9281      29.1156
                      Bloomington, MN-WI.
33540..............  Missoula, MT.............      26.4227      24.2896
33660..............  Mobile, AL...............      22.1076      20.9624
33700..............  Modesto, CA..............      33.0964      31.0034
33740..............  Monroe, LA...............      22.5035      20.9918
33780..............  Monroe, MI...............      26.4882      25.0486
33860..............  Montgomery, AL...........      24.0586      21.7643
34060..............  Morgantown, WV...........      23.6097      22.7263
34100..............  Morristown, TN...........      24.5017      21.6486
34580..............  Mount Vernon-Anacortes,        29.2146      27.8316
                      WA.
34620..............  Muncie, IN...............      25.0449      23.0977
34740..............  Muskegon-Norton Shores,        27.0713      25.4822
                      MI.
34820..............  Myrtle Beach-Conway-North      24.8106      23.7419
                      Myrtle Beach, SC.
34900..............  Napa, CA.................      35.3683      32.9923
34940..............  Naples-Marco Island, FL..      28.2979      26.9037
34980..............  Nashville-Davidson--           27.2968      26.1014
                      Murfreesboro, TN.
35004..............  Nassau-Suffolk, NY.......      35.7543      34.1418
35084..............  Newark-Union, NJ-PA......      34.1064      31.1564
35300..............  New Haven-Milford, CT....      32.7989      31.1765
35380..............  New Orleans-Metairie-          25.1852      23.9697
                      Kenner, LA.
35644..............  New York-Wayne-White           36.9026      35.2542
                      Plains, NY-NJ.
35660..............  Niles-Benton Harbor, MI..      24.8541      23.3997
35980..............  Norwich-New London, CT...      31.8510      30.4182
36084..............  Oakland-Fremont-Hayward,       42.8742      40.0207
                      CA.
36100..............  Ocala, FL................      25.0519      24.4578
36140..............  Ocean City, NJ...........      30.8612      28.5543
36220..............  Odessa, TX...............      27.6769      25.1761
36260..............  Ogden-Clearfield, UT.....      25.2772      24.5654
36420..............  Oklahoma City, OK........      25.2975      23.7988
36500..............  Olympia, WA..............      30.5859      28.9079
36540..............  Omaha-Council Bluffs, NE-      26.7314      25.5410
                      IA.
36740..............  Orlando, FL..............      26.4250      25.3813
36780..............  Oshkosh-Neenah, WI.......      25.6249      23.9585
36980..............  Owensboro, KY............      24.6348      22.4970
37100..............  Oxnard-Thousand Oaks-          32.4624      29.7410
                      Ventura, CA.
37340..............  Palm Bay-Melbourne-            27.4887      25.7496
                      Titusville, FL.
37460..............  Panama City-Lynn Haven,        22.3439      21.3568
                      FL.
37620..............  Parkersburg-Marietta, WV-      23.2293      21.7277
                      OH.
37700..............  Pascagoula, MS...........      22.8397      21.4591
37860..............  Pensacola-Ferry Pass-          22.6287      22.0289
                      Brent, FL.
37900..............  Peoria, IL...............      24.7421      23.2730
37964..............  Philadelphia, PA.........      30.8573      28.8565
38060..............  Phoenix-Mesa-Scottsdale,       28.3642      26.6530
                      AZ.
38220..............  Pine Bluff, AR...........      24.3824      22.1870
38300..............  Pittsburgh, PA...........      24.7296      23.2597
38340..............  Pittsfield, MA...........      28.4877      27.1701
38540..............  Pocatello, ID............      26.1526      24.5528
38660..............  Ponce, PR................      14.4851      13.0375
38860..............  Portland-South Portland-       29.0440      26.7442
                      Biddeford, ME.

[[Page 23548]]

 
38900..............  Portland-Vancouver-            31.4148      29.7614
                      Beaverton, OR-WA.
38940..............  Port St. Lucie-Fort            28.3669      26.5761
                      Pierce, FL.
39100..............  Poughkeepsie-Newburgh-         30.1207      29.3034
                      Middletown, NY.
39140..............  Prescott, AZ.............      27.6508      26.3318
39300..............  Providence-New Bedford-        30.6398      28.8359
                      Fall River, RI-MA.
39340..............  Provo-Orem, UT...........      26.5574      25.4669
39380..............  Pueblo, CO...............      24.1431      23.0046
39460..............  Punta Gorda, FL..........      25.9442      24.8140
39540..............  Racine, WI...............      25.2201      23.6789
39580..............  Raleigh-Cary, NC.........      27.1623      25.4788
39660..............  Rapid City, SD...........      25.2538      23.5560
39740..............  Reading, PA..............      27.1301      24.7239
39820..............  Redding, CA..............      34.1503      31.2183
39900..............  Reno-Sparks, NV..........      30.7272      28.3079
40060..............  Richmond, VA.............      26.0695      24.6756
40140..............  Riverside-San Bernardino-      30.8328      29.3251
                      Ontario, CA.
40220..............  Roanoke, VA..............      23.4915      22.4289
40340..............  Rochester, MN............      31.1302      30.1737
40380..............  Rochester, NY............      25.5065      24.5493
40420..............  Rockford, IL.............      27.9047      25.7304
40484..............  Rockingham County-             29.0055      27.0997
                      Strafford County, NH.
40580..............  Rocky Mount, NC..........      24.9648      23.6953
40660..............  Rome, GA.................      26.3370      23.8100
40900..............  Sacramento--Arden-Arcade--     36.2362      32.0754
                      Roseville, CA.
40980..............  Saginaw-Saginaw Township       26.5050      25.8822
                      North, MI.
41060..............  St. Cloud, MN............      28.0585      26.3196
41100..............  St. George, UT...........      26.3420      25.1139
41140..............  St. Joseph, MO-KS........      26.7587      25.8174
41180..............  St. Louis, MO-IL.........      25.0452      23.7896
41420..............  Salem, OR................      29.2207      27.6647
41500..............  Salinas, CA..............      39.5570      37.1828
41540..............  Salisbury, MD............      25.3485      24.0517
41620..............  Salt Lake City, UT.......      26.3970      25.4439
41660..............  San Angelo, TX...........      23.1837      21.9567
41700..............  San Antonio, TX..........      25.1428      23.6255
41740..............  San Diego-Carlsbad-San         31.9401      29.8191
                      Marcos, CA.
41780..............  Sandusky, OH.............      25.2690      23.6568
41884..............  San Francisco-San Mateo-       41.8804      38.9640
                      Redwood City, CA.
41900..............  San Germ[aacute]n-Cabo         12.9971      13.4135
                      Rojo, PR.
41940..............  San Jose-Sunnyvale-Santa       42.2833      39.0995
                      Clara, CA.
41980..............  San Juan-Caguas-Guaynabo,      13.1085      12.3738
                      PR.
42020..............  San Luis Obispo-Paso           31.7731      29.7965
                      Robles, CA.
42044..............  Santa Ana-Anaheim-Irvine,      32.3515      30.4088
                      CA.
42060..............  Santa Barbara-Santa Maria-     32.2413      28.8239
                      Goleta, CA.
42100..............  Santa Cruz-Watsonville,        42.4095      37.7929
                      CA.
42140..............  Santa Fe, NM.............      30.5158      28.6521
42220..............  Santa Rosa-Petaluma, CA..      37.7122      34.7294
42260..............  Sarasota-Bradenton-            26.6769      25.5601
                      Venice, FL.
42340..............  Savannah, GA.............      26.5289      24.9832
42540..............  Scranton--Wilkes-Barre,        23.8629      22.4039
                      PA.
42644..............  Seattle-Bellevue-Everett,      32.3774      30.4447
                      WA.
43100..............  Sheboygan, WI............      24.9924      23.3301
43300..............  Sherman-Denison, TX......      26.6281      25.3544
43340..............  Shreveport-Bossier City,       24.5258      23.6868
                      LA.
43580..............  Sioux City, IA-NE-SD.....      26.1843      24.0956
43620..............  Sioux Falls, SD..........      26.9025      25.0103
43780..............  South Bend-Mishawaka, IN-      27.3743      25.4781
                      MI.
43900..............  Spartanburg, SC..........      25.6900      24.5737
44060..............  Spokane, WA..............      30.4868      28.5450
44100..............  Springfield, IL..........      24.8405      23.3039
44140..............  Springfield, MA..........      28.7008      27.2255
44180..............  Springfield, MO..........      23.0819      22.2164
44220..............  Springfield, OH..........      23.4939      22.7752
44300..............  State College, PA........      23.4099      22.4626
44700..............  Stockton, CA.............      31.7047      28.5078
44940..............  Sumter, SC...............      23.4355      22.1331
45060..............  Syracuse, NY.............      26.8425      25.0698
45104..............  Tacoma, WA...............      30.0701      28.9533
45220..............  Tallahassee, FL..........      24.3724      22.7559

[[Page 23549]]

 
45300..............  Tampa-St. Petersburg-          25.8608      24.1485
                      Clearwater, FL.
45460..............  Terre Haute, IN..........      23.2574      22.0638
45500..............  Texarkana, TX-Texarkana,       23.2000      21.8927
                      AR.
45780..............  Toledo, OH...............      26.7822      25.0440
45820..............  Topeka, KS...............      24.9561      23.6665
45940..............  Trenton-Ewing, NJ........      30.3180      27.8778
46060..............  Tucson, AZ...............      25.1965      23.6781
46140..............  Tulsa, OK................      23.2484      22.9280
46220..............  Tuscaloosa, AL...........      24.4051      22.1412
46340..............  Tyler, TX................      26.0797      24.9826
46540..............  Utica-Rome, NY...........      23.2558      21.9605
46660..............  Valdosta, GA.............      24.8233      22.4638
46700..............  Vallejo-Fairfield, CA....      41.6513      38.4022
46940..............  Vero Beach, FL...........      26.4579      25.3120
47020..............  Victoria, TX.............      22.7937      21.7127
47220..............  Vineland-Millville-            27.5232      27.0476
                      Bridgeton, NJ.
47260..............  Virginia Beach-Norfolk-        24.7332      23.2422
                      Newport News, VA-NC.
47300..............  Visalia-Porterville, CA..      28.2676      26.4299
47380..............  Waco, TX.................      23.8678      22.0533
47580..............  Warner Robins, GA........      24.2312      22.6117
47644..............  Warren-Farmington Hills-       27.5791      26.2703
                      Troy, MI.
47894..............  Washington-Arlington-          30.5916      28.8815
                      Alexandria, DC-VA-MD-WV.
47940..............  Waterloo-Cedar Falls, IA.      23.9572      22.5445
48140..............  Wausau, WI...............      27.0185      25.5053
48260..............  Weirton-Steubenville, WV-      21.8793      21.4989
                      OH.
48300..............  Wenatchee, WA............      28.1544      26.5892
48424..............  West Palm Beach-Boca           28.1452      26.6150
                      Raton-Boynton Beach, FL.
48540..............  Wheeling, WV-OH..........      20.0483      19.3905
48620..............  Wichita, KS..............      25.6152      24.4842
48660..............  Wichita Falls, TX........      23.2954      21.9177
48700..............  Williamsport, PA.........      23.4090      21.9892
48864..............  Wilmington, DE-MD-NJ.....      29.4490      28.5184
48900..............  Wilmington, NC...........      26.7996      24.9839
49020..............  Winchester, VA-WV........      28.5744      27.1963
49180..............  Winston-Salem, NC........      25.0655      24.1158
49340..............  Worcester, MA............      30.8969      29.3320
49420..............  Yakima, WA...............      28.4267      27.0960
49500..............  Yauco, PR................      12.3449      12.0750
49620..............  York-Hanover, PA.........      26.3577      24.3575
49660..............  Youngstown-Warren-             24.0832      23.4935
                      Boardman, OH-PA.
49700..............  Yuba City, CA............      30.6351      27.8070
49740..............  Yuma, AZ.................      25.7050     23.8047
------------------------------------------------------------------------
\1\This area has no average hourly wage because there are no IPPS
  hospitals in the area.


  Table 3B.--FY 2006 and 3-Year* Average Hourly Wage for Rural Areas by
                                  CBSA
[*Based on the sum of the salaries and hours computed for Federal fiscal
                       years 2004, 2005, and 2006]
------------------------------------------------------------------------
                                                                3-Year
                                                  FY 2006      Average
     CBSA  code            Nonurban area          average       Hourly
                                                hourly wage      Wage
------------------------------------------------------------------------
01.................  Alabama..................      20.9677      19.9301
02.................  Alaska...................      33.5065      31.4748
03.................  Arizona..................      24.5771      23.5781
04.................  Arkansas.................      20.9189      19.6660
05.................  California...............      30.3466      27.6453
06.................  Colorado.................      26.2370      24.6175
07.................  Connecticut..............      32.9843      31.5388
08.................  Delaware.................      26.8747      25.1962
10.................  Florida..................      24.0946      22.8362
11.................  Georgia..................      21.4961      20.5018
12.................  Hawaii...................      29.6476      27.4203
13.................  Idaho....................      22.5556      21.6678
14.................  Illinois.................      23.1784      21.8542
15.................  Indiana..................      24.1494      22.9960
16.................  Iowa.....................      23.7869      22.2470
17.................  Kansas...................      22.3594      21.2491

[[Page 23550]]

 
18.................  Kentucky.................      21.7864      20.6370
19.................  Louisiana................      20.8290      19.5920
20.................  Maine....................      24.7292      23.4474
21.................  Maryland.................      25.4559      24.0971
22.................  Massachusetts \1\........  ...........  ...........
23.................  Michigan.................      24.8226      23.3712
24.................  Minnesota................      25.6894      24.4485
25.................  Mississippi..............      21.5005      20.3551
26.................  Missouri.................      22.1717      20.6813
27.................  Montana..................      24.6808      23.0871
28.................  Nebraska.................      24.2446      23.3257
29.................  Nevada...................      25.3983      24.4345
30.................  New Hampshire............      29.8455      26.8676
31.................  New Jersey \1\...........  ...........  ...........
32.................  New Mexico...............      24.1961      22.4946
33.................  New York.................      22.8600      21.6353
34.................  North Carolina...........      23.9761      22.5825
35.................  North Dakota.............      20.3602      20.0510
36.................  Ohio.....................      24.5857      23.0443
37.................  Oklahoma.................      21.2973      20.1660
38.................  Oregon...................      27.4748      25.9138
39.................  Pennsylvania.............      23.2205      21.9390
40.................  Puerto Rico \1\..........  ...........  ...........
41.................  Rhode Island \1\.........  ...........  ...........
42.................  South Carolina...........      24.2359      22.7771
43.................  South Dakota.............      23.7080      21.9887
44.................  Tennessee................      22.1430      20.8103
45.................  Texas....................      22.4855      21.0274
46.................  Utah.....................      22.7561      21.7771
47.................  Vermont..................      27.4761      24.9413
49.................  Virginia.................      22.4489      21.2273
50.................  Washington...............      29.2600      27.4343
51.................  West Virginia............      21.6576      20.5854
52.................  Wisconsin................      26.5156      24.7363
53.................  Wyoming..................      25.7561     24.1767
------------------------------------------------------------------------
\1\ All counties within the State or territory are classified as urban.


Table 4A.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
                           Urban Areas by CBSA
------------------------------------------------------------------------
                         Urban area (constituent       Wage
      CBSA code                 counties)             index       GAF
------------------------------------------------------------------------
10180................  \2\ Abilene, TX............     0.8038     0.8611
                         Callahan County, TX
                         Jones County, TX
                         Taylor County, TX
10380................  Aguadilla-Isabela-San           0.4736     0.5994
                        Sebastian, PR.
                         Aguada Municipio, PR
                         Aguadilla Municipio, PR
                         Anasco Municipio, PR
                         Isabela Municipio, PR
                         Lares Municipio, PR
                         Moca Municipio, PR
                         Rincon Municipio, PR
                         San Sebastian Municipio,
                       PR
10420................  Akron, OH..................     0.8979     0.9289
                         Portage County, OH
                         Summit County, OH
10500................  Albany, GA.................     0.8645     0.9051
                         Baker County, GA
                         Dougherty County, GA
                         Lee County, GA
                         Terrell County, GA
                         Worth County, GA
10580................  Albany-Schenectady-Troy, NY     0.8565     0.8994
                         Albany County, NY
                         Rensselaer County, NY

[[Page 23551]]

 
                         Saratoga County, NY
                         Schenectady County, NY
                         Schoharie County, NY
10740................  Albuquerque, NM............     0.9696     0.9791
                         Bernalillo County, NM
                         Sandoval County, NM
                         Torrance County, NM
                         Valencia County, NM
10780................  Alexandria, LA.............     0.8048     0.8618
                         Grant Parish, LA
                         Rapides Parish, LA
10900................  Allentown-Bethlehem-Easton,     0.9844     0.9893
                        PA-NJ (PA Hospitals).
                         Warren County, NJ
                         Carbon County, PA
                         Lehigh County, PA
                         Northampton County, PA
10900................  \2\ Allentown-Bethlehem-        1.0607     1.0412
                        Easton, PA-NJ (NJ
                        Hospitals).
                         Warren County, NJ
                         Carbon County, PA
                         Lehigh County, PA
                         Northampton County, PA
11020................  Altoona, PA................     0.8942     0.9263
                         Blair County, PA
11100................  Amarillo, TX...............     0.9165     0.9420
                         Armstrong County, TX
                         Carson County, TX
                         Potter County, TX
                         Randall County, TX
11180................  Ames, IA...................     0.9546     0.9687
                         Story County, IA
11260................  Anchorage, AK..............     1.2110     1.1401
                         Anchorage Municipality,
                       AK
                         Matanuska-Susitna
                       Borough, AK
11300................  Anderson, IN...............     0.8634     0.9043
                         Madison County, IN
11340................  Anderson, SC...............     0.8887     0.9224
                         Anderson County, SC
11460................  Ann Arbor, MI..............     1.0885     1.0598
                         Washtenaw County, MI
11500................  Anniston-Oxford, AL........     0.7702     0.8363
                         Calhoun County, AL
11540................  \2\Appleton, WI............     0.9478     0.9640
                         Calumet County, WI
                         Outagamie County, WI
11700................  Asheville, NC..............     0.9312     0.9524
                         Buncombe County, NC
                         Haywood County, NC
                         Henderson County, NC
                         Madison County, NC
12020................  Athens-Clarke County, GA...     0.9813     0.9872
                         Clarke County, GA
                         Madison County, GA
                         Oconee County, GA
                         Oglethorpe County, GA
12060................  \1\ Atlanta-Sandy Springs-      0.9637     0.9750
                        Marietta, GA.
                         Barrow County, GA
                         Bartow County, GA
                         Butts County, GA
                         Carroll County, GA
                         Cherokee County, GA
                         Clayton County, GA
                         Cobb County, GA
                         Coweta County, GA
                         Dawson County, GA
                         DeKalb County, GA
                         Douglas County, GA
                         Fayette County, GA
                         Forsyth County, GA
                         Fulton County, GA
                         Gwinnett County, GA

[[Page 23552]]

 
                         Haralson County, GA
                         Heard County, GA
                         Henry County, GA
                         Jasper County, GA
                         Lamar County, GA
                         Meriwether County, GA
                         Newton County, GA
                         Paulding County, GA
                         Pickens County, GA
                         Pike County, GA
                         Rockdale County, GA
                         Spalding County, GA
                         Walton County, GA
12100................  Atlantic City, NJ..........     1.1618     1.1082
                         Atlantic County, NJ
12220................  Auburn-Opelika, AL.........     0.8113     0.8666
                         Lee County, AL
12260................  Augusta-Richmond County, GA-    0.9567     0.9701
                        SC.
                         Burke County, GA
                         Columbia County, GA
                         McDuffie County, GA
                         Richmond County, GA
                         Aiken County, SC
                         Edgefield County, SC
12420................  \1\Austin-Round Rock, TX...     0.9451     0.9621
                         Bastrop County, TX
                         Caldwell County, TX
                         Hays County, TX
                         Travis County, TX
                         Williamson County, TX
12540................  \2\ Bakersfield, CA........     1.0848     1.0573
                         Kern County, CA
12580................  \1\ Baltimore-Towson, MD...     0.9892     0.9926
                         Anne Arundel County, MD
                         Baltimore County, MD
                         Carroll County, MD
                         Harford County, MD
                         Howard County, MD
                         Queen Anne's County, MD
                         Baltimore City, MD
12620................  Bangor, ME.................     0.9985     0.9990
                         Penobscot County, ME
12700................  Barnstable Town, MA........     1.2518     1.1663
                         Barnstable County, MA
12940................  Baton Rouge, LA............     0.8605     0.9022
                         Ascension Parish, LA
                         East Baton Rouge Parish,
                       LA
                         East Feliciana Parish, LA
                         Iberville Parish, LA
                         Livingston Parish, LA
                         Pointe Coupee Parish, LA
                         St. Helena Parish, LA
                         West Baton Rouge Parish,
                       LA
                         West Feliciana Parish, LA
12980................  Battle Creek, MI...........     0.9492     0.9649
                         Calhoun County, MI
13020................  Bay City, MI...............     0.9535     0.9679
                         Bay County, MI
13140................  Beaumont-Port Arthur, TX...     0.8422     0.8890
                         Hardin County, TX
                         Jefferson County, TX
                         Orange County, TX
13380................  Bellingham, WA.............     1.1705     1.1138
                         Whatcom County, WA
13460................  Bend, OR...................     1.0783     1.0530
                         Deschutes County, OR
13644................  \1\ Bethesda-Frederick-         1.1471     1.0985
                        Gaithersburg, MD.
                         Frederick County, MD
                         Montgomery County, MD
13740................  Billings, MT...............     0.8855     0.9201

[[Page 23553]]

 
                         Carbon County, MT
                         Yellowstone County, MT
13780................  Binghamton, NY.............     0.8588     0.9010
                         Broome County, NY
                         Tioga County, NY
13820................  \1\ Birmingham-Hoover, AL..     0.8979     0.9289
                         Bibb County, AL
                         Blount County, AL
                         Chilton County, AL
                         Jefferson County, AL
                         St. Clair County, AL
                         Shelby County, AL
                         Walker County, AL
13900................  Bismarck, ND...............     0.7519     0.8226
                         Burleigh County, ND
                         Morton County, ND
13980................  \2\ Blacksburg-                 0.8024     0.8601
                        Christiansburg-Radford, VA.
                         Giles County, VA
                         Montgomery County, VA
                         Pulaski County, VA
                         Radford City, VA
14020................  \2\ Bloomington, IN........     0.8632     0.9042
                         Greene County, IN
                         Monroe County, IN
                         Owen County, IN
14060................  Bloomington-Normal, IL.....     0.9083     0.9363
                         McLean County, IL
14260................  Boise City-Nampa, ID.......     0.9048     0.9338
                         Ada County, ID
                         Boise County, ID
                         Canyon County, ID
                         Gem County, ID
                         Owyhee County, ID
14484................  \1\ Boston-Quincy, MA......     1.1537     1.1029
                         Norfolk County, MA
                         Plymouth County, MA
                         Suffolk County, MA
14500................  Boulder, CO................     0.9743     0.9823
                         Boulder County, CO
14540................  Bowling Green, KY..........     0.8222     0.8745
                         Edmonson County, KY
                         Warren County, KY
14740................  Bremerton-Silverdale, WA...     1.0681     1.0461
                         Kitsap County, WA
14860................  Bridgeport-Stamford-            1.2607     1.1719
                        Norwalk, CT.
                         Fairfield County, CT
15180................  Brownsville-Harlingen, TX..     0.9853     0.9899
                         Cameron County, TX
15260................  Brunswick, GA..............     0.9341     0.9544
                         Brantley County, GA
                         Glynn County, GA
                         McIntosh County, GA
15380................  \1\ Buffalo-Niagara Falls,      0.8888     0.9224
                        NY.
                         Erie County, NY
                         Niagara County, NY
15500................  Burlington, NC.............     0.8902     0.9234
                         Alamance County, NC
15540................  \2\ Burlington-South            1.0199     1.0136
                        Burlington, VT.
                         Chittenden County, VT
                         Franklin County, VT
                         Grand Isle County, VT
15764................  \1\ Cambridge-Newton-           1.1078     1.0726
                        Framingham, MA.
                         Middlesex County, MA
15804................  \1\ \2\ Camden, NJ.........     1.0607     1.0412
                         Burlington County, NJ
                         Camden County, NJ
                         Gloucester County, NJ
15940................  Canton-Massillon, OH.......     0.8957     0.9273
                         Carroll County, OH
                         Stark County, OH

[[Page 23554]]

 
15980................  Cape Coral-Fort Myers, FL..     0.9333     0.9538
                         Lee County, FL
16180................  Carson City, NV............     1.0229     1.0156
                         Carson City, NV
16220................  \2\ Casper, WY.............     0.9207     0.9450
                         Natrona County, WY
16300................  Cedar Rapids, IA...........     0.8605     0.9022
                         Benton County, IA
                         Jones County, IA
                         Linn County, IA
16580................  Champaign-Urbana, IL.......     0.9591     0.9718
                         Champaign County, IL
                         Ford County, IL
                         Piatt County, IL
16620................  Charleston, WV.............     0.8429     0.8896
                         Boone County, WV
                         Clay County, WV
                         Kanawha County, WV
                         Lincoln County, WV
                         Putnam County, WV
16700................  Charleston-North                0.9433     0.9608
                        Charleston, SC.
                         Berkeley County, SC
                         Charleston County, SC
                         Dorchester County, SC
16740................  \1\ Charlotte-Gastonia-         0.9717     0.9805
                        Concord, NC-SC.
                         Anson County, NC
                         Cabarrus County, NC
                         Gaston County, NC
                         Mecklenburg County, NC
                         Union County, NC
                         York County, SC
16820................  Charlottesville, VA........     1.0230     1.0157
                         Albemarle County, VA
                         Fluvanna County, VA
                         Greene County, VA
                         Nelson County, VA
                         Charlottesville City, VA
16860................  Chattanooga, TN-GA.........     0.9099     0.9374
                         Catoosa County, GA
                         Dade County, GA
                         Walker County, GA
                         Hamilton County, TN
                         Marion County, TN
                         Sequatchie County, TN
16940................  \2\ Cheyenne, WY...........     0.9207     0.9450
                         Laramie County, WY
16974................  \1\ Chicago-Naperville-         1.0846     1.0572
                        Joliet, IL.
                         Cook County, IL
                         DeKalb County, IL
                         DuPage County, IL
                         Grundy County, IL
                         Kane County, IL
                         Kendall County, IL
                         McHenry County, IL
                         Will County, IL
17020................  \2\ Chico, CA..............     1.0848     1.0573
                         Butte County, CA
17140................  \1\ Cincinnati-Middletown,      0.9604     0.9727
                        OH-KY-IN.
                         Dearborn County, IN
                         Franklin County, IN
                         Ohio County, IN
                         Boone County, KY
                         Bracken County, KY
                         Campbell County, KY
                         Gallatin County, KY
                         Grant County, KY
                         Kenton County, KY
                         Pendleton County, KY
                         Brown County, OH
                         Butler County, OH

[[Page 23555]]

 
                         Clermont County, OH
                         Hamilton County, OH
                         Warren County, OH
17300................  Clarksville, TN-KY.........     0.8272     0.8782
                         Christian County, KY
                         Trigg County, KY
                         Montgomery County, TN
                         Stewart County, TN
17420................  Cleveland, TN..............     0.8160     0.8700
                         Bradley County, TN
                         Polk County, TN
17460................  \1\ Cleveland-Elyria-           0.9197     0.9443
                        Mentor, OH.
                         Cuyahoga County, OH
                         Geauga County, OH
                         Lake County, OH
                         Lorain County, OH
                         Medina County, OH
17660................  Coeur d'Alene, ID..........     0.9642     0.9753
                         Kootenai County, ID
17780................  College Station-Bryan, TX..     0.8911     0.9241
                         Brazos County, TX
                         Burleson County, TX
                         Robertson County, TX
17820................  Colorado Springs, CO.......     0.9457     0.9625
                         El Paso County, CO
                         Teller County, CO
17860................  Columbia, MO...............     0.8346     0.8835
                         Boone County, MO
                         Howard County, MO
17900................  Columbia, SC...............     0.9057     0.9344
                         Calhoun County, SC
                         Fairfield County, SC
                         Kershaw County, SC
                         Lexington County, SC
                         Richland County, SC
                         Saluda County, SC
17980................  Columbus, GA-AL............     0.8570     0.8997
                         Russell County, AL
                         Chattahoochee County, GA
                         Harris County, GA
                         Marion County, GA
                         Muscogee County, GA
18020................  Columbus, IN...............     0.9596     0.9722
                         Bartholomew County, IN
18140................  \1\ Columbus, OH...........     0.9848     0.9896
                         Delaware County, OH
                         Fairfield County, OH
                         Franklin County, OH
                         Licking County, OH
                         Madison County, OH
                         Morrow County, OH
                         Pickaway County, OH
                         Union County, OH
18580................  Corpus Christi, TX.........     0.8557     0.8988
                         Aransas County, TX
                         Nueces County, TX
                         San Patricio County, TX
18700................  Corvallis, OR..............     1.0711     1.0482
                         Benton County, OR
19060................  Cumberland, MD-WV..........     0.9310     0.9522
                         Allegany County, MD
                         Mineral County, WV
19124................  \1\ Dallas-Plano-Irving, TX     1.0226     1.0154
                         Collin County, TX
                         Dallas County, TX
                         Delta County, TX
                         Denton County, TX
                         Ellis County, TX
                         Hunt County, TX
                         Kaufman County, TX

[[Page 23556]]

 
                         Rockwall County, TX
19140................  Dalton, GA.................     0.9033     0.9327
                         Murray County, GA
                         Whitfield County, GA
19180................  Danville, IL...............     0.9048     0.9338
                         Vermilion County, IL
19260................  Danville, VA...............     0.8514     0.8957
                         Pittsylvania County, VA
                         Danville City, VA
19340................  Davenport-Moline-Rock           0.8716     0.9102
                        Island, IA-IL.
                         Henry County, IL
                         Mercer County, IL
                         Rock Island County, IL
                         Scott County, IA
19380................  Dayton, OH.................     0.9069     0.9353
                         Greene County, OH
                         Miami County, OH
                         Montgomery County, OH
                         Preble County, OH
19460................  Decatur, AL................     0.8517     0.8959
                         Lawrence County, AL
                         Morgan County, AL
19500................  \2\ Decatur, IL............     0.8285     0.8791
                         Macon County, IL
19660................  Deltona-Daytona Beach-          0.9307     0.9520
                        Ormond Beach, FL.
                         Volusia County, FL
19740................  \1\ Denver-Aurora, CO......     1.0710     1.0481
                         Adams County, CO
                         Arapahoe County, CO
                         Broomfield County, CO
                         Clear Creek County, CO
                         Denver County, CO
                         Douglas County, CO
                         Elbert County, CO
                         Gilpin County, CO
                         Jefferson County, CO
                         Park County, CO
19780................  Des Moines, IA.............     0.9650     0.9759
                         Dallas County, IA
                         Guthrie County, IA
                         Madison County, IA
                         Polk County, IA
                         Warren County, IA
19804................  \1\ Detroit-Livonia-            1.0453     1.0308
                        Dearborn, MI.
                         Wayne County, MI
20020................  Dothan, AL.................     0.7743     0.8393
                         Geneva County, AL
                         Henry County, AL
                         Houston County, AL
20100................  Dover, DE..................     0.9821     0.9877
                         Kent County, DE
20220................  Dubuque, IA................     0.9116     0.9386
                         Dubuque County, IA
20260................  Duluth, MN-WI..............     1.0224     1.0153
                         Carlton County, MN
                         St. Louis County, MN
                         Douglas County, WI
20500................  Durham, NC.................     1.0260     1.0177
                         Chatham County, NC
                         Durham County, NC
                         Orange County, NC
                         Person County, NC
20740................  \2\ Eau Claire, WI.........     0.9478     0.9640
                         Chippewa County, WI
                         Eau Claire County, WI
20764................  \1\ Edison, NJ.............     1.1301     1.0874
                         Middlesex County, NJ
                         Monmouth County, NJ
                         Ocean County, NJ
                         Somerset County, NJ

[[Page 23557]]

 
20940................  \2\ El Centro, CA..........     1.0848     1.0573
                         Imperial County, CA
21060................  Elizabethtown, KY..........     0.8816     0.9173
                         Hardin County, KY
                         Larue County, KY
21140................  Elkhart-Goshen, IN.........     0.9616     0.9735
                         Elkhart County, IN
21300................  Elmira, NY.................     0.8276     0.8785
                         Chemung County, NY
21340................  El Paso, TX................     0.8954     0.9271
                         El Paso County, TX
21500................  Erie, PA...................     0.8746     0.9123
                         Erie County, PA
21604................  Essex County, MA...........     1.0525     1.0357
                         Essex County, MA
21660................  Eugene-Springfield, OR.....     1.0810     1.0548
                         Lane County, OR
21780................  Evansville, IN-KY..........     0.8735     0.9115
                         Gibson County, IN
                         Posey County, IN
                         Vanderburgh County, IN
                         Warrick County, IN
                         Henderson County, KY
                         Webster County, KY
21820................  \2\ Fairbanks, AK..........     1.1977     1.1315
                         Fairbanks North Star
                       Borough, AK
21940................  Fajardo, PR................     0.4160     0.5485
                         Ceiba Municipio, PR
                         Fajardo Municipio, PR
                         Luquillo Municipio, PR
22020................  Fargo, ND-MN (ND Hospitals)     0.8778     0.9146
                         Clay County, MN
                         Cass County, ND
22020................  \2\ Fargo, ND-MN (MN            0.9183     0.9433
                        Hospitals).
                         Clay County, MN
                         Cass County, ND
22140................  \2\ Farmington, NM.........     0.8649     0.9054
                         San Juan County, NM
22180................  Fayetteville, NC...........     0.9426     0.9603
                         Cumberland County, NC
                         Hoke County, NC
22220................  Fayetteville-Springdale-        0.8615     0.9029
                        Rogers, AR-MO.
                         Benton County, AR
                         Madison County, AR
                         Washington County, AR
                         McDonald County, MO
22380................  Flagstaff, AZ..............     1.2094     1.1391
                         Coconino County, AZ
22420................  Flint, MI..................     1.0654     1.0443
                         Genesee County, MI
22500................  Florence, SC...............     0.8988     0.9295
                         Darlington County, SC
                         Florence County, SC
22520................  Florence-Muscle Shoals, AL.     0.8305     0.8806
                         Colbert County, AL
                         Lauderdale County, AL
22540................  Fond du Lac, WI............     0.9649     0.9758
                         Fond du Lac County, WI
22660................  Fort Collins-Loveland, CO..     1.0146     1.0100
                         Larimer County, CO
22744................  \1\ Fort Lauderdale-Pompano     1.0508     1.0345
                        Beach-Deerfield Beach, FL.
                         Broward County, FL
22900................  Fort Smith, AR-OK..........     0.8231     0.8752
                         Crawford County, AR
                         Franklin County, AR
                         Sebastian County, AR
                         Le Flore County, OK
                         Sequoyah County, OK
23020................  Fort Walton Beach-Crestview-    0.8877     0.9217
                        Destin, FL.
                         Okaloosa County, FL

[[Page 23558]]

 
23060................  Fort Wayne, IN.............     0.9797     0.9861
                         Allen County, IN
                         Wells County, IN
                         Whitley County, IN
23104................  \1\ Fort Worth-Arlington,       0.9514     0.9665
                        TX.
                         Johnson County, TX
                         Parker County, TX
                         Tarrant County, TX
                         Wise County, TX
23420................  \2\ Fresno, CA.............     1.0848     1.0573
                         Fresno County, CA
23460................  Gadsden, AL................     0.7974     0.8564
                         Etowah County, AL
23540................  Gainesville, FL............     0.9461     0.9628
                         Alachua County, FL
                         Gilchrist County, FL
23580................  Gainesville, GA............     0.8897     0.9231
                         Hall County, GA
23844................  Gary, IN...................     0.9366     0.9561
                         Jasper County, IN
                         Lake County, IN
                         Newton County, IN
                         Porter County, IN
24020................  Glens Falls, NY............     0.8587     0.9009
                         Warren County, NY
                         Washington County, NY
24140................  Goldsboro, NC..............     0.8781     0.9148
                         Wayne County, NC
24220................  Grand Forks, ND-MN.........     1.1521     1.1018
                         Polk County, MN
                         Grand Forks County, ND
24300................  Grand Junction, CO.........     0.9590     0.9717
                         Mesa County, CO
24340................  Grand Rapids-Wyoming, MI...     0.9398     0.9584
                         Barry County, MI
                         Ionia County, MI
                         Kent County, MI
                         Newaygo County, MI
24500................  Great Falls, MT............     0.9074     0.9356
                         Cascade County, MT
24540................  Greeley, CO................     0.9597     0.9722
                         Weld County, CO
24580................  \2\ Green Bay, WI..........     0.9478     0.9640
                         Brown County, WI
                         Kewaunee County, WI
                         Oconto County, WI
24660................  Greensboro-High Point, NC..     0.9133     0.9398
                         Guilford County, NC
                         Randolph County, NC
                         Rockingham County, NC
24780................  Greenville, NC.............     0.9414     0.9595
                         Greene County, NC
                         Pitt County, NC
24860................  Greenville, SC.............     1.0138     1.0094
                         Greenville County, SC
                         Laurens County, SC
                         Pickens County, SC
25020................  Guayama, PR................     0.3186     0.4569
                         Arroyo Municipio, PR
                         Guayama Municipio, PR
                         Patillas Municipio, PR
25060................  Gulfport-Biloxi, MS........     0.8922     0.9249
                         Hancock County, MS
                         Harrison County, MS
                         Stone County, MS
25180................  Hagerstown-Martinsburg, MD-     0.9528     0.9674
                        WV.
                         Washington County, MD
                         Berkeley County, WV
                         Morgan County, WV
25260................  \2\ Hanford-Corcoran, CA...     1.0848     1.0573

[[Page 23559]]

 
                         Kings County, CA
25420................  Harrisburg-Carlisle, PA....     0.9317     0.9527
                         Cumberland County, PA
                         Dauphin County, PA
                         Perry County, PA
25500................  Harrisonburg, VA...........     0.9101     0.9375
                         Rockingham County, VA
                         Harrisonburg City, VA
25540................  \1\ \2\ Hartford-West           1.1790     1.1194
                        Hartford-East Hartford, CT.
                         Hartford County, CT
                         Litchfield County, CT
                         Middlesex County, CT
                         Tolland County, CT
25620................  \2\ Hattiesburg, MS........     0.7685     0.8350
                         Forrest County, MS
                         Lamar County, MS
                         Perry County, MS
25860................  Hickory-Lenoir-Morganton,       0.8931     0.9255
                        NC.
                         Alexander County, NC
                         Burke County, NC
                         Caldwell County, NC
                         Catawba County, NC
25980................  Hinesville-Fort Stewart, GA     0.7684     0.8349
                         Liberty County, GA
                         Long County, GA
26100................  Holland-Grand Haven, MI....     0.9133     0.9398
                         Ottawa County, MI
26180................  Honolulu, HI...............     1.1206     1.0811
                         Honolulu County, HI
26300................  Hot Springs, AR............     0.9066     0.9351
                         Garland County, AR
26380................  Houma-Bayou Cane-Thibodaux,     0.7903     0.8512
                        LA.
                         Lafourche Parish, LA
                         Terrebonne Parish, LA
26420................  \1\ Houston-Baytown-Sugar       1.0008     1.0005
                        Land, TX.
                         Austin County, TX
                         Brazoria County, TX
                         Chambers County, TX
                         Fort Bend County, TX
                         Galveston County, TX
                         Harris County, TX
                         Liberty County, TX
                         Montgomery County, TX
                         San Jacinto County, TX
                         Waller County, TX
26580................  Huntington-Ashland, WV-KY-      0.9482     0.9642
                        OH.
                         Boyd County, KY
                         Greenup County, KY
                         Lawrence County, OH
                         Cabell County, WV
                         Wayne County, WV
26620................  Huntsville, AL.............     0.9124     0.9391
                         Limestone County, AL
                         Madison County, AL
26820................  Idaho Falls, ID............     0.9409     0.9591
                         Bonneville County, ID
                         Jefferson County, ID
26900................  \1\ Indianapolis, IN.......     0.9922     0.9947
                         Boone County, IN
                         Brown County, IN
                         Hamilton County, IN
                         Hancock County, IN
                         Hendricks County, IN
                         Johnson County, IN
                         Marion County, IN
                         Morgan County, IN
                         Putnam County, IN
                         Shelby County, IN
26980................  Iowa City, IA..............     0.9751     0.9829
                         Johnson County, IA

[[Page 23560]]

 
                         Washington County, IA
27060................  Ithaca, NY.................     0.9855     0.9900
                         Tompkins County, NY
27100................  Jackson, MI................     0.9300     0.9515
                         Jackson County, MI
27140................  Jackson, MS................     0.8313     0.8812
                         Copiah County, MS
                         Hinds County, MS
                         Madison County, MS
                         Rankin County, MS
                         Simpson County, MS
27180................  Jackson, TN................     0.8964     0.9278
                         Chester County, TN
                         Madison County, TN
27260................  \1\ Jacksonville, FL.......     0.9303     0.9517
                         Baker County, FL
                         Clay County, FL
                         Duval County, FL
                         Nassau County, FL
                         St. Johns County, FL
27340................  \2\ Jacksonville, NC.......     0.8570     0.8997
                         Onslow County, NC
27500................  Janesville, WI.............     0.9561     0.9697
                         Rock County, WI
27620................  Jefferson City, MO.........     0.8389     0.8867
                         Callaway County, MO
                         Cole County, MO
                         Moniteau County, MO
                         Osage County, MO
27740................  Johnson City, TN...........     0.7958     0.8552
                         Carter County, TN
                         Unicoi County, TN
                         Washington County, TN
27780................  Johnstown, PA..............     0.8348     0.8837
                         Cambria County, PA
27860................  Jonesboro, AR..............     0.7968     0.8559
                         Craighead County, AR
                         Poinsett County, AR
27900................  Joplin, MO.................     0.8594     0.9014
                         Jasper County, MO
                         Newton County, MO
28020................  Kalamazoo-Portage, MI......     1.0403     1.0274
                         Kalamazoo County, MI
                         Van Buren County, MI
28100................  Kankakee-Bradley, IL.......     1.0991     1.0668
                         Kankakee County, IL
28140................  \1\ Kansas City, MO-KS.....     0.9454     0.9623
                         Franklin County, KS
                         Johnson County, KS
                         Leavenworth County, KS
                         Linn County, KS
                         Miami County, KS
                         Wyandotte County, KS
                         Bates County, MO
                         Caldwell County, MO
                         Cass County, MO
                         Clay County, MO
                         Clinton County, MO
                         Jackson County, MO
                         Lafayette County, MO
                         Platte County, MO
                         Ray County, MO
28420................  Kennewick-Richland-Pasco,       1.0619     1.0420
                        WA.
                         Benton County, WA
                         Franklin County, WA
28660................  Killeen-Temple-Fort Hood,       0.8566     0.8994
                        TX.
                         Bell County, TX
                         Coryell County, TX
                         Lampasas County, TX
28700................  Kingsport-Bristol-Bristol,      0.8095     0.8653
                        TN-VA.

[[Page 23561]]

 
                         Hawkins County, TN
                         Sullivan County, TN
                         Bristol City, VA
                         Scott County, VA
                         Washington County, VA
28740................  Kingston, NY...............     0.9260     0.9487
                         Ulster County, NY
28940................  Knoxville, TN..............     0.8470     0.8925
                         Anderson County, TN
                         Blount County, TN
                         Knox County, TN
                         Loudon County, TN
                         Union County, TN
29020................  Kokomo, IN.................     0.9555     0.9693
                         Howard County, IN
                         Tipton County, IN
29100................  La Crosse, WI-MN...........     0.9557     0.9694
                         Houston County, MN
                         La Crosse County, WI
29140................  Lafayette, IN..............     0.8730     0.9112
                         Benton County, IN
                         Carroll County, IN
                         Tippecanoe County, IN
29180................  Lafayette, LA..............     0.8429     0.8896
                         Lafayette Parish, LA
                         St. Martin Parish, LA
29340................  Lake Charles, LA...........     0.7847     0.8470
                         Calcasieu Parish, LA
                         Cameron Parish, LA
29404................  Lake County-Kenosha County,     1.0444     1.0302
                        IL-WI.
                         Lake County, IL
                         Kenosha County, WI
29460................  Lakeland, FL...............     0.8934     0.9257
                         Polk County, FL
29540................  Lancaster, PA..............     0.9716     0.9805
                         Lancaster County, PA
29620................  Lansing-East Lansing, MI...     0.9786     0.9853
                         Clinton County, MI
                         Eaton County, MI
                         Ingham County, MI
29700................  Laredo, TX.................     0.8101     0.8657
                         Webb County, TX
29740................  \2\ Las Cruces, NM.........     0.8649     0.9054
                         Dona Ana County, NM
29820................  \1\ Las Vegas-Paradise, NV.     1.1416     1.0949
                         Clark County, NV
29940................  Lawrence, KS...............     0.8538     0.8974
                         Douglas County, KS
30020................  Lawton, OK.................     0.7916     0.8521
                         Comanche County, OK
30140................  Lebanon, PA................     0.8654     0.9057
                         Lebanon County, PA
30300................  Lewiston, ID-WA (ID             0.9878     0.9916
                        Hospitals).
                         Nez Perce County, ID
                         Asotin County, WA
30300................  \2\ Lewiston, ID-WA (WA         1.0459     1.0312
                        Hospitals).
                         Nez Perce County, ID
                         Asotin County, WA
30340................  Lewiston-Auburn, ME........     0.9332     0.9538
                         Androscoggin County, ME
30460................  Lexington-Fayette, KY......     0.9060     0.9346
                         Bourbon County, KY
                         Clark County, KY
                         Fayette County, KY
                         Jessamine County, KY
                         Scott County, KY
                         Woodford County, KY
30620................  Lima, OH...................     0.9263     0.9489
                         Allen County, OH
30700................  Lincoln, NE................     1.0197     1.0134

[[Page 23562]]

 
                         Lancaster County, NE
                         Seward County, NE
30780................  Little Rock-North Little        0.8768     0.9139
                        Rock, AR.
                         Faulkner County, AR
                         Grant County, AR
                         Lonoke County, AR
                         Perry County, AR
                         Pulaski County, AR
                         Saline County, AR
30860................  Logan, UT-ID...............     0.9183     0.9433
                         Franklin County, ID
                         Cache County, UT
30980................  Longview, TX...............     0.8741     0.9120
                         Gregg County, TX
                         Rusk County, TX
                         Upshur County, TX
31020................  \2\ Longview, WA...........     1.0459     1.0312
                         Cowlitz County, WA
31084................  \1\ Los Angeles-Long Beach-     1.1762     1.1175
                        Glendale, CA.
                         Los Angeles County, CA
31140................  \1\ Louisville, KY-IN......     0.9264     0.9490
                         Clark County, IN
                         Floyd County, IN
                         Harrison County, IN
                         Washington County, IN
                         Bullitt County, KY
                         Henry County, KY
                         Jefferson County, KY
                         Meade County, KY
                         Nelson County, KY
                         Oldham County, KY
                         Shelby County, KY
                         Spencer County, KY
                         Trimble County, KY
31180................  Lubbock, TX................     0.8790     0.9155
                         Crosby County, TX
                         Lubbock County, TX
31340................  Lynchburg, VA..............     0.8706     0.9095
                         Amherst County, VA
                         Appomattox County, VA
                         Bedford County, VA
                         Campbell County, VA
                         Bedford City, VA
                         Lynchburg City, VA
31420................  Macon, GA..................     0.9485     0.9644
                         Bibb County, GA
                         Crawford County, GA
                         Jones County, GA
                         Monroe County, GA
                         Twiggs County, GA
31460................  \2\ Madera, CA.............     1.0848     1.0573
                         Madera County, CA
31540................  Madison, WI................     1.0629     1.0427
                         Columbia County, WI
                         Dane County, WI
                         Iowa County, WI
31700................  \2\ Manchester-Nashua, NH..     1.0668     1.0453
                         Hillsborough County, NH
                         Merrimack County, NH
31900................  Mansfield, OH..............     0.8788     0.9153
                         Richland County, OH
32420................  Mayaguez, PR...............     0.4016     0.5354
                         Hormigueros Municipio, PR
                         Mayag[uuml]ez Municipio,
                       PR
32580................  McAllen-Edinburg-Pharr, TX.     0.8945     0.9265
                         Hidalgo County, TX
32780................  \2\ Medford, OR............     1.0284     1.0194
                         Jackson County, OR
32820................  \1\ Memphis, TN-MS-AR......     0.9346     0.9547
                         Crittenden County, AR

[[Page 23563]]

 
                         DeSoto County, MS
                         Marshall County, MS
                         Tate County, MS
                         Tunica County, MS
                         Fayette County, TN
                         Shelby County, TN
                         Tipton County, TN
32900................  Merced, CA.................     1.1123     1.0756
                         Merced County, CA
33124................  \1\ Miami-Miami Beach-          0.9757     0.9833
                        Kendall, FL.
                         Miami-Dade County, FL
33140................  Michigan City-La Porte, IN.     0.9409     0.9591
                         LaPorte County, IN
33260................  Midland, TX................     0.9522     0.9670
                         Midland County, TX
33340................  \1\ Milwaukee-Waukesha-West     1.0111     1.0076
                        Allis, WI.
                         Milwaukee County, WI
                         Ozaukee County, WI
                         Washington County, WI
                         Waukesha County, WI
33460................  \1\ Minneapolis-St. Paul-       1.1055     1.0711
                        Bloomington, MN-WI.
                         Anoka County, MN
                         Carver County, MN
                         Chisago County, MN
                         Dakota County, MN
                         Hennepin County, MN
                         Isanti County, MN
                         Ramsey County, MN
                         Scott County, MN
                         Sherburne County, MN
                         Washington County, MN
                         Wright County, MN
                         Pierce County, WI
                         St. Croix County, WI
33540................  Missoula, MT...............     0.9535     0.9679
                         Missoula County, MT
33660................  Mobile, AL.................     0.7902     0.8511
                         Mobile County, AL
33700................  Modesto, CA................     1.1885     1.1255
                         Stanislaus County, CA
33740................  Monroe, LA.................     0.8044     0.8615
                         Ouachita Parish, LA
                         Union Parish, LA
33780................  Monroe, MI.................     0.9468     0.9633
                         Monroe County, MI
33860................  Montgomery, AL.............     0.8600     0.9019
                         Autauga County, AL
                         Elmore County, AL
                         Lowndes County, AL
                         Montgomery County, AL
34060................  Morgantown, WV.............     0.8439     0.8903
                         Monongalia County, WV
                         Preston County, WV
34100................  Morristown, TN.............     0.8758     0.9132
                         Grainger County, TN
                         Hamblen County, TN
                         Jefferson County, TN
34580................  \2\ Mount Vernon-Anacortes,     1.0459     1.0312
                        WA.
                         Skagit County, WA
34620................  Muncie, IN.................     0.8952     0.9270
                         Delaware County, IN
34740................  Muskegon-Norton Shores, MI.     0.9677     0.9778
                         Muskegon County, MI
34820................  Myrtle Beach-Conway-North       0.8869     0.9211
                        Myrtle Beach, SC.
                         Horry County, SC
34900................  Napa, CA...................     1.2643     1.1742
                         Napa County, CA
34940................  Naples-Marco Island, FL....     1.0115     1.0079
                         Collier County, FL
34980................  \1\ Nashville-Davidson--        0.9757     0.9833
                        Murfreesboro, TN.

[[Page 23564]]

 
                         Cannon County, TN
                         Cheatham County, TN
                         Davidson County, TN
                         Dickson County, TN
                         Hickman County, TN
                         Macon County, TN
                         Robertson County, TN
                         Rutherford County, TN
                         Smith County, TN
                         Sumner County, TN
                         Trousdale County, TN
                         Williamson County, TN
                         Wilson County, TN
35004................  \1\ Nassau-Suffolk, NY.....     1.2781     1.1830
                         Nassau County, NY
                         Suffolk County, NY
35084................  \1\ Newark-Union, NJ-PA....     1.2192     1.1454
                         Essex County, NJ
                         Hunterdon County, NJ
                         Morris County, NJ
                         Sussex County, NJ
                         Union County, NJ
                         Pike County, PA
35300................  \2\ New Haven-Milford, CT..     1.1790     1.1194
                         New Haven County, CT
35380................  \1\ New Orleans-Metairie-       0.9003     0.9306
                        Kenner, LA.
                         Jefferson Parish, LA
                         Orleans Parish, LA
                         Plaquemines Parish, LA
                         St. Bernard Parish, LA
                         St. Charles Parish, LA
                         St. John the Baptist
                       Parish, LA
                         St. Tammany Parish, LA
35644................  \1\ New York-Wayne-White        1.3191     1.2088
                        Plains, NY-NJ.
                         Bergen County, NJ
                         Hudson County, NJ
                         Passaic County, NJ
                         Bronx County, NY
                         Kings County, NY
                         New York County, NY
                         Putnam County, NY
                         Queens County, NY
                         Richmond County, NY
                         Rockland County, NY
                         Westchester County, NY
35660................  \2\ Niles-Benton Harbor, MI     0.8923     0.9249
                         Berrien County, MI
35980................  \2\ Norwich-New London, CT.     1.1790     1.1194
                         New London County, CT
36084................  \1\ Oakland-Fremont-            1.5474     1.3485
                        Hayward, CA.
                         Alameda County, CA
                         Contra Costa County, CA
36100................  Ocala, FL..................     0.8955     0.9272
                         Marion County, FL
36140................  Ocean City, NJ.............     1.1031     1.0695
                         Cape May County, NJ
36220................  Odessa, TX.................     0.9893     0.9927
                         Ector County, TX
36260................  Ogden-Clearfield, UT.......     0.9048     0.9338
                         Davis County, UT
                         Morgan County, UT
                         Weber County, UT
36420................  \1\ Oklahoma City, OK......     0.9043     0.9334
                         Canadian County, OK
                         Cleveland County, OK
                         Grady County, OK
                         Lincoln County, OK
                         Logan County, OK
                         McClain County, OK
                         Oklahoma County, OK

[[Page 23565]]

 
36500................  Olympia, WA................     1.0970     1.0655
                         Thurston County, WA
36540................  Omaha-Council Bluffs, NE-IA     0.9555     0.9693
                         Harrison County, IA
                         Mills County, IA
                         Pottawattamie County, IA
                         Cass County, NE
                         Douglas County, NE
                         Sarpy County, NE
                         Saunders County, NE
                         Washington County, NE
36740................  \1\ Orlando, FL............     0.9446     0.9617
                         Lake County, FL
                         Orange County, FL
                         Osceola County, FL
                         Seminole County, FL
36780................  \2\ Oshkosh-Neenah, WI.....     0.9478     0.9640
                         Winnebago County, WI
36980................  Owensboro, KY..............     0.8806     0.9166
                         Daviess County, KY
                         Hancock County, KY
                         McLean County, KY
37100................  Oxnard-Thousand Oaks-           1.1604     1.1072
                        Ventura, CA.
                         Ventura County, CA
37340................  Palm Bay-Melbourne-             0.9826     0.9881
                        Titusville, FL.
                         Brevard County, FL
37460................  \2\ Panama City-Lynn Haven,     0.8613     0.9028
                        FL.
                         Bay County, FL
37620................  Parkersburg-Marietta, WV-OH     0.8303     0.8804
                        (WV Hospitals).
                         Washington County, OH
                         Pleasants County, WV
                         Wirt County, WV
                         Wood County, WV
37620................  \2\ Parkersburg-Marietta,       0.8788     0.9153
                        WV-OH (OH Hospitals).
                         Washington County, OH
                         Pleasants County, WV
                         Wirt County, WV
                         Wood County, WV
37700................  Pascagoula, MS.............     0.8164     0.8703
                         George County, MS
                         Jackson County, MS
37860................  \2\ Pensacola-Ferry Pass-       0.8613     0.9028
                        Brent, FL.
                         Escambia County, FL
                         Santa Rosa County, FL
37900................  Peoria, IL.................     0.8844     0.9193
                         Marshall County, IL
                         Peoria County, IL
                         Stark County, IL
                         Tazewell County, IL
                         Woodford County, IL
37964................  \1\ Philadelphia, PA.......     1.1030     1.0694
                         Bucks County, PA
                         Chester County, PA
                         Delaware County, PA
                         Montgomery County, PA
                         Philadelphia County, PA
38060................  \1\ Phoenix-Mesa-               1.0139     1.0095
                        Scottsdale, AZ.
                         Maricopa County, AZ
                         Pinal County, AZ
38220................  Pine Bluff, AR.............     0.8716     0.9102
                         Cleveland County, AR
                         Jefferson County, AR
                         Lincoln County, AR
38300................  \1\ Pittsburgh, PA.........     0.8840     0.9190
                         Allegheny County, PA
                         Armstrong County, PA
                         Beaver County, PA
                         Butler County, PA
                         Fayette County, PA
                         Washington County, PA

[[Page 23566]]

 
                         Westmoreland County, PA
38340................  Pittsfield, MA.............     1.0183     1.0125
                         Berkshire County, MA
38540................  Pocatello, ID..............     0.9348     0.9549
                         Bannock County, ID
                         Power County, ID
38660................  Ponce, PR..................     0.5178     0.6372
                         Juana Diaz Municipio, PR
                         Ponce Municipio, PR
                         Villalba Municipio, PR
38860................  Portland-South Portland-        1.0382     1.0260
                        Biddeford, ME.
                         Cumberland County, ME
                         Sagadahoc County, ME
                         York County, ME
38900................  \1\ Portland-Vancouver-         1.1229     1.0826
                        Beaverton, OR-WA.
                         Clackamas County, OR
                         Columbia County, OR
                         Multnomah County, OR
                         Washington County, OR
                         Yamhill County, OR
                         Clark County, WA
                         Skamania County, WA
38940................  Port St. Lucie-Fort Pierce,     1.0162     1.0111
                        FL.
                         Martin County, FL
                         St. Lucie County, FL
39100................  Poughkeepsie-Newburgh-          1.0767     1.0519
                        Middletown, NY.
                         Dutchess County, NY
                         Orange County, NY
39140................  Prescott, AZ...............     0.9884     0.9920
                         Yavapai County, AZ
39300................  \1\ Providence-New Bedford-     1.0952     1.0643
                        Fall River, RI-MA.
                         Bristol County, MA
                         Bristol County, RI
                         Kent County, RI
                         Newport County, RI
                         Providence County, RI
                         Washington County, RI
39340................  Provo-Orem, UT.............     0.9578     0.9709
                         Juab County, UT
                         Utah County, UT
39380................  \2\ Pueblo, CO.............     0.9379     0.9570
                         Pueblo County, CO
39460................  Punta Gorda, FL............     0.9274     0.9497
                         Charlotte County, FL
39540................  \2\ Racine, WI.............     0.9478     0.9640
                         Racine County, WI
39580................  Raleigh-Cary, NC...........     0.9709     0.9800
                         Franklin County, NC
                         Johnston County, NC
                         Wake County, NC
39660................  Rapid City, SD.............     0.9027     0.9323
                         Meade County, SD
                         Pennington County, SD
39740................  Reading, PA................     0.9698     0.9792
                         Berks County, PA
39820................  Redding, CA................     1.2207     1.1463
                         Shasta County, CA
39900................  Reno-Sparks, NV............     1.0984     1.0664
                         Storey County, NV
                         Washoe County, NV
40060................  \1\ Richmond, VA...........     0.9319     0.9528
                         Amelia County, VA
                         Caroline County, VA
                         Charles City County, VA
                         Chesterfield County, VA
                         Cumberland County, VA
                         Dinwiddie County, VA
                         Goochland County, VA
                         Hanover County, VA
                         Henrico County, VA

[[Page 23567]]

 
                         King and Queen County, VA
                         King William County, VA
                         Louisa County, VA
                         New Kent County, VA
                         Powhatan County, VA
                         Prince George County, VA
                         Sussex County, VA
                         Colonial Heights City, VA
                         Hopewell City, VA
                         Petersburg City, VA
                         Richmond City, VA
40140................  \1\ Riverside-San               1.1021     1.0688
                        Bernardino-Ontario, CA.
                         Riverside County, CA
                         San Bernardino County, CA
40220................  Roanoke, VA................     0.8450     0.8911
                         Botetourt County, VA
                         Craig County, VA
                         Franklin County, VA
                         Roanoke County, VA
                         Roanoke City, VA
                         Salem City, VA
40340................  Rochester, MN..............     1.1128     1.0759
                         Dodge County, MN
                         Olmsted County, MN
                         Wabasha County, MN
40380................  \1\ Rochester, NY..........     0.9117     0.9387
                         Livingston County, NY
                         Monroe County, NY
                         Ontario County, NY
                         Orleans County, NY
                         Wayne County, NY
40420................  Rockford, IL...............     0.9975     0.9983
                         Boone County, IL
                         Winnebago County, IL
40484................  \2\ Rockingham County-          1.0668     1.0453
                        Strafford County, NH.
                         Rockingham County, NH
                         Strafford County, NH
40580................  Rocky Mount, NC............     0.8924     0.9250
                         Edgecombe County, NC
                         Nash County, NC
40660................  Rome, GA...................     0.9414     0.9595
                         Floyd County, GA
40900................  \1\ Sacramento--Arden-          1.2953     1.1939
                        Arcade--Roseville, CA.
                         El Dorado County, CA
                         Placer County, CA
                         Sacramento County, CA
                         Yolo County, CA
40980................  Saginaw-Saginaw Township        0.9474     0.9637
                        North, MI.
                         Saginaw County, MI
41060................  St. Cloud, MN..............     1.0030     1.0021
                         Benton County, MN
                         Stearns County, MN
41100................  St. George, UT.............     0.9416     0.9596
                         Washington County, UT
41140................  St. Joseph, MO-KS..........     0.9565     0.9700
                         Doniphan County, KS
                         Andrew County, MO
                         Buchanan County, MO
                         DeKalb County, MO
41180................  St. Louis, MO-IL...........     0.8953     0.9271
                         Bond County, IL
                         Calhoun County, IL
                         Clinton County, IL
                         Jersey County, IL
                         Macoupin County, IL
                         Madison County, IL
                         Monroe County, IL
                         St. Clair County, IL
                         Crawford County, MO
                         Franklin County, MO

[[Page 23568]]

 
                         Jefferson County, MO
                         Lincoln County, MO
                         St. Charles County, MO
                         St. Louis County, MO
                         Warren County, MO
                         Washington County, MO
                         St. Louis City, MO
41420................  Salem, OR..................     1.0445     1.0303
                         Marion County, OR
                         Polk County, OR
41500................  Salinas, CA................     1.4140     1.2677
                         Monterey County, CA
41540................  \2\ Salisbury, MD..........     0.9099     0.9374
                         Somerset County, MD
                         Wicomico County, MD
41620................  Salt Lake City, UT.........     0.9436     0.9610
                         Salt Lake County, UT
                         Summit County, UT
                         Tooele County, UT
41660................  San Angelo, TX.............     0.8287     0.8793
                         Irion County, TX
                         Tom Green County, TX
41700................  \1\ San Antonio, TX........     0.8987     0.9295
                         Atascosa County, TX
                         Bandera County, TX
                         Bexar County, TX
                         Comal County, TX
                         Guadalupe County, TX
                         Kendall County, TX
                         Medina County, TX
                         Wilson County, TX
41740................  \1\ San Diego-Carlsbad-San      1.1417     1.0950
                        Marcos, CA.
                         San Diego County, CA
41780................  Sandusky, OH...............     0.9033     0.9327
                         Erie County, OH
41884................  \1\ San Francisco-San Mateo-    1.4970     1.3182
                        Redwood City, CA.
                         Marin County, CA
                         San Francisco County, CA
                         San Mateo County, CA
41900................  San German-Cabo Rojo, PR...     0.4646     0.5916
                         Cabo Rojo Municipio, PR
                         Lajas Municipio, PR
                         Sabana Grande Municipio,
                       PR
                         San German Municipio, PR
41940................  \1\ San Jose-Sunnyvale-         1.5114     1.3269
                        Santa Clara, CA.
                         San Benito County, CA
                         Santa Clara County, CA
41980................  \1\ San Juan-Caguas-            0.4686     0.5951
                        Guaynabo, PR.
                         Aguas Buenas Municipio,
                       PR
                         Aibonito Municipio, PR
                         Arecibo Municipio, PR
                         Barceloneta Municipio, PR
                         Barranquitas Municipio,
                       PR
                         Bayam[oacute]n Municipio,
                       PR
                         Caguas Municipio, PR
                         Camuy Municipio, PR
                         Can[oacute]vanas
                       Municipio, PR
                         Carolina Municipio, PR
                         Cata[ntilde]o Municipio,
                       PR
                         Cayey Municipio, PR
                         Ciales Municipio, PR
                         Cidra Municipio, PR
                         Comer[iacute]o Municipio,
                       PR
                         Corozal Municipio, PR
                         Dorado Municipio, PR
                         Florida Municipio, PR
                         Guaynabo Municipio, PR
                         Gurabo Municipio, PR
                         Hatillo Municipio, PR
                         Humacao Municipio, PR

[[Page 23569]]

 
                         Juncos Municipio, PR
                         Las Piedras Municipio, PR
                         Lo[iacute]za Municipio,
                       PR
                         Manat[iacute] Municipio,
                       PR
                         Maunabo Municipio, PR
                         Morovis Municipio, PR
                         Naguabo Municipio, PR
                         Naranjito Municipio, PR
                         Orocovis Municipio, PR
                         Quebradillas Municipio,
                       PR
                         R[iacute]o Grande
                       Municipio, PR
                         San Juan Municipio, PR
                         San Lorenzo Municipio, PR
                         Toa Alta Municipio, PR
                         Toa Baja Municipio, PR
                         Trujillo Alto Municipio,
                       PR
                         Vega Alta Municipio, PR
                         Vega Baja Municipio, PR
                         Yabucoa Municipio, PR
42020................  San Luis Obispo-Paso            1.1357     1.0910
                        Robles, CA.
                         San Luis Obispo County,
                       CA
42044................  \1\ Santa Ana-Anaheim-          1.1564     1.1046
                        Irvine, CA.
                         Orange County, CA
42060................  Santa Barbara-Santa Maria-      1.1525     1.1021
                        Goleta, CA.
                         Santa Barbara County, CA
42100................  Santa Cruz-Watsonville, CA.     1.5159     1.3296
                         Santa Cruz County, CA
42140................  Santa Fe, NM...............     1.0908     1.0613
                         Santa Fe County, NM
42220................  Santa Rosa-Petaluma, CA....     1.3480     1.2269
                         Sonoma County, CA
42260................  Sarasota-Bradenton-Venice,      0.9554     0.9692
                        FL.
                         Manatee County, FL
                         Sarasota County, FL
42340................  Savannah, GA...............     0.9483     0.9643
                         Bryan County, GA
                         Chatham County, GA
                         Effingham County, GA
42540................  Scranton--Wilkes-Barre, PA.     0.8530     0.8968
                         Lackawanna County, PA
                         Luzerne County, PA
                         Wyoming County, PA
42644................  \1\ Seattle-Bellevue-           1.1573     1.1052
                        Everett, WA.
                         King County, WA
                         Snohomish County, WA
43100................  \2\ Sheboygan, WI..........     0.9478     0.9640
                         Sheboygan County, WI
43300................  Sherman-Denison, TX........     0.9518     0.9667
                         Grayson County, TX
43340................  Shreveport-Bossier City, LA     0.8767     0.9138
                         Bossier Parish, LA
                         Caddo Parish, LA
                         De Soto Parish, LA
43580................  Sioux City, IA-NE-SD.......     0.9360     0.9557
                         Woodbury County, IA
                         Dakota County, NE
                         Dixon County, NE
                         Union County, SD
43620................  Sioux Falls, SD............     0.9616     0.9735
                         Lincoln County, SD
                         McCook County, SD
                         Minnehaha County, SD
                         Turner County, SD
43780................  South Bend-Mishawaka, IN-MI     0.9785     0.9852
                         St. Joseph County, IN
                         Cass County, MI
43900................  Spartanburg, SC............     0.9183     0.9433
                         Spartanburg County, SC
44060................  Spokane, WA................     1.0898     1.0607
                         Spokane County, WA

[[Page 23570]]

 
44100................  Springfield, IL............     0.8879     0.9218
                         Menard County, IL
                         Sangamon County, IL
44140................  Springfield, MA............     1.0259     1.0177
                         Franklin County, MA
                         Hampden County, MA
                         Hampshire County, MA
44180................  Springfield, MO............     0.8251     0.8766
                         Christian County, MO
                         Dallas County, MO
                         Greene County, MO
                         Polk County, MO
                         Webster County, MO
44220................  \2\ Springfield, OH........     0.8788     0.9153
                         Clark County, OH
44300................  State College, PA..........     0.8368     0.8851
                         Centre County, PA
44700................  Stockton, CA...............     1.1333     1.0895
                         San Joaquin County, CA
44940................  \2\ Sumter, SC.............     0.8663     0.9064
                         Sumter County, SC
45060................  Syracuse, NY...............     0.9595     0.9721
                         Madison County, NY
                         Onondaga County, NY
                         Oswego County, NY
45104................  Tacoma, WA.................     1.0794     1.0537
                         Pierce County, WA
45220................  Tallahassee, FL............     0.8712     0.9099
                         Gadsden County, FL
                         Jefferson County, FL
                         Leon County, FL
                         Wakulla County, FL
45300................  \1\ Tampa-St. Petersburg-       0.9292     0.9510
                        Clearwater, FL.
                         Hernando County, FL
                         Hillsborough County, FL
                         Pasco County, FL
                         Pinellas County, FL
45460................  \2\ Terre Haute, IN........     0.8632     0.9042
                         Clay County, IN
                         Sullivan County, IN
                         Vermillion County, IN
                         Vigo County, IN
45500................  Texarkana, TX-Texarkana, AR     0.8293     0.8797
                         Miller County, AR
                         Bowie County, TX
45780................  Toledo, OH.................     0.9573     0.9706
                         Fulton County, OH
                         Lucas County, OH
                         Ottawa County, OH
                         Wood County, OH
45820................  Topeka, KS.................     0.8921     0.9248
                         Jackson County, KS
                         Jefferson County, KS
                         Osage County, KS
                         Shawnee County, KS
                         Wabaunsee County, KS
45940................  Trenton-Ewing, NJ..........     1.0837     1.0566
                         Mercer County, NJ
46060................  Tucson, AZ.................     0.9007     0.9309
                         Pima County, AZ
46140................  Tulsa, OK..................     0.8313     0.8812
                         Creek County, OK
                         Okmulgee County, OK
                         Osage County, OK
                         Pawnee County, OK
                         Rogers County, OK
                         Tulsa County, OK
                         Wagoner County, OK
46220................  Tuscaloosa, AL.............     0.8724     0.9108
                         Greene County, AL

[[Page 23571]]

 
                         Hale County, AL
                         Tuscaloosa County, AL
46340................  Tyler, TX..................     0.9322     0.9531
                         Smith County, TX
46540................  Utica-Rome, NY.............     0.8313     0.8812
                         Herkimer County, NY
                         Oneida County, NY
46660................  Valdosta, GA...............     0.8873     0.9214
                         Brooks County, GA
                         Echols County, GA
                         Lanier County, GA
                         Lowndes County, GA
46700................  Vallejo-Fairfield, CA......     1.4888     1.3133
                         Solano County, CA
46940................  Vero Beach, FL.............     0.9458     0.9626
                         Indian River County, FL
47020................  Victoria, TX...............     0.8148     0.8691
                         Calhoun County, TX
                         Goliad County, TX
                         Victoria County, TX
47220................  \2\ Vineland-Millville-         1.0607     1.0412
                        Bridgeton, NJ.
                         Cumberland County, NJ
47260................  \1\ Virginia Beach-Norfolk-     0.8841     0.9191
                        Newport News, VA-NC.
                         Currituck County, NC
                         Gloucester County, VA
                         Isle of Wight County, VA
                         James City County, VA
                         Mathews County, VA
                         Surry County, VA
                         York County, VA
                         Chesapeake City, VA
                         Hampton City, VA
                         Newport News City, VA
                         Norfolk City, VA
                         Poquoson City, VA
                         Portsmouth City, VA
                         Suffolk City, VA
                         Virginia Beach City, VA
                         Williamsburg City, VA
47300................  \2\ Visalia-Porterville, CA     1.0848     1.0573
                         Tulare County, CA
47380................  Waco, TX...................     0.8532     0.8970
                         McLennan County, TX
47580................  Warner Robins, GA..........     0.8662     0.9063
                         Houston County, GA
47644................  \1\ Warren-Farmington Hills-    0.9858     0.9903
                        Troy, MI.
                         Lapeer County, MI
                         Livingston County, MI
                         Macomb County, MI
                         Oakland County, MI
                         St. Clair County, MI
47894................  \1\ Washington-Arlington-       1.0935     1.0631
                        Alexandria, DC-VA-MD-WV.
                         District of Columbia, DC
                         Calvert County, MD
                         Charles County, MD
                         Prince George's County,
                       MD
                         Arlington County, VA
                         Clarke County, VA
                         Fairfax County, VA
                         Fauquier County, VA
                         Loudoun County, VA
                         Prince William County, VA
                         Spotsylvania County, VA
                         Stafford County, VA
                         Warren County, VA
                         Alexandria City, VA
                         Fairfax City, VA
                         Falls Church City, VA
                         Fredericksburg City, VA
                         Manassas City, VA

[[Page 23572]]

 
                         Manassas Park City, VA
                         Jefferson County, WV
47940................  Waterloo-Cedar Falls, IA...     0.8564     0.8993
                         Black Hawk County, IA
                         Bremer County, IA
                         Grundy County, IA
48140................  Wausau, WI.................     0.9964     0.9975
                         Marathon County, WI
48260................  Weirton-Steubenville, WV-OH     0.7821     0.8451
                        (WV Hospitals).
                         Jefferson County, OH
                         Brooke County, WV
                         Hancock County, WV
48260................  \2\ Weirton-Steubenville,       0.8788     0.9153
                        WV-OH (OH Hospitals).
                         Jefferson County, OH
                         Brooke County, WV
                         Hancock County, WV
48300................  \2\ Wenatchee, WA..........     1.0459     1.0312
                         Chelan County, WA
                         Douglas County, WA
48424................  \1\ West Palm Beach-Boca        1.0061     1.0042
                        Raton-Boynton Beach, FL.
                         Palm Beach County, FL
48540................  \2\ Wheeling, WV-OH (WV         0.7742     0.8392
                        Hospitals).
                         Belmont County, OH
                         Marshall County, WV
                         Ohio County, WV
48540................  \2\ Wheeling, WV-OH (OH         0.8788     0.9153
                        Hospitals).
                         Belmont County, OH
                         Marshall County, WV
                         Ohio County, WV
48620................  Wichita, KS................     0.9156     0.9414
                         Butler County, KS
                         Harvey County, KS
                         Sedgwick County, KS
                         Sumner County, KS
48660................  Wichita Falls, TX..........     0.8327     0.8822
                         Archer County, TX
                         Clay County, TX
                         Wichita County, TX
48700................  Williamsport, PA...........     0.8368     0.8851
                         Lycoming County, PA
48864................  Wilmington, DE-MD-NJ.......     1.0652     1.0442
                         New Castle County, DE
                         Cecil County, MD
                         Salem County, NJ
48900................  Wilmington, NC.............     0.9580     0.9710
                         Brunswick County, NC
                         New Hanover County, NC
                         Pender County, NC
49020................  Winchester, VA-WV..........     1.0214     1.0146
                         Frederick County, VA
                         Winchester City, VA
                         Hampshire County, WV
49180................  Winston-Salem, NC..........     0.9020     0.9318
                         Davie County, NC
                         Forsyth County, NC
                         Stokes County, NC
                         Yadkin County, NC
49340................  Worcester, MA..............     1.1044     1.0704
                         Worcester County, MA
49420................  \2\ Yakima, WA.............     1.0459     1.0312
                         Yakima County, WA
49500................  Yauco, PR..................     0.4413     0.5711
                         Gu[aacute]nica Municipio,
                       PR
                         Guayanilla Municipio, PR
                         Pe[ntilde]uelas
                       Municipio, PR
                         Yauco Municipio, PR
49620................  York-Hanover, PA...........     0.9422     0.9600
                         York County, PA
49660................  \2\ Youngstown-Warren-          0.8788     0.9153
                        Boardman, OH-PA (OH
                        Hospitals).
                         Mahoning County, OH

[[Page 23573]]

 
                         Trumbull County, OH
                         Mercer County, PA
49660................  Youngstown-Warren-Boardman,     0.8609     0.9025
                        OH-PA (PA Hospitals).
                         Mahoning County, OH
                         Trumbull County, OH
                         Mercer County, PA
49700................  Yuba City, CA..............     1.0951     1.0642
                         Sutter County, CA
                         Yuba County, CA
49740................  Yuma, AZ...................     0.9188     0.9437
                         Yuma County, AZ
------------------------------------------------------------------------
\1\ Large urban area.
\2\ Hospitals geographically located in the area are assigned the
  statewide rural wage index for FY 2006.


Table 4B.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
                           Rural Areas by CBSA
------------------------------------------------------------------------
                                                       Wage
      CBSA  code              Nonurban area           index       GAF
------------------------------------------------------------------------
01...................  Alabama....................     0.7495     0.8208
02...................  Alaska.....................     1.1977     1.1315
03...................  Arizona....................     0.8991     0.9298
04...................  Arkansas...................     0.7478     0.8195
05...................  California.................     1.0848     1.0573
06...................  Colorado...................     0.9379     0.9570
07...................  Connecticut................     1.1790     1.1194
08...................  Delaware...................     0.9606     0.9728
10...................  Florida....................     0.8613     0.9028
11...................  Georgia....................     0.7684     0.8349
12...................  Hawaii.....................     1.0598     1.0406
13...................  Idaho......................     0.8810     0.9169
14...................  Illinois...................     0.8285     0.8791
15...................  Indiana....................     0.8632     0.9042
16...................  Iowa.......................     0.8563     0.8992
17...................  Kansas.....................     0.8032     0.8606
18...................  Kentucky...................     0.7788     0.8427
19...................  Louisiana..................     0.7445     0.8171
20...................  Maine......................     0.8840     0.9190
21...................  Maryland...................     0.9099     0.9374
22...................  Massachusetts \1\..........     1.0066     1.0045
23...................  Michigan...................     0.8923     0.9249
24...................  Minnesota..................     0.9183     0.9433
25...................  Mississippi................     0.7685     0.8350
26...................  Missouri...................     0.7927     0.8529
27...................  Montana....................     0.8822     0.9177
28...................  Nebraska...................     0.8666     0.9066
29...................  Nevada.....................     0.9079     0.9360
30...................  New Hampshire..............     1.0668     1.0453
31...................  New Jersey \1\.............     1.0607     1.0412
32...................  New Mexico.................     0.8649     0.9054
33...................  New York...................     0.8220     0.8744
34...................  North Carolina.............     0.8570     0.8997
35...................  North Dakota...............     0.7278     0.8045
36...................  Ohio.......................     0.8788     0.9153
37...................  Oklahoma...................     0.7615     0.8298
38...................  Oregon.....................     1.0284     1.0194
39...................  Pennsylvania...............     0.8300     0.8802
40...................  Puerto Rico \1\............  .........  .........
41...................  Rhode Island \1\...........     0.8807     0.9167
42...................  South Carolina.............     0.8663     0.9064
43...................  South Dakota...............     0.8475     0.8929
44...................  Tennessee..................     0.7915     0.8520
45...................  Texas......................     0.8038     0.8611
46...................  Utah.......................     0.8134     0.8681
47...................  Vermont....................     1.0199     1.0136
49...................  Virginia...................     0.8024     0.8601
50...................  Washington.................     1.0459     1.0312
51...................  West Virginia..............     0.7742     0.8392
52...................  Wisconsin..................     0.9478     0.9640

[[Page 23574]]

 
53...................  Wyoming....................     0.9207    0.9450
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban, with the
  exception of Massachusetts. Massachusetts has area(s) designated as
  rural, however, no short-term, acute care hospitals are located in the
  area(s) for FY 2006.
Massachusetts, New Jersey, and Rhode Island rural floors are imputed as
  discussed in section III. H. of the preamble of this proposed rule.


Table 4C.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
                 Hospitals That Are Reclassified by CBSA
------------------------------------------------------------------------
                                                       Wage
      CBSA  code                   Area               index       GAF
------------------------------------------------------------------------
10180................  Abilene, TX................     0.8038     0.8611
10420................  Akron, OH..................     0.8979     0.9289
10580................  Albany-Schenectady-Troy, NY     0.8565     0.8994
10740................  Albuquerque, NM............     0.9558     0.9695
10780................  Alexandria, LA.............     0.8048     0.8618
10900................  Allentown-Bethlehem-Easton,     0.9844     0.9893
                        PA-NJ.
11020................  Altoona, PA................     0.8942     0.9263
11100................  Amarillo, TX...............     0.9165     0.9420
11180................  Ames, IA...................     0.9231     0.9467
11460................  Ann Arbor, MI..............     1.0628     1.0426
11500................  Anniston-Oxford, AL........     0.7702     0.8363
11700................  Asheville, NC..............     0.9312     0.9524
12020................  Athens-Clarke County, GA...     0.9684     0.9783
12060................  Atlanta-Sandy Springs-          0.9637     0.9750
                        Marietta, GA.
12420................  Austin-Round Rock, TX......     0.9451     0.9621
12620................  Bangor, ME.................     0.9985     0.9990
12700................  Barnstable Town, MA........     1.2254     1.1494
12940................  Baton Rouge, LA............     0.8470     0.8925
13020................  Bay City, MI...............     0.9535     0.9679
13780................  Binghamton, NY.............     0.8471     0.8926
13820................  Birmingham-Hoover, AL......     0.8872     0.9213
14260................  Boise City-Nampa, ID.......     0.9048     0.9338
14484................  Boston-Quincy, MA..........     1.1233     1.0829
14540................  Bowling Green, KY..........     0.8222     0.8745
15380................  Buffalo-Niagara Falls, NY..     0.8888     0.9224
15540................  Burlington-South                0.9306     0.9519
                        Burlington, VT.
15764................  Cambridge-Newton-               1.0903     1.0610
                        Framingham, MA.
16180................  Carson City, NV............     0.9786     0.9853
16220................  Casper, WY.................     0.9207     0.9450
16580................  Champaign-Urbana, IL.......     0.9335     0.9540
16620................  Charleston, WV (WV              0.8274     0.8783
                        Hospitals).
16620................  Charleston, WV(OH               0.8788     0.9153
                        Hospitals).
16700................  Charleston-North                0.9317     0.9527
                        Charleston, SC.
16740................  Charlotte-Gastonia-Concord,     0.9585     0.9714
                        NC-SC.
16820................  Charlottesville, VA........     0.9806     0.9867
16860................  Chattanooga, TN-GA.........     0.9099     0.9374
16974................  Chicago-Naperville-Joliet,      1.0698     1.0473
                        IL.
17140................  Cincinnati-Middletown, OH-      0.9604     0.9727
                        KY-IN.
17300................  Clarksville, TN-KY.........     0.8092     0.8650
17460................  Cleveland-Elyria-Mentor, OH     0.9197     0.9443
17780................  College Station-Bryan, TX..     0.8911     0.9241
17860................  Columbia, MO...............     0.8346     0.8835
17900................  Columbia, SC...............     0.9057     0.9344
17980................  Columbus, GA-AL............     0.8402     0.8876
18140................  Columbus, OH...............     0.9848     0.9896
18700................  Corvallis, OR..............     1.0328     1.0223
19124................  Dallas-Plano-Irving, TX....     0.9955     0.9969
19380................  Dayton, OH.................     0.9069     0.9353
19460................  Decatur, AL................     0.8517     0.8959
19740................  Denver-Aurora, CO..........     1.0517     1.0351
19780................  Des Moines, IA.............     0.9413     0.9594
19804................  Detroit-Livonia-Dearborn,       1.0453     1.0308
                        MI.
20260................  Duluth, MN-WI..............     1.0224     1.0153
20500................  Durham, NC.................     0.9993     0.9995
20764................  Edison, NJ.................     1.1301     1.0874
20940................  El Centro, CA..............     0.9102     0.9376
21060................  Elizabethtown, KY..........     0.8286     0.8792
21500................  Erie, PA...................     0.8424     0.8892

[[Page 23575]]

 
21604................  Essex County, MA...........     1.0668     1.0453
21660................  Eugene-Springfield, OR.....     1.0492     1.0334
21780................  Evansville, IN-KY..........     0.8508     0.8953
22020................  Fargo, ND-MN (ND, SD            0.8778     0.9146
                        Hospitals).
22020................  Fargo, ND-MN (MN Hospitals)     0.9183     0.9433
22180................  Fayetteville, NC...........     0.9193     0.9440
22220................  Fayetteville-Springdale-        0.8615     0.9029
                        Rogers, AR-MO.
22380................  Flagstaff, AZ..............     1.1713     1.1144
22420................  Flint, MI..................     1.0654     1.0443
22540................  Fond du Lac, WI............     0.9478     0.9640
22660................  Fort Collins-Loveland, CO..     1.0146     1.0100
22744................  Ft Lauderdale-Pompano Beach-    1.0508     1.0345
                        Deerfield Beach, FL.
22900................  Fort Smith, AR-OK..........     0.7986     0.8573
23020................  Fort Walton Beach-Crestview-    0.8672     0.9070
                        Destin, FL.
23060................  Fort Wayne, IN.............     0.9797     0.9861
23104................  Fort Worth-Arlington, TX...     0.9514     0.9665
23540................  Gainesville, FL............     0.9461     0.9628
23844................  Gary, IN...................     0.9366     0.9561
24340................  Grand Rapids-Wyoming, MI...     0.9398     0.9584
24500................  Great Falls, MT............     0.9074     0.9356
24540................  Greeley, CO................     0.9597     0.9722
24580................  Green Bay, WI (MI               0.9439     0.9612
                        Hospitals).
24580................  Green Bay, WI (WI               0.9478     0.9640
                        Hospitals).
24780................  Greenville, NC.............     0.9414     0.9595
24860................  Greenville, SC.............     0.9807     0.9867
25060................  Gulfport-Biloxi, MS........     0.8612     0.9027
25420................  Harrisburg-Carlisle, PA....     0.9145     0.9406
25500................  Harrisonburg, VA...........     0.8998     0.9302
25540................  Hartford-West Hartford-East     1.1085     1.0731
                        Hartford, CT (MA
                        Hospitals).
25540................  Hartford-West Hartford-East     1.1790     1.1194
                        Hartford, CT (CT
                        Hospitals).
25860................  Hickory-Lenoir-Morganton,       0.8931     0.9255
                        NC.
26100................  Holland-Grand Haven, MI....     0.9133     0.9398
26180................  Honolulu, HI...............     1.1206     1.0811
26420................  Houston-Baytown-Sugar Land,     1.0008     1.0005
                        TX.
26580................  Huntington-Ashland, WV-KY-      0.9119     0.9388
                        OH.
26620................  Huntsville, AL.............     0.9124     0.9391
26900................  Indianapolis, IN...........     0.9776     0.9846
26980................  Iowa City, IA..............     0.9574     0.9706
27060................  Ithaca, NY.................     0.9204     0.9448
27140................  Jackson, MS................     0.8182     0.8716
27180................  Jackson, TN................     0.8799     0.9161
27260................  Jacksonville, FL...........     0.9303     0.9517
27860................  Jonesboro, AR..............     0.7793     0.8430
27900................  Joplin, MO.................     0.8458     0.8916
28020................  Kalamazoo-Portage, MI......     1.0403     1.0274
28100................  Kankakee-Bradley, IL.......     1.0991     1.0668
28140................  Kansas City, MO-KS.........     0.9454     0.9623
28420................  Kennewick-Richland-Pasco,       1.0459     1.0312
                        WA.
28700................  Kingsport-Bristol-Bristol,      0.8095     0.8653
                        TN-VA.
28740................  Kingston, NY...............     0.8904     0.9236
28940................  Knoxville, TN..............     0.8470     0.8925
29180................  Lafayette, LA..............     0.8429     0.8896
29404................  Lake County-Kenosha County,     1.0444     1.0302
                        IL-WI.
29460................  Lakeland, FL...............     0.8934     0.9257
29620................  Lansing-East Lansing, MI...     0.9786     0.9853
29740................  Las Cruces, NM.............     0.8649     0.9054
29820................  Las Vegas-Paradise, NV.....     1.1249     1.0839
30020................  Lawton, OK.................     0.7673     0.8341
30460................  Lexington-Fayette, KY......     0.8830     0.9183
30620................  Lima, OH...................     0.9263     0.9489
30700................  Lincoln, NE................     0.9666     0.9770
30780................  Little Rock-North Little        0.8552     0.8984
                        Rock, AR.
30980................  Longview, TX...............     0.8621     0.9034
31084................  Los Angeles-Long Beach-         1.1660     1.1109
                        Santa Ana, CA.
31140................  Louisville, KY-IN..........     0.9264     0.9490
31180................  Lubbock, TX................     0.8790     0.9155
31340................  Lynchburg, VA..............     0.8596     0.9016
31420................  Macon, GA..................     0.9087     0.9365
31540................  Madison, WI................     1.0416     1.0283
31700................  Manchester-Nashua, NH......     1.0668     1.0453

[[Page 23576]]

 
32780................  Medford, OR................     1.0284     1.0194
32820................  Memphis, TN-MS-AR..........     0.9108     0.9380
33124................  Miami-Miami Beach-Kendall,      0.9757     0.9833
                        FL.
33260................  Midland, TX................     0.9317     0.9527
33340................  Milwaukee-Waukesha-West         0.9957     0.9971
                        Allis, WI.
33460................  Minneapolis-St. Paul-           1.0905     1.0611
                        Bloomington, MN-WI.
33540................  Missoula, MT...............     0.9535     0.9679
33660................  Mobile, AL.................     0.7902     0.8511
33700................  Modesto, CA................     1.1885     1.1255
33860................  Montgomery, AL.............     0.8276     0.8785
34060................  Morgantown, WV.............     0.8332     0.8825
34980................  Nashville-Davidson--            0.9492     0.9649
                        Murfreesboro, TN.
35084................  Newark-Union, NJ-PA........     1.2192     1.1454
35380................  New Orleans-Metairie-           0.9003     0.9306
                        Kenner, LA.
35644................  New York-Wayne-White            1.3191     1.2088
                        Plains, NY-NJ.
36084................  Oakland-Fremont-Hayward, CA     1.5474     1.3485
36100................  Ocala, FL..................     0.8955     0.9272
36140................  Ocean City, NJ.............     1.0289     1.0197
36220................  Odessa, TX.................     0.9593     0.9719
36260................  Ogden-Clearfield, UT.......     0.9048     0.9338
36420................  Oklahoma City, OK..........     0.9043     0.9334
36500................  Olympia, WA................     1.0970     1.0655
36540................  Omaha-Council Bluffs, NE-IA     0.9555     0.9693
36740................  Orlando, FL................     0.9446     0.9617
37860................  Pensacola-Ferry Pass-Brent,     0.8089     0.8648
                        FL.
37900................  Peoria, IL.................     0.8844     0.9193
37964................  Philadelphia, PA...........     1.1030     1.0694
38220................  Pine Bluff, AR.............     0.8099     0.8656
38300................  Pittsburgh, PA.............     0.8840     0.9190
38340................  Pittsfield, MA.............     1.0199     1.0136
38860................  Portland-South Portland-        0.9884     0.9920
                        Biddeford, ME.
38900................  Portland-Vancouver-             1.1229     1.0826
                        Beaverton, OR-WA.
38940................  Port St. Lucie-Fort Pierce,     1.0162     1.0111
                        FL.
39100................  Poughkeepsie-Newburgh-          1.0576     1.0391
                        Middletown, NY.
39340................  Provo-Orem, UT.............     0.9578     0.9709
39580................  Raleigh-Cary, NC...........     0.9476     0.9638
39740................  Reading, PA................     0.9500     0.9655
39820................  Redding, CA................     1.1909     1.1271
39900................  Reno-Sparks, NV (NV             1.0805     1.0545
                        Hospitals).
39900................  Reno-Sparks, NV (CA             1.0848     1.0573
                        Hospitals).
40060................  Richmond, VA...............     0.9319     0.9528
40220................  Roanoke, VA................     0.8450     0.8911
40340................  Rochester, MN..............     1.1128     1.0759
40380................  Rochester, NY..............     0.9117     0.9387
40420................  Rockford, IL...............     0.9667     0.9771
40484................  Rockingham County, NH......     1.0503     1.0342
40660................  Rome, GA...................     0.9414     0.9595
40900................  Sacramento--Arden-Arcade--      1.2953     1.1939
                        Roseville, CA.
40980................  Saginaw-Saginaw Township        0.9090     0.9368
                        North, MI.
41060................  St. Cloud, MN..............     0.9785     0.9852
41100................  St. George, UT.............     0.9416     0.9596
41180................  St. Louis, MO-IL...........     0.8953     0.9271
41620................  Salt Lake City, UT.........     0.9436     0.9610
41700................  San Antonio, TX............     0.8987     0.9295
41884................  San Francisco-San Mateo-        1.4739     1.3043
                        Redwood City,CA.
41980................  San Juan-Caguas-Guaynabo,       0.4686     0.5951
                        PR.
42044................  Santa Ana-Anaheim-Irvine,       1.1297     1.0871
                        CA.
42140................  Santa Fe, NM...............     1.0163     1.0111
42220................  Santa Rosa-Petaluma, CA....     1.3480     1.2269
42260................  Sarasota-Bradenton-Venice,      0.9554     0.9692
                        FL.
42340................  Savannah, GA...............     0.9316     0.9526
42644................  Seattle-Bellevue-Everett,       1.1573     1.1052
                        WA.
43300................  Sherman-Denison, TX........     0.8971     0.9283
43340................  Shreveport-Bossier City, LA     0.8767     0.9138
43620................  Sioux Falls, SD............     0.9616     0.9735
43780................  South Bend-Mishawaka, IN-MI     0.9785     0.9852
43900................  Spartanburg, SC............     0.9183     0.9433
44060................  Spokane, WA................     1.0722     1.0489
44180................  Springfield, MO............     0.8251     0.8766
44300................  State College, PA..........     0.8300     0.8802

[[Page 23577]]

 
44940................  Sumter, SC.................     0.8663     0.9064
45060................  Syracuse, NY...............     0.9315     0.9526
45104................  Tacoma, WA.................     1.0794     1.0537
45220................  Tallahassee, FL............     0.8420     0.8889
45300................  Tampa-St. Petersburg-           0.9292     0.9510
                        Clearwater, FL.
45500................  Texarkana, TX-Texarkana, AR     0.8293     0.8797
45820................  Topeka, KS.................     0.8785     0.9151
46140................  Tulsa, OK..................     0.8313     0.8812
46220................  Tuscaloosa, AL.............     0.8614     0.9029
46340................  Tyler, TX..................     0.9164     0.9420
46660................  Valdosta, GA...............     0.8710     0.9098
46700................  Vallejo-Fairfield, CA......     1.3955     1.2564
47260................  Virginia Beach-Norfolk-         0.8841     0.9191
                        Newport News, VA.
47380................  Waco, TX...................     0.8532     0.8970
47894................  Washington-Arlington-           1.0813     1.0550
                        Alexandria DC-VA.
48140................  Wausau, WI.................     0.9964     0.9975
48620................  Wichita, KS................     0.8946     0.9266
48700................  Williamsport, PA...........     0.8300     0.8802
48864................  Wilmington, DE-MD-NJ.......     1.0652     1.0442
48900................  Wilmington, NC.............     0.9394     0.9581
49020................  Winchester, VA-WV..........     1.0214     1.0146
49180................  Winston-Salem, NC..........     0.9020     0.9318
49660................  Youngstown-Warren-Boardman,     0.8446     0.8908
                        OH-PA (PA Hospitals).
49660................  Youngstown-Warren-Boardman,     0.8788     0.9153
                        OH-PA (OH Hospitals).
03...................  Rural Arizona..............     0.8991     0.9298
04...................  Rural Arkansas.............     0.7478     0.8195
05...................  Rural California...........     1.0848     1.0573
07...................  Rural Connecticut..........     1.0448     1.0305
10...................  Rural Florida..............     0.8613     0.9028
13...................  Rural Idaho................     0.8810     0.9169
14...................  Rural Illinois.............     0.8285     0.8791
15...................  Rural Indiana..............     0.8632     0.9042
16...................  Rural Iowa.................     0.8563     0.8992
17...................  Rural Kansas...............     0.8032     0.8606
19...................  Rural Louisiana............     0.7445     0.8171
23...................  Rural Michigan.............     0.8923     0.9249
24...................  Rural Minnesota............     0.9183     0.9433
26...................  Rural Missouri.............     0.7927     0.8529
30...................  Rural New Hampshire........     1.0668     1.0453
37...................  Rural Oklahoma.............     0.7615     0.8298
38...................  Rural Oregon...............     1.0284     1.0194
45...................  Rural Texas................     0.8038     0.8611
50...................  Rural Washington (ID            1.0061     1.0042
                        Hospitals).
50...................  Rural Washington (WA            1.0459     1.0312
                        Hospitals).
53...................  Rural Wyoming..............     0.9207     0.9450
------------------------------------------------------------------------


            Table 4F.--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF) by CBSA
----------------------------------------------------------------------------------------------------------------
                                                                                      Wage Index -      GAF -
          CBSA Code                        Area              Wage Index      GAF      Reclassified  Reclassified
                                                                                        Hospitals     Hospitals
----------------------------------------------------------------------------------------------------------------
10380........................  Aguadilla-Isabela-San             1.0196       1.0134  ............  ............
                                Sebasti[aacute]n, PR.
21940........................  Fajardo, PR................       0.8956       0.9273  ............  ............
25020........................  Guayama, PR................       0.6858       0.7724  ............  ............
32420........................  Mayag[uuml]ez, PR..........       0.8647       0.9052  ............  ............
38660........................  Ponce, PR..................       1.1147       1.0772  ............  ............
41900........................  San Germ[aacute]n-Cabo            1.0002       1.0001  ............  ............
                                Rojo, PR.
41980........................  San Juan-Caguas-Guaynabo,         1.0087       1.0059        1.0087        1.0059
                                PR.
49500........................  Yauco, PR..................       0.9500       0.9655  ............  ............
----------------------------------------------------------------------------------------------------------------

    The following list represents all hospitals that are eligible to 
have their wage index increased by the out-migration adjustment listed 
in this table. Hospitals cannot receive the out-migration adjustment if 
they are reclassified under section 1886(d)(10) of the Act or 
redesignated under section 1886(d)(8)(B) of the Act. Hospitals that 
have already been reclassified under section 1886(d)(10) of the Act or 
redesignated under section

[[Page 23578]]

1886(d)(8)(B) of the Act are designated with an asterisk. Hospitals 
have the opportunity to use the new additional 30-day period to review 
their individual situation to determine whether to submit a request to 
withdraw their reclassification/redesignation and receive the out-
migration adjustment instead. We will automatically assume that 
hospitals that have already been reclassified under section 1886(d)(10) 
of the Act or redesignated under section 1886(d)(8)(B) of the Act wish 
to retain their reclassification/redesignation status and waive the 
application of the out-migration adjustment. Hospitals are not required 
to provide CMS with any type of formal notification that they wish to 
remain reclassified/redesignated.

              Table 4J.--Out-Migration Adjustment--FY 2006
------------------------------------------------------------------------
                                  Out-
       Provider number         migration       Qualifying county name
                               adjustment
------------------------------------------------------------------------
010005*.....................       0.0259  MARSHALL
010008*.....................       0.0212  CRENSHAW
010009......................       0.0092  MORGAN
010010......................       0.0259  MARSHALL
010012*.....................       0.0205  DE KALB
010022*.....................       0.0714  CHEROKEE
010025*.....................       0.0225  CHAMBERS
010029*.....................       0.0107  LEE
010035*.....................       0.0375  CULLMAN
010038......................       0.0062  CALHOUN
010045*.....................       0.0160  FAYETTE
010047......................       0.0155  BUTLER
010054......................       0.0092  MORGAN
010061......................       0.0506  JACKSON
010072*.....................       0.0310  TALLADEGA
010078......................       0.0062  CALHOUN
010083*.....................       0.0121  BALDWIN
010085......................       0.0092  MORGAN
010100*.....................       0.0121  BALDWIN
010101*.....................       0.0310  TALLADEGA
010109......................       0.0464  PICKENS
010115......................       0.0093  FRANKLIN
010129......................       0.0121  BALDWIN
010143*.....................       0.0375  CULLMAN
010146......................       0.0062  CALHOUN
010150......................       0.0155  BUTLER
010158*.....................       0.0093  FRANKLIN
040014*.....................       0.0159  WHITE
040019*.....................       0.0697  ST. FRANCIS
040047*.....................       0.0090  RANDOLPH
040066......................       0.0382  CLARK
040069*.....................       0.0140  MISSISSIPPI
040070......................       0.0140  MISSISSIPPI
040071*.....................       0.0026  JEFFERSON
040076*.....................       0.1075  HOT SPRING
040100*.....................       0.0159  WHITE
040143......................       0.0026  JEFFERSON
050008......................       0.0028  SAN FRANCISCO
050009*.....................       0.0478  NAPA
050013*.....................       0.0478  NAPA
050014*.....................       0.0131  AMADOR
050016......................       0.0087  SAN LUIS OBISPO
050042*.....................       0.0219  TEHAMA
050046*.....................       0.0156  VENTURA
050047......................       0.0028  SAN FRANCISCO
050055......................       0.0028  SAN FRANCISCO
050065*.....................       0.0029  ORANGE
050069*.....................       0.0029  ORANGE
050073*.....................       0.0269  SOLANO
050076*.....................       0.0028  SAN FRANCISCO
050082*.....................       0.0156  VENTURA
050084......................       0.0555  SAN JOAQUIN
050088......................       0.0087  SAN LUIS OBISPO
050089*.....................       0.0152  SAN BERNARDINO
050090*.....................       0.0308  SONOMA
050099*.....................       0.0152  SAN BERNARDINO
050101......................       0.0269  SOLANO
050117......................       0.0463  MERCED
050118*.....................       0.0555  SAN JOAQUIN
050122......................       0.0555  SAN JOAQUIN
050129*.....................       0.0152  SAN BERNARDINO
050133......................        0.017  YUBA
050136*.....................       0.0308  SONOMA
050140*.....................       0.0152  SAN BERNARDINO
050150*.....................       0.0316  NEVADA
050152......................       0.0028  SAN FRANCISCO
050159*.....................       0.0156  VENTURA
050167......................       0.0555  SAN JOAQUIN
050168*.....................       0.0029  ORANGE
050173*.....................       0.0029  ORANGE
050174*.....................       0.0308  SONOMA
050177*.....................       0.0156  VENTURA
050193*.....................       0.0029  ORANGE
050224*.....................       0.0029  ORANGE
050226*.....................       0.0029  ORANGE
050228*.....................       0.0028  SAN FRANCISCO
050230*.....................       0.0029  ORANGE
050232......................       0.0087  SAN LUIS OBISPO
050236*.....................       0.0156  VENTURA
050245*.....................       0.0152  SAN BERNARDINO
050253......................       0.0029  ORANGE
050272*.....................       0.0152  SAN BERNARDINO
050279*.....................       0.0152  SAN BERNARDINO
050291*.....................       0.0308  SONOMA
050298*.....................       0.0152  SAN BERNARDINO
050300*.....................       0.0152  SAN BERNARDINO
050313......................       0.0555  SAN JOAQUIN
050325......................       0.0176  TUOLUMNE
050327*.....................       0.0152  SAN BERNARDINO
050331*.....................       0.0308  SONOMA
050335......................       0.0176  TUOLUMNE
050336......................       0.0555  SAN JOAQUIN
050348*.....................       0.0029  ORANGE
050366......................       0.0096  CALAVERAS
050367......................       0.0269  SOLANO
050385*.....................       0.0308  SONOMA
050394*.....................       0.0156  VENTURA
050407......................       0.0028  SAN FRANCISCO
050426*.....................       0.0029  ORANGE
050444......................       0.0463  MERCED
050454......................       0.0028  SAN FRANCISCO
050457......................       0.0028  SAN FRANCISCO
050469*.....................       0.0152  SAN BERNARDINO
050476......................       0.0257  LAKE
050491......................       0.0029  ORANGE
050494......................       0.0316  NEVADA
050506......................       0.0087  SAN LUIS OBISPO
050517*.....................       0.0152  SAN BERNARDINO
050526*.....................       0.0029  ORANGE
050528*.....................       0.0463  MERCED
050535*.....................       0.0029  ORANGE
050539......................       0.0257  LAKE
050543*.....................       0.0029  ORANGE
050547*.....................       0.0308  SONOMA
050548*.....................       0.0029  ORANGE
050549......................       0.0156  VENTURA
050550*.....................       0.0029  ORANGE
050551*.....................       0.0029  ORANGE
050567*.....................       0.0029  ORANGE
050568......................       0.0062  MADERA
050570*.....................       0.0029  ORANGE
050580*.....................       0.0029  ORANGE
050584*.....................       0.0152  SAN BERNARDINO
050585*.....................       0.0029  ORANGE
050586*.....................       0.0152  SAN BERNARDINO
050589*.....................       0.0029  ORANGE
050592*.....................       0.0029  ORANGE
050594*.....................       0.0029  ORANGE
050603*.....................       0.0029  ORANGE
050609*.....................       0.0029  ORANGE
050616*.....................       0.0156  VENTURA
050618*.....................       0.0152  SAN BERNARDINO
050633......................       0.0087  SAN LUIS OBISPO
050667*.....................       0.0478  NAPA
050668*.....................       0.0028  SAN FRANCISCO
050678*.....................       0.0029  ORANGE
050680......................       0.0269  SOLANO
050690*.....................       0.0308  SONOMA
050693......................       0.0029  ORANGE
050695......................       0.0555  SAN JOAQUIN
050720*.....................       0.0029  ORANGE
050728*.....................       0.0308  SONOMA
060001*.....................       0.0294  WELD
060003*.....................       0.0203  BOULDER
060027*.....................       0.0203  BOULDER
060103*.....................       0.0203  BOULDER
070003*.....................       0.0009  WINDHAM
070006......................       0.0047  FAIRFIELD
070010......................       0.0047  FAIRFIELD
070018......................       0.0047  FAIRFIELD
070020......................       0.0073  MIDDLESEX
070021*.....................       0.0009  WINDHAM
070028......................       0.0047  FAIRFIELD
070033*.....................       0.0047  FAIRFIELD

[[Page 23579]]

 
070034......................       0.0047  FAIRFIELD
080001......................       0.0059  NEW CASTLE
080003......................       0.0059  NEW CASTLE
100014......................       0.0118  VOLUSIA
100017......................       0.0118  VOLUSIA
100023*.....................       0.0069  CITRUS
100045*.....................       0.0118  VOLUSIA
100047......................       0.0021  CHARLOTTE
100062......................       0.0060  MARION
100068......................       0.0118  VOLUSIA
100072......................       0.0118  VOLUSIA
100077......................       0.0021  CHARLOTTE
100102......................       0.0133  COLUMBIA
100118*.....................       0.0398  FLAGLER
100156......................       0.0133  COLUMBIA
100175......................       0.0231  DE SOTO
100212......................       0.0060  MARION
100232*.....................       0.0347  PUTNAM
100236......................       0.0021  CHARLOTTE
100249*.....................       0.0069  CITRUS
100252*.....................       0.0233  OKEECHOBEE
110023*.....................       0.0500  GORDON
110026......................       0.0220  ELBERT
110027......................       0.0387  FRANKLIN
110029*.....................       0.0063  HALL
110041*.....................       0.0777  HABERSHAM
110063......................       0.0290  LIBERTY
110069*.....................       0.0474  HOUSTON
110120......................       0.0873  POLK
110124......................       0.0428  WAYNE
110136......................       0.0261  BALDWIN
110146......................       0.0642  CAMDEN
110150*.....................       0.0261  BALDWIN
110153*.....................       0.0474  HOUSTON
110187*.....................       0.1172  LUMPKIN
110189*.....................       0.0031  FANNIN
110190......................       0.0182  MACON
110205*.....................       0.0779  GILMER
130003*.....................       0.0095  NEZ PERCE
130011......................       0.0218  LATAH
130024......................       0.0275  BONNER
130049*.....................       0.0349  KOOTENAI
140001......................       0.0199  FULTON
140012*.....................        0.022  LEE
140026......................       0.0346  LA SALLE
140033......................       0.0147  LAKE
140043*.....................       0.0046  WHITESIDE
140058*.....................       0.0081  MORGAN
140084......................       0.0147  LAKE
140100......................       0.0147  LAKE
140110*.....................       0.0346  LA SALLE
140129......................       0.0096  WABASH
140130......................       0.0147  LAKE
140155......................       0.0027  KANKAKEE
140160*.....................       0.0286  STEPHENSON
140161*.....................       0.0138  LIVINGSTON
140167*.....................       0.0937  IROQUOIS
140173......................       0.0046  WHITESIDE
140186......................       0.0027  KANKAKEE
140199......................       0.0109  MONTGOMERY
140202......................       0.0147  LAKE
140205......................       0.0163  BOONE
140234*.....................       0.0346  LA SALLE
140291*.....................       0.0147  LAKE
150002*.....................       0.0241  LAKE
150004*.....................       0.0241  LAKE
150008*.....................       0.0241  LAKE
150022......................       0.0249  MONTGOMERY
150030*.....................       0.0201  HENRY
150034......................       0.0241  LAKE
150035......................       0.0083  PORTER
150045......................       0.0416  DE KALB
150060......................       0.0052  VERMILLION
150062......................       0.0153  DECATUR
150065*.....................       0.0139  JACKSON
150076*.....................       0.0189  MARSHALL
150088*.....................       0.0196  MADISON
150090*.....................       0.0241  LAKE
150091......................       0.0573  HUNTINGTON
150102*.....................       0.0160  STARKE
150113*.....................       0.0196  MADISON
150122......................       0.0199  RIPLEY
150125*.....................       0.0241  LAKE
150126*.....................       0.0241  LAKE
150132*.....................       0.0241  LAKE
150147*.....................       0.0241  LAKE
150156......................       0.0241  LAKE
160013......................       0.0218  MUSCATINE
160026*.....................       0.0496  BOONE
160030......................       0.0032  STORY
160032......................       0.0272  JASPER
160080*.....................       0.0049  CLINTON
160140......................       0.0364  PLYMOUTH
170137*.....................       0.0331  DOUGLAS
180012*.....................       0.0083  HARDIN
180049......................       0.0532  MADISON
180055......................       0.0532  MADISON
180066*.....................       0.0567  LOGAN
180127*.....................       0.0352  FRANKLIN
180128......................       0.0282  LAWRENCE
190001*.....................       0.0645  WASHINGTON
190003*.....................       0.0107  IBERIA
190010......................       0.0401  TANGIPAHOA
190015*.....................       0.0401  TANGIPAHOA
190017......................       0.0235  ST. LANDRY
190049......................       0.0645  WASHINGTON
190054......................       0.0107  IBERIA
190078......................       0.0235  ST. LANDRY
190086*.....................       0.0129  LINCOLN
190088......................       0.0705  WEBSTER
190099*.....................        0.039  AVOYELLES
190106*.....................       0.0238  ALLEN
190116......................       0.0179  MOREHOUSE
190133......................       0.0238  ALLEN
190144......................       0.0705  WEBSTER
190147......................       0.0401  TANGIPAHOA
190148......................        0.039  AVOYELLES
190191*.....................       0.0235  ST. LANDRY
200002*.....................       0.0129  LINCOLN
200013......................       0.0186  WALDO
200019......................       0.0067  YORK
200020*.....................       0.0067  YORK
200024*.....................       0.0071  ANDROSCOGGIN
200032......................        0.046  OXFORD
200034*.....................       0.0071  ANDROSCOGGIN
200040......................       0.0067  YORK
200050*.....................       0.0140  HANCOCK
210001......................       0.0129  WASHINGTON
210004......................       0.0040  MONTGOMERY
210016......................       0.0040  MONTGOMERY
210018......................       0.0040  MONTGOMERY
210022......................       0.0040  MONTGOMERY
210023......................       0.0209  ANNE ARUNDEL
210028......................       0.0512  ST. MARYS
210043......................       0.0209  ANNE ARUNDEL
210048......................       0.0287  HOWARD
210057......................       0.0040  MONTGOMERY
220001*.....................       0.0056  WORCESTER
220002*.....................       0.0249  MIDDLESEX
220003*.....................       0.0056  WORCESTER
220006......................       0.0306  ESSEX
220010*.....................       0.0306  ESSEX
220011*.....................       0.0249  MIDDLESEX
220019*.....................       0.0056  WORCESTER
220025*.....................       0.0056  WORCESTER
220028*.....................       0.0056  WORCESTER
220029*.....................       0.0306  ESSEX
220033*.....................       0.0306  ESSEX
220035*.....................       0.0306  ESSEX
220049*.....................       0.0249  MIDDLESEX
220058*.....................       0.0056  WORCESTER
220062*.....................       0.0056  WORCESTER
220063*.....................       0.0249  MIDDLESEX
220070*.....................       0.0249  MIDDLESEX
220076......................       0.0249  MIDDLESEX
220080*.....................       0.0306  ESSEX
220082*.....................       0.0249  MIDDLESEX
220084*.....................       0.0249  MIDDLESEX
220089*.....................       0.0249  MIDDLESEX
220090*.....................       0.0056  WORCESTER
220095*.....................       0.0056  WORCESTER
220098*.....................       0.0249  MIDDLESEX
220101*.....................       0.0249  MIDDLESEX
220105*.....................       0.0249  MIDDLESEX
220163*.....................       0.0056  WORCESTER
220171*.....................       0.0249  MIDDLESEX
220174*.....................       0.0306  ESSEX
230003......................       0.0035  OTTAWA
230005......................       0.0598  LENAWEE
230013......................       0.0091  OAKLAND
230015......................       0.0359  ST. JOSEPH
230019......................       0.0091  OAKLAND
230021......................       0.0136  BERRIEN
230022*.....................       0.0113  BRANCH
230029......................       0.0091  OAKLAND
230037*.....................       0.0178  HILLSDALE
230041......................       0.0099  BAY
230042*.....................       0.0685  ALLEGAN
230047*.....................       0.0082  MACOMB
230069*.....................       0.0487  LIVINGSTON
230071......................       0.0091  OAKLAND
230072......................       0.0035  OTTAWA
230075......................       0.0145  CALHOUN
230078*.....................       0.0136  BERRIEN
230092......................       0.0389  JACKSON
230093*.....................       0.0079  MECOSTA
230096*.....................       0.0359  ST. JOSEPH
230099*.....................       0.0339  MONROE
230106......................       0.0030  NEWAYGO
230120......................       0.0598  LENAWEE
230121*.....................       0.0691  SHIAWASSEE
230130......................       0.0091  OAKLAND
230151......................       0.0091  OAKLAND
230174......................       0.0035  OTTAWA
230184......................       0.0389  JACKSON
230195*.....................       0.0082  MACOMB
230204*.....................       0.0082  MACOMB
230207......................       0.0091  OAKLAND
230217*.....................       0.0145  CALHOUN
230222......................       0.0228  MIDLAND
230223......................       0.0091  OAKLAND
230227*.....................       0.0082  MACOMB
230254......................       0.0091  OAKLAND
230257*.....................       0.0082  MACOMB
230264*.....................       0.0082  MACOMB

[[Page 23580]]

 
230269......................       0.0091  OAKLAND
230277......................       0.0091  OAKLAND
230279*.....................       0.0487  LIVINGSTON
230295*.....................       0.0685  ALLEGAN
240011......................       0.0506  MC LEOD
240013*.....................       0.0226  MORRISON
240014......................       0.0454  RICE
240018*.....................       0.1196  GOODHUE
240021......................       0.0897  LE SUEUR
240044......................       0.0868  WINONA
240064*.....................       0.0138  ITASCA
240069*.....................       0.0419  STEELE
240071*.....................       0.0454  RICE
240089......................       0.1196  GOODHUE
240133......................       0.0319  MEEKER
240152*.....................       0.0735  KANABEC
240154......................       0.0138  ITASCA
240187*.....................       0.0506  MC LEOD
240205......................       0.0138  ITASCA
240211*.....................       0.0705  PINE
250030......................       0.0318  LEAKE
250040*.....................       0.0294  JACKSON
250045......................       0.0042  HANCOCK
250088......................       0.0122  WILKINSON
250154......................       0.0318  LEAKE
260011*.....................       0.0007  COLE
260025*.....................       0.0078  MARION
260047*.....................       0.0007  COLE
260073......................       0.0197  BARTON
260074*.....................       0.0158  RANDOLPH
260097......................       0.0425  JOHNSON
260127......................       0.0158  PIKE
280054......................       0.0137  GAGE
280077*.....................       0.0089  DODGE
280123......................       0.0137  GAGE
290019*.....................       0.0026  CARSON CITY
290020......................       0.1013  NYE
300007*.....................       0.0080  HILLSBOROUGH
300011*.....................       0.0080  HILLSBOROUGH
300012*.....................       0.0080  HILLSBOROUGH
300017*.....................       0.0361  ROCKINGHAM
300020*.....................       0.0080  HILLSBOROUGH
300023*.....................       0.0361  ROCKINGHAM
300029*.....................       0.0361  ROCKINGHAM
300034*.....................       0.0080  HILLSBOROUGH
310002*.....................       0.0351  ESSEX
310009*.....................       0.0351  ESSEX
310010......................       0.0180  MERCER
310011......................       0.0181  CAPE MAY
310013*.....................       0.0351  ESSEX
310014......................       0.0156  CAMDEN
310018*.....................       0.0351  ESSEX
310021......................       0.0180  MERCER
310022......................       0.0156  CAMDEN
310029......................       0.0156  CAMDEN
310031*.....................       0.0137  BURLINGTON
310032*.....................       0.0065  CUMBERLAND
310038*.....................       0.0350  MIDDLESEX
310039......................       0.0350  MIDDLESEX
310044......................       0.0180  MERCER
310054*.....................       0.0351  ESSEX
310057......................       0.0137  BURLINGTON
310061......................       0.0137  BURLINGTON
310070*.....................       0.0350  MIDDLESEX
310076*.....................       0.0351  ESSEX
310078*.....................       0.0351  ESSEX
310083*.....................       0.0351  ESSEX
310086......................       0.0156  CAMDEN
310092......................       0.0180  MERCER
310093*.....................       0.0351  ESSEX
310096*.....................       0.0351  ESSEX
310108......................       0.0350  MIDDLESEX
310110......................       0.0180  MERCER
310119*.....................       0.0351  ESSEX
320003......................       0.0630  SAN MIGUEL
320011......................       0.0442  RIO ARRIBA
320018......................       0.0063  DONA ANA
320085......................       0.0063  DONA ANA
330001*.....................       0.0560  ORANGE
330004*.....................       0.0959  ULSTER
330008*.....................       0.0470  WYOMING
330027*.....................       0.0137  NASSAU
330094*.....................       0.0778  COLUMBIA
330106......................       0.0137  NASSAU
330126......................       0.0560  ORANGE
330135......................       0.0560  ORANGE
330167......................       0.0137  NASSAU
330175......................       0.0268  CORTLAND
330181*.....................       0.0137  NASSAU
330182*.....................       0.0137  NASSAU
330191*.....................       0.0026  WARREN
330198......................       0.0137  NASSAU
330205......................       0.0560  ORANGE
330209......................       0.0560  ORANGE
330222......................       0.0003  SARATOGA
330224......................       0.0959  ULSTER
330225......................       0.0137  NASSAU
330235*.....................       0.0270  CAYUGA
330259......................       0.0137  NASSAU
330264......................       0.0560  ORANGE
330276......................       0.0063  FULTON
330331......................       0.0137  NASSAU
330332......................       0.0137  NASSAU
330333......................       0.0137  NASSAU
330372......................       0.0137  NASSAU
330386*.....................       0.1139  SULLIVAN
330402......................       0.0959  ULSTER
340003......................       0.0116  SURRY
340015......................       0.0267  ROWAN
340016......................       0.1312  JACKSON
340020......................       0.0207  LEE
340021*.....................       0.0216  CLEVELAND
340027*.....................       0.0126  LENOIR
340037......................       0.0216  CLEVELAND
340039*.....................       0.0144  IREDELL
340069*.....................       0.0053  WAKE
340070......................       0.0448  ALAMANCE
340073*.....................       0.0053  WAKE
340085......................       0.0377  DAVIDSON
340088......................       0.0115  TRANSYLVANIA
340096......................       0.0377  DAVIDSON
340097......................       0.0116  SURRY
340104......................       0.0216  CLEVELAND
340114*.....................       0.0053  WAKE
340126......................       0.0161  WILSON
340127*.....................       0.0961  GRANVILLE
340129*.....................       0.0144  IREDELL
340133......................       0.0302  MARTIN
340138*.....................       0.0053  WAKE
340144*.....................       0.0144  IREDELL
340145*.....................       0.0563  LINCOLN
340173*.....................       0.0053  WAKE
360013*.....................       0.0166  SHELBY
360025*.....................       0.0087  ERIE
360034......................       0.0263  WAYNE
360036*.....................       0.0263  WAYNE
360040......................       0.0327  KNOX
360065*.....................       0.0141  HURON
360070......................       0.0028  STARK
360078*.....................       0.0159  PORTAGE
360084......................       0.0028  STARK
360086*.....................       0.0168  CLARK
360093......................       0.0120  DEFIANCE
360095......................       0.0087  HANCOCK
360096*.....................       0.0031  COLUMBIANA
360099......................       0.0087  HANCOCK
360100......................       0.0028  STARK
360107*.....................       0.0213  SANDUSKY
360131......................       0.0028  STARK
360151......................       0.0028  STARK
360156......................       0.0213  SANDUSKY
360175*.....................       0.0159  CLINTON
360177......................       0.0212  FAYETTE
360185*.....................       0.0031  COLUMBIANA
360187*.....................       0.0168  CLARK
360197*.....................       0.0092  LOGAN
370004*.....................       0.0193  OTTAWA
370014*.....................       0.0831  BRYAN
370015*.....................       0.0463  MAYES
370023......................       0.0084  STEPHENS
370043......................       0.0294  MARSHALL
370065......................       0.0121  CRAIG
370113*.....................       0.0205  DELAWARE
370138......................       0.0073  TEXAS
370149......................       0.0356  POTTAWATOMIE
370179*.....................       0.0314  OKFUSKEE
380002......................       0.0130  JOSEPHINE
380008*.....................       0.0201  LINN
380022*.....................       0.0201  LINN
380029......................       0.0073  MARION
380051......................       0.0073  MARION
380056......................       0.0073  MARION
390011......................       0.0012  CAMBRIA
390030*.....................       0.0274  SCHUYLKILL
390031*.....................       0.0274  SCHUYLKILL
390044......................       0.0200  BERKS
390046......................       0.0098  YORK
390052*.....................       0.0036  CLEARFIELD
390056......................       0.0042  HUNTINGDON
390065*.....................       0.0501  ADAMS
390066*.....................       0.0259  LEBANON
390086*.....................       0.0036  CLEARFIELD
390096......................       0.0200  BERKS
390101......................       0.0098  YORK
390110*.....................       0.0012  CAMBRIA
390130......................       0.0012  CAMBRIA
390138*.....................       0.0325  FRANKLIN
390146......................       0.0053  WARREN
390150*.....................       0.0206  GREENE
390151*.....................       0.0325  FRANKLIN
390162......................       0.0149  NORTHAMPTON
390173......................       0.0074  INDIANA
390181*.....................       0.0274  SCHUYLKILL
390183*.....................       0.0274  SCHUYLKILL
390201*.....................       0.1127  MONROE
390233......................       0.0098  YORK
420007......................       0.0001  SPARTANBURG
420009*.....................       0.0162  OCONEE
420020*.....................       0.0035  GEORGETOWN
420027......................       0.0210  ANDERSON
420030*.....................       0.0103  COLLETON
420039*.....................       0.0156  UNION
420043......................       0.0177  CHEROKEE
420062......................       0.0247  CHESTERFIELD
420068*.....................       0.0097  ORANGEBURG
420070*.....................       0.0101  SUMTER
420083......................       0.0001  SPARTANBURG

[[Page 23581]]

 
420093......................       0.0001  SPARTANBURG
420098......................       0.0035  GEORGETOWN
430008......................       0.0504  BROOKINGS
430048......................       0.0088  LAWRENCE
430094*.....................       0.0088  LAWRENCE
440008*.....................       0.0663  HENDERSON
440016......................       0.0224  CARROLL
440024......................       0.0387  BRADLEY
440025......................       0.0037  GREENE
440033......................       0.0159  CAMPBELL
440035*.....................       0.0441  MONTGOMERY
440047......................       0.0499  GIBSON
440050*.....................       0.0037  GREENE
440051......................       0.0110  MC NAIRY
440056......................       0.0321  JEFFERSON
440060*.....................       0.0499  GIBSON
440063......................       0.0011  WASHINGTON
440073*.....................       0.0513  MAURY
440105......................       0.0011  WASHINGTON
440114......................       0.0523  LAUDERDALE
440115......................       0.0499  GIBSON
440143......................       0.0448  MARSHALL
440148*.....................       0.0568  DE KALB
440153......................       0.0145  COCKE
440174......................       0.0372  HAYWOOD
440180*.....................       0.0159  CAMPBELL
440181......................       0.0407  HARDEMAN
440182......................       0.0224  CARROLL
440184......................       0.0011  WASHINGTON
440185*.....................       0.0387  BRADLEY
450032*.....................       0.0416  HARRISON
450039*.....................       0.0097  TARRANT
450050......................       0.0750  WARD
450059*.....................       0.0073  COMAL
450064*.....................       0.0097  TARRANT
450087*.....................       0.0097  TARRANT
450099*.....................       0.0180  GRAY
450113......................       0.0195  ANDERSON
450121*.....................       0.0097  TARRANT
450135*.....................       0.0097  TARRANT
450137*.....................       0.0097  TARRANT
450144*.....................       0.0573  ANDREWS
450151......................       0.0210  FAYETTE
450163......................       0.0134  KLEBERG
450187*.....................       0.0264  WASHINGTON
450194*.....................       0.0328  CHEROKEE
450214*.....................       0.0368  WHARTON
450224*.....................       0.0411  WOOD
450347*.....................       0.0427  WALKER
450362......................       0.0486  BURNET
450370......................       0.0258  COLORADO
450389*.....................       0.0881  HENDERSON
450395......................       0.0484  POLK
450419*.....................       0.0097  TARRANT
450438*.....................       0.0258  COLORADO
450447*.....................       0.0358  NAVARRO
450451*.....................       0.0551  SOMERVELL
450465......................       0.0435  MATAGORDA
450547*.....................       0.0411  WOOD
450563*.....................       0.0097  TARRANT
450565......................       0.0492  PALO PINTO
450596......................      10.0808  HOOD
450597......................       0.0077  DE WITT
450623*.....................       0.0492  FANNIN
450626......................       0.0294  JACKSON
450639*.....................       0.0097  TARRANT
450672*.....................       0.0097  TARRANT
450675*.....................       0.0097  TARRANT
450677*.....................       0.0097  TARRANT
450694*.....................       0.0368  WHARTON
450747*.....................       0.0195  ANDERSON
450755*.....................       0.0484  HOCKLEY
450763......................       0.0236  HUTCHINSON
450779*.....................       0.0097  TARRANT
450813......................       0.0195  ANDERSON
450858*.....................       0.0097  TARRANT
460017......................       0.0392  BOX ELDER
460036*.....................       0.0700  WASATCH
460039*.....................       0.0392  BOX ELDER
470018......................       0.0287  WINDSOR
470023......................       0.0118  CALEDONIA
490019......................       0.1240  CULPEPER
490038......................       0.0022  SMYTH
490047*.....................       0.0198  PAGE
490084......................       0.0167  ESSEX
490105*.....................       0.0022  SMYTH
490110......................       0.0082  MONTGOMERY
500003*.....................       0.0208  SKAGIT
500007......................       0.0208  SKAGIT
500019......................       0.0213  LEWIS
500021......................       0.0055  PIERCE
500024*.....................       0.0023  THURSTON
500039*.....................       0.0174  KITSAP
500041*.....................       0.0118  COWLITZ
500079......................       0.0055  PIERCE
500108......................       0.0055  PIERCE
500118......................       0.0548  MASON
500122*.....................       0.0459  ISLAND
500129......................       0.0055  PIERCE
500139*.....................       0.0023  THURSTON
500143*.....................       0.0023  THURSTON
510018*.....................       0.0209  JACKSON
510028*.....................       0.0141  FAYETTE
510039......................       0.0112  OHIO
510047*.....................       0.0275  MARION
510050......................       0.0112  OHIO
510077*.....................       0.0021  MINGO
510088......................       0.0141  FAYETTE
520028*.....................       0.0157  GREEN
520035......................       0.0077  SHEBOYGAN
520042......................       0.0118  SAUK
520044......................       0.0077  SHEBOYGAN
520057......................       0.0118  SAUK
520059*.....................       0.0200  RACINE
520071*.....................       0.0239  JEFFERSON
520076*.....................       0.0181  DODGE
520094*.....................       0.0200  RACINE
520095*.....................       0.0118  SAUK
520096*.....................       0.0200  RACINE
520102*.....................       0.0298  WALWORTH
520116*.....................       0.0239  JEFFERSON
520132......................       0.0077  SHEBOYGAN
------------------------------------------------------------------------


 Table 5.--List of Diagnosis-Related Groups (DRGs, Relative Weighting Factors, and Geometric and Arithmetic Mean
                                              Length of Stay (LOS)
----------------------------------------------------------------------------------------------------------------
         DRG              MDC              TYPE                 DRG Title         Weights    Mean LOS   Mean LOS
----------------------------------------------------------------------------------------------------------------
1....................         01  SURG.................  CRANIOTOMY AGE >17 W       3.4276        7.6       10.1
                                                          CC.
2....................         01  SURG.................  CRANIOTOMY AGE >17 W/O     1.9544        3.5        4.6
                                                          CC.
3....................         01  SURG *...............  CRANIOTOMY AGE 0-17...     1.9830       12.7       12.7
4....................         01  SURG.................  NO LONGER VALID.......      .0000         .0         .0
5....................         01  SURG.................  NO LONGER VALID.......      .0000         .0          0
6....................         01  SURG.................  CARPAL TUNNEL RELEASE.      .7868        2.2        3.1
7....................         01  SURG.................  PERIPH & CRANIAL NERVE     2.6679        6.6        9.5
                                                          & OTHER NERV SYST
                                                          PROC W CC.
8....................         01  SURG.................  PERIPH & CRANIAL NERVE     1.5008        2.0        2.9
                                                          & OTHER NERV SYST
                                                          PROC W/O CC.
9....................         01  MED..................  SPINAL DISORDERS &         1.3993        4.5        6.3
                                                          INJURIES.
10...................         01  MED..................  NERVOUS SYSTEM             1.2219        4.6        6.2
                                                          NEOPLASMS W CC.
11...................         01  MED..................  NERVOUS SYSTEM              .8704        2.9        3.8
                                                          NEOPLASMS W/O CC.
12...................         01  MED..................  DEGENERATIVE NERVOUS        .8972        4.3        5.5
                                                          SYSTEM DISORDERS.
13...................         01  MED..................  MULTIPLE SCLEROSIS &        .8520        4.0        5.0
                                                          CEREBELLAR ATAXIA.
14...................         01  MED..................  INTRACRANIAL               1.2533        4.5        5.8
                                                          HEMORRHAGE OR STROKE
                                                          WITH INFARCT.
15...................         01  MED..................  NONSPECIFIC CVA &           .9402        3.7        4.6
                                                          PRECEREBRAL OCCLUSION
                                                          W/O INFARCT.
16...................         01  MED..................  NONSPECIFIC                1.3315        5.0        6.5
                                                          CEREBROVASCULAR
                                                          DISORDERS W CC.
17...................         01  MED..................  NONSPECIFIC                 .7191        2.5        3.2
                                                          CEREBROVASCULAR
                                                          DISORDERS W/O CC.
18...................         01  MED..................  CRANIAL & PERIPHERAL        .9891        4.1        5.3
                                                          NERVE DISORDERS W CC.
19...................         01  MED..................  CRANIAL & PERIPHERAL        .7058        2.7        3.4
                                                          NERVE DISORDERS W/O
                                                          CC.

[[Page 23582]]

 
20...................         01  MED..................  NERVOUS SYSTEM             2.7787        8.0       10.4
                                                          INFECTION EXCEPT
                                                          VIRAL MENINGITIS.
21...................         01  MED..................  VIRAL MENINGITIS......     1.4424        4.9        6.4
22...................         01  MED..................  HYPERTENSIVE               1.1269        4.0        5.2
                                                          ENCEPHALOPATHY.
23...................         01  MED..................  NONTRAUMATIC STUPOR &       .7695        3.0        3.9
                                                          COMA.
24...................         01  MED..................  SEIZURE & HEADACHE AGE      .9954        3.6        4.8
                                                          >17 W CC.
25...................         01  MED..................  SEIZURE & HEADACHE AGE      .6165        2.5        3.1
                                                          >17 W/O CC.
26...................         01  MED..................  SEIZURE & HEADACHE AGE     1.8098        3.4        6.3
                                                          0-17.
27...................         01  MED..................  TRAUMATIC STUPOR &         1.3455        3.2        5.1
                                                          COMA, COMA >1 HR.
28...................         01  MED..................  TRAUMATIC STUPOR &         1.3324        4.4        5.9
                                                          COMA, COMA <1 HR AGE
                                                          >17 W CC.
29...................         01  MED..................  TRAUMATIC STUPOR &          .7210        2.6        3.4
                                                          COMA, COMA <1 HR AGE
                                                          >17 W/O CC.
30...................         01  MED *................  TRAUMATIC STUPOR &          .3354        2.0        2.0
                                                          COMA, COMA <1 HR AGE
                                                          0-17.
31...................         01  MED..................  CONCUSSION AGE >17 W        .9529        3.0        4.0
                                                          CC.
32...................         01  MED..................  CONCUSSION AGE >17 W/O      .6185        1.9        2.4
                                                          CC.
33...................         01  MED *................  CONCUSSION AGE 0-17...      .2106        1.6        1.6
34...................         01  MED..................  OTHER DISORDERS OF         1.0047        3.7        4.8
                                                          NERVOUS SYSTEM W CC.
35...................         01  MED..................  OTHER DISORDERS OF          .6253        2.4        3.0
                                                          NERVOUS SYSTEM W/O CC.
36...................         02  SURG.................  RETINAL PROCEDURES....      .7238        1.3        1.6
37...................         02  SURG.................  ORBITAL PROCEDURES....     1.1761        2.7        4.1
38...................         02  SURG.................  PRIMARY IRIS                .6963        2.5        3.5
                                                          PROCEDURES.
39...................         02  SURG.................  LENS PROCEDURES WITH        .7109        1.7        2.4
                                                          OR WITHOUT VITRECTOMY.
40...................         02  SURG.................  EXTRAOCULAR PROCEDURES      .9624        3.0        4.1
                                                          EXCEPT ORBIT AGE >17.
41...................         02  SURG *...............  EXTRAOCULAR PROCEDURES      .3414        1.6        1.6
                                                          EXCEPT ORBIT AGE 0-17.
42...................         02  SURG.................  INTRAOCULAR PROCEDURES      .7865        2.0        2.8
                                                          EXCEPT RETINA, IRIS &
                                                          LENS.
43...................         02  MED..................  HYPHEMA...............      .6146        2.4        3.1
44...................         02  MED..................  ACUTE MAJOR EYE             .6811        3.9        4.8
                                                          INFECTIONS.
45...................         02  MED..................  NEUROLOGICAL EYE            .7462        2.5        3.1
                                                          DISORDERS.
46...................         02  MED..................  OTHER DISORDERS OF THE      .7471        3.2        4.2
                                                          EYE AGE >17 W CC.
47...................         02  MED..................  OTHER DISORDERS OF THE      .5189        2.3        2.9
                                                          EYE AGE >17 W/O CC.
48...................         02  MED *................  OTHER DISORDERS OF THE      .3008        2.9        2.9
                                                          EYE AGE 0-17.
49...................         03  SURG.................  MAJOR HEAD & NECK          1.6375        3.2        4.4
                                                          PROCEDURES.
50...................         03  SURG.................  SIALOADENECTOMY.......      .8661        1.5        1.8
51...................         03  SURG.................  SALIVARY GLAND              .8829        1.9        2.8
                                                          PROCEDURES EXCEPT
                                                          SIALOADENECTOMY.
52...................         03  SURG.................  CLEFT LIP & PALATE          .8428        1.5        2.0
                                                          REPAIR.
53...................         03  SURG.................  SINUS & MASTOID            1.3302        2.5        4.0
                                                          PROCEDURES AGE >17.
54...................         03  SURG *...............  SINUS & MASTOID             .4874        3.2        3.2
                                                          PROCEDURES AGE 0-17.
55...................         03  SURG.................  MISCELLANEOUS EAR,          .9577        2.1        3.1
                                                          NOSE, MOUTH & THROAT
                                                          PROCEDURES.
56...................         03  SURG.................  RHINOPLASTY...........      .8623        1.9        2.6
57...................         03  SURG.................  T&A PROC, EXCEPT           1.1330        2.6        4.2
                                                          TONSILLECTOMY &/OR
                                                          ADENOIDECTOMY ONLY,
                                                          AGE >17.
58...................         03  SURG *...............  T&A PROC, EXCEPT            .2768        1.5        1.5
                                                          TONSILLECTOMY &/OR
                                                          ADENOIDECTOMY ONLY,
                                                          AGE 0-17.
59...................         03  SURG.................  TONSILLECTOMY &/OR          .7950        1.8        2.5
                                                          ADENOIDECTOMY ONLY,
                                                          AGE >17.
60...................         03  SURG *...............  TONSILLECTOMY &/OR          .2107        1.5        1.5
                                                          ADENOIDECTOMY ONLY,
                                                          AGE 0-17.
61...................         03  SURG.................  MYRINGOTOMY W TUBE         1.2804        3.3        5.4
                                                          INSERTION AGE >17.
62...................         03  SURG *...............  MYRINGOTOMY W TUBE          .2984        1.3        1.3
                                                          INSERTION AGE 0-17.
63...................         03  SURG.................  OTHER EAR, NOSE, MOUTH     1.3908        3.0        4.5
                                                          & THROAT O.R.
                                                          PROCEDURES.
64...................         03  MED..................  EAR, NOSE, MOUTH &         1.1606        4.1        6.1
                                                          THROAT MALIGNANCY.
65...................         03  MED..................  DYSEQUILIBRIUM........      .5987        2.3        2.8
66...................         03  MED..................  EPISTAXIS.............      .5940        2.4        3.1
67...................         03  MED..................  EPIGLOTTITIS..........      .7724        2.9        3.7
68...................         03  MED..................  OTITIS MEDIA & URI AGE      .6646        3.2        4.0
                                                          >17 W CC.
69...................         03  MED..................  OTITIS MEDIA & URI AGE      .4860        2.5        3.0
                                                          >17 W/O CC.
70...................         03  MED..................  OTITIS MEDIA & URI AGE      .4062        2.1        2.4
                                                          0-17.
71...................         03  MED..................  LARYNGOTRACHEITIS.....      .7509        3.2        4.0
72...................         03  MED..................  NASAL TRAUMA &              .7479        2.6        3.5
                                                          DEFORMITY.
73...................         03  MED..................  OTHER EAR, NOSE, MOUTH      .8285        3.3        4.4
                                                          & THROAT DIAGNOSES
                                                          AGE >17.
74...................         03  MED *................  OTHER EAR, NOSE, MOUTH      .3393        2.1        2.1
                                                          & THROAT DIAGNOSES
                                                          AGE 0-17.
75...................         04  SURG.................  MAJOR CHEST PROCEDURES     3.0699        7.6        9.9
76...................         04  SURG.................  OTHER RESP SYSTEM O.R.     2.8748        8.4       11.1
                                                          PROCEDURES W CC.
77...................         04  SURG.................  OTHER RESP SYSTEM O.R.     1.1897        3.4        4.7
                                                          PROCEDURES W/O CC.
78...................         04  MED..................  PULMONARY EMBOLISM....     1.2411        5.4        6.4
79...................         04  MED..................  RESPIRATORY INFECTIONS     1.6212        6.7        8.4
                                                          & INFLAMMATIONS AGE
                                                          >17 W CC.
80...................         04  MED..................  RESPIRATORY INFECTIONS      .8872        4.4        5.5
                                                          & INFLAMMATIONS AGE
                                                          >17 W/O CC.
81...................         04  MED *................  RESPIRATORY INFECTIONS     1.5360        6.1        6.1
                                                          & INFLAMMATIONS AGE 0-
                                                          17.
82...................         04  MED..................  RESPIRATORY NEOPLASMS.     1.3925        5.1        6.8
83...................         04  MED..................  MAJOR CHEST TRAUMA W        .9818        4.2        5.3
                                                          CC.
84...................         04  MED..................  MAJOR CHEST TRAUMA W/O      .5736        2.6        3.2
                                                          CC.
85...................         04  MED..................  PLEURAL EFFUSION W CC.     1.2401        4.8        6.4

[[Page 23583]]

 
86...................         04  MED..................  PLEURAL EFFUSION W/O        .6943        2.8        3.6
                                                          CC.
87...................         04  MED..................  PULMONARY EDEMA &          1.3592        4.9        6.4
                                                          RESPIRATORY FAILURE.
88...................         04  MED..................  CHRONIC OBSTRUCTIVE         .8854        4.0        4.9
                                                          PULMONARY DISEASE.
89...................         04  MED..................  SIMPLE PNEUMONIA &         1.0317        4.7        5.7
                                                          PLEURISY AGE >17 W CC.
90...................         04  MED..................  SIMPLE PNEUMONIA &          .6085        3.2        3.8
                                                          PLEURISY AGE >17 W/O
                                                          CC.
91...................         04  MED..................  SIMPLE PNEUMONIA &          .8173        3.4        4.4
                                                          PLEURISY AGE 0-17.
92...................         04  MED..................  INTERSTITIAL LUNG          1.1859        4.9        6.1
                                                          DISEASE W CC.
93...................         04  MED..................  INTERSTITIAL LUNG           .7022        3.1        3.8
                                                          DISEASE W/O CC.
94...................         04  MED..................  PNEUMOTHORAX W CC.....     1.1435        4.7        6.2
95...................         04  MED..................  PNEUMOTHORAX W/O CC...      .6039        2.9        3.7
96...................         04  MED..................  BRONCHITIS & ASTHMA         .7356        3.6        4.4
                                                          AGE >17 W CC.
97...................         04  MED..................  BRONCHITIS & ASTHMA         .5340        2.8        3.4
                                                          AGE >17 W/O CC.
98...................         04  MED *................  BRONCHITIS & ASTHMA         .5552        3.7        3.7
                                                          AGE 0-17.
99...................         04  MED..................  RESPIRATORY SIGNS &         .7075        2.4        3.1
                                                          SYMPTOMS W CC.
100..................         04  MED..................  RESPIRATORY SIGNS &         .5386        1.7        2.1
                                                          SYMPTOMS W/O CC.
101..................         04  MED..................  OTHER RESPIRATORY           .8715        3.3        4.3
                                                          SYSTEM DIAGNOSES W CC.
102..................         04  MED..................  OTHER RESPIRATORY           .5390        2.0        2.5
                                                          SYSTEM DIAGNOSES W/O
                                                          CC.
103..................        PRE  SURG.................  HEART TRANSPLANT OR       18.3069       23.5       37.5
                                                          IMPLANT OF HEART
                                                          ASSIST SYSTEM.
104..................         05  SURG.................  CARDIAC VALVE & OTH        8.2206       12.7       14.9
                                                          MAJOR CARDIOTHORACIC
                                                          PROC W CARD CATH.
105..................         05  SURG.................  CARDIAC VALVE & OTH        6.0149        8.5       10.2
                                                          MAJOR CARDIOTHORACIC
                                                          PROC W/O CARD CATH.
106..................         05  SURG.................  CORONARY BYPASS W PTCA     7.0409        9.5       11.2
107..................         05  SURG.................  CORONARY BYPASS W          5.4802        9.4       10.7
                                                          CARDIAC CATH.
108..................         05  SURG.................  OTHER CARDIOTHORACIC       5.7861        8.6       10.9
                                                          PROCEDURES.
109..................         05  SURG.................  CORONARY BYPASS W/O        4.0452        6.8        7.9
                                                          PTCA OR CARDIAC CATH.
110..................         05  SURG.................  MAJOR CARDIOVASCULAR       3.8908        5.8        8.4
                                                          PROCEDURES W CC.
111..................         05  SURG.................  MAJOR CARDIOVASCULAR       2.4927        2.6        3.4
                                                          PROCEDURES W/O CC.
112..................         05  SURG.................  NO LONGER VALID.......      .0000         .0         .0
113..................         05  SURG.................  AMPUTATION FOR CIRC        3.1547       10.8       13.7
                                                          SYSTEM DISORDERS
                                                          EXCEPT UPPER LIMB &
                                                          TOE.
114..................         05  SURG.................  UPPER LIMB & TOE           1.7288        6.7        8.9
                                                          AMPUTATION FOR CIRC
                                                          SYSTEM DISORDERS.
115..................         05  SURG.................  PRM CARD PACEM IMPL W      3.5839        4.5        6.8
                                                          AMI/HR/SHOCK OR AICD
                                                          LEAD OR GNRTR.
116..................         05  SURG.................  OTHER PERMANENT            2.2975        3.0        4.3
                                                          CARDIAC PACEMAKER
                                                          IMPLANT.
117..................         05  SURG.................  CARDIAC PACEMAKER          1.3232        2.6        4.2
                                                          REVISION EXCEPT
                                                          DEVICE REPLACEMENT.
118..................         05  SURG.................  CARDIAC PACEMAKER          1.6347        2.1        3.0
                                                          DEVICE REPLACEMENT.
119..................         05  SURG.................  VEIN LIGATION &            1.3473        3.3        5.5
                                                          STRIPPING.
120..................         05  SURG.................  OTHER CIRCULATORY          2.3814        5.9        9.2
                                                          SYSTEM O.R.
                                                          PROCEDURES.
121..................         05  MED..................  CIRCULATORY DISORDERS      1.6110        5.3        6.6
                                                          W AMI & MAJOR COMP,
                                                          DISCHARGED ALIVE.
122..................         05  MED..................  CIRCULATORY DISORDERS       .9818        2.8        3.5
                                                          W AMI W/O MAJOR COMP,
                                                          DISCHARGED ALIVE.
123..................         05  MED..................  CIRCULATORY DISORDERS      1.5321        2.9        4.8
                                                          W AMI, EXPIRED.
124..................         05  MED..................  CIRCULATORY DISORDERS      1.4417        3.3        4.4
                                                          EXCEPT AMI, W CARD
                                                          CATH & COMPLEX DIAG.
125..................         05  MED..................  CIRCULATORY DISORDERS      1.0932        2.1        2.7
                                                          EXCEPT AMI, W CARD
                                                          CATH W/O COMPLEX DIAG.
126..................         05  MED..................  ACUTE & SUBACUTE           2.7261        9.4       11.9
                                                          ENDOCARDITIS.
127..................         05  MED..................  HEART FAILURE & SHOCK.     1.0330        4.1        5.2
128..................         05  MED..................  DEEP VEIN                   .6919        4.4        5.2
                                                          THROMBOPHLEBITIS.
129..................         05  MED..................  CARDIAC ARREST,            1.0365        1.7        2.6
                                                          UNEXPLAINED.
130..................         05  MED..................  PERIPHERAL VASCULAR         .9412        4.4        5.5
                                                          DISORDERS W CC.
131..................         05  MED..................  PERIPHERAL VASCULAR         .5555        3.2        3.9
                                                          DISORDERS W/O CC.
132..................         05  MED..................  ATHEROSCLEROSIS W CC..      .6252        2.2        2.8
133..................         05  MED..................  ATHEROSCLEROSIS W/O CC      .5323        1.8        2.2
134..................         05  MED..................  HYPERTENSION..........      .6057        2.5        3.1
135..................         05  MED..................  CARDIAC CONGENITAL &        .8969        3.3        4.4
                                                          VALVULAR DISORDERS
                                                          AGE >17 W CC.
136..................         05  MED..................  CARDIAC CONGENITAL &        .6228        2.2        2.8
                                                          VALVULAR DISORDERS
                                                          AGE >17 W/O CC.
137..................         05  MED *................  CARDIAC CONGENITAL &        .8275        3.3        3.3
                                                          VALVULAR DISORDERS
                                                          AGE 0-17.
138..................         05  MED..................  CARDIAC ARRHYTHMIA &        .8313        3.1        3.9
                                                          CONDUCTION DISORDERS
                                                          W CC.
139..................         05  MED..................  CARDIAC ARRHYTHMIA &        .5222        2.0        2.4
                                                          CONDUCTION DISORDERS
                                                          W/O CC.
140..................         05  MED..................  ANGINA PECTORIS.......      .5076        2.0        2.4
141..................         05  MED..................  SYNCOPE & COLLAPSE W        .7513        2.7        3.5
                                                          CC.
142..................         05  MED..................  SYNCOPE & COLLAPSE W/O      .5848        2.0        2.5
                                                          CC.
143..................         05  MED..................  CHEST PAIN............      .5655        1.7        2.1

[[Page 23584]]

 
144..................         05  MED..................  OTHER CIRCULATORY          1.2734        4.1        5.8
                                                          SYSTEM DIAGNOSES W CC.
145..................         05  MED..................  OTHER CIRCULATORY           .5843        2.1        2.6
                                                          SYSTEM DIAGNOSES W/O
                                                          CC.
146..................         06  SURG.................  RECTAL RESECTION W CC.     2.6565        8.6       10.0
147..................         06  SURG.................  RECTAL RESECTION W/O       1.4778        5.2        5.8
                                                          CC.
148..................         06  SURG.................  MAJOR SMALL & LARGE        3.4400       10.0       12.3
                                                          BOWEL PROCEDURES W CC.
149..................         06  SURG.................  MAJOR SMALL & LARGE        1.4304        5.4        6.0
                                                          BOWEL PROCEDURES W/O
                                                          CC.
150..................         06  SURG.................  PERITONEAL                 2.7986        8.9       11.0
                                                          ADHESIOLYSIS W CC.
151..................         06  SURG.................  PERITONEAL                 1.2620        4.0        5.1
                                                          ADHESIOLYSIS W/O CC.
152..................         06  SURG.................  MINOR SMALL & LARGE        1.8768        6.7        8.0
                                                          BOWEL PROCEDURES W CC.
153..................         06  SURG.................  MINOR SMALL & LARGE        1.0833        4.5        5.0
                                                          BOWEL PROCEDURES W/O
                                                          CC.
154..................         06  SURG.................  STOMACH, ESOPHAGEAL &      4.0333        9.9       13.2
                                                          DUODENAL PROCEDURES
                                                          AGE >17 W CC.
155..................         06  SURG.................  STOMACH, ESOPHAGEAL &      1.2855        3.1        4.1
                                                          DUODENAL PROCEDURES
                                                          AGE >17 W/O CC.
156..................         06  SURG *...............  STOMACH, ESOPHAGEAL &       .8522        6.0        6.0
                                                          DUODENAL PROCEDURES
                                                          AGE 0-17.
157..................         06  SURG.................  ANAL & STOMAL              1.3317        4.1        5.8
                                                          PROCEDURES W CC.
158..................         06  SURG.................  ANAL & STOMAL               .6634        2.1        2.6
                                                          PROCEDURES W/O CC.
159..................         06  SURG.................  HERNIA PROCEDURES          1.4163        3.8        5.1
                                                          EXCEPT INGUINAL &
                                                          FEMORAL AGE >17 W CC.
160..................         06  SURG.................  HERNIA PROCEDURES           .8423        2.2        2.7
                                                          EXCEPT INGUINAL &
                                                          FEMORAL AGE >17 W/O
                                                          CC.
161..................         06  SURG.................  INGUINAL & FEMORAL         1.1998        3.1        4.4
                                                          HERNIA PROCEDURES AGE
                                                          >17 W CC.
162..................         06  SURG.................  INGUINAL & FEMORAL          .6763        1.7        2.1
                                                          HERNIA PROCEDURES AGE
                                                          >17 W/O CC.
163..................         06  SURG.................  HERNIA PROCEDURES AGE       .6711        2.2        2.9
                                                          0-17.
164..................         06  SURG.................  APPENDECTOMY W             2.2488        6.6        8.0
                                                          COMPLICATED PRINCIPAL
                                                          DIAG W CC.
165..................         06  SURG.................  APPENDECTOMY W             1.1833        3.6        4.2
                                                          COMPLICATED PRINCIPAL
                                                          DIAG W/O CC.
166..................         06  SURG.................  APPENDECTOMY W/O           1.4517        3.3        4.5
                                                          COMPLICATED PRINCIPAL
                                                          DIAG W CC.
167..................         06  SURG.................  APPENDECTOMY W/O            .8918        1.9        2.2
                                                          COMPLICATED PRINCIPAL
                                                          DIAG W/O CC.
168..................         03  SURG.................  MOUTH PROCEDURES W CC.     1.2650        3.3        4.9
169..................         03  SURG.................  MOUTH PROCEDURES W/O        .7251        1.8        2.3
                                                          CC.
170..................         06  SURG.................  OTHER DIGESTIVE SYSTEM     2.9522        7.8       11.0
                                                          O.R. PROCEDURES W CC.
171..................         06  SURG.................  OTHER DIGESTIVE SYSTEM     1.1837        3.1        4.1
                                                          O.R. PROCEDURES W/O
                                                          CC.
172..................         06  MED..................  DIGESTIVE MALIGNANCY W     1.4115        5.1        7.0
                                                          CC.
173..................         06  MED..................  DIGESTIVE MALIGNANCY W/     .7442        2.7        3.6
                                                          O CC.
174..................         06  MED..................  G.I. HEMORRHAGE W CC..     1.0138        3.8        4.7
175..................         06  MED..................  G.I. HEMORRHAGE W/O CC      .5644        2.4        2.9
176..................         06  MED..................  COMPLICATED PEPTIC         1.1228        4.1        5.2
                                                          ULCER.
177..................         06  MED..................  UNCOMPLICATED PEPTIC        .9158        3.6        4.4
                                                          ULCER W CC.
178..................         06  MED..................  UNCOMPLICATED PEPTIC        .7014        2.6        3.1
                                                          ULCER W/O CC.
179..................         06  MED..................  INFLAMMATORY BOWEL         1.0877        4.5        5.9
                                                          DISEASE.
180..................         06  MED..................  G.I. OBSTRUCTION W CC.      .9769        4.2        5.4
181..................         06  MED..................  G.I. OBSTRUCTION W/O        .5609        2.8        3.3
                                                          CC.
182..................         06  MED..................  ESOPHAGITIS, GASTROENT      .8463        3.4        4.5
                                                          & MISC DIGEST
                                                          DISORDERS AGE >17 W
                                                          CC.
183..................         06  MED..................  ESOPHAGITIS, GASTROENT      .5846        2.3        2.9
                                                          & MISC DIGEST
                                                          DISORDERS AGE >17 W/O
                                                          CC.
184..................         06  MED..................  ESOPHAGITIS, GASTROENT      .5700        2.5        3.3
                                                          & MISC DIGEST
                                                          DISORDERS AGE 0-17.
185..................         03  MED..................  DENTAL & ORAL DIS           .8689        3.3        4.5
                                                          EXCEPT EXTRACTIONS &
                                                          RESTORATIONS, AGE >17.
186..................         03  MED *................  DENTAL & ORAL DIS           .3248        2.9        2.9
                                                          EXCEPT EXTRACTIONS &
                                                          RESTORATIONS, AGE 0-
                                                          17.
187..................         03  MED..................  DENTAL EXTRACTIONS &        .8435        3.1        4.2
                                                          RESTORATIONS.
188..................         06  MED..................  OTHER DIGESTIVE SYSTEM     1.1257        4.2        5.6
                                                          DIAGNOSES AGE >17 W
                                                          CC.
189..................         06  MED..................  OTHER DIGESTIVE SYSTEM      .6052        2.4        3.1
                                                          DIAGNOSES AGE >17 W/O
                                                          CC.
190..................         06  MED..................  OTHER DIGESTIVE SYSTEM      .6258        3.2        4.4
                                                          DIAGNOSES AGE 0-17.
191..................         07  SURG.................  PANCREAS, LIVER &          3.9443        9.0       12.8
                                                          SHUNT PROCEDURES W CC.
192..................         07  SURG.................  PANCREAS, LIVER &          1.6802        4.3        5.7
                                                          SHUNT PROCEDURES W/O
                                                          CC.
193..................         07  SURG.................  BILIARY TRACT PROC         3.2837        9.9       12.1
                                                          EXCEPT ONLY CHOLECYST
                                                          W OR W/O C.D.E. W CC.
194..................         07  SURG.................  BILIARY TRACT PROC         1.5786        5.6        6.7
                                                          EXCEPT ONLY CHOLECYST
                                                          W OR W/O C.D.E. W/O
                                                          CC.
195..................         07  SURG.................  CHOLECYSTECTOMY W          3.0503        8.8       10.6
                                                          C.D.E. W CC.
196..................         07  SURG.................  CHOLECYSTECTOMY W          1.6011        4.9        5.7
                                                          C.D.E. W/O CC.
197..................         07  SURG.................  CHOLECYSTECTOMY EXCEPT     2.5397        7.5        9.2
                                                          BY LAPAROSCOPE W/O
                                                          C.D.E. W CC.
198..................         07  SURG.................  CHOLECYSTECTOMY EXCEPT     1.1571        3.7        4.3
                                                          BY LAPAROSCOPE W/O
                                                          C.D.E. W/O CC.

[[Page 23585]]

 
199..................         07  SURG.................  HEPATOBILIARY              2.4077        6.8        9.5
                                                          DIAGNOSTIC PROCEDURE
                                                          FOR MALIGNANCY.
200..................         07  SURG.................  HEPATOBILIARY              2.7777        6.4        9.8
                                                          DIAGNOSTIC PROCEDURE
                                                          FOR NON-MALIGNANCY.
201..................         07  SURG.................  OTHER HEPATOBILIARY OR     3.7156        9.9       13.8
                                                          PANCREAS O.R.
                                                          PROCEDURES.
202..................         07  MED..................  CIRRHOSIS & ALCOHOLIC      1.3463        4.7        6.3
                                                          HEPATITIS.
203..................         07  MED..................  MALIGNANCY OF              1.3719        4.9        6.6
                                                          HEPATOBILIARY SYSTEM
                                                          OR PANCREAS.
204..................         07  MED..................  DISORDERS OF PANCREAS      1.1216        4.2        5.6
                                                          EXCEPT MALIGNANCY.
205..................         07  MED..................  DISORDERS OF LIVER         1.2026        4.4        6.0
                                                          EXCEPT MALIG, CIRR,
                                                          ALC HEPA W CC.
206..................         07  MED..................  DISORDERS OF LIVER          .7289        3.0        3.9
                                                          EXCEPT MALIG, CIRR,
                                                          ALC HEPA W/O CC.
207..................         07  MED..................  DISORDERS OF THE           1.1730        4.1        5.3
                                                          BILIARY TRACT W CC.
208..................         07  MED..................  DISORDERS OF THE            .6880        2.3        2.9
                                                          BILIARY TRACT W/O CC.
209..................         08  SURG.................  NO LONGER VALID.......      .0000       17.1       17.1
210..................         08  SURG.................  HIP & FEMUR PROCEDURES     1.9035        6.1        6.9
                                                          EXCEPT MAJOR JOINT
                                                          AGE >17 W CC.
211..................         08  SURG.................  HIP & FEMUR PROCEDURES     1.2676        4.4        4.7
                                                          EXCEPT MAJOR JOINT
                                                          AGE >17 W/O CC.
212..................         08  SURG.................  HIP & FEMUR PROCEDURES     1.2786        2.4        2.9
                                                          EXCEPT MAJOR JOINT
                                                          AGE 0-17.
213..................         08  SURG.................  AMPUTATION FOR             2.0393        7.2        9.7
                                                          MUSCULOSKELETAL
                                                          SYSTEM & CONN TISSUE
                                                          DISORDERS.
214..................         08  SURG.................  NO LONGER VALID.......      .0000         .0         .0
215..................         08  SURG.................  NO LONGER VALID.......      .0000         .0         .0
216..................         08  SURG.................  BIOPSIES OF                1.9099        3.3        5.8
                                                          MUSCULOSKELETAL
                                                          SYSTEM & CONNECTIVE
                                                          TISSUE.
217..................         08  SURG.................  WND DEBRID & SKN GRFT      3.0414        9.3       13.2
                                                          EXCEPT HAND, FOR
                                                          MUSCSKELET & CONN
                                                          TISS DIS.
218..................         08  SURG.................  LOWER EXTREM & HUMER       1.6068        4.3        5.5
                                                          PROC EXCEPT HIP,
                                                          FOOT, FEMUR AGE >17 W
                                                          CC.
219..................         08  SURG.................  LOWER EXTREM & HUMER       1.0427        2.6        3.1
                                                          PROC EXCEPT HIP,
                                                          FOOT, FEMUR AGE >17 W/
                                                          O CC.
220..................         08  SURG *...............  LOWER EXTREM & HUMER        .5904        5.3        5.3
                                                          PROC EXCEPT HIP,
                                                          FOOT, FEMUR AGE 0-17.
221..................         08  SURG.................  NO LONGER VALID.......      .0000         .0         .0
222..................         08  SURG.................  NO LONGER VALID.......      .0000         .0         .0
223..................         08  SURG.................  MAJOR SHOULDER/ELBOW       1.1119        2.3        3.2
                                                          PROC, OR OTHER UPPER
                                                          EXTREMITY PROC W CC.
224..................         08  SURG.................  SHOULDER, ELBOW OR          .8172        1.6        1.9
                                                          FOREARM PROC, EXC
                                                          MAJOR JOINT PROC, W/O
                                                          CC.
225..................         08  SURG.................  FOOT PROCEDURES.......     1.2189        3.7        5.2
226..................         08  SURG.................  SOFT TISSUE PROCEDURES     1.5839        4.5        6.5
                                                          W CC.
227..................         08  SURG.................  SOFT TISSUE PROCEDURES      .8338        2.1        2.6
                                                          W/O CC.
228..................         08  SURG.................  MAJOR THUMB OR JOINT       1.1414        2.8        4.1
                                                          PROC, OR OTH HAND OR
                                                          WRIST PROC W CC.
229..................         08  SURG.................  HAND OR WRIST PROC,         .6957        1.9        2.5
                                                          EXCEPT MAJOR JOINT
                                                          PROC, W/O CC.
230..................         08  SURG.................  LOCAL EXCISION &           1.3137        3.7        5.6
                                                          REMOVAL OF INT FIX
                                                          DEVICES OF HIP &
                                                          FEMUR.
231..................         08  SURG.................  NO LONGER VALID.......      .0000         .0         .0
232..................         08  SURG.................  ARTHROSCOPY...........      .9699        1.8        2.8
233..................         08  SURG.................  OTHER MUSCULOSKELET        1.9137        4.6        6.8
                                                          SYS & CONN TISS O.R.
                                                          PROC W CC.
234..................         08  SURG.................  OTHER MUSCULOSKELET        1.2204        2.0        2.8
                                                          SYS & CONN TISS O.R.
                                                          PROC W/O CC.
235..................         08  MED..................  FRACTURES OF FEMUR....      .7770        3.8        4.8
236..................         08  MED..................  FRACTURES OF HIP &          .7393        3.8        4.6
                                                          PELVIS.
237..................         08  MED..................  SPRAINS, STRAINS, &         .6084        3.0        3.7
                                                          DISLOCATIONS OF HIP,
                                                          PELVIS & THIGH.
238..................         08  MED..................  OSTEOMYELITIS.........     1.4237        6.7        8.6
239..................         08  MED..................  PATHOLOGICAL FRACTURES     1.0758        5.0        6.2
                                                          & MUSCULOSKELETAL &
                                                          CONN TISS MALIGNANCY.
240..................         08  MED..................  CONNECTIVE TISSUE          1.4024        5.0        6.7
                                                          DISORDERS W CC.
241..................         08  MED..................  CONNECTIVE TISSUE           .6613        3.0        3.7
                                                          DISORDERS W/O CC.
242..................         08  MED..................  SEPTIC ARTHRITIS......     1.1452        5.1        6.7
243..................         08  MED..................  MEDICAL BACK PROBLEMS.      .7752        3.6        4.6
244..................         08  MED..................  BONE DISEASES &             .7098        3.6        4.5
                                                          SPECIFIC
                                                          ARTHROPATHIES W CC.
245..................         08  MED..................  BONE DISEASES &             .4555        2.5        3.1
                                                          SPECIFIC
                                                          ARTHROPATHIES W/O CC.
246..................         08  MED..................  NON-SPECIFIC                .5910        2.8        3.6
                                                          ARTHROPATHIES.
247..................         08  MED..................  SIGNS & SYMPTOMS OF         .5787        2.6        3.3
                                                          MUSCULOSKELETAL
                                                          SYSTEM & CONN TISSUE.
248..................         08  MED..................  TENDONITIS, MYOSITIS &      .8556        3.8        4.8
                                                          BURSITIS.
249..................         08  MED..................  AFTERCARE,                  .7025        2.7        3.8
                                                          MUSCULOSKELETAL
                                                          SYSTEM & CONNECTIVE
                                                          TISSUE.

[[Page 23586]]

 
250..................         08  MED..................  FX, SPRN, STRN & DISL       .6949        3.2        3.9
                                                          OF FOREARM, HAND,
                                                          FOOT AGE >17 W CC.
251..................         08  MED..................  FX, SPRN, STRN & DISL       .4752        2.3        2.8
                                                          OF FOREARM, HAND,
                                                          FOOT AGE >17 W/O CC.
252..................         08  MED *................  FX, SPRN, STRN & DISL       .2563        1.8        1.8
                                                          OF FOREARM, HAND,
                                                          FOOT AGE 0-17.
253..................         08  MED..................  FX, SPRN, STRN & DISL       .7734        3.8        4.6
                                                          OF UPARM, LOWLEG EX
                                                          FOOT AGE >17 W CC.
254..................         08  MED..................  FX, SPRN, STRN & DISL       .4588        2.6        3.1
                                                          OF UPARM, LOWLEG EX
                                                          FOOT AGE >17 W/O CC.
255..................         08  MED *................  FX, SPRN, STRN & DISL       .2985        2.9        2.9
                                                          OF UPARM, LOWLEG EX
                                                          FOOT AGE 0-17.
256..................         08  MED..................  OTHER MUSCULOSKELETAL       .8459        3.9        5.1
                                                          SYSTEM & CONNECTIVE
                                                          TISSUE DIAGNOSES.
257..................         09  SURG.................  TOTAL MASTECTOMY FOR        .8958        2.0        2.6
                                                          MALIGNANCY W CC.
258..................         09  SURG.................  TOTAL MASTECTOMY FOR        .7129        1.5        1.7
                                                          MALIGNANCY W/O CC.
259..................         09  SURG.................  SUBTOTAL MASTECTOMY         .9650        1.8        2.8
                                                          FOR MALIGNANCY W CC.
260..................         09  SURG.................  SUBTOTAL MASTECTOMY         .7028        1.2        1.4
                                                          FOR MALIGNANCY W/O CC.
261..................         09  SURG.................  BREAST PROC FOR NON-        .9710        1.6        2.2
                                                          MALIGNANCY EXCEPT
                                                          BIOPSY & LOCAL
                                                          EXCISION.
262..................         09  SURG.................  BREAST BIOPSY & LOCAL       .9783        3.4        4.8
                                                          EXCISION FOR NON-
                                                          MALIGNANCY.
263..................         09  SURG.................  SKIN GRAFT &/OR DEBRID     2.1033        8.5       11.4
                                                          FOR SKN ULCER OR
                                                          CELLULITIS W CC.
264..................         09  SURG.................  SKIN GRAFT &/OR DEBRID     1.0576        5.0        6.5
                                                          FOR SKN ULCER OR
                                                          CELLULITIS W/O CC.
265..................         09  SURG.................  SKIN GRAFT &/OR DEBRID     1.6577        4.4        6.7
                                                          EXCEPT FOR SKIN ULCER
                                                          OR CELLULITIS W CC.
266..................         09  SURG.................  SKIN GRAFT &/OR DEBRID      .8664        2.3        3.2
                                                          EXCEPT FOR SKIN ULCER
                                                          OR CELLULITIS W/O CC.
267..................         09  SURG.................  PERIANAL & PILONIDAL        .8946        2.8        4.2
                                                          PROCEDURES.
268..................         09  SURG.................  SKIN, SUBCUTANEOUS         1.1389        2.4        3.5
                                                          TISSUE & BREAST
                                                          PLASTIC PROCEDURES.
269..................         09  SURG.................  OTHER SKIN, SUBCUT         1.8291        6.2        8.6
                                                          TISS & BREAST PROC W
                                                          CC.
270..................         09  SURG.................  OTHER SKIN, SUBCUT          .8270        2.7        3.8
                                                          TISS & BREAST PROC W/
                                                          O CC.
271..................         09  MED..................  SKIN ULCERS...........     1.0072        5.5        7.0
272..................         09  MED..................  MAJOR SKIN DISORDERS W      .9814        4.5        5.9
                                                          CC.
273..................         09  MED..................  MAJOR SKIN DISORDERS W/     .5536        2.9        3.7
                                                          O CC.
274..................         09  MED..................  MALIGNANT BREAST           1.1223        4.7        6.3
                                                          DISORDERS W CC.
275..................         09  MED..................  MALIGNANT BREAST            .5302        2.4        3.2
                                                          DISORDERS W/O CC.
276..................         09  MED..................  NON-MALIGANT BREAST         .6879        3.5        4.5
                                                          DISORDERS.
277..................         09  MED..................  CELLULITIS AGE >17 W        .8652        4.6        5.6
                                                          CC.
278..................         09  MED..................  CELLULITIS AGE >17 W/O      .5371        3.4        4.1
                                                          CC.
279..................         09  MED *................  CELLULITIS AGE 0-17...      .7810        4.2        4.2
280..................         09  MED..................  TRAUMA TO THE SKIN,         .7309        3.2        4.1
                                                          SUBCUT TISS & BREAST
                                                          AGE >17 W CC.
281..................         09  MED..................  TRAUMA TO THE SKIN,         .4897        2.3        2.9
                                                          SUBCUT TISS & BREAST
                                                          AGE >17 W/O CC.
282..................         09  MED *................  TRAUMA TO THE SKIN,         .2596        2.2        2.2
                                                          SUBCUT TISS & BREAST
                                                          AGE 0-17.
283..................         09  MED..................  MINOR SKIN DISORDERS W      .7398        3.5        4.6
                                                          CC.
284..................         09  MED..................  MINOR SKIN DISORDERS W/     .4563        2.4        3.0
                                                          O CC.
285..................         10  SURG.................  AMPUTAT OF LOWER LIMB      2.1793        8.2       10.5
                                                          FOR ENDOCRINE,
                                                          NUTRIT,& METABOL
                                                          DISORDERS.
286..................         10  SURG.................  ADRENAL & PITUITARY        1.9353        4.0        5.5
                                                          PROCEDURES.
287..................         10  SURG.................  SKIN GRAFTS & WOUND        1.9237        7.8       10.3
                                                          DEBRID FOR ENDOC,
                                                          NUTRIT & METAB
                                                          DISORDERS.
288..................         10  SURG.................  O.R. PROCEDURES FOR        2.0358        3.2        4.1
                                                          OBESITY.
289..................         10  SURG.................  PARATHYROID PROCEDURES      .9314        1.7        2.6
290..................         10  SURG.................  THYROID PROCEDURES....      .8875        1.6        2.1
291..................         10  SURG.................  THYROGLOSSAL               1.1155        1.5        2.8
                                                          PROCEDURES.
292..................         10  SURG.................  OTHER ENDOCRINE,           2.6316        7.3       10.3
                                                          NUTRIT & METAB O.R.
                                                          PROC W CC.
293..................         10  SURG.................  OTHER ENDOCRINE,           1.3434        3.2        4.5
                                                          NUTRIT & METAB O.R.
                                                          PROC W/O CC.
294..................         10  MED..................  DIABETES AGE >35......      .7642        3.3        4.3
295..................         10  MED..................  DIABETES AGE 0-35.....      .7250        2.9        3.7
296..................         10  MED..................  NUTRITIONAL & MISC          .8175        3.7        4.8
                                                          METABOLIC DISORDERS
                                                          AGE >17 W CC.
297..................         10  MED..................  NUTRITIONAL & MISC          .4845        2.5        3.1
                                                          METABOLIC DISORDERS
                                                          AGE >17 W/O CC.
298..................         10  MED..................  NUTRITIONAL & MISC          .5246        2.5        4.0
                                                          METABOLIC DISORDERS
                                                          AGE 0-17.
299..................         10  MED..................  INBORN ERRORS OF           1.0293        3.7        5.2
                                                          METABOLISM.
300..................         10  MED..................  ENDOCRINE DISORDERS W      1.0918        4.6        6.0
                                                          CC.
301..................         10  MED..................  ENDOCRINE DISORDERS W/      .6113        2.7        3.4
                                                          O CC.
302..................         11  SURG.................  KIDNEY TRANSPLANT.....     3.1542        7.0        8.2

[[Page 23587]]

 
303..................         11  SURG.................  KIDNEY, URETER & MAJOR     2.2358        5.9        7.4
                                                          BLADDER PROCEDURES
                                                          FOR NEOPLASM.
304..................         11  SURG.................  KIDNEY, URETER & MAJOR     2.3647        6.1        8.6
                                                          BLADDER PROC FOR NON-
                                                          NEOPL W CC.
305..................         11  SURG.................  KIDNEY, URETER & MAJOR     1.1580        2.6        3.2
                                                          BLADDER PROC FOR NON-
                                                          NEOPL W/O CC.
306..................         11  SURG.................  PROSTATECTOMY W CC....     1.2674        3.6        5.5
307..................         11  SURG.................  PROSTATECTOMY W/O CC..      .6192        1.7        2.1
308..................         11  SURG.................  MINOR BLADDER              1.6518        4.0        6.2
                                                          PROCEDURES W CC.
309..................         11  SURG.................  MINOR BLADDER               .9082        1.6        2.0
                                                          PROCEDURES W/O CC.
310..................         11  SURG.................  TRANSURETHRAL              1.1948        3.1        4.5
                                                          PROCEDURES W CC.
311..................         11  SURG.................  TRANSURETHRAL               .6425        1.5        1.9
                                                          PROCEDURES W/O CC.
312..................         11  SURG.................  URETHRAL PROCEDURES,       1.1170        3.2        4.8
                                                          AGE >17 W CC.
313..................         11  SURG.................  URETHRAL PROCEDURES,        .6756        1.8        2.2
                                                          AGE >17 W/O CC.
314..................         11  SURG *...............  URETHRAL PROCEDURES,        .5004        2.3        2.3
                                                          AGE 0-17.
315..................         11  SURG.................  OTHER KIDNEY & URINARY     2.0801        3.6        6.8
                                                          TRACT O.R. PROCEDURES.
316..................         11  MED..................  RENAL FAILURE.........     1.2673        4.9        6.4
317..................         11  MED..................  ADMIT FOR RENAL             .7965        2.4        3.5
                                                          DIALYSIS.
318..................         11  MED..................  KIDNEY & URINARY TRACT     1.1535        4.2        5.8
                                                          NEOPLASMS W CC.
319..................         11  MED..................  KIDNEY & URINARY TRACT      .6388        2.1        2.8
                                                          NEOPLASMS W/O CC.
320..................         11  MED..................  KIDNEY & URINARY TRACT      .8644        4.2        5.2
                                                          INFECTIONS AGE >17 W
                                                          CC.
321..................         11  MED..................  KIDNEY & URINARY TRACT      .5644        3.0        3.6
                                                          INFECTIONS AGE >17 W/
                                                          O CC.
322..................         11  MED..................  KIDNEY & URINARY TRACT      .5569        2.9        3.5
                                                          INFECTIONS AGE 0-17.
323..................         11  MED..................  URINARY STONES W CC, &/     .8200        2.3        3.1
                                                          OR ESW LITHOTRIPSY.
324..................         11  MED..................  URINARY STONES W/O CC.      .5045        1.6        1.9
325..................         11  MED..................  KIDNEY & URINARY TRACT      .6417        2.9        3.7
                                                          SIGNS & SYMPTOMS AGE
                                                          >17 W CC.
326..................         11  MED..................  KIDNEY & URINARY TRACT      .4385        2.1        2.6
                                                          SIGNS & SYMPTOMS AGE
                                                          >17 W/O CC.
327..................         11  MED *................  KIDNEY & URINARY TRACT      .3742        3.1        3.1
                                                          SIGNS & SYMPTOMS AGE
                                                          0-17.
328..................         11  MED..................  URETHRAL STRICTURE AGE      .7085        2.6        3.5
                                                          >17 W CC.
329..................         11  MED..................  URETHRAL STRICTURE AGE      .4712        1.5        1.8
                                                          >17 W/O CC.
330..................         11  MED *................  URETHRAL STRICTURE AGE      .3222        1.6        1.6
                                                          0-17.
331..................         11  MED..................  OTHER KIDNEY & URINARY     1.0606        4.1        5.5
                                                          TRACT DIAGNOSES AGE
                                                          >17 W CC.
332..................         11  MED..................  OTHER KIDNEY & URINARY      .6119        2.4        3.1
                                                          TRACT DIAGNOSES AGE
                                                          >17 W/O CC.
333..................         11  MED..................  OTHER KIDNEY & URINARY      .9788        3.6        5.4
                                                          TRACT DIAGNOSES AGE 0-
                                                          17.
334..................         12  SURG.................  MAJOR MALE PELVIC          1.4366        3.5        4.3
                                                          PROCEDURES W CC.
335..................         12  SURG.................  MAJOR MALE PELVIC          1.0980        2.4        2.7
                                                          PROCEDURES W/O CC.
336..................         12  SURG.................  TRANSURETHRAL               .8409        2.5        3.3
                                                          PROSTATECTOMY W CC.
337..................         12  SURG.................  TRANSURETHRAL               .5737        1.7        1.9
                                                          PROSTATECTOMY W/O CC.
338..................         12  SURG.................  TESTES PROCEDURES, FOR     1.3738        3.9        6.2
                                                          MALIGNANCY.
339..................         12  SURG.................  TESTES PROCEDURES, NON-    1.1809        3.2        5.1
                                                          MALIGNANCY AGE >17.
340..................         12  SURG *...............  TESTES PROCEDURES, NON-     .2864        2.4        2.4
                                                          MALIGNANCY AGE 0-17.
341..................         12  SURG.................  PENIS PROCEDURES......     1.2585        1.9        3.2
342..................         12  SURG.................  CIRCUMCISION AGE >17..      .8721        2.5        3.4
343..................         12  SURG *...............  CIRCUMCISION AGE 0-17.      .1557        1.7        1.7
344..................         12  SURG.................  OTHER MALE                 1.2458        1.7        2.7
                                                          REPRODUCTIVE SYSTEM
                                                          O.R. PROCEDURES FOR
                                                          MALIGNANCY.
345..................         12  SURG.................  OTHER MALE                 1.1474        3.1        4.8
                                                          REPRODUCTIVE SYSTEM
                                                          O.R. PROC EXCEPT FOR
                                                          MALIGNANCY.
346..................         12  MED..................  MALIGNANCY, MALE           1.0439        4.2        5.7
                                                          REPRODUCTIVE SYSTEM,
                                                          W CC.
347..................         12  MED..................  MALIGNANCY, MALE            .6080        2.2        3.0
                                                          REPRODUCTIVE SYSTEM,
                                                          W/O CC.
348..................         12  MED..................  BENIGN PROSTATIC            .7191        3.2        4.1
                                                          HYPERTROPHY W CC.
349..................         12  MED..................  BENIGN PROSTATIC            .4223        1.9        2.4
                                                          HYPERTROPHY W/O CC.
350..................         12  MED..................  INFLAMMATION OF THE         .7274        3.5        4.5
                                                          MALE REPRODUCTIVE
                                                          SYSTEM.
351..................         12  MED *................  STERILIZATION, MALE...      .2389        1.3        1.3
352..................         12  MED..................  OTHER MALE                  .7388        2.9        4.0
                                                          REPRODUCTIVE SYSTEM
                                                          DIAGNOSES.
353..................         13  SURG.................  PELVIC EVISCERATION,       1.8474        4.7        6.3
                                                          RADICAL HYSTERECTOMY
                                                          & RADICAL VULVECTOMY.
354..................         13  SURG.................  UTERINE, ADNEXA PROC       1.5238        4.6        5.7
                                                          FOR NON-OVARIAN/
                                                          ADNEXAL MALIG W CC.
355..................         13  SURG.................  UTERINE, ADNEXA PROC        .8834        2.8        3.1
                                                          FOR NON-OVARIAN/
                                                          ADNEXAL MALIG W/O CC.
356..................         13  SURG.................  FEMALE REPRODUCTIVE         .7429        1.7        1.9
                                                          SYSTEM RECONSTRUCTIVE
                                                          PROCEDURES.
357..................         13  SURG.................  UTERINE & ADNEXA PROC      2.2212        6.5        8.1
                                                          FOR OVARIAN OR
                                                          ADNEXAL MALIGNANCY.
358..................         13  SURG.................  UTERINE & ADNEXA PROC      1.1428        3.2        4.0
                                                          FOR NON-MALIGNANCY W
                                                          CC.

[[Page 23588]]

 
359..................         13  SURG.................  UTERINE & ADNEXA PROC       .7936        2.2        2.4
                                                          FOR NON-MALIGNANCY W/
                                                          O CC.
360..................         13  SURG.................  VAGINA, CERVIX & VULVA      .8559        2.0        2.6
                                                          PROCEDURES.
361..................         13  SURG.................  LAPAROSCOPY &              1.0844        2.2        3.0
                                                          INCISIONAL TUBAL
                                                          INTERRUPTION.
362..................         13  SURG *...............  ENDOSCOPIC TUBAL            .3053        1.4        1.4
                                                          INTERRUPTION.
363..................         13  SURG.................  D&C, CONIZATION &           .9742        2.7        3.8
                                                          RADIO-IMPLANT, FOR
                                                          MALIGNANCY.
364..................         13  SURG.................  D&C, CONIZATION EXCEPT      .8710        3.0        4.2
                                                          FOR MALIGNANCY.
365..................         13  SURG.................  OTHER FEMALE               2.0317        5.3        7.7
                                                          REPRODUCTIVE SYSTEM
                                                          O.R. PROCEDURES.
366..................         13  MED..................  MALIGNANCY, FEMALE         1.2296        4.8        6.5
                                                          REPRODUCTIVE SYSTEM W
                                                          CC.
367..................         13  MED..................  MALIGNANCY, FEMALE          .5734        2.3        3.0
                                                          REPRODUCTIVE SYSTEM W/
                                                          O CC.
368..................         13  MED..................  INFECTIONS, FEMALE         1.1668        5.2        6.7
                                                          REPRODUCTIVE SYSTEM.
369..................         13  MED..................  MENSTRUAL & OTHER           .6297        2.4        3.2
                                                          FEMALE REPRODUCTIVE
                                                          SYSTEM DISORDERS.
370..................         14  SURG.................  CESAREAN SECTION W CC.      .8956        4.1        5.2
371..................         14  SURG.................  CESAREAN SECTION W/O        .6037        3.1        3.4
                                                          CC.
372..................         14  MED..................  VAGINAL DELIVERY W          .5047        2.6        3.2
                                                          COMPLICATING
                                                          DIAGNOSES.
373..................         14  MED..................  VAGINAL DELIVERY W/O        .3562        2.0        2.2
                                                          COMPLICATING
                                                          DIAGNOSES.
374..................         14  SURG.................  VAGINAL DELIVERY W          .6762        2.4        2.7
                                                          STERILIZATION &/OR
                                                          D&C.
375..................         14  SURG *...............  VAGINAL DELIVERY W          .5829        4.4        4.4
                                                          O.R. PROC EXCEPT
                                                          STERIL &/OR D&C.
376..................         14  MED..................  POSTPARTUM & POST           .5215        2.6        3.4
                                                          ABORTION DIAGNOSES W/
                                                          O O.R. PROCEDURE.
377..................         14  SURG.................  POSTPARTUM & POST          1.6547        2.9        4.5
                                                          ABORTION DIAGNOSES W
                                                          O.R. PROCEDURE.
378..................         14  MED..................  ECTOPIC PREGNANCY.....      .7508        1.9        2.3
379..................         14  MED..................  THREATENED ABORTION...      .3590        2.0        2.8
380..................         14  MED..................  ABORTION W/O D&C......      .3913        1.6        2.1
381..................         14  SURG.................  ABORTION W D&C,             .6059        1.7        2.3
                                                          ASPIRATION CURETTAGE
                                                          OR HYSTEROTOMY.
382..................         14  MED..................  FALSE LABOR...........      .2071        1.3        1.4
383..................         14  MED..................  OTHER ANTEPARTUM            .5053        2.6        3.7
                                                          DIAGNOSES W MEDICAL
                                                          COMPLICATIONS.
384..................         14  MED..................  OTHER ANTEPARTUM            .3187        1.8        2.6
                                                          DIAGNOSES W/O MEDICAL
                                                          COMPLICATIONS.
385..................         15  MED *................  NEONATES, DIED OR          1.3909        1.8        1.8
                                                          TRANSFERRED TO
                                                          ANOTHER ACUTE CARE
                                                          FACILITY.
386..................         15  MED *................  EXTREME IMMATURITY OR      4.5865       17.9       17.9
                                                          RESPIRATORY DISTRESS
                                                          SYNDROME, NEONATE.
387..................         15  MED *................  PREMATURITY W MAJOR        3.1325       13.3       13.3
                                                          PROBLEMS.
388..................         15  MED *................  PREMATURITY W/O MAJOR      1.8900        8.6        8.6
                                                          PROBLEMS.
389..................         15  MED *................  FULL TERM NEONATE W        3.2177        4.7        4.7
                                                          MAJOR PROBLEMS.
390..................         15  MED *................  NEONATE W OTHER            1.1388        3.4        3.4
                                                          SIGNIFICANT PROBLEMS.
391..................         15  MED *................  NORMAL NEWBORN........      .1542        3.1        3.1
392..................         16  SURG.................  SPLENECTOMY AGE >17...     3.0278        6.5        9.2
393..................         16  SURG *...............  SPLENECTOMY AGE 0-17..     1.3624        9.1        9.1
394..................         16  SURG.................  OTHER O.R. PROCEDURES      1.9019        4.5        7.4
                                                          OF THE BLOOD AND
                                                          BLOOD FORMING ORGANS.
395..................         16  MED..................  RED BLOOD CELL              .8303        3.2        4.3
                                                          DISORDERS AGE >17.
396..................         16  MED *................  RED BLOOD CELL             2.5374        4.1        4.1
                                                          DISORDERS AGE 0-17.
397..................         16  MED..................  COAGULATION DISORDERS.     1.3113        3.8        5.2
398..................         16  MED..................  RETICULOENDOTHELIAL &      1.2212        4.5        5.8
                                                          IMMUNITY DISORDERS W
                                                          CC.
399..................         16  MED..................  RETICULOENDOTHELIAL &       .6665        2.7        3.3
                                                          IMMUNITY DISORDERS W/
                                                          O CC.
400..................         17  SURG.................  NO LONGER VALID.......      .0000         .0         .0
401..................         17  SURG.................  LYMPHOMA & NON-ACUTE       2.9643        8.0       11.3
                                                          LEUKEMIA W OTHER O.R.
                                                          PROC W CC.
402..................         17  SURG.................  LYMPHOMA & NON-ACUTE       1.1793        2.8        4.1
                                                          LEUKEMIA W OTHER O.R.
                                                          PROC W/O CC.
403..................         17  MED..................  LYMPHOMA & NON-ACUTE       1.8406        5.8        8.1
                                                          LEUKEMIA W CC.
404..................         17  MED..................  LYMPHOMA & NON-ACUTE        .9244        3.0        4.2
                                                          LEUKEMIA W/O CC.
405..................         17  MED *................  ACUTE LEUKEMIA W/O         1.9316        4.9        4.9
                                                          MAJOR O.R. PROCEDURE
                                                          AGE 0-17.
406..................         17  SURG.................  MYELOPROLIF DISORD OR      2.7989        7.0        9.9
                                                          POORLY DIFF NEOPL W
                                                          MAJ O.R.PROC W CC.
407..................         17  SURG.................  MYELOPROLIF DISORD OR      1.2325        3.0        3.8
                                                          POORLY DIFF NEOPL W
                                                          MAJ O.R.PROC W/O CC.
408..................         17  SURG.................  MYELOPROLIF DISORD OR      2.2303        4.8        8.2
                                                          POORLY DIFF NEOPL W
                                                          OTHER O.R.PROC.
409..................         17  MED..................  RADIOTHERAPY..........     1.2066        4.3        5.8
410..................         17  MED..................  CHEMOTHERAPY W/O ACUTE     1.1022        3.0        3.8
                                                          LEUKEMIA AS SECONDARY
                                                          DIAGNOSIS.
411..................         17  MED..................  HISTORY OF MALIGNANCY       .3645        2.5        3.3
                                                          W/O ENDOSCOPY.
412..................         17  MED..................  HISTORY OF MALIGNANCY       .8442        1.8        2.8
                                                          W ENDOSCOPY.

[[Page 23589]]

 
413..................         17  MED..................  OTHER MYELOPROLIF DIS      1.3035        5.0        6.8
                                                          OR POORLY DIFF NEOPL
                                                          DIAG W CC.
414..................         17  MED..................  OTHER MYELOPROLIF DIS       .7784        3.0        4.0
                                                          OR POORLY DIFF NEOPL
                                                          DIAG W/O CC.
415..................         18  SURG.................  O.R. PROCEDURE FOR         3.9753       11.0       14.8
                                                          INFECTIOUS &
                                                          PARASITIC DISEASES.
416..................         18  MED..................  SEPTICEMIA AGE >17....     1.6705        5.6        7.5
417..................         18  MED..................  SEPTICEMIA AGE 0-17...     1.2962        3.6        5.3
418..................         18  MED..................  POSTOPERATIVE & POST-      1.1035        4.9        6.4
                                                          TRAUMATIC INFECTIONS.
419..................         18  MED..................  FEVER OF UNKNOWN            .8526        3.4        4.4
                                                          ORIGIN AGE >17 W CC.
420..................         18  MED..................  FEVER OF UNKNOWN            .6088        2.7        3.4
                                                          ORIGIN AGE >17 W/O CC.
421..................         18  MED..................  VIRAL ILLNESS AGE >17.      .7680        3.1        4.1
422..................         18  MED..................  VIRAL ILLNESS & FEVER       .6185        2.6        3.7
                                                          OF UNKNOWN ORIGIN AGE
                                                          0-17.
423..................         18  MED..................  OTHER INFECTIOUS &         1.9163        6.0        8.4
                                                          PARASITIC DISEASES
                                                          DIAGNOSES.
424..................         19  SURG.................  O.R. PROCEDURE W           2.2400        7.3       11.7
                                                          PRINCIPAL DIAGNOSES
                                                          OF MENTAL ILLNESS.
425..................         19  MED..................  ACUTE ADJUSTMENT            .6187        2.6        3.5
                                                          REACTION &
                                                          PSYCHOSOCIAL
                                                          DYSFUNCTION.
426..................         19  MED..................  DEPRESSIVE NEUROSES...      .4655        3.0        4.1
427..................         19  MED..................  NEUROSES EXCEPT             .5159        3.2        4.7
                                                          DEPRESSIVE.
428..................         19  MED..................  DISORDERS OF                .6944        4.6        7.2
                                                          PERSONALITY & IMPULSE
                                                          CONTROL.
429..................         19  MED..................  ORGANIC DISTURBANCES &      .7893        4.3        5.6
                                                          MENTAL RETARDATION.
430..................         19  MED..................  PSYCHOSES.............      .6306        5.6        7.7
431..................         19  MED..................  CHILDHOOD MENTAL            .5194        4.0        5.9
                                                          DISORDERS.
432..................         19  MED..................  OTHER MENTAL DISORDER       .6322        2.9        4.3
                                                          DIAGNOSES.
433..................         20  MED..................  ALCOHOL/DRUG ABUSE OR       .2774        2.2        3.0
                                                          DEPENDENCE, LEFT AMA.
434..................         20  MED..................  NO LONGER VALID.......      .0000         .0         .0
435..................         20  MED..................  NO LONGER VALID.......      .0000         .0         .0
436..................         20  MED..................  NO LONGER VALID.......      .0000         .0         .0
437..................         20  MED..................  NO LONGER VALID.......      .0000         .0         .0
438..................         20  .....................  NO LONGER VALID.......      .0000         .0         .0
439..................         21  SURG.................  SKIN GRAFTS FOR            1.9204        5.4        8.8
                                                          INJURIES.
440..................         21  SURG.................  WOUND DEBRIDEMENTS FOR     1.9346        5.9        9.2
                                                          INJURIES.
441..................         21  SURG.................  HAND PROCEDURES FOR         .9334        2.3        3.4
                                                          INJURIES.
442..................         21  SURG.................  OTHER O.R. PROCEDURES      2.5647        6.0        8.9
                                                          FOR INJURIES W CC.
443..................         21  SURG.................  OTHER O.R. PROCEDURES       .9911        2.6        3.4
                                                          FOR INJURIES W/O CC.
444..................         21  MED..................  TRAUMATIC INJURY AGE        .7540        3.2        4.1
                                                          >17 W CC.
445..................         21  MED..................  TRAUMATIC INJURY AGE        .5016        2.3        2.8
                                                          >17 W/O CC.
446..................         21  MED *................  TRAUMATIC INJURY AGE 0-     .2995        2.4        2.4
                                                          17.
447..................         21  MED..................  ALLERGIC REACTIONS AGE      .5572        1.9        2.6
                                                          >17.
448..................         21  MED *................  ALLERGIC REACTIONS AGE      .0985        2.9        2.9
                                                          0-17.
449..................         21  MED..................  POISONING & TOXIC           .8509        2.6        3.7
                                                          EFFECTS OF DRUGS AGE
                                                          >17 W CC.
450..................         21  MED..................  POISONING & TOXIC           .4288        1.6        2.0
                                                          EFFECTS OF DRUGS AGE
                                                          >17 W/O CC.
451..................         21  MED *................  POISONING & TOXIC           .2658        2.1        2.1
                                                          EFFECTS OF DRUGS AGE
                                                          0-17.
452..................         21  MED..................  COMPLICATIONS OF           1.0388        3.5        4.9
                                                          TREATMENT W CC.
453..................         21  MED..................  COMPLICATIONS OF            .5278        2.2        2.8
                                                          TREATMENT W/O CC.
454..................         21  MED..................  OTHER INJURY,               .8128        2.9        4.1
                                                          POISONING & TOXIC
                                                          EFFECT DIAG W CC.
455..................         21  MED..................  OTHER INJURY,               .4700        1.7        2.2
                                                          POISONING & TOXIC
                                                          EFFECT DIAG W/O CC.
456..................         22  .....................  NO LONGER VALID.......      .0000         .0         .0
457..................         22  MED..................  NO LONGER VALID.......      .0000         .0         .0
458..................         22  SURG.................  NO LONGER VALID.......      .0000         .0         .0
459..................         22  SURG.................  NO LONGER VALID.......      .0000         .0         .0
460..................         22  MED..................  NO LONGER VALID.......      .0000         .0         .0
461..................         23  SURG.................  O.R. PROC W DIAGNOSES      1.3957        3.0        5.1
                                                          OF OTHER CONTACT W
                                                          HEALTH SERVICES.
462..................         23  MED..................  REHABILITATION........      .8496        8.8       10.7
463..................         23  MED..................  SIGNS & SYMPTOMS W CC.      .6946        3.1        3.9
464..................         23  MED..................  SIGNS & SYMPTOMS W/O        .5057        2.4        2.9
                                                          CC.
465..................         23  MED..................  AFTERCARE W HISTORY OF      .6015        2.4        3.6
                                                          MALIGNANCY AS
                                                          SECONDARY DIAGNOSIS.
466..................         23  MED..................  AFTERCARE W/O HISTORY       .6922        2.7        4.7
                                                          OF MALIGNANCY AS
                                                          SECONDARY DIAGNOSIS.
467..................         23  MED..................  OTHER FACTORS               .4789        2.0        2.7
                                                          INFLUENCING HEALTH
                                                          STATUS.
468..................  .........  .....................  EXTENSIVE O.R.             3.9877        9.7       13.2
                                                          PROCEDURE UNRELATED
                                                          TO PRINCIPAL
                                                          DIAGNOSIS.
469..................  .........  **...................  PRINCIPAL DIAGNOSIS         .0000         .0         .0
                                                          INVALID AS DISCHARGE
                                                          DIAGNOSIS.
470..................  .........  **...................  UNGROUPABLE...........      .0000         .0         .0
471..................         08  SURG.................  BILATERAL OR MULTIPLE      3.1328        4.5        5.1
                                                          MAJOR JOINT PROCS OF
                                                          LOWER EXTREMITY.
472..................         22  SURG.................  NO LONGER VALID.......      .0000         .0         .0
473..................         17  MED..................  ACUTE LEUKEMIA W/O         3.4949        7.6       12.9
                                                          MAJOR O.R. PROCEDURE
                                                          AGE >17.

[[Page 23590]]

 
474..................         04  SURG.................  NO LONGER VALID.......      .0000         .0         .0
475..................         04  MED..................  RESPIRATORY SYSTEM         3.5930        8.1       11.3
                                                          DIAGNOSIS WITH
                                                          VENTILATOR SUPPORT.
476..................  .........  SURG.................  PROSTATIC O.R.             2.1792        7.4       10.5
                                                          PROCEDURE UNRELATED
                                                          TO PRINCIPAL
                                                          DIAGNOSIS.
477..................  .........  SURG.................  NON-EXTENSIVE O.R.         2.0539        5.8        8.7
                                                          PROCEDURE UNRELATED
                                                          TO PRINCIPAL
                                                          DIAGNOSIS.
478..................         05  SURG.................  OTHER VASCULAR             2.4118        4.7        7.2
                                                          PROCEDURES W CC.
479..................         05  SURG.................  OTHER VASCULAR             1.4433        2.1        2.8
                                                          PROCEDURES W/O CC.
480..................        PRE  SURG.................  LIVER TRANSPLANT AND/      8.9426       13.7       17.9
                                                          OR INTESTINAL
                                                          TRANSPLANT.
481..................        PRE  SURG.................  BONE MARROW TRANSPLANT     6.2341       18.3       21.8
482..................        PRE  SURG.................  TRACHEOSTOMY FOR FACE,     3.3281        9.7       12.1
                                                          MOUTH & NECK
                                                          DIAGNOSES.
483..................        PRE  SURG.................  NO LONGER VALID.......      .0000         .0         .0
484..................         24  SURG.................  CRANIOTOMY FOR             5.1050        9.3       12.8
                                                          MULTIPLE SIGNIFICANT
                                                          TRAUMA.
485..................         24  SURG.................  LIMB REATTACHMENT, HIP     3.4619        8.3       10.2
                                                          AND FEMUR PROC FOR
                                                          MULTIPLE SIGNIFICANT
                                                          TRA.
486..................         24  SURG.................  OTHER O.R. PROCEDURES      4.7225        8.5       12.4
                                                          FOR MULTIPLE
                                                          SIGNIFICANT TRAUMA.
487..................         24  MED..................  OTHER MULTIPLE             1.9309        5.3        7.3
                                                          SIGNIFICANT TRAUMA.
488..................         25  SURG.................  HIV W EXTENSIVE O.R.       4.4100       11.7       16.4
                                                          PROCEDURE.
489..................         25  MED..................  HIV W MAJOR RELATED        1.8294        6.0        8.5
                                                          CONDITION.
490..................         25  MED..................  HIV W OR W/O OTHER         1.0638        3.9        5.4
                                                          RELATED CONDITION.
491..................         08  SURG.................  MAJOR JOINT & LIMB         1.6734        2.6        3.1
                                                          REATTACHMENT
                                                          PROCEDURES OF UPPER
                                                          EXTREMITY.
492..................         17  MED..................  CHEMOTHERAPY W ACUTE       3.5856        8.8       13.6
                                                          LEUKEMIA OR W USE OF
                                                          HI DOSE CHEMOAGENT.
493..................         07  SURG.................  LAPAROSCOPIC               1.8413        4.6        6.1
                                                          CHOLECYSTECTOMY W/O
                                                          C.D.E. W CC.
494..................         07  SURG.................  LAPAROSCOPIC               1.0275        2.1        2.7
                                                          CHOLECYSTECTOMY W/O
                                                          C.D.E. W/O CC.
495..................        PRE  SURG.................  LUNG TRANSPLANT.......     8.5766       13.9       17.3
496..................         08  SURG.................  COMBINED ANTERIOR/         6.2260        6.6        9.0
                                                          POSTERIOR SPINAL
                                                          FUSION.
497..................         08  SURG.................  SPINAL FUSION EXCEPT       3.6385        5.0        5.9
                                                          CERVICAL W CC.
498..................         08  SURG.................  SPINAL FUSION EXCEPT       2.7792        3.4        3.8
                                                          CERVICAL W/O CC.
499..................         08  SURG.................  BACK & NECK PROCEDURES     1.3903        3.1        4.3
                                                          EXCEPT SPINAL FUSION
                                                          W CC.
500..................         08  SURG.................  BACK & NECK PROCEDURES      .9033        1.8        2.2
                                                          EXCEPT SPINAL FUSION
                                                          W/O CC.
501..................         08  SURG.................  KNEE PROCEDURES W PDX      2.6488        8.5       10.4
                                                          OF INFECTION W CC.
502..................         08  SURG.................  KNEE PROCEDURES W PDX      1.4419        4.9        5.8
                                                          OF INFECTION W/O CC.
503..................         08  SURG.................  KNEE PROCEDURES W/O        1.2014        2.9        3.8
                                                          PDX OF INFECTION.
504..................         22  SURG.................  EXTEN. BURNS OR FULL      11.6990       21.6       27.3
                                                          THICKNESS BURN W/MV
                                                          96+HRS W/SKIN GFT.
505..................         22  MED..................  EXTEN. BURNS OR FULL       2.3035        2.4        4.7
                                                          THICKNESS BURN W/MV
                                                          96+HRS W/O SKIN GFT.
506..................         22  SURG.................  FULL THICKNESS BURN W      4.1098       11.2       15.9
                                                          SKIN GRAFT OR INHAL
                                                          INJ W CC OR SIG
                                                          TRAUMA.
507..................         22  SURG.................  FULL THICKNESS BURN W      1.7419        5.9        8.5
                                                          SKIN GRFT OR INHAL
                                                          INJ W/O CC OR SIG
                                                          TRAUMA.
508..................         22  MED..................  FULL THICKNESS BURN W/     1.2672        5.1        7.3
                                                          O SKIN GRFT OR INHAL
                                                          INJ W CC OR SIG
                                                          TRAUMA.
509..................         22  MED..................  FULL THICKNESS BURN W/      .8233        3.6        5.2
                                                          O SKIN GRFT OR INH
                                                          INJ W/O CC OR SIG
                                                          TRAUMA.
510..................         22  MED..................  NON-EXTENSIVE BURNS W      1.1808        4.4        6.5
                                                          CC OR SIGNIFICANT
                                                          TRAUMA.
511..................         22  MED..................  NON-EXTENSIVE BURNS W/      .7452        2.7        4.1
                                                          O CC OR SIGNIFICANT
                                                          TRAUMA.
512..................        PRE  SURG.................  SIMULTANEOUS PANCREAS/     5.3328       10.7       12.8
                                                          KIDNEY TRANSPLANT.
513..................        PRE  SURG.................  PANCREAS TRANSPLANT...     5.9670        8.9       10.0
514..................         05  SURG.................  NO LONGER VALID.......      .0000         .0         .0
515..................         05  SURG.................  CARDIAC DEFIBRILLATOR      5.5196        2.6        4.3
                                                          IMPLANT W/O CARDIAC
                                                          CATH.
516..................         05  SURG.................  NO LONGER VALID.......      .0000         .0         .0
517..................         05  SURG.................  PERC CARDIO PROC W NON-    2.0601        1.8        2.6
                                                          DRUG ELUTING STENT W/
                                                          O AMI.
518..................         05  SURG.................  PERC CARDIO PROC W/O       1.7772        2.3        3.5
                                                          CORONARY ARTERY STENT
                                                          OR AMI.
519..................         08  SURG.................  CERVICAL SPINAL FUSION     2.4826        3.0        4.8
                                                          W CC.
520..................         08  SURG.................  CERVICAL SPINAL FUSION     1.6774        1.6        2.0
                                                          W/O CC.
521..................         20  MED..................  ALCOHOL/DRUG ABUSE OR       .6935        4.2        5.6
                                                          DEPENDENCE W CC.
522..................         20  MED..................  ALC/DRUG ABUSE OR           .4767        7.7        9.6
                                                          DEPEND W
                                                          REHABILITATION
                                                          THERAPY W/O CC.
523..................         20  MED..................  ALC/DRUG ABUSE OR           .3785        3.2        3.9
                                                          DEPEND W/O
                                                          REHABILITATION
                                                          THERAPY W/O CC.
524..................         01  MED..................  TRANSIENT ISCHEMIA....      .7274        2.6        3.2
525..................         05  SURG.................  OTHER HEART ASSIST        11.5451        7.3       13.9
                                                          SYSTEM IMPLANT.
526..................         05  SURG.................  NO LONGER VALID.......      .0000         .0         .0
527..................         05  SURG.................  PERCUTNEOUS                2.3161        1.6        2.2
                                                          CARDIOVASULAR PROC W
                                                          DRUG ELUTING STENT W/
                                                          O AMI.

[[Page 23591]]

 
528..................         01  SURG.................  INTRACRANIAL VASCULAR      7.0396       13.8       17.2
                                                          PROC W PDX HEMORRHAGE.
529..................         01  SURG.................  VENTRICULAR SHUNT          2.3118        5.3        8.3
                                                          PROCEDURES W CC.
530..................         01  SURG.................  VENTRICULAR SHUNT          1.2020        2.4        3.1
                                                          PROCEDURES W/O CC.
531..................         01  SURG.................  SPINAL PROCEDURES W CC     3.1221        6.5        9.6
532..................         01  SURG.................  SPINAL PROCEDURES W/O      1.4172        2.8        3.7
                                                          CC.
533..................         01  SURG.................  EXTRACRANIAL               1.5728        2.4        3.7
                                                          PROCEDURES W CC.
534..................         01  SURG.................  EXTRACRANIAL               1.0198        1.5        1.8
                                                          PROCEDURES W/O CC.
535..................         05  SURG.................  CARDIAC DEFIB IMPLANT      8.0777        8.0       10.4
                                                          W CARDIAC CATH W AMI/
                                                          HF/SHOCK.
536..................         05  SURG.................  CARDIAC DEFIB IMPLANT      6.9110        5.9        7.7
                                                          W CARDIAC CATH W/O
                                                          AMI/HF/SHOCK.
537..................         08  SURG.................  LOCAL EXCIS & REMOV OF     1.8333        4.8        6.9
                                                          INT FIX DEV EXCEPT
                                                          HIP & FEMUR W CC.
538..................         08  SURG.................  LOCAL EXCIS & REMOV OF      .9815        2.1        2.8
                                                          INT FIX DEV EXCEPT
                                                          HIP & FEMUR W/O CC.
539..................         17  SURG.................  LYMPHOMA & LEUKEMIA W      3.2371        7.0       10.8
                                                          MAJOR OR PROCEDURE W
                                                          CC.
540..................         17  SURG.................  LYMPHOMA & LEUKEMIA W      1.1892        2.6        3.6
                                                          MAJOR OR PROCEDURE W/
                                                          O CC.
541..................        PRE  SURG.................  ECMO OR TRACH W MV        19.6693       38.0       45.4
                                                          96+HRS OR PDX EXC
                                                          FACE, MTH, FACE&NECK
                                                          DX W/MAJ OR.
542..................        PRE  SURG.................  TRACH W MV 96+HRS OR      12.7797       29.0       34.9
                                                          PDX EXC FACE, MTH,
                                                          FACE&NECK DX W/O MJ
                                                          OR.
543..................         01  SURG.................  CRANIOTOMY W/IMPLANT       4.4062        8.5       12.2
                                                          OF CHEMO AGENT OR
                                                          ACUTE COMPLX CNS PDX.
544..................         08  SURG.................  MAJOR JOINT                1.9612        4.1        4.6
                                                          REPLACEMENT OR
                                                          REATTACHMENT OF LOWER
                                                          EXTREMITY.
545..................         08  SURG.................  REVISION OF HIP OR         2.4781        4.5        5.2
                                                          KNEE REPLACEMENT.
546..................         08  SURG.................  SPINAL FUSION EXC CERV     5.0779        7.2        9.1
                                                          WITH PDX OF CURVATURE
                                                          OF THE SPINE OR MALIG.
547..................         05  SURG.................  PERCUTANEOUS               2.8246        4.4        5.6
                                                          CARDIOVASCULAR PROC W
                                                          AMI W CC.
548..................         05  SURG.................  PERCUTANEOUS               2.0984        2.7        3.0
                                                          CARDIOVASCULAR PROC W
                                                          AMI W/O CC.
549..................         05  SURG.................  PERCUTANEOUS               3.2154        4.1        5.2
                                                          CARDIOVASCULAR PROC W
                                                          DRUG ELUTING STENT W
                                                          AMI W CC.
550..................         05  SURG.................  PERCUTANEOUS               2.5116        2.5       2.9
                                                          CARDIOVASCULAR PROC W
                                                          DRUG ELUTING STENT W
                                                          AMI W/O CC.
----------------------------------------------------------------------------------------------------------------
*Medicare data has been supplemented by data from 19 States for low-volume DRGs.
**DRGs 469 and 470 contain cases which could not be assigned to valid DRGs.
Note: Geometric mean is used only to determine payment for transfer cases.
Note: Arithmetic means are presented for informational purposes only.
Note: Relative weights are based on Medicare patient data and may not be appropriate for other patients.


                     Table 6A.--New Diagnosis Codes
------------------------------------------------------------------------
Diagnosis code     Description       CC       MDC            DRG
------------------------------------------------------------------------
259.5.........  Androgen          N             10  300, 301
                 insensitivity
                 syndrome.
276.50........  Volume            Y             10  296, 297, 298
                 depletion,                     15  387,\1\ 3891
                 unspecified.               \2\ 25  490
276.51........  Dehydration.....  Y             10  296, 297, 298
                                                15  387,\1\ 389 \1\
                                            \2\ 52  490
276.52........  Hypovolemia.....  Y             10  296, 297, 298
                                                15  387,\1\ 389 \1\
                                            \2\ 52  490
278.02........  Overweight......  N             10  296, 297, 298
287.30........  Primary           Y             16  397
                 thrombocytopeni
                 a, unspecified.
287.31........  Immune            Y             16  397
                 thrombocytopeni
                 c purpura.
287.32........  Evans' syndrome.  Y             16  397
287.33........  Congenital and    Y             16  397
                 hereditary
                 thrombocytopeni
                 c purpura.
287.39........  Other primary     Y             16  397
                 thrombocytopeni
                 a.
291.82........  Alcohol induced   N             20  521, 522, 523
                 sleep disorders.
292.85........  Drug induced      N             20  521, 522, 523
                 sleep disorders.
327.00........  Organic           N             19  432
                 insomnia,
                 unspecified.
327.01........  Insomnia due to   N             19  432
                 medical
                 condition
                 classified
                 elsewhere.
327.02........  Insomnia due to   N             19  432
                 mental disorder.
327.09........  Other organic     N             19  432
                 insomnia.
327.10........  Organic           N             19  432
                 hypersomnia,
                 unspecified.
327.11........  Idiopathic        N             19  432
                 hypersomnia
                 with long sleep
                 time.
327.12........  Idiopathic        N             19  432
                 hypersomnia
                 without long
                 sleep time.

[[Page 23592]]

 
327.13........  Recurrent         N             19  432
                 hypersomnia.
327.14........  Hypersomnia due   N             19  432
                 to medical
                 condition.
327.15........  Hypersomnia due   N             19  432
                 to mental
                 disorder.
327.19........  Other organic     N             19  432
                 hypersomnia.
327.20........  Organic sleep     N            PRE  482
                 apnea,                          3  73, 74
                 unspecified.
327.21........  Primary central   N            PRE  482
                 sleep apnea.                    1  34, 35
327.22........  High altitude     N            PRE  482
                 periodic                        4  99, 100
                 breathing.
327.23........  Obstructive       N            PRE  482
                 sleep apnea                     3  73, 74
                 (adult)
                 (pediatric).
327.24........  Idiopathic sleep  N            PRE  482
                 related non-                    3  73, 74
                 obstructive
                 alveolar
                 hypoventilation.
327.26........  Sleep related     N            PRE  482
                 hypoventilation/                3  73, 74
                 hypoxemia in
                 conditions
                 classifiable
                 elsewhere.
327.27........  Central sleep     N            PRE  482
                 apnea in                        1  34, 35
                 conditions
                 classified
                 elsewhere.
327.29........  Other organic     N            PRE  482
                 sleep apnea.                    3  73, 74
362.03........  Nonproliferative  N              2  46, 47, 48
                 diabetic
                 retinopathy NOS.
362.04........  Mild              N              2  46, 47, 48
                 nonproliferativ
                 e diabetic
                 retinopathy.
362.05........  Moderate          N              2  46, 47, 48
                 nonproliferativ
                 e diabetic
                 retinopathy.
362.06........  Severe            N              2  46, 47, 48
                 nonproliferativ
                 e diabetic
                 retinopathy.
362.07........  Diabetic macular  N              2  46, 47, 48
                 edema.
426.82........  Long QT syndrome  N              5  138, 139
443.82........  Erythromelalgia.  N              5  130, 131
525.40........  Complete          N            PRE  482
                 edentulism,                     3  185, 186, 187
                 unspecified.
525.41........  Complete          N            PRE  482
                 edentulism,                     3  185, 186, 187
                 class I.
525.42........  Complete          N            PRE  482
                 edentulism,                     3  185, 186, 187
                 class II.
525.43........  Complete          N            PRE  482
                 edentulism,                     3  185, 186, 187
                 class III.
525.44........  Complete          N            PRE  482
                 edentulism,                     3  185, 186, 187
                 class IV.
525.50........  Partial           N            PRE  482
                 edentulism,                     3  185, 186, 187
                 unspecified.
525.51........  Partial           N            PRE  482
                 edentulism,                     3  185, 186, 187
                 class I.
525.52........  Partial           N            PRE  482
                 edentulism,                     3  185, 186, 187
                 class II.
525.53........  Partial           N            PRE  482
                 edentulism,                     3  185, 186, 187
                 class III.
525.54........  Partial           N            PRE  482
                 edentulism,                     3  185, 186, 187
                 class IV.
567.21........  Peritonitis       Y              6  188, 189, 190
                 (acute)                        15  387,\1\ 389 \1\
                 generalized.
567.22........  Peritoneal        Y              6  188, 189, 190
                 abscess.                       15  387,\1\ 389 \1\
567.23........  Spontaneous       Y              6  188, 189, 190
                 bacterial                      15  387,\1\ 389 \1\
                 peritonitis.
567.29........  Other             Y              6  188, 189, 190
                 suppurative                    15  387,\1\ 389 \1\
                 peritonitis.
567.38........  Other             Y              6  188, 189, 190
                 retroperitoneal                15  387,\1\ 389 \1\
                 abscess.
567.39........  Other             Y              6  188, 189, 190
                 retroperitoneal                15  387,\1\ 389 \1\
                 infections.
567.81........  Choleperitonitis  Y              6  188, 189, 190
                                                15  387,\1\ 389 \1\
567.82........  Sclerosing        Y              6  188, 189, 190
                 mesenteritis.                  15  387,\1\ 389 \1\
567.89........  Other specified   Y              6  188, 189, 190
                 peritonitis.                   15  387,\1\ 389 \1\
585.1.........  Chronic kidney    Y            PRE  512, 513
                 disease, Stage                 11  315, 316
                 I.
585.2.........  Chronic kidney    Y            PRE  512, 513
                 disease, Stage                 11  315, 316
                 II (mild).
585.3.........  Chronic kidney    Y            PRE  512, 513
                 disease, Stage                 11  315, 316
                 III (moderate).

[[Page 23593]]

 
585.4.........  Chronic kidney    Y            PRE  512, 513
                 disease, Stage                 11  315, 316
                 IV (severe).
585.5.........  Chronic kidney    Y            PRE  512, 513
                 disease, Stage                 11  315, 316
                 V.
585.6.........  End stage renal   Y            PRE  512, 513
                 disease.                       11  315, 316
585.9.........  Chronic kidney    Y            PRE  512, 513
                 disease,                       11  315, 316
                 unspecified.
599.60........  Urinary           Y             15  331, 332, 333
                 obstruction,     11                387,\1\ 389 \1\
                 unspecified.
599.69........  Urinary           Y             11  331, 332, 333
                 obstruction,                   15  387,\1\ 389 \1\
                 not elsewhere
                 classified.
651.70........  Multiple          N             14  469
                 gestation
                 following
                 (elective)
                 fetal
                 reduction,
                 unspecified as
                 to episode of
                 care or not
                 applicable.
651.71........  Multiple          N             14  370, 371, 372, 373,
                 gestation                           374, 375
                 following
                 (elective)
                 fetal
                 reduction,
                 delivered, with
                 or without
                 mention of
                 antepartum
                 condition.
651.73........  Multiple          N             14  383, 384
                 gestation
                 following
                 (elective)
                 fetal
                 reduction,
                 antepartum
                 condition or
                 complication.
760.77........  Anticonvulsants.  N             15  390
760.78........  Antimetabolic     N             15  390
                 agents.
763.84........  Meconium passage  N             15  390
                 during delivery.
770.10........  Fetal and         N             15  387,\3\ 389 \3\
                 newborn
                 aspiration,
                 unspecified.
770.11........  Meconium          N             15  387,\3\ 389 \3\
                 aspiration
                 without
                 respiratory
                 symptoms.
770.12........  Meconium          Y             15  387,\3\ 389 \3\
                 aspiration with
                 respiratory
                 symptoms.
770.17........  Other fetal and   N             15  387,\3\ 389 \3\
                 newborn
                 aspiration
                 without
                 respiratory
                 symptoms.
770.18........  Other fetal and   Y             15  387,\3\ 389 \3\
                 newborn
                 aspiration with
                 respiratory
                 symptoms.
779.84........  Meconium          N             15  390
                 staining.
780.95........  Other excessive   N             23  463, 464
                 crying.
799.01........  Asphyxia........  Y              4  101, 102
799.02........  Hypoxemia.......  Y              4  101, 102
996.40........  Unspecified       Y              8  249
                 mechanical
                 complication of
                 internal
                 orthopedic
                 device,
                 implant, and
                 graft.
996.41........  Mechanical        Y              8  249
                 loosening of
                 prosthetic
                 joint.
996.42........  Dislocation of    Y              8  249
                 prosthetic
                 joint.
996.43........  Prosthetic joint  Y              8  249
                 implant failure.
996.44........  Peri-prosthetic   Y              8  249
                 fracture around
                 prosthetic
                 joint.
996.45........  Peri-prosthetic   Y              8  249
                 osteolysis.
996.46........  Articular         Y              8  249
                 bearing surface
                 wear of
                 prosthetic
                 joint.
996.47........  Other mechanical  Y              8  249
                 complication of
                 prosthetic
                 joint implant.
996.49........  Other mechanical  Y              8  249
                 complication of
                 other internal
                 orthopedic
                 device,
                 implant, and
                 graft.
V12.42........  Person history,   N             23  467
                 Infections of
                 the central
                 nervous system.
V12.60........  Person history,   N             23  467
                 Unspecified
                 disease of
                 respiratory
                 system.
V12.61........  Person history,   N             23  467
                 Pneumonia
                 (recurrent).
V12.69........  Person history,   N             23  467
                 Other diseases
                 of respiratory
                 system.
V13.02........  Person history,   N             23  467
                 Urinary (tract)
                 infection.
V13.03........  Person history,   N             23  467
                 Nephrotic
                 syndrome.
V15.88........  History of fall.  N             23  467
V17.81........  Family history,   N             23  467
                 Osteoporosis.
V17.89........  Family history,   N             23  467
                 Other
                 musculoskeletal
                 diseases.
V18.9.........  Family history,   N             23  467
                 Genetic disease
                 carrier.
V26.31........  Testing for       N             23  467
                 genetic disease
                 carrier status.
V26.32........  Other genetic     N             23  467
                 testing.
V26.33........  Genetic           N             23  467
                 counseling.
V46.13........  Encounter for     Y             23  467
                 weaning from
                 respirator
                 [ventilator].
V46.14........  Mechanical        Y             23  467
                 complication of
                 respirator
                 [ventilator].
V49.84........  Bed confinement   N             23  467
                 status.
V59.70........  Egg (oocyte)      N             23  467
                 (ovum) donor,
                 unspecified.
V59.71........  Egg (oocyte)      N             23  467
                 (ovum) donor,
                 under age
                 35,anonymous
                 recipient.
V59.72........  Egg (oocyte)      N             23  467
                 (ovum) donor,
                 under age 35,
                 designated
                 recipient.
V59.73........  Egg (oocyte)      N             23  467
                 (ovum) donor,
                 age 35 and
                 over,anonymous
                 recipient.
V59.74........  Egg (oocyte)      N             23  467
                 (ovum) donor,
                 age 35 and
                 over,
                 designated
                 recipient.
V62.84........  Suicidal          N             19  425
                 ideation.
V64.00........  Vaccination not   N             23  467
                 carried out,
                 unspecified
                 reason.
V64.01........  Vaccination not   N             23  467
                 carried out
                 because of
                 acute illness.
V64.02........  Vaccination not   N             23  467
                 carried out
                 because of
                 chronic illness
                 or condition.
V64.03........  Vaccination not   N             23  467
                 carried out
                 because of
                 immune
                 compromised
                 state.
V64.04........  Vaccination not   N             23  467
                 carried out
                 because of
                 allergy to
                 vaccine or
                 component.
V64.05........  Vaccination not   N             23  467
                 carried out
                 because of
                 caregiver
                 refusal.
V64.06........  Vaccination not   N             23  467
                 carried out
                 because of
                 patient refusal.
V64.07........  Vaccination not   N             23  467
                 carried out for
                 religious
                 reasons.
V64.08........  Vaccination not   N             23  467
                 carried out
                 because patient
                 had disease
                 being
                 vaccinated
                 against.
V64.09........  Vaccination not   N             23  467
                 carried out for
                 other reason.
V69.5.........  Behavioral        N             23  467
                 insomnia of
                 childhood.

[[Page 23594]]

 
V72.86........  Encounter for     N             23  467
                 blood typing.
V85.0.........  Body Mass Index   N             23  467
                 less than 19,
                 adult.
V85.1.........  Body Mass Index   N             23  467
                 between 19-24,
                 adult.
V85.21........  Body Mass Index   N             23  467
                 25.0-25.9,
                 adult.
V85.22........  Body Mass Index   N             23  467
                 26.0-26.9,
                 adult.
V85.23........  Body Mass Index   N             23  467
                 27.0-27.9,
                 adult.
V85.24........  Body Mass Index   N             23  467
                 28.0-28.9,
                 adult.
V85.25........  Body Mass Index   N             23  467
                 29.0-29.9,
                 adult.
V85.30........  Body Mass Index   N             23  467
                 30.0-30.9,
                 adult.
V85.31........  Body Mass Index   N             23  467
                 31.0-31.9,
                 adult.
V85.32........  Body Mass Index   N             23  467
                 32.0-32.9,
                 adult.
V85.33........  Body Mass Index   N             23  467
                 33.0-33.9,
                 adult.
V85.34........  Body Mass Index   N             23  467
                 34.0-34.9,
                 adult.
V85.35........  Body Mass Index   N             23  467
                 35.0-35.9,
                 adult.
V85.36........  Body Mass Index   N             23  467
                 36.0-36.9,
                 adult.
V85.37........  Body Mass Index   N             23  467
                 37.0-37.9,
                 adult.
V85.38........  Body Mass Index   N             23  467
                 38.0-38.9,
                 adult.
V85.39........  Body Mass Index   N             23  467
                 39.0-39.9,
                 adult.
V85.4.........  Body Mass Index   N             10  296, 297, 298
                 40 and over,
                 adult.
------------------------------------------------------------------------
\1\ Secondary diagnosis of major problem in DRGs 387 and 389.
\2\ Principal diagnosis of significant HIV-related condition.
\3\ Principal or secondary diagnosis of major problem.


                     Table 6B.--New Procedure Codes
------------------------------------------------------------------------
   Procedure
     code          Description       OR       MDC            DRG
------------------------------------------------------------------------
00.40.........  Procedure on      N
                 single vessel.
00.41.........  Procedure on two  N
                 vessels.
00.42.........  Procedure on      N
                 three vessels.
00.43.........  Procedure on      N
                 four or more
                 vessels.
00.45.........  Insertion of one  N
                 vascular stent.
00.46.........  Insertion of two  N
                 vascular stents.
00.47.........  Insertion of      N
                 three vascular
                 stents.
00.48.........  Insertion of      N
                 four or more
                 vascular stents.
00.70.........  Revision of hip   Y              8  471, 545
                 replacement,                   10  292, 293
                 both acetabular                21  442, 443
                 and femoral                    24  485
                 components.
00.71.........  Revision of hip   Y              8  471, 545
                 replacement,                   10  292, 293
                 acetabular                   21 2  442, 443
                 component.                      4  485
00.72.........  Revision of hip   Y              8  471, 545
                 replacement,                   10  292, 293
                 femoral                        21  442, 443
                 component.                     24  485
00.73.........  Revision of hip   Y              8  471, 545
                 replacement,                   10  292, 293
                 acetabular                     21  442, 443
                 liner and/or                   24  485
                 femoral head
                 only.
00.80.........  Revision of knee  Y              8  471, 545
                 replacement,                   21  442, 443
                 total (all                     24  486
                 components).
00.81.........  Revision of knee  Y              8  471, 545
                 replacement,                   21  442, 443
                 tibial                         24  486
                 component.
00.82.........  Revision of knee  Y              8  471, 545
                 replacement,                   21  442, 443
                 femoral                        24  486
                 component.
00.83.........  Revision of knee  Y              8  471, 545
                 replacement,                   21  442, 443
                 patellar                       24  486
                 component.
00.84.........  Revision of       Y              8  471, 545
                 total knee                     21  442, 443
                 replacement,                   24  486
                 tibial insert
                 (liner).
37.41.........  Implantation of   Y              5  110, 111
                 prosthetic
                 cardiac support
                 device around
                 the heart.

[[Page 23595]]

 
37.49.........  Other repair of   Y              5  110, 111
                 heart and                      21  442, 443
                 pericardium.                   24  486
84.56.........  Insertion of      N
                 (cement) spacer.
84.57.........  Removal of        N
                 (cement) spacer.
86.97.........  Insertion or      Y              1  7, 8
                 replacement of
                 single array
                 rechargeable
                 neurostimulator
                 pulse generator.
86.98.........  Insertion or      Y              1  7, 8
                 replacement of
                 dual array
                 rechargeable
                 neurostimulator
                 pulse generator.
------------------------------------------------------------------------


                   Table 6C.--Invalid Diagnosis Codes
------------------------------------------------------------------------
   Diagnosis
     code          Description       CC       MDC            DRG
------------------------------------------------------------------------
276.5.........  Volume depletion  Y             10  296, 297, 298
                                                15  387,\1\ 3891
                                            \2\ 25  490
287.3.........  Primary           Y             16  397
                 thrombocytopeni
                 a.
567.2.........  Other             Y              6  188, 189, 190
                 suppurative                    15  387,\1\ 389 \1\
                 peritonitis.
67.8..........  Other specified   Y              6  188, 189, 190
                 peritonitis.                   15  387,\1\ 389 \1\
585...........  Chronic renal     Y            PRE  512, 513
                 failure.                       11  315,316
599.6.........  Urinary           Y             11  331, 332, 333
                 obstruction,                   15  387,\1\ 389 \1\
                 unspecified.
770.1.........  Meconium          Y             15  387,\3\ 389 \3\
                 aspiration
                 syndrome.
799.0.........  Asphyxia........  N              4  101, 102
996.4.........  Mechanical        Y              8  249
                 complication of
                 internal
                 orthopedic
                 device,
                 implant, and
                 graft.
V12.6.........  Diseases of the   N             23  467
                 respiratory
                 system.
V17.8.........  Other             N             23  467
                 musculoskeletal
                 diseases.
V26.3.........  Genetic           N             23  467
                 counseling and
                 testing.
V64.0.........  Vaccination not   N             23  467
                 carried out
                 because of
                 contradiction.
------------------------------------------------------------------------
\1\ Secondary Diagnosis of Major Problem
\2\ Principal diagnosis of Significant HIV Related Condition
\3\ Principal or Secondary Diagnosis of Major Problem


                   Table 6D.--Invalid Procedure Codes
------------------------------------------------------------------------
Procedure Code     Description       OR       MDC            DRG
------------------------------------------------------------------------
36.02.........  Single vessel     Y              5  106, 516, 517, 518,
                 percutaneous                        526, 527
                 transluminal
                 coronary
                 angioplasty
                 [PTCA] or
                 coronary
                 atherectomy
                 with mention of
                 thrombolytic
                 agent.
36.05.........  Multiple vessel   Y              5  106, 516, 517, 518,
                 percutaneous                        526, 527
                 transluminal
                 coronary
                 angioplasty
                 [PTCA] or
                 coronary
                 atherectomy
                 performed
                 during the same
                 operation, with
                 or without
                 mention of
                 thrombolytic
                 agent.
37.4..........  Repair of heart   Y              5  110, 111
                 and pericardium.               21  442, 443
                                                24  486
------------------------------------------------------------------------


                Table 6E.--Revised Diagnosis Code Titles
------------------------------------------------------------------------
Diagnosis Code     Description       CC       MDC            DRG
------------------------------------------------------------------------
403.00........  Hypertensive      Y             11  331, 332, 333
                 kidney disease,
                 malignant,
                 without chronic
                 kidney disease.
403.01........  Hypertensive      Y             11  315, 316
                 kidney disease,
                 malignant, with
                 chronic kidney
                 disease.
403.10........  Hypertensive      N             11  331, 332, 333
                 kidney disease,
                 benign, without
                 chronic kidney
                 disease.
403.11........  Hypertensive      Y             11  315, 316
                 kidney disease,
                 benign, with
                 chronic kidney
                 disease.
403.90........  Hypertensive      N             11  331, 332, 333
                 kidney disease,
                 unspecified,
                 without chronic
                 kidney disease.
403.91........  Hypertensive      Y             11  315, 316
                 kidney disease,
                 unspecified,
                 with chronic
                 kidney disease.
404.00........  Hypertensive      Y              5  134
                 heart and
                 kidney disease,
                 malignant,
                 without heart
                 failure or
                 chronic kidney
                 disease.
404.01........  Hypertensive      Y              5  115, 121, 124, 127,
                 heart and                  ......   535
                 kidney disease,                15  1387, 389 \1\
                 malignant, with
                 heart failure.
404.02........  Hypertensive      Y             11  315, 316
                 heart and
                 kidney disease,
                 malignant, with
                 chronic kidney
                 disease.

[[Page 23596]]

 
404.03........  Hypertensive      Y              5  115, 121, 124, 127,
                 heart and                  ......   535
                 kidney disease,                15  387, 389 \1\
                 malignant, with
                 heart failure
                 and chronic
                 kidney disease.
404.10........  Hypertensive      N              5  134
                 heart and
                 kidney disease,
                 benign, without
                 heart failure
                 or chronic
                 kidney disease.
404.11........  Hypertensive      Y              5  115, 121, 124, 127,
                 heart and                  ......   535
                 kidney disease,                15  387, 389 \1\
                 benign, with
                 heart failure.
404.12........  Hypertensive      Y             11  315, 316
                 heart and
                 kidney disease,
                 benign, with
                 chronic kidney
                 disease.
404.13........  Hypertensive      Y              5  115, 121, 124, 127,
                 heart and                  ......   535
                 kidney disease,                15  387, 3891
                 benign, with
                 heart failure
                 and chronic
                 kidney disease.
404.90........  Hypertensive      N              5  34
                 heart and
                 kidney disease,
                 unspecified,
                 without heart
                 failure or
                 chronic kidney
                 disease.
404.91........  Hypertensive      Y              5  115, 121, 124, 127,
                 heart and                  ......   535
                 kidney disease,                15  387, 389 \1\
                 unspecified,
                 with heart
                 failure.
404.92........  Hypertensive      Y             11  315, 316
                 heart and
                 kidney disease,
                 unspecified,
                 with chronic
                 kidney disease.
404.93........  Hypertensive      Y              5  115, 121, 124, 127,
                 heart and                  ......   535
                 kidney disease,                15  387, 389 \1\
                 unspecified,
                 with heart
                 failure and
                 chronic kidney
                 disease.
728.87........  Muscle weakness   N              8  247
                 (generalized).
780.51........  Insomnia with     N            PRE  482
                 sleep apnea,                    3  73, 74
                 unspecified.
780.52........  Insomnia,         N             19  432
                 unspecified.
780.53........  Hypersomnia with  N            PRE  482
                 sleep apnea,                    3  73, 74
                 unspecified.
780.54........  Hypersomnia,      N             19  432
                 unspecified.
780.57........  Unspecified       N            PRE  482
                 sleep apnea.                    3  73, 74
------------------------------------------------------------------------
\1\ Major problem in DRGs 387 and 389.


                Table 6F.--Revised Procedure Code Titles
------------------------------------------------------------------------
Procedure Code     Description       OR       MDC            DRG
------------------------------------------------------------------------
36.01.........  Percutaneous      Y              5  106, 516, 517, 518,
                 transluminal                        526, 527
                 coronary
                 angioplasty
                 [PTCA] or
                 coronary
                 atherectomy.
37.79.........  Revision or       Y              1  7, 8
                 relocation of                   5  117
                 cardiac device                  9  269, 270
                 pocket.                        21  442, 443
                                                24  486
81.53.........  Revision of hip   Y              8  471, 545
                 replacement,                   10  292, 293
                 not otherwise                  21  442, 443
                 specified.                     24  485
81.55.........  Revision of knee  Y              8  471, 545
                 replacement,                   21  442, 443
                 not otherwise                  24  486
                 specified.
------------------------------------------------------------------------


             Table 6G.--Additions to the CC Exclusions List
   [CCs that are added to the list are in Table 6G-Additions to the CC
    Exclusions List. Each of the principal diagnoses is shown with an
asterisk, and the revisions to the CC Exclusions List are provided in an
indented column immediately following the affected principal diagnosis.]
 
 
 
*185
  59960
  59969
*1880
  59960
  59969
*1881
  59960
  59969
*1882
  59960
  59969
*1883
  59960
  59969
*1884
  59960
  59969
*1885
  59960
  59969
*1886
  59960
  59969

[[Page 23597]]

 
*1887
  59960
  59969
*1888
  59960
  59969
*1889
  59960
  59969
*1892
  59960
  59969
*1893
  59960
  59969
*1894
  59960
  59969
*1898
  59960
  59969
*1899
  59960
  59969
*25040
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*25041
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*25042
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*25043
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*25080
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*25081
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*25082
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*25083
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*25090
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*25091
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*25092
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*25093
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*2595
  24200
  24201
  24210
  24211
  24220
  24221
  24230
  24231
  24240
  24241
  24280
  24281
  24290
  24291
  25001
  25002
  25003
  25011
  25012
  25013
  25021
  25022
  25023
  25031
  25032
  25033
  25041
  25042
  25043
  25051
  25052
  25053
  25061
  25062
  25063
  25071
  25072
  25073
  25081
  25082
  25083
  25091
  25092
  25093
  2510
  2513
  2521
  2532
  2535
  2541
  2550
  2553
  2554
  2555
  2556
  2580
  2581
  2588
  2589
  2592
*27410
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*27411
  59960
  59969
*27419
  5851
  5852
  5853
  5854
  5855

[[Page 23598]]

 
  5856
  5859
*2760
  27650
  27651
  27652
*2761
  27650
  27651
  27652
*2762
  27650
  27651
  27652
*2763
  27650
  27651
  27652
*2764
  27650
  27651
  27652
*27650
  2760
  2761
  2762
  2763
  2764
  27650
  27651
  27652
  2766
  2767
  2769
*27651
  2760
  2761
  2762
  2763
  2764
  27650
  27651
  27652
  2766
  2767
  2769
*27652
  2760
  2761
  2762
  2763
  2764
  27650
  27651
  27652
  2766
  2767
  2769
*2766
  27650
  27651
  27652
*2767
  27650
  27651
  27652
*2768
  27650
  27651
  27652
*2769
  27650
  27651
  27652
*2860
  28730
  28731
  28732
  28733
  28739
*2861
  28730
  28731
  28732
  28733
  28739
*2862
  28730
  28731
  28732
  28733
  28739
*2863
  28730
  28731
  28732
  28733
  28739
*2864
  28730
  28731
  28732
  28733
  28739
*2865
  28730
  28731
  28732
  28733
  28739
*2866
  28730
  28731
  28732
  28733
  28739
*2867
  28730
  28731
  28732
  28733
  28739
*2869
  28730
  28731
  28732
  28733
  28739
*2870
  28730
  28731
  28732
  28733
  28739
*2871
  28730
  28731
  28732
  28733
  28739
*2872
  28730
  28731
  28732
  28733
  28739
*28730
  2860
  2861
  2862
  2863
  2864
  2865
  2866
  2867
  2869
  2870
  2871
  2872
  28730
  28731
  28732
  28733
  28739
  2874
  2875
  2878
  2879
*28731
  2860
  2861
  2862
  2863
  2864
  2865
  2866
  2867
  2869
  2870
  2871
  2872
  28730
  28731
  28732
  28733
  28739
  2874
  2875
  2878
  2879
*28732
  2860
  2861
  2862
  2863
  2864
  2865
  2866

[[Page 23599]]

 
  2867
  2869
  2870
  2871
  2872
  28730
  28731
  28732
  28733
  28739
  2874
  2875
  2878
  2879
*28733
  2860
  2861
  2862
  2863
  2864
  2865
  2866
  2867
  2869
  2870
  2871
  2872
  28730
  28731
  28732
  28733
  28739
  2874
  2875
  2878
  2879
*28739
  2860
  2861
  2862
  2863
  2864
  2865
  2866
  2867
  2869
  2870
  2871
  2872
  28730
  28731
  28732
  28733
  28739
  2874
  2875
  2878
  2879
*2874
  28730
  28731
  28732
  28733
  28739
*2875
  28730
  28731
  28732
  28733
  28739
*2878
  28730
  28731
  28732
  28733
  28739
*2879
  28730
  28731
  28732
  28733
  28739
*28981
  28730
  28731
  28732
  28733
  28739
*28982
  28730
  28731
  28732
  28733
  28739
*28989
  28730
  28731
  28732
  28733
  28739
*2899
  28730
  28731
  28732
  28733
  28739
*29182
  2910
  2911
  2912
  2913
  2914
  29181
  29189
  2919
  2920
  29211
  29212
  2922
  29281
  29282
  29283
  29284
  29289
  2929
  29381
  29382
  29383
  29384
  30300
  30301
  30302
  30390
  30391
  30392
  30400
  30401
  30402
  30410
  30411
  30412
  30420
  30421
  30422
  30440
  30441
  30442
  30450
  30451
  30452
  30460
  30461
  30462
  30470
  30471
  30472
  30480
  30481
  30482
  30490
  30491
  30492
  30500
  30501
  30502
  30530
  30531
  30532
  30540
  30541
  30542
  30550
  30551
  30552
  30560
  30561
  30562
  30570
  30571
  30572
  30590
  30591
  30592
*29285
  2910
  2911
  2912
  2913
  2914
  29181
  29189
  2919
  2920
  29211
  29212
  2922
  29281
  29282

[[Page 23600]]

 
  29283
  29284
  29289
  2929
  29381
  29382
  29383
  29384
  30300
  30301
  30302
  30390
  30391
  30392
  30400
  30401
  30402
  30410
  30411
  30412
  30420
  30421
  30422
  30440
  30441
  30442
  30450
  30451
  30452
  30460
  30461
  30462
  30470
  30471
  30472
  30480
  30481
  30482
  30490
  30491
  30492
  30500
  30501
  30502
  30530
  30531
  30532
  30540
  30541
  30542
  30550
  30551
  30552
  30560
  30561
  30562
  30570
  30571
  30572
  30590
  30591
  30592
  7105
*34461
  59960
  59969
*42682
  4260
  42612
  42613
  42653
  42654
  4266
  4267
  42681
  42689
  4269
  4270
  4271
  4272
  42731
  42732
  42741
  42742
*51881
  79901
  79902
*51882
  79901
  79902
*51883
  79901
  79902
*51884
  79901
  79902
*5670
  56721
  56722
  56723
  56729
  56733
  56739
  56781
  56782
  56789
*5671
  56721
  56722
  56723
  56729
  56733
  56739
  56781
  56782
  56789
*56721
  5670
  5671
  56721
  56722
  56723
  56729
  56733
  56739
  56781
  56782
  56789
  5679
*56722
  5670
  5671
  56721
  56722
  56723
  56729
  56733
  56739
  56781
  56782
  56789
  5679
*56723
  5670
  5671
  56721
  56722
  56723
  56729
  56733
  56739
  56781
  56782
  56789
  5679
*56729
  5670
  5671
  56721
  56722
  56723
  56729
  56733
  56739
  56781
  56782
  56789
  5679
*56733
  5670
  5671
  56721
  56722
  56723
  56729
  56733
  56739
  56781
  56782
  56789
  5679
*56739
  5670
  5671
  56721
  56722
  56723
  56729
  56733
  56739
  56781
  56782
  56789
  5679
*56781
  5670
  5671
  56721

[[Page 23601]]

 
  56722
  56723
  56729
  56733
  56739
  56781
  56782
  56789
  5679
*56782
  5670
  5671
  56721
  56722
  56723
  56729
  56733
  56739
  56781
  56782
  56789
  5679
*56789
  5670
  5671
  56721
  56722
  56723
  56729
  56733
  56739
  56781
  56782
  56789
  5679
*5679
  56721
  56722
  56723
  56729
  56733
  56739
  56781
  56782
  56789
*56989
  56721
  56722
  56723
  56729
  56733
  56739
  56781
  56782
  56789
*5699
  56721
  56722
  56723
  56729
  56733
  56739
  56781
  56782
  56789
*5800
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*5804
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*58081
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*58089
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*5809
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*5810
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*5811
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*5812
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*5813
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*58181
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*58189
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*5819
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*5820
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*5821
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*5822
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*5824
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*58281
  5851
  5852
  5853
  5854

[[Page 23602]]

 
  5855
  5856
  5859
*58289
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*5829
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*5830
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*5831
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*5832
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*5834
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*5836
  5851
  5852
  5853
  5854
  5855
  5856
  5859
*5837
  5851
  5852
  5853
  5854
  5855
  5856
  5859
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[[Page 23603]]

 
  591
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*5856
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*5859
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*586
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*5881
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[[Page 23604]]

 
  5853
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*5899
  5851
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*59000
  5851
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*59001
  5851
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*59010
  5851
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*59011
  5851
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*5902
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*5903
  5851
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*59080
  5851
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*59081
  5851
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*5909
  5851
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*591
  5851
  5852
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*5921
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*5929
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*5930
  5851
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*5931
  5851
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*5932
  5851
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*5933
  59960
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*5934
  59960
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*5935
  59960
  59969
*59389
  5851
  5852
  5853
  5854
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  59960
  59969
*5939
  5851
  5852
  5853
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*5940
  59960
  59969
*5941
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[[Page 23605]]

 
*5942
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*5948
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*5949
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*5950
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*5951
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*5952
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*5953
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*5954
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*59581
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*59582
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*59780
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*59781
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*59789
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*59800
  59960
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*59801
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*5982
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*5988
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*5990
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*5991
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*59960
  5921
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  5970
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  78820
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*59969
  5921
  5935
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  59589
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  5970
  5981
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  5990
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  78820
  78829
*5997
  5851
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  59969
*59981
  5851
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  59969
*59982
  5851
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  59969
*59983
  5851
  5852
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  5854
  5855
  5856
  5859
  59960
  59969
*59984
  5851
  5852
  5853
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  5855
  5856

[[Page 23606]]

 
  5859
  59960
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*59989
  5851
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*5999
  5851
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*60000
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*60001
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*60010
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*60011
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*60020
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*6003
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*6023
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*6028
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*7530
  5851
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*75310
  5851
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*75311
  5851
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  59969
*75312
  5851
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  59969
*75313
  5851
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  59969
*75314
  5851
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*75315
  5851
  5852
  5853
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  5855
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  59969
*75316
  5851
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*75317
  5851
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  59969
*75319
  5851
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  5856
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  59969
*75320
  5851
  5852
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  59960

[[Page 23607]]

 
  59969
*75321
  5851
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*75322
  5851
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*75323
  5851
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*75329
  5851
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*7533
  5851
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*7534
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*7535
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*7536
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*7537
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*7538
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*7539
  5851
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*7685
  77012
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*7686
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*7689
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*769
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*77010
  7685
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*77011
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*77012
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*77017
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*77018
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  769
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*7702
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*7703
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*7704
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*7705
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*7706
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*7707
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*77081
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*77082
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*77083
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*77084
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*77089
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*7709
  77012
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*77981
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*77982
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*77983
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*77984
  76501

[[Page 23608]]

 
  76502
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*77989
  77012
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*78091
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*78092
  79901
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*78093
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*78094
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*78095
  04082
  44024
  78001
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  78031
  78039
  7817
  7854
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  78559
  7863
  78820
  78829
  7895
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  7911
  7913
  79901
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  7994
*78099
  79901
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*7881
  59960
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*7980
  79901
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*79901
  79901
  79902
  7991
*79902
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*7991
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*79981
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*79989
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*99640
  99640
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  99657
  99660
  99666
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  99677
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*99641
  99640
  99641
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  99646
  99647
  99649
  99657
  99660
  99666
  99667
  99669
  99670
  99677
  99678
  99679
*99642
  99640
  99641
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  99643
  99644
  99645
  99646
  99647
  99649
  99657
  99660
  99666
  99667
  99669
  99670
  99677
  99678
  99679
*99643
  99640
  99641
  99642
  99643
  99644
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  99646
  99647

[[Page 23609]]

 
  99649
  99657
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*99644
  99640
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  99657
  99660
  99666
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  99677
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*99645
  99640
  99641
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  99646
  99647
  99649
  99657
  99660
  99666
  99667
  99669
  99670
  99677
  99678
  99679
*99646
  99640
  99641
  99642
  99643
  99644
  99645
  99646
  99647
  99649
  99657
  99660
  99666
  99667
  99669
  99670
  99677
  99678
  99679
*99647
  99640
  99641
  99642
  99643
  99644
  99645
  99646
  99647
  99649
  99657
  99660
  99666
  99667
  99669
  99670
  99677
  99678
  99679
*99649
  99640
  99641
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  99643
  99644
  99645
  99646
  99647
  99649
  99657
  99660
  99666
  99667
  99669
  99670
  99677
  99678
  99679
*99666
  99640
  99641
  99642
  99643
  99644
  99645
  99646
  99647
  99649
*99667
  99640
  99641
  99642
  99643
  99644
  99645
  99646
  99647
  99649
*99677
  99640
  99641
  99642
  99643
  99644
  99645
  99646
  99647
  99649
*99678
  99640
  99641
  99642
  99643
  99644
  99645
  99646
  99647
  99649
*99791
  99640
  99641
  99642
  99643
  99644
  99645
  99646
  99647
  99649
*99799
  99640
  99641
  99642
  99643
  99644
  99645
  99646
  99647
  99649
*99881
  99640
  99641
  99642
  99643
  99644
  99645
  99646
  99647
  99649
*99883
  99640
  99641
  99642
  99643
  99644
  99645
  99646
  99647
  99649
*99889
  99640
  99641
  99642
  99643
  99644
  99645
  99646
  99647
  99649
*9989
  99640
  99641

[[Page 23610]]

 
  99642
  99643
  99644
  99645
  99646
  99647
  99649
*V460
  V4613
  V4614
*V4611
  V4613
  V4614
*V4612
  V4613
  V4614
*V4613
  V4611
  V4612
  V4613
  V4614
*V4614
  V4611
  V4612
  V4613
  V4614
*V462
  V4613
  V4614
*V468
  V4613
  V4614
*V469
  V4613
  V4614
 


             Table 6H.--Deletions to the CC Exclusions List
 [CCs that are deleted from the list are in Table 6H-Deletions to the CC
    Exclusions List. Each of the principal diagnoses is shown with an
asterisk, and the revisions to the CC Exclusions List are provided in an
indented column immediately following the affected] principal diagnosis.
 
 
 
*185
  5996
*1880
  5996
*1881
  5996
*1882
  5996
*1883
  5996
*1884
  5996
*1885
  5996
*1886
  5996
*1887
  5996
*1888
  5996
*1889
  5996
*1892
  5996
*1893
  5996
*1894
  5996
*1898
  5996
*1899
  5996
*25040
  585
*25041
  585
*25042
  585
*25043
  585
*25080
  585
*25081
  585
*25082
  585
*25083
  585
*25090
  585
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  585
*25092
  585
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  585
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  585
*27411
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*27419
  585
*2760
  2765
*2761
  2765
*2762
  2765
*2763
  2765
*2764
  2765
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  2760
  2761
  2762
  2763
  2764
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  2766
  2767
  2769
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*2767
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*2768
  2765
*2769
  2765
*2860
  2873
*2861
  2873
*2862
  2873
*2863
  2873
*2864
  2873
*2865
  2873
*2866
  2873
*2867
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*2869
  2873
*2870
  2873
*2871
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*2872
  2873
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  2860
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*2878
  2873
*2879
  2873
*28981
  2873
*28982
  2873
*28989
  2873
*2899
  2873
*34461
  5996
*5670
  5672

[[Page 23611]]

 
  5678
*5671
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*5672
  5670
  5671
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*5678
  5670
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  5678
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*5679
  5672
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*56989
  5672
  5678
*5699
  5672
  5678
*5800
  585
*5804
  585
*58081
  585
*58089
  585
*5809
  585
*5810
  585
*5811
  585
*5812
  585
*5813
  585
*58181
  585
*58189
  585
*5819
  585
*5820
  585
*5821
  585
*5822
  585
*5824
  585
*58281
  585
*58289
  585
*5829
  585
*5830
  585
*5831
  585
*5832
  585
*5834
  585
*5836
  585
*5837
  585
*58381
  585
*58389
  585
*5839
  585
*5845
  585
*5846
  585
*5847
  585
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  585
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  585
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  5800
  5804
  58081
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  5849
  585
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  59011
  5902
  5903
  59080
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  591
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  585
*587
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*5880
  585
*5881
  585
*58881
  585
*58889
  585
*5889
  585
*5890
  585
*5891
  585
*5899
  585
*59000
  585
*59001
  585
*59010
  585
*59011
  585
*5902
  585
*5903
  585
*59080
  585
*59081
  585
*5909
  585
*591
  585
*5921
  5996
*5929
  5996
*5930
  585
*5931
  585
*5932
  585
*5933
  5996
*5934
  5996
*5935
  5996
*59389
  585
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*5939
  585
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*5940
  5996
*5941
  5996
*5942
  5996
*5948
  5996
*5949
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*5950
  5996
*5951
  5996
*5952
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*5953

[[Page 23612]]

 
  5996
*5954
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*59581
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*59582
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*59654
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*59655
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*59659
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*5968
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*5969
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*5970
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*59780
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*59781
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*59789
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*59800
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*59801
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*5981
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*5982
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*5988
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*5989
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*5990
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*5991
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*5992
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  5921
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  585
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*60000
  5996
*60001
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*60010
  5996
*60011
  5996
*60020
  5996
*60021
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*6003
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*60090
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*60091
  5996
*6010
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*6011
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*6012
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*7533
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*7536

[[Page 23613]]

 
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*7537
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  7685
  769
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*7702
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*7703
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*7706
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*7707
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*77081
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*77082
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*77083
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*77084
  7701
*77089
  7701
*7709
  7701
*77981
  7701
*77982
  7701
*77983
  7701
*77989
  7701
*7881
  5996
*7990
  7991
*9964
  9964
  99657
  99660
  99666
  99667
  99669
  99670
  99677
  99678
  99679
*99666
  9964
*99667
  9964
*99677
  9964
*99678
  9964
*99791
  9964
*99799
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*99881
  9964
*99883
  9964
*99889
  9964
*9989
  9964
 


                                   Table 7A.--Medicare Prospective Payment System Selected Percentile Lengths of Stay
                                                   [FY 2004 MedPAR Update December 2004 GROUPER V22.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                Number of    Arithmetic      10th         25th         50th          75          90th
                             DRG                                discharges   means LOS    percentile   percentile   percentile   percentile   percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1............................................................       23,272       9.8371            3            5            8           13           19
2............................................................       10,351       4.5604            1            2            4            6            9
3............................................................            4       9.5000            1            1            8           14           15
6............................................................          410       3.0512            1            1            2            4            7
7............................................................       15,592       9.2952            2            4            7           12           19
8............................................................        3,701       2.8652            1            1            2            4            7
9............................................................        1,945       6.1594            1            3            5            7           12
10...........................................................       19,511       6.0234            2            3            5            8           12
11...........................................................        3,279       3.7600            1            2            3            5            7
12...........................................................       54,431       5.3747            2            3            4            6           10
13...........................................................        7,337       4.9162            2            3            4            6            8
14...........................................................      236,958       5.6626            2            3            4            7           11
15...........................................................       76,129       4.5225            1            2            4            6            8
16...........................................................       16,264       6.3451            2            3            5            8           12
17...........................................................        3,008       3.2114            1            2            2            4            6
18...........................................................       33,082       5.2590            2            3            4            7           10
19...........................................................        8,568       3.4383            1            2            3            4            6
20...........................................................        6,532       9.8403            3            5            8           12           19
21...........................................................        2,197       6.3245            2            3            5            8           13
22...........................................................        3,316       5.2223            2            2            4            7           10
23...........................................................       10,732       3.8906            1            2            3            5            7
24...........................................................       63,863       4.7303            1            2            4            6            9
25...........................................................       28,153       3.1246            1            2            3            4            6
26...........................................................           18       6.2778            1            2            3            4            8
27...........................................................        5,387       5.1142            1            1            3            6           11
28...........................................................       17,558       5.7440            1            3            4            7           12
29...........................................................        6,274       3.3202            1            1            3            4            6

[[Page 23614]]

 
30...........................................................            1      19.0000           19           19           19           19           19
31...........................................................        5,090       3.9800            1            2            3            5            8
32...........................................................        1,982       2.4001            1            1            2            3            5
34...........................................................       27,872       4.7722            1            2            4            6            9
35...........................................................        7,895       3.0011            1            1            3            4            6
36...........................................................        1,472       1.6019            1            1            1            1            3
37...........................................................        1,241       4.1281            1            1            3            5            9
38...........................................................           56       3.5179            1            1            2            4            6
39...........................................................          448       2.3772            1            1            1            2            5
40...........................................................        1,383       4.1063            1            1            4            5            8
42...........................................................        1,145       2.7721            1            1            2            4            6
43...........................................................          125       3.1440            1            1            2            4            6
44...........................................................        1,160       4.7836            2            3            4            6            8
45...........................................................        2,803       3.0756            1            2            2            4            6
46...........................................................        3,819       4.1712            1            2            3            5            8
47...........................................................        1,335       2.8854            1            1            2            4            5
49...........................................................        2,478       4.3906            1            2            3            5            8
50...........................................................        2,170       1.8143            1            1            1            2            3
51...........................................................          190       2.7632            1            1            1            3            6
52...........................................................          165       1.9818            1            1            1            2            4
53...........................................................        2,225       3.9542            1            1            2            5            9
54...........................................................            1       7.0000            7            7            7            7            7
55...........................................................        1,354       3.1300            1            1            2            4            7
56...........................................................          435       2.5724            1            1            1            3            6
57...........................................................          698       4.1547            1            1            2            5            9
59...........................................................          102       2.5392            1            1            1            2            6
60...........................................................            8       3.2500            1            1            2            4            4
61...........................................................          219       5.4064            1            1            3            7           12
63...........................................................        2,842       4.4838            1            2            3            5            9
64...........................................................        3,343       6.0464            1            2            4            8           13
65...........................................................       41,424       2.7728            1            1            2            3            5
66...........................................................        8,007       3.1309            1            1            2            4            6
67...........................................................          419       3.6826            1            2            3            4            7
68...........................................................       17,328       3.9720            1            2            3            5            7
69...........................................................        4,816       3.0328            1            2            3            4            5
70...........................................................           25       2.3600            1            1            2            3            4
71...........................................................           68       4.0000            1            2            3            5            7
72...........................................................        1,066       3.4531            1            2            3            4            7
73...........................................................        7,935       4.3806            1            2            3            6            9
74...........................................................            4       2.5000            2            2            2            3            3
75...........................................................       45,034       9.8129            3            5            7           12           20
76...........................................................       47,341      10.8198            3            5            8           13           21
77...........................................................        2,153       4.6716            1            2            4            6            9
78...........................................................       45,631       6.2559            2            4            6            8           10
79...........................................................      170,684       8.1939            3            4            7           10           15
80...........................................................        7,724       5.3718            2            3            4            7           10
81...........................................................            4      11.5000            8            8           11           13           14
82...........................................................       65,161       6.6908            2            3            5            9           13
83...........................................................        6,950       5.2373            2            3            4            7           10
84...........................................................        1,472       3.1454            1            2            3            4            6
85...........................................................       21,878       6.2321            2            3            5            8           12
86...........................................................        1,861       3.6239            1            2            3            5            7
87...........................................................       82,727       6.4131            2            3            5            8           12
88...........................................................      413,844       4.9009            2            3            4            6            9
89...........................................................      550,707       5.6477            2            3            5            7           10
90...........................................................       45,868       3.8123            2            2            3            5            7
91...........................................................           45       4.3556            1            2            3            5            9
92...........................................................       16,495       5.9978            2            3            5            8           11
93...........................................................        1,598       3.8273            1            2            3            5            7
94...........................................................       13,338       6.1223            2            3            5            8           12
95...........................................................        1,612       3.6340            1            2            3            5            7
96...........................................................       59,134       4.3754            2            2            4            5            8
97...........................................................       27,017       3.3864            1            2            3            4            6
98...........................................................            8       2.5000            1            2            2            3            3
99...........................................................       21,547       3.1101            1            1            2            4            6
100..........................................................        6,953       2.1151            1            1            2            3            4
101..........................................................       23,105       4.2502            1            2            3            5            8
102..........................................................        5,237       2.4921            1            1            2            3            5
103..........................................................          724      37.3798            8           12           23           48           79
104..........................................................       20,953      14.4988            6            8           12           18           25

[[Page 23615]]

 
105..........................................................       31,568       9.9544            4            6            8           12           18
106..........................................................        3,499      11.2138            5            7            9           13           19
107..........................................................       70,111      10.5005            5            7            9           12           17
108..........................................................        8,878       9.8314            1            5            8           12           19
109..........................................................       50,742       7.7661            4            5            6            9           13
110..........................................................       57,167       8.3880            1            3            7           11           17
111..........................................................       10,077       3.4273            1            1            3            5            7
113..........................................................       37,263      12.5945            4            6           10           16           24
114..........................................................        8,514       8.4514            2            4            7           11           16
115..........................................................       22,137       6.8327            1            2            5            9           14
116..........................................................      118,685       4.2655            1            1            3            6            9
117..........................................................        5,151       4.2386            1            1            2            5           10
118..........................................................        7,605       3.0473            1            1            2            4            7
119..........................................................          993       5.4945            1            1            3            7           13
120..........................................................       36,309       9.0439            1            3            6           12           20
121..........................................................      159,575       6.2485            2            3            5            8           12
122..........................................................       61,768       3.3855            1            2            3            4            6
123..........................................................       33,656       4.7990            1            1            3            6           11
124..........................................................      130,770       4.3991            1            2            3            6            9
125..........................................................       95,808       2.7249            1            1            2            3            5
126..........................................................        5,823      11.2705            3            6            9           14           21
127..........................................................      695,800       5.1260            2            3            4            6           10
128..........................................................        5,181       5.1662            2            3            5            6            9
129..........................................................        3,762       2.5944            1            1            1            3            6
130..........................................................       89,126       5.4275            1            3            5            7           10
131..........................................................       23,839       3.8048            1            2            4            5            7
132..........................................................      117,297       2.8049            1            1            2            3            5
133..........................................................        7,287       2.1806            1            1            2            3            4
134..........................................................       42,414       3.1069            1            2            2            4            6
135..........................................................        7,439       4.2879            1            2            3            5            8
136..........................................................        1,133       2.7643            1            1            2            3            5
138..........................................................      207,068       3.9126            1            2            3            5            7
139..........................................................       78,609       2.4367            1            1            2            3            5
140..........................................................       38,178       2.4370            1            1            2            3            5
141..........................................................      121,892       3.4612            1            2            3            4            6
142..........................................................       52,279       2.4785            1            1            2            3            5
143..........................................................      249,312       2.0936            1            1            2            3            4
144..........................................................       99,715       5.6964            1            2            4            7           12
145..........................................................        6,187       2.6198            1            1            2            3            5
146..........................................................       10,769       9.8862            5            6            8           12           17
147..........................................................        2,634       5.8193            3            4            6            7            9
148..........................................................      135,681      12.0864            5            7            9           15           22
149..........................................................       19,915       5.9490            3            4            6            7            9
150..........................................................       22,708      10.8769            4            6            9           14           20
151..........................................................        5,353       5.1362            1            2            5            7           10
152..........................................................        5,007       8.0429            3            5            7            9           14
153..........................................................        2,092       4.9809            2            3            5            6            8
154..........................................................       28,497      13.0520            3            6           10           16           25
155..........................................................        6,161       4.1344            1            2            3            6            8
156..........................................................            6      24.1667            1            5            9           27           27
157..........................................................        8,260       5.7196            1            2            4            7           12
158..........................................................        4,106       2.6086            1            1            2            3            5
159..........................................................       19,174       5.1209            1            2            4            7           10
160..........................................................       11,988       2.6625            1            1            2            3            5
161..........................................................       10,428       4.3945            1            2            3            6            9
162..........................................................        5,497       2.0806            1            1            1            3            4
163..........................................................           10       2.9000            1            1            2            3            6
164..........................................................        5,945       7.9862            3            5            7           10           14
165..........................................................        2,523       4.2089            2            3            4            5            7
166..........................................................        4,933       4.5046            1            2            3            5            9
167..........................................................        4,634       2.2169            1            1            2            3            4
168..........................................................        1,544       4.9087            1            2            3            6           10
169..........................................................          756       2.2844            1            1            2            3            5
170..........................................................       17,471      10.7718            2            5            8           14           22
171..........................................................        1,484       4.0964            1            2            3            5            8
172..........................................................       32,879       6.8401            2            3            5            9           14
173..........................................................        2,392       3.5920            1            1            3            5            7
174..........................................................      267,905       4.7020            2            3            4            6            9
175..........................................................       32,657       2.8910            1            2            2            4            5
176..........................................................       14,560       5.1422            2            3            4            6           10

[[Page 23616]]

 
177..........................................................        8,554       4.4329            2            2            4            5            8
178..........................................................        2,909       3.1158            1            2            3            4            5
179..........................................................       14,429       5.8559            2            3            5            7           11
180..........................................................       92,193       5.3215            2            3            4            7           10
181..........................................................       25,897       3.3265            1            2            3            4            6
182..........................................................      292,198       4.4293            1            2            3            5            8
183..........................................................       86,576       2.8664            1            1            2            4            5
184..........................................................           78       3.2821            1            2            2            4            6
185..........................................................        5,680       4.4905            1            2            3            5            9
186..........................................................            4       2.0000            1            1            1            3            3
187..........................................................          621       4.1723            1            2            3            5            8
188..........................................................       90,968       5.5332            1            2            4            7           11
189..........................................................       13,182       3.0882            1            1            2            4            6
190..........................................................           69       4.3768            1            2            3            5            8
191..........................................................       10,411      12.6933            3            6            9           16           26
192..........................................................        1,322       5.6899            1            3            5            7           10
193..........................................................        4,514      12.0549            5            7           10           15           22
194..........................................................          521       6.6756            3            4            6            8           11
195..........................................................        3,249      10.6190            4            6            9           13           19
196..........................................................          701       5.7275            2            4            5            7            9
197..........................................................       17,317       9.0988            3            5            7           11           17
198..........................................................        4,645       4.3208            2            3            4            6            7
199..........................................................        1,425       9.5298            2            4            7           13           19
200..........................................................          936       9.6976            1            4            7           12           20
201..........................................................        2,665      13.7471            3            6           10           18           28
202..........................................................       27,281       6.1787            2            3            5            8           12
203..........................................................       31,656       6.4850            2            3            5            8           13
204..........................................................       72,845       5.5246            2            3            4            7           11
205..........................................................       31,474       5.8950            2            3            4            7           12
206..........................................................        2,081       3.8847            1            2            3            5            8
207..........................................................       35,754       5.2393            1            2            4            7           10
208..........................................................        9,758       2.9364            1            1            2            4            6
209..........................................................      461,222       4.5677            3            3            4            5            7
210..........................................................      128,455       6.6967            3            4            6            8           11
211..........................................................       26,708       4.6708            3            3            4            5            7
212..........................................................           10       2.9000            1            1            3            4            4
213..........................................................       10,257       9.1059            2            4            7           12           18
216..........................................................       17,656       5.7608            1            1            3            8           14
217..........................................................       17,622      12.4479            3            5            9           15           26
218..........................................................       28,708       5.4480            2            3            4            7           10
219..........................................................       21,361       3.1063            1            2            3            4            5
220..........................................................            4       2.7500            2            2            3            3            3
223..........................................................       13,425       3.2055            1            1            2            4            6
224..........................................................       10,889       1.8875            1            1            1            2            3
225..........................................................        6,514       5.1650            1            2            4            7           11
226..........................................................        6,660       6.3380            1            2            4            8           13
227..........................................................        5,074       2.6139            1            1            2            3            5
228..........................................................        2,640       4.1258            1            1            3            5            9
229..........................................................        1,201       2.5129            1            1            2            3            5
230..........................................................        2,565       5.5922            1            2            4            7           12
232..........................................................          729       2.8230            1            1            1            3            6
233..........................................................       15,118       6.6726            1            2            5            9           14
234..........................................................        7,676       2.7952            1            1            2            4            6
235..........................................................        4,970       4.6463            1            2            4            6            9
236..........................................................       42,408       4.4748            1            3            4            5            8
237..........................................................        2,022       3.6682            1            2            3            4            7
238..........................................................        9,869       8.2633            3            4            6           10           15
239..........................................................       42,943       6.0632            2            3            5            7           11
240..........................................................       12,653       6.6177            2            3            5            8           13
241..........................................................        2,696       3.7066            1            2            3            5            7
242..........................................................        2,742       6.5864            2            3            5            8           12
243..........................................................      101,477       4.5166            1            2            4            6            8
244..........................................................       15,792       4.4924            1            2            4            6            8
245..........................................................        5,840       3.1334            1            1            3            4            6
246..........................................................        1,430       3.5664            1            2            3            4            7
247..........................................................       21,671       3.3172            1            2            3            4            6
248..........................................................       15,118       4.8397            1            3            4            6            9
249..........................................................       14,026       3.8285            1            1            3            5            8
250..........................................................        4,155       3.8876            1            2            3            5            7
251..........................................................        2,148       2.7514            1            1            3            3            5

[[Page 23617]]

 
252..........................................................            1       1.0000            1            1            1            1            1
253..........................................................       24,857       4.5324            2            3            4            5            8
254..........................................................       10,420       3.0461            1            2            3            4            5
255..........................................................            1       7.0000            7            7            7            7            7
256..........................................................        7,152       5.0301            1            2            4            6           10
257..........................................................       13,512       2.6104            1            1            2            3            5
258..........................................................       12,042       1.7498            1            1            1            2            3
259..........................................................        2,903       2.7689            1            1            1            3            7
260..........................................................        2,991       1.4055            1            1            1            1            2
261..........................................................        1,603       2.2052            1            1            1            2            4
262..........................................................          636       4.8428            1            2            4            7           10
263..........................................................       23,809      10.7403            3            5            8           13           21
264..........................................................        3,922       6.2358            2            3            5            8           12
265..........................................................        4,307       6.5677            1            2            4            8           14
266..........................................................        2,304       3.1788            1            1            2            4            7
267..........................................................          272       4.1838            1            1            3            5           10
268..........................................................        1,004       3.5508            1            1            2            4            7
269..........................................................       10,686       8.3273            2            4            6           11           16
270..........................................................        2,639       3.8151            1            1            3            5            8
271..........................................................       21,054       6.7875            2            3            5            8           12
272..........................................................        5,942       5.8009            2            3            4            7           11
273..........................................................        1,349       3.6449            1            2            3            5            7
274..........................................................        2,288       6.2592            2            3            5            8           12
275..........................................................          228       3.2456            1            1            2            4            7
276..........................................................        1,447       4.4630            1            2            4            6            8
277..........................................................      112,318       5.5013            2            3            5            7           10
278..........................................................       33,865       4.0567            2            2            3            5            7
279..........................................................            6       4.6667            1            3            5            6            6
280..........................................................       19,272       4.0080            1            2            3            5            7
281..........................................................        7,093       2.8429            1            1            2            4            5
283..........................................................        6,274       4.5695            1            2            3            6            9
284..........................................................        1,833       3.0295            1            1            2            4            6
285..........................................................        7,623      10.0454            3            5            8           12           19
286..........................................................        2,703       5.4802            2            2            4            6           10
287..........................................................        6,114       9.8368            3            5            7           12           19
288..........................................................       10,450       4.1090            2            2            3            4            7
289..........................................................        6,894       2.5582            1            1            1            2            5
290..........................................................       10,859       2.1325            1            1            1            2            4
291..........................................................           64       2.7969            1            1            1            2            5
292..........................................................        7,331      10.0308            2            4            8           13           20
293..........................................................          368       4.4674            1            2            3            6            9
294..........................................................       98,963       4.2920            1            2            3            5            8
295..........................................................        4,102       3.6675            1            2            3            4            7
296..........................................................      254,706       4.7202            1            2            4            6            9
297..........................................................       45,347       3.0710            1            2            3            4            6
298..........................................................           81       3.9383            1            1            2            4            7
299..........................................................        1,478       5.1604            1            2            4            6           10
300..........................................................       21,343       5.8673            2            3            5            7           11
301..........................................................        3,901       3.4107            1            2            3            4            6
302..........................................................        9,649       8.1898            4            5            6            9           14
303..........................................................       23,760       7.3943            3            4            6            9           14
304..........................................................       13,826       8.4735            2            3            6           11           18
305..........................................................        3,087       3.2096            1            2            3            4            6
306..........................................................        6,350       5.4737            1            2            3            8           12
307..........................................................        2,066       2.0736            1            1            2            2            3
308..........................................................        7,093       6.1095            1            2            4            8           14
309..........................................................        3,559       2.0014            1            1            1            2            4
310..........................................................       26,035       4.5265            1            2            3            6           10
311..........................................................        6,480       1.8782            1            1            1            2            3
312..........................................................        1,456       4.8365            1            1            3            6           11
313..........................................................          508       2.2165            1            1            2            3            4
314..........................................................            1       2.0000            2            2            2            2            2
315..........................................................       36,565       6.7584            1            1            4            9           16
316..........................................................      180,999       6.2874            2            3            5            8           12
317..........................................................        2,766       3.4678            1            1            2            4            7
318..........................................................        5,927       5.7441            1            2            4            7           11
319..........................................................          383       2.7546            1            1            2            3            6
320..........................................................      218,684       5.0953            2            3            4            6            9
321..........................................................       31,401       3.5963            1            2            3            4            6
322..........................................................           61       3.4918            2            2            3            4            6

[[Page 23618]]

 
323..........................................................       20,482       3.0937            1            1            2            4            6
324..........................................................        5,421       1.8843            1            1            1            2            3
325..........................................................        9,615       3.6813            1            2            3            5            7
326..........................................................        2,584       2.6207            1            1            2            3            5
327..........................................................            5       2.6000            1            1            2            3            5
328..........................................................          606       3.4719            1            1            3            5            7
329..........................................................           72       1.8333            1            1            1            2            3
331..........................................................       54,798       5.4332            1            2            4            7           11
332..........................................................        4,389       3.1246            1            1            2            4            6
333..........................................................          252       5.4921            1            2            3            7           13
334..........................................................        9,810       4.3009            2            2            3            5            7
335..........................................................       11,931       2.6866            1            2            3            3            4
336..........................................................       31,264       3.2999            1            2            2            4            7
337..........................................................       25,156       1.9182            1            1            2            2            3
338..........................................................          652       6.1748            1            2            3            9           14
339..........................................................        1,253       5.1173            1            1            3            7           11
340..........................................................            2       5.0000            4            4            6            6            6
341..........................................................        3,185       3.1586            1            1            2            3            7
342..........................................................          565       3.4248            1            2            2            4            8
344..........................................................        2,693       2.7037            1            1            1            2            6
345..........................................................        1,461       4.8077            1            1            3            6           11
346..........................................................        3,966       5.7307            1            3            4            7           11
347..........................................................          247       3.0202            1            1            2            4            7
348..........................................................        4,171       4.0897            1            2            3            5            8
349..........................................................          575       2.3583            1            1            2            3            4
350..........................................................        7,137       4.4541            2            2            4            5            8
352..........................................................          975       4.0133            1            2            3            5            8
353..........................................................        2,735       6.3192            2            3            4            7           12
354..........................................................        7,612       5.6967            2            3            4            6           10
355..........................................................        4,937       3.0614            2            2            3            4            4
356..........................................................       23,993       1.9281            1            1            2            2            3
357..........................................................        5,570       8.1269            3            4            6           10           15
358..........................................................       20,798       3.9629            2            2            3            4            7
359..........................................................       28,741       2.4058            1            2            2            3            4
360..........................................................       14,764       2.5880            1            1            2            3            4
361..........................................................          272       3.0184            1            1            2            3            7
362..........................................................            2       1.0000            1            1            1            1            1
363..........................................................        2,128       3.7810            1            2            2            4            8
364..........................................................        1,451       4.1909            1            2            3            5            9
365..........................................................        1,622       7.7404            2            3            5            9           17
366..........................................................        4,789       6.4792            2            3            5            8           13
367..........................................................          456       2.9934            1            1            2            4            6
368..........................................................        3,924       6.6351            2            3            5            8           13
369..........................................................        3,613       3.2419            1            1            2            4            6
370..........................................................        1,843       5.1557            2            3            4            5            8
371..........................................................        2,244       3.3944            2            3            3            4            5
372..........................................................        1,164       3.1847            2            2            2            3            5
373..........................................................        4,871       2.2373            1            2            2            3            3
374..........................................................          156       2.7436            2            2            2            3            4
375..........................................................            6       4.0000            1            2            2            6            6
376..........................................................          388       3.3711            1            2            2            4            6
377..........................................................           77       4.4805            1            1            3            4            8
378..........................................................          196       2.3163            1            1            2            3            4
379..........................................................          508       2.8130            1            1            2            3            6
380..........................................................           91       2.1099            1            1            1            2            4
381..........................................................          212       2.2642            1            1            1            2            4
382..........................................................           43       1.4419            1            1            1            2            2
383..........................................................        2,473       3.6526            1            1            2            4            7
384..........................................................          132       2.5606            1            1            1            3            5
385..........................................................            1       1.0000            1            1            1            1            1
389..........................................................            1      21.0000           21           21           21           21           21
390..........................................................            1       1.0000            1            1            1            1            1
392..........................................................        2,203       9.1770            2            4            6           11           19
393..........................................................            1       4.0000            4            4            4            4            4
394..........................................................        2,820       7.3553            1            2            5            9           16
395..........................................................      116,129       4.2575            1            2            3            5            8
396..........................................................            9       4.4444            1            1            2            3            6
397..........................................................       18,482       5.1407            1            2            4            6           10
398..........................................................       18,288       5.7016            2            3            4            7           11
399..........................................................        1,640       3.3250            1            2            3            4            6

[[Page 23619]]

 
401..........................................................        6,328      11.0390            2            5            9           14           22
402..........................................................        1,401       4.0293            1            1            3            5            9
403..........................................................       31,865       7.9367            2            3            6           10           16
404..........................................................        3,802       4.1528            1            2            3            5            8
406..........................................................        2,224       9.9150            2            4            7           12           21
407..........................................................          584       3.8253            1            2            3            5            7
408..........................................................        2,170       8.1949            1            2            5           10           19
409..........................................................        1,808       5.7954            1            3            4            6           12
410..........................................................       28,417       3.8214            1            2            3            5            6
411..........................................................           12       3.2500            1            2            2            4            4
412..........................................................           12       2.7500            1            1            1            3            4
413..........................................................        5,198       6.7563            2            3            5            9           13
414..........................................................          573       4.0244            1            2            3            5            8
415..........................................................       50,827      14.0035            4            6           11           18           28
416..........................................................      239,006       7.3769            2            3            6            9           14
417..........................................................           23       5.2174            1            2            3            5           10
418..........................................................       28,508       6.1657            2            3            5            8           12
419..........................................................       16,282       4.3857            1            2            3            5            8
420..........................................................        2,941       3.3747            1            2            3            4            6
421..........................................................       11,882       4.0613            1            2            3            5            7
422..........................................................           52       3.7115            1            1            2            4            7
423..........................................................        8,637       8.2173            2            3            6           10           17
424..........................................................        1,071      11.7274            2            4            8           14           22
425..........................................................       14,779       3.4569            1            1            3            4            7
426..........................................................        4,313       4.1203            1            2            3            5            8
427..........................................................        1,505       4.7375            1            2            3            5            9
428..........................................................          773       7.2549            1            2            5            8           15
429..........................................................       25,479       5.4228            2            3            4            6           10
430..........................................................       71,439       7.6737            2            3            6            9           15
431..........................................................          304       5.8947            1            2            4            7           12
432..........................................................          420       4.2548            1            2            3            5            8
433..........................................................        5,191       2.9626            1            1            2            3            6
439..........................................................        1,739       8.7993            1            3            5           10           19
440..........................................................        5,613       8.7825            2            3            6           10           18
441..........................................................          779       3.3813            1            1            2            4            7
442..........................................................       18,017       8.6810            2            3            6           11           18
443..........................................................        3,385       3.4003            1            1            3            4            7
444..........................................................        5,892       4.0324            1            2            3            5            8
445..........................................................        2,346       2.8372            1            1            2            4            5
447..........................................................        6,264       2.5686            1            1            2            3            5
448..........................................................            1       2.0000            2            2            2            2            2
449..........................................................       38,802       3.6742            1            1            3            4            7
450..........................................................        7,805       1.9867            1            1            1            2            4
451..........................................................            3       1.6667            1            1            1            3            3
452..........................................................       27,634       4.8762            1            2            3            6           10
453..........................................................        5,437       2.7993            1            1            2            3            5
454..........................................................        3,837       4.1058            1            2            3            5            8
455..........................................................          846       2.2222            1            1            2            3            4
461..........................................................        2,722       5.1267            1            1            3            6           12
462..........................................................        7,761      10.1584            4            6            8           13           18
463..........................................................       31,045       3.8939            1            2            3            5            7
464..........................................................        7,661       2.9141            1            1            2            4            5
465..........................................................          219       3.6347            1            1            2            4            7
466..........................................................        1,377       4.7117            1            1            2            5            9
467..........................................................        1,015       2.6788            1            1            2            3            5
468..........................................................       50,481      12.8082            3            6           10           16           25
471..........................................................       15,614       5.0496            3            3            4            5            8
473..........................................................        8,778      12.4026            2            3            7           18           32
475..........................................................      116,534      11.0157            2            5            9           14           21
476..........................................................        3,025      10.4998            2            4            9           14           21
477..........................................................       29,407       8.5221            1            3            6           11           18
478..........................................................      113,660       7.1046            1            2            5            9           15
479..........................................................       24,603       2.7884            1            1            2            4            6
480..........................................................          802      17.9102            7            9           13           22           36
481..........................................................        1,066      21.8208           10           16           20           25           35
482..........................................................        5,076      11.4967            4            6            9           14           21
484..........................................................          449      12.7506            2            6           10           17           25
485..........................................................        3,420       9.6038            4            5            7           11           18
486..........................................................        2,562      12.3478            2            6           10           16           25
487..........................................................        4,644       7.0540            1            3            5            9           14

[[Page 23620]]

 
488..........................................................          786      16.3422            4            7           13           22           35
489..........................................................       13,461       8.3538            2            3            6           10           17
490..........................................................        5,204       5.3918            1            2            4            7           11
491..........................................................       19,789       3.1423            1            2            3            3            5
492..........................................................        4,012      13.6269            3            5            6           23           31
493..........................................................       61,628       6.0515            1            3            5            8           12
494..........................................................       25,626       2.6772            1            1            2            4            5
495..........................................................          307      17.4072            8            9           13           19           31
496..........................................................        3,261       8.9877            3            4            6           11           18
497..........................................................       29,453       6.0617            3            4            5            7           10
498..........................................................       19,400       3.7954            2            3            3            5            6
499..........................................................       35,676       4.3236            1            2            3            5            9
500..........................................................       48,323       2.2420            1            1            2            3            4
501..........................................................        3,122       9.9308            4            5            8           13           18
502..........................................................          717       5.6987            2            3            5            7            9
503..........................................................        5,909       3.8284            1            2            3            5            7
504..........................................................          187      27.1818            8           16           23           36           49
505..........................................................          179       4.6704            1            1            1            6           11
506..........................................................        1,004      15.9273            3            7           13           21           33
507..........................................................          307       8.4919            1            3            7           11           18
508..........................................................          641       7.2044            1            3            5            9           15
509..........................................................          168       5.1607            1            2            3            6           11
510..........................................................        1,755       6.4160            1            2            4            8           14
511..........................................................          635       4.0787            1            1            2            5            8
512..........................................................          513      12.7719            7            8           10           14           23
513..........................................................          227       9.9824            5            7            8           12           16
515..........................................................       27,312       4.2899            1            1            2            6           11
516..........................................................       38,732       4.7893            2            2            4            6            9
517..........................................................       66,287       2.5801            1            1            1            3            6
518..........................................................       41,113       3.4800            1            1            2            4            8
519..........................................................       11,506       4.8233            1            1            3            6           11
520..........................................................       15,266       2.0074            1            1            1            2            4
521..........................................................       32,148       5.4742            2            3            4            7           11
522..........................................................        5,646       9.3666            3            4            7           12           19
523..........................................................       15,866       3.8769            1            2            3            5            7
524..........................................................      118,949       3.1907            1            2            3            4            6
525..........................................................          315      13.4222            1            3            8           16           32
526..........................................................       55,877       4.3572            1            2            3            5            8
527..........................................................      192,230       2.2326            1            1            1            2            5
528..........................................................        1,770      17.1090            6           10           15           22           30
529..........................................................        4,032       7.9923            1            2            5           10           18
530..........................................................        2,363       3.1240            1            1            2            4            6
531..........................................................        4,799       9.4049            2            4            7           12           20
532..........................................................        2,622       3.7227            1            1            3            5            8
533..........................................................       47,609       3.7364            1            1            2            4            9
534..........................................................       45,285       1.7909            1            1            1            2            3
535..........................................................       13,002       8.2678            1            3            7           11           17
536..........................................................       19,606       5.4113            1            2            4            7           12
537..........................................................        8,641       6.7775            1            3            5            8           14
538..........................................................        5,604       2.8164            1            1            2            4            6
539..........................................................        5,020      10.7639            2            4            7           14           23
540..........................................................        1,510       3.5808            1            1            3            4            7
541..........................................................       22,369      42.8902           17           25           35           52           76
542..........................................................       24,376      32.5434           12           18           27           40           58
543..........................................................        5,415      11.9830            2            5           10           16           24
                                                              -------------
                                                                12,140,152
--------------------------------------------------------------------------------------------------------------------------------------------------------


                                   Table 7B.--Medicare Prospective Payment System Selected Percentile Lengths of Stay
                                                   [FY 2004 MedPAR Update December 2004 GROUPER V23.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                Number of    Arithmetic      10th         25th         50th         75th         90th
                             DRG                                discharges    mean LOS    percentile   percentile   percentile   percentile   percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1............................................................       23,271       9.8373            3            5            8           13           19
2............................................................       10,351       4.5604            1            2            4            6            9
3............................................................            4       9.5000            1            1            8           14           15
6............................................................          410       3.0512            1            1            2            4            7
7............................................................       15,592       9.2952            2            4            7           12           19

[[Page 23621]]

 
8............................................................        3,701       2.8652            1            1            2            4            7
9............................................................        1,945       6.1594            1            3            5            7           12
10...........................................................       19,511       6.0234            2            3            5            8           12
11...........................................................        3,279       3.7600            1            2            3            5            7
12...........................................................       54,431       5.3747            2            3            4            6           10
13...........................................................        7,337       4.9162            2            3            4            6            8
14...........................................................      236,958       5.6626            2            3            4            7           11
15...........................................................       76,129       4.5225            1            2            4            6            8
16...........................................................       16,264       6.3451            2            3            5            8           12
17...........................................................        3,008       3.2114            1            2            2            4            6
18...........................................................       33,082       5.2590            2            3            4            7           10
19...........................................................        8,568       3.4383            1            2            3            4            6
20...........................................................        6,532       9.8403            3            5            8           12           19
21...........................................................        2,197       6.3245            2            3            5            8           13
22...........................................................        3,316       5.2223            2            2            4            7           10
23...........................................................       10,732       3.8906            1            2            3            5            7
24...........................................................       63,863       4.7303            1            2            4            6            9
25...........................................................       28,153       3.1246            1            2            3            4            6
26...........................................................           18       6.2778            1            2            3            4            8
27...........................................................        5,387       5.1142            1            1            3            6           11
28...........................................................       17,558       5.7440            1            3            4            7           12
29...........................................................        6,274       3.3202            1            1            3            4            6
30...........................................................            1      19.0000           19           19           19           19           19
31...........................................................        5,090       3.9800            1            2            3            5            8
32...........................................................        1,982       2.4001            1            1            2            3            5
34...........................................................       27,872       4.7722            1            2            4            6            9
35...........................................................       17,895       3.0011            1            1            3            4            6
36...........................................................        1,472       1.6019            1            1            1            1            3
37...........................................................        1,241       4.1281            1            1            3            5            9
38...........................................................           56       3.5179            1            1            2            4            6
39...........................................................          448       2.3772            1            1            1            2            5
40...........................................................        1,383       4.1063            1            1            4            5            8
42...........................................................        1,145       2.7721            1            1            2            4            6
43...........................................................          125       3.1440            1            1            2            4            6
44...........................................................        1,160       4.7836            2            3            4            6            8
45...........................................................        2,803       3.0756            1            2            2            4            6
46...........................................................        3,819       4.1712            1            2            3            5            8
47...........................................................        1,335       2.8854            1            1            2            4            5
49...........................................................        2,478       4.3906            1            2            3            5            8
50...........................................................        2,170       1.8143            1            1            1            2            3
51...........................................................          190       2.7632            1            1            1            3            6
52...........................................................          165       1.9818            1            1            1            2            4
53...........................................................        2,225       3.9542            1            1            2            5            9
54...........................................................            1       7.0000            7            7            7            7            7
55...........................................................        1,354       3.1300            1            1            2            4            7
56...........................................................          435       2.5724            1            1            1            3            6
57...........................................................          698       4.1547            1            1            2            5            9
59...........................................................          102       2.5392            1            1            1            2            6
60...........................................................            8       3.2500            1            1            2            4            4
61...........................................................          219       5.4064            1            1            3            7           12
63...........................................................        2,842       4.4838            1            2            3            5            9
64...........................................................        3,343       6.0464            1            2            4            8           13
65...........................................................       41,424       2.7728            1            1            2            3            5
66...........................................................        8,007       3.1309            1            1            2            4            6
67...........................................................          419       3.6826            1            2            3            4            7
68...........................................................       17,328       3.9720            1            2            3            5            7
69...........................................................        4,816       3.0328            1            2            3            4            5
70...........................................................           25       2.3600            1            1            2            3            4
71...........................................................           68       4.0000            1            2            3            5            7
72...........................................................        1,066       3.4531            1            2            3            4            7
73...........................................................        7,935       4.3806            1            2            3            6            9
74...........................................................            4       2.5000            2            2            2            3            3
75...........................................................       45,031       9.8127            3            5            7           12           20
76...........................................................       47,341      10.8198            3            5            8           13           21
77...........................................................        2,153       4.6716            1            2            4            6            9
78...........................................................       45,631       6.2559            2            4            6            8           10
79...........................................................      170,684       8.1939            3            4            7           10           15
80...........................................................        7,724       5.3718            2            3            4            7           10
81...........................................................            4      11.5000            8            8           11           13           14
82...........................................................       65,161       6.6908            2            3            5            9           13

[[Page 23622]]

 
83...........................................................        6,950       5.2373            2            3            4            7           10
84...........................................................        1,472       3.1454            1            2            3            4            6
85...........................................................       21,878       6.2321            2            3            5            8           12
86...........................................................        1,861       3.6239            1            2            3            5            7
87...........................................................       82,727       6.4131            2            3            5            8           12
88...........................................................      413,844       4.9009            2            3            4            6            9
89...........................................................      550,707       5.6477            2            3            5            7           10
90...........................................................       45,868       3.8123            2            2            3            5            7
91...........................................................           45       4.3556            1            2            3            5            9
92...........................................................       16,495       5.9978            2            3            5            8           11
93...........................................................        1,598       3.8273            1            2            3            5            7
94...........................................................       13,338       6.1223            2            3            5            8           12
95...........................................................        1,612       3.6340            1            2            3            5            7
96...........................................................       59,134       4.3754            2            2            4            5            8
97...........................................................       27,017       3.3864            1            2            3            4            6
98...........................................................            8       2.5000            1            2            2            3            3
99...........................................................       21,547       3.1101            1            1            2            4            6
100..........................................................        6,953       2.1151            1            1            2            3            4
101..........................................................       23,105       4.2502            1            2            3            5            8
102..........................................................        5,237       2.4921            1            1            2            3            5
103..........................................................          724      37.3798            8           12           23           48           79
104..........................................................       20,929      14.5053            6            8           12           18           25
105..........................................................       31,544       9.9561            4            6            8           12           18
106..........................................................        3,499      11.2138            5            7            9           13           19
107..........................................................       70,111      10.5005            5            7            9           12           17
108..........................................................        7,947      10.6922            4            6            9           13           19
109..........................................................       50,742       7.7661            4            5            6            9           13
110..........................................................       57,167       8.3880            1            3            7           11           17
111..........................................................       10,077       3.4273            1            1            3            5            7
113..........................................................       37,263      12.5945            4            6           10           16           24
114..........................................................        8,514       8.4514            2            4            7           11           16
115..........................................................       22,137       6.8327            1            2            5            9           14
116..........................................................      118,685       4.2655            1            1            3            6            9
117..........................................................        5,151       4.2386            1            1            2            5           10
118..........................................................        7,605       3.0473            1            1            2            4            7
119..........................................................          993       5.4945            1            1            3            7           13
120..........................................................       36,309       9.0439            1            3            6           12           20
121..........................................................      159,575       6.2485            2            3            5            8           12
122..........................................................       61,768       3.3855            1            2            3            4            6
123..........................................................       33,656       4.7990            1            1            3            6           11
124..........................................................      130,770       4.3991            1            2            3            6            9
125..........................................................       95,808       2.7249            1            1            2            3            5
126..........................................................        5,823      11.2705            3            6            9           14           21
127..........................................................      695,800       5.1260            2            3            4            6           10
128..........................................................        5,181       5.1662            2            3            5            6            9
129..........................................................        3,762       2.5944            1            1            1            3            6
130..........................................................       89,126       5.4275            1            3            5            7           10
131..........................................................       23,839       3.8048            1            2            4            5            7
132..........................................................      117,297       2.8049            1            1            2            3            5
133..........................................................        7,287       2.1806            1            1            2            3            4
134..........................................................       42,414       3.1069            1            2            2            4            6
135..........................................................        7,439       4.2879            1            2            3            5            8
136..........................................................        1,133       2.7643            1            1            2            3            5
138..........................................................      207,068       3.9126            1            2            3            5            7
139..........................................................       78,609       2.4367            1            1            2            3            5
140..........................................................       38,178       2.4370            1            1            2            3            5
141..........................................................      121,892       3.4612            1            2            3            4            6
142..........................................................       52,279       2.4785            1            1            2            3            5
143..........................................................      249,312       2.0936            1            1            2            3            4
144..........................................................       99,715       5.6964            1            2            4            7           12
145..........................................................        6,187       2.6198            1            1            2            3            5
146..........................................................       10,769       9.8862            5            6            8           12           17
147..........................................................        2,634       5.8193            3            4            6            7            9
148..........................................................      135,681      12.0864            5            7            9           15           22
149..........................................................       19,915       5.9490            3            4            6            7            9
150..........................................................       22,708      10.8769            4            6            9           14           20
151..........................................................        5,353       5.1362            1            2            5            7           10
152..........................................................        5,007       8.0429            3            5            7            9           14
153..........................................................        2,092       4.9809            2            3            5            6            8
154..........................................................       28,496      13.0519            3            6           10           16           25

[[Page 23623]]

 
155..........................................................        6,161       4.1344            1            2            3            6            8
156..........................................................            6      24.1667            1            5            9           27           27
157..........................................................        8,260       5.7196            1            2            4            7           12
158..........................................................        4,106       2.6086            1            1            2            3            5
159..........................................................       19,174       5.1209            1            2            4            7           10
160..........................................................       11,988       2.6625            1            1            2            3            5
161..........................................................       10,428       4.3945            1            2            3            6            9
162..........................................................        5,497       2.0806            1            1            1            3            4
163..........................................................           10       2.9000            1            1            2            3            6
164..........................................................        5,945       7.9862            3            5            7           10           14
165..........................................................        2,523       4.2089            2            3            4            5            7
166..........................................................        4,933       4.5046            1            2            3            5            9
167..........................................................        4,634       2.2169            1            1            2            3            4
168..........................................................        1,544       4.9087            1            2            3            6           10
169..........................................................          756       2.2844            1            1            2            3            5
170..........................................................       17,471      10.7718            2            5            8           14           22
171..........................................................        1,484       4.0964            1            2            3            5            8
172..........................................................       32,879       6.8401            2            3            5            9           14
173..........................................................        2,392       3.5920            1            1            3            5            7
174..........................................................      267,905       4.7020            2            3            4            6            9
175..........................................................       32,657       2.8910            1            2            2            4            5
176..........................................................       14,560       5.1422            2            3            4            6           10
177..........................................................        8,554       4.4329            2            2            4            5            8
178..........................................................        2,909       3.1158            1            2            3            4            5
179..........................................................       14,429       5.8559            2            3            5            7           11
180..........................................................       92,193       5.3215            2            3            4            7           10
181..........................................................       25,897       3.3265            1            2            3            4            6
182..........................................................      292,198       4.4293            1            2            3            5            8
183..........................................................       86,576       2.8664            1            1            2            4            5
184..........................................................           78       3.2821            1            2            2            4            6
185..........................................................        5,680       4.4905            1            2            3            5            9
186..........................................................            4       2.0000            1            1            1            3            3
187..........................................................          621       4.1723            1            2            3            5            8
188..........................................................       90,968       5.5332            1            2            4            7           11
189..........................................................       13,182       3.0882            1            1            2            4            6
190..........................................................           69       4.3768            1            2            3            5            8
191..........................................................       10,411      12.6933            3            6            9           16           26
192..........................................................        1,322       5.6899            1            3            5            7           10
193..........................................................        4,514      12.0549            5            7           10           15           22
194..........................................................          521       6.6756            3            4            6            8           11
195..........................................................        3,249      10.6190            4            6            9           13           19
196..........................................................          701       5.7275            2            4            5            7            9
197..........................................................       17,316       9.0988            3            5            7           11           17
198..........................................................        4,645       4.3208            2            3            4            6            7
199..........................................................        1,425       9.5298            2            4            7           13           19
200..........................................................          936       9.6976            1            4            7           12           20
201..........................................................        2,665      13.7471            3            6           10           18           28
202..........................................................       27,281       6.1787            2            3            5            8           12
203..........................................................       31,656       6.4850            2            3            5            8           13
204..........................................................       72,845       5.5246            2            3            4            7           11
205..........................................................       31,474       5.8950            2            3            4            7           12
206..........................................................        2,081       3.8847            1            2            3            5            8
207..........................................................       35,754       5.2393            1            2            4            7           10
208..........................................................        9,758       2.9364            1            1            2            4            6
210..........................................................      128,455       6.6967            3            4            6            8           11
211..........................................................       26,708       4.6708            3            3            4            5            7
212..........................................................           10       2.9000            1            1            3            4            4
213..........................................................       10,257       9.1059            2            4            7           12           18
216..........................................................       17,656       5.7608            1            1            3            8           14
217..........................................................       17,622      12.4479            3            5            9           15           26
218..........................................................       28,708       5.4480            2            3            4            7           10
219..........................................................       21,361       3.1063            1            2            3            4            5
220..........................................................            4       2.7500            2            2            3            3            3
223..........................................................       13,425       3.2055            1            1            2            4            6
224..........................................................       10,889       1.8875            1            1            1            2            3
225..........................................................        6,514       5.1650            1            2            4            7           11
226..........................................................        6,660       6.3380            1            2            4            8           13
227..........................................................        5,074       2.6139            1            1            2            3            5
228..........................................................        2,640       4.1258            1            1            3            5            9
229..........................................................        1,201       2.5129            1            1            2            3            5

[[Page 23624]]

 
230..........................................................        2,565       5.5922            1            2            4            7           12
232..........................................................          729       2.8230            1            1            1            3            6
233..........................................................       15,118       6.6726            1            2            5            9           14
234..........................................................        7,676       2.7952            1            1            2            4            6
235..........................................................        4,970       4.6463            1            2            4            6            9
236..........................................................       42,408       4.4748            1            3            4            5            8
237..........................................................        2,022       3.6682            1            2            3            4            7
238..........................................................        9,869       8.2633            3            4            6           10           15
239..........................................................       42,943       6.0632            2            3            5            7           11
240..........................................................       12,653       6.6177            2            3            5            8           13
241..........................................................        2,696       3.7066            1            2            3            5            7
242..........................................................        2,742       6.5864            2            3            5            8           12
243..........................................................      101,477       4.5166            1            2            4            6            8
244..........................................................       15,792       4.4924            1            2            4            6            8
245..........................................................        5,840       3.1334            1            1            3            4            6
246..........................................................        1,430       3.5664            1            2            3            4            7
247..........................................................       21,671       3.3172            1            2            3            4            6
248..........................................................       15,118       4.8397            1            3            4            6            9
249..........................................................       14,026       3.8285            1            1            3            5            8
250..........................................................        4,155       3.8876            1            2            3            5            7
251..........................................................        2,148       2.7514            1            1            3            3            5
252..........................................................            1       1.0000            1            1            1            1            1
253..........................................................       24,857       4.5324            2            3            4            5            8
254..........................................................       10,420       3.0461            1            2            3            4            5
255..........................................................            1       7.0000            7            7            7            7            7
256..........................................................        7,152       5.0301            1            2            4            6           10
257..........................................................       13,512       2.6104            1            1            2            3            5
258..........................................................       12,042       1.7498            1            1            1            2            3
259..........................................................        2,903       2.7689            1            1            1            3            7
260..........................................................        2,991       1.4055            1            1            1            1            2
261..........................................................        1,603       2.2052            1            1            1            2            4
262..........................................................          636       4.8428            1            2            4            7           10
263..........................................................       23,809      10.7403            3            5            8           13           21
264..........................................................        3,922       6.2358            2            3            5            8           12
265..........................................................        4,307       6.5677            1            2            4            8           14
266..........................................................        2,304       3.1788            1            1            2            4            7
267..........................................................          272       4.1838            1            1            3            5           10
268..........................................................        1,004       3.5508            1            1            2            4            7
269..........................................................       10,686       8.3273            2            4            6           11           16
270..........................................................        2,639       3.8151            1            1            3            5            8
271..........................................................       21,054       6.7875            2            3            5            8           12
272..........................................................        5,942       5.8009            2            3            4            7           11
273..........................................................        1,349       3.6449            1            2            3            5            7
274..........................................................        2,288       6.2592            2            3            5            8           12
275..........................................................          228       3.2456            1            1            2            4            7
276..........................................................        1,447       4.4630            1            2            4            6            8
277..........................................................      112,318       5.5013            2            3            5            7           10
278..........................................................       33,865       4.0567            2            2            3            5            7
279..........................................................            6       4.6667            1            3            5            6            6
280..........................................................       19,272       4.0080            1            2            3            5            7
281..........................................................        7,093       2.8429            1            1            2            4            5
283..........................................................        6,274       4.5695            1            2            3            6            9
284..........................................................        1,833       3.0295            1            1            2            4            6
285..........................................................        7,623      10.0454            3            5            8           12           19
286..........................................................        2,703       5.4802            2            2            4            6           10
287..........................................................        6,114       9.8368            3            5            7           12           19
288..........................................................       10,450       4.1090            2            2            3            4            7
289..........................................................        6,894       2.5582            1            1            1            2            5
290..........................................................       10,859       2.1325            1            1            1            2            4
291..........................................................           64       2.7969            1            1            1            2            5
292..........................................................        7,331      10.0308            2            4            8           13           20
293..........................................................          368       4.4674            1            2            3            6            9
294..........................................................       98,963       4.2920            1            2            3            5            8
295..........................................................        4,102       3.6675            1            2            3            4            7
296..........................................................      254,706       4.7202            1            2            4            6            9
297..........................................................       45,347       3.0710            1            2            3            4            6
298..........................................................           81       3.9383            1            1            2            4            7
299..........................................................        1,478       5.1604            1            2            4            6           10
300..........................................................       21,343       5.8673            2            3            5            7           11
301..........................................................        3,901       3.4107            1            2            3            4            6

[[Page 23625]]

 
302..........................................................        9,649       8.1898            4            5            6            9           14
303..........................................................       23,760       7.3943            3            4            6            9           14
304..........................................................       13,826       8.4735            2            3            6           11           18
305..........................................................        3,087       3.2096            1            2            3            4            6
306..........................................................        6,350       5.4737            1            2            3            8           12
307..........................................................        2,066       2.0736            1            1            2            2            3
308..........................................................        7,093       6.1095            1            2            4            8           14
309..........................................................        3,559       2.0014            1            1            1            2            4
310..........................................................       26,035       4.5265            1            2            3            6           10
311..........................................................        6,480       1.8782            1            1            1            2            3
312..........................................................        1,456       4.8365            1            1            3            6           11
313..........................................................          508       2.2165            1            1            2            3            4
314..........................................................            1       2.0000            2            2            2            2            2
315..........................................................       36,565       6.7584            1            1            4            9           16
316..........................................................      180,999       6.2874            2            3            5            8           12
317..........................................................        2,766       3.4678            1            1            2            4            7
318..........................................................        5,927       5.7441            1            2            4            7           11
319..........................................................          383       2.7546            1            1            2            3            6
320..........................................................      218,684       5.0953            2            3            4            6            9
321..........................................................       31,401       3.5963            1            2            3            4            6
322..........................................................           61       3.4918            2            2            3            4            6
323..........................................................       20,482       3.0937            1            1            2            4            6
324..........................................................        5,421       1.8843            1            1            1            2            3
325..........................................................        9,615       3.6813            1            2            3            5            7
326..........................................................        2,584       2.6207            1            1            2            3            5
327..........................................................            5       2.6000            1            1            2            3            5
328..........................................................          606       3.4719            1            1            3            5            7
329..........................................................           72       1.8333            1            1            1            2            3
331..........................................................       54,798       5.4332            1            2            4            7           11
332..........................................................        4,389       3.1246            1            1            2            4            6
333..........................................................          252       5.4921            1            2            3            7           13
334..........................................................        9,810       4.3009            2            2            3            5            7
335..........................................................       11,931       2.6866            1            2            3            3            4
336..........................................................       31,264       3.2999            1            2            2            4            7
337..........................................................       25,156       1.9182            1            1            2            2            3
338..........................................................          652       6.1748            1            2            3            9           14
339..........................................................        1,253       5.1173            1            1            3            7           11
340..........................................................            2       5.0000            4            4            6            6            6
341..........................................................        3,185       3.1586            1            1            2            3            7
342..........................................................          565       3.4248            1            2            2            4            8
344..........................................................        2,693       2.7037            1            1            1            2            6
345..........................................................        1,461       4.8077            1            1            3            6           11
346..........................................................        3,966       5.7307            1            3            4            7           11
347..........................................................          247       3.0202            1            1            2            4            7
348..........................................................        4,171       4.0897            1            2            3            5            8
349..........................................................          575       2.3583            1            1            2            3            4
350..........................................................        7,137       4.4541            2            2            4            5            8
352..........................................................          975       4.0133            1            2            3            5            8
353..........................................................        2,735       6.3192            2            3            4            7           12
354..........................................................        7,612       5.6967            2            3            4            6           10
355..........................................................        4,937       3.0614            2            2            3            4            4
356..........................................................       23,993       1.9281            1            1            2            2            3
357..........................................................        5,570       8.1269            3            4            6           10           15
358..........................................................       20,798       3.9629            2            2            3            4            7
359..........................................................       28,741       2.4058            1            2            2            3            4
360..........................................................       14,764       2.5880            1            1            2            3            4
361..........................................................          272       3.0184            1            1            2            3            7
362..........................................................            2       1.0000            1            1            1            1            1
363..........................................................        2,128       3.7810            1            2            2            4            8
364..........................................................        1,451       4.1909            1            2            3            5            9
365..........................................................        1,622       7.7404            2            3            5            9           17
366..........................................................        4,789       6.4792            2            3            5            8           13
367..........................................................          456       2.9934            1            1            2            4            6
368..........................................................        3,924       6.6351            2            3            5            8           13
369..........................................................        3,613       3.2419            1            1            2            4            6
370..........................................................        1,843       5.1557            2            3            4            5            8
371..........................................................        2,244       3.3944            2            3            3            4            5
372..........................................................        1,164       3.1847            2            2            2            3            5
373..........................................................        4,871       2.2373            1            2            2            3            3
374..........................................................          156       2.7436            2            2            2            3            4

[[Page 23626]]

 
375..........................................................            6       4.0000            1            2            2            6            6
376..........................................................          388       3.3711            1            2            2            4            6
377..........................................................           77       4.4805            1            1            3            4            8
378..........................................................          196       2.3163            1            1            2            3            4
379..........................................................          508       2.8130            1            1            2            3            6
380..........................................................           91       2.1099            1            1            1            2            4
381..........................................................          212       2.2642            1            1            1            2            4
382..........................................................           43       1.4419            1            1            1            2            2
383..........................................................        2,473       3.6526            1            1            2            4            7
384..........................................................          132       2.5606            1            1            1            3            5
385..........................................................            1       1.0000            1            1            1            1            1
389..........................................................            1      21.0000           21           21           21           21           21
390..........................................................            1       1.0000            1            1            1            1            1
392..........................................................        2,203       9.1770            2            4            6           11           19
393..........................................................            1       4.0000            4            4            4            4            4
394..........................................................        2,820       7.3553            1            2            5            9           16
395..........................................................      116,129       4.2575            1            2            3            5            8
396..........................................................            9       4.4444            1            1            2            3            6
397..........................................................       18,482       5.1407            1            2            4            6           10
398..........................................................       18,288       5.7016            2            3            4            7           11
399..........................................................        1,640       3.3250            1            2            3            4            6
401..........................................................        6,328      11.0390            2            5            9           14           22
402..........................................................        1,401       4.0293            1            1            3            5            9
403..........................................................       31,865       7.9367            2            3            6           10           16
404..........................................................        3,802       4.1528            1            2            3            5            8
406..........................................................        2,224       9.9150            2            4            7           12           21
407..........................................................          584       3.8253            1            2            3            5            7
408..........................................................        2,170       8.1949            1            2            5           10           19
409..........................................................        1,808       5.7954            1            3            4            6           12
410..........................................................       28,417       3.8214            1            2            3            5            6
411..........................................................           12       3.2500            1            2            2            4            4
412..........................................................           12       2.7500            1            1            1            3            4
413..........................................................        5,198       6.7563            2            3            5            9           13
414..........................................................          573       4.0244            1            2            3            5            8
415..........................................................       50,826      14.0037            4            6           11           18           28
416..........................................................      239,006       7.3769            2            3            6            9           14
417..........................................................           23       5.2174            1            2            3            5           10
418..........................................................       28,508       6.1657            2            3            5            8           12
419..........................................................       16,282       4.3857            1            2            3            5            8
420..........................................................        2,941       3.3747            1            2            3            4            6
421..........................................................       11,882       4.0613            1            2            3            5            7
422..........................................................           52       3.7115            1            1            2            4            7
423..........................................................        8,637       8.2173            2            3            6           10           17
424..........................................................        1,071      11.7274            2            4            8           14           22
425..........................................................       14,779       3.4569            1            1            3            4            7
426..........................................................        4,313       4.1203            1            2            3            5            8
427..........................................................        1,505       4.7375            1            2            3            5            9
428..........................................................          773       7.2549            1            2            5            8           15
429..........................................................       25,479       5.4228            2            3            4            6           10
430..........................................................       71,439       7.6737            2            3            6            9           15
431..........................................................          304       5.8947            1            2            4            7           12
432..........................................................          420       4.2548            1            2            3            5            8
433..........................................................        5,191       2.9626            1            1            2            3            6
439..........................................................        1,739       8.7993            1            3            5           10           19
440..........................................................        5,613       8.7825            2            3            6           10           18
441..........................................................          779       3.3813            1            1            2            4            7
442..........................................................       18,017       8.6810            2            3            6           11           18
443..........................................................        3,384       3.3992            1            1            3            4            7
444..........................................................        5,892       4.0324            1            2            3            5            8
445..........................................................        2,346       2.8372            1            1            2            4            5
447..........................................................        6,264       2.5686            1            1            2            3            5
448..........................................................            1       2.0000            2            2            2            2            2
449..........................................................       38,802       3.6742            1            1            3            4            7
450..........................................................        7,805       1.9867            1            1            1            2            4
451..........................................................            3       1.6667            1            1            1            3            3
452..........................................................       27,634       4.8762            1            2            3            6           10
453..........................................................        5,437       2.7993            1            1            2            3            5
454..........................................................        3,837       4.1058            1            2            3            5            8
455..........................................................          846       2.2222            1            1            2            3            4
461..........................................................        2,722       5.1267            1            1            3            6           12

[[Page 23627]]

 
462..........................................................        7,761      10.1584            4            6            8           13           18
463..........................................................       31,045       3.8939            1            2            3            5            7
464..........................................................        7,661       2.9141            1            1            2            4            5
465..........................................................          219       3.6347            1            1            2            4            7
466..........................................................        1,377       4.7117            1            1            2            5            9
467..........................................................        1,015       2.6788            1            1            2            3            5
468..........................................................       50,458      12.8082            3            6           10           16           25
471..........................................................       15,614       5.0496            3            3            4            5            8
473..........................................................        8,778      12.4026            2            3            7           18           32
475..........................................................      116,534      11.0157            2            5            9           14           21
476..........................................................        3,025      10.4998            2            4            9           14           21
477..........................................................       29,425       8.5246            1            3            6           11           18
478..........................................................      113,660       7.1046            1            2            5            9           15
479..........................................................       24,603       2.7884            1            1            2            4            6
480..........................................................          802      17.9102            7            9           13           22           36
481..........................................................        1,066      21.8208           10           16           20           25           35
482..........................................................        5,076      11.4967            4            6            9           14           21
484..........................................................          449      12.7506            2            6           10           17           25
485..........................................................        3,420       9.6038            4            5            7           11           18
486..........................................................        2,562      12.3478            2            6           10           16           25
487..........................................................        4,644       7.0540            1            3            5            9           14
488..........................................................          786      16.3422            4            7           13           22           35
489..........................................................       13,461       8.3538            2            3            6           10           17
490..........................................................        5,204       5.3918            1            2            4            7           11
491..........................................................       19,789       3.1423            1            2            3            3            5
492..........................................................        4,012      13.6269            3            5            6           23           31
493..........................................................       61,628       6.0515            1            3            5            8           12
494..........................................................       25,626       2.6772            1            1            2            4            5
495..........................................................          304      17.3092            8            9           13           19           31
496..........................................................        3,261       8.9877            3            4            6           11           18
497..........................................................       27,838       5.8368            3            3            5            7           10
498..........................................................       19,057       3.7703            2            3            3            5            6
499..........................................................       35,676       4.3236            1            2            3            5            9
500..........................................................       48,323       2.2420            1            1            2            3            4
501..........................................................        3,122       9.9308            4            5            8           13           18
502..........................................................          717       5.6987            2            3            5            7            9
503..........................................................        5,909       3.8284            1            2            3            5            7
504..........................................................          187      27.1818            8           16           23           36           49
505..........................................................          179       4.6704            1            1            1            6           11
506..........................................................        1,004      15.9273            3            7           13           21           33
507..........................................................          307       8.4919            1            3            7           11           18
508..........................................................          641       7.2044            1            3            5            9           15
509..........................................................          168       5.1607            1            2            3            6           11
510..........................................................        1,755       6.4160            1            2            4            8           14
511..........................................................          635       4.0787            1            1            2            5            8
512..........................................................          513      12.7719            7            8           10           14           23
513..........................................................          227       9.9824            5            7            8           12           16
515..........................................................       44,478       4.3401            1            1            2            6           10
517..........................................................       66,287       2.5801            1            1            1            3            6
518..........................................................       42,044       3.4580            1            1            2            4            8
519..........................................................       11,506       4.8233            1            1            3            6           11
520..........................................................       15,266       2.0074            1            1            1            2            4
521..........................................................       32,148       5.4742            2            3            4            7           11
522..........................................................        5,646       9.3666            3            4            7           12           19
523..........................................................       15,866       3.8769            1            2            3            5            7
524..........................................................      118,949       3.1907            1            2            3            4            6
525..........................................................          313      13.4952            1            3            8           16           32
527..........................................................      192,230       2.2326            1            1            1            2            5
528..........................................................        1,770      17.1090            6           10           15           22           30
529..........................................................        4,032       7.9923            1            2            5           10           18
530..........................................................        2,363       3.1240            1            1            2            4            6
531..........................................................        4,799       9.4049            2            4            7           12           20
532..........................................................        2,622       3.7227            1            1            3            5            8
533..........................................................       47,609       3.7364            1            1            2            4            9
534..........................................................       45,285       1.7909            1            1            1            2            3
535..........................................................        7,387      10.3013            3            5            8           13           20
536..........................................................        8,055       7.6500            2            4            6            9           14
537..........................................................        8,641       6.7775            1            3            5            8           14
538..........................................................        5,604       2.8164            1            1            2            4            6
539..........................................................        5,020      10.7639            2            4            7           14           23

[[Page 23628]]

 
540..........................................................        1,510       3.5808            1            1            3            4            7
541..........................................................       22,435      42.7921           17           24           35           52           76
542..........................................................       24,376      32.5434           12           18           27           40           58
543..........................................................        5,415      11.9830            2            5           10           16           24
544..........................................................      418,885       4.5100            3            3            4            5            7
545..........................................................       42,337       5.1387            3            3            4            6            8
546..........................................................        1,958       9.1062            3            5            7           11           18
547..........................................................       26,797       5.5682            2            3            4            7           10
548..........................................................       11,935       3.0404            1            2            3            4            5
549..........................................................       35,690       5.2044            2            3            4            6           10
550..........................................................       20,187       2.8595            1            2            3            4            5
                                                              -------------
                                                                12,140,152
--------------------------------------------------------------------------------------------------------------------------------------------------------


Table 8A.--Statewide Average Operating Cost-to-Charge Ratios--March 2005
------------------------------------------------------------------------
                       State                          Urban      Rural
------------------------------------------------------------------------
Alabama...........................................      0.279      0.348
Alaska............................................      0.454      0.784
Arizona...........................................      0.295      0.392
Arkansas..........................................      0.359      0.383
California........................................      0.251      0.354
Colorado..........................................      0.328      0.483
Connecticut.......................................      0.458      0.522
Delaware..........................................      0.546      0.548
District of Columbia..............................      0.386  .........
Florida...........................................      0.257      0.304
Georgia...........................................      0.373      0.426
Hawaii............................................      0.404      0.479
Idaho.............................................      0.487      0.577
Illinois..........................................      0.337      0.442
Indiana...........................................      0.439       0.47
Iowa..............................................      0.407      0.505
Kansas............................................      0.313      0.471
Kentucky..........................................      0.401      0.404
Louisiana.........................................      0.306      0.369
Maine.............................................      0.504      0.489
Maryland..........................................      0.762      0.827
Massachusetts.....................................      0.485  .........
Michigan..........................................      0.396      0.496
Minnesota.........................................      0.404      0.531
Mississippi.......................................      0.354      0.391
Missouri..........................................      0.346      0.408
Montana...........................................      0.437      0.481
Nebraska..........................................      0.371      0.503
Nevada............................................      0.245      0.558
New Hampshire.....................................      0.467      0.508
New Jersey........................................      0.196  .........
New Mexico........................................      0.428      0.414
New York..........................................      0.372      0.526
North Carolina....................................      0.454      0.439
North Dakota......................................      0.418      0.467
Ohio..............................................      0.389      0.543
Oklahoma..........................................      0.332      0.423
Oregon............................................      0.499      0.481
Pennsylvania......................................      0.299      0.472
Puerto Rico.......................................      0.443  .........
Rhode Island......................................      0.439  .........
South Carolina....................................      0.313       0.34
South Dakota......................................      0.385      0.498
Tennessee.........................................      0.337      0.402
Texas.............................................      0.309       0.38
Utah..............................................      0.428      0.598
Vermont...........................................      0.577      0.635
Virginia..........................................      0.386      0.398
Washington........................................      0.454      0.497
West Virginia.....................................      0.492      0.472
Wisconsin.........................................      0.458      0.497
Wyoming...........................................      0.442      0.614
------------------------------------------------------------------------


 Table 8B.--Statewide Average Capital Cost-to-Charge Ratios--March 2005
------------------------------------------------------------------------
                            State                                Ratio
------------------------------------------------------------------------
Alabama......................................................      0.027
Alaska.......................................................      0.044
Arizona......................................................      0.029
Arkansas.....................................................       0.03
California...................................................      0.019
Colorado.....................................................       0.03
Connecticut..................................................      0.035
Delaware.....................................................      0.047
District of Columbia.........................................      0.029
Florida......................................................      0.026
Georgia......................................................      0.035
Hawaii.......................................................      0.034
Idaho........................................................      0.041
Illinois.....................................................       0.03
Indiana......................................................      0.041
Iowa.........................................................      0.033
Kansas.......................................................      0.033
Kentucky.....................................................      0.033
Louisiana....................................................      0.032
Maine........................................................      0.036
Maryland.....................................................      0.016
Massachusetts................................................      0.036
Michigan.....................................................      0.037
Minnesota....................................................      0.034
Mississippi..................................................      0.032
Missouri.....................................................      0.029
Montana......................................................      0.039
Nebraska.....................................................      0.039
Nevada.......................................................      0.019
New Hampshire................................................      0.037
New Jersey...................................................      0.015
New Mexico...................................................      0.036
New York.....................................................      0.033
North Carolina...............................................      0.039
North Dakota.................................................      0.041
Ohio.........................................................      0.032
Oklahoma.....................................................      0.031
Oregon.......................................................      0.038
Pennsylvania.................................................      0.026
Puerto Rico..................................................      0.033
Rhode Island.................................................      0.022
South Carolina...............................................       0.03
South Dakota.................................................       0.04
Tennessee....................................................      0.034
Texas........................................................       0.03
Utah.........................................................      0.039
Vermont......................................................      0.045
Virginia.....................................................      0.039
Washington...................................................      0.037
West Virginia................................................      0.033
Wisconsin....................................................      0.038
Wyoming......................................................      0.046
------------------------------------------------------------------------


 Table 9A.--Hospitals Reclassifications and Redesignations by Individual
                       Hospitals and CBSA--FY 2006
------------------------------------------------------------------------
                                Geographic     Reclassified
       Provider number             CBSA            CBSA          Lugar
------------------------------------------------------------------------
010005......................              01           13820  ..........
010008......................              01           33860  ..........
010012......................              01           16860  ..........
010022......................              01           40660  LUGAR

[[Page 23629]]

 
010025......................              01           17980  ..........
010029......................           12220           17980  ..........
010035......................              01           13820  ..........
010044......................              01           13820  ..........
010045......................              01           13820  ..........
010065......................              01           33860  ..........
010072......................              01           11500  LUGAR
010083......................              01           37860  ..........
010100......................              01           37860  ..........
010101......................              01           11500  LUGAR
010118......................              01           33860  ..........
010120......................              01           33660  ..........
010126......................              01           33860  ..........
010143......................              01           13820  ..........
010158......................              01           19460  ..........
030013......................           49740           20940  ..........
030033......................              03           22380  ..........
040014......................              04           30780  ..........
040017......................              04           44180  ..........
040019......................              04           32820  ..........
040020......................           27860           32820  ..........
040027......................              04           44180  ..........
040039......................              04           27860  ..........
040041......................              04           30780  ..........
040047......................              04           27860  ..........
040069......................              04           32820  ..........
040071......................           38220           30780  ..........
040072......................              04           30780  ..........
040076......................              04           30780  ..........
040078......................           26300           30780  ..........
040080......................              04           27860  ..........
040088......................              04           43340  ..........
040091......................              04           45500  ..........
040100......................              04           30780  ..........
040119......................              04           30780  ..........
050006......................              05           39820  ..........
050009......................           34900           46700  ..........
050013......................           34900           46700  ..........
050014......................              05           40900  ..........
050022......................           40140           42044  ..........
050042......................              05           39820  ..........
050046......................           37100           31084  ..........
050054......................           40140           42044  ..........
050065......................           42044           31084  ..........
050069......................           42044           31084  ..........
050071......................           41940           36084  ..........
050073......................           46700           36084  ..........
050076......................           41884           36084  ..........
050082......................           37100           31084  ..........
050089......................           40140           31084  ..........
050090......................           42220           41884  ..........
050099......................           40140           31084  ..........
050102......................           40140           42044  ..........
050118......................           44700           33700  ..........
050129......................           40140           31084  ..........
050136......................           42220           41884  ..........
050140......................           40140           31084  ..........
050150......................              05           40900  ..........
050159......................           37100           31084  ..........
050168......................           42044           31084  ..........
050173......................           42044           31084  ..........
050174......................           42220           41884  ..........
050177......................           37100           31084  ..........
050193......................           42044           31084  ..........
050224......................           42044           31084  ..........
050226......................           42044           31084  ..........
050228......................           41884           36084  ..........
050230......................           42044           31084  ..........
050236......................           37100           31084  ..........
050243......................           40140           42044  ..........

[[Page 23630]]

 
050245......................           40140           31084  ..........
050251......................              05           39900  ..........
050272......................           40140           31084  ..........
050279......................           40140           31084  ..........
050291......................           42220           41884  ..........
050292......................           40140           42044  ..........
050298......................           40140           31084  ..........
050300......................           40140           31084  ..........
050327......................           40140           31084  ..........
050329......................           40140           42044  ..........
050331......................           42220           41884  ..........
050348......................           42044           31084  ..........
050385......................           42220           41884  ..........
050390......................           40140           42044  ..........
050394......................           37100           31084  ..........
050419......................              05           39820  ..........
050423......................           40140           42044  ..........
050426......................           42044           31084  ..........
050430......................              05           39900  ..........
050510......................           41884           36084  ..........
050517......................           40140           31084  ..........
050526......................           42044           31084  ..........
050534......................           40140           42044  ..........
050535......................           42044           31084  ..........
050541......................           41884           36084  ..........
050543......................           42044           31084  ..........
050547......................           42220           41884  ..........
050548......................           42044           31084  ..........
050550......................           42044           31084  ..........
050551......................           42044           31084  ..........
050567......................           42044           31084  ..........
050569......................              05           42220  ..........
050570......................           42044           31084  ..........
050573......................           40140           42044  ..........
050580......................           42044           31084  ..........
050584......................           40140           31084  ..........
050585......................           42044           31084  ..........
050586......................           40140           31084  ..........
050589......................           42044           31084  ..........
050592......................           42044           31084  ..........
050594......................           42044           31084  ..........
050603......................           42044           31084  ..........
050609......................           42044           31084  ..........
050616......................           37100           31084  ..........
050667......................           34900           46700  ..........
050668......................           41884           36084  ..........
050678......................           42044           31084  ..........
050684......................           40140           42044  ..........
050686......................           40140           42044  ..........
050690......................           42220           41884  ..........
050693......................           42044           31084  ..........
050694......................           40140           42044  ..........
050701......................           40140           42044  ..........
050709......................           40140           31084  ..........
050718......................           40140           42044  ..........
050720......................           42044           31084  ..........
050728......................           42220           41884  ..........
060001......................           24540           19740  ..........
060003......................           14500           19740  ..........
060023......................           24300           39340  ..........
060027......................           14500           19740  ..........
060044......................              06           19740  ..........
060049......................              06           22660  ..........
060096......................              06           19740  ..........
060103......................           14500           19740  ..........
070003......................              07           25540  LUGAR
070021......................              07           25540  LUGAR
070033......................           14860           35644  ..........
080004......................           20100           48864  ..........
080007......................              08           36140  ..........

[[Page 23631]]

 
100022......................           33124           22744  ..........
100023......................              10           36740  ..........
100024......................              10           33124  ..........
100045......................           19660           36740  ..........
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100081......................              10           23020  LUGAR
100109......................              10           36740  ..........
100118......................              10           27260  ..........
100139......................              10           23540  LUGAR
100150......................              10           33124  ..........
100157......................           29460           45300  ..........
100176......................           48424           38940  ..........
100217......................           46940           38940  ..........
100232......................              10           27260  ..........
100239......................           45300           42260  ..........
100249......................              10           36100  ..........
100252......................              10           38940  ..........
100292......................              10           23020  LUGAR
110001......................           19140           12060  ..........
110002......................              11           12060  ..........
110003......................              11           27260  ..........
110023......................              11           12060  ..........
110025......................           15260           27260  ..........
110029......................           23580           12060  ..........
110038......................              11           45220  ..........
110040......................              11           12060  LUGAR
110041......................              11           12020  ..........
110052......................              11           16860  LUGAR
110054......................           40660           12060  ..........
110069......................           47580           31420  ..........
110075......................              11           42340  ..........
110088......................              11           12060  LUGAR
110095......................              11           46660  ..........
110117......................              11           12060  LUGAR
110122......................           46660           45220  ..........
110125......................              11           31420  ..........
110128......................              11           42340  ..........
110150......................              11           31420  ..........
110153......................           47580           31420  ..........
110168......................           40660           12060  ..........
110187......................              11           12060  LUGAR
110189......................              11           12060  ..........
110205......................              11           12060  ..........
120028......................              12           26180  ..........
130002......................              13           14260  ..........
130003......................           30300              50  ..........
130049......................           17660           44060  ..........
140012......................              14           16974  ..........
140015......................              14           41180  ..........
140032......................              14           41180  ..........
140034......................              14           41180  ..........
140040......................              14           37900  ..........
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140046......................              14           41180  ..........
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140064......................              14           37900  ..........
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140160......................              14           40420  ..........
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140164......................              14           41180  ..........
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140233......................           40420           16974  ..........
140234......................              14           37900  ..........
140236......................              14           28100  LUGAR
140291......................           29404           16974  ..........
150002......................           23844           16974  ..........
150004......................           23844           16974  ..........
150006......................           33140           43780  ..........

[[Page 23632]]

 
150008......................           23844           16974  ..........
150011......................              15           26900  ..........
150015......................           33140           16974  ..........
150030......................              15           26900  LUGAR
150048......................              15           17140  ..........
150065......................              15           26900  ..........
150069......................              15           17140  ..........
150076......................              15           43780  ..........
150088......................           11300           26900  ..........
150090......................           23844           16974  ..........
150102......................              15           23844  LUGAR
150112......................           18020           26900  ..........
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150125......................           23844           16974  ..........
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150133......................              15           23060  ..........
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160001......................              16           11180  ..........
160016......................              16           19780  ..........
160026......................              16           11180  LUGAR
160057......................              16           26980  ..........
160080......................              16           40420  ..........
160089......................              16           19780  ..........
160147......................              16           11180  ..........
170006......................              17           27900  ..........
170010......................              17           46140  ..........
170012......................              17           48620  ..........
170013......................              17           48620  ..........
170020......................              17           48620  ..........
170022......................              17           28140  ..........
170023......................              17           48620  ..........
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170068......................              17           11100  ..........
170120......................              17           27900  ..........
170142......................              17           45820  ..........
170175......................              17           48620  ..........
180005......................              18           26580  ..........
180011......................              18           30460  ..........
180012......................           21060           31140  ..........
180013......................           14540           34980  ..........
180017......................              18           21060  ..........
180018......................              18           30460  ..........
180019......................              18           17140  ..........
180024......................              18           31140  ..........
180027......................              18           17300  ..........
180028......................              18           26580  ..........
180029......................              18           28700  ..........
180044......................              18           26580  ..........
180048......................              18           31140  ..........
180066......................              18           34980  ..........
180069......................              18           26580  ..........
180075......................              18           14540  LUGAR
180078......................              18           26580  ..........
180080......................              18           28940  ..........
180093......................              18           21780  ..........
180102......................              18           17300  ..........
180104......................              18           17300  ..........
180116......................              18              14  ..........
180124......................           14540           34980  ..........
180127......................              18           31140  ..........
180132......................              18           30460  ..........
180139......................              18           30460  ..........
190001......................              19           35380  ..........
190003......................              19           29180  ..........
190015......................              19           35380  ..........
190086......................              19           43340  ..........
190099......................              19           12940  ..........

[[Page 23633]]

 
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190155......................              19           12940  LUGAR
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190223......................              19           12940  LUGAR
200002......................              20           38860  ..........
200020......................           38860           40484  ..........
200024......................           30340           38860  ..........
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200039......................              20           38860  ..........
200050......................              20           12620  ..........
200063......................              20           38860  ..........
220001......................           49340           14484  ..........
220002......................           15764           14484  ..........
220003......................           49340           14484  ..........
220010......................           21604           14484  ..........
220011......................           15764           14484  ..........
220019......................           49340           14484  ..........
220025......................           49340           14484  ..........
220028......................           49340           14484  ..........
220029......................           21604           14484  ..........
220033......................           21604           14484  ..........
220035......................           21604           14484  ..........
220049......................           15764           14484  ..........
220058......................           49340           14484  ..........
220060......................           14484           12700  ..........
220062......................           49340           14484  ..........
220063......................           15764           14484  ..........
220070......................           15764           14484  ..........
220077......................           44140           25540  ..........
220080......................           21604           14484  ..........
220082......................           15764           14484  ..........
220084......................           15764           14484  ..........
220089......................           15764           14484  ..........
220090......................           49340           14484  ..........
220095......................           49340           14484  ..........
220098......................           15764           14484  ..........
220101......................           15764           14484  ..........
220105......................           15764           14484  ..........
220133......................           15764           14484  ..........
220163......................           49340           14484  ..........
220171......................           15764           14484  ..........
220174......................           21604           14484  ..........
230022......................              23           11460  ..........
230030......................              23           40980  ..........
230035......................              23           24340  LUGAR
230037......................              23           11460  ..........
230042......................              23           26100  LUGAR
230047......................           47644           19804  ..........
230054......................              23           24580  ..........
230069......................           47644           22420  ..........
230077......................           40980           22420  ..........
230080......................              23           40980  ..........
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230096......................              23           28020  ..........
230099......................           33780           11460  ..........
230105......................              23           13020  ..........
230121......................              23           29620  LUGAR
230134......................              23           26100  LUGAR
230195......................           47644           19804  ..........
230204......................           47644           19804  ..........
230208......................              23           24340  LUGAR
230217......................           12980           29620  ..........
230227......................           47644           19804  ..........
230235......................              23           40980  LUGAR
230257......................           47644           19804  ..........
230264......................           47644           19804  ..........
230279......................           47644           22420  ..........
230295......................              23           26100  LUGAR

[[Page 23634]]

 
240013......................              24           33460  ..........
240018......................              24           33460  ..........
240030......................              24           41060  ..........
240031......................           41060           33460  ..........
240036......................           41060           33460  ..........
240052......................              24           22020  ..........
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240105......................              24           40340  LUGAR
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240152......................              24           33460  ..........
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240211......................              24           33460  ..........
250004......................              25           32820  ..........
250006......................              25           32820  ..........
250009......................              25           27180  ..........
250023......................              25           25060  LUGAR
250031......................              25           27140  ..........
250034......................              25           32820  ..........
250040......................           37700           25060  ..........
250042......................              25           32820  ..........
250069......................              25           46220  ..........
250079......................              25           27140  ..........
250081......................              25           27140  ..........
250082......................              25           38220  ..........
250094......................           25620           25060  ..........
250097......................              25           12940  ..........
250099......................              25           27140  ..........
250100......................              25           46220  ..........
250104......................              25           27140  ..........
250117......................              25           25060  LUGAR
260009......................              26           28140  ..........
260011......................           27620           17860  ..........
260017......................              26           41180  ..........
260022......................              26              16  ..........
260025......................              26           41180  ..........
260047......................           27620           17860  ..........
260049......................              26           44180  LUGAR
260064......................              26           17860  ..........
260074......................             126           17860  ..........
260094......................              26           44180  ..........
260110......................              26           41180  ..........
260113......................              26              14  ..........
260116......................              26              14  ..........
260183......................              26           41180  ..........
260186......................              26           17860  ..........
270003......................              27           24500  ..........
270011......................              27           24500  ..........
270017......................              27           33540  ..........
270051......................              27           33540  ..........
280009......................              28           30700  ..........
280023......................              28           30700  ..........
280032......................              28           30700  ..........
280057......................              28           30700  ..........
280061......................              28              53  ..........
280065......................              28           24540  ..........
280077......................              28           36540  ..........
290002......................              29           16180  LUGAR
290006......................              29           39900  ..........
290008......................              29           29820  ..........
290019......................           16180           39900  ..........
300003......................              30           31700  ..........
300005......................              30           31700  ..........
300007......................           31700           15764  ..........
300011......................           31700           15764  ..........
300012......................           31700           15764  ..........

[[Page 23635]]

 
300014......................           40484           31700  ..........
300017......................           40484           21604  ..........
300018......................           40484           31700  ..........
300019......................              30           15764  ..........
300020......................           31700           15764  ..........
300023......................           40484           21604  ..........
300029......................           40484           21604  ..........
300034......................           31700           15764  ..........
310002......................           35084           35644  ..........
310009......................           35084           35644  ..........
310013......................           35084           35644  ..........
310015......................           35084           35644  ..........
310018......................           35084           35644  ..........
310031......................           15804           20764  ..........
310032......................           47220           48864  ..........
310038......................           20764           35644  ..........
310048......................           20764           35084  ..........
310054......................           35084           35644  ..........
310070......................           20764           35644  ..........
310076......................           35084           35644  ..........
310078......................           35084           35644  ..........
310083......................           35084           35644  ..........
310093......................           35084           35644  ..........
310096......................           35084           35644  ..........
310119......................           35084           35644  ..........
320005......................           22140           10740  ..........
320006......................              32           42140  ..........
320013......................              32           42140  ..........
320014......................              32           29740  ..........
320033......................              32           42140  LUGAR
320063......................              32           36220  ..........
320065......................              32           36220  ..........
330001......................           39100           35644  ..........
330004......................           28740           39100  ..........
330008......................              33           15380  LUGAR
330027......................           35004           35644  ..........
330038......................              33           40380  LUGAR
330062......................              33           27060  LUGAR
330073......................              33           40380  LUGAR
330085......................              33           45060  ..........
330094......................              33           28740  ..........
330136......................              33           45060  ..........
330157......................              33           45060  ..........
330181......................           35004           35644  ..........
330182......................           35004           35644  ..........
330191......................           24020           10580  ..........
330229......................           27460           21500  ..........
330235......................              33           45060  LUGAR
330239......................           27460           21500  ..........
330250......................              33           15540  ..........
330277......................              33           27060  ..........
330359......................              33           39100  LUGAR
330386......................              33           39100  LUGAR
340004......................           24660           49180  ..........
340008......................              34           16740  ..........
340010......................           24140           39580  ..........
340013......................              34           16740  ..........
340018......................              34           43900  LUGAR
340021......................              34           16740  ..........
340023......................           11700           24860  ..........
340027......................              34           24780  ..........
340039......................              34           16740  ..........
340050......................              34           22180  ..........
340051......................              34           25860  ..........
340068......................              34           48900  ..........
340069......................           39580           20500  ..........
340071......................              34           39580  LUGAR
340073......................           39580           20500  ..........
340091......................           24660           49180  ..........
340109......................              34           47260  ..........

[[Page 23636]]

 
340114......................           39580           20500  ..........
340115......................              34           20500  ..........
340124......................              34           39580  LUGAR
340127......................              34           20500  LUGAR
340129......................              34           16740  ..........
340131......................              34           24780  ..........
340136......................              34           20500  LUGAR
340138......................           39580           20500  ..........
340144......................              34           16740  ..........
340145......................              34           16740  LUGAR
340147......................           40580           39580  ..........
340173......................           39580           20500  ..........
350009......................              35           22020  ..........
360008......................              36           26580  ..........
360010......................              36           10420  ..........
360011......................              36           18140  ..........
360013......................              36           30620  ..........
360014......................              36           18140  ..........
360019......................           10420           17460  ..........
360020......................           10420           17460  ..........
360025......................           41780           17460  ..........
360027......................           10420           17460  ..........
360036......................              36           17460  ..........
360039......................              36           18140  ..........
360054......................              36           16620  ..........
360065......................              36           17460  ..........
360078......................           10420           17460  ..........
360079......................           19380           17140  ..........
360086......................           44220           19380  ..........
360096......................              36           49660  LUGAR
360107......................              36           17460  ..........
360112......................           45780           11460  ..........
360125......................              36           17460  LUGAR
360150......................           10420           17460  ..........
360159......................              36           18140  ..........
360175......................              36           18140  ..........
360185......................              36           49660  LUGAR
360187......................           44220           19380  ..........
360197......................              36           18140  ..........
360211......................           48260           38300  ..........
360238......................              36           49660  LUGAR
360241......................           10420           17460  ..........
360245......................              36           17460  LUGAR
370004......................              37           27900  ..........
370014......................              37           43300  ..........
370015......................              37           46140  ..........
370018......................              37           46140  ..........
370022......................              37           30020  ..........
370025......................              37           46140  ..........
370034......................              37           22900  ..........
370047......................              37           43300  ..........
370049......................              37           36420  ..........
370099......................              37           46140  ..........
370103......................              37              45  ..........
370113......................              37           22220  ..........
370179......................              37           46140  ..........
380001......................              38           38900  ..........
380008......................              38           18700  LUGAR
380022......................              38           18700  LUGAR
380027......................              38           21660  ..........
380047......................           13460           21660  ..........
380050......................              38           32780  ..........
380070......................              38           38900  ..........
390006......................              39           25420  ..........
390013......................              39           25420  ..........
390016......................              39           49660  ..........
390030......................              39           10900  ..........
390031......................              39           39740  LUGAR
390048......................              39           25420  ..........
390052......................              39           11020  ..........

[[Page 23637]]

 
390065......................              39           47894  ..........
390066......................           30140           25420  ..........
390071......................              39           48700  LUGAR
390079......................              39           13780  ..........
390081......................           37964           48864  ..........
390086......................              39           44300  ..........
390091......................              39           49660  ..........
390093......................              39           49660  ..........
390110......................           27780           38300  ..........
390113......................              39           49660  ..........
390133......................           10900           37964  ..........
390138......................              39           47894  ..........
390150......................              39           38300  LUGAR
390151......................              39           47894  ..........
390156......................           37964           48864  ..........
390180......................           37964           48864  ..........
390222......................           37964           48864  ..........
390224......................              39           13780  LUGAR
390244......................              39           48700  LUGAR
390246......................              39           48700  ..........
390249......................              39           13780  LUGAR
400048......................           25020           41980  ..........
410001......................           39300           14484  ..........
410004......................           39300           14484  ..........
410005......................           39300           14484  ..........
410006......................           39300           14484  ..........
410007......................           39300           14484  ..........
410008......................           39300           14484  ..........
410009......................           39300           14484  ..........
410011......................           39300           14484  ..........
410012......................           39300           14484  ..........
410013......................           39300           14484  ..........
420009......................              42           24860  LUGAR
420020......................              42           16700  ..........
420028......................              42           44940  LUGAR
420030......................              42           16700  ..........
420036......................              42           16740  ..........
420039......................              42           43900  LUGAR
420067......................              42           42340  ..........
420068......................              42           16700  ..........
420069......................              42           44940  LUGAR
420070......................           44940           17900  ..........
420071......................              42           24860  ..........
420080......................              42           42340  ..........
420085......................           34820           48900  ..........
430012......................              43           43620  ..........
430014......................              43           22020  ..........
430094......................              43              53  ..........
440008......................              44           21780  ..........
440020......................              44           26620  ..........
440035......................           17300           34980  ..........
440050......................              44           11700  ..........
440058......................              44           16860  ..........
440059......................              44           34980  ..........
440060......................              44           27180  ..........
440067......................           34100           28940  ..........
440068......................              44           16860  ..........
440072......................              44           32820  ..........
440073......................              44           34980  ..........
440148......................              44           34980  ..........
440151......................              44           34980  ..........
440175......................              44           34980  ..........
440180......................              44           28940  ..........
440185......................           17420           16860  ..........
440192......................              44           34980  ..........
450007......................              45           41700  ..........
450032......................              45           43340  ..........
450039......................           23104           19124  ..........
450059......................           41700           12420  ..........
450064......................           23104           19124  ..........

[[Page 23638]]

 
450073......................              45           10180  ..........
450080......................              45           30980  ..........
450087......................           23104           19124  ..........
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450099......................              45           11100  ..........
450121......................           23104           19124  ..........
450135......................           23104           19124  ..........
450137......................           23104           19124  ..........
450144......................              45           36220  ..........
450148......................           23104           19124  ..........
450187......................              45           26420  ..........
450192......................              45           19124  ..........
450194......................              45           19124  ..........
450196......................              45           19124  ..........
450211......................              45           26420  ..........
450214......................              45           26420  ..........
450224......................              45           46340  ..........
450283......................              45           19124  LUGAR
450286......................              45           17780  LUGAR
450347......................              45           26420  ..........
450351......................              45           23104  ..........
450389......................              45           19124  LUGAR
450400......................              45           47380  ..........
450419......................           23104           19124  ..........
450438......................              45           26420  ..........
450447......................              45           19124  ..........
450451......................              45           23104  ..........
450484......................              45           26420  ..........
450508......................              45           46340  ..........
450547......................              45           19124  ..........
450563......................           23104           19124  ..........
450623......................              45           19124  LUGAR
450639......................           23104           19124  ..........
450653......................              45           33260  ..........
450656......................              45           46340  ..........
450672......................           23104           19124  ..........
450675......................           23104           19124  ..........
450677......................           23104           19124  ..........
450694......................              45           26420  ..........
450747......................              45           19124  ..........
450755......................              45           31180  ..........
450770......................              45           12420  LUGAR
450779......................           23104           19124  ..........
450830......................              45           36220  ..........
450839......................              45           43340  ..........
450858......................           23104           19124  ..........
450872......................           23104           19124  ..........
450880......................           23104           19124  ..........
460004......................           36260           41620  ..........
460005......................           36260           41620  ..........
460007......................              46           41100  ..........
460011......................              46           39340  ..........
460021......................           41100           29820  ..........
460036......................              46           39340  ..........
460039......................              46           36260  ..........
460041......................           36260           41620  ..........
460042......................           36260           41620  ..........
470001......................              47              30  ..........
470011......................              47           15764  ..........
470012......................              47           38340  ..........
490004......................           25500           16820  ..........
490005......................           49020           47894  ..........
490006......................              49           49020  LUGAR
490013......................              49           31340  ..........
490018......................              49           16820  ..........
490047......................              49           25500  LUGAR
490079......................              49           49180  ..........
490092......................              49           40060  ..........
490105......................              49           28700  ..........
490106......................              49           16820  ..........

[[Page 23639]]

 
490109......................           47260           40060  ..........
500002......................              50           28420  ..........
500003......................           34580           42644  ..........
500016......................           48300           42644  ..........
500024......................           36500           45104  ..........
500031......................              50           36500  ..........
500039......................           14740           42644  ..........
500041......................           31020           38900  ..........
500072......................              50           42644  ..........
500139......................           36500           45104  ..........
500143......................           36500           45104  ..........
510001......................           34060           38300  ..........
510002......................              51           40220  ..........
510006......................              51           38300  ..........
510018......................              51           16620  LUGAR
510024......................           34060           38300  ..........
510028......................              51           16620  ..........
510030......................              51           34060  ..........
510046......................              51           16620  ..........
510047......................              51           38300  ..........
510070......................              51           16620  ..........
510071......................              51           16620  ..........
510077......................              51           26580  ..........
520002......................              52           48140  ..........
520021......................           29404           16974  ..........
520028......................              52           31540  LUGAR
520037......................              52           48140  ..........
520059......................           39540           29404  ..........
520060......................              52           22540  LUGAR
520066......................           27500           31540  ..........
520071......................              52           33340  LUGAR
520076......................              52           31540  ..........
520088......................           22540           33340  ..........
520094......................           39540           33340  ..........
520095......................              52           31540  ..........
520096......................           39540           33340  ..........
520102......................              52           33340  LUGAR
520107......................              52           24580  ..........
520113......................              52           24580  ..........
520116......................              52           33340  LUGAR
520152......................              52           24580  ..........
520173......................              52           20260  ..........
520189......................           29404           16974  ..........
530002......................              53           16220  ..........
530025......................              53           22660
------------------------------------------------------------------------


Table 9B.--Hospital Reclassifications and Redesignations by Individual Hospital Under Section 508 of Pub. L. 108-
                                                       173
----------------------------------------------------------------------------------------------------------------
                                                                                 Wage index CBSA
                        Provider number                           Geographic           508        Own wage index
                                                                     CBSA       reclassification
----------------------------------------------------------------------------------------------------------------
010150........................................................              01            17980   ..............
020008........................................................              02  ................          1.2841
050494........................................................              05            42220   ..............
050549........................................................           37100            42220   ..............
060057........................................................              06            19740   ..............
060075........................................................              06  ................          1.1709
070001........................................................           35300            35004   ..............
070005........................................................           35300            35004   ..............
070010........................................................           14860            35644   ..............
070016........................................................           35300            35004   ..............
070017........................................................           35300            35004   ..............
070019........................................................           35300            35004   ..............
070022........................................................           35300            35004   ..............
070028........................................................           14860            35644   ..............
070031........................................................           35300            35004   ..............
070036........................................................           25540  ................          1.2926

[[Page 23640]]

 
070039........................................................           35300            35004   ..............
120025........................................................              12            26180   ..............
150034........................................................           23844            16974   ..............
160040........................................................           47940            16300   ..............
160064........................................................              16  ................          1.0228
160067........................................................           47940            16300   ..............
160110........................................................           47940            16300   ..............
190218........................................................              19            43340   ..............
220046........................................................           38340            14484   ..............
230003........................................................           26100            28020   ..............
230004........................................................           34740            28020   ..............
230013........................................................           47644            22420   ..............
230019........................................................           47644            22420   ..............
230020........................................................           19804            11460   ..............
230024........................................................           19804            11460   ..............
230029........................................................           47644            22420   ..............
230036........................................................              23            22420   ..............
230038........................................................           24340            28020   ..............
230053........................................................           19804            11460   ..............
230059........................................................           24340            28020   ..............
230066........................................................           34740            28020   ..............
230071........................................................           47644            22420   ..............
230072........................................................           26100            28020   ..............
230089........................................................           19804            11460   ..............
230092........................................................           27100            24340   ..............
230097........................................................              23            28020   ..............
230104........................................................           19804            11460   ..............
230106........................................................           24340            28020   ..............
230119........................................................           19804            11460   ..............
230130........................................................           47644            22420   ..............
230135........................................................           19804            11460   ..............
230146........................................................           19804            11460   ..............
230151........................................................           47644            22420   ..............
230165........................................................           19804            11460   ..............
230174........................................................           26100            28020   ..............
230176........................................................           19804            11460   ..............
230207........................................................           47644            22420   ..............
230223........................................................           47644            22420   ..............
230236........................................................           24340            28020   ..............
230254........................................................           47644            22420   ..............
230269........................................................           47644            22420   ..............
230270........................................................           19804            11460   ..............
230273........................................................           19804            11460   ..............
230277........................................................           47644            22420   ..............
250002........................................................              25            25060   ..............
250122........................................................              25            25060   ..............
270021........................................................              27            13740   ..............
270023........................................................           33540            13740   ..............
270032........................................................              27            13740   ..............
270050........................................................              27            13740   ..............
270057........................................................              27            13740   ..............
310021........................................................           45940            35644   ..............
310028........................................................           35084            35644   ..............
310050........................................................           35084            35644   ..............
310051........................................................           35084            35644   ..............
310060........................................................           10900            35644   ..............
310115........................................................           10900            35644   ..............
310120........................................................           35084            35644   ..............
330049........................................................           39100            35644   ..............
330067........................................................           39100            35300   ..............
330106........................................................           35004  ................          1.4734
330126........................................................           39100            35644   ..............
330135........................................................           39100            35644   ..............
330205........................................................           39100            35644   ..............
330264........................................................           39100            35004   ..............
340002........................................................           11700            16740   ..............
350002........................................................           13900            22020   ..............
350003........................................................              35            22020   ..............
350006........................................................              35            22020   ..............

[[Page 23641]]

 
350010........................................................              35            22020   ..............
350014........................................................              35            22020   ..............
350015........................................................           13900            22020   ..............
350017........................................................              35            22020   ..............
350030........................................................              35            22020   ..............
350061........................................................              35            22020   ..............
380090........................................................              38  ................          1.2316
390001........................................................           42540            10900   ..............
390003........................................................              39            10900   ..............
390054........................................................           42540            29540   ..............
390072........................................................              39            10900   ..............
390095........................................................           42540            10900   ..............
390109........................................................           42540            10900   ..............
390119........................................................           42540            10900   ..............
390137........................................................           42540            10900   ..............
390169........................................................           42540            10900   ..............
390185........................................................           42540            29540   ..............
390192........................................................           42540            10900   ..............
390237........................................................           42540            10900   ..............
390270........................................................           42540            29540   ..............
410010........................................................           39300  ................          1.1746
430005........................................................              43            39660   ..............
430015........................................................              43            43620   ..............
430048........................................................              43            43620   ..............
430060........................................................              43            43620   ..............
430064........................................................              43            43620   ..............
430077........................................................           39660            43620   ..............
430091........................................................           39660            43620   ..............
450010........................................................           48660            32580   ..............
450072........................................................           26420            26420   ..............
450591........................................................           26420            26420   ..............
470003........................................................           15540            14484   ..............
490001........................................................              49            31340   ..............
490024........................................................           40220            19260   ..............
530015........................................................              53  ................          0.9897
070006*.......................................................           14860            35644   ..............
070018*.......................................................           14860            35644   ..............
070034*.......................................................           14860            35644   ..............
140155*.......................................................           28100            16974   ..............
140186*.......................................................           28100            16974   ..............
250078*.......................................................           25620            25060   ..............
270002*.......................................................              27            33540   ..............
270012*.......................................................           24500            33540   ..............
270084*.......................................................              27            33540   ..............
330023*.......................................................           39100            35644   ..............
330067*.......................................................           39100            35644   ..............
350019*.......................................................           24220            22020   ..............
430008*.......................................................              43            43620   ..............
430013*.......................................................              43            43620   ..............
430031*.......................................................              43            43620   ..............
530008*.......................................................              53            16220   ..............
530010*.......................................................              53            16220
----------------------------------------------------------------------------------------------------------------


 Table 9C.--Hospitals Redesignated as Rural Under Section 1886(d)(8)(E)
                               of the Act
------------------------------------------------------------------------
                                            Geographic     Redesignated
             Provider number                   CBSA         rural area
------------------------------------------------------------------------
030007..................................           39140              03
040075..................................           22220              04
050192..................................           23420              05
050469..................................           40140              05
050528..................................           32900              05
050618..................................           40140              05
070004..................................           25540              07
100048..................................           37860              10
100134..................................           27260              10
130018..................................           26820              13

[[Page 23642]]

 
140167..................................              14              14
150051..................................           14020              15
150078..................................           23844              15
170137..................................           29940              17
190048..................................           26380              19
230078..................................           35660              23
240037..................................           33460              24
260006..................................           41140              26
300009..................................           31700              30
370054..................................           36420              37
380040..................................           13460              38
380084..................................           41420              38
390181..................................              39              39
390183..................................              39              39
390201..................................              39              39
450052..................................              45              45
450078..................................           10180              45
450243..................................           10180              45
450276..................................           48660              45
450348..................................              45              45
500023..................................           28420              50
500037..................................           49420              50
500122..................................              50              50
500147..................................           42644              50
500148..................................           48300              50
------------------------------------------------------------------------


    Table 10.--Geometric Mean Plus the Lesser of .75 of the National
Adjusted Operating Standardized Payment Amount (Increased to Reflect the
 Difference Between Costs and Charges) or .75 of One Standard Deviation
    of Mean Charges by Diagnosis-Related Group (DRG)--March 2005 \1\
------------------------------------------------------------------------
                      DRG                          Cases      Threshold
------------------------------------------------------------------------
1.............................................       23,252      $53,083
2.............................................       10,344      $37,759
3.............................................            4      $48,426
6.............................................          410      $15,918
7.............................................       15,583      $41,465
8.............................................        3,699      $30,770
9.............................................        1,942      $26,987
10............................................       19,496      $24,514
11............................................        3,278      $17,942
12............................................       54,365      $17,418
13............................................        7,327      $16,737
14............................................      236,739      $24,767
15............................................       76,007      $18,842
16............................................       16,254      $26,229
17............................................        3,005      $14,673
18............................................       33,048      $19,757
19............................................        8,553      $14,440
20............................................        6,528      $41,346
21............................................        2,195      $28,454
22............................................        3,315      $23,057
23............................................       10,714      $15,561
24............................................       63,800      $19,706
25............................................       28,130      $12,635
26............................................           18      $25,170
27............................................        5,385      $26,078
28............................................       17,543      $26,266
29............................................        6,262      $14,651
31............................................        5,087      $19,123
32............................................        1,981      $12,778
34............................................       27,853      $19,761
35............................................        7,887      $12,867
36............................................        1,469      $14,560
37............................................        1,237      $23,489
38............................................           56      $14,212
39............................................          447      $14,248
40............................................        1,382      $19,777
42............................................        1,144      $16,384
43............................................          125      $11,950
44............................................        1,159      $13,657
45............................................        2,798      $15,147
46............................................        3,816      $15,156
47............................................        1,334      $10,768
49............................................        2,474      $32,109
50............................................        2,161      $17,332
51............................................          190      $18,236
52............................................          165      $17,220
53............................................        2,223      $26,424
55............................................        1,353      $18,794
56............................................          435      $17,620
57............................................          697      $22,175
59............................................          102      $15,452
60............................................            8      $16,595
61............................................          219      $25,804
63............................................        2,841      $27,928
64............................................        3,339      $23,367
65............................................       41,395      $12,285
66............................................        8,002      $11,762
67............................................          418      $15,509
68............................................       17,310      $13,327
69............................................        4,810       $9,913
70............................................           25       $8,304
71............................................           68      $15,084
72............................................        1,065      $15,307
73............................................        7,925      $16,547
74............................................            4       $7,279
75............................................       45,004      $47,996
76............................................       47,304      $43,717
77............................................        2,153      $24,202
78............................................       45,589      $24,850
79............................................      170,543      $30,457
80............................................        7,717      $17,767
81............................................            4      $37,091
82............................................       65,088      $27,672
83............................................        6,944      $19,629
84............................................        1,470      $11,706
85............................................       21,855      $24,898
86............................................        1,859      $14,235
87............................................       82,642      $27,783
88............................................      413,274      $17,776
89............................................      550,119      $20,636
90............................................       45,801      $12,316
91............................................           45      $16,785
92............................................       16,483      $23,911
93............................................        1,596      $14,444
94............................................       13,330      $23,013
95............................................        1,609      $12,307
96............................................       59,079      $14,840

[[Page 23643]]

 
97............................................       26,996      $10,870
98............................................            8       $8,495
99............................................       21,531      $14,399
100...........................................        6,934      $11,081
101...........................................       23,083      $17,487
102...........................................        5,236      $11,147
103...........................................          724     $214,160
104...........................................       20,904     $117,844
105...........................................       31,499      $89,729
106...........................................        3,492     $108,656
107...........................................       69,982      $85,171
108...........................................        7,942      $85,326
109...........................................       50,600      $65,918
110...........................................       57,121      $59,055
111...........................................       10,070      $44,900
113...........................................       37,225      $44,754
114...........................................        8,509      $31,122
115...........................................       22,119      $58,803
116...........................................      118,448      $43,379
117...........................................        5,146      $26,461
118...........................................        7,591      $33,464
119...........................................          993      $26,580
120...........................................       36,272      $36,812
121...........................................      159,450      $30,813
122...........................................       61,715      $19,625
123...........................................       33,617      $27,218
124...........................................      130,598      $28,749
125...........................................       95,641      $22,067
126...........................................        5,822      $42,108
127...........................................      695,047      $20,505
128...........................................        5,170      $13,906
129...........................................        3,751      $20,637
130...........................................       89,029      $18,640
131...........................................       23,806      $11,216
132...........................................      117,219      $12,597
133...........................................        7,276      $10,986
134...........................................       42,382      $12,400
135...........................................        7,433      $17,747
136...........................................        1,133      $12,797
138...........................................      206,854      $16,622
139...........................................       78,506      $10,671
140...........................................       38,098      $10,335
141...........................................      121,790      $15,337
142...........................................       52,218      $12,040
143...........................................      249,138      $11,604
144...........................................       99,593      $25,098
145...........................................        6,178      $11,899
146...........................................       10,762      $44,908
147...........................................        2,627      $29,912
148...........................................      135,543      $51,340
149...........................................       19,884      $28,508
150...........................................       22,692      $45,073
151...........................................        5,351      $25,703
152...........................................        5,006      $34,651
153...........................................        2,089      $21,823
154...........................................       28,473      $55,952
155...........................................        6,159      $25,835
156...........................................            6      $52,265
157...........................................        8,254      $26,362
158...........................................        4,104      $13,493
159...........................................       19,160      $28,111
160...........................................       11,968      $17,182
161...........................................       10,417      $23,781
162...........................................        5,486      $13,865
163...........................................           10      $14,004
164...........................................        5,941      $39,874
165...........................................        2,518      $23,716
166...........................................        4,928      $28,877
167...........................................        4,623      $17,916
168...........................................        1,544      $25,383
169...........................................          754      $14,788
170...........................................       17,464      $44,402
171...........................................        1,483      $24,371
172...........................................       32,853      $27,512
173...........................................        2,388      $15,475
174...........................................      267,618      $20,328
175...........................................       32,616      $11,567
176...........................................       14,542      $22,357
177...........................................        8,545      $18,625
178...........................................        2,903      $14,386
179...........................................       14,417      $21,872
180...........................................       92,094      $19,340
181...........................................       25,878      $11,462
182...........................................      291,824      $16,956
183...........................................       86,469      $12,060
184...........................................           78      $10,539
185...........................................        5,678      $17,264
186...........................................            4       $6,213
187...........................................          621      $17,068
188...........................................       90,890      $22,183
189...........................................       13,170      $12,414
190...........................................           69      $12,679
191...........................................       10,395      $54,119
192...........................................        1,322      $33,415
193...........................................        4,505      $50,334
194...........................................          520      $32,038
195...........................................        3,247      $49,676
196...........................................          699      $32,386
197...........................................       17,294      $41,808
198...........................................        4,629      $24,029
199...........................................        1,422      $38,851
200...........................................          936      $39,812
201...........................................        2,664      $51,676
202...........................................       27,245      $26,568
203...........................................       31,633      $27,380
204...........................................       72,764      $22,089
205...........................................       31,436      $23,369
206...........................................        2,075      $14,944
207...........................................       35,719      $23,543
208...........................................        9,747      $14,208
210...........................................      128,257      $35,917
211...........................................       26,620      $24,559
212...........................................           10      $26,686
213...........................................       10,256      $34,143
216...........................................       17,645      $36,166
217...........................................       17,611      $42,611
218...........................................       28,683      $32,278
219...........................................       21,323      $20,929
220...........................................            4      $31,838
223...........................................       13,414      $22,467
224...........................................       10,864      $16,561
225...........................................        6,508      $24,064
226...........................................        6,656      $29,923
227...........................................        5,068      $16,786
228...........................................        2,639      $23,112
229...........................................        1,198      $14,205
230...........................................        2,564      $26,523
232...........................................          721      $19,464
233...........................................       15,107      $35,245
234...........................................        7,659      $25,357
235...........................................        4,964      $14,917
236...........................................       42,358      $14,238
237...........................................        2,019      $12,305
238...........................................        9,863      $27,442
239...........................................       42,910      $21,095
240...........................................       12,638      $25,924
241...........................................        2,693      $13,360
242...........................................        2,742      $22,347
243...........................................      101,378      $15,581
244...........................................       15,777      $14,369
245...........................................        5,832       $9,431
246...........................................        1,429      $12,106
247...........................................       21,645      $11,781
248...........................................       15,098      $17,268
249...........................................       14,017      $13,881
250...........................................        4,149      $13,866
251...........................................        2,146       $9,765
253...........................................       24,829      $15,141
254...........................................       10,404       $9,271
256...........................................        7,144      $16,671
257...........................................       13,494      $17,881
258...........................................       12,014      $14,270
259...........................................        2,898      $19,381
260...........................................        2,981      $14,202
261...........................................        1,603      $19,576
262...........................................          636      $19,862
263...........................................       23,791      $33,555
264...........................................        3,921      $20,803
265...........................................        4,304      $29,777
266...........................................        2,303      $17,605
267...........................................          272      $18,035
268...........................................        1,003      $23,142
269...........................................       10,670      $31,752
270...........................................        2,635      $16,856
271...........................................       21,019      $19,407
272...........................................        5,931      $19,148
273...........................................        1,348      $11,532
274...........................................        2,287      $23,181
275...........................................          228      $11,152
276...........................................        1,445      $13,974
277...........................................      112,171      $17,127
278...........................................       33,823      $10,861
279...........................................            6      $17,172
280...........................................       19,255      $14,562
281...........................................        7,092       $9,993
283...........................................        6,268      $14,563
284...........................................        1,829       $9,200
285...........................................        7,615      $35,872
286...........................................        2,702      $35,486
287...........................................        6,107      $32,104
288...........................................       10,432      $37,872
289...........................................        6,881      $18,298
290...........................................       10,827      $17,619

[[Page 23644]]

 
291...........................................           64      $18,543
292...........................................        7,321      $41,142
293...........................................          367      $27,840
294...........................................       98,864      $15,044
295...........................................        4,096      $14,601
296...........................................      254,455      $16,168
297...........................................       45,318       $9,887
298...........................................           81       $9,998
299...........................................        1,478      $20,010
300...........................................       21,321      $21,770
301...........................................        3,896      $12,544
302...........................................        9,646      $52,723
303...........................................       23,740      $39,286
304...........................................       13,816      $38,375
305...........................................        3,084      $23,623
306...........................................        6,341      $25,247
307...........................................        2,061      $12,398
308...........................................        7,089      $30,158
309...........................................        3,555      $18,659
310...........................................       26,019      $23,711
311...........................................        6,468      $13,013
312...........................................        1,454      $22,529
313...........................................          507      $14,119
315...........................................       36,526      $35,138
316...........................................      180,759      $25,061
317...........................................        2,756      $16,124
318...........................................        5,923      $23,425
319...........................................          382      $13,277
320...........................................      218,425      $17,103
321...........................................       31,366      $11,424
322...........................................           61      $11,164
323...........................................       20,454      $16,793
324...........................................        5,414      $10,413
325...........................................        9,600      $13,014
326...........................................        2,574       $9,069
327...........................................            5       $5,743
328...........................................          606      $14,673
329...........................................           71      $10,155
331...........................................       54,748      $20,954
332...........................................        4,387      $12,467
333...........................................          251      $18,573
334...........................................        9,802      $28,443
335...........................................       11,919      $21,877
336...........................................       31,235      $16,658
337...........................................       25,130      $11,427
338...........................................          652      $27,712
339...........................................        1,253      $23,286
340...........................................            2      $18,734
341...........................................        3,183      $25,976
342...........................................          563      $17,354
344...........................................        2,691      $25,572
345...........................................        1,461      $22,328
346...........................................        3,962      $21,235
347...........................................          247      $12,515
348...........................................        4,171      $14,696
349...........................................          575       $8,797
350...........................................        7,134      $14,636
352...........................................          973      $14,967
353...........................................        2,725      $32,476
354...........................................        7,603      $29,914
355...........................................        4,922      $17,549
356...........................................       23,932      $14,960
357...........................................        5,563      $38,097
358...........................................       20,763      $22,658
359...........................................       28,654      $15,907
360...........................................       14,748      $17,209
361...........................................          272      $22,454
362...........................................            2      $11,608
363...........................................        2,127      $19,999
364...........................................        1,449      $17,758
365...........................................        1,620      $32,955
366...........................................        4,786      $24,830
367...........................................          455      $12,018
368...........................................        3,920      $23,343
369...........................................        3,610      $12,832
370...........................................        1,838      $17,389
371...........................................        2,236      $11,866
372...........................................        1,162       $9,834
373...........................................        4,860       $7,061
374...........................................          156      $13,290
375...........................................            6      $33,543
376...........................................          388      $10,147
377...........................................           77      $25,958
378...........................................          195      $15,828
379...........................................          507       $7,202
380...........................................           91       $7,834
381...........................................          212      $12,620
382...........................................           43       $4,126
383...........................................        2,472       $9,812
384...........................................          132       $6,300
392...........................................        2,202      $45,471
394...........................................        2,818      $31,480
395...........................................      115,973      $16,480
396...........................................            9      $15,832
397...........................................       18,425      $24,257
398...........................................       18,256      $24,100
399...........................................        1,634      $13,682
401...........................................        6,325      $43,589
402...........................................        1,401      $24,076
403...........................................       31,827      $30,787
404...........................................        3,799      $18,943
406...........................................        2,222      $42,772
407...........................................          583      $24,742
408...........................................        2,170      $33,802
409...........................................        1,807      $24,850
410...........................................       28,395      $22,712
411...........................................           12       $7,141
412...........................................           12      $16,545
413...........................................        5,193      $26,451
414...........................................          572      $16,081
415...........................................       50,799      $51,864
416...........................................      238,848      $29,646
417...........................................           23      $20,595
418...........................................       28,478      $21,320
419...........................................       16,269      $17,124
420...........................................        2,939      $12,324
421...........................................       11,866      $14,876
422...........................................           52      $10,935
423...........................................        8,631      $29,978
424...........................................        1,071      $36,011
425...........................................       14,758      $12,572
426...........................................        4,309       $9,562
427...........................................        1,504      $10,543
428...........................................          769      $13,558
429...........................................       25,454      $15,545
430...........................................       71,402      $12,774
431...........................................          304      $10,532
432...........................................          420      $12,850
433...........................................        5,189       $5,613
439...........................................        1,738      $30,816
440...........................................        5,606      $30,736
441...........................................          779      $18,744
442...........................................       18,000      $37,969
443...........................................        3,382      $20,255
444...........................................        5,891      $14,879
445...........................................        2,345      $10,336
447...........................................        6,258      $10,696
449...........................................       38,766      $16,579
450...........................................        7,787       $8,697
451...........................................            3       $5,847
452...........................................       27,610      $20,394
453...........................................        5,431      $10,730
454...........................................        3,835      $15,920
455...........................................          846       $9,717
461...........................................        2,722      $27,440
462...........................................        7,751      $16,591
463...........................................       31,026      $13,855
464...........................................        7,651      $10,292
465...........................................          219      $12,019
466...........................................        1,377      $12,550
467...........................................        1,013       $9,726
468...........................................       50,411      $55,817
470...........................................           32      $13,204
471...........................................       15,474      $55,297
473...........................................        8,761      $39,707
475...........................................      116,437      $51,182
476...........................................        3,018      $36,994
477...........................................       29,401      $33,866
478...........................................      113,571      $40,296
479...........................................       24,583      $29,518
480...........................................          800     $120,367
481...........................................        1,065      $86,015
482...........................................        5,070      $49,484
484...........................................          449      $74,694
485...........................................        3,412      $50,963
486...........................................        2,562      $66,540
487...........................................        4,640      $32,711
488...........................................          786      $58,001
489...........................................       13,453      $29,620
490...........................................        5,203      $21,034
491...........................................       19,730      $32,883
492...........................................        4,005      $44,873
493...........................................       61,564      $35,020
494...........................................       25,546      $20,780
495...........................................          303     $109,115
496...........................................        3,255      $92,679
497...........................................       27,777      $59,046
498...........................................       19,008      $49,170
499...........................................       35,640      $27,782
500...........................................       48,213      $18,126
501...........................................        3,120      $43,064
502...........................................          717      $28,008
503...........................................        5,905      $24,316

[[Page 23645]]

 
504...........................................          187     $136,123
505...........................................          179      $27,684
506...........................................        1,004      $51,873
507...........................................          307      $32,100
508...........................................          641      $24,619
509...........................................          168      $14,897
510...........................................        1,755      $21,890
511...........................................          633      $12,748
512...........................................          513      $81,413
513...........................................          227      $97,844
515...........................................       44,389      $88,758
517...........................................       66,155      $40,225
518...........................................       42,015      $35,092
519...........................................       11,497      $43,638
520...........................................       15,218      $33,659
521...........................................       32,138      $13,596
522...........................................        5,642       $9,515
523...........................................       15,863       $7,639
524...........................................      118,842      $14,823
525...........................................          313     $139,715
527...........................................      191,680      $44,147
528...........................................        1,767     $102,318
529...........................................        4,030      $37,957
530...........................................        2,362      $24,232
531...........................................        4,796      $45,158
532...........................................        2,622      $29,368
533...........................................       47,549      $31,277
534...........................................       45,166      $20,426
535...........................................        7,384     $123,742
536...........................................        8,047     $108,821
537...........................................        8,640      $33,393
538...........................................        5,598      $20,028
539...........................................        5,014      $44,863
540...........................................        1,509      $23,964
541...........................................       22,410     $242,891
542...........................................       24,343     $155,852
543...........................................        5,403      $62,826
544...........................................      417,780      $37,604
545...........................................       42,280      $44,313
546...........................................        1,954      $77,955
547...........................................       26,756      $49,899
548...........................................       11,898      $41,613
549...........................................       35,640      $55,680
550...........................................       20,130     $47,573
------------------------------------------------------------------------
\1\ Cases are taken from the FY 2004 MedPAR file; DRGs are from GROUPER
  Version 23.0.


    Table 11.--Proposed FY 2006 LTC-DRGs, Relative Weights, Geometric
  Average Length of Stay, and 5/6ths of the Geometric Average Length of
                                  Stay
------------------------------------------------------------------------
                                                              5/6ths of
                                                 Geometric       the
                                     Relative     average     geometric
    LTC-DRG         Description       weight     length of     average
                                                    stay      length of
                                                                 stay
------------------------------------------------------------------------
1..............  \5\ CRANIOTOMY         1.6862         38.0         31.7
                  AGE >17 W CC.
2..............  \7\ CRANIOTOMY         1.6862         38.0         31.7
                  AGE >17 W/O CC.
3..............  \7\ CRANIOTOMY         1.6862         38.0         31.7
                  AGE 0-17.
6..............  \7\ CARPAL             0.4502         18.8         15.7
                  TUNNEL RELEASE.
7..............  PERIPH & CRANIAL       1.3854         37.5         31.3
                  NERVE & OTHER
                  NERV SYST PROC
                  W CC.
8..............  \3\ PERIPH &           0.7586         24.5         20.4
                  CRANIAL NERVE &
                  OTHER NERV SYST
                  PROC W/O CC.
9..............  SPINAL DISORDERS       0.9617         33.2         27.7
                  & INJURIES.
10.............  NERVOUS SYSTEM         0.7441         24.2         20.2
                  NEOPLASMS W CC.
11.............  \2\ NERVOUS            0.5834         21.0         17.5
                  SYSTEM
                  NEOPLASMS W/O
                  CC.
12.............  DEGENERATIVE           0.6903         25.5         21.3
                  NERVOUS SYSTEM
                  DISORDERS.
13.............  MULTIPLE               0.6625         23.0         19.2
                  SCLEROSIS &
                  CEREBELLAR
                  ATAXIA.
14.............  INTERCRANIAL           0.7758         25.9         21.6
                  HEMORRHAGE OR
                  STROKE WITH
                  INFARCT.
15.............  NONSPECIFIC CVA        0.7398         27.0         22.5
                  & PRECEREBRAL
                  OCCULUSION
                  WITHOUT INFARCT.
16.............  NONSPECIFIC            0.7507         23.5         19.6
                  CEREBROVASCULAR
                  DISORDERS W CC.
17.............  \1\ NONSPECIFIC        0.4502         18.8         15.7
                  CEREBROVASCULAR
                  DISORDERS W/O
                  CC.
18.............  CRANIAL &              0.7242         23.6         19.7
                  PERIPHERAL
                  NERVE DISORDERS
                  W CC.
19.............  CRANIAL &              0.4809         21.2         17.7
                  PERIPHERAL
                  NERVE DISORDERS
                  W/O CC.
20.............  NERVOUS SYSTEM         1.0284         27.1         22.6
                  INFECTION
                  EXCEPT VIRAL
                  MENINGITIS.
21.............  \3\ VIRAL              0.7586         24.5         20.4
                  MENINGITIS.
22.............  \4\ HYPERTENSIVE       1.1679         29.6         24.7
                  ENCEPHALOPATHY.
23.............  NONTRAUMATIC           0.8101         25.4         21.2
                  STUPOR & COMA.
24.............  SEIZURE &              0.6262         22.4         18.7
                  HEADACHE AGE
                  >17 W CC.
25.............  \1\ SEIZURE &          0.4502         18.8         15.7
                  HEADACHE AGE
                  >17 W/O CC.
26.............  \7\ SEIZURE &          0.4502         18.8         15.7
                  HEADACHE AGE 0-
                  17.
27.............  TRAUMATIC STUPOR       0.9658         27.7         23.1
                  & COMA, COMA >1
                  HR.
28.............  TRAUMATIC STUPOR       0.9042         30.2         25.2
                  & COMA, COMA <1
                  HR AGE >17 W CC.
29.............  \1\ TRAUMATIC          0.4502         18.8         15.7
                  STUPOR & COMA,
                  COMA <1 HR AGE
                  >17 W/O CC.
30.............  \7\ TRAUMATIC          0.4502         18.8         15.7
                  STUPOR & COMA,
                  COMA <1 HR AGE
                  0-17.
31.............  \3\ CONCUSSION         0.7586         24.5         20.4
                  AGE >17 W CC.
32.............  \7\ CONCUSSION         0.4502         18.8         15.7
                  AGE >17 W/O CC.
33.............  \7\ CONCUSSION         0.4502         18.8         15.7
                  AGE 0-17.
34.............  OTHER DISORDERS        0.8056         25.2           21
                  OF NERVOUS
                  SYSTEM W CC.
35.............  OTHER DISORDERS        0.5758         24.0           20
                  OF NERVOUS
                  SYSTEM W/O CC.
36.............  \7\ RETINAL            1.1679         29.6         24.7
                  PROCEDURES.
37.............  \7\ ORBITAL            1.1679         29.6         24.7
                  PROCEDURES.

[[Page 23646]]

 
38.............  \7\ PRIMARY IRIS       1.1679         29.6         24.7
                  PROCEDURES.
39.............  \7\ LENS               1.1679         29.6         24.7
                  PROCEDURES WITH
                  OR WITHOUT
                  VITRECTOMY.
40.............  \4\ EXTRAOCULAR        1.1679         29.6         24.7
                  PROCEDURES
                  EXCEPT ORBIT
                  AGE >17.
41.............  \7\ EXTRAOCULAR        1.1679         29.6         24.7
                  PROCEDURES
                  EXCEPT ORBIT
                  AGE 0-17.
42.............  \7\ INTRAOCULAR        1.1679         29.6         24.7
                  PROCEDURES
                  EXCEPT RETINA,
                  IRIS & LENS.
43.............  \7\ HYPHEMA.....       1.1679         29.6         24.7
44.............  \2\ ACUTE MAJOR        0.5834         21.0         17.5
                  EYE INFECTIONS.
45.............  \7\ NEUROLOGICAL       1.1679         29.6         24.7
                  EYE DISORDERS.
46.............  \2\ OTHER              0.5834         21.0         17.5
                  DISORDERS OF
                  THE EYE AGE >17
                  W CC.
47.............  \7\ OTHER              1.1679         29.6         24.7
                  DISORDERS OF
                  THE EYE AGE >17
                  W/O CC.
48.............  \7\ OTHER              1.1679         29.6         24.7
                  DISORDERS OF
                  THE EYE AGE 0-
                  17.
49.............  \7\ MAJOR HEAD &       1.1679         29.6         24.7
                  NECK PROCEDURES.
50.............  \7\                    1.1679         29.6         24.7
                  SIALOADENECTOMY.
51.............  \7\ SALIVARY           1.1679         29.6         24.7
                  GLAND
                  PROCEDURES
                  EXCEPT
                  SIALOADENECTOMY.
52.............  \7\ CLEFT LIP &        1.1679         29.6         24.7
                  PALATE REPAIR.
53.............  \7\ SINUS &            1.1679         29.6         24.7
                  MASTOID
                  PROCEDURES AGE
                  >17.
54.............  \7\ SINUS &            1.1679         29.6         24.7
                  MASTOID
                  PROCEDURES AGE
                  0-17.
55.............  \7\                    1.1679         29.6         24.7
                  MISCELLANEOUS
                  EAR, NOSE,
                  MOUTH & THROAT
                  PROCEDURES.
56.............  \7\ RHINOPLASTY.       1.1679         29.6         24.7
57.............  \7\ T&A PROC,          0.4502         18.8         15.7
                  EXCEPT
                  TONSILLECTOMY &/
                  OR
                  ADENOIDECTOMY
                  ONLY, AGE >17.
58.............  \7\ T&A PROC,          0.4502         18.8         15.7
                  EXCEPT
                  TONSILLECTOMY &/
                  OR
                  ADENOIDECTOMY
                  ONLY, AGE 0-17.
59.............  \7\                    0.4502         18.8         15.7
                  TONSILLECTOMY &/
                  OR
                  ADENOIDECTOMY
                  ONLY, AGE >17.
60.............  \7\                    0.4502         18.8         15.7
                  TONSILLECTOMY &/
                  OR
                  ADENOIDECTOMY
                  ONLY, AGE 0-17.
61.............  \3\ MYRINGOTOMY        0.7586         24.5         20.4
                  W TUBE
                  INSERTION AGE
                  >17.
62.............  \7\ MYRINGOTOMY        0.4502         18.8         15.7
                  W TUBE
                  INSERTION AGE 0-
                  17.
63.............  \4\ OTHER EAR,         1.1679         29.6         24.7
                  NOSE, MOUTH &
                  THROAT O.R.
                  PROCEDURES.
64.............  EAR, NOSE, MOUTH       1.1477         26.2         21.8
                  & THROAT
                  MALIGNANCY.
65.............  \1\                    0.4502         18.8         15.7
                  DYSEQUILIBRIUM.
66.............  \7\ EPISTAXIS...       0.4502         18.8         15.7
67.............  \3\ EPIGLOTTITIS       0.7586         24.5         20.4
68.............  OTITIS MEDIA &         0.5134         18.0           15
                  URI AGE >17
                  W CC.
69.............  \1\ OTITIS MEDIA       0.4502         18.8         15.7
                  & URI AGE
                  >17 W/O CC.
70.............  \7\ OTITIS MEDIA       0.4502         18.8         15.7
                  & URI AGE 0-17.
71.............  \7\                    0.5834         21.0         17.5
                  LARYNGOTRACHEIT
                  IS.
72.............  \7\ NASAL TRAUMA       0.5834         21.0         17.5
                  & DEFORMITY.
73.............  OTHER EAR, NOSE,       0.6360         20.4           17
                  MOUTH & THROAT
                  DIAGNOSES AGE
                  >17.
74.............  \7\ OTHER EAR,         0.4502         18.8         15.7
                  NOSE, MOUTH &
                  THROAT
                  DIAGNOSES AGE 0-
                  17.
75.............  \5\ MAJOR CHEST        1.6862         38.0         31.7
                  PROCEDURES.
76.............  OTHER RESP             2.5324         43.6         36.3
                  SYSTEM O.R.
                  PROCEDURES W CC.
77.............  \5\ OTHER RESP         1.6862         38.0         31.7
                  SYSTEM O.R.
                  PROCEDURES W/O
                  CC.
78.............  PULMONARY              0.6955         21.9         18.3
                  EMBOLISM.
79.............  RESPIRATORY            0.8252         22.8           19
                  INFECTIONS &
                  INFLAMMATIONS
                  AGE >17 W CC.
80.............  RESPIRATORY            0.5993         21.5         17.9
                  INFECTIONS &
                  INFLAMMATIONS
                  AGE >17 W/O CC.
81.............  \7\ RESPIRATORY        0.4502         18.8         15.7
                  INFECTIONS &
                  INFLAMMATIONS
                  AGE 0-17.
82.............  RESPIRATORY            0.7138         20.1         16.8
                  NEOPLASMS.
83.............  \2\ MAJOR CHEST        0.5834         21.0         17.5
                  TRAUMA W CC.
84.............  \7\ MAJOR CHEST        0.5834         21.0         17.5
                  TRAUMA W/O CC.
85.............  PLEURAL EFFUSION       0.7308         21.2         17.7
                  W CC.
86.............  \2\ PLEURAL            0.5834         21.0         17.5
                  EFFUSION W/O CC.
87.............  PULMONARY EDEMA        1.0797         25.3         21.1
                  & RESPIRATORY
                  FAILURE.
88.............  CHRONIC                0.6620         19.6         16.3
                  OBSTRUCTIVE
                  PULMONARY
                  DISEASE.
89.............  SIMPLE PNEUMONIA       0.7027         20.8         17.3
                  & PLEURISY AGE
                  >17 W CC.
90.............  SIMPLE PNEUMONIA       0.5004         17.8         14.8
                  & PLEURISY AGE
                  >17 W/O CC.
91.............  \7\ SIMPLE             0.4502         18.8         15.7
                  PNEUMONIA &
                  PLEURISY AGE 0-
                  17.
92.............  INTERSTITIAL           0.6764         20.2         16.8
                  LUNG DISEASE W
                  CC.
93.............  \2\ INTERSTITIAL       0.5834         21.0         17.5
                  LUNG DISEASE W/
                  O CC.
94.............  PNEUMOTHORAX W         0.5913         17.0         14.2
                  CC.
95.............  \1\ PNEUMOTHORAX       0.4502         18.8         15.7
                  W/O CC.
96.............  BRONCHITIS &           0.6436         19.4         16.2
                  ASTHMA AGE >17
                  W CC.
97.............  \2\ BRONCHITIS &       0.5834         21.0         17.5
                  ASTHMA AGE >17
                  W/O CC.
98.............  \7\ BRONCHITIS &       0.5834         21.0         17.5
                  ASTHMA AGE 0-17.
99.............  RESPIRATORY            0.9262         23.3         19.4
                  SIGNS &
                  SYMPTOMS W CC.
100............  \3\ RESPIRATORY        0.7586         24.5         20.4
                  SIGNS &
                  SYMPTOMS W/O CC.
101............  OTHER                  0.8143         21.1         17.6
                  RESPIRATORY
                  SYSTEM
                  DIAGNOSES W CC.
102............  \1\ OTHER              0.4502         18.8         15.7
                  RESPIRATORY
                  SYSTEM
                  DIAGNOSES W/O
                  CC.
103............  \6\ HEART              0.0000          1.0          0.8
                  TRANSPLANT OR
                  IMPLANT OF
                  HEART ASSIST
                  SYSTEM.

[[Page 23647]]

 
104............  \7\ CARDIAC            1.1679         29.6         24.7
                  VALVE & OTH
                  MAJOR
                  CARDIOTHORACIC
                  PROC W CARD
                  CATH.
105............  \7\ CARDIAC            1.1679         29.6         24.7
                  VALVE & OTH
                  MAJOR
                  CARDIOTHORACIC
                  PROC W/O CARD
                  CATH.
106............  \7\ CORONARY           1.1679         29.6         24.7
                  BYPASS W PTCA.
107............  \7\ CORONARY           1.1679         29.6         24.7
                  BYPASS W
                  CARDIAC CATH.
108............  \7\ OTHER              1.1679         29.6         24.7
                  CARDIOTHORACIC
                  PROCEDURES.
109............  \7\ CORONARY           1.1679         29.6         24.7
                  BYPASS W/O PTCA
                  OR CARDIAC CATH.
110............  \4\ MAJOR              1.1679         29.6         24.7
                  CARDIOVASCULAR
                  PROCEDURES W CC.
111............  \7\ MAJOR              1.1679         29.6         24.7
                  CARDIOVASCULAR
                  PROCEDURES W/O
                  CC.
113............  AMPUTATION FOR         1.4877         39.2         32.7
                  CIRC SYSTEM
                  DISORDERS
                  EXCEPT UPPER
                  LIMB & TOE.
114............  UPPER LIMB & TOE       1.2453         33.2         27.7
                  AMPUTATION FOR
                  CIRC SYSTEM
                  DISORDERS.
115............  \5\ PRM CARD           1.6862         38.0         31.7
                  PACEM IMPL W
                  AMI,HRT FAIL OR
                  SHK,OR AICD
                  LEAD OR GNRTR P.
116............  \4\ OTH PERM           1.1679         29.6         24.7
                  CARD PACEMAK
                  IMPL OR PTCA W
                  CORONARY ARTERY
                  STENT IMPLNT.
117............  5CARDIAC               1.6862         38.0         31.7
                  PACEMAKER
                  REVISION EXCEPT
                  DEVICE
                  REPLACEMENT.
118............  \4\ CARDIAC            1.1679         29.6         24.7
                  PACEMAKER
                  DEVICE
                  REPLACEMENT.
119............  \3\ VEIN               0.7586         24.5         20.4
                  LIGATION &
                  STRIPPING.
120............  OTHER                  1.1050         31.8         26.5
                  CIRCULATORY
                  SYSTEM O.R.
                  PROCEDURES.
121............  CIRCULATORY            0.8200         22.6         18.8
                  DISORDERS W AMI
                  & MAJOR COMP,
                  DISCHARGED
                  ALIVE.
122............  \2\ CIRCULATORY        0.5834         21.0         17.5
                  DISORDERS W AMI
                  W/O MAJOR COMP,
                  DISCHARGED
                  ALIVE.
123............  CIRCULATORY            0.8678         18.7         15.6
                  DISORDERS W
                  AMI, EXPIRED.
124............  \4\ CIRCULATORY        1.1679         29.6         24.7
                  DISORDERS
                  EXCEPT AMI, W
                  CARD CATH &
                  COMPLEX DIAG.
125............  \3\ CIRCULATORY        0.7586         24.5         20.4
                  DISORDERS
                  EXCEPT AMI, W
                  CARD CATH W/O
                  COMPLEX DIAG.
126............  ACUTE & SUBACUTE       0.8467         25.3         21.1
                  ENDOCARDITIS.
127............  HEART FAILURE &        0.6890         21.1         17.6
                  SHOCK.
128............  \2\ DEEP VEIN          0.5834         21.0         17.5
                  THROMBOPHLEBITI
                  S.
129............  \7\ CARDIAC            1.1679         29.6         24.7
                  ARREST,
                  UNEXPLAINED.
130............  PERIPHERAL             0.6755         23.1         19.3
                  VASCULAR
                  DISORDERS W CC.
131............  PERIPHERAL             0.4698         20.4           17
                  VASCULAR
                  DISORDERS W/O
                  CC.
132............  ATHEROSCLEROSIS        0.6639         21.8         18.2
                  W CC.
133............  \1\                    0.4502         18.8         15.7
                  ATHEROSCLEROSIS
                  W/O CC.
134............  HYPERTENSION....       0.6388         24.7         20.6
135............  CARDIAC                0.7272         23.7         19.8
                  CONGENITAL &
                  VALVULAR
                  DISORDERS AGE
                  >17 W CC.
136............  \2\ CARDIAC            0.5834         21.0         17.5
                  CONGENITAL &
                  VALVULAR
                  DISORDERS AGE
                  >17 W/O CC.
137............  \7\ CARDIAC            0.5834         21.0         17.5
                  CONGENITAL &
                  VALVULAR
                  DISORDERS AGE 0-
                  17.
138............  CARDIAC                0.6183         20.4           17
                  ARRHYTHMIA &
                  CONDUCTION
                  DISORDERS W CC.
139............  \2\ CARDIAC            0.5834         21.0         17.5
                  ARRHYTHMIA &
                  CONDUCTION
                  DISORDERS W/O
                  CC.
140............  \1\ ANGINA             0.4502         18.8         15.7
                  PECTORIS.
141............  SYNCOPE &              0.4356         18.3         15.3
                  COLLAPSE W CC.
142............  \1\ SYNCOPE &          0.4502         18.8         15.7
                  COLLAPSE W/O CC.
143............  \2\ CHEST PAIN..       0.5834         21.0         17.5
144............  OTHER                  0.7364         21.6           18
                  CIRCULATORY
                  SYSTEM
                  DIAGNOSES W CC.
145............  OTHER                  0.4544         18.0           15
                  CIRCULATORY
                  SYSTEM
                  DIAGNOSES W/O
                  CC.
146............  \7\ RECTAL             1.6862         38.0         31.7
                  RESECTION W CC.
147............  \7\ RECTAL             1.6862         38.0         31.7
                  RESECTION W/O
                  CC.
148............  MAJOR SMALL &          1.8800         40.8           34
                  LARGE BOWEL
                  PROCEDURES W CC.
149............  \7\ MAJOR SMALL        0.7586         24.5         20.4
                  & LARGE BOWEL
                  PROCEDURES W/O
                  CC.
150............  \4\ PERITONEAL         1.1679         29.6         24.7
                  ADHESIOLYSIS W
                  CC.
151............  \2\ PERITONEAL         0.5834         21.0         17.5
                  ADHESIOLYSIS W/
                  O CC.
152............  \3\ MINOR SMALL        0.7586         24.5         20.4
                  & LARGE BOWEL
                  PROCEDURES W CC.
153............  \7\ MINOR SMALL        0.7586         24.5         20.4
                  & LARGE BOWEL
                  PROCEDURES W/O
                  CC.
154............  \5\ STOMACH,           1.6862         38.0         31.7
                  ESOPHAGEAL &
                  DUODENAL
                  PROCEDURES AGE
                  >17 W CC.
155............  \7\ STOMACH,           1.6862         38.0         31.7
                  ESOPHAGEAL &
                  DUODENAL
                  PROCEDURES AGE
                  >17 W/O CC.
156............  \7\ STOMACH,           1.6862         38.0         31.7
                  ESOPHAGEAL &
                  DUODENAL
                  PROCEDURES AGE
                  0-17.
157............  \4\ ANAL &             1.1679         29.6         24.7
                  STOMAL
                  PROCEDURES W CC.
158............  \7\ ANAL &             1.1679         29.6         24.7
                  STOMAL
                  PROCEDURES W/O
                  CC.
159............  \7\ HERNIA             0.7586         24.5         20.4
                  PROCEDURES
                  EXCEPT INGUINAL
                  & FEMORAL AGE
                  >17 W CC.
160............  \7\ HERNIA             0.7586         24.5         20.4
                  PROCEDURES
                  EXCEPT INGUINAL
                  & FEMORAL AGE
                  >17 W/O CC.
161............  \5\ INGUINAL &         1.6862         38.0         31.7
                  FEMORAL HERNIA
                  PROCEDURES AGE
                  >17 W CC.
162............  \7\ INGUINAL &         0.7586         24.5         20.4
                  FEMORAL HERNIA
                  PROCEDURES AGE
                  >17 W/O CC.
163............  \7\ HERNIA             0.7586         24.5         20.4
                  PROCEDURES AGE
                  0-17.
164............  \7\ APPENDECTOMY       1.6862         38.0         31.7
                  W COMPLICATED
                  PRINCIPAL DIAG
                  W CC.
165............  \7\ APPENDECTOMY       1.6862         38.0         31.7
                  W COMPLICATED
                  PRINCIPAL DIAG
                  W/O CC.
166............  \7\ APPENDECTOMY       1.6862         38.0         31.7
                  W/O COMPLICATED
                  PRINCIPAL DIAG
                  W CC.
167............  \7\ APPENDECTOMY       1.6862         38.0         31.7
                  W/O COMPLICATED
                  PRINCIPAL DIAG
                  W/O CC.
168............  \4\ MOUTH              1.1679         29.6         24.7
                  PROCEDURES W CC.
169............  \7\ MOUTH              0.7586         24.5         20.4
                  PROCEDURES W/O
                  CC.

[[Page 23648]]

 
170............  OTHER DIGESTIVE        1.6319         35.9         29.9
                  SYSTEM O.R.
                  PROCEDURES W CC.
171............  \1\ OTHER              0.4502         18.8         15.7
                  DIGESTIVE
                  SYSTEM O.R.
                  PROCEDURES W/O
                  CC.
172............  DIGESTIVE              0.8568         21.8         18.2
                  MALIGNANCY W CC.
173............  \2\ DIGESTIVE          0.5834         21.0         17.5
                  MALIGNANCY W/O
                  CC.
174............  G.I. HEMORRHAGE        0.6984         22.0         18.3
                  W CC.
175............  \1\ G.I.               0.4502         18.8         15.7
                  HEMORRHAGE W/O
                  CC.
176............  COMPLICATED            0.8510         21.5         17.9
                  PEPTIC ULCER.
177............  \3\                    0.7586         24.5         20.4
                  UNCOMPLICATED
                  PEPTIC ULCER W
                  CC.
178............  \3\                    0.7586         24.5         20.4
                  UNCOMPLICATED
                  PEPTIC ULCER W/
                  O CC.
179............  INFLAMMATORY           0.9834         24.1         20.1
                  BOWEL DISEASE.
180............  G.I. OBSTRUCTION       0.9417         23.5         19.6
                  W CC.
181............  \3\ G.I.               0.7586         24.5         20.4
                  OBSTRUCTION W/O
                  CC.
182............  ESOPHAGITIS,           0.7753         22.6         18.8
                  GASTROENT &
                  MISC DIGEST
                  DISORDERS AGE
                  >17 W CC.
183............  ESOPHAGITIS,           0.3959         17.2         14.3
                  GASTROENT &
                  MISC DIGEST
                  DISORDERS AGE
                  >17 W/O CC.
184............  \7\ ESOPHAGITIS,       0.4502         18.8         15.7
                  GASTROENT &
                  MISC DIGEST
                  DISORDERS AGE 0-
                  17.
185............  \3\ DENTAL &           0.7586         24.5         20.4
                  ORAL DIS EXCEPT
                  EXTRACTIONS &
                  RESTORATIONS,
                  AGE >17.
186............  \7\ DENTAL &           0.7586         24.5         20.4
                  ORAL DIS EXCEPT
                  EXTRACTIONS &
                  RESTORATIONS,
                  AGE 0-17.
187............  \7\ DENTAL             0.7586         24.5         20.4
                  EXTRACTIONS &
                  RESTORATIONS.
188............  OTHER DIGESTIVE        1.0009         24.0           20
                  SYSTEM
                  DIAGNOSES AGE
                  >17 W CC.
189............  OTHER DIGESTIVE        0.4730         18.2         15.2
                  SYSTEM
                  DIAGNOSES AGE
                  >17 W/O CC.
190............  \7\ OTHER              0.4502         18.8         15.7
                  DIGESTIVE
                  SYSTEM
                  DIAGNOSES AGE 0-
                  17.
191............  \4\ PANCREAS,          1.1679         29.6         24.7
                  LIVER & SHUNT
                  PROCEDURES W CC.
192............  \7\ PANCREAS,          1.1679         29.6         24.7
                  LIVER & SHUNT
                  PROCEDURES W/O
                  CC.
193............  \3\ BILIARY            0.7586         24.5         20.4
                  TRACT PROC
                  EXCEPT ONLY
                  CHOLECYST W OR
                  W/O C.D.E. W CC.
194............  \7\ BILIARY            0.7586         24.5         20.4
                  TRACT PROC
                  EXCEPT ONLY
                  CHOLECYST W OR
                  W/O C.D.E. W/O
                  CC.
195............  \4\                    1.1679         29.6         24.7
                  CHOLECYSTECTOMY
                  W C.D.E. W CC.
196............  \7\                    0.7586         24.5         20.4
                  CHOLECYSTECTOMY
                  W C.D.E. W/O CC.
197............  \3\                    0.7586         24.5         20.4
                  CHOLECYSTECTOMY
                  EXCEPT BY
                  LAPAROSCOPE W/O
                  C.D.E. W CC.
198............  \7\                    0.7586         24.5         20.4
                  CHOLECYSTECTOMY
                  EXCEPT BY
                  LAPAROSCOPE W/O
                  C.D.E. W/O CC.
199............  \7\                    1.6862         38.0         31.7
                  HEPATOBILIARY
                  DIAGNOSTIC
                  PROCEDURE FOR
                  MALIGNANCY.
200............  \5\                    1.6862         38.0         31.7
                  HEPATOBILIARY
                  DIAGNOSTIC
                  PROCEDURE FOR
                  NON-MALIGNANCY.
201............  OTHER                  2.0391         36.1         30.1
                  HEPATOBILIARY
                  OR PANCREAS
                  O.R. PROCEDURES.
202............  CIRRHOSIS &            0.6636         20.5         17.1
                  ALCOHOLIC
                  HEPATITIS.
203............  MALIGNANCY OF          0.7939         19.5         16.3
                  HEPATOBILIARY
                  SYSTEM OR
                  PANCREAS.
204............  DISORDERS OF           0.9564         22.9         19.1
                  PANCREAS EXCEPT
                  MALIGNANCY.
205............  DISORDERS OF           0.6709         20.6         17.2
                  LIVER EXCEPT
                  MALIG,CIRR,ALC
                  HEPA W CC.
206............  \2\ DISORDERS OF       0.5834         21.0         17.5
                  LIVER EXCEPT
                  MALIG,CIRR,ALC
                  HEPA W/O CC.
207............  DISORDERS OF THE       0.7600         21.5         17.9
                  BILIARY TRACT W
                  CC.
208............  \2\ DISORDERS OF       0.5834         21.0         17.5
                  THE BILIARY
                  TRACT W/O CC.
210............  \5\ HIP & FEMUR        1.6862         38.0         31.7
                  PROCEDURES
                  EXCEPT MAJOR
                  JOINT AGE >17 W
                  CC.
211............  \4\ HIP & FEMUR        1.1679         29.6         24.7
                  PROCEDURES
                  EXCEPT MAJOR
                  JOINT AGE >17 W/
                  O CC.
212............  \7\ HIP & FEMUR        1.6862         38.0         31.7
                  PROCEDURES
                  EXCEPT MAJOR
                  JOINT AGE 0-17.
213............  AMPUTATION FOR         1.2016         33.9         28.3
                  MUSCULOSKELETAL
                  SYSTEM & CONN
                  TISSUE
                  DISORDERS.
216............  \4\ BIOPSIES OF        1.1679         29.6         24.7
                  MUSCULOSKELETAL
                  SYSTEM &
                  CONNECTIVE
                  TISSUE.
217............  WND DEBRID & SKN       1.2917         38.0         31.7
                  GRFT EXCEPT
                  HAND,FOR
                  MUSCSKELET &
                  CONN TISS DIS.
218............  \5\ LOWER EXTREM       1.6862         38.0         31.7
                  & HUMER PROC
                  EXCEPT
                  HIP,FOOT,FEMUR
                  AGE >17 W CC.
219............  \1\ LOWER EXTREM       0.4502         18.8         15.7
                  & HUMER PROC
                  EXCEPT
                  HIP,FOOT,FEMUR
                  AGE >17 W/O CC.
220............  \7\ LOWER EXTREM       1.6862         38.0         31.7
                  & HUMER PROC
                  EXCEPT
                  HIP,FOOT,FEMUR
                  AGE 0-17.
223............  \3\ MAJOR              0.7586         24.5         20.4
                  SHOULDER/ELBOW
                  PROC, OR OTHER
                  UPPER EXTREMITY
                  PROC W CC.
224............  \7\                    0.7586         24.5         20.4
                  SHOULDER,ELBOW
                  OR FOREARM
                  PROC,EXC MAJOR
                  JOINT PROC, W/O
                  CC.
225............  FOOT PROCEDURES.       0.9996         28.9         24.1
226............  SOFT TISSUE            0.9487         30.0           25
                  PROCEDURES W CC.
227............  \3\ SOFT TISSUE        0.7586         24.5         20.4
                  PROCEDURES W/O
                  CC.
228............  \4\ MAJOR THUMB        1.1679         29.6         24.7
                  OR JOINT
                  PROC,OR OTH
                  HAND OR WRIST
                  PROC W CC.
229............  \7\ HAND OR            0.4502         18.8         15.7
                  WRIST PROC,
                  EXCEPT MAJOR
                  JOINT PROC, W/O
                  CC.
230............  \5\ LOCAL              1.6862         38.0         31.7
                  EXCISION &
                  REMOVAL OF INT
                  FIX DEVICES OF
                  HIP & FEMUR.
232............  \7\ ARTHROSCOPY.       0.4502         18.8         15.7
233............  OTHER                  1.2832         33.9         28.3
                  MUSCULOSKELET
                  SYS & CONN TISS
                  O.R. PROC W CC.
234............  \7\ OTHER              0.4502         18.8         15.7
                  MUSCULOSKELET
                  SYS & CONN TISS
                  O.R. PROC W/O
                  CC.
235............  \3\ FRACTURES OF       0.7586         24.5         20.4
                  FEMUR.
236............  FRACTURES OF HIP       0.6553         25.2           21
                  & PELVIS.
237............  \1\ SPRAINS,           0.4502         18.8         15.7
                  STRAINS, &
                  DISLOCATIONS OF
                  HIP, PELVIS &
                  THIGH.
238............  OSTEOMYELITIS...       0.8271         28.2         23.5
239............  PATHOLOGICAL           0.6923         23.6         19.7
                  FRACTURES &
                  MUSCULOSKELETAL
                  & CONN TISS
                  MALIGNANCY.
240............  CONNECTIVE             0.7320         24.5         20.4
                  TISSUE
                  DISORDERS W CC.

[[Page 23649]]

 
241............  \1\ CONNECTIVE         0.4502         18.8         15.7
                  TISSUE
                  DISORDERS W/O
                  CC.
242............  SEPTIC ARTHRITIS       0.7931         26.6         22.2
243............  MEDICAL BACK           0.6107         23.4         19.5
                  PROBLEMS.
244............  BONE DISEASES &        0.5280         22.2         18.5
                  SPECIFIC
                  ARTHROPATHIES W
                  CC.
245............  BONE DISEASES &        0.4651         20.4           17
                  SPECIFIC
                  ARTHROPATHIES W/
                  O CC.
246............  \1\ NON-SPECIFIC       0.4502         18.8         15.7
                  ARTHROPATHIES.
247............  SIGNS & SYMPTOMS       0.5269         21.4         17.8
                  OF
                  MUSCULOSKELETAL
                  SYSTEM & CONN
                  TISSUE.
248............  TENDONITIS,            0.6627         22.6         18.8
                  MYOSITIS &
                  BURSITIS.
249............  AFTERCARE,             0.6614         24.7         20.6
                  MUSCULOSKELETAL
                  SYSTEM &
                  CONNECTIVE
                  TISSUE.
250............  \2\ FX, SPRN,          0.5834         21.0         17.5
                  STRN & DISL OF
                  FOREARM, HAND,
                  FOOT AGE >17 W
                  CC.
251............  \1\ FX, SPRN,          0.4502         18.8         15.7
                  STRN & DISL OF
                  FOREARM, HAND,
                  FOOT AGE >17 W/
                  O CC.
252............  \7\ FX, SPRN,          0.7586         24.5         20.4
                  STRN & DISL OF
                  FOREARM, HAND,
                  FOOT AGE 0-17.
253............  FX, SPRN, STRN &       0.6838         26.3         21.9
                  DISL OF
                  UPARM,LOWLEG EX
                  FOOT AGE >17 W
                  CC.
254............  \1\ FX, SPRN,          0.4502         18.8         15.7
                  STRN & DISL OF
                  UPARM,LOWLEG EX
                  FOOT AGE >17 W/
                  O CC.
255............  \7\ FX, SPRN,          0.7586         24.5         20.4
                  STRN & DISL OF
                  UPARM,LOWLEG EX
                  FOOT AGE 0-17.
256............  OTHER                  0.7953         25.3         21.1
                  MUSCULOSKELETAL
                  SYSTEM &
                  CONNECTIVE
                  TISSUE
                  DIAGNOSES.
257............  \7\ TOTAL              0.7586         24.5         20.4
                  MASTECTOMY FOR
                  MALIGNANCY W CC.
258............  \7\ TOTAL              0.7586         24.5         20.4
                  MASTECTOMY FOR
                  MALIGNANCY W/O
                  CC.
259............  \2\ SUBTOTAL           0.5834         21.0         17.5
                  MASTECTOMY FOR
                  MALIGNANCY W CC.
260............  \7\ SUBTOTAL           0.7586         24.5         20.4
                  MASTECTOMY FOR
                  MALIGNANCY W/O
                  CC.
261............  \7\ BREAST PROC        0.7586         24.5         20.4
                  FOR NON-
                  MALIGNANCY
                  EXCEPT BIOPSY &
                  LOCAL EXCISION.
262............  \1\ BREAST             0.4502         18.8         15.7
                  BIOPSY & LOCAL
                  EXCISION FOR
                  NON-MALIGNANCY.
263............  SKIN GRAFT &/OR        1.3245         39.4         32.8
                  DEBRID FOR SKN
                  ULCER OR
                  CELLULITIS W CC.
264............  SKIN GRAFT &/OR        0.9555         31.9         26.6
                  DEBRID FOR SKN
                  ULCER OR
                  CELLULITIS W/O
                  CC.
265............  SKIN GRAFT &/OR        1.0426         33.1         27.6
                  DEBRID EXCEPT
                  FOR SKIN ULCER
                  OR CELLULITIS W
                  CC.
266............  \3\ SKIN GRAFT &/      0.7586         24.5         20.4
                  OR DEBRID
                  EXCEPT FOR SKIN
                  ULCER OR
                  CELLULITIS W/O
                  CC.
267............  \7\ PERIANAL &         0.7586         24.5         20.4
                  PILONIDAL
                  PROCEDURES.
268............  \5\ SKIN,              1.6862         38.0         31.7
                  SUBCUTANEOUS
                  TISSUE & BREAST
                  PLASTIC
                  PROCEDURES.
269............  OTHER SKIN,            1.2945         35.9         29.9
                  SUBCUT TISS &
                  BREAST PROC W
                  CC.
270............  \3\ OTHER SKIN,        0.7586         24.5         20.4
                  SUBCUT TISS &
                  BREAST PROC W/O
                  CC.
271............  SKIN ULCERS.....       0.8707         27.6           23
272............  MAJOR SKIN             0.7490         22.5         18.8
                  DISORDERS W CC.
273............  \1\ MAJOR SKIN         0.4502         18.8         15.7
                  DISORDERS W/O
                  CC.
274............  \3\ MALIGNANT          0.7586         24.5         20.4
                  BREAST
                  DISORDERS W CC.
275............  \7\ MALIGNANT          0.7586         24.5         20.4
                  BREAST
                  DISORDERS W/O
                  CC.
276............  \2\ NON-MALIGANT       0.5834         21.0         17.5
                  BREAST
                  DISORDERS.
277............  CELLULITIS AGE         0.6281         20.9         17.4
                  >17 W CC.
278............  CELLULITIS AGE         0.4440         17.8         14.8
                  >17 W/O CC.
279............  \7\ CELLULITIS         0.4502         18.8         15.7
                  AGE 0-17.
280............  TRAUMA TO THE          0.6728         24.3         20.3
                  SKIN, SUBCUT
                  TISS & BREAST
                  AGE >17 W CC.
281............  \1\ TRAUMA TO          0.4502         18.8         15.7
                  THE SKIN,
                  SUBCUT TISS &
                  BREAST AGE >17
                  W/O CC.
282............  \7\ TRAUMA TO          0.4502         18.8         15.7
                  THE SKIN,
                  SUBCUT TISS &
                  BREAST AGE 0-17.
283............  MINOR SKIN             0.6968         23.9         19.9
                  DISORDERS W CC.
284............  \1\ MINOR SKIN         0.4502         18.8         15.7
                  DISORDERS W/O
                  CC.
285............  AMPUTAT OF LOWER       1.3552         35.6         29.7
                  LIMB FOR
                  ENDOCRINE,NUTRI
                  T,& METABOL
                  DISORDERS.
286............  \7\ ADRENAL &          1.6862         38.0         31.7
                  PITUITARY
                  PROCEDURES.
287............  SKIN GRAFTS &          1.1270         33.6           28
                  WOUND DEBRID
                  FOR ENDOC,
                  NUTRIT & METAB
                  DISORDERS.
288............  \4\ O.R.               1.1679         29.6         24.7
                  PROCEDURES FOR
                  OBESITY.
289............  \7\ PARATHYROID        1.1679         29.6         24.7
                  PROCEDURES.
290............  \5\ THYROID            1.6862         38.0         31.7
                  PROCEDURES.
291............  \7\ THYROGLOSSAL       1.1679         29.6         24.7
                  PROCEDURES.
292............  OTHER ENDOCRINE,       1.3437         31.7         26.4
                  NUTRIT & METAB
                  O.R. PROC W CC.
293............  \2\ OTHER              0.5834         21.0         17.5
                  ENDOCRINE,
                  NUTRIT & METAB
                  O.R. PROC W/O
                  CC.
294............  DIABETES AGE >35       0.7330         24.8         20.7
295............  \3\ DIABETES AGE       0.7586         24.5         20.4
                  0-35.
296............  NUTRITIONAL &          0.7232         23.1         19.3
                  MISC METABOLIC
                  DISORDERS AGE
                  >17 W CC.
297............  NUTRITIONAL &          0.5262         18.4         15.3
                  MISC METABOLIC
                  DISORDERS AGE
                  >17 W/O CC.
298............  \7\ NUTRITIONAL        0.5834         21.0         17.5
                  & MISC
                  METABOLIC
                  DISORDERS AGE 0-
                  17.
299............  \4\ INBORN             1.1679         29.6         24.7
                  ERRORS OF
                  METABOLISM.
300............  ENDOCRINE              0.6413         21.2         17.7
                  DISORDERS W CC.
301............  \1\ ENDOCRINE          0.4502         18.8         15.7
                  DISORDERS W/O
                  CC.
302............  \6\ KIDNEY             0.0000          1.0          0.8
                  TRANSPLANT.
303............  \4\                    1.1679         29.6         24.7
                  KIDNEY,URETER &
                  MAJOR BLADDER
                  PROCEDURES FOR
                  NEOPLASM.
304............  \5\                    1.6862         38.0         31.7
                  KIDNEY,URETER &
                  MAJOR BLADDER
                  PROC FOR NON-
                  NEOPL W CC.
305............  \1\                    0.4502         18.8         15.7
                  KIDNEY,URETER &
                  MAJOR BLADDER
                  PROC FOR NON-
                  NEOPL W/O CC.
306............  \2\                    0.5834         21.0         17.5
                  PROSTATECTOMY W
                  CC.
307............  \7\                    0.5834         21.0         17.5
                  PROSTATECTOMY W/
                  O CC.

[[Page 23650]]

 
308............  \4\ MINOR              1.1679         29.6         24.7
                  BLADDER
                  PROCEDURES W CC.
309............  \7\ MINOR              1.1679         29.6         24.7
                  BLADDER
                  PROCEDURES W/O
                  CC.
310............  \4\                    1.1679         29.6         24.7
                  TRANSURETHRAL
                  PROCEDURES W CC.
311............  \7\                    1.1679         29.6         24.7
                  TRANSURETHRAL
                  PROCEDURES W/O
                  CC.
312............  \1\ URETHRAL           0.4502         18.8         15.7
                  PROCEDURES, AGE
                  >17 W CC.
313............  \7\ URETHRAL           0.4502         18.8         15.7
                  PROCEDURES, AGE
                  >17 W/O CC.
314............  \7\ URETHRAL           0.4502         18.8         15.7
                  PROCEDURES, AGE
                  0-17.
315............  OTHER KIDNEY &         1.4005         31.5         26.3
                  URINARY TRACT
                  O.R. PROCEDURES.
316............  RENAL FAILURE...       0.8208         22.6         18.8
317............  ADMIT FOR RENAL        1.0001         25.5         21.3
                  DIALYSIS.
318............  KIDNEY & URINARY       0.7648         20.2         16.8
                  TRACT NEOPLASMS
                  W CC.
319............  \1\ KIDNEY &           0.4502         18.8         15.7
                  URINARY TRACT
                  NEOPLASMS W/O
                  CC.
320............  KIDNEY & URINARY       0.6185         22.1         18.4
                  TRACT
                  INFECTIONS AGE
                  >17 W CC.
321............  KIDNEY & URINARY       0.4813         19.0         15.8
                  TRACT
                  INFECTIONS AGE
                  >17 W/O CC.
322............  \7\ KIDNEY &           0.4502         18.8         15.7
                  URINARY TRACT
                  INFECTIONS AGE
                  0-17.
323............  \4\ URINARY            1.1679         29.6         24.7
                  STONES W CC, &/
                  OR ESW
                  LITHOTRIPSY.
324............  \7\ URINARY            0.4502         18.8         15.7
                  STONES W/O CC.
325............  \2\ KIDNEY &           0.5834         21.0         17.5
                  URINARY TRACT
                  SIGNS &
                  SYMPTOMS AGE
                  >17 W CC.
326............  \1\ KIDNEY &           0.4502         18.8         15.7
                  URINARY TRACT
                  SIGNS &
                  SYMPTOMS AGE
                  >17 W/O CC.
327............  \7\ KIDNEY &           0.4502         18.8         15.7
                  URINARY TRACT
                  SIGNS &
                  SYMPTOMS AGE 0-
                  17.
328............  \1\ URETHRAL           0.4502         18.8         15.7
                  STRICTURE AGE
                  >17 W CC.
329............  \7\ URETHRAL           0.4502         18.8         15.7
                  STRICTURE AGE
                  >17 W/O CC.
330............  \7\ URETHRAL           0.4502         18.8         15.7
                  STRICTURE AGE 0-
                  17.
331............  OTHER KIDNEY &         0.8033         23.0         19.2
                  URINARY TRACT
                  DIAGNOSES AGE
                  >17 W CC.
332............  \3\ OTHER KIDNEY       0.7586         24.5         20.4
                  & URINARY TRACT
                  DIAGNOSES AGE
                  >17 W/O CC.
333............  \7\ OTHER KIDNEY       0.7586         24.5         20.4
                  & URINARY TRACT
                  DIAGNOSES AGE 0-
                  17.
334............  \2\ MAJOR MALE         0.5834         21.0         17.5
                  PELVIC
                  PROCEDURES W CC.
335............  \7\ MAJOR MALE         1.6862         38.0         31.7
                  PELVIC
                  PROCEDURES W/O
                  CC.
336............  \2\                    0.5834         21.0         17.5
                  TRANSURETHRAL
                  PROSTATECTOMY W
                  CC.
337............  \7\                    0.5834         21.0         17.5
                  TRANSURETHRAL
                  PROSTATECTOMY W/
                  O CC.
338............  \7\ TESTES             0.5834         21.0         17.5
                  PROCEDURES, FOR
                  MALIGNANCY.
339............  \4\ TESTES             1.1679         29.6         24.7
                  PROCEDURES, NON-
                  MALIGNANCY AGE
                  >17.
340............  \7\ TESTES             1.1679         29.6         24.7
                  PROCEDURES, NON-
                  MALIGNANCY AGE
                  0-17.
341............  \4\ PENIS              1.1679         29.6         24.7
                  PROCEDURES.
342............  \7\ CIRCUMCISION       1.1679         29.6         24.7
                  AGE >17.
343............  \7\ CIRCUMCISION       1.1679         29.6         24.7
                  AGE 0-17.
344............  \1\ OTHER MALE         0.4502         18.8         15.7
                  REPRODUCTIVE
                  SYSTEM O.R.
                  PROCEDURES FOR
                  MALIGNANCY.
345............  \5\ OTHER MALE         1.6862         38.0         31.7
                  REPRODUCTIVE
                  SYSTEM O.R.
                  PROC EXCEPT FOR
                  MALIGNANCY.
346............  MALIGNANCY, MALE       0.6105         20.6         17.2
                  REPRODUCTIVE
                  SYSTEM, W CC.
347............  \2\ MALIGNANCY,        0.5834         21.0         17.5
                  MALE
                  REPRODUCTIVE
                  SYSTEM, W/O CC.
348............  \2\ BENIGN             0.5834         21.0         17.5
                  PROSTATIC
                  HYPERTROPHY W
                  CC.
349............  \7\ BENIGN             1.1679         29.6         24.7
                  PROSTATIC
                  HYPERTROPHY W/O
                  CC.
350............  INFLAMMATION OF        0.6562         21.6           18
                  THE MALE
                  REPRODUCTIVE
                  SYSTEM.
351............  \7\                    1.1679         29.6         24.7
                  STERILIZATION,
                  MALE.
352............  OTHER MALE             0.6360         23.4         19.5
                  REPRODUCTIVE
                  SYSTEM
                  DIAGNOSES.
353............  \7\ PELVIC             1.1679         29.6         24.7
                  EVISCERATION,
                  RADICAL
                  HYSTERECTOMY &
                  RADICAL
                  VULVECTOMY.
354............  \7\                    1.1679         29.6         24.7
                  UTERINE,ADNEXA
                  PROC FOR NON-
                  OVARIAN/ADNEXAL
                  MALIG W CC.
355............  \7\                    1.1679         29.6         24.7
                  UTERINE,ADNEXA
                  PROC FOR NON-
                  OVARIAN/ADNEXAL
                  MALIG W/O CC.
356............  \7\ FEMALE             1.1679         29.6         24.7
                  REPRODUCTIVE
                  SYSTEM
                  RECONSTRUCTIVE
                  PROCEDURES.
357............  \7\ UTERINE &          1.1679         29.6         24.7
                  ADNEXA PROC FOR
                  OVARIAN OR
                  ADNEXAL
                  MALIGNANCY.
358............  \7\ UTERINE &          1.1679         29.6         24.7
                  ADNEXA PROC FOR
                  NON-MALIGNANCY
                  W CC.
359............  \7\ UTERINE &          1.1679         29.6         24.7
                  ADNEXA PROC FOR
                  NON-MALIGNANCY
                  W/O CC.
360............  \4\ VAGINA,            1.1679         29.6         24.7
                  CERVIX & VULVA
                  PROCEDURES.
361............  \7\ LAPAROSCOPY        1.1679         29.6         24.7
                  & INCISIONAL
                  TUBAL
                  INTERRUPTION.
362............  \7\ ENDOSCOPIC         1.1679         29.6         24.7
                  TUBAL
                  INTERRUPTION.
363............  \7\ D&C,               1.1679         29.6         24.7
                  CONIZATION &
                  RADIO-IMPLANT,
                  FOR MALIGNANCY.
364............  \5\ D&C,               1.6862         38.0         31.7
                  CONIZATION
                  EXCEPT FOR
                  MALIGNANCY.
365............  \5\ OTHER FEMALE       1.6862         38.0         31.7
                  REPRODUCTIVE
                  SYSTEM O.R.
                  PROCEDURES.
366............  MALIGNANCY,            0.7126         20.3         16.9
                  FEMALE
                  REPRODUCTIVE
                  SYSTEM W CC.
367............  \7\ MALIGNANCY,        1.1679         29.6         24.7
                  FEMALE
                  REPRODUCTIVE
                  SYSTEM W/O CC.
368............  INFECTIONS,            0.6455         20.7         17.3
                  FEMALE
                  REPRODUCTIVE
                  SYSTEM.
369............  \3\ MENSTRUAL &        0.7586         24.5         20.4
                  OTHER FEMALE
                  REPRODUCTIVE
                  SYSTEM
                  DISORDERS.
370............  \7\ CESAREAN           0.7586         24.5         20.4
                  SECTION W CC.
371............  \7\ CESAREAN           0.5834         21.0         17.5
                  SECTION W/O CC.
372............  \7\ VAGINAL            1.1679         29.6         24.7
                  DELIVERY W
                  COMPLICATING
                  DIAGNOSES.
373............  \7\ VAGINAL            1.1679         29.6         24.7
                  DELIVERY W/O
                  COMPLICATING
                  DIAGNOSES.

[[Page 23651]]

 
374............  \7\ VAGINAL            1.1679         29.6         24.7
                  DELIVERY W
                  STERILIZATION &/
                  OR D&C.
375............  \7\ VAGINAL            1.1679         29.6         24.7
                  DELIVERY W O.R.
                  PROC EXCEPT
                  STERIL &/OR D&C.
376............  \7\ POSTPARTUM &       1.1679         29.6         24.7
                  POST ABORTION
                  DIAGNOSES W/O
                  O.R. PROCEDURE.
377............  \7\ POSTPARTUM &       1.1679         29.6         24.7
                  POST ABORTION
                  DIAGNOSES W
                  O.R. PROCEDURE.
378............  \7\ ECTOPIC            0.7586         24.5         20.4
                  PREGNANCY.
379............  \7\ THREATENED         1.1679         29.6         24.7
                  ABORTION.
380............  \7\ ABORTION W/O       1.1679         29.6         24.7
                  D&C.
381............  \7\ ABORTION W         1.1679         29.6         24.7
                  D&C, ASPIRATION
                  CURETTAGE OR
                  HYSTEROTOMY.
382............  \7\ FALSE LABOR.       1.1679         29.6         24.7
383............  \7\ OTHER              1.1679         29.6         24.7
                  ANTEPARTUM
                  DIAGNOSES W
                  MEDICAL
                  COMPLICATIONS.
384............  \7\ OTHER              1.1679         29.6         24.7
                  ANTEPARTUM
                  DIAGNOSES W/O
                  MEDICAL
                  COMPLICATIONS.
385............  \7\ NEONATES,          1.1679         29.6         24.7
                  DIED OR
                  TRANSFERRED TO
                  ANOTHER ACUTE
                  CARE FACILITY.
386............  \7\ EXTREME            1.1679         29.6         24.7
                  IMMATURITY OR
                  RESPIRATORY
                  DISTRESS
                  SYNDROME,
                  NEONATE.
387............  \7\ PREMATURITY        1.1679         29.6         24.7
                  W MAJOR
                  PROBLEMS.
388............  \7\ PREMATURITY        1.1679         29.6         24.7
                  W/O MAJOR
                  PROBLEMS.
389............  \7\ FULL TERM          1.1679         29.6         24.7
                  NEONATE W MAJOR
                  PROBLEMS.
390............  \7\ NEONATE W          1.1679         29.6         24.7
                  OTHER
                  SIGNIFICANT
                  PROBLEMS.
391............  \7\ NORMAL             1.1679         29.6         24.7
                  NEWBORN.
392............  \7\ SPLENECTOMY        0.7586         24.5         20.4
                  AGE >17.
393............  \7\ SPLENECTOMY        0.7586         24.5         20.4
                  AGE 0-17.
394............  \5\ OTHER O.R.         1.6862         38.0         31.7
                  PROCEDURES OF
                  THE BLOOD AND
                  BLOOD FORMING
                  ORGANS.
395............  RED BLOOD CELL         0.6611         21.8         18.2
                  DISORDERS AGE
                  >17.
396............  \7\ RED BLOOD          0.5834         21.0         17.5
                  CELL DISORDERS
                  AGE 0-17.
397............  COAGULATION            0.8665         22.5         18.8
                  DISORDERS.
398............  RETICULOENDOTHEL       0.8193         23.5         19.6
                  IAL & IMMUNITY
                  DISORDERS W CC.
399............  \2\                    0.5834         21.0         17.5
                  RETICULOENDOTHE
                  LIAL & IMMUNITY
                  DISORDERS W/O
                  CC.
401............  \5\ LYMPHOMA &         1.6862         38.0         31.7
                  NON-ACUTE
                  LEUKEMIA W
                  OTHER O.R. PROC
                  W CC.
402............  \7\ LYMPHOMA &         0.5834         21.0         17.5
                  NON-ACUTE
                  LEUKEMIA W
                  OTHER O.R. PROC
                  W/O CC.
403............  LYMPHOMA & NON-        0.8844         21.3         17.8
                  ACUTE LEUKEMIA
                  W CC.
404............  \2\ LYMPHOMA &         0.5834         21.0         17.5
                  NON-ACUTE
                  LEUKEMIA W/O CC.
405............  \7\ ACUTE              0.5834         21.0         17.5
                  LEUKEMIA W/O
                  MAJOR O.R.
                  PROCEDURE AGE 0-
                  17.
406............  \4\ MYELOPROLIF        1.1679         29.6         24.7
                  DISORD OR
                  POORLY DIFF
                  NEOPL W MAJ
                  O.R.PROC W CC.
407............  \7\ MYELOPROLIF        1.1679         29.6         24.7
                  DISORD OR
                  POORLY DIFF
                  NEOPL W MAJ
                  O.R.PROC W/O CC.
408............  \4\ MYELOPROLIF        1.1679         29.6         24.7
                  DISORD OR
                  POORLY DIFF
                  NEOPL W OTHER
                  O.R.PROC.
409............  RADIOTHERAPY....       0.8567         23.4         19.5
410............  CHEMOTHERAPY W/O       1.1719         26.4           22
                  ACUTE LEUKEMIA
                  AS SECONDARY
                  DIAGNOSIS.
411............  \7\ HISTORY OF         1.1679         29.6         24.7
                  MALIGNANCY W/O
                  ENDOSCOPY.
412............  \7\ HISTORY OF         1.1679         29.6         24.7
                  MALIGNANCY W
                  ENDOSCOPY.
413............  OTHER                  0.8990         20.5         17.1
                  MYELOPROLIF DIS
                  OR POORLY DIFF
                  NEOPL DIAG W CC.
414............  \7\ OTHER              0.5834         21.0         17.5
                  MYELOPROLIF DIS
                  OR POORLY DIFF
                  NEOPL DIAG W/O
                  CC.
415............  O.R. PROCEDURE         1.4237         35.5         29.6
                  FOR INFECTIOUS
                  & PARASITIC
                  DISEASES.
416............  SEPTICEMIA AGE         0.8255         23.4         19.5
                  >17.
417............  \7\ SEPTICEMIA         0.7586         24.5         20.4
                  AGE 0-17.
418............  POSTOPERATIVE &        0.8296         24.7         20.6
                  POST-TRAUMATIC
                  INFECTIONS.
419............  \3\ FEVER OF           0.7586         24.5         20.4
                  UNKNOWN ORIGIN
                  AGE >17 W CC.
420............  \7\ FEVER OF           0.7586         24.5         20.4
                  UNKNOWN ORIGIN
                  AGE >17 W/O CC.
421............  VIRAL ILLNESS          0.9474         27.3         22.8
                  AGE >17.
422............  \7\ VIRAL              0.4502         18.8         15.7
                  ILLNESS & FEVER
                  OF UNKNOWN
                  ORIGIN AGE 0-17.
423............  OTHER INFECTIOUS       0.9403         21.7         18.1
                  & PARASITIC
                  DISEASES
                  DIAGNOSES.
424............  \3\ O.R.               0.7586         24.5         20.4
                  PROCEDURE W
                  PRINCIPAL
                  DIAGNOSES OF
                  MENTAL ILLNESS.
425............  \2\ ACUTE              0.5834         21.0         17.5
                  ADJUSTMENT
                  REACTION &
                  PSYCHOLOGICAL
                  DYSFUNCTION.
426............  DEPRESSIVE             0.4131         20.7         17.3
                  NEUROSES.
427............  NEUROSES EXCEPT        0.4713         23.8         19.8
                  DEPRESSIVE.
428............  \1\ DISORDERS OF       0.4502         18.8         15.7
                  PERSONALITY &
                  IMPULSE CONTROL.
429............  ORGANIC                0.5831         26.5         22.1
                  DISTURBANCES &
                  MENTAL
                  RETARDATION.
430............  PSYCHOSES.......       0.4350         24.1         20.1
431............  \1\ CHILDHOOD          0.4502         18.8         15.7
                  MENTAL
                  DISORDERS.
432............  \2\ OTHER MENTAL       0.5834         21.0         17.5
                  DISORDER
                  DIAGNOSES.
433............  \2\ ALCOHOL/DRUG       0.5834         21.0         17.5
                  ABUSE OR
                  DEPENDENCE,
                  LEFT AMA.
439............  SKIN GRAFTS FOR        1.3758         35.6         29.7
                  INJURIES.
440............  WOUND                  1.3261         35.9         29.9
                  DEBRIDEMENTS
                  FOR INJURIES.
441............  \1\ HAND               0.4502         18.8         15.7
                  PROCEDURES FOR
                  INJURIES.
442............  OTHER O.R.             1.4028         33.4         27.8
                  PROCEDURES FOR
                  INJURIES W CC.
443............  \3\ OTHER O.R.         0.7586         24.5         20.4
                  PROCEDURES FOR
                  INJURIES W/O CC.
444............  TRAUMATIC INJURY       0.7551         25.9         21.6
                  AGE >17 W CC.
445............  \1\ TRAUMATIC          0.4502         18.8         15.7
                  INJURY AGE >17
                  W/O CC.
446............  \7\ TRAUMATIC          0.4502         18.8         15.7
                  INJURY AGE 0-17.

[[Page 23652]]

 
447............  \2\ ALLERGIC           0.5834         21.0         17.5
                  REACTIONS AGE
                  >17.
448............  \7\ ALLERGIC           0.5834         21.0         17.5
                  REACTIONS AGE 0-
                  17.
449............  \3\ POISONING &        0.7586         24.5         20.4
                  TOXIC EFFECTS
                  OF DRUGS AGE
                  >17 W CC.
450............  \7\ POISONING &        0.7586         24.5         20.4
                  TOXIC EFFECTS
                  OF DRUGS AGE
                  >17 W/O CC.
451............  \7\ POISONING &        0.7586         24.5         20.4
                  TOXIC EFFECTS
                  OF DRUGS AGE 0-
                  17.
452............  COMPLICATIONS OF       0.9139         25.2           21
                  TREATMENT W CC.
453............  COMPLICATIONS OF       0.5449         23.2         19.3
                  TREATMENT W/O
                  CC.
454............  \3\ OTHER              0.7586         24.5         20.4
                  INJURY,
                  POISONING &
                  TOXIC EFFECT
                  DIAG W CC.
455............  \7\ OTHER              0.7586         24.5         20.4
                  INJURY,
                  POISONING &
                  TOXIC EFFECT
                  DIAG W/O CC.
461............  O.R. PROC W            1.2315         34.0         28.3
                  DIAGNOSES OF
                  OTHER CONTACT W
                  HEALTH SERVICES.
462............  REHABILITATION..       0.5815         22.4         18.7
463............  SIGNS & SYMPTOMS       0.6234         23.7         19.8
                  W CC.
464............  SIGNS & SYMPTOMS       0.5565         24.1         20.1
                  W/O CC.
465............  AFTERCARE W            0.6959         21.8         18.2
                  HISTORY OF
                  MALIGNANCY AS
                  SECONDARY
                  DIAGNOSIS.
466............  AFTERCARE W/O          0.6713         21.9         18.3
                  HISTORY OF
                  MALIGNANCY AS
                  SECONDARY
                  DIAGNOSIS.
467............  \3\ OTHER              0.7586         24.5         20.4
                  FACTORS
                  INFLUENCING
                  HEALTH STATUS.
468............  EXTENSIVE O.R.         2.1439         40.0         33.3
                  PROCEDURE
                  UNRELATED TO
                  PRINCIPAL
                  DIAGNOSIS.
469............  \6\ PRINCIPAL          0.0000          1.0          0.8
                  DIAGNOSIS
                  INVALID AS
                  DISCHARGE
                  DIAGNOSIS.
470............  \6\ UNGROUPABLE.       0.0000          1.0          0.8
471............  \5\ BILATERAL OR       1.6862         38.0         31.7
                  MULTIPLE MAJOR
                  JOINT PROCS OF
                  LOWER EXTREMITY.
473............  ACUTE LEUKEMIA W/      0.8580         20.0         16.7
                  O MAJOR O.R.
                  PROCEDURE AGE
                  >17.
475............  RESPIRATORY            2.0848         34.5         28.8
                  SYSTEM
                  DIAGNOSIS WITH
                  VENTILATOR
                  SUPPORT.
476............  \4\ PROSTATIC          1.1679         29.6         24.7
                  O.R. PROCEDURE
                  UNRELATED TO
                  PRINCIPAL
                  DIAGNOSIS.
477............  NON-EXTENSIVE          1.5867         35.2         29.3
                  O.R. PROCEDURE
                  UNRELATED TO
                  PRINCIPAL
                  DIAGNOSIS.
478............  OTHER VASCULAR         1.3338         30.7         25.6
                  PROCEDURES W CC.
479............  \7\ OTHER              1.1679         29.6         24.7
                  VASCULAR
                  PROCEDURES W/O
                  CC.
480............  \6\ LIVER              0.0000          1.0          0.8
                  TRANSPLANT.
481............  \7\ BONE MARROW        1.6862         38.0         31.7
                  TRANSPLANT.
482............  \3\ TRACHEOSTOMY       0.7586         24.5         20.4
                  FOR FACE, MOUTH
                  & NECK
                  DIAGNOSES.
484............  \2\ CRANIOTOMY         0.5834         21.0         17.5
                  FOR MULTIPLE
                  SIGNIFICANT
                  TRAUMA.
485............  \7\ LIMB               0.7586         24.5         20.4
                  REATTACHMENT,
                  HIP AND FEMUR
                  PROC FOR
                  MULTIPLE
                  SIGNIFICANT TR.
486............  \5\ OTHER O.R.         1.6862         38.0         31.7
                  PROCEDURES FOR
                  MULTIPLE
                  SIGNIFICANT
                  TRAUMA.
487............  OTHER MULTIPLE         0.9046         26.0         21.7
                  SIGNIFICANT
                  TRAUMA.
488............  \5\ HIV W              1.6862         38.0         31.7
                  EXTENSIVE O.R.
                  PROCEDURE.
489............  HIV W MAJOR            0.8348         21.1         17.6
                  RELATED
                  CONDITION.
490............  HIV W OR W/O           0.5012         16.4         13.7
                  OTHER RELATED
                  CONDITION.
491............  \5\ MAJOR JOINT        1.6862         38.0         31.7
                  & LIMB
                  REATTACHMENT
                  PROCEDURES OF
                  UPPER EXTREMITY.
492............  \7\ CHEMOTHERAPY       1.6862         38.0         31.7
                  W ACUTE
                  LEUKEMIA OR W
                  USE OF HI DOSE
                  CHEMOAGENT.
493............  \4\ LAPAROSCOPIC       1.1679         29.6         24.7
                  CHOLECYSTECTOMY
                  W/O C.D.E. W CC.
494............  \7\ LAPAROSCOPIC       1.1679         29.6         24.7
                  CHOLECYSTECTOMY
                  W/O C.D.E. W/O
                  CC.
495............  \6\ LUNG               0.0000          1.0          0.8
                  TRANSPLANT.
496............  \7\ COMBINED           1.1679         29.6         24.7
                  ANTERIOR/
                  POSTERIOR
                  SPINAL FUSION.
497............  \4\ SPINAL             1.1679         29.6         24.7
                  FUSION W CC.
498............  \7\ SPINAL             1.1679         29.6         24.7
                  FUSION EXCEPT
                  CERVICAL W/O CC.
499............  \5\ BACK & NECK        1.6862         38.0         31.7
                  PROCEDURES
                  EXCEPT SPINAL
                  FUSION W CC.
500............  \4\ BACK & NECK        1.1679         29.6         24.7
                  PROCEDURES
                  EXCEPT SPINAL
                  FUSION W/O CC.
501............  \5\ KNEE               1.6862         38.0         31.7
                  PROCEDURES W
                  PDX OF
                  INFECTION W CC.
502............  \4\ KNEE               1.1679         29.6         24.7
                  PROCEDURES W
                  PDX OF
                  INFECTION W/O
                  CC.
503............  \2\ KNEE               0.5834         21.0         17.5
                  PROCEDURES W/O
                  PDX OF
                  INFECTION.
504............  \7\ EXTENSIVE          1.6862         38.0         31.7
                  BURNS OF FULL
                  THICKNESS BURNS
                  WITH MECH VENT
                  96+HRS WITH
                  SKIN GRAFT.
505............  \4\ EXTENSIVE          1.1679         29.6         24.7
                  BURN OR FULL
                  THICKNESS BURNS
                  WITH MECH VENT
                  96+ HOURS
                  WITHOUT SKIN
                  GRAFT.
506............  \4\ FULL               1.1679         29.6         24.7
                  THICKNESS BURN
                  W SKIN GRAFT OR
                  INHAL INJ W CC
                  OR SIG TRAUMA.
507............  \3\ FULL               0.7586         24.5         20.4
                  THICKNESS BURN
                  W SKIN GRFT OR
                  INHAL INJ W/O
                  CC OR SIG
                  TRAUMA.
508............  FULL THICKNESS         0.8403         29.4         24.5
                  BURN W/O SKIN
                  GRFT OR INHAL
                  INJ W CC OR SIG
                  TRAUMA.
509............  \1\ FULL               0.4502         18.8         15.7
                  THICKNESS BURN
                  W/O SKIN GRFT
                  OR INH INJ W/O
                  CC OR SIG
                  TRAUMA.
510............  NON-EXTENSIVE          0.7737         24.6         20.5
                  BURNS W CC OR
                  SIGNIFICANT
                  TRAUMA.
511............  \1\ NON-               0.4502         18.8         15.7
                  EXTENSIVE BURNS
                  W/O CC OR
                  SIGNIFICANT
                  TRAUMA.
512............  \6\ SIMULTANEOUS       0.0000          1.0          0.8
                  PANCREAS/KIDNEY
                  TRANSPLANT.
513............  \6\ PANCREAS           0.0000          1.0          0.8
                  TRANSPLANT.
515............  \5\ CARDIAC            1.6862         38.0         31.7
                  DEFIBRILATOR
                  IMPLANT W/O
                  CARDIAC CATH.
517............  \5\ PERCUTANEOUS       1.6862         38.0         31.7
                  CARDIVASCULAR
                  PROC W NON-DRUG
                  ELUTING STENT W/
                  O AMI.
518............  \3\ PERCUTANEOUS       0.7586         24.5         20.4
                  CARDIVASCULAR
                  PROC W/O
                  CORONARY ARTERY
                  STENT OR AMI.

[[Page 23653]]

 
519............  \5\ CERVICAL           1.6862         38.0         31.7
                  SPINAL FUSION W
                  CC.
520............  \7\ CERVICAL           1.1679         29.6         24.7
                  SPINAL FUSION W/
                  O CC.
521............  ALCOHOL/DRUG           0.4533         19.8         16.5
                  ABUSE OR
                  DEPENDENCE W CC.
522............  \7\ ALCOHOL/DRUG       0.4502         18.8         15.7
                  ABUSE OR
                  DEPENDENCE W
                  REHABILITATION
                  THERAPY W/O CC.
523............  \7\ ALCOHOL/DRUG       0.4502         18.8         15.7
                  ABUSE OR
                  DEPENDENCE W/O
                  REHABILITATION
                  THERAPY W/O CC.
524............  TRANSIENT              0.5069         21.1         17.6
                  ISCHEMIA.
525............  \7\ OTHER HEART        1.6862         38.0         31.7
                  ASSIST SYSTEM
                  IMPLANT.
527............  \5\ PERCUTANEOUS       1.6862         38.0         31.7
                  CARVIOVASCULAR
                  PROC W DRUG-
                  ELUTING STENT W/
                  O AMI.
528............  \7\ INTRACRANIAL       1.6862         38.0         31.7
                  VASCULAR PROC W
                  PDX HEMORRHAGE.
529............  \5\ VENTRICULAR        1.6862         38.0         31.7
                  SHUNT
                  PROCEDURES W CC.
530............  \7\ VENTRICULAR        1.6862         38.0         31.7
                  SHUNT
                  PROCEDURES W/O
                  CC.
531............  \3\ SPINAL             0.7586         24.5         20.4
                  PROCEDURES WITH
                  CC.
532............  \8\ SPINAL             0.7586         24.5         20.4
                  PROCEDURES
                  WITHOUT CC.
533............  \5\ EXTRACRANIAL       1.6862         38.0         31.7
                  VASCULAR
                  PROCEDURES WITH
                  CC.
534............  \7\ EXTRACRANIAL       1.1679         29.6         24.7
                  PROCEDURES W/O
                  CC.
535............  \7\ CARDIAC            1.6862         38.0         31.7
                  DEFIB IMPLANT W
                  CARDIAC CATH W
                  AMI/HF/SHOCK.
536............  \7\ CARDIAC            1.6862         38.0         31.7
                  DEFIB IMPLANT W
                  CARDIAC CATH W/
                  O AMI/HF/SHOCK.
537............  LOCAL EXCISION         1.1670         34.6         28.8
                  AND REMOVAL OF
                  INTERNAL
                  FIXATION
                  DEVICES EXCEPT
                  HIP AND FEMUR
                  WITH CC.
538............  \7\ LOCAL              1.1679         29.6         24.7
                  EXCISION AND
                  REMOVAL OF
                  INTERNAL
                  FIXATION
                  DEVICES EXCEPT
                  HIP AND FEMUR
                  WITHOUT CC.
539............  \4\ LYMPHOMA AND       1.1679         29.6         24.7
                  LEUKEMIA WITH
                  MAJOR O.R.
                  PROCEDURE WITH
                  CC.
540............  \7\ LYMPHOMA &         0.5834         21.0         17.5
                  LEUKEMIA W
                  MAJOR OR
                  PROCEDURE W/O
                  CC.
541............  ECMO OR TRACH W        4.2566         65.6         54.7
                  MECH VENT 96+
                  HRS OR PDX
                  EXCEPT FACE,
                  MOUTH & NECK
                  DIAG WITH MAJOR
                  OR.
542............  TRACH W MECH           3.1821         47.9         39.9
                  VENT 96+ HRS OR
                  PDX EXCEPT
                  FACE, MOUTH &
                  NECK DIAG
                  WITHOUT MAJOR
                  OR.
543............  \5\ CRANIOTOMY W       1.6862         38.0         31.7
                  IMPLANT OF
                  CHEMO AGENT OR
                  ACUTE COMPLEX
                  CNS PDX.
544............  \5\ MAJOR JOINT        1.6862         38.0         31.7
                  REPLACEMENT OR
                  REATTACHMENT OF
                  LOWER EXTREMITY.
545............  \5\ REVISION OF        1.6862         38.0         31.7
                  HIP OR KNEE
                  REPLACEMENT.
546............  \7\ SPINAL             1.6862         38.0         31.7
                  FUSION EXCEPT
                  CERVICAL WITH
                  PRINCIPAL
                  DIAGNOSIS OF
                  CURVATURE OF
                  SPINE OR
                  MALIGNANCY.
547............  \7\ PERCUTANEOUS       1.6862         38.0         31.7
                  CARDIOVASCULAR
                  PROCEDURE WITH
                  AMI WITH CC.
548............  \7\ PERCUTANEOUS       1.6862         38.0         31.7
                  CARDIOVASCULAR
                  PROCEDURE WITH
                  AMI WITHOUT CC.
549............  \7\ PERCUTANEOUS       1.6862         38.0         31.7
                  CARDIOVASCULAR
                  PROCEDURE WITH
                  DRUG-ELUTING
                  STENT WITH AMI
                  WITH CC.
550............  \7\ PERCUTANEOUS       1.6862         38.0        31.7
                  CARDIOVASCULAR
                  PROCEDURE WITH
                  DRUG-ELUTING
                  STENT WITH AMI
                  WITHOUT CC.
------------------------------------------------------------------------
\1\ Proposed relative weights for these proposed LTC-DRGs were
  determined by assigning these cases to proposed low-volume quintile 1.
 
\2\ Proposed relative weights for these proposed LTC-DRGs were
  determined by assigning these cases to proposed low-volume quintile 2.
 
\3\ Proposed relative weights for these proposed LTC-DRGs were
  determined by assigning these cases to proposed low-volume quintile
  quintile 3.
\4\ Proposed relative weights for these proposed LTC-DRGs were
  determined by assigning these cases to proposed low-volume quintile 4.
 
\5\ Proposed relative weights for these proposed LTC-DRGs were
  determined by assigning these cases to proposed low-volume quintile
  quintile 5.
\6\ Proposed relative weights for these proposed LTC-DRGs were assigned
  a value of 0.0000.
\7\ Proposed relative weights for these proposed LTC-DRGs were
  determined by assigning these cases to the appropriate proposed low
  volume quintile because there are no LTCH cases in the FY 2004 MedPAR
  file.
\8\ Proposed relative weights for these proposed LTC-DRGs were
  determined after adjusting to account for nonmonotonicity (see step 5
  above).

Appendix A--Regulatory Analysis of Impacts

    (If you choose to comment on issues in this section, please 
include the caption ``Impact Analyses'' at the beginning of your 
comment.)

I. Background and Summary

    We have examined the impacts of this proposed rule as required 
by Executive Order 12866 (September 1993, Regulatory Planning and 
Review) and the Regulatory Flexibility Act (RFA) (September 19, 
1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, 
the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and 
Executive Order 13132.
    Executive Order 12866 directs agencies to assess all costs and 
benefits of available regulatory alternatives and, if regulation is 
necessary, to select regulatory approaches that maximize net 
benefits (including potential economic, environmental, public health 
and safety effects, distributive impacts, and equity). A regulatory 
impact analysis (RIA) must be prepared for major rules with 
economically significant effects ($100 million or more in any 1 
year).
    We have determined that this proposed rule is a major rule as 
defined in 5 U.S.C. 804(2). We estimate that the total impact of 
these proposed changes for FY 2006 payments compared to FY 2005 
payments to be approximately a $2.40 billion increase. This amount 
does not reflect changes in hospital admissions or case-mix 
intensity, which would also affect overall payment changes.
    The RFA requires agencies to analyze options for regulatory 
relief of small

[[Page 23654]]

businesses. For purposes of the RFA, small entities include small 
businesses, nonprofit organizations, and government agencies. Most 
hospitals and most other providers and suppliers are small entities, 
either by nonprofit status or by having revenues of $5 million to 
$25 million in any 1 year. For purposes of the RFA, all hospitals 
and other providers and suppliers are considered to be small 
entities. Individuals and States are not included in the definition 
of a small entity.
    In addition, section 1102(b) of the Act requires us to prepare a 
regulatory impact analysis for any proposed rule that may have a 
significant impact on the operations of a substantial number of 
small rural hospitals. This analysis must conform to the provisions 
of section 603 of the RFA. With the exception of hospitals located 
in certain New England counties, for purposes of section 1102(b) of 
the Act, we previously defined 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). However, under the new labor market definitions, we no 
longer employ NECMAs to define urban areas in New England. 
Therefore, we now define a small rural hospital as a hospital with 
fewer than 100 beds that is located outside of a Metropolitan 
Statistical Area (MSA). 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 continue to classify these hospitals as 
urban hospitals.
    Section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L. 
104-4) also requires that agencies assess anticipated costs and 
benefits before issuing any proposed rule (or a final rule that has 
been preceded by a proposed rule) that may result in an expenditure 
in any one year by State, local, or tribal governments, in the 
aggregate, or by the private sector, of $110 million. This proposed 
rule 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 proposed rule in 
light of Executive Order 13132 and have determined that it would not 
have any negative impact on the rights, roles, and responsibilities 
of State, local, or tribal governments.
    In accordance with the provisions of Executive Order 12866, this 
proposed rule was reviewed by the Office of Management and Budget.
    The following analysis, in conjunction with the remainder of 
this document, demonstrates that this proposed rule is consistent 
with the regulatory philosophy and principles identified in 
Executive Order 12866, the RFA, and section 1102(b) of the Act. The 
proposed rule 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 proposed changes in this proposed 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 
proposed 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 proposed policy changes, as well as statutory changes 
effective for FY 2006, on various hospital groups. We estimate the 
effects of individual policy changes by estimating payments per case 
while holding all other payment policies constant. We use the best 
data available, but we do not attempt to predict behavioral 
responses to our policy changes, and we do not make adjustments for 
future changes in such variables as admissions, lengths of stay, or 
case-mix. As we have done in the previous proposed rules, we are 
soliciting comments and information about the anticipated effects of 
these proposed changes on hospitals and our methodology for 
estimating them. Any comments that we receive in response to this 
proposed rule will be addressed in the 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 35 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 46 such hospitals in Maryland 
remain excluded from the IPPS under the waiver at section 1814(b)(3) 
of the Act.
    As of March 2005, there are 3,693 IPPS hospitals to be included 
in our analysis. This represents about 63 percent of all Medicare-
participating hospitals. The majority of this impact analysis 
focuses on this set of hospitals. There are also approximately 974 
critical access hospitals (CAHs). These small, limited service 
hospitals are paid on the basis of reasonable costs rather than 
under the IPPS. There are also 1,138 specialty hospitals and units 
that are excluded from the IPPS. These specialty hospitals include 
psychiatric hospitals and units, rehabilitation hospitals and units, 
long-term care hospitals, children's hospitals, and cancer 
hospitals. The impacts of our proposed policy changes on these 
hospitals are discussed below.

V. Impact on Excluded Hospitals and Hospital Units

    As of March 2005, there were 1,138 specialty hospitals excluded 
from the IPPS. Of these 1,138 specialty hospitals, 467 psychiatric 
hospitals, 80 children's, 11 cancer hospitals, and 21 LTCHs that are 
paid under the LTCH PPS blend methodology are being paid, in whole 
or in part, on a reasonable cost basis subject to the rate-of-
increase ceiling under Sec.  413.40. The remaining providers--218 
IRFs and 361 LTCHs are paid 100 percent of the Federal prospective 
rate under the IRF PPS and the LTCH PPS, respectively. In addition, 
there were 1,342 psychiatric units (paid on a blend of the IPF PPS 
per diem payment and the TEFRA reasonable cost-based payment) and 
1,006 rehabilitation units (paid under the IRF PPS) 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 46 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 2006. For these 
hospitals, the proposed update is the percentage increase in the 
excluded hospital market basket, currently estimated at 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 2005, 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 proposed rule.
    Effective for cost reporting periods beginning on or after 
October 1, 2002, LTCHs are paid under a LTCH PPS, based on a Federal 
prospective payment amount that is updated annually. LTCHs will 
receive a blended payment that consists of the Federal prospective 
payment rate and a reasonable cost-based payment rate over a 5-year 
transition period. However, under the LTCH PPS, a LTCH may also 
elect to be paid at 100 percent of the Federal prospective rate at 
the beginning of any of its cost reporting periods during the 5-year 
transition period. For purposes of the update factor, the portion of 
the LTCH PPS transition blend payment based on reasonable costs for 
inpatient operating services would be determined by updating the 
LTCH's TEFRA limit by the estimate of the excluded hospital market 
basket (or 3.4 percent).
    Section 124 of the Medicare, Medicaid, and SCHIP Balanced Budget 
Refinement Act of 1999 (BBRA) required the development of a per diem 
prospective payment system (PPS) for payment of inpatient hospital 
services furnished in psychiatric hospitals and psychiatric units of 
acute care hospitals and

[[Page 23655]]

CAHs (inpatient psychiatric facilities (IPFs)). We published a final 
rule to implement the IPF PPS on November 15, 2004 (69 FR 66922). 
The final rule established a 3-year transition to the IPF PPS during 
which some providers will receive a blend of the IPF PPS per diem 
payment and the TEFRA reasonable cost-based payment. For purposes of 
determining what the TEFRA payment to the IPF would be, we are 
proposing that the IPF's TEFRA limit will be updated by the estimate 
of 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 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. 
However, at the same time, 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 proposed rule, we are announcing policy changes and 
payment rate updates for the IPPS for operating costs. Changes to 
the capital payments are discussed in section VIII. of this 
Appendix. Based on the overall percentage change in payments per 
case estimated using our payment simulation model (a 2.5 percent 
increase), we estimate the total impact of these proposed changes 
for FY 2006 operating payments compared to FY 2005 operating 
payments to be approximately a $2.41 billion increase. This amount 
does not reflect changes in hospital admissions or case-mix 
intensity, which would also affect overall payment changes.
    We have prepared separate impact analyses of the proposed 
changes to each system. This section deals with proposed changes to 
the operating prospective payment system. Our payment simulation 
model relies on the most recent available data to enable us to 
estimate the impacts on payments per case of certain changes we are 
proposing in this rule. However, there are other changes we are 
proposing for which we do not have data available that would allow 
us to estimate the payment impacts using this model. For those 
proposed changes, we have attempted to predict the payment impacts 
of those proposed changes based upon our experience and other more 
limited data.
    The data used in developing the quantitative analyses of changes 
in payments per case presented below are taken from the FY 2004 
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 the proposed policy changes, and we do not adjust for 
future changes in such variables as admissions, lengths of stay, or 
case-mix. Second, due to the interdependent nature of the IPPS 
payment components, it is very difficult to precisely quantify the 
impact associated with each proposed change. Third, we draw upon 
various sources for the data used to categorize hospitals in the 
tables. In some cases, particularly the number of beds, there is a 
fair degree of variation in the data from different sources. We have 
attempted to construct these variables with the best available 
source overall. However, for individual hospitals, some 
miscategorizations are possible.
    Using cases in the FY 2004 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 
IPPS (Indian Health Service hospitals and hospitals in Maryland) 
were excluded from the simulations. The impact of payments under the 
capital IPPS, or the impact of payments for costs other than 
inpatient operating costs, are not analyzed in this section. 
Estimated payment impacts of proposed FY 2006 changes to the capital 
IPPS are discussed in section VIII of this Appendix.
    The proposed changes discussed separately below are the 
following:
     The effects of the annual reclassification of diagnoses 
and procedures and the recalibration of the DRG relative weights 
required by section 1886(d)(4)(C) of the Act.
     The effects of the proposed changes in hospitals' wage 
index values reflecting wage data from hospitals' cost reporting 
periods beginning during FY 2002, compared to the FY 2001 wage data.
     The effect of the proposed change in the way we use the 
wage data for hospitals that reclassify as rural under section 401 
of the BBRA to compute wage indexes.
     The effect of the proposed wage and recalibration 
budget neutrality factors.
     The effect of the remaining labor market area 
transition for those hospitals that were urban under the old labor 
market area designations and are now considered rural hospitals.
     The effects of geographic reclassifications by the 
MGCRB that will be effective in FY 2006.
     The effects of section 505 of Pub. L. 108-173, which 
provides for an increase in a hospital's wage index if the hospital 
qualifies by meeting a threshold percentage of residents of the 
county where the hospital is located who commute to work at 
hospitals in counties with higher wage indexes.
     The total change in payments based on proposed FY 2006 
policies and MMA-imposed changes relative to payments based on FY 
2005 policies.
    To illustrate the impacts of the proposed FY 2006 changes, our 
analysis begins with a FY 2006 baseline simulation model using: the 
proposed update of 3.2 percent; the FY 2005 DRG GROUPER (version 
22.0); the CBSA designations for hospitals based on OMB's June 2003 
MSA definitions; the FY 2005 wage index; and no MGCRB 
reclassifications. Outlier payments are set at 5.1 percent of total 
operating DRG and outlier payments.
    Section 1886(b)(3)(B)(vii) of the Act, as added by section 
501(b) of Pub. L. 108-173, provides that, for FYs 2005 through 2007, 
the update factors will be reduced by 0.4 percentage points for any 
hospital that does not submit quality data. For purposes of the FY 
2006 simulations in this proposed impact analysis, we are assuming 
all hospitals will qualify for the full update.
    Each proposed and statutory policy change is then added 
incrementally to this baseline model, finally arriving at an FY 2006 
model incorporating all of the proposed changes. This allows us to 
isolate the effects of each proposed change.
    Our final comparison illustrates the percent change in payments 
per case from FY 2005 to FY 2006. Three factors not discussed 
separately have significant impacts here. The first is the update to 
the standardized amount. In accordance with section 1886(b)(3)(B)(i) 
of the Act, we have updated standardized amounts for FY 2006 using 
the most recently forecasted hospital market basket increase for FY 
2006 of 3.2 percent. (Hospitals that fail to comply with the quality 
data submission requirement to receive the full update will receive 
an update reduced by 0.4 percentage points to 2.8 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 3.2 percent.
    A second significant factor that impacts changes in hospitals' 
payments per case from FY 2005 to FY 2006 is the change in MGCRB 
status from one year to the next. That is, hospitals reclassified in 
FY 2005 that are no longer reclassified in FY 2006 may have a 
negative payment impact going from FY 2005 to FY 2006; conversely, 
hospitals not reclassified in FY 2005 that are reclassified in FY 
2006 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

[[Page 23656]]

payments during FY 2005 will be 4.4 percent of total DRG payments. 
When the FY 2005 final rule was published, we projected FY 2005 
outlier payments would be 5.1 percent of total DRG plus outlier 
payments; the average standardized amounts were offset 
correspondingly. The effects of the lower than expected outlier 
payments during FY 2005 (as discussed in the Addendum to this 
proposed rule) are reflected in the analyses below comparing our 
current estimates of FY 2005 payments per case to estimated FY 2006 
payments per case (with outlier payments projected to equal 5.1 
percent of total DRG payments).

B. Analysis of Table I

    Table I displays the results of our analysis of proposed changes 
for FY 2006. 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 3,693 hospitals included in the 
analysis. This number is 204 fewer hospitals than were included in 
the impact analysis in the FY 2005 final rule (69 FR 49758 ).
    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 2,537 
hospitals located in urban areas included in our analysis. Among 
these, there are 1,399 hospitals located in large urban areas 
(populations over 1 million), and 1,138 hospitals in other urban 
areas (populations of 1 million or fewer). In addition, there are 
1,156 hospitals in rural areas. The next two groupings are by bed-
size categories, shown separately for urban and rural hospitals. The 
final groupings by geographic location are by census divisions, also 
shown separately for urban and rural hospitals.
    The second part of Table I shows hospital groups based on 
hospitals' FY 2006 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 2,575, 
1,410, 1,165, and 1,118, respectively.
    The next three groupings examine the impacts of the proposed 
changes on hospitals grouped by whether or not they have GME 
residency programs (teaching hospitals that receive an IME 
adjustment) or receive DSH payments, or some combination of these 
two adjustments. There are 2,615 nonteaching hospitals in our 
analysis, 841 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 
for DSH purposes. The next category groups hospitals considered 
urban after geographic reclassification, in terms of whether they 
receive the IME adjustment, the DSH adjustment, both, or neither.
    The next five rows examine the impacts of the proposed changes 
on rural hospitals by special payment groups (SCHs, rural referral 
centers (RRCs), and Medicare dependant hospitals (MDHs)), as well as 
rural hospitals not receiving a special payment designation. There 
were 134 RRCs, 405 SCHs, 158 MDHs, and 73 hospitals that are both 
SCH and RRC.
    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 2002 
Medicare cost report files, if available (otherwise FY 2001 data are 
used).
    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 2006. The 
next two groupings separate the hospitals in the first group by 
urban and rural status. The final two rows in Table I contain 
hospitals located in rural counties but deemed to be urban under 
section 1886(d)(8)(B) of the Act and hospitals located in urban 
counties, but deemed to be rural under section 1886(d)(8)(E) of the 
Act.

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C. Impact of the Proposed Changes to the Postacute Care Transfer 
Policy (Column 2)

    In Column 2 of Table I, we present the effects of Option 2 for 
the proposed expansion of the postacute care transfer policy, as 
discussed in section V.A. of the preamble to this proposed rule. We 
compared aggregate payments using the FY 2005 DRG relative weights 
(GROUPER version 22.0) and Option 2 for the proposed expansion of 
the postacute care transfer policy to aggregate payments using the 
FY 2005 DRG relative weights (GROUPER version 22.0) and the FY 2005 
postacute care transfer policy. The changes we are proposing are 
estimated to result in a 1.1 percent decrease in payments to 
hospitals overall. We estimate the total savings at approximately 
$880 million.
    To simulate the impact of this proposed policy, we calculated 
two sets of transfer-adjusted discharges and case-mix index values 
for hospitals. The first set was based on the FY 2005 transfer 
policy rules and the second was based on Option 2 for the proposed 
expanded transfer policy discussed in the preamble to this proposed 
rule. Estimated payments were computed for both sets of data and 
were then compared. The transfer-adjusted discharge fraction is 
calculated in one of two ways, depending on the transfer payment 
methodology. Under the transfer payment methodology in place in FY 
2005, 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. There are 88 DRGs (including 210, 211) 
that would qualify to receive the special payment consideration. DRG 
209 which formerly received the special payment has been split into 
two new DRGs 544 and 545. Both DRG 544 and DRG 545 are included in 
the 88 special payment DRGs as they continue to 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 proposed 
change to the transfer policy.
    This proposed expansion of the policy, which represents a 
significant change from our prior policy, has a negative 1.1 percent 
payment impact overall among both urban and rural hospitals. There 
is only small variation among all of the hospital categories from 
this negative 1.1 percent impact. The areas that are most 
dramatically impacted are urban areas, with urban New England 
experiencing a 1.9 percent decline in payments and the Middle 
Atlantic experiencing a 1.2 percent decline. Although rural New 
England hospitals are losing 1.1 percent, most of the other rural 
regions lose less than 1 percent from this policy change. Urban 
areas tend to have a greater concentration of postacute care 
facilities to which to discharge patients than do rural areas and 
are, therefore, more likely to be impacted by this policy proposal.

D. Impact of the Proposed Changes to the DRG Reclassifications and 
Recalibration of Relative Weights (Column 3)

    In Column 3 of Table I, we present the combined effects of the 
DRG reclassifications and recalibration, as discussed in section II. 
of the preamble to this proposed rule. Section 1886(d)(4)(C)(i) of 
the Act requires us annually to make appropriate classification 
changes and to recalibrate the DRG weights in order to reflect 
changes in treatment patterns, technology, and any other factors 
that may change the relative use of hospital resources.
    We compared aggregate payments using the FY 2005 DRG relative 
weights (GROUPER version 22.0) to aggregate payments using the 
proposed FY 2006 DRG relative weights (GROUPER version 23.0). We 
note that, consistent with section 1886(d)(4)(C)(iii) of the Act, we 
have applied a budget neutrality factor to ensure that the overall 
payment impact of the DRG changes (combined with the wage index 
changes) is budget neutral. This proposed budget neutrality factor 
of 1.002494 is applied to payments in Column 6. Because this is a 
combined DRG reclassification and recalibration and wage index 
budget neutrality factor, it is not applied to payments in Column 3.
    The major DRG classification changes we are proposing include: 
reassigning procedure code 35.52 (Repair of atrial septal defect 
with prosthesis, closed technique) from DRG 108 to DRG 518 
(Percutaneous Cardiovascular Procedure Without Coronary Artery Stent 
or AMI); reassigning procedure code 37.26 (Cardiac 
electrophysiologic stimulation and recording studies) from DRGs 535 
and 536 to DRGs 515 (Cardiac Defibrillator Implant Without Cardiac 
Catheterization); splitting DRG 209 into two new DRGs based on the 
presence or absence of the procedure codes for major joint 
replacement or reattachment of lower extremity and revision of hip 
or knee replacement, DRG 545 (Revision of Hip or Knee Replacement) 
and DRG 544 (Major Joint Replacement or Reattachment of Lower 
Extremity); reassigning procedure code 26.12 (Open biopsy of 
salivary gland or duct) from DRG 468 to DRG 477 (Non-Extensive O.R. 
Procedure Unrelated To Principal Diagnosis); reassigning the 
principal diagnosis codes for curvature of the spine or malignancy 
from DRGs 497 and 498 to new DRG 546 (Spinal Fusion Except Cervical 
with PDX of Curvature of the Spine or Malignancy); splitting DRGs 
516 and 526 into four new DRGs based on the presence or absence of a 
CC, DRG 547 (Percutaneous Cardiovascular Procedure With AMI With 
CC), DRG 548 (Percutaneous Cardiovascular Procedure With AMI Without 
CC), DRG 549 (Percutaneous Cardiovascular Procedure With Drug-
Eluting Stent With AMI With CC), DRG 550 (Percutaneous 
Cardiovascular Procedure With Drug-Eluting Stent With AMI Without 
CC); reassigning procedure code 39.65 (Extracorporeal membrane 
oxygenation [ECMO]) from DRGs 104 and 105 to DRG 541 (ECMO or 
Tracheostomy with Mechanical Ventilation 96+ Hours or Principal 
Diagnosis Except Face, Mouth and Neck Diagnoses With Major Operating 
Room Procedure).
    In the aggregate, these proposed changes would result in a 0.1 
percent increase in overall payments to hospitals. On average, the 
impacts of these changes on any particular hospital group are very 
small, with urban hospitals experiencing a 0.2 percent increase and 
rural hospitals experiencing a 0.1 percent decrease. The largest 
impact is a 0.4 percent increase among urban hospitals in New 
England. This is in part due to the residual effects of the proposed 
change to the postacute care transfer policy on the relative 
weights. Including a DRG in the postacute care transfer group 
reduces the number of cases in the DRG (cases that qualify as 
transfers are only counted as a fraction of a case) which in turn 
increases the average charge for the DRG and the weight.

E. Impact of Proposed Wage Index Changes (Column 4)

    Section 1886(d)(3)(E) of the Act requires that, beginning 
October 1, 1993, we annually update the wage data used to calculate 
the wage index. In accordance with this requirement, the proposed 
wage index for FY 2006 is based on data submitted for hospital cost 
reporting periods beginning on or after October 1, 2001 and before 
October 1, 2002. 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 2005 wage 
index, based on FY 2001 wage data, to a model using the FY 2006 pre-
reclassification wage index, based on FY 2002 wage data. The FY 2005 
wage index baseline incorporated a blended wage index of 50 percent 
of the MSA wage index and 50 percent of the CBSA wage index in areas 
where the CBSA wage index was lower than the MSA wage index to 
reflect the transition policy that was in effect in FY 2005. The 
wage data collected on the FY 2002 cost report is the same as the FY 
2001 wage data that were used to calculate the FY 2005 wage index.
    Column 4 shows the impacts of updating the wage data using FY 
2002 cost reports. Overall, the new wage data will lead to a 0.4 
percent decrease for all hospitals and for hospitals in urban areas. 
This decrease is due to both fluctuations in the wage data itself 
and the fact that the transition blended wage index, which benefited 
areas that were negatively impacted by the labor market

[[Page 23662]]

transition is no longer in effect for FY 2006. Among regions, the 
largest increase is in the rural New England which is experiencing a 
1.0 percent increase. The largest decline from updating the wage 
data is seen in the urban New England region (a 1.1 percent 
decrease).
    In looking at the wage data itself, the national average hourly 
wage increased 6.1 percent compared to FY 2005. Therefore, the only 
manner in which to maintain or exceed the previous year's wage index 
was to match the national 6.1 increase in average hourly wage. Of 
the 3,617 hospitals with wage index values in both FYs 2005 and 
2006, 1,642, or 45.4 percent, also experienced an average hourly 
wage increase of 6.1 percent or more.
    The following chart compares the shifts in wage index values for 
hospitals for FY 2006 relative to FY 2005. Among urban hospitals, 58 
will experience an increase of between 5 percent and 10 percent and 
24 will experience an increase of more than 10 percent. A total of 
14 rural hospitals would experience increases greater than 5 
percent, but none will experience increases of greater than 10 
percent. On the negative side, 56 urban hospitals will experience 
decreases in their wage index values of at least 5 percent, but less 
than 10 percent. Fourteen urban hospitals will experience decreases 
in their wage index values greater than 10 percent.
    The following chart shows the projected impact for urban and 
rural hospitals.
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F. Impact of Proposed Change in Treatment of Section 1886(d)(8)(E) 
Wage Data (Column 5)

    For the FY 2006 wage index, we are proposing to leave the wage 
data for a hospital redesignated as rural under section 
1886(d)(8)(E) of the Act in the urban area in which the hospital is 
geographically located for purposes of calculating the wage index of 
those areas. We are proposing to move the wage data for these 
hospitals into the rural wage index only if it increases the wage 
index in the rural area. In this way, the rural floor is only 
affected by the wage data for these redesignated hospitals if it 
would increase the rural wage index and thus reset the rural floor 
at a higher value. Previously, the wage data for these redesignated 
hospitals was moved into the rural area wage index calculations 
regardless of whether it increased or decreased the rural wage 
index, and this caused the rural floor for several States to be 
lower than it would have been had the redesignated providers' data 
not been included.
    Column 5 shows the impact of adopting this policy. In aggregate, 
this policy proposal has no effect on payments to providers. 
Hospitals in the urban New England region experience an increase in 
payments of 0.2 percent, which indicates that CBSAs in that region 
that receive the rural floor are now receiving a higher wage index. 
Hospitals in West North Central are shown to experience a 0.2 
decline. However, when the redesignated data are added to the rural 
wage index, their rural floor increases and they do not actually 
experience a loss from this policy. Hospitals reclassified as rural 
under section 1886(d)(8)(E) of the Act will experience a 0.2 percent 
increase.

G. Combined Impact of Proposed DRG and Wage Index Changes, 
Including Budget Neutrality Adjustment (Column 6)

    The impact of the DRG reclassifications and recalibration on 
aggregate payments is required by section 1886(d)(4)(C)(iii) of the 
Act to be budget neutral. In addition, section 1886(d)(3)(E) of the 
Act specifies that any updates or adjustments to the wage index are 
to be budget neutral. As noted in the Addendum to this proposed rule 
compared simulated aggregate payments using the FY 2005 DRG relative 
weights and wage index to simulated aggregate payments using the 
proposed FY 2006 DRG relative weights and blended wage index.
    We computed a proposed wage and recalibration budget neutrality 
factor of 1.002494. 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 6. The 
changes in this column are the sum of the proposed changes in 
Columns 3, 4, and 5, combined with the budget neutrality factor and 
the wage index floor for urban areas required by section 4410 of 
Pub. L. 105-33 to be budget neutral. There also may be some 
variation of plus or minus 0.1 percentage point due to rounding.
    Among urban regions, the largest impacts are in the West North 
Central region and Puerto Rico, with 0.3 and 0.4 percent declines, 
respectively. The Pacific region experiences the largest increase of 
1.1 percent. Among rural regions, the New England region benefits 
the most with a 1.3 percent increase, while the Mountain region 
experiences the largest decline (1.2 percent).

H. Impact of Allowing Urban Hospitals That Were Converted to Rural 
as a Result of the CBSA Designations To Maintain the Wage Index of 
the MSA Where They Are Located (Column 7)

    To help alleviate the decreased payments for urban hospitals 
that became rural under the new labor market area definitions, for 
purposes of the wage index, we adopted a policy in FY 2005 to allow 
them to maintain the wage index assignment of the MSA where they 
were located for the 3-year period FY 2005, FY 2006, and FY 2007. 
Column 7 shows the impact of the remaining labor market area 
transition, for those hospitals that were urban under the old labor 
market area designations and are now considered rural hospitals. 
Section 1886(d)(3)(E) of the Act specifies that any updates or 
adjustments to the wage index are to be budget neutral. Therefore, 
we applied an adjustment of 0.999529 to ensure that the effects of 
reclassification are budget neutral as indicated by the zero effect 
on payments to hospitals overall. The rural hospital row shows a 0.3 
percent benefit from this provision as these hold harmless hospitals 
are now considered geographically rural.

I. Impact of MGCRB Reclassifications (Column 8)

    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 8 reflect 
the per case payment impact of moving from this baseline to a 
simulation incorporating the MGCRB decisions for FY 2006. These 
decisions affect hospitals' standardized amount and wage index area 
assignments.

[[Page 23663]]

    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 
wage index value. The proposed FY 2006 wage index values incorporate 
all of the MGCRB's reclassification decisions for FY 2006. The wage 
index values also reflect any decisions made by the CMS 
Administrator through the appeals and review process through 
February 28, 2005. Additional changes that result from the 
Administrator's review of MGCRB decisions or a request by a hospital 
to withdraw its application will be reflected in the final rule for 
FY 2006.
    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 0.992905 to ensure that the effects of 
reclassification are budget neutral. (See section II.A.4.b. of the 
Addendum to this proposed rule.)
    As a group, rural hospitals benefit from geographic 
reclassification. We estimate that their payments will rise 2.0 
percent in Column 8. Payments to urban hospitals will decline by 0.3 
percent. Hospitals in other urban areas will experience an overall 
decrease in payments of 0.2 percent, while large urban hospitals 
will 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 all of the rural hospital 
groups. The smallest increase among the rural census divisions is 
0.5 for the Mountain and New England regions. The largest increases 
are in the rural East South Central region, with an increase of 3.0 
percent and in the West South Central region, which would experience 
an increase of 2.5 percent.
    Urban hospitals reclassified for FY 2006 are expected to receive 
an increase of 2.3 percent, while rural reclassified hospitals are 
expected to benefit from the MGCRB changes with a 3.7 percent 
increase in payments. Payments to urban and rural hospitals that did 
not reclassify are expected to decrease slightly due to the MGCRB 
changes, decreasing by 0.6 percent for urban hospitals and 0.3 
percent for rural hospitals.

J. Impacts of the Proposed Wage Index Adjustment for Out-Migration 
(Column 9)

    Section 1886(d)(13) of the Act, as added by section 505 of Pub. 
L. 108-173, provides for an increase in the wage index for hospitals 
located in certain counties that have a relatively high percentage 
of hospital employees who reside in the county, but work in a 
different area with a higher wage index. Hospitals located in 
counties that qualify for the payment adjustment are to receive an 
increase in the wage index that is equal to a weighted average of 
the difference between the wage index of the resident county and the 
higher wage index work area(s), weighted by the overall percentage 
of workers who are employed in an area with a higher wage index. 
Using our established criteria, 345 counties and 688 hospitals 
qualify to receive a commuting adjustment in FY 2006.
    Due to the statutory formula to calculate the adjustment and the 
small number of counties that qualify, the impact on hospitals is 
minimal, with an overall impact on all hospitals of 0.1 percent.

K. All Changes (Column 10)

    Column 10 compares our estimate of payments per case, 
incorporating all changes reflected in this proposed rule for FY 
2006 (including statutory changes), to our estimate of payments per 
case in FY 2005. This column includes all of the proposed policy 
changes. Because the reclassifications shown in Column 8 do not 
reflect FY 2005 reclassifications, the impacts of FY 2006 
reclassifications only affect the impacts from FY 2005 to FY 2006 if 
the reclassification impacts for any group of hospitals are 
different in FY 2006 compared to FY 2005.
     Column 10 reflects all FY 2006 changes relative to FY 
2005, shown in Columns 2 through 9 and those not applied until the 
final rates are calculated. The average increase for all hospitals 
is approximately 2.5 percent. This increase includes the effects of 
the proposed 3.2 percent market basket update. It also reflects the 
0.7 percentage point difference between the projected outlier 
payments in FY 2005 (5.1 percent of total DRG payments) and the 
current estimate of the percentage of actual outlier payments in FY 
2005 (4.4 percent), as described in the introduction to this 
Appendix and the Addendum to this proposed rule. As a result, 
payments are projected to be 0.7 percentage point lower in FY 2005 
than originally estimated, resulting in a 0.7 percentage point 
greater increase for FY 2006 than would otherwise occur. In 
addition, the impact of section 505 adjustments accounted for a 0.1 
percent increase. Payment decreases of 1.5 percent are primarily 
attributable to the impact of expanding the postacute care transfer 
policy (-1.1 percent). Indirect medical education formula changes 
for teaching hospitals under section 502 of Pub. L. 108-173, changes 
in payments due to the difference between the FY 2005 and FY 2006 
wage index values assigned to providers reclassified under section 
508 of Pub. L. 108-173, and changes in the incremental increase in 
payments from section 505 of Pub. L. 108-173 out migration 
adjustments account for the remaining -0.4 percent.
    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 2006, eligible 
SCHs receive 100 percent of their 1996 hospital-specific rate. In 
addition, in this proposed rule we are proposing to revise the 
budget neutrality adjustment applied to the hospital-specific rates 
to reflect only the payment changes resulting from DRG 
recalibration. Previously, we had also adjusted the hospital-
specific rates to reflect payment changes based on area wage levels. 
The impact of this provision is modeled in Column 10 as well. In 
addition, section 402 of Pub. L. 108-173 increases the DSH 
adjustment for hospitals that serve a disproportionate share of low-
income Medicare and Medicaid patients, which include rural hospitals 
and urban hospitals with fewer than 100 beds, SCHs, rural referral 
centers, and rural hospitals with less than 500 beds. The increase 
in DSH payments became effective for discharges occurring on or 
after April 1, 2004. As provided in the new Medicare law, the cap on 
DSH payment adjustments increased from 5.25 percent to 12 percent 
for urban hospitals with fewer than 100 beds, SCHs, and rural 
hospitals with less than 500 beds. There is no cap on rural referral 
centers, large urban hospitals over 100 beds, or rural hospitals 
over 500 beds.
    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 2006 
would increase by 2.5 percent. Hospitals in urban areas would 
experience a 2.5 percent increase in payments per case compared to 
FY 2005. Hospitals in rural areas, meanwhile, would experience a 2.6 
percent payment increase. Hospitals in large urban areas would 
experience a 2.4 percent increase in payments and hospitals in other 
urban areas would experience a 2.7 percent increase in payments.
    Among urban census divisions, the largest payment increase would 
be 4.0 percent in the Pacific region. Hospitals in the urban East 
South Central and West South Central regions would experience the 
next largest overall increases of 3.0 percent and 3.1 percent, 
respectively. The smallest urban increase would occur in the New 
England region, with an increase of 1.0 percent.
    Among rural regions in Column 10, no hospital category will 
experience overall payment decreases. The Pacific and Middle 
Atlantic regions will benefit the most, with 3.3 and 3.2 percent 
increases, respectively. The smallest increase will occur in the 
West South Central region, with 2.2 percent increases in payments.
    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 2.8 
percent, 2.4 percent, and 2.7 percent, respectively. This outcome is 
primarily related to the fact that, for hospitals receiving payments 
under the hospital-specific methodology, there were several 
increases to payments made in relation to implementation of the Pub. 
L. 108-173.
    Urban hospitals reclassified for FY 2006 are anticipated to 
receive an increase of 3.0 percent, while rural reclassified 
hospitals are expected to benefit from reclassification with a 2.8 
percent increase in payments. Those hospitals located in rural 
counties, but deemed to be urban under section 1886(d)(8)(B) of the 
Act, are expected to receive an increase in payments of 1.4 percent.

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    Table II presents the projected impact of the proposed changes 
for FY 2006 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 2005 with the average estimated per case 
payments for FY 2006, 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 Proposed Policy Changes

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

A. Impact of Proposed LTC-DRG Reclassifications and Relative 
Weights for LTCHs

    In section II.D. of the preamble of this proposed rule, we 
discuss the proposed changes in the LTC-DRG relative weights for FY 
2006 based on the proposed version 23.0 of the CMS GROUPER 
(including the

[[Page 23667]]

proposed changes in the classifications, relative weights and 
geometric mean length of stay for each LTC-DRG). Based on LTCH cases 
in the FY 2004 MedPAR file, we estimate that the proposed changes 
would result in an aggregate decrease in LTCH payments of 
approximately 4.7 percent. When we compared the version 22 (FY 2005) 
LTC-DRG relative weights to the proposed version 23 (FY 2006) LTC-
DRG relative weights, we found that approximately 72 percent of the 
LTC-DRGs had higher relative weights under version 22 in comparison 
to the proposed version 23. We also found that the version 22 LTC-
DRG relative weights were, on average, approximately 16 percent 
higher than the proposed version 23 LTC-DRG relative weights.
    In addition, based on an analysis of the most recent available 
LTCH claims data from the FY 2004 MedPAR file, we continue to 
observe that the proposed average LTC-DRG relative weight decreases 
due to an increase of relatively lower charge cases being assigned 
to LTC-DRGs with higher relative weights in the prior year. 
Contributing to this increase in these relatively lower charge cases 
being assigned to LTC-DRGs with higher relative weights in the prior 
year are improvements in coding practices, which are typically found 
when moving from a reasonable cost-based payment system to a PPS. 
The impact of including cases with relatively lower charges into 
LTC-DRGs that had a relatively higher relative weight in the version 
22.0 (FY 2005) GROUPER is a decrease in the average relative weight 
for those LTC-DRGs in the proposed GROUPER version 23.0. We also 
found that there is over a 15 percent increase in the average LTCH 
charge across all LTC-DRGs from FY 2003 to FY 2004. For some LTC-
DRGs in which the average charge within the LTC-DRG increase is less 
than 15 percent, the relative weights for those LTC-DRGs will 
decrease because the average charge for each of those LTC-DRGs is 
being divided by a larger number (that is, the average charge across 
all LTC-DRGs). For the reasons discussed above, we believe that the 
proposed changes in the LTC-DRG relative weights, which include a 
number of proposed LTC-DRGs with lower proposed relative weights, 
would result in approximately a 4.6 percent decrease in aggregate 
LTCH PPS payments.

B. Impact of Proposed New Technology Add-On Payments

    We are no longer required to ensure that any add-on payments for 
new technology under section 1886(d)(5)(K) of the Act are budget 
neutral (see section II.E. of the preamble to this proposed rule). 
However, we are still providing an estimate of the payment increases 
here, as they will have a significant impact on total payments made 
in FY 2006. New technology add-on payments are limited to the lesser 
of 50 percent of the costs of the technology, or 50 percent of the 
costs in excess of the DRG payment for the case. Because it is 
difficult to predict the actual new technology add-on payment for 
each case, we are estimating the increase in payment for FY 2006 as 
if every claim with these add-on payments will receive the maximum 
add-on payment. As discussed in section II.E. of the preamble of 
this proposed rule, we are not proposing to approve any of the new 
technology applications that were filed for FY 2006. However, we are 
proposing to continue to make add-on payments in FY 2006 for an FY 
2005 new technology: KinetraTM implants. We estimate this 
approval would increase overall payments by $12.8 million. The 
increase in payments for this new technology is not reflected in the 
tables.

C. Impact of Requirements for Hospital Reporting of Quality Data 
for Annual Hospital Payment Update

    In section V.B. of the preamble to this proposed rule, we 
discuss our implementation of section 1886(b)(3)(B)(vii) of the Act, 
as added by section 501(b) of Pub. L. 108-173, which revised the 
mechanism used to update the standardized amount of payment for 
inpatient hospital operating costs. Specifically, section 
1886(b)(3)(B)(vii) of the Act provides for a reduction of 0.4 
percentage points to the update percentage increase (also known as 
the market basket update) for each of FYs 2005 through 2007 for any 
subsection (d) hospital that does not submit data on a set of 10 
quality indicators established by the Secretary as of November 1, 
2003. The statute also provides that any reduction will apply only 
to the year involved, and will not be taken into account in 
computing the applicable percentage increase for a subsequent fiscal 
year. We are unable to precisely estimate the effect of this 
provision because, while receiving the full update for those years 
is conditional upon the submission of quality data by a hospital, 
the submitted data must also be validated, as described in section 
V.B. above. The final date for submission of quality data for 
purposes of receiving the full adjustment in FY 2006 is May 15, 
2005. Preliminary results indicate that over 98 percent of IPPS 
hospitals have submitted quality data. The QIOs are still in the 
process of validating that data and certifying those hospitals 
eligible to receive the full update for FY 2006. We have continued 
our efforts to ensure that QIOs provide assistance to all hospitals 
that wish to submit data. In the preamble to this proposed rule, we 
are proposing additional validation criteria to ensure that the 
quality data being sent to CMS are accurate. Our validation process 
requires participating hospitals to submit five charts per quarter. 
We reimburse each hospital for the cost of sending charts to the 
Clinical Data Abstraction Center at the rate of 12 cents per page 
for copying and approximately $4.00 per chart for postage. Based on 
our experience, the average size of a chart is 140 pages. Therefore, 
we estimate our expenditures for chart collection at $380,000 per 
quarter. Because we provide reimbursement to hospitals for the costs 
of chart submission, we believe that this requirement represents a 
minimal burden to participating hospitals. Based on test 
applications of these validation criteria to quality data that have 
been submitted thus far, we currently estimate that approximately 5 
percent of hospitals will fail the edits and receive the reduced 
market basket update to the standardized amount. Based on this 
reduced payment to some hospitals, we estimate savings to the 
Medicare program of approximately $20 million for FY 2006.

D. Impact of Proposed Policy on Payment Adjustments for Low-Volume 
Hospitals

    In section V.E. of the preamble to this proposed rule, we 
discussed our proposed FY 2006 implementation of section 1886(d)(12) 
of the Act, as added by section 406 of Pub. L. 108-173, which 
provides for a payment adjustment to account for the higher costs 
per discharge of low-volume hospitals under the IPPS. For FY 2006, 
we are proposing to continue to apply the low-volume adjustment 
criteria that we specified in the FY 2005 IPPS final rule (69 FR 
49099). Currently, our fiscal intermediaries have identified 10 
providers that are eligible for the low-volume adjustment. We 
estimate that the impact of these providers receiving the additional 
25 percent payment increase to be approximately $1.5 million.

E. Impact of Proposed Policies on Payment for Indirect Costs of 
Graduate Medical Education

1. IME Adjustment for TEFRA Hospitals Converting to IPPS Hospitals

    In section V.F.2. of the preamble of this proposed rule, we 
discuss our proposal to incorporate into regulations our existing 
policy regarding the IME adjustment for TEFRA hospitals converting 
to IPPS hospitals. We establish an FTE resident cap for TEFRA 
hospitals converting to an IPPS hospital for IME payment purposes as 
if the hospital had been an IPPS hospital during the base year used 
to compute the hospital's direct GME FTE resident cap. We are only 
aware of four hospitals where this issue has arisen. The proposed 
addition to the regulations clarifies the established policy for 
computing an IME FTE resident cap for these hospitals. Because this 
is a proposal to clarify existing policy and codify it in 
regulations, there is no financial impact for FY 2006.

2. Section 1886(d)(8)(E) Teaching Hospitals That Withdraw Rural 
Reclasssification

    In section V.F.3. of the preamble to this proposed rule, we 
present our proposal to adjust the IME FTE resident caps of 
hospitals that rescind their section 1886(d)(8)(E) rural 
reclassifications so that they do not continue to receive the 
increase in the FTE resident cap that is applied for rural teaching 
hositals. The purpose of this policy is to prevent urban hospitals 
from reclassifying to rural areas under section 1886(d)(8)(E) of the 
Act for a short period of time, solely as a means of receiving a 
permanent increase to their IME FTE caps. The impact of this policy 
is that section 1886(d)(8)(E) hospitals may receive decreased IME 
payments if they return to urban status. This impact cannot be 
quantified because we are unable to determine the number of 
hospitals that would otherwise game the system in the absence of 
this proposal and we are not aware of any teaching hospitals that 
became rural under the provision of section 1886(d)(8)(E) of the Act 
that have subsequently reverted to urban status.

[[Page 23668]]

F. Impact of Proposed Policy Relating to Geographic 
Reclassifications of Multicampus Hospitals

    In section V.H. of the preamble of this proposed rule, we 
discuss the impact of our implementation of the new labor market 
areas on multicampus hospital systems. Under our current policy, a 
multicampus hospital with campuses located in the same labor market 
area receives a single wage index. However, if the campuses are 
located in more than one labor market area, payment for each 
discharge is determined using the wage index value for the labor 
market area in which the campus of the hospital is located. In 
addition, current provisions provide that, in the case of a merger 
of hospitals, if the merged facilities operate as a single 
institution, the institution must submit a single cost report, which 
necessitates a single provider identification number. This provision 
also does not differentiate between merged facilities in a single 
wage index area or in multiple wage index areas. As a result, the 
wage index data for the merged facility is reported for the entire 
entity on a single cost report.
    The current criteria for a hospital being reclassified to 
another wage area by the MGCRB do not address the circumstances 
under which a single campus of a multicampus hospital may seek 
reclassification.
    Specifically, we are proposing that for reclassification 
applications submitted for FY 2006 (that is, applications received 
by September 1, 2004), we would allow a campus or campuses of a 
multicampus hospital system to seek geographic reclassification on 
the basis of the average hourly wage data submitted for the entire 
hospital system. For reclassification applications that would take 
effect for FY 2007 (that is, applications received by September 1, 
2005) and thereafter, a campus of a multihospital system could not 
use the wage data of the entire hospital system, but rather, would 
have the opportunity to separate out campus-specific wage data for 
purposes of seeking reclassification for such campus. We estimate 
that this proposal will apply to fewer than 12 multicampus hospital 
systems nationwide and, therefore, will not lead to additional 
program expenditures because hospital geographic reclassifications 
are budget neutral under section 1886(d)(8)(D) of the Act.

G. Impact of Proposed Policy on Payment for Direct Costs of 
Graduate Medical Education

1. GME Initial Residency--Match for Second Year

    In section V.I.2. of the preamble to this proposed rule, we 
discuss our proposed changes related to the initial residency period 
for residents that match into an advanced residency program, but 
fail to match into a clinical base year of training. We are 
proposing that, in instances where a hospital can document that, 
prior to commencement of any residency training, a resident matched 
into an advanced program that begins in the second residency year, 
that resident's initial residency period will be determined based on 
the period of board eligibility for the advanced program, without 
regard to the fact that the resident had not matched for a clinical 
base year training program. For purposes of this proposed rule, we 
have estimated the impact of this proposed rule change for FY 2006, 
using assumptions about the national average per resident amount, 
the number of affected residents, and the national average Medicare 
utilization rate. We estimate that this provision will affect 
approximately 600 residents. Using a national average per resident 
amount of $92,000, and an average Medicare utilization rate of 35 
percent, we estimate that, for FY 2006, the impact of treating those 
residents as a full FTE rather than .50 FTE, Medicare payments for 
direct GME will increase by approximately $9.7 million.

2. New Teaching Hospitals' Participation in Medicare GME Affiliated 
Groups

    In section V.I.3. of the preamble to this proposed rule, we 
discuss our proposed changes related to new teaching hospitals' 
participation in Medicare GME affiliated groups. Under current 
regulations, a new teaching hospital located in an urban area that 
establishes an FTE resident cap under Sec.  413.79(e) may not 
participate in a Medicare GME affiliated group. We are proposing to 
revise the regulations to allow a new teaching hospital located in 
an urban area to participate in a Medicare GME affiliated group, but 
only if any adjustments made by the Medicare GME affiliation 
agreement result in an increase to the new teaching hospital's 
adjusted resident FTE resident caps for purposes of IME and direct 
GME payment. There is no estimated increase in program payments 
related to this proposed change because any additional residents 
that would be counted at the new teaching hospitals as a result of 
this change could have been counted prior to the affiliation for 
Medicare GME payment purposes at the hospital that is losing slots 
under the affiliation agreement.

H. Impact of Policy on Rural Community Hospital Demonstration 
Program

    In section V.K. of the preamble to this proposed rule, we 
discuss our implementation of section 410A of Pub.L. 108-173 that 
required the Secretary to establish a demonstration that will modify 
reimbursement for inpatient services for up to 15 small rural 
hospitals. Section 410A(c)(2) requires that ``in conducting the 
demonstration program under this section, the Secretary shall ensure 
that the aggregate payments made by the Secretary do not exceed the 
amount which the Secretary would have paid if the demonstration 
program under this section was not implemented.'' As discussed in 
section V.K. of the preamble to this proposed rule, we are 
satisfying this requirement by adjusting national IPPS rates by a 
factor that is sufficient to account for the added costs of this 
demonstration. We estimate that the average additional annual 
payment for FY 2006 that will be made to each participating hospital 
under the demonstration will be approximately $977,410. We based 
this estimate on the recent historical experience of the difference 
between inpatient cost and payment for hospitals that have applied 
for the demonstration. For 13 participating hospitals, the total 
annual impact of the demonstration program is estimated to be 
$12,706,334. We describe the budget neutrality adjustment required 
for this purpose in the Addendum to this proposed rule.

I. Impact of Proposed Policy on CAH Relocation Provisions

    In section VII.B.3. of the preamble to this proposed rule, we 
discuss the proposed change to the necessary provider provision as 
it applies to CAHs. As required by statute, no additional CAHs will 
be certified as a necessary provider on or after January 1, 2006. We 
are proposing to revise the regulations to allow some flexibility 
for those CAHs previously designated as necessary providers that 
embarked on a replacement facility project before the sunset 
provision was enacted on December 8, 2003, but find that they cannot 
be operational in the replacement facility by January 1, 2006. We 
are proposing that, when a CAH is determined to have relocated, it 
may continue to operate under its existing necessary provider 
designation that exempts CAHs from the distance from another 
provider requirement only if certain conditions are met. The 
proposed clarification to the sunset of the necessary provider 
provision is intended to allow CAHs to complete construction 
projects that were initiated prior to the enactment of Pub. L. 108-
173. The Health Resources Services Administration (HRSA) estimates 
that this proposal will apply to fewer than six CAHs nationwide. The 
average cost of construction of a new 25 bed CAH is approximately 
$25 million. Given a depreciation schedule based on a 25 useful life 
and Medicare utilization of approximately 50 percent, the additional 
capital costs for six CAHs would be $3 million. However, the actual 
cost to the program would be further reduced since those 6 CAH are 
currently being reimbursed for their existing capital costs and also 
the increased operating costs that are associated with operating an 
aged facility. Accordingly, the budgetary impact for the proposed 
change on the affected CAHs is estimated at between $1 million and 
$2 million. Expressed on a per-facility basis, the budgetary impact 
of this proposed change is estimated at between $167,000 and 
$333,000 per CAH.

VIII. Impact of Proposed Changes in the Capital PPS

A. General Considerations

    Fiscal year (FY) 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

[[Page 23669]]

for new capital costs based on a proportion of the capital Federal 
rate (see Sec.  412.344). As we state in section VI. of the preamble 
of this proposed rule, with the 10-year transition period ending 
with hospital cost reporting periods beginning on or after October 
1, 2001 (FY 2002), beginning in FY 2002 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 PPS 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 +3 
Disproportionate Share (DSH) Adjustment Factor + Indirect Medical 
Education (IME) Adjustment Factor, if applicable).
    In addition, hospitals may also receive outlier payments for 
those cases that qualify under the threshold established for each 
fiscal year.
    The data used in developing the impact analysis presented below 
are taken from the December 2004 update of the FY 2004 MedPAR file 
and the December 2004 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 2004 update of the most recently available 
hospital cost report data (FY 2003) 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 IPPS, 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 December 2004 update of the FY 2004 MedPAR 
file, we simulated payments under the capital PPS for FY 2005 and FY 
2006 for a comparison of total payments per case. Any short-term, 
acute care hospitals not paid under the general IPPS (Indian Health 
Service hospitals and hospitals in Maryland) are excluded from the 
simulations.
    As we explain in section III.A.4. of the Addendum of this 
proposed rule, payments are no longer made under the regular 
exceptions provision under Sec. Sec.  412.348(b) through (e). 
Therefore, we no longer use the actuarial capital cost model 
(described in Appendix B of the August 1, 2001 proposed 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:
     We estimate that the Medicare case-mix index would 
increase by 1.0 percent in both FYs 2005 and 2006.
     We estimate that the Medicare discharges will be 13.5 
million in FY 2005 and 13.3 million in FY 2006 for a 1.5 percent 
decrease from FY 2005 to FY 2006.
     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 proposed FY 2006 update is 0.7 
percent (see section III.A.1.a. of the Addendum to this proposed 
rule).
     In addition to the proposed FY 2006 update factor, the 
proposed FY 2006 capital Federal rate was calculated based on a 
proposed GAF/DRG budget neutrality factor of 1.0019, a proposed 
outlier adjustment factor of 0.9497, and a proposed (special) 
exceptions adjustment factor of 0.9997.

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 PPS 
transition period payment methodology. We are no longer including 
this information because all hospitals (except new hospitals under 
Sec.  412.324(b) and under Sec.  412.304(c)(2)) will be paid 100 
percent of the capital Federal rate in FY 2006.
    We used the actuarial model described above to estimate the 
potential impact of our changes for FY 2006 on total capital 
payments per case, using a universe of 3,693 hospitals. As described 
above, the individual hospital payment parameters are taken from the 
best available data, including the December 2004 update of the FY 
2004 MedPAR file, the December 2004 update to the Provider-Specific 
File, and the most recent cost report data from the December 2004 
update of HCRIS. In Table III, we present a comparison of total 
payments per case for FY 2005 compared to FY 2006 based on the 
proposed FY 2006 payment policies. Column 2 shows estimates of 
payments per case under our model for FY 2005. Column 3 shows 
estimates of payments per case under our model for FY 2006. Column 4 
shows the total percentage change in payments from FY 2005 to FY 
2006. The change represented in Column 4 includes the 0.7 percent 
update to the capital Federal rate, a 1.0 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 GAF), and 
reclassifications by the MGCRB, as well as changes in special 
exception payments. The comparisons are provided by: (1) Geographic 
location; (2) region; and (3) payment classification.
    The simulation results show that, on average, capital payments 
per case can be expected to increase 1.7 percent in FY 2006. In 
addition to the 0.7 percent increase due to the capital market 
basket update, this projected increase in capital payments per case 
is largely attributable to an estimated increase in outlier payments 
in FY 2006. Our comparison by geographic location shows that urban 
hospitals are expected to experience a 1.8 percent increase in IPPS 
capital payments per case, while rural hospitals are only expected 
to experience a 1.2 percent increase in capital payments per case. 
This difference is mostly due to a projection that urban hospitals 
would experience a larger increase in estimated outlier payments 
from FY 2005 to FY 2006 compared to rural hospitals.
    All regions are estimated to receive an increase in total 
capital payments per case from FY 2005 to FY 2006. Changes by region 
vary from a minimum increase of 0.1 percent (Middle Atlantic rural 
region) to a maximum increase of 3.3 percent (Pacific urban region). 
The relatively small increase in projected capital payments per 
discharge for hospitals located in the Middle Atlantic rural region 
is largely attributable to the proposed changes in the GAF values 
(that is, the proposed GAFs for most of these hospitals for FY 2006 
are lower than the weighted average of the GAFs for FY 2005) . The 
relatively large increase in capital payments per discharge for 
hospitals located in the Pacific urban region is largely due to the 
proposed changes in the GAF values (that is, the proposed GAFs for 
most of these hospitals for FY 2006 are higher than the average of 
the GAFs for FY 2005) and a larger than average increase in 
estimated outlier payments for FY 2006.
    Hospitals located in Puerto Rico are expected to experience an 
increase in total capital payments per case of 1.0 percent. This 
slightly lower than average increase in payment per case for 
hospitals located in Puerto Rico is largely due to the proposed 
changes in the proposed GAF values (that is, the proposed GAFs for 
most of these hospitals for FY 2006 are higher than the average of 
the GAFs for FY 2005).
    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 and proprietary hospitals are 
expected to increase 1.6 percent and 1.8 percent, respectively. As 
noted above, this slightly larger projected increase in capital 
payments per case for government hospitals is mostly due to the 
larger than average increase in projected outlier payments for FY 
2006 and a smaller than average decrease in the proposed GAF values.
    Section 1886(d)(10) of the Act established the MGCRB. 
Previously, hospitals could apply for reclassification for purposes 
of the standardized amount, wage index, or both. Section 401(c) of 
Pub. L. 108-173 equalized the standardized amounts under the 
operating IPPS. Therefore, beginning in FY 2005, there is no longer 
reclassification for the purposes of the standardized amounts; 
hospitals may apply for reclassification for purposes of the wage 
index in FY 2006. Reclassification for wage index purposes also

[[Page 23670]]

affects the GAF because that factor is constructed from the hospital 
wage index.
    To present the effects of the hospitals being reclassified for 
FY 2006 compared to the effects of reclassification for FY 2005, 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 2006 as a whole are projected to 
experience a 2.0 percent increase in payments. Payments to 
nonreclassified hospitals in FY 2006 are expected to increase 1.7 
percent. Hospitals reclassified during both FY 2005 and FY 2006 are 
projected to experience an increase in payments of 1.3 percent. 
Hospitals reclassified during FY 2006 only are projected to receive 
an increase in payments of 3.2 percent. This relatively large 
increase is primarily due to the proposed changes in the GAF values 
(that is, the proposed GAFs for most of these hospitals for FY 2006 
are higher than the average of the GAFs for FY 2005).

BILLING CODE 4120-01-P
[GRAPHIC] [TIFF OMITTED] TP04MY05.078


[[Page 23671]]


[GRAPHIC] [TIFF OMITTED] TP04MY05.079

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

    (If you choose to comment on issues in this section, please 
include the caption ``Update Factors'' at the beginning of your 
comment.)

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 update factors recommended by the Secretary in the proposed 
and final rule. Accordingly, this Appendix provides the 
recommendations of appropriate update factors for the IPPS 
standardized amount, the hospital-specific rates for SCHs and MDHs, 
and the rate-of-increase limits and Federal prospective payment 
amounts for hospitals and hospitals units excluded from the IPPS. We 
also discuss our update framework and respond to MedPAC's 
recommendations concerning the update factors.

II. Secretary's Recommendations

    Section 1886(b)(3)(B)(i)(XIX) of the Act sets the FY 2006 
percentage increase in the operating cost standardized amount equal 
to the rate-of-increase in the hospital market basket for IPPS 
hospitals in all areas subject to the hospital submitting quality 
information under rules established by the Secretary under section 
1886(b)(3)(B)(vii) of the Act. For hospitals that do not provide 
these data, the update is equal to the market

[[Page 23672]]

basket percentage increase less 0.4 percentage points. Based on the 
Office of the Actuary's fourth quarter 2004 forecast of the FY 2006 
market basket increase, we are proposing an update to the 
standardized amount of 3.2 percent (that is, the market basket rate-
of-increase) for hospitals in all areas, provided the hospital 
submits quality data in accordance with our rules.
    Section 1886(b)(3)(B)(iv) of the Act sets the FY 2006 percentage 
increase in the hospital-specific rates applicable to SCHs and MDHs 
equal to the rate set forth in section 1886(b)(3)(B)(i) of the Act 
(that is, the same update factor as for all other hospitals subject 
to the IPPS, or the rate-of-increase in the market basket). 
Therefore, the proposed update to the hospital-specific rate 
applicable to SCHs and MDHs is also 3.2 percent.
    Section 1886(b)(3)(B)(ii) of the Act sets the FY 2006 percentage 
increase in the rate-of-increase limits for various hospitals and 
hospital units excluded from the IPPS, that is, certain psychiatric 
hospitals and units (now referred to as inpatient psychiatric 
facilities (IPFs)), certain LTCHs, cancer hospitals, and children's 
hospitals, equal to the market basket percentage increase. In the 
past, hospitals and hospital units excluded from the IPPS have been 
paid based on their reasonable costs subject to TEFRA limits. 
However, some of these categories of excluded hospitals and units 
are currently, or soon will be, paid under their own prospective 
payment systems. Currently, children's and cancer hospitals and 
RNHCIs are the remaining three types of hospitals still reimbursed 
fully under reasonable costs. Those psychiatric hospitals and units 
of hospitals not yet paid under a PPS are still reimbursed fully on 
a reasonable cost basis subject to TEFRA limits. In addition, those 
LTCHs and IPFs paid under a blend methodology have the TEFRA portion 
of that payment subject to the TEFRA limits. Hospitals and units 
that receive any reasonable cost-based payments will have those 
payments determined subject to the TEFRA limits for FY 2006.
    As we discuss in section IV. of the preamble and in section IV. 
of the Addendum to this proposed rule, we are proposing to use the 
estimated FY 2006 IPPS operating market basket percentage increase 
(3.2 percent) to update the target limits for children's hospitals, 
cancer hospitals, and religious nonmedical institutions.
    As described in greater detail below, under their respective 
PPSs, LTCHs and IPFs are in a transition period during which some 
LTCHs and IPFs are paid a blend of reasonable cost-based payments 
(subject to the TEFRA limits) and a Federal prospective payment 
amount. Under the respective transition period methodologies for the 
LTCH PPS and IPF PPS, which are described below, payment is based, 
in part, on a decreasing percentage of the reasonable cost-based 
payment amount. As we discuss in section IV. of the preamble of this 
proposed rule, we are proposing to rebase the market basket used to 
determine the reasonable cost-based payment amount for LTCHs and 
IPFs. We are proposing that the portion of payments to LTCHs and 
IPFs that are reasonable cost-based will be determined using the FY 
2002-based excluded hospital market basket (currently estimated at 
3.4 percent).
    Effective for cost reporting periods beginning FY 2003, LTCHs 
are paid under the LTCH PPS, which was implemented with a 5-year 
transition period. (Refer to the August 30, 2002 final rule (67 FR 
55954).) A LTCH may elect to be paid on 100 percent of the Federal 
prospective rate at the start of any of its cost reporting periods 
during the 5-year transition period. For purposes of the update 
factor for inpatient operating services for FY 2006, the portion of 
the LTCH PPS transition blend payment that is based on reasonable 
costs would be determined by updating the LTCH's TEFRA limit by the 
current estimate of the FY 2002-based excluded hospital market 
basket (or 3.4 percent).
    Effective for cost reporting periods beginning on or after 
January 1, 2005, IPFs are paid under the IPF PPS under which they 
receive payment based on a Federal per diem rate that is based on 
the sum of the average routine operating, ancillary, and capital 
costs for each patient day of psychiatric care in an IPF, adjusted 
for budget neutrality. During a transition period between January 1, 
2005 and January 1, 2008, some IPFs are paid based on a blend of the 
reasonable cost-based payments, subject to the TEFRA limit, and the 
Federal per diem base rate. For cost reporting periods beginning on 
or after January 1, 2008, IPFs will be paid based on 100 percent of 
the Federal per diem rate. For purposes of the update factor for FY 
2006, the portion of the IPF PPS transitional blend payment based on 
reasonable costs would be determined by updating the IPF's TEFRA 
limit by the current estimate of the FY 2002-based excluded hospital 
market basket (or 3.4 percent).
    IRFs are paid under the IRF PPS for cost reporting periods 
beginning on or after January 1, 2002. For cost reporting periods 
beginning during FY 2004, and thereafter, the Federal prospective 
payments to IRFs are based on 100 percent of the adjusted Federal 
IRF prospective payment amount, updated annually. (Refer to the July 
30, 2004 final rule (69 FR 45721).)

III. Update Framework

    Consistent with the current law, for FY 2006, for IPPS 
hospitals, we are recommending an update of 3.2 percent, which 
reflects the CMS Office of the Actuary's most recent (fourth 
quarter) 2004 forecast of the FY 2006 market basket increase. In 
previous years, in making a recommendation, we included an update 
framework that analyzed hospital productivity, scientific and 
technological advances, practice pattern changes, changes in case 
mix, the effects of reclassification on recalibration and forecast 
error correction. Although we have used this framework in past 
years, we are no longer including this analysis in our 
recommendation for the update. We are not discussing the framework 
because the productivity measure cannot be adequately computed for 
FY 2006 because of the anticipated effects on admissions due to the 
expected increases in enrollment in Medicare Advantage plans. The 
increased enrollment in Medicare Advantage plans has the effect of 
causing admissions to decline. However, we do not have information 
on how hospital employment will be affected for our methodology. 
Thus, in the absence of data to predict the effect of a decline in 
hospital admissions on hospital employment, we cannot appropriately 
reflect productivity in our framework. As a result, based on the 
discussion above, we believe it is appropriate to recommend an 
update of 3.2 percent, based on the Office of the Actuary's fourth 
quarter 2004 forecast of the FY 2006 market basket percentage 
increase.
    We note that, although we are not using the framework for our 
recommendation to update the operating standardized amounts due to 
the reasons above, we continue to use the framework to calculate the 
capital standardized amounts as discussed in section III.A.1.a. of 
the Addendum to this proposed rule. This is due to the fact that the 
framework for the capital standardized amounts is calculated without 
a productivity factor and, therefore, the reasons discussed above do 
not apply to the update framework of the capital standardized 
amounts.
    We also note that section 1886(e)(3) of the Act directs the 
Secretary to report to Congress an initial estimate of the 
recommendation of an appropriate payment inflation update for 
inpatient hospital services for the upcoming fiscal year. Earlier 
this year, the Secretary reported to Congress that the initial 
estimate of the recommendation of an update factor was 3.3 percent, 
which was the market basket update for the IPPS standardized amount 
in the President's FY 2006 budget. The difference between the 
Secretary's initial estimate and the update we are recommending in 
this proposed rule (3.2 percent) is due to the availability and use 
of more recent data for the market basket than were available at the 
time the Secretary's initial estimate was developed. In addition, 
the Secretary's initial estimate was based on the FY 1997-based 
hospital market basket, while the proposed update in this proposed 
rule (the current update recommendation) is based on the proposed FY 
2002-based hospital market basket.
    Aside from making a recommendation for IPPS hospitals, in 
accordance with section 1886(e)(4)(A) of the Act, it is necessary to 
make a recommendation of the update factor for all other types of 
hospitals. Consistent with current law, for FY 2006, for SCHs and 
MDHs, we are recommending an update of 3.2 percent, which reflects 
the CMS Office of the Actuary's most recent (fourth quarter) 2004 
forecast of the FY 2006 market basket percentage increase.
    Consistent with our proposal in section IV. of the preamble of 
this proposed rule, for FY 2006, for cancer hospitals, religious 
nonmedical health care institutions, and children's hospitals, we 
are recommending an update of 3.2 percent to the target limits. 
Consistent with our proposal in the February 3, 2005 LTCH PPS 
proposed rule (70 FR 5735), we are recommending an update factor of 
3.1 percent for rate year (RY) 2006. For LTCHs that currently may be 
paid during a transition period a blend of reasonable cost-based 
payments (subject to the TEFRA limits) and Federal prospective 
payment amounts,

[[Page 23673]]

we are recommending an update factor of 3.4 percent for the portion 
of the payment that is based on reasonable costs, subject to the 
TEFRA limits, consistent with our proposal in section IV. of the 
preamble of this proposed rule. For the Federal portion of this same 
blended payment amount, we are recommending an update of 3.1 
percent. Because the IPF PPS was effective for cost reporting 
periods beginning on or after January 1, 2005, and the base rates 
are effective until July 1, 2006, we are recommending an update of 
zero for IPFs (69 FR 66922). Finally, for the IRF PPS, we have not 
published a proposed rule proposing an update for FY 2006. As a 
result, we are recommending an update of 3.1 percent to IRF PPS for 
FY 2006, the same update used for FY 2005.

IV. MedPAC Recommendation for Assessing Payment Adequacy and Updating 
Payments in Traditional Medicare

    In the past, MedPAC has suggested specific adjustments to its 
update recommendation for each of the factors discussed under 
section III. of this Appendix. In its March 2005 Report to Congress, 
MedPAC assessed the adequacy of current payments and costs and the 
relationship between payments and an appropriate cost base, 
utilizing an established methodology used by the Commission in the 
past several years. MedPAC stressed that the issue at hand was 
whether payments were too high or too low, and not how they became 
either too high or too low.
    In the first portion of MedPAC's analysis on the assessment of 
payment adequacy, the Commission reviewed the relationship between 
costs and payments. MedPAC's indicator of the relationship between 
payments and costs is the overall Medicare margin. The overall 
Medicare margin is calculated as the difference between payments and 
costs divided by payments. Based on the latest cost report data 
available, MedPAC estimated an inpatient hospital Medicare operating 
margin for FY 2003 of 1.3 percent (down from 5.9 percent and 9.8 
percent for FY 2002 and FY 2001, respectively).
    MedPAC also projected margins for FY 2005, making certain 
assumptions about changes in payments and costs. On the payment 
side, MedPAC applied the annual payment updates (as specified by law 
for FYs 2001 through 2005), and then modeled the effects of other 
policy changes that have affected the level of payments. On the cost 
side, MedPAC estimated the increases in cost per unit of output over 
the same time period at the rate of inflation as measured by the 
applicable market basket index generated by CMS.
    In addition to considering the relationship between estimated 
payments and costs, MedPAC also considered the following three 
factors to assess whether current payments are adequate:
     Changes in access to or quality of care;
     Changes in the volume of services or number of 
providers; and
     Change in providers' access to capital.
    MedPAC's recommendation was to increase payments under the IPPS 
by the projected increase in the hospital market basket index, less 
0.4 percent, for FY 2006. MedPAC noted that the indicators of 
payment adequacy present a mixed picture. MedPAC was concerned about 
the trend of falling hospital margins, which may result in hospitals 
having a limited financial cushion for dealing with pressures that 
may arise in the coming year. On the other hand, MedPAC stated that 
the current cost trend was unsustainable and may have been driven by 
a lack of cost containment. Therefore, MedPAC concluded that an 
update of the hospital market basket index minus 0.4 percent is 
appropriate.
    Response: As described above, we are recommending a full market 
basket update for FY 2006 consistent with current law. We believe 
this will appropriately balance incentives for hospitals to operate 
efficiently with the need to provide sufficient payments to maintain 
access to quality care for Medicare beneficiaries.
    In addition, because the operating and capital prospective 
payment systems remain separate, we are proposing to continue to use 
separate updates for operating and capital payments. The proposed 
update to the capital payment rate is discussed in section III. of 
the Addendum to this proposed rule.
[FR Doc. 05-8507 Filed 4-25-05; 4:12 pm]
BILLING CODE 4120-01-P